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Potential Cost Savings from Medical Education and Training' which was 
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United States Government Accountability Office: 
GAO: 

Report to Congressional Committees: 

July 2014: 

Defense Health Care Reform: 

Actions Needed to Help Realize Potential Cost Savings from Medical 
Education and Training: 

GAO-14-630: 

GAO Highlights: 

Highlights of GAO-14-630, a report to congressional committees. 

Why GAO Did This Study: 

To help address DOD's escalating health care costs, in 2013 DOD
established the DHA to, among other things, combine common medical
services such as medical education and training. DOD trains its
servicemembers for a wide variety of medical positions, such as 
physicians, nurses, therapists, and pharmacists. DHA's Education and 
Training Directorate is to oversee many aspects of DOD's medical 
education and training and is now expected to begin operations in 
August 2014. GAO was mandated to review DOD's efforts to consolidate 
medical education and training. 

GAO examined the extent to which DOD has (1) conducted analysis to
reform medical education and training to achieve cost savings and (2)
determined whether the consolidation of training at METC has resulted in
cost savings and designed processes to assess its effectiveness. GAO
compared DHA implementation plans and METC budget information from
fiscal years 2010 through 2012 with best practices and interviewed 
officials from the DHA, METC, and military services' Surgeons General 
offices. 

What GAO Found: 

In its 2013 plans for the implementation of the Defense Health Agency 
(DHA), the Department of Defense (DOD) outlined the responsibilities 
of a new Education and Training Directorate, but has not demonstrated 
how its proposed reforms will result in cost savings. The National 
Defense Authorization Act for Fiscal Year 2013 required DOD to develop 
business case analyses for its shared service proposals as part of its 
submissions on its plans for the implementation of DHA, including, 
among other things, the purpose of the shared service and the 
anticipated cost savings. Although DOD has stated that the Directorate 
is a shared service that combines common services and that it will 
result in cost savings, DOD has not fully developed the required 
business case analysis for the medical education and training reforms. 
This is because DOD has not yet completed the first step of the 
process, which includes identifying the specific problems that the 
reform is intended to address and thereby achieve cost savings. Unlike 
the medical education and training reforms, other DOD shared service 
projects present a clear linkage between (1) a stated problem, (2) 
proposed process changes, and (3) an estimate of benefits, costs, and 
risks. For the Directorate, DOD has identified the new processes it 
will employ, but has not identified the concerns the proposed new 
processes are intended to address and how they will achieve cost 
savings. In addition, some officials are unconvinced that the 
potential cost savings will be achieved, and stated that the creation 
of the Directorate serves more as a functional realignment than a cost 
savings endeavor. Without a fully developed business case analysis, it 
is unclear how DOD will measure any accomplishments and hold the 
Directorate accountable for achieving cost savings. 

DOD is unable to determine whether the consolidation of training at 
the Medical Education and Training Campus (METC) resulted in cost 
savings; however, DOD is taking action to improve some of the 
processes for evaluating the effectiveness of training at METC. DOD co-
located medical training for enlisted medical servicemembers at METC 
as part of the 2005 Base Realignment and Closure Commission (BRAC) 
process to achieve cost savings, and subsequently, the services 
decided to consolidate their training. However, some officials stated 
they were unsure whether all funds were transferred to METC. 
Furthermore, due to a shortage of military service funds, the Office 
of the Assistant Secretary of Defense for Health Affairs provided 
funding for METC in addition to the services' transfers. DOD is unable 
to determine whether the consolidation of training at METC resulted in 
cost savings because it did not develop baseline cost information as 
part of its metrics to assess METC's success. Baseline cost 
information is a key characteristic of performance metrics critical to 
ensuring that processes achieve the desired results. Without baseline 
cost information prior to future course consolidation of training at 
METC and within the Education and Training Directorate, DOD will be 
unable to assess potential cost savings. DOD has designed processes to 
evaluate the quality of training at METC—-including processes related 
to certification rates, accreditation, and surveys. Further, DOD
has taken action to improve some processes. For example, to improve 
the level of feedback received from METC surveys, METC officials have 
begun a pilot process to conduct their own post-graduation surveys. 

What GAO Recommends: 

GAO recommends that DOD conduct a fully developed business case analysis
for the Education and Training Directorate and develop baseline cost
information as part of its metrics to assess cost savings for future
consolidation efforts. In comments to a draft of this report, DOD 
concurred with each of GAO's recommendations. 

View [hyperlink, http://www.gao.gov/products/GAO-14-630]. For more 
information, contact Brenda S. Farrell at (202) 512-3604 or 
farrellb@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

DOD Has Outlined the Responsibilities of the New Directorate, but Has 
Not Conducted a Business Case Analysis to Demonstrate How It Will 
Achieve Cost Savings: 

DOD Cannot Determine Whether the Consolidation of Training at METC Has 
Resulted in Cost Savings but Is Taking Action to Improve Some 
Processes for Evaluating Training Effectiveness: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments: 

Appendix I: Medical Education and Training Campus Courses and the 
Course Participants: 

Appendix II: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1. Amounts Transferred by Each Service to Fund the Medical 
Education and Training Campus (METC), by Fiscal Year: 

Table 2: Service Participation in Medical Education and Training 
Campus (METC) Programs: 

Figures: 

Figure 1: Defense Health Agency (DHA) Organizational Chart: 

Figure 2: Tri-Service and Service-Specific Department of Defense 
Medical Training Sites: 

Figure 3: Service-Specific Medical Basic and Specialty Enlisted 
Department of Defense (DOD) Training Sites Relocated to Form the 
Medical Education and Training Campus (METC) in Fort Sam Houston, 
Texas: 

Abbreviations: 

ACE: American Council on Education: 

AETC: Air Education and Training Command: 

AFMC: Air Force Material Command: 

AMEDD C&S: Army Medical Department Center and School: 

BRAC: Base Realignment and Closure: 

CCAF: Community College of the Air Force: 

DHA: Defense Health Agency: 

DMRTI: Defense Medical Readiness Training Institute: 

DOD: Department of Defense: 

JMESI: Joint Medical Executive Skills Institute: 

METC: Medical Education and Training Campus: 

MHS: Military Health System: 

NMETC: Navy Medicine Education and Training Command: 

USAFSAM: United State Air Force School of Aerospace Medicine: 

USUHS: Uniformed Services University of the Health Sciences: 

[End of section] 

[End of section] 

United States Government Accountability Office: 
GAO:
441 G St. N.W. 
Washington, DC 20548: 

July 31, 2014: 

The Honorable Carl Levin: 
Chairman: 
The Honorable James M. Inhofe: 
Ranking Member: 
Committee on Armed Services: 
United States Senate: 

The Honorable Howard P. "Buck" McKeon: 
Chairman: 
The Honorable Adam Smith: 
Ranking Member: 
Committee on Armed Services: 
House of Representatives: 

The Department of Defense (DOD) operates a complex medical training 
network that educates both officers and enlisted servicemembers. This 
network consists of institutions located across the United States, 
with some providing training to participants from all three military 
services and others providing training within a single service 
setting. DOD trains its officers and enlisted servicemembers for a 
wide variety of medical positions (e.g., physicians, dentists, nurses, 
therapists, and laboratory technicians) and expended approximately 
$655 million on such training in fiscal year 2013. This includes funds 
appropriated to the Defense Health Program, which provides support for 
education and training opportunities for medical personnel and 
includes resources for specialized skill training, formal educational 
programs outside DOD, and professional development education programs 
at various military sponsored schools. 

Over the past decade, decisionmakers have recognized the need to 
transform the Military Health System (MHS) to better control rapidly 
escalating health care costs and take advantage of opportunities to 
realize savings. For example, the 2005 Base Realignment and Closure 
(BRAC) Commission and DOD in its 2006 Quadrennial Defense Review 
called for transforming medical education and training. Specifically, 
the 2005 BRAC recommended co-locating all (except Aerospace Medicine) 
medical basic and specialty training for enlisted servicemembers from 
several locations to a single site, known as the Medical Education and 
Training Campus (METC), in San Antonio, Texas. In implementing this 
BRAC recommendation, the services decided to consolidate courses where 
feasible to achieve cost savings and facilitate interservice training, 
and METC began training students in 2010 as a tri-service institution. 
In April 2012, we reported that DOD had not documented savings 
resulting from the creation of METC, but agency officials believed 
that combining several training sites into METC had saved money and 
that other efficiencies had been achieved.[Footnote 1] We recommended, 
and DOD concurred, that DOD should employ key management practices to 
show both financial and nonfinancial achievements from its governance 
initiatives. Further, in October 2013, DOD established the Defense 
Health Agency (DHA) to, among other things, combine common ("shared") 
medical services with the intent of achieving cost savings.[Footnote 
2] DHA's Education and Training Directorate is intended to oversee and 
manage many aspects of medical education and training and is scheduled 
to begin operations in August 2014. Our recent report on DOD's efforts 
to reform the MHS focused on the establishment of the DHA.[Footnote 3] 
Specifically, in November 2013, we found that DOD lacked a thorough 
explanation of the potential sources of cost savings in its shared 
service projects, a plan to monitor potential implementation costs 
increases for these projects, and a current baseline assessment of MHS 
personnel and final staffing requirements for the DHA. As a result, we 
made a number of recommendations to provide decision makers with more 
complete information on the planned implementation, management, and 
oversight of DOD's newly created DHA, and DOD concurred with our 
recommendations, as discussed later in this report.[Footnote 4] 

The House Armed Services Committee Report accompanying the National 
Defense Authorization Act for Fiscal Year 2014 (H.R. Rep. No. 113-102) 
mandated us to review DOD's efforts to consolidate its medical 
training and report the results of our review to the congressional 
defense committees. This report examines the extent to which DOD has 
(1) developed plans and conducted analyses to reform medical education 
and training to achieve cost savings and (2) determined whether the 
consolidation of training at the Medical Education and Training Campus 
has resulted in cost savings and has designed processes to assess its 
effectiveness. 

To determine the extent to which DOD has developed plans and conducted 
analyses to reform medical education and training to achieve cost 
savings, we obtained and reviewed documents concerning DOD's plans for 
the implementation of the DHA, including the Education and Training 
Directorate's Concept of Operations, and briefings to internal 
stakeholders. We compared DOD's implementation plans with best 
practices from GAO's Business Process Reengineering and Assessment 
Guide and DOD's shared service analysis process.[Footnote 5] In 
addition, we reviewed the requirement in the National Defense 
Authorization Act for Fiscal Year 2013 for DOD to develop business 
case analyses for its shared service proposals as part of its 
submissions on its plans for the implementation of the DHA. We 
interviewed each of the service Surgeons General, and officials from 
the DHA and METC, concerning their understanding of the role and 
objectives of the Education and Training Directorate. 

To determine the extent to which DOD examined whether the 
consolidation of training at METC resulted in cost savings, we 
reviewed METC's resource data from fiscal years 2010 through 2012 and 
best practices from GAO's Business Process Reengineering and 
Assessment Guide.[Footnote 6] We interviewed officials responsible for 
the data concerning their quality control processes, and determined 
that the data were sufficiently reliable for our purposes. To 
determine the processes that METC has designed to assess effectiveness 
of its training, we obtained documentation from METC about those 
processes, including information on certification rates, internal 
metrics, accreditation standards, and survey procedures. We also 
reviewed the cost-savings and quality-related goals of BRAC 2005 for 
creating METC. To obtain context, we interviewed the Commandant and 
other officials from METC; each of the service Surgeons General; 
officials from the Navy Medicine Education and Training Command, the 
U.S. Army Medical Department Center and School, the Air Force Air 
Education and Training Command, and the Health Care Inter-service 
Training Office concerning issues related to the establishment of METC. 

We conducted this performance audit from November 2013 to July 2014 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

Defense Health Agency: 

The National Defense Authorization Act for Fiscal Year 2013 required 
that DOD develop a detailed implementation plan for carrying out its 
health care system reform of creating the DHA, and provide the plan to 
the congressional defense committees in three separate submissions in 
fiscal year 2013. In October 2013, DOD established the DHA to assume 
management responsibility for numerous functions of its medical health 
care system, support the services in carrying out their medical 
missions, manage the military's health plan, oversee the medical 
operations within the National Capital Region,[Footnote 7] and provide 
10 shared services, including oversight of medical education and 
training. According to DOD, a "shared services concept" is a 
combination of common services performed across the medical community 
with the goal of achieving cost savings. The DHA's Education and 
Training Directorate, a shared service, is scheduled to begin 
operations in August 2014 and, according to DOD officials, when 
operational, will constitute the first instance of oversight of 
medical education and training at the Office of the Secretary of 
Defense level.[Footnote 8] While the services establish training 
requirements, operate their own service-specific training 
institutions, and provide manpower to conduct the training at tri-
service institutions, such as METC, the Directorate plans to provide 
administrative support; academic review and policy oversight; and 
professional development, sustainment, and program management to the 
military departments' medical services, the combatant commands, and 
the Joint Staff. See figure 1 below for the organizational chart of 
the DHA. 

Figure 1: Defense Health Agency (DHA) Organizational Chart: 

[Refer to PDF for image: Organizational Chart] 

Policy development: 

Top level: 
Secretary of Defense; 
- Under Secretary of Defense (Personnel and Readiness); 
- Assistant Secretary of Defense (Health Affairs); 
Policy execution: 
- Defense Health Agency Director***; 
- Deputy Director. 

Chairman, Joint Chiefs of Staff: 
Direct connection to Secretary of Defense and Defense Health Agency 
Director. 

Second level, reporting up: 

Healthcare Operations Directorate**: 
- Readiness; 
- Pharmacy; 
- Public Health; 
- TRICARE Health Plan; 
- Clinical Support; 
- Warrior Care Program. 

Research, Development and Acquisition Directorate[A]: 
- Advanced Development; 
- Science and Technology; 
- Clinical Infrastructure Program; 
- Veterans Affairs Research and Development Liaison. 

Health Information Technology Directorate: 
- Innovation and Advanced Technology Development; 
- Solution Delivery; 
- Information Delivery; 
- Portfolio Management and Customer Relations; 
- Infrastructure and Operations; 
- Cyber Security; 
- Defense Health Service System; 
- Defense Health Clinical Systems. 

Education and Training Directorate[A]*: 
- Administrative Support; 
- Medical Enlisted Training Campus Headquarters; 
- Defense Medical Readiness Training Institute; 
- Joint Medical Executive Skills Institute; 
- Academic Review and Oversight; 
- Professional Development, Sustainment, and Program Management. 

Business Support Directorate: 
- Facility Planning; 
- Medical Logistics; 
- Program Integrity; 
- Budget and Resource Management. 

National Capital Region Medical Directorate**: 
- Walter Reed National Military Medical Center*; 
- Ft. Belvoir Community Hospital; 
- Joint Pathology Center. 

* One-star flag officer heads the directorate; 
** Two-star flag officer heads the directorate; 
*** Three-star flag officer heads the Defense Health Agency. 

Source: Defense Health Agency. GAO-14-630. 

Notes: This is an updated DHA organization chart from the one that we 
published in November 2013 in GAO-14-49. 

Under the DHA, the services' Surgeons General (three-star flag/general 
officers) will continue to head their respective medical organizations. 

[A] This directorate has not yet reached Initial Operating Capability 
as of July 2014. 

[End of figure] 

DOD's Medical Training Network: 

Medical personnel receive training throughout their careers to develop 
and enhance their skills. Examples of the types of medical training 
they can receive include: 

1. initial training for enlisted servicemembers, which results in a 
new occupational classification; 

2. sustainment training for enlisted servicemembers, which does not 
result in a new occupational classification but refreshes or augments 
initial training; 

3. operational or readiness skills training, which provides training 
to perform in operational situations throughout the world and includes 
such training as burn and trauma care as well as emergency and 
Chemical, Biological, Radiological, Nuclear, and Explosive 
preparedness; and: 

4. executive skills training for enlisted servicemembers, officers, 
and civilians, which provides military health care leaders with 
executive management and professional administrative skills. 

These training courses can be presented in shared or service-specific 
settings that involve varying degrees of a consolidated approach to 
course curricula, faculty instruction, equipment, and facilities. 
Figure 2 depicts the locations of this training and whether it is 
shared ("tri-service") or service-specific training. 

Figure 2: Tri-Service and Service-Specific Department of Defense 
Medical Training Sites: 

[Refer to PDF for image: illustrated U.S. map] 

Air Force Medicine Training Site: 
Bethesda: Navy Medicine Professional Development Center Headquarters; 
Air Force Materiel Command (Cincinnati): U.S. Air Force School of 
Aerospace Medicine; 
Cincinnati: Center for Sustainment of Trauma and Readiness Skills; 
St. Louis: Center for Sustainment of Trauma and Readiness Skills; 
San Antonio: Air Education and Training Command; 
San Antonio: 937th Training Group. 

Army Medicine Training Site: 
Fort Rucker: U.S. Army School of Aviation Medicine; 
Miami: Army Trauma Training Center; 
San Antonio: Army Medical Department Center and School. 

Navy Medicine Training Site: 
Baltimore: Center for Sustainment of Trauma and Readiness Skills; 
Camp Pendleton: Navy Expeditionary Medical Training Institute; 
Cherry Point: Navy Aviation Survival Training Center Detachment; 
Fort Bragg: Navy Special Operations Medical Institute; 
Groton: Navy Undersea Medical Institute; 
Jacksonville: 
* Navy Aviation Survival Training Center Detachment; 
* Naval Reserve-Navy Medical Education and Training Command; 
Lemoore: Navy Aviation Survival Training Center Detachment; 
Los Angeles: Navy Trauma Training Center; 
Miramar: Navy Aviation Survival Training Center Detachment; 
Norfolk: Navy Aviation Survival Training Center Detachment; 
Pensacola: 
* Navy Medicine Operational Training Center Headquarters; 
* Naval Aviation Medical Institute; 
* Navy Survival Training Institute Center; 
* Navy Aviation Survival Training Center Detachment; 
Patuxent River: Navy Aviation Survival Training Center Detachment; 
Portsmouth: Navy Medical Training Support Center Detachment; 
San Antonio: Navy Medicine Education and Training Command Headquarters; 
San Antonio: Navy Medicine Training Support Center; 
San Diego: 
* Navy Surface Warfare Medical Institute; 
* Navy Medicine Training Support Center Detachment; 
Whidbey Island: Naval Aviation Survival Training Center Detachment; 

Tri-Service: 
Bethesda: Uniformed Services University of the Health Sciences; 
San Antonio: Defense Medical Readiness Training Institute; 
San Antonio: Joint Medical Executive Skills Institute; 
San Antonio: Medical Education and Training Campus; 
San Antonio: U.S. Army Baylor Graduate Program. 

Source: GAO analysis of Department of Defense information; Map 
Resources (map). GAO-14-630. 

[End of figure] 

Tri-Service Medical Training: 

Four DOD institutions offer medical training to servicemembers from 
all three services. These institutions vary in size and subject 
matter, and include the following: 

* Uniformed Services University of the Health Sciences (USUHS): DOD-
funded medical school in Bethesda, Maryland, with a fiscal year 2015 
budget estimate of about $146 million. This university provides 
medical training to health professionals dedicated to a career as a 
physician, dentist, or nurse in DOD or the U.S. Public Health Service. 

* Medical Education and Training Campus (METC): Provides initial 
skills training to most medical enlisted servicemembers in about 50 
areas such as pharmacy, laboratory, and dental technology; combat 
medics, basic hospital corpsmen, basic medical technicians; and a 
number of advanced medical training courses. METC resulted from a 2005 
BRAC recommendation to establish a medical education and training 
complex that collocated medical enlisted training being conducted at 
five different locations by each of the military services into one 
location at Fort Sam Houston, Texas. (See figure 3.) 

Figure 3: Service-Specific Medical Basic and Specialty Enlisted 
Department of Defense (DOD) Training Sites Relocated to Form the 
Medical Education and Training Campus (METC) in Fort Sam Houston, 
Texas: 

[Refer to PDF for image: illustrated U.S. map] 

Medical Education and Training Campus, Fort Sam Houston, Texas: 
composed of former sites: 
- Air Force 882nd Training Group, Wichita Falls, Texas; 
- Navy Hospital Corps School, Great Lakes, Illinois; 
- Naval School of Health Science, Portsmouth, Virginia; 
- Naval School of Health Science, San Diego, California; 
- U.S. Army Medical Department Center and School, Fort Sam Houston, 
Texas. 

Source: Department of Defense; Map Resources (map). GAO-14-630. 

[End of figure] 

Since first becoming operational in 2010, METC has created 14 new 
consolidated courses while 22 of its courses were consolidated prior 
to METC's creation. METC trains, on average, about 20,000 students 
annually and is estimated to cost almost $27 million in fiscal year 
2015.[Footnote 9] See appendix I for a list of courses taught at METC 
and course participants. 

* Defense Medical Readiness Training Institute (DMRTI): Tri-service 
organization that is staffed by servicemembers from the Army, the 
Navy, and the Air Force as well as Department of the Army civilians 
and according to officials, had a $1.4 million budget in fiscal year 
2013. This organization offers resident and nonresident joint medical 
readiness training courses as well as professional medical programs 
that enable military medical personnel, both active duty and reserve, 
to better perform a wide range of medical and health support missions 
they face throughout the world. Courses include trauma care, burn 
care, public health emergency preparedness, humanitarian assistance, 
and emergency response to chemical, biological, nuclear, and other 
events. During fiscal year 2013, approximately 3,600 students 
participated in 122 course iterations in 51 different locations. 
According to officials, besides providing medical readiness training 
to U.S. servicemembers, DMRTI has provided this training to officials 
in 38 countries at the request of a combatant command. 

* Joint Medical Executive Skills Institute (JMESI): Tri-service 
organization that provides military health care leaders with executive 
management skill programs, products, and services that are designed to 
enhance their performance as managers and leaders in the military 
healthcare environment. The training JMESI provides centers on the 
Core Curriculum which is a collection of 35 executive administrative 
competencies required of a military hospital commander that tri-
service senior leaders are responsible for reviewing and updating 
every 3 years. Each year approximately 200 managers graduate from 
JMESI's Healthcare Management Seminar and MHS Capstone Symposium, and 
nearly 20,000 students participate in its online, distance learning 
program. 

Service-Specific Medical Training: 

In addition to tri-service training, each of the services operates its 
own education and training entities that provide additional training 
to their medical servicemembers. The Army and Navy education and 
training entities are constituent commands of the Army Medical Command 
and the Bureau of Medicine and Surgery, respectively, which are headed 
by Surgeons General. The Air Force education and training entities 
conduct a wide variety of training, including nonmedical training, and 
do not report directly to the Air Force Surgeon General. These 
organizations include the following: 

* Army Medical Department Center and School (AMEDD C&S): Army training 
headquarters located at Fort Sam Houston, Texas. The center formulates 
the Army Medical Department's medical organization, tactics, doctrine, 
and equipment. The school educates and trains Army medical personnel. 
More specifically, the Academy of Health Sciences is the "school" and 
is part vocational institution, part community college, and part major 
university. The Academy of Health Sciences includes 361 programs of 
instructions, with 41 of them taught at METC; 2 levels of officer 
leader development programs; 6 Masters Degree programs; 7 Doctoral 
Degree programs; 94 professional postgraduate programs; as well as pre-
deployment training within three main centers and a graduate school. 
First, the Center for Health Education and Training consists of 10 
departments whose primary mission is to instruct advanced or specialty 
courses enhancing and building upon the initial training that enlisted 
soldiers receive from METC and officers receive after finishing their 
basic courses. Second, the Center for Pre-Deployment Medicine 
analyzes, designs, and develops individual pre-deployment training 
courses and products and provides professional expertise and pre-
deployment training to increase the technical and tactical abilities 
of physicians, nurses, and other healthcare professionals. Third, the 
Leader Training Center provides professional education, doctrinal, and 
individual leadership training to execute Army missions across a full 
spectrum of military operations. Additionally, aviation medicine 
classes are taught at the US Army School of Aviation Medicine, in Fort 
Rucker, Alabama, and forward surgical teams preparing for overseas 
deployment go through training at the Army Trauma Training Center in 
Miami, Florida. 

* Navy Medicine Education and Training Command (NMETC): Consists of 
four centers that provide education, training, and support for Navy 
medical personnel. The first center is the Navy Medicine Professional 
Development Center headquartered in Bethesda, Maryland, which offers 
educational programs such as the Naval Postgraduate Dental School as 
well as leadership and specialty courses that focus on the practice 
and business of military medicine in both the operational and hospital 
settings delivered via in-person classes and online. The second center 
is the Navy Medicine Training Support Center headquartered in San 
Antonio, Texas. It serves as the Navy's component command for METC 
students and instructors to provide administrative and operational 
control of Navy personnel assigned to METC. The third center is the 
Navy Medicine Operational Training Center, which is headquartered in 
Pensacola, Florida, and consists of six detachments and nine training 
centers at 14 locations throughout the country that teach such areas 
of Navy medicine as undersea, aviation, expeditionary, special 
operations, and survival training. Fourth, another section of the 
NMETC provides medical education and training to the reserve 
components. 

* Air Force: There is no specific Air Force organization focused 
exclusively on medical training. The Air Force Surgeon General assists 
Air Force leadership in developing policies, plans, and programs, 
establishing requirements, and providing resources to the Air Force 
Medical Service, while the Air Force's Air Education and Training 
Command (AETC) and the Air Force Material Command (AFMC) provide 
medical training. AETC, which is headquartered at Joint Base San 
Antonio--Randolph, Texas, oversees a wide variety of medical and 
nonmedical training. AETC is responsible for 114 medical-related 
courses: 35 initial skills courses conducted mostly at METC; 73 
sustainment or skills progression courses conducted at METC and other 
various locations; and 6 medical readiness courses taught at a 
military training site near San Antonio, Texas. AFMC, which is 
headquartered at Wright-Patterson Air Force Base, Ohio, includes the 
Air Force School of Aerospace Medicine (USAFSAM). USAFSAM is a center 
for aerospace medical education and training, and offers a series of 
courses comprising the initial qualification training for flight 
surgeons, including hyperbaric medicine, occupational medicine, 
aviation mishap prevention, and other unique aeromedical issues 
pertinent to the flight environment. The school trains 6,000 students 
annually. 

DOD Has Outlined the Responsibilities of the New Directorate, but Has 
Not Conducted a Business Case Analysis to Demonstrate How It Will 
Achieve Cost Savings: 

DOD has outlined the areas of responsibility for its Education and 
Training Directorate, including consolidation and management of a 
number of activities currently performed by the services. However, in 
its plans, DOD has not demonstrated through a fully developed business 
case analysis how creating a shared service for education and training 
will result in cost savings. 

According to DOD's third submission[Footnote 10] to Congress on its 
plans for the implementation of the DHA in October 2013, DOD proposed 
a number of projects or "product lines" for its shared service 
Education and Training Directorate.[Footnote 11] Specifically, DOD 
identified three product lines for the directorate, which involve (1) 
management of professional development, sustainment, and related 
programs, including the METC, the Defense Medical Readiness and 
Training Institute, and the Joint Medical Executive Skills Institute; 
(2) academic review and policy oversight functions, including 
management of online courses and modeling and simulation programs; and 
(3) management of academic and administrative support functions, such 
as training and conference approval processes. According to DOD's 
second submission to Congress, the overall purpose and core measure of 
success for all shared services is the achievement of cost savings. 
This focus differentiates the objective of establishing shared 
services from the six other objectives outlined in DOD's plans for the 
implementation of the DHA.[Footnote 12] However, in its plans, DOD has 
not demonstrated how its Education and Training Directorate projects 
will result in cost savings through a fully developed business case 
analysis, including an analysis of benefits, costs, and risks. In its 
third submission to Congress on its implementation plans for DHA, DOD 
presented estimates of costs and cost savings for two "sub-product 
lines" concerning modeling and simulation and online learning. 
However, these projects do not represent the core of the directorate's 
mission, but rather a portion of the academic review and policy 
oversight project. Further, these projects overlap with DHA's 
contracting and information technology shared services. Specifically, 
while cost savings for modeling and simulation are allocated to the 
Education and Training Directorate, implementation costs are to be 
incurred by the DHA contracting shared service. In addition, the 
savings for the online learning project are found within the DHA 
information technology shared service portfolio. Aside from these 
projects, DOD did not present information concerning the cost savings 
of its other shared service projects within the Education and Training 
Directorate. 

GAO's Business Process Reengineering Assessment Guide states that a 
business case begins with (1) measuring performance and identifying 
problems in meeting mission goals, which is then addressed through (2) 
the development and selection of a new process.[Footnote 13] As noted 
above, the primary stated purpose of the DHA's shared service projects 
is to achieve cost savings. The Guide further states that as a project 
matures, the business case should be enlarged and updated to present a 
full picture of the benefits, costs, and risks involved in moving to a 
new process. Such analysis is to provide a sound basis to proceed with 
the reengineering process. DOD's own process for developing its shared 
services, outlined in its second submission on implementation of the 
DHA, states that after an assessment of the current state of 
performance and measures of effectiveness have been identified, 
performance improvement and cost reduction opportunities should be 
identified. It also states that new processes and initiatives are to 
be developed to address these challenges, along with associated 
implementation costs. Further, the National Defense Authorization Act 
for Fiscal Year 2013 required DOD to develop business case analyses 
for its shared service proposals as part of its submissions on its 
plans for the implementation of the DHA, including, among other 
things, the purpose of the shared service and the anticipated cost 
savings. 

DOD does not have a fully developed business case analysis for medical 
education and training because it has not yet completed the first step 
of that analysis, which is to identify specific problems, which, given 
the stated purpose of shared services, should be directed toward the 
achievement of cost savings. Several of DOD's other shared service 
projects present a clear linkage between (1) a stated problem, (2) 
proposed process changes, and (3) an estimate of benefits, costs, and 
risks. For example, DOD's third submission[Footnote 14] on the 
implementation of DHA, states that the pharmacy shared service will 
address rising costs due to variation in drug purchasing, staffing, 
and formulary management (the problem) through the introduction of MHS-
wide standards and business rules (the new processes), which will 
result in cost savings. Similarly, the plan states that the 
contracting shared services will address rising costs due to 
fragmentation in its acquisition strategy (the problem) through a 
common approach to acquisition planning, program management, contract 
execution, management, and administration (the new processes). In 
contrast, DOD listed the new processes the Directorate will employ, 
but it did not explain the problem its proposed new processes will 
address, and how they will achieve cost savings. 

DOD officials stated that they believe that a central problem for the 
Directorate to address is unnecessary variation of practice between 
the services, and they believe that efficiencies could be generated 
through the consolidation of training. However, in its official plans 
for the Directorate, DOD has not identified this issue or any other 
challenge related to cost savings as the problem its shared service 
will address. DOD also lacks the information to assess its current 
performance to then identify a problem. Specifically, DOD officials 
stated that they lack data on the cost of DOD's education programs and 
potential redundancy within its portfolio of courses, which would 
allow them to identify a problem and develop processes to address 
these challenges. In fact, officials stated they have identified the 
need for developing a baseline of current medical education and 
training courses and associated spending as a goal for the 
Directorate, and therefore have acknowledged the lack of such 
information. In addition, some officials cast doubt on the potential 
cost savings that could be achieved. Several DOD officials told us 
that the creation of the Directorate represents a logical step in the 
course of further cooperation among the services in the area of 
medical training. However, senior service officials stated that the 
Directorate was unlikely to achieve significant savings and that its 
creation serves more as a functional realignment than a cost savings 
endeavor. For example, officials stated that the Directorate provides 
an opportunity to assign a parent agency to METC, JMESI, and DMRTI, 
which they described as "orphan" agencies that lack a parent 
organization. Officials made similar comments during our 2012 review, 
[Footnote 15] in which we found that DOD was not able to demonstrate 
potential financial savings from the creation of METC, but agency 
officials stated at the time that they believed combining several 
training sites into the formation of METC had saved money and that 
other efficiencies had been achieved. 

DOD's reform of medical education and training reflects prior similar 
problems we have identified with DOD initiating major changes to the 
MHS without a clear understanding of how cost savings will be 
achieved. In its 2011 analysis of options to reform the MHS, DOD 
stated it anticipated $46.5 million in personnel savings as a result 
of the establishment of the DHA. However, in our November 2013 
report,[Footnote 16] we found that DOD did not know how the 
establishment of the DHA would affect total MHS staff levels. We 
recommended that DOD develop a baseline assessment of the current 
number of military, civilian, and contractor personnel currently 
working within the MHS headquarters and an estimate for the DHA at 
full operating capability, including estimates of changes in 
contractor full-time equivalents. DOD concurred with our 
recommendation and stated that it planned to conduct a baseline 
assessment of headquarters staffing levels and submit a revised 
estimate of its staffing needs in the department's third and final 
implementation plan submission. However, as we testified in February 
2014,[Footnote 17] DOD did not include this information in its third 
and final submission. In that testimony, we noted that DOD continued 
to lack discrete cost savings estimates for the various functions it 
had identified as part of its 10 shared service projects, and it had 
not clarified its plan to monitor implementation costs. DOD's reform 
of medical education and training now risks similar challenges to 
those DOD had encountered in establishing the DHA. In particular, 
given that DOD continues to lack an understanding of how the 
establishment of the DHA will affect staff levels, its challenges in 
identifying cost savings and a clear mission for its education reforms 
could result in increases in staff levels without any savings. As we 
noted in our reviews of DOD's plans for the implementation of the DHA, 
[Footnote 18] DOD's submissions did not include critical information 
necessary to help ensure that DOD achieves the goals of its reform of 
the MHS. Accordingly, in a recent report, the House Committee on Armed 
Services has expressed concern[Footnote 19] regarding DHA's staffing 
requirements, cost estimates, performance metrics, and medical 
education and training shared service. 

Without a business case analysis that links (1) a stated problem, (2) 
proposed process changes, and (3) an estimate of benefits, costs, and 
risks, the role of the Directorate remains ambiguous, and it is 
unclear how DOD will measure its accomplishments and hold the 
Directorate accountable for achieving cost savings by sharing training 
and education services. Without such information, the Directorate also 
potentially risks increasing staff levels without achieving any cost 
savings. 

DOD Cannot Determine Whether the Consolidation of Training at METC Has 
Resulted in Cost Savings but Is Taking Action to Improve Some 
Processes for Evaluating Training Effectiveness: 

DOD established METC as part of the 2005 BRAC process to provide 
interservice training for enlisted service members and to achieve cost 
savings. However, DOD is unable to determine whether the consolidation 
of medical education and training for enlisted personnel at METC has 
resulted in cost savings because it did not establish a baseline for 
spending on education and training prior to METC's establishment. METC 
has designed processes to assess the effectiveness of its training and 
is taking action to improve them. 

DOD Officials Cannot Demonstrate Whether the Consolidation of Training 
at METC Has Resulted in Cost Savings: 

DOD cannot demonstrate whether the consolidation of training at METC 
has resulted in cost savings. However, officials stated that while 
they could not document cost savings, they believe that the 
consolidation of training at METC has led to cost savings because of 
(1) increased equipment sharing; (2) personnel reductions; and (3) 
cost avoidances, such as those associated with the closure of medical 
education facilities that were service-specific. In contrast, 
officials also identified areas where the consolidation of training at 
METC may have resulted in cost increases because of, for example, (1) 
the construction of new facilities; (2) relocation of students to 
METC;[Footnote 20] and (3) replacement of personnel within their 
organizations who had been transferred to METC. 

To fund training at METC, the services transferred funding to a single 
METC budget managed by the Air Force over 3 years from fiscal year 
2010 through fiscal year 2012. The services continue to fund 
compensation for military instructors at METC. Civilian funding was 
transferred to the Air Force, and officials told us that this funding 
is likely to be transferred to the DHA. 

When METC was established, the services transferred funding for their 
enlisted medical programs being consolidated at METC into a single 
METC budget. However, some officials stated they are unsure whether 
the services' transfers were representative of their true costs for 
the transferred programs prior to the creation of METC. Additionally, 
the funding transfers from the services were not sufficient to fund 
training at METC, and the Office of the Assistant Secretary of Defense 
for Health Affairs provided additional funding to cover this 
shortfall. For instance, of the total METC budget of $26.6 million in 
fiscal year 2012, Health Affairs provided 28 percent; the Air Force, 
22 percent; the Army, 36 percent; and the Navy, 14 percent. Table 1 
shows the funding amounts transferred by each service to fund METC, 
from fiscal year 2010, the first year in which the services 
transferred funds, until fiscal year 2012, when the services completed 
a permanent transfer of their funds to METC. 

Table 1: Amounts Transferred by Each Service to Fund the Medical 
Education and Training Campus (METC), by Fiscal Year: 

Nominal dollars: 

Organization: Air Force; 
Fiscal year 2010: $612,000; 
Fiscal year 2011: $2,284,000; 
Fiscal year 2012: $5,862,000. 

Organization: Army; 
Fiscal year 2010: $273,000; 
Fiscal year 2011: $4,051,000; 
Fiscal year 2012: $9,462,000. 

Organization: Navy; 
Fiscal year 2010: $272,000; 
Fiscal year 2011: $1,757,000; 
Fiscal year 2012: $3,828,000. 

Organization: Health Affairs; 
Fiscal year 2010: $315,000; 
Fiscal year 2011: $10,146,000; 
Fiscal year 2012: $7,500,000. 

Organization: Total; 
Fiscal year 2010: $1,472,000; 
Fiscal year 2011: $18,238,000; 
Fiscal year 2012: $26,652,000. 

Source: Department of Defense (DOD). GAO-14-630. 

[End of table] 

GAO's Business Process Reengineering Assessment Guide states that 
performance measures are a critical part of a comprehensive 
implementation process to ensure that a new process is achieving the 
desired results.[Footnote 21] Additionally, through our prior work on 
performance metrics, we have identified several important attributes 
of these assessment tools, including the need to develop a baseline 
and trend data to identify, monitor, and report changes in performance 
and to help ensure that performance is viewed in context.[Footnote 22] 
By tracking and developing a performance baseline for all measures, 
agencies can better evaluate progress made and whether goals are being 
achieved, such as cost savings targets. 

DOD did not establish and monitor baseline cost information as part of 
its metrics to assess performance to ensure that the establishment of 
METC provided costs savings. Officials told us that their focus in 
establishing METC was to ensure that DOD met the BRAC recommendation 
to co-locate enlisted medical training, not to ensure that this 
consolidation led to cost savings. However, the METC business plan, 
[Footnote 23] developed in response to the BRAC recommendation, noted 
that the intent of establishing METC was to reduce costs while 
leveraging best practice training programs of the three services. We 
found in April 2012[Footnote 24] that DOD was unable to provide 
documented savings associated with the establishment of METC. We 
recommended that DOD employ key management practices in order to show 
the financial and nonfinancial outcomes of its reform efforts, and DOD 
concurred with our recommendation. DOD noted that it would employ key 
management practices in order to identify those outcomes; however, as 
of June 2014, DOD officials have not documented the financial outcome 
of the establishment of METC. 

DOD justified its request for the 2005 BRAC round in part based on 
anticipated savings. For example, DOD submitted to the 2005 BRAC 
Commission a recommendation for the consolidation of 26 military 
installations operated by individual military services into 12 joint 
bases to take advantage of opportunities for efficiencies arising from 
such consolidation and elimination of similar support services on 
bases located close to one another. However, we found in 2012 that DOD 
did not have a plan for achieving cost savings.[Footnote 25] For 
example, during our review of DOD's effort to implement this BRAC 
recommendation, joint base officials provided us with anecdotal 
examples of efficiencies that had been achieved at joint bases, but it 
was unclear whether DOD had achieved any significant cost savings to 
date, due in part to weaknesses in such areas as DOD's approach to 
tracking costs and estimated savings. Specifically, it did not 
establish quantifiable and measurable implementation goals for how to 
achieve cost savings or efficiencies through joint basing. We 
recommended that DOD develop and implement a plan that provides 
measurable goals linked to achieving savings and efficiencies at the 
joint bases and provide guidance to the joint bases that directs them 
to identify opportunities for cost savings and efficiencies. DOD did 
not concur with our recommendation, and we noted that this position 
contradicts DOD's position that joint basing would realize cost 
savings. Similarly, the co-location and consolidation of training at 
METC was, in part, premised on the achievement of cost savings, but 
DOD did not establish baseline costs as part of its metrics for 
assessing performance. 

It is now likely not possible to develop baseline cost information for 
fiscal year 2009 to determine the extent to which the establishment of 
METC resulted in cost savings. However, without developing baseline 
cost information before undergoing future course consolidation of 
training at METC and within the Education and Training Directorate, 
DOD will be unable to accurately assess cost savings in the future. 

DOD Has Designed Processes for Evaluating the Effectiveness of 
Training and Is Taking Action to Address Accreditation and Survey 
Response Issues: 

METC has designed quality assurance processes to provide continuous, 
evaluative feedback related to improvements in education and training 
support, and is taking action to address issues regarding course 
accreditation and the post-graduation survey process. 

METC Has Established Quality Assurance Processes: 

* Certification Rates: METC monitors the national certification exam 
pass rates of its students, both to meet national requirements and to 
make comparisons with national averages. According to METC officials, 
certification rates are generally higher since the consolidation of 
training at METC. Currently, certification rates for seven programs 
exceed the national average.[Footnote 26] 

* Internal Metrics: According to METC officials, METC regularly 
monitors a number of internal metrics, such as attrition, course 
repetition, and graduation rates. To manage performance information 
for all of their courses, officials produce a monthly snapshot of 
these data to track trends in performance over time. Additionally, all 
of METC's courses are to be reviewed through a comprehensive program 
review process conducted by the Health Care Interservice Training 
Office.[Footnote 27] This office is to review 30 specific standards to 
help ensure, for example, that all service and accreditation 
requirements are met; that faculty meet all required qualifications; 
and that internal and external surveys are conducted, analyzed, 
reported, and acted on according to policy. 

* Accreditation Standards: METC is institutionally accredited by the 
Council on Occupational Education and is officially an affiliated 
school within the Community College of the Air Force (CCAF). Most METC 
courses are accredited by a relevant external accrediting body, such 
as the American Council on Education (ACE) or the CCAF. 

* Surveys: The METC Memorandum of Agreement states that METC and the 
services will conduct external evaluations to document program 
efficacy and to facilitate curriculum review, by gathering feedback to 
measure whether the training received was relevant and to determine 
whether the graduates are proficient in their job duties. METC 
solicits this feedback through surveys sent by the services to the 
supervisors of METC graduates at the gaining commands to gauge 
satisfaction with the training they received at METC. These surveys 
ask such questions as whether the graduates have the cognitive skills 
necessary to do their jobs, whether they have met the entry-level 
practice requirements of their organizations, and whether any job 
tasks should be added to the METC curriculum for their programs of 
study. 

METC Is Taking Action to Address Issues Related to Course 
Accreditation and the Post-Graduate Survey Process: 

METC officials told us that some training courses were awarded fewer 
recommended credits by the ACE than similar service-run courses had 
received prior to METC's consolidation.[Footnote 28] Officials also 
stated that the consolidation of service-run curricula into single 
programs at METC was conducted by a contractor, and that these 
consolidated curricula could be improved. METC officials further noted 
that the ACE review of METC's consolidated curricula occurred after a 
change to that body's process for recommending credits, and that they 
are unaware whether the decrease in the number of recommended credits 
was due to the consolidated curricula or changes to ACE's process. 
METC officials told us that they are attempting to improve their 
programs through their regular process of curriculum review ahead of 
future ACE reviews of recommended credits for their courses. 

METC officials also told us that the post-graduate survey process has 
been ongoing since before METC was established; however, these surveys 
have historically exhibited low response rates. For instance, one 
sample survey provided by METC officials had a 14 percent student 
response rate and a 0 percent supervisor response rate. To improve the 
level of feedback received from these surveys, METC officials have 
begun a pilot process to conduct their own post-graduation surveys, 
using an online survey program that can be sent directly to the 
students' and supervisors' personal email addresses. Depending on the 
success of the pilot, METC officials plan to extend the process 
throughout all of METC. 

Conclusions: 

DHA's Education and Training Directorate is scheduled to begin 
operations in August 2014 to oversee medical education and training 
reform, but DOD does not have key information necessary to assess its 
progress in realizing the reform effort's goal of achieving cost 
savings. When DOD responded to the 2005 BRAC recommendation to 
relocate some medical education and training programs for enlisted 
servicemembers at METC, DOD similarly did not have key information 
necessary to determine whether the consolidation of training there had 
resulted in cost savings. Although DOD's plans for the implementation 
of the DHA acknowledge the benefits of conducting business case 
analyses, it has not done so for its medical education and training 
reforms. DOD's inability to demonstrate that cost savings had resulted 
from the consolidation of training at METC risks being repeated on a 
larger scale in the reform effort of the DHA's Education and Training 
Directorate. Specifically, absent analysis demonstrating how the 
Directorate's efforts will result in cost savings, the creation of the 
Directorate could increase costs by increasing staff levels without 
achieving any cost savings. In addition, without baseline cost 
information prior to future course consolidation of training at METC 
and within the Education and Training Directorate, DOD will be unable 
to assess potential cost savings. The risk of cost growth also exists 
for any future consolidations of training at METC, which could require 
significant investment of time and resources without any long-term 
efficiencies. 

Recommendations for Executive Action: 

To help realize the reform effort's goal of achieving cost savings, we 
recommend that the Assistant Secretary of Defense for Health Affairs 
direct the Director of the DHA to conduct a fully developed business 
case analysis for the Education and Training Directorate's reform 
effort. In this analysis the Director should: 

* identify the cost-related problem that it seeks to address by 
establishing the Education and Training Directorate, 

* explain how the processes it has identified will address the cost- 
related problem, and: 

* conduct and document an analysis of benefits, costs, and risks. 

To help ensure that DOD has the necessary information to determine the 
extent to which cost savings result from any future consolidation of 
training within METC or the Education and Training Directorate, we 
recommend that Assistant Secretary of Defense for Health Affairs 
direct the Director of the DHA to develop baseline cost information as 
part of its metrics to assess achievement of cost savings. 

Agency Comments: 

We provided a draft of this product to DOD for comment. The Acting MHS 
Chief Human Capital Officer provided DOD's comments in an email dated 
July 21, 2014. In that email, DOD concurred with the draft report's 
findings, conclusions, and recommendations. Additionally, noted in the 
email was that Medical Education and Training is the only shared 
service that has never had any type of oversight by the Office of the 
Assistant Secretary of Defense for Health Affairs or the pre-DHA 
TRICARE Management Activity. Further, in that email, DOD noted that 
much credit goes to the sub-working group which has worked numerous 
hours over the past 2 years to put this shared service together so the 
MHS can realize efficiencies and garner maximum value, exploit best 
practices from the services, and achieve standardization where it 
makes sense. 

We are sending copies of this report to the appropriate congressional 
committees; the Secretary of Defense; the Assistant Secretary of 
Defense for Health Affairs; the Director, DHA; and the Surgeons 
General of the Army, the Navy, and the Air Force. In addition, the 
report is available at no charge on GAO's website at [hyperlink, 
http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-3604 or farrellb@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major 
contributions to this report are included in appendix II. 

Signed by: 

Brenda S. Farrell: 
Director: 
Defense Capabilities and Management: 

[End of section] 

Appendix I: Medical Education and Training Campus Courses and the 
Course Participants: 

The Medical Education and Training Campus (METC) is the result of the 
2005 Base Realignment and Closure (BRAC) Commission legislation that 
required the bulk of enlisted medical training in the Army, Air Force, 
and the Navy to be co-located at Fort Sam Houston, Texas. As a result, 
four major learning institutions for Navy and Air Force relocated to 
Fort Sam Houston, where the Army was already training its enlisted 
medical force under the Army Medical Department Center & School's 
(AMEDD C&S) Academy of Health Sciences. The Naval School of Health 
Sciences in San Diego, California; Naval School of Health Sciences in 
Portsmouth, Virginia; Navy Hospital Corps School in Great Lakes, 
Illinois; and the 882nd Training Group (now the 937th Training Group) 
at Sheppard Air Force Base moved to Fort Sam Houston, Texas. METC is 
now the largest military medical education and training facility in 
the world. 

METC started operating on June 30, 2010. Its initial training course 
was radiography specialist. Other courses were phased in throughout 
the rest of the year and into 2011. METC became fully operational on 
September 15, 2011. The longest program offered is cytology, which is 
the study of cells, at 52 weeks; and the shortest, at 4 weeks, is 
patient administration. METC offers about 50 medical training 
programs, which are listed in table 2 along with the course 
participants. 

Table 2: Service Participation in Medical Education and Training 
Campus (METC) Programs: 

Program: Ancillary Training Department; 

Course title: Diet Therapy Fundamentals; 
Army: [Empty]; 
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Nutrition and Diet Therapy; 
Army: [Check];
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Nutrition in Prevention; 
Army: [Empty]; 
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Occupational Therapy; 
Army: [Check];
Navy: [Check];
Air Force: [Empty]. 

Course title: Pharmacy; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Course title: Pharmacy Craftsman; 
Army: [Empty]; 
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Physical Therapy; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Program: Basic Medical Technician Corpsman Department; 

Course title: Basic Medical Technician/Corpsman; 
Army: [Empty]; 
Navy: [Check];
Air Force: [Check]. 

Course title: Combat Medic Department; 
Army: [Empty]; 
Navy: [Empty]; 
Air Force: [Empty]. 

Course title: Combat Medic; 
Army: [Check];
Navy: [Empty]; 
Air Force: [Empty]. 

Program: Dental Services Department; 

Course title: Advanced Dental Laboratory; 
Army: [Empty]; 
Navy: [Check];
Air Force: [Empty]. 

Course title: Advanced Porcelain Technician; 
Army: [Check];
Navy: [Check];
Air Force: [Empty]. 

Course title: Dental Assistant (Air Force only); 
Army: [Empty]; 
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Dental Assistant (Army only); 
Army: [Check];
Navy: [Empty]; 
Air Force: [Empty]. 

Course title: Dental Assistant (Navy only); 
Army: [Empty]; 
Navy: [Check];
Air Force: [Empty]. 

Course title: Dental Laboratory Basic; 
Army: [Check];
Navy: [Check];
Air Force: [Empty]. 

Course title: Fixed Prosthodontics; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Course title: Removable Prosthodontics; 
Army: [Empty]; 
Navy: [Check];
Air Force: [Check]. 

Program: Diagnostic Services Department; 

Course title: Cytotechnologist; 
Army: [Check];
Navy: [Empty]; 
Air Force: [Empty]. 

Course title: Electroneurodiagnostic; 
Army: [Empty]; 
Navy: [Check];
Air Force: [Check]. 

Course title: Histopathology; 
Army: [Empty]; 
Navy: [Check];
Air Force: [Check]. 

Course title: Medical Laboratory (Air Force only); 
Army: [Empty]; 
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Medical Laboratory; 
Army: [Check];
Navy: [Check];
Air Force: [Empty]. 

Course title: Nuclear Medicine; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Course title: Radiographer; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Program: Healthcare Support Department; 

Course title: Advanced Field Medical Systems; 
Army: [Check];
Navy: [Check];
Air Force: [Empty]. 

Course title: Advanced Sterilization Systems; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Course title: Biomedical Equipment Management; 
Army: [Check];
Navy: [Check];
Air Force: [Empty]. 

Course title: Biomedical Equipment Technician; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Course title: Biomedical Officer Management Orientation; 
Army: [Empty]; 
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Computed Tomography; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Course title: Computer Based Medical Systems; 
Army: [Check];
Navy: [Check];
Air Force: [Empty]. 

Course title: Mammography Imaging Systems; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Course title: Medical Expense/Performance Reporting System; 
Army: [Empty]; 
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Medical Logistics; 
Army: [Check];
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Medical Materiel Supervisor; 
Army: [Empty]; 
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Patient Administration; 
Army: [Check];
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Radiographic Acceptance Procedures; 
Army: [Check];
Navy: [Check];
Air Force: [Empty]. 

Course title: Radiographic/Fluoroscopic Imaging Systems; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Course title: Telemedicine; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Course title: Ultrasound Imaging Systems; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Program: Nursing and Specialty Medical Training Department; 

Course title: Cardiopulmonary; 
Army: [Empty]; 
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Cardiovascular Technologist; 
Army: [Check];
Navy: [Check];
Air Force: [Empty]. 

Course title: Independent Duty Medical Technician; 
Army: [Empty]; 
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Ophthalmic; 
Army: [Check];
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Orthopedic; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Course title: Otolaryngology Technologist; 
Army: [Check];
Navy: [Empty]; 
Air Force: [Check]. 

Course title: Respiratory Therapy; 
Army: [Check];
Navy: [Check];
Air Force: [Empty]. 

Course title: Surgical Technologist; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Course title: Urology; 
Army: [Empty]; 
Navy: [Check];
Air Force: [Check]. 

Program: Public Health Services Department; 

Course title: Behavioral Health; 
Army: [Check];
Navy: [Check];
Air Force: [Check]. 

Course title: Preventative Medicine; 
Army: [Check];
Navy: [Check];
Air Force: [Empty]. 

Source: METC. GAO-14-630. 

[End of table] 

[End of section] 

Appendix II: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Brenda S. Farrell, (202) 512-3604 or farrellb@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Lori Atkinson, Assistant 
Director; Rebecca Beale; Jeffrey Heit; Mae Jones; Carol Petersen; 
Michael Silver; Adam Smith; and Sabrina Streagle made key 
contributions to this report. 

[End of section] 

Related GAO Products: 

Military Health System: Sustained Senior Leadership Needed to Fully 
Develop Plans for Achieving Cost Savings. [hyperlink, 
http://www.gao.gov/products/GAO-14-396T]. Washington, D.C.: February 
26, 2014. 

Defense Health Care Reform: Additional Implementation Details Would 
Increase Transparency of DOD's Plans and Enhance Accountability. 
[hyperlink, http://www.gao.gov/products/GAO-14-49]. Washington, D.C.: 
November 6, 2013. 

Defense Health Care: Additional Analysis of Costs and Benefits of 
Potential Governance Structures Is Needed. [hyperlink, 
http://www.gao.gov/products/GAO-12-911]. Washington, D.C.: September 
26, 2012. 

Defense Health Care: Applying Key Management Practices Should Help 
Achieve Efficiencies within the Military Health System. [hyperlink, 
http://www.gao.gov/products/GAO-12-224]. Washington, D.C.: April 12, 
2012. 

2012 Annual Report: Opportunities to Reduce Duplication, Overlap and 
Fragmentation, Achieve Savings, and Enhance Revenue. [hyperlink, 
http://www.gao.gov/products/GAO-12-342SP]. Washington, D.C.: February 
28, 2012. 

Follow-up on 2011 Report, Status of Actions Taken to Reduce 
Duplication, Overlap, and Fragmentation, Save Tax Dollars, and Enhance 
Revenue. [hyperlink, http://www.gao.gov/products/GAO-12-453SP]. 
Washington, D.C.: February 28, 2012. 

Opportunities to Reduce Potential Duplication in Government Programs, 
Save Tax Dollars, and Enhance Revenue. [hyperlink, 
http://www.gao.gov/products/GAO-11-318SP]. Washington, D.C.: March 1, 
2011. 

Military Personnel: Enhanced Collaboration and Process Improvements 
Needed for Determining Military Treatment Facility Medical Personnel 
Requirements. [hyperlink, http://www.gao.gov/products/GAO-10-696]. 
Washington, D.C.: July 29, 2010. 

Defense Health Care: DOD Needs to Address the Expected Benefits, 
Costs, and Risks for Its Newly Approved Medical Command Structure. 
[hyperlink, http://www.gao.gov/products/GAO-08-122]. Washington, D.C.: 
October 12, 2007. 

[End of section] 

Footnotes: 

[1] GAO, Defense Health Care: Applying Key Management Practices Should 
Help Achieve Efficiencies within the Military Health System, 
[hyperlink, http://www.gao.gov/products/GAO-12-224] (Washington, D.C.: 
Apr. 12, 2012). 

[2] According to DOD, a "shared services" concept is a combination of 
common services performed across the medical community. DOD identified 
10 shared services it plans to implement: medical logistics, facility 
planning, health information technology, health plan management, 
pharmacy, medical education and training, medical research and 
development, public health, acquisition, and budget and resource 
management. 

[3] GAO, Defense Health Care Reform: Additional Implementation Details 
Would Increase Transparency of DOD's Plans and Enhance Accountability, 
[hyperlink, http://www.gao.gov/products/GAO-14-49] (Washington, D.C.: 
Nov. 6, 2013). 

[4] For further information on DOD medical governance issues, see: 
GAO, Defense Health Care: DOD Needs to Address the Expected Benefits, 
Costs, and Risks for Its Newly Approved Medical Command Structure, 
[hyperlink, http://www.gao.gov/products/GAO-08-122] (Washington, D.C.: 
Oct. 12, 2007); [hyperlink, http://www.gao.gov/products/GAO-12-224]; 
Defense Health Care: Additional Analysis of Costs and Benefits of 
Potential Governance Structures is Needed, [hyperlink, 
http://www.gao.gov/products/GAO-12-911] (Washington, D.C.: Sept. 26, 
2012); and Military Health System: Sustained Senior Leadership Needed 
to Fully Develop Plans for Achieving Cost Savings Testimony, 
[hyperlink, http://www.gao.gov/products/GAO-14-396T] (Washington, 
D.C.: Feb. 26, 2014). 

[5] GAO, Business Process Reengineering Assessment Guide, [hyperlink, 
http://www.gao.gov/products/GAO/AIMD-10.1.15] (May 1997). To develop 
the Business Process Reengineering and Assessment Guide, we consulted 
with outside experts in the area of public and private sector process 
redesign and reengineering, reviewed literature and methodologies on 
process redesign and reengineering, and consulted GAO staff with 
relevant experience and expertise in areas such as government results 
and performance issues and performance measurement and benchmarking. 
The Guide is relevant because it provides a framework for assessing 
issues similar to those DOD faces in the establishment of the DHA. 

[6] [hyperlink, http://www.gao.gov/products/GAO/AIMD-10.1.15]. 

[7] The National Capital Region is the geographic area that includes 
Washington, D.C., and other specific surrounding cities and counties 
in both Maryland and Virginia. 

[8] The DHA and the Education and Training Directorate are expected to 
reach full operational capability no later than October 1, 2015. 

[9] This figure does not include costs for civilian compensation. 

[10] The National Defense Authorization Act for Fiscal Year 2013 
required that DOD develop a detailed implementation plan for carrying 
out its health care system reform of creating the DHA, and provide it 
to the congressional defense committees in three separate submissions 
in fiscal year 2013. 

[11] Department of Defense, Plan for Reform of the Administration of 
the Military Health System: Third Submission under Section 731 of the 
National Defense Authorization Act for Fiscal Year 2013 (Oct. 25, 
2013). 

[12] The seven goals of the DHA include: (1) promote more-effective 
and more-efficient health care operations through enhanced enterprise-
wide shared services; (2) deliver more-comprehensive primary care and 
integrated health services using advanced patient-centered medical 
homes; (3) coordinate care over time and across treatment settings to 
improve outcomes in the management of chronic illness, particularly 
for patients with complex medical and social problems; (4) match 
personnel, infrastructure, and funding to current missions, future 
missions, and population demand; (5) establish more interservice 
standards and metrics, and standardize processes to promote learning 
and continuous improvement; (6) create enhanced value in military 
medical markets using an integrated approach specified in 5-year 
business performance plans; and (7) align incentives with health and 
readiness outcomes to reward value creation. 

[13] [hyperlink, http://www.gao.gov/products/GAO-AIMD-10.1.15]. 

[14] Department of Defense, Plan for Reform of the Administration of 
the Military Health System: Third Submission under Section 731 of the 
National Defense Authorization Act for Fiscal Year 2013. 

[15] [hyperlink, http://www.gao.gov/products/GAO-12-224]. 

[16] [hyperlink, http://www.gao.gov/products/GAO-14-49]. 

[17] [hyperlink, http://www.gao.gov/products/GAO-14-396T]. 

[18] [hyperlink, http://www.gao.gov/products/GAO-14-49] and 
[hyperlink, http://www.gao.gov/products/GAO-14-396T]. 

[19] Report of the Committee on Armed Services, House of 
Representatives, on the National Defense Authorization Act for Fiscal 
Year 2015, H.R. Rep. No. 113-446, at 168 (2014). 

[20] Officials stated that although the cost of relocating students is 
mostly incurred by the Navy, it is still an additional cost incurred 
by DOD. Officials stated that prior to the establishment of METC, Navy 
enlisted servicemembers completed basic training at Great Lakes Naval 
Station and would then complete the Navy's enlisted medical training 
at a nearby location. Since the establishment of METC, enlisted 
servicemembers complete basic training at Great Lakes Naval Station 
and are then transferred to METC in the San Antonio, Texas, area to 
complete enlisted medical training. 

[21] [hyperlink, http://www.gao.gov/products/GAO-AIMD-10.1.15]. 

[22] GAO, Tax Administration: IRS Needs to Further Refine Its Tax 
Filing Season Performance Measures, [hyperlink, 
http://www.gao.gov/products/GAO-03-143] (Washington, D.C.: Nov. 22, 
2002); GPRA Performance Reports, [hyperlink, 
http://www.gao.gov/products/GAO/GGD-96-66R], (Washington, D.C.: Feb. 
14, 1996); Missile Defense: Opportunity to Refocus on Strengthening 
Acquisition Management, [hyperlink, 
http://www.gao.gov/products/GAO-13-432] (Washington, D.C.: Apr. 26, 
2013); Performance Measurement and Evaluation: Definitions and 
Relationships, [hyperlink, http://www.gao.gov/products/GAO-11-646SP] 
(Washington, D.C.: May 2011); and Agency Performance Plans: Examples 
of Practices That Can Improve Usefulness to Decisionmakers, 
[hyperlink, http://www.gao.gov/products/GAO/GGD/AIMD-99-69] 
(Washington, D.C.: Feb. 26, 1999). 

[23] Department of Defense, Appendix B of San Antonio Business Plan 
172, Commission and DOD Recommendation Number: MED-0016, (Feb. 23, 
2011). 

[24] [hyperlink, http://www.gao.gov/products/GAO-12-224]. 

[25] GAO, 2013 Annual Report: Actions Needed to Reduce Fragmentation, 
Overlap, and Duplication and Achieve Other Financial Benefits, 
[hyperlink, http://www.gao.gov/products/GAO-13-279SP] (Washington, 
D.C.: Apr. 9, 2013) and GAO, DOD Joint Bases: Management Improvements 
Needed to Achieve Greater Efficiencies, [hyperlink, 
http://www.gao.gov/products/GAO-13-134], (Washington, D.C.: Nov. 15, 
2012). 

[26] We did not verify the accuracy of these figures. 

[27] The Health Care Interservice Training Office serves as a 
facilitating and coordination support office and as the point of 
contact on health care interservice training for all military 
services. It is one of five Interservice Training Offices under the 
Interservice Training Review Organization. 

[28] The ACE reviews METC courses and recommends the number of credits 
that outside colleges, universities, and training programs should 
accept for completion of courses at METC. 

[End of section] 

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