All Branch Topic (ABT) THE PENTAGON’S FIG TREE: REFORMING THE MILITARY HEALTH SYSTEM

[dr zaius]

I looked but couldn't find this article posted here yet. It's a pretty decent, albeit more friendly than I would be, explanation of some of the major problems with military medicine.

http://warontherocks.com/2016/09/the-pentagons-fig-tree-reforming-the-military-health-system/

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[HighPriest]

We may have some of the same Facebook friends, because I read this article late last week. It's hard to argue, I feel, with most of the points. The article concentrates on surgical complications and the need for surgeons, but I think that's primarily because most of the data we have is in regards to surgical complication rates in the military (as opposed to what goes on in the primary care setting). They do mention that most of the medical care that occurs during deployment has nothing to do with surgery, however. A friend of mine who is a general surgeon made the comment that most of the combat related trauma that occurs during deployment isn't akin to civilian trauma, and that stationing surgeons in trauma centers wouldn't necessarily help to prepare them for deployment. He's been deployed more times than I can count, so I can't be the one to disagree. Undoubtedly you see fewer IED-related injuries at civilian trauma centers, but you would certainly see gunshot wounds and MVAs. That being said, it isn't as if the choice is "dealing with combat-related trauma" versus "dealing with civilian trauma." The choice is "next to no trauma at a MEDCEN or no trauma at all ad a MEDDAC" versus "copious amounts of civilian trauma to include gunshot wounds." That seems like a no brainer to me.

Ultimately, my experience has been and unless something changes dramatically will continue to be that the problem with military medicine isn't the surgeons it's the military. Our hospitals are run like crap. The biggest bottleneck I have, by far, is the simply inability to book more cases. The second biggest challenge to volume that I have is the ability of our inpatient wards to handle it (we have plenty of beds and nurses, but we don't have plenty of people who want to work). The third biggest challenge to volume is the mountain of non-clinical BS I have to deal with on a daily or weekly basis - such as the complete closure of hospital clinics and non-emergent OR space for a hospital-wide pep session that the hospital commander feels is absolutely necessary. The patient demographic comes in a very distant 4th, or even 5th.

 

[Perrotfish]

I looked but couldn't find this article posted here yet. It's a pretty decent, albeit more friendly than I would be, explanation of some of the major problems with military medicine.

http://warontherocks.com/2016/09/the-pentagons-fig-tree-reforming-the-military-health-system/

The author makes it seem like deferring all the dependents to the civilian network is as simple as a policy decision allowing it. That's probably true in DC and San Diego, but where I work there is no network. The majority of civilians in the community already can't get care because there is absolutely no one who wants to be a physician near my MTF, if we threw all the military dependents at the network more than half of them would just be without medical care. The quality of the care that is available is also questionable. I'm not sure I'd want to be at a military tertiary care center in a major city rather than at a civilian hospital, but I am 100% sure our small MTFs are superior to the local civilian alternatives.

I guess we could try replacing AD physicians with contractors, but I hate to think what our small MTFs would degenerate into if they were staffed exclusively by the kind of government contractors that would be willing to come out to these locations. Its not like we haven't run into issues just with the contractors we have right now. When you don't count the contractors that are either ex-military or married to a military physician the percentage that have serious issues is astoundingly high.

If we are going to continue to station Marines and Sailors in Twentynine Palms, Guam, Lejune, and Lemore we are going to need some mechanism to provide care beyond Tricare insurance and government contractors staffing the MTFs. Maybe the correct alternative is to dramatically expand the public health service, and allow them to take over the small MTFs?

 

[Perrotfish]

The third biggest challenge to volume is the mountain of non-clinical BS I have to deal with on a daily or weekly basis - such as the complete closure of hospital clinics and non-emergent OR space for a hospital-wide pep session that the hospital commander feels is absolutely necessary. .

+1. We also seem to have an ever expanding number of partially or completely non-clinical positions that we are required to fill, despite being asked to provide the same amount of care to the same number of dependents while dealing with annual cuts to our total staff. Its at every level of the hospital. We have multiple MAs/Corpsmen per team who are tasked with massaging HEDIS numbers, or reviewing charts for Joint Commission, or tracking something for medical homeport numbers, or doing mock inspections. One of our nurses does nothing but medical homeport metrics, and another one does nothing but HEDIS numbers. The implementation of medical home turned one of our physicians into a 0.5 FTE department head . The implementation of the new CMO position turned another physician into a 0.5 FTE administrator. It is now perfectly possible to be the only full time doctor or nurse on a medical homeport team. How can they not see the problem with this?

I'm still terrified of the day when 'High reliability organization' becomes a metric. Right now it seems to be just an empty buzzword, but it seems like such a popular and persistent buzzword that I feel like they will eventually need a way to show they're achieving it. The day HRO compliance becomes measurable we will lose another doctor, several nurses, and half a dozen corpsmen to admin.

 

[HighPriest]

The author makes it seem like deferring all the dependents to the civilian network is as simple as a policy decision allowing it. That's probably true in DC and San Diego, but where I work there is no network. The majority of civilians in the community already can't get care because there is absolutely no one who wants to be a physician near my MTF, if we threw all the military dependents at the network more than half of them would just be without medical care. The quality of the care that is available is also questionable. I'm not sure I'd want to be at a military tertiary care center in a major city rather than at a civilian hospital, but I am 100% sure our small MTFs are superior to the local civilian alternatives.

I guess we could try replacing AD physicians with contractors, but I hate to think what our small MTFs would degenerate into if they were staffed exclusively by the kind of government contractors that would be willing to come out to these locations. Its not like we haven't run into issues just with the contractors we have right now. When you don't count the contractors that are either ex-military or married to a military physician the percentage of our contractors that have serious issues is astoundingly high, like more than half.

If we are going to continue to station Marines and Sailors in Twentynine Palms, Guam, Lejune, and Lemore we are going to need some mechanism to provide care beyond Tricare insurance and government contractors staffing the MTFs. Maybe the correct alternative is to dramatically expand the public health service, and allow them to take over the small MTFs?

What they suggested was turning smaller MEDDACs into clinics, not just sending everyone to the network everywhere. This is in line with the most recent recommendation to congress and it would probably be necessary in places like 29 Palms. But you also don't need to be doing knee replacements at 29 Palms. That can be farmed out to MEDCENs or to civilian centers where the complication rates are in line with the standard of care.

But my experience has generally been that the quality of care at military centers is pretty questionable as well. There are plenty of good docs, and some bad ones (just like on the civilian side), but there are a TON of really poor quality unsupervised PAs and NPs who control the gateway to all of your other care - assuming, of course, you see the same person more than once. If that's not the case in the Navy, then bravo for the Navy.

 

[HighPriest]

+1. We also seem to have an ever expanding number of partially or completely non-clinical positions that we are required to fill, despite being asked to provide the same amount of care to the same number of dependents while dealing with annual cuts to our total staff. Its at every level of the hospital. We have multiple MAs/Corpsmen per team who are tasked with massaging HEDIS numbers, or reviewing charts for Joint Commission, or tracking something for medical homeport numbers, or doing mock inspections. One of our nurses does nothing but medical homeport metrics, and another one does nothing but HEDIS numbers. The implementation of medical home turned one of our physicians into a 0.5 FTE department head . The implementation of the new CMO turned another physician into a 0.5 FTE administrator. It is now perfectly possible to be the only full time doctor or nurse on a medical homeport team. How can they not see the problem with this?

I'm still terrified of the day when 'High reliability organization' becomes a metric. Right now it seems to be just an empty buzzword, but it seems like such a popular and persistent buzzword that I feel like they will eventually need a way to show they're achieving it. The day HRO compliance becomes measurable we will lose another doctor, several nurses, and half a dozen corpsmen to admin.

Thankfully, thus far none of the HEDIS measures fall within my specialty. For that, I am grateful because that seems like a YUGE Cluster F*&^.

I had a conversation with one of my civilian friends about the nigh-unmanageable amount of non-clinical crap we're required to do. We recently had a nurse who would routinely leave work in the middle of the day for hours, lie about it, not show up or show up late in the morning, and even once asked a colleague to sell her oxycodone. When confronted about it, she said it wasn't for her to use but for her to sell because she needed the money (because, of course, that makes it....better??) In light of this felony, our department head removed her from patient care and told HR that he'd prefer to remove her from the clinic, but at the very least that she couldn't function in her current position. All he got, of course, was push back and grief from the union. So this has eaten up many, many hours of his time. My civilian friend, who manages people for a living, suggested that it might have gone easier if he just had a weekly 10-15 minute formal counseling session with each of his employees so that there was a better paper trail....except, you can't do that and also run a full clinic. This is exactly why practices have office managers - because if you're a clinician you cannot effectively do both jobs. So the Army wants him to be a good, productive surgeon and a good, productive OIC but it really isn't possible to do both jobs well.

 

[Perrotfish]

But my experience has generally been that the quality of care at military centers is pretty questionable as well. There are plenty of good docs, and some bad ones (just like on the civilian side),

I don't think you understand the ratio of good to bad doctors in my community. By some miracle we have a couple of competent OBs nearby, and occasionally we have a good doctor or midlevel drift through because their spouse is stationed here, but that's about it. We have PCMs in this area who got here by failing out of residency and coming out here to set up a shingle.

but there are a TON of really poor quality unsupervised PAs and NPs who control the gateway to all of your other care - assuming, of course, you see the same person more than once. If that's not the case in the Navy, then bravo for the Navy

We have very few unsupervised PAs and NPs at my hospital and by random chance they all also happen to be excellent ( better than many FPs I've worked with), so Ill admit the midlevel has been a non-issue for me since my PCS to this location. Also when you get out to the sticks the unsupervised midlevel thing stops being unique to the military: in my community what care exists is mostly provided y unsupervised NPs and PAs. And when I say unsupervised, I mean there's not even a physician in the same building as them and they don't have access to uptodate. At least our midlevels work within an extensive support network, with lots of reference materials, board certified physicians sharing their office, and specialists a phone call away. Supervision for midlevels, much like same day appointments and ED physicians staffing the ED, is something that doesn't happen in communities like the one I currently live in.

I am surprised, though, at how few midlevels the Navy hires, considering that they don't seem to care if they're experienced or supervised. If you're fine letting a brand new NP act as a completely unsupervised FP for medically complicated dependents, why would you still continue to have more midlevels than doctors? It seems like a weird middle ground.

 

[Perrotfish]

Thankfully, thus far none of the HEDIS measures fall within my specialty. For that, I am grateful because that seems like a YUGE Cluster F*&^.

Funny thing is that HEDIS is probably the best in breed, when it comes to Navy metrics. At least their are some positives to balance out all the negatives: we have increased our compliance with some screening tests since we started HEDIS. The medical home, as far as I can tell, is an even bigger time sink and all of its effects on clinical care are actually negative.

 

[HighPriest]

I don't think you understand the ratio of good to bad doctors in my community. By some miracle we have a couple of competent OBs nearby, and occasionally we have a good doctor or midlevel drift through because their spouse is stationed here, but that's about it. We have PCMs in this area who got here by failing out of residency and coming out here to set up a shingle.



We have very few unsupervised PAs and NPs at my hospital and by random chance they all also happen to be excellent ( better than many FPs I've worked with), so Ill admit the midlevel has been a non-issue for me since my PCS to this location. Also when you get out to the sticks the unsupervised midlevel thing stops being unique to the military: in my community what care exists is mostly provided y unsupervised NPs and PAs. And when I say unsupervised, I mean there's not even a physician in the same building as them and they don't have access to uptodate. At least our midlevels work within an extensive support network, with lots of reference materials, board certified physicians sharing their office, and specialists a phone call away. Supervision for midlevels, much like same day appointments and ED physicians staffing the ED, is something that doesn't happen in communities like the one I currently live in.

I am surprised, though, at how few midlevels the Navy hires, considering that they don't seem to care if they're experienced or supervised. If you're fine letting a brand new NP act as a completely unsupervised FP for medically complicated dependents, why would you still continue to have more midlevels than doctors? It seems like a weird middle ground.

My experience at four military hospitals hasn't been that way. In fact, it's generally been the reverse (better docs in the community). Now keep in mind that a large part (not all) of what makes me say that is that I review consults coming in from both civilian and military providers. Generally speaking when I get a consult from a civilian provider, there is some logic to how the patient was treated. For many military docs that is also true, but I get so much more nonsense from the military side - usually from PAs and NPs.

At every station to which I've been assigned, the PAs and NPs outnumber the docs by a significant margin. Neither I nor my wife can even see a doc. There just aren't enough. Which is why I pay for standard so that my wife can be seen in the community, and not mishandled in the military system. My first station was out in the sticks, and almost no one on the outside saw a PA and if they did the PA was generally supervised. I say this because when I would review their records, they would generally bump a patient to a supervising physician before referring. The PAs and NPs here are totally unsupervised, and I'm not in a small MEDDAC anymore. There might be a doc in the building, but that's irrelevant as they never discuss anything with them. At most they may look at up to date for information, but my experience on reviewing their consults is that they usually just make a guess as to how to treat a patient. In the clinics I've worked during ODE, all but one of which were in the sticks, all of the PAs have their charts reviewed by physicians. That is in a subspecialty clinic, however.

So perhaps 29 Palms is unique, or perhaps my experience is unique, but I can say that my experience holds true at at least four stations ranging from MEDCENs to 10 bed MEDDACs. 29 Palms, you have to admit, is not a typical representation. Having not been there, my understanding is that its more remote than most places, is it not?

Obviously, medical care on the outside isn't perfect. However it is a fact that studies repeatedly demonstrate that it is better than in the military system when you're not being site-specific. That's not my opinion, the research reflects it.

 

[Perrotfish]

Obviously, medical care on the outside isn't perfect. However it is a fact that studies repeatedly demonstrate that it is better than in the military system when you're not being site-specific. That's not my opinion, the research reflects it.

My understanding is that almost all studies draw from the large medcens. To the best of my knowledge, there is no data about how our small MTFs perform vs their local counterparts, just vs a national average on certain metrics

 

[HighPriest]

My understanding is that almost all studies draw from the large medcens. To the best of my knowledge, there is no data about how our small MTFs perform vs their local counterparts, just vs a national average on certain metrics

There is data looking at small military hospitals. This is part of the reason it was recommended that we turn small military hospitals into clinics rather than continue to try to provide surgical care. They do compare them to national averages rather than local numbers, because that's the available metric. However when we compared our metrics to those the local hospitals were reporting (back when I was at a small hospital), we were lagging far behind. Ultimately small hospitals do have to answer for deficiencies to some extent, be it joint commission findings or insurance companies. Their complication rates are available. While I have no doubts that there are small civilian hospitals that are out of range, from what I have seen they are not so far off as the military. Obviously different communities will produce different results.

 

[HighPriest]

Another point to consider is that we're not necessarily talking about getting rid of military providers. They're still out there, they're just working at locations where they can maintain their skills and actually improve themselves as providers. military patients could still see a military physician - just not at a military hospital. While I carry my opinions regarding PAs and NPs in the Army, I still do believe that most military docs are fairly good. The system in which they work strangles them.

We're also not talking about sending the guy who needs a knee replacement from 29 Palms (or wherever) where the complication rates are high to a local hospital where complication rates are high. The whole point is to send these patients to places where the surgery is performed frequently enough to keep the complication rates to a minimum - whether they have a military doc caring for them or not.

The issue is this: we're not doing a good job. If we can do better, so be it, but for a long time now we've failed the test of time. So either we can continue providing sub-optimal care or we can change the system.

 

[pgg]

A few years ago, one of the most compelling reasons for keeping OB in house at Lemoore was the inability of the locals to pick up the load.

Nearest biggish city is an hour away.

Locally, the civilian hospital that did OB was something like a 50+ year old building that wasn't up to earthquake code. Only a handful of OBs, and two of them were in their 70s. This is already an underserved area.

About a year or two ago they opened a new OB wing to the Hanford hospital so the access problem may be gone now. Assuming they were able to hire some OBs.

But just "send them out" isn't always going to be an option, so long as we have military bases in deserts and swamps and BFE.

 

[HighPriest]

It is an option for most surgical procedures, which again, is the point of the article. While you may not be able to send out every C-section you can send out non-emergent surgery even in remote areas. You can even send out emergent surgery to a large extent, as I have no doubt they did with any major trauma that came through at any of those centers.

Granted, our OB statistics are atrocious as well. We did have that same issue at my last duty station - the civilian institutions couldn't immediately support the volume. That is why the proposal was to continue to provide primary care coverage as well as a "birthing center."

The answer is to send them out as much as possible, and to let our providers work at civilian institutions as much as possible. If the local area can't support it due to facility issues, then that is an exceptional issue that will affect a relatively small percentage of the medical facilities in which case we may be forced to provide sub-optimal care like we're currently doing. The problem is that the military isn't good at running hospitals. It needs to be fixed.

All of these issues can be addressed on a case-by-case basis. I know the military has a big problem with the idea that you can actually make decisions on an as-needed basis as opposed to blanket judgments, but that is the answer. The alternative is to continue to provide substandard care everywhere because that is the only option at some places (the throwing out the baby with the bathwater option).

So I suppose my response would be "send out as much as possible, to military docs working in civilian centers whenever possible." Plus, as was the case at my last station, the civilian centers are surprisingly willing to expand their facilities to accommodate an influx of military providers who are bringing a regular stream of facility fees with them.

 

[dr zaius]

We may have some of the same Facebook friends, because I read this article late last week. It's hard to argue, I feel, with most of the points. The article concentrates on surgical complications and the need for surgeons, but I think that's primarily because most of the data we have is in regards to surgical complication rates in the military (as opposed to what goes on in the primary care setting). They do mention that most of the medical care that occurs during deployment has nothing to do with surgery, however. A friend of mine who is a general surgeon made the comment that most of the combat related trauma that occurs during deployment isn't akin to civilian trauma, and that stationing surgeons in trauma centers wouldn't necessarily help to prepare them for deployment. He's been deployed more times than I can count, so I can't be the one to disagree. Undoubtedly you see fewer IED-related injuries at civilian trauma centers, but you would certainly see gunshot wounds and MVAs. That being said, it isn't as if the choice is "dealing with combat-related trauma" versus "dealing with civilian trauma." The choice is "next to no trauma at a MEDCEN or no trauma at all ad a MEDDAC" versus "copious amounts of civilian trauma to include gunshot wounds." That seems like a no brainer to me.

Ultimately, my experience has been and unless something changes dramatically will continue to be that the problem with military medicine isn't the surgeons it's the military. Our hospitals are run like crap. The biggest bottleneck I have, by far, is the simply inability to book more cases. The second biggest challenge to volume that I have is the ability of our inpatient wards to handle it (we have plenty of beds and nurses, but we don't have plenty of people who want to work). The third biggest challenge to volume is the mountain of non-clinical BS I have to deal with on a daily or weekly basis - such as the complete closure of hospital clinics and non-emergent OR space for a hospital-wide pep session that the hospital commander feels is absolutely necessary. The patient demographic comes in a very distant 4th, or even 5th.

I agree with this post 100%. Here the trauma/acute care surgery service sees cold trauma transferred from the outside/downrange or the occasional person who got in an MVA and refused an ambulance ride, but turned up a day later when their pain didn't go away. It's primarily a handful of appys, choles, and a ton of BS wound care in the geriatric population. It's not busy at all, and kind of a joke.

Booking additional cases is a nightmare. In medical school and on my outside rotations if a case needed to be booked...it just happened. Not the case here. You have to beg and plead even if it's a 30 minute case.

Inpatient beds is another problem here. It has multiple factors. One is that patient's dictate when they go home. There's no medical reason for a patient to stay, but they don't feel comfortable going home. They're also a retired BG (or not even a flag rank, to be honest)? Well, they just got an extra night. Why should they care, they aren't paying for it. That bed is taken up for another night for No. Medical. Reason. If you discharge them they write the commander or complain about it and you end up getting in trouble, despite the fact that they discharged home without any sort of complication or bounce back. The second is that no one wants to work. I have frequently called the nursing supervisor to admit a patient (another thing that I never have to do at outside facilities) to be told that there are no beds on the surgical floor. Many times I have caught the floor not moving patients into the d/c or hold section in essentris after they have left for the purposes of preventing anyone else from taking that room until after shift change. Mind blowing.

What really bugs me about this is that there is a lot of talent here. The surgeons are smart and hardworking, but reading about surgery rather than performing it only takes you so far. These are young, smart, surgeons with good fellowship training experiencing massive skill atrophy. If you can count the number of Whipples per year on one hand you probably shouldn't perform a Whipple. For us in urology we actually have a decent case volume, but I fear what will happen when I graduate and get sent out to a likely low volume area.

 

[Perrotfish]

So I suppose my response would be "send out as much as possible, to military docs working in civilian centers whenever possible."

The way for us to provide the best care to everyone would be to have two parallel systems: active duty healthcare professional alternating between civilian instructions and active duty roles, and some kind of non-deployable purple service manning the hospitals where we can't defer everyone to network. We could have the Corpsmen spending their 'shore' duty working as EMTs in EDs and on EMS, and have the nurses rotating through high volume ICUs while our docs man high volume EDs in major trauma centers.

But that would, unfortunately, mean paying for everything twice. The active duty doctors would provide 0% of the dependent coverage, they would be a pure cost. It would also mean paying a huge premium to the active duty side of this equation, because you would be trying to pay ED physicians enough to deploy, when they're charging $550/hour just to do locums somewhere undesirable. And the military is absolutely not going to do that. I'm not even sure they could. So we are stuck with the system we have.

 

[Gastrapathy]

All reservist system. Small cadre of primary care, PT/OT, and psychiatrists on AD full time to manage duty dispo stuff. Encourage the marketplace meet the need around CONUS bases by not having TRICARE be worse than Medicaid as a payer. Cycle reservist MDs through with a 8 year reserve commitment instead of the 4 year AD commitment. Get rid of all the no load civis in the basements and at the headquarters. Disestablish the nurse corps. Basically, fire everyone except the corpsmen.

 

[Perrotfish]

All reservist system. Small cadre of primary care, PT/OT, and psychiatrists on AD full time to manage duty dispo stuff. Encourage the marketplace meet the need around CONUS bases by not having TRICARE be worse than Medicaid as a payer. Cycle reservist MDs through with a 8 year reserve commitment instead of the 4 year AD commitment. Get rid of all the no load civis in the basements and at the headquarters. Disestablish the nurse corps. Basically, fire everyone except the corpsmen.

Why in the world would anyone sign up for an 8 year contract for a reserve that is responsible for filling all of our active duty billets? That sounds like the worst of all worlds for physicians.

 

[Gastrapathy]

There would be far fewer AD billets to cycle through and they could pay more without all the waste.

 

[HighPriest]

The way for us to provide the best care to everyone would be to have two parallel systems: active duty healthcare professional alternating between civilian instructions and active duty roles, and some kind of non-deployable purple service manning the hospitals where we can't defer everyone to network. We could have the Corpsmen spending their 'shore' duty working as EMTs in EDs and on EMS, and have the nurses rotating through high volume ICUs while our docs man high volume EDs in major trauma centers.

But that would, unfortunately, mean paying for everything twice. The active duty doctors would provide 0% of the dependent coverage, they would be a pure cost. It would also mean paying a huge premium to the active duty side of this equation, because you would be trying to pay ED physicians enough to deploy, when they're charging $550/hour just to do locums somewhere undesirable. And the military is absolutely not going to do that. I'm not even sure they could. So we are stuck with the system we have.

I would argue that the system we do have is woefully inefficient, overpriced, and nothing more than a sinkhole into which we throw money. The ideal system is to minimize the DOD's presence in healthcare management as much as possible. And for a system that lost 6.5 trillion dollars, I'm not extremely confident in their ability to keep costs to a minimum. The idea that we're "stuck" with the system we have is exactly why we're stuck with the $#!TTY system we have. And the idea that accepting a very sub-par medical system because change is scary is exactly why I have no plans to stay.

There's no reason that an active duty physician working at a far more efficient civilian center couldn't see and treat AD or dependents or both without charging them a physician's fee. They would be charged facility fees, which I would argue in the long run would cost the government less than the system they currently run. Additionally, you would still have active duty ER physicians. They would just be working in real hospitals. They could deploy from real hospitals at no cost to the hospital because they're making exactly what they make in the military now, paid by the military. The only difference is that they would be expected to work more and they'd have more experience. Maybe I'm not understanding your scenario?

 

[HighPriest]

Why in the world would anyone sign up for an 8 year contract for a reserve that is responsible for filling all of our active duty billets? That sounds like the worst of all worlds for physicians.

Given the choice between what I'm doing now and that, I would take the reserve option.

 

[Fmres16]

Im enjoying this thread and wish we had this clear reasoning in leadership.

I'm in residency as an MTF struggling to prove it's value, pulling beneficiaries getting specialty care in the civ network for years back to our MTF (only to subsequently lose that specialty to 6 month deployments and PCS changes), trying to get us to hold referrals to unstaffed specialty clinics for 2 month gaps between separating or PCSing specialists so we dont lose them to the network (multiple specialties this past summer), and filling our inpatient services with the overflow from local inefficient VA facility and doubling our residents call burden and forcing already overworked faculty to take in-house overnight call. All for the sake of keeping this sinking ship afloat a while longer while we dump millions into renovations and still come up short on the volume we need to keep open.

All this to keep a small hospital open in a metro area with great civ care minutes away.

We're not benefitting our patients with this model, we're not benefiting tax payers.

We have great models established to train residents in civilian programs and maintain an influence on their training so we can't argue military MTFs are required to train our future docs. On that note though I'm with the poster above, we only need AD primary care, occ med, operational med and psych. Within the wartime-essential specialties we need a strong reserve force.

 

[Perrotfish]

There's no reason that an active duty physician working at a far more efficient civilian center couldn't see and treat AD or dependents or both without charging them a physician's fee. They would be charged facility fees, which I would argue in the long run would cost the government less than the system they currently run. Additionally, you would still have active duty ER physicians. They would just be working in real hospitals. They could deploy from real hospitals at no cost to the hospital because they're making exactly what they make in the military now, paid by the military. The only difference is that they would be expected to work more and they'd have more experience. Maybe I'm not understanding your scenario?

There are so many new pieces to this I can't even imagine how it would work. You want private practice groups to hire physicians that have a very high chance of disappearing all at once for no reason? And also accept that a large subset of that physician's patients will be AD military and will generate non income for the group? Also how do you want the military to decide which ERs count as 'real'. Level one trauma centers only? And we make sure military patients get to those non-military hospitals, when our guys are on shift, how exactly? And to increase physician satisfaction we will be paying them military salaries to do civilian work in civilian centers where everyone is just paid four times what they are?

Its not a bad starting point for an intellectual exercise, but what your proposing is basically untested in military medical history. Things that are untested have a tendency to ultimately fail when tested.

The idea that we're "stuck" with the system we have is exactly why we're stuck with the $#!TTY system we have. And the idea that accepting a very sub-par medical system because change is scary is exactly why I have no plans to stay.

I don't disagree that something needs to change, but change IS scary. If you don't know why you haven't been paying attention the last several times the military has changed things. Even the best engineered changes usually take years of troubleshooting to get working, and often when you try to introduce something radially new you end up with something that's such a cluster that it can't even be 'fixed' to the level of your previous problem (see: littoral combat ship, F35, and AHLTA for relevant examples).

The best change is the one that involves the least change necessary to fix the problem. I think, for the military, though would mean one of two options. Either

1) Allow the military hospitals to accept private insurance, and to become revenue centers

Or

2) Get rid of Tricare Standard, and drag everyone back into the military HMO we had before Tricare.

Either option would allow an adequate number of patients without tearing down the entire structure of the Medical Corps. FWIW I would vote for option 1, which would provide an adequate caseload not just in the tertiary care centers, but also in rural communities like mine, and would also be a huge service to those same communities (who could really use our infrastructure).

 

[Gastrapathy]

Yikes. You think you'd be a revenue center? Why in the world should the military be in the healthcare business? The military is in the killing business. You don't really think you could compete with Kaiser do you? Civilian health systems are better equipped to handle a reservist model than ever before because so many systems have employed physicians. People who take this model of HPSP would gravitate to employed jobs for that reason (they mostly are choosing them anyway). Medicine is not your organization's mission. Getting out of the way of organizations who actually want to do medicine is the inevitable future. It will either happen slowly as the milmed system fails or with a proactive change.

Its not untested. Its the British system. It isn't perfect but its better. They rotate on 3 month cycles in theater. Ask some of your colleagues who've deployed about their experience with the Brits.

 

[HighPriest]

You want private practice groups to hire physicians that have a very high chance of disappearing all at once for no reason?

Nope. I want hospitals, or I suppose a private practice if they wanted, to provide a place for a physician who is paid by the military. They get to bill for any non-tricare patient he sees, and they keep the money. They would also have any overhead he didn't use paid for by the DoD, which would almost certainly be cheaper than the crappy system we currently have. That physician may deploy, which might hurt the time-to-service for that hospital. But since they're not out any money, it's not that big of a deal. The AF already does this, and it's working out great.


The military doesn't need to decide what constitutes a level 1 trauma center. This is something decided outside of their hands. You think that is a military designator? Are you asking how we decide where to send people? If they need trauma, you pick the nearest, largest trauma center. If they do not, it's a moot point.

 

[HighPriest]

And we make sure military patients get to those non-military hospitals, when our guys are on shift, how exactly

I'm not sure that's any different than the way it works currently. They would just have to drive, in most cases, across town for care. Again, most posts have a nearby civilian hospital.

 

[HighPriest]

And to increase physician satisfaction we will be paying them military salaries to do civilian work in civilian centers where everyone is just paid four times what they are?

Yes. Because believe it or not for many of us the issue is skill rot and the inefficiency of our system, rather than how much we have to work. I already see close to what my civilian counterparts see, I just do it in a highly ineffective system with exorbitant amounts of waste where no one else cares about our product. I'd be thrilled to go somewhere where I could do real cases in a real hospital. But for those of you who like doingvless work, there's no reason you couldn't do that in a civilian center. They're not paying you. So long as their overhead is covered, they shouldn't care.

 

[HighPriest]

If you don't know why you haven't been paying attention the last several times the military has changed things.

This is -because- we let the military make these decisions, and they suck at hospital management. This is like saying "if you don't think that 3 year old is going to burn down the house, you haven't been watching the last several times we gave him a lighter." No kidding. Don't give him a lighter in the first place.

-No one-No one would come to a military hospital for care if they had private insurance. Not in a million years. Why in the hell would you pay for a 6 week wait to see a mediocre provider in a place where the employees want nothing more than for you to leave them alone?

"Honey, I know we could go to Methodist, but why not try going to the MTF? Everyone has an attitude, the appointment won't be for two months, and if I need a referral maybe 3-4 months more, and their complication rates are through the roof. Plus I love that they constantly lose my paperworkand the billing is screwed up 80% of the time."

That's why option 1 is out.

The problem with option 2 is that, again, just seeing more patients isnt the answer. The system cannot safely support the services we need. The nurses don't want to work, the support staff never sees anything as their problem. And bringing in a bunch more young healthy patients doesn't bring the same pathology. Seeing 50 more people a week for vasectomies isn't solving the problems our urologists have.

That's the problem with option 2.

 

[Perrotfish]

Its not untested. Its the British system. It isn't perfect but its better. They rotate on 3 month cycles in theater. Ask some of your colleagues who've deployed about their experience with the Brits.

The British government owns their national healthcare system. They don't need to worry about negotiating cost sharing contracts with a thousand groups because there are no groups. They don't need to worry about employers discriminating against deployable physicians because they are the employer. They don't need to worry about double paying for care for their dependents because their military doesn't have a budget for insuring dependents, they're just insured nationally like everyone else. They also kind of stopped having an empire, which means they don't need to worry about manufacturing healthcare centers for large military in places no one else lives (at least not nearly to the extent that we do), or trying to maintain anything like the number of deployable medical professionals that we are for the wars that we keep fighting.

Trying to import our military healthcare system into our privatized clusterf--k of a civilian healthcare system would be incredibly complicated. Maybe not impossible, but it would involve no less than a dozen new ways for civilian and military healthcare to interact and I'm not at aall convinced it would be a better system that we have now. On the other hand we had a more or less functional military healthcare system in the not too distant past. It wouldn't be real hard to go back. Fire most of the midlevels, get rid of Tricare, and make everyone come back to the military hospitals for all but the most subspecialized care. Then we're back to a system that we know actually works.

 

[HighPriest]

It wouldn't be real hard to go back. Fire most of the midlevels, get rid of Tricare, and make everyone come back to the military hospitals for all but the most subspecialized care. Then we're back to a system that we know actually works.

If only the flux capacitor were a real thing. That is never going to happen. As the civilian sector becomes first more employed and ultimately a single payer system, military medicine as we know it will go away because it's needlessly expensive and poorly run. The things I'm suggesting aren't things I just made up. These are all more or less paraphrased from the recommendations made to congress when they ordered the system audited (the difference being they didn't want t touch large MTFs). I don't think it would be as complicated as you think. Negotiating with the federal workers union isn't a cakewalk either, and we get less out of it. I think that in most cases, some overhead pay, the promise of free labor and increased facility fees, and a couple tax cuts would be more than enough to introduce a standard contract for most institutions. We already do it, just on a smaller scale. We have four ERSA agreements as it is which dictate what hospitals get when we work at them. I already operate once per week at a hospital that bills tricare for the patients I see. If I saw patients there, I'd already be a part of the system I'm describing. It's just not that different from what we're already doing. Larger, yes. Far more complicated, I don't think so. Certainly less complicated than time travel.

And would it be better? My opinion is it couldn't be much worse. Also, the data suggests it would be better. But you know, that's just data.

Look, who knows what the best answer really is. But in my opinion, the DoD is simply not interested in running medical facilities, it shows, and it's really bad for patients and I'm comparing it to the civilian sector, not some ideal. That's just based on my experience. Except the part where we do a worse job for patients. That's been repeatedly demonstrated.

 

[narcusprince]

I have been wanting to respond to this post for awhile.
From my perspective Perrot had two good ideas allow military medicine to take private insurance and have to compete for business with other similar sized hospitals. Or put active duty physicians in civilian private practice jobs.
I think both solutions require a better assessment of risk/reward for the physician. In my field Anesthesiology I would not want to assume the same risk(patient population) and get compensated less then the civilian partners around me. In the practice I see now my patients are for the most part ASA 1-3, in a civilian practice you may see ASA 3-5. I am comfortable taking care of really sick patients, but I am happiest when the reward=risk when I am moonlighting and being reimbursed. The answer is not just to take in riskier sicker patients. In my field we have a ton of anesthesiologist who are just waiting for the day their EOS comes around and really have little to no interest in the Navy I feel these gentleman and women would do better if the rewared=risk.