Navy Small Hospital Study

[BigNavyPedsGuy]

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I've heard the Navy Small Hospital Study results are working their way back down from BUMED. Anybody have any inside info they'd be willing to share?

 

[NavyFP]

I've heard the Navy Small Hospital Study results are working their way back down from BUMED. Anybody have any inside info they'd be willing to share?

Have not heard of it. What is it?

 

[pgg]

Have not heard of it. What is it?

Ditto, and I'm at a small hospital, so I'm curious.

 

[BigNavyPedsGuy]

Have not heard of it. What is it?

Seriously? They are looking at each small hospital in the Navy. Rumor is they're shutting down some FP programs (Bremerton, P-cola) and they are closing the inpatient wards and ERs of a lot of smaller places (possibly, Lemoore, Oak Harbor, 29 Palms. etc).

It's been routed up to the under secretary for health affairs and is trickling its way back down.

Rumor is that a lot of small hospitals are going to adopt the Air Force's super-clinic model

Has nobody else really heard of this? It's been common knowledge at my command and with my specialty leader for a while.

 

[bricktamland]

Seriously? They are looking at each small hospital in the Navy. Rumor is they're shutting down some FP programs (Bremerton, P-cola) and they are closing the inpatient wards and ERs of a lot of smaller places (possibly, Lemoore, Oak Harbor, 29 Palms. etc).

It's been routed up to the under secretary for health affairs and is trickling its way back down.

Rumor is that a lot of small hospitals are going to adopt the Air Force's super-clinic model

Has nobody else really heard of this? It's been common knowledge at my command and with my specialty leader for a while.

This is the first time I've heard about this too. But now my interest is piqued. I'm located at a small Navy Hospital as well, and am curious if some of these changes may indeed come to fruition.

 

[BigNavyPedsGuy]

I'm surprised nobody has heard of this. Supposedly they are broad sweeping changes that will be implemented fairly quickly when they come out.

I do not consider my self to be "in the know" at all

 

[bricktamland]

broad sweeping changes that will be implemented fairly quickly.

Are you sure you're in the same Navy. . . .the United States Navy? I have a hard time believing any broad sweeping changes will be implemented quickly. The smallest, most minor changes take a least 2 years to get approved. . . . and then 3 years to get implemented.

Seriously, though. If you hear anything, please post.

 

[pgg]

At my little hospital, they've been talking for years about getting rid of OB (only 30ish deliveries/month), closing the rarely-used inpatient ward, etc. The little 24/7 urgent care "ER" has been a target, too. I didn't realize there was yet another study, survey, analysis, whatever of this place percolating through the Navy.

I don't think anything will change, at least not for a couple years. The only civilian hospital within ~40 minutes that handles OB is in a building that ought to be condemned, and surely will be when they build their new facility in a few years. I've moonlighted there and I don't even like working in that place - sure wouldn't want to deliver a baby there. And if my Navy hospital keeps doing OB, well, they've already sunk the cost of anesthesia and OR support, so we might as well keep surgicentering along as usual.

Will not hold my breath for significant changes, but I'll read the report with interest.

 

[narcusprince]

I have heard not-officially that all except one hospital in the Navy is profitable. PGG you know the place well. I am sure when the budget bean counters have looked up and down some of the larger and smaller medcen will be radically restructured into more of the "slaveship" model. Its cheaper to send people to OSH via tri-care then it is to treat them at a large medcen. And once oct 1 rolls around OSH may be competing for business from Tri-care. The only purpose of large medcen is to train staff for deployment which at some point the cost of this may cause those doors to close.

 

[BigNavyPedsGuy]

Heard more about it today. We'll see if it's all bluster for nothing or not.....

 

[Bernie3144]

It's legit.

 

[IlDestriero]

It's legit.

Like phasing out GMOs?
Like combining all .mil medicine?
Like farming out all the sick old gomers with complex diseases to civilian hospitals? Oh wait, they already did that one...🙁

 

[rotatores]

I've heard the Navy Small Hospital Study results are working their way back down from BUMED. Anybody have any inside info they'd be willing to share?

It's been in the making for a while. I believe I first heard of this when I was at a small FP hospital about 3-4 years ago. FPs are too valuable to the Navy to shut down too many of the training programs. Like anything in the Navy, I'll believe it when I see it.

I'm just curious what would happen to all the non-primary care specialist who are currently stationed at these institutions. The MTFs are already over-staffed in a lot of specialties.

 

[d2305]

I don't see how they could shut down the ER at 29 stumps. It's out in BFE and there's dangerous training going on.

 

[IlDestriero]

I don't see how they could shut down the ER at 29 stumps. It's out in BFE and there's dangerous training going on.

Yes. The remote hospitals are quite remote and whatever nearby remote shady "hospitals" exist are guaranteed to be staffed by the unemployable and be lacking in pretty much everything.
It looks good on paper, but the reality ain't pretty. I wouldn't want to dump the care of our best on their worst.

 

[bricktamland]

Yes. The remote hospitals are quite remote and whatever nearby remote shady "hospitals" exist are guaranteed to be staffed by the unemployable and be lacking in pretty much everything.
It looks good on paper, but the reality ain't pretty. I wouldn't want to dump the care of our best on their worst.

So true. I'm stationed at a fairly remote military hospital. The physicians at the local civilian hospital are pretty sketchy. I wouldn't go so far as to say incompetent, but definitely sub par. On the other hand, the "ER" at my hospital (really just an acute care clinic) is staffed by civilian providers. I would say 75% of these jokers are as bad or worse than the ones at the local hospitals. Our civilian ObGyn isn't the greatest either. I shudder at the thought of all medical care in these remote places being turned over to shady civilian hospitals.

 

[BigNavyPedsGuy]

Yes. The remote hospitals are quite remote and whatever nearby remote shady "hospitals" exist are guaranteed to be staffed by the unemployable and be lacking in pretty much everything.
It looks good on paper, but the reality ain't pretty. I wouldn't want to dump the care of our best on their worst.

I agree to a point, but as hospitals become better and better, and specialization increases, small rural hospitals just can't keep up. This goes for military hospitals as well as civilian. That's why so many rural hospitals are getting bought up by larger ones. They do this for financial reasons. The money it takes to keep a tiny rural place open for rare occurrences is expensive (think about the expense it takes to keep an inpatient unit at JC standards for 3 admissions/month). That goes for military or civilian.

In this age of cutting costs to things that are actually important, it makes sense to restructure and trim some of that waste

 

[narcusprince]

This is where telemedicine and E ICU comes in to play. I think the model of large centers exporting healthcare is the next wave. Military GME will be cut and the large mtfs will slowly export services to a point where mtfs will be minimally staffed. And the reserve pool of deployable physicians will come from reservists. Far cheaper then maintaining the current model.

 

[Bernie3144]

We were told that 2 FM Progs are to close by 2016. Mine is one. Perfect timing for selection board season. Good luck!

 

[backrow]

The results I heard were that Pensacola and Bremerton would be losing their residency programs in the next few years. In my opinion this should have been published to all applicants a lot sooner, as it will directly effect them.

Poor communication about a possible life changing event in my opinion.

 

[orbitsurgMD]

Do they understand that the "reserve pool" has limited depth? Private practice docs cannot tolerate active duty callups; it can bankrupt a small practice and it really annoys larger ones.

 

[Bernie3144]

Agreed. Where these slots go will be interesting. There is supposed to be no loss in total FM training billets. We were told that some would be dispersed to the remaining programs. What about the others? Army and/or Air Force FM programs? Civilian?

 

[BigNavyPedsGuy]

Got confirmed info this week, but not at liberty for broader release. Safe to say that every CONUS hospital except Balboa and Portsmouth will have changes coming - many of them very big changes.

 

[IlDestriero]

Tease.

 

[Kingfisher]

Agreed. Where these slots go will be interesting. There is supposed to be no loss in total FM training billets. We were told that some would be dispersed to the remaining programs. What about the others? Army and/or Air Force FM programs? Civilian?

My guess will be that the remaining programs will be maxed out and the rest will be deferred. There is no way they can make the remaining programs take like 4 or 5 extra residents when they are already at capacity. The Navy also can't do without a good compliment of FPs coming out each year. Unless the number of GMO slots start increasing again. 😕

 

[Perrotfish]

Have they ever considered opening up FM residencies at OCONUS locations like Guam and Okinawa? It seems kind of strange to me that they maintain full service hospitals to support residencies in locations where we're competing with viable civilian alternatives, but then we don't set up residencies in locations where we need full service hospitals anyway because there are no viable civilian alternatives.

 

[pgg]

Got confirmed info this week, but not at liberty for broader release. Safe to say that every CONUS hospital except Balboa and Portsmouth will have changes coming - many of them very big changes.

Do you have a date for release?

I heard yesterday that Lemoore, Cherry Point, and Oak Harbor were square in the cross hairs. But no further info was forthcoming.

 

[BigNavyPedsGuy]

Do you have a date for release?

I heard yesterday that Lemoore, Cherry Point, and Oak Harbor were square in the cross hairs. But no further info was forthcoming.

Within a couple of weeks. You heard right. PM if you'd like.

 

[155HE]

I can't speak to Guam, but I can say that the volume is far too low in Okinawa to have an accredidated residency program. The inpatient census had 1, maybe 2 patients at any give time, if that. Many inpatients were etoh withdrawal. Not enough retirees there for a geriatric pt population.

 

[ninjagaiden9876]

Got confirmed info this week, but not at liberty for broader release. Safe to say that every CONUS hospital except Balboa and Portsmouth will have changes coming - many of them very big changes.

What type of changes? Good or bad?

 

[BigNavyPedsGuy]

What type of changes? Good or bad?

Mostly a decrease in services across the board. Good from a cost stance. Good for people that feel like their small hospital struggles to stay current/competent.

Bad for people that don't like outsourcing services to the civilian sector. Bad for people trying to maintain a broad depth if experience while serving their Navy time

Good vs bad depends on your situation.

 

[grotto]

Got confirmed info this week, but not at liberty for broader release. Safe to say that every CONUS hospital except Balboa and Portsmouth will have changes coming - many of them very big changes.

I am assuming Walter Reed is included in the hospitals that are not going to see big changes or am I wrong?

 

[BigNavyPedsGuy]

I am assuming Walter Reed is included in the hospitals that are not going to see big changes or am I wrong?

Walter Reed wasn't even on the list. BUMED takes care of themselves.

 

[grotto]

I think the issues with small hospitals and services needed and not needed for the military population again points to a logical end point for the military - no one service wants to spend the money to have a "world class" medical system. At the same time, the services don't want to lose control of assets. There seem to be a few options, all with pluses and minuses:

a)combine all the services into one joint medical corps and combine all hospitals under the aegis of the MHS. Why is there a Navy hospital with an ICU in Bremerton anyway? A large Army MEDCEN with ICU (with a family medicine program mind you) sits down the road at Ft Lewis. The Navy could make due with zero inpatient capability, a fam med and women's health clinic, and a robust ambulance service to get people to Madigan. This is probably a very good option and one that many have advocated in the past.

b) do the above and combine with the VA as a Federal Health Service offering hugely expanded coverage area for troops - with this solution you could close NH Pensacola altogether and provide care at an expanded VA on the gulf coast (they are right next door anyway). That joke of a "USAF medical center" at Wright Patterson could finally be put out of its misery and patients could go to the Dayton VA with military coverage. AD docs and VA docs could work together at these hospitals. Prob the most expensive but best option.

c) Get rid of the military health system all together and pay military doctors to train and work at civilian hospitals. Military gets civilian insurance. Branch clinics at bases to do sick call staffed by whoever - NP's, PA's to do physicals and sick call. Buy space at large civilian centers to provide beds in case of large scale conflict. Invest in local medical capability at remote locales (and base military doctors there). This is prob the cheapest option (for now).

 

[idq1i]

I think the issues with small hospitals and services needed and not needed for the military population again points to a logical end point for the military - no one service wants to spend the money to have a "world class" medical system. At the same time, the services don't want to lose control of assets. There seem to be a few options, all with pluses and minuses:

a)combine all the services into one joint medical corps and combine all hospitals under the aegis of the MHS. Why is there a Navy hospital with an ICU in Bremerton anyway? A large Army MEDCEN with ICU (with a family medicine program mind you) sits down the road at Ft Lewis. The Navy could make due with zero inpatient capability, a fam med and women's health clinic, and a robust ambulance service to get people to Madigan. This is probably a very good option and one that many have advocated in the past.

b) do the above and combine with the VA as a Federal Health Service offering hugely expanded coverage area for troops - with this solution you could close NH Pensacola altogether and provide care at an expanded VA on the gulf coast (they are right next door anyway). That joke of a "USAF medical center" at Wright Patterson could finally be put out of its misery and patients could go to the Dayton VA with military coverage. AD docs and VA docs could work together at these hospitals. Prob the most expensive but best option.

c) Get rid of the military health system all together and pay military doctors to train and work at civilian hospitals. Military gets civilian insurance. Branch clinics at bases to do sick call staffed by whoever - NP's, PA's to do physicals and sick call. Buy space at large civilian centers to provide beds in case of large scale conflict. Invest in local medical capability at remote locales (and base military doctors there). This is prob the cheapest option (for now).

Small hospitals continue to exist not to treat patients, but to allow marginally competent 0-5, 6s to play commander, polish up OERs and prepare them for for senior command, where they will continue to erode and destroy the MC from within. Some will close, but I seriously doubt many are going away. They are talking about the same small hospital thing on the army side.

 

[pgg]

We're having a big middle-school style assembly in the base theater tomorrow to get the Word and the Plan. It's deemed important enough that we're arranging the surgical schedule around it to maximize attendance, which implies that large changes are coming to at least this Small Navy Hospital.

 

[Perrotfish]

I think the issues with small hospitals and services needed and not needed for the military population again points to a logical end point for the military - no one service wants to spend the money to have a "world class" medical system. At the same time, the services don't want to lose control of assets. There seem to be a few options, all with pluses and minuses:

a)combine all the services into one joint medical corps and combine all hospitals under the aegis of the MHS. Why is there a Navy hospital with an ICU in Bremerton anyway? A large Army MEDCEN with ICU (with a family medicine program mind you) sits down the road at Ft Lewis. The Navy could make due with zero inpatient capability, a fam med and women's health clinic, and a robust ambulance service to get people to Madigan. This is probably a very good option and one that many have advocated in the past.

b) do the above and combine with the VA as a Federal Health Service offering hugely expanded coverage area for troops - with this solution you could close NH Pensacola altogether and provide care at an expanded VA on the gulf coast (they are right next door anyway). That joke of a "USAF medical center" at Wright Patterson could finally be put out of its misery and patients could go to the Dayton VA with military coverage. AD docs and VA docs could work together at these hospitals. Prob the most expensive but best option.

c) Get rid of the military health system all together and pay military doctors to train and work at civilian hospitals. Military gets civilian insurance. Branch clinics at bases to do sick call staffed by whoever - NP's, PA's to do physicals and sick call. Buy space at large civilian centers to provide beds in case of large scale conflict. Invest in local medical capability at remote locales (and base military doctors there). This is prob the cheapest option (for now).

With options b and c, how do you control disability? A big part of military healthcare is figuring out who needs special treatment: EFMP, recalling spouses from warzones, limited duty, wounded warrior, and early separation. How can you outsource that?

Also I feel like c is a very physician centered option. Where do you train the corpsmen? The wards train more than just physicians. Of course we can train elsewhere, maybe even nurses can train in the civilian world, but how do you train an 18 y/o who has no equivalent qualification in the civilian world?

 

[pgg]

Also I feel like c is a very physician centered option. Where do you train the corpsmen? The wards train more than just physicians. Of course we can train elsewhere, maybe even nurses can train in the civilian world, but how do you train an 18 y/o who has no equivalent qualification in the civilian world?

I'm not sure this would really be a problem.

As a former FMF GMO, who deployed twice with 40+ FMF Corpsmen that were augmented by 15+ IA Corpsmen plucked from hospitals, I can say without reservation that the junior Corpsmen coming from hospitals were on the edge of 'field competence' upon arrival. We kept most of them in the BAS and out of the field, because they were essentially UNtrained.

Hospitals really don't train Corpsmen. Most are parked at a reception desk answering phones, or checking vitals, or giving immunizations, or acting as assistants to ward nurses.

Corpsmen on ships and with FMF units get field, trauma, CASEVAC, and other relevant training. And responsibility.

The Corpsmen with specific skill sets (surgical techs, radiology techs, etc) do of course have equivalent jobs in the civilian world.

 

[grotto]

With options b and c, how do you control disability? A big part of military healthcare is figuring out who needs special treatment: EFMP, recalling spouses from warzones, limited duty, wounded warrior, and early separation. How can you outsource that?

Also I feel like c is a very physician centered option. Where do you train the corpsmen? The wards train more than just physicians. Of course we can train elsewhere, maybe even nurses can train in the civilian world, but how do you train an 18 y/o who has no equivalent qualification in the civilian world?

That is a good point, and one that I totally overlooked. I don't think it is out of the question to train corpsman at VA's although the unions would have a conniption fit because VA has some ridiculous rules for what its nurses and techs can provide (i.e. VA nurses will not draw blood or give transfusions). I think that milmed was smart to base all enlisted medical training down at BAMC and that is a model they should continue.

My medical school which is well known in military circles allowed me the "opportunity" to travel a bit as well as work a little on the civilian side and at the VA for rotations and see how things are done. The VA, while it obviously has its issues, provides pretty good care for a very difficult patient population. However, access to specialty care is not great. There are obviously major differences based on the particular VA - I only have direct experience at the DCVA which isn't bad, but I've heard bad things elsewhere (the Hampton VA is a well known cesspool). The military, at least at the medical centers and small hospitals I have seen provides very good care with easy access to specialty care for a relatively easy patient population with less problems.

There doesn't seem to be a lot of motivation to combine the services medical establishments right now, but I think it might be inevitable. Walter Reed "seems" to be recovering from the initial shock of joint operations. When I was last on wards there a few months the IM and Heme/onc services were actually full and on divert, and the ICU's have more patients from a year ago. I also admitted people by VA sharing agreement, which was a first. We'll see I guess, especially with transition out of combat operations.

 

[bobbyseal]

b) do the above and combine with the VA as a Federal Health Service offering hugely expanded coverage area for troops - with this solution you could close NH Pensacola altogether and provide care at an expanded VA on the gulf coast (they are right next door anyway). That joke of a "USAF medical center" at Wright Patterson could finally be put out of its misery and patients could go to the Dayton VA with military coverage. AD docs and VA docs could work together at these hospitals. Prob the most expensive but best option.

This has already happened at Great Lakes. The Navy hospital shut down and got absorbed into the North Chicago VA to make the Lovell Federal Health Care Center.

 

[BigNavyPedsGuy]

Bremerton: Losing ICU (soon), converting ER to UCC (soon), losing FP residency program in 2 years
Lemoore: losing all inpatient (including OB). Will just be a clinic.
Oak Harbor: inpatient will become strictly a birthing center, shutting down UCC, outsourcing surgery to local hospital
Pensacola: losing FP program (in 2 years)
Beaufort: shutting down ER, shutting down UCC. Keeping some inpatient for recruits
29 Palms: not many changes
Pendleton: expanding
Lejune: expanding
Jacksonville: keeping FP program/expanding it

Everybody that matches into FP with this selection board will be able to finish their training there.

The kicker: all of these places shutting down UCCs but keeping any inpatient will now have to have docs stay in-house 24-7 to meet JC requirement for Code Blue call.

There are more, but this is all I can recall.

Thoughts?

 

[Kingfisher]

Bremerton: Losing ICU (soon), converting ER to UCC (soon), losing FP residency program in 2 years
Lemoore: losing all inpatient (including OB). Will just be a clinic.
Oak Harbor: inpatient will become strictly a birthing center, shutting down UCC, outsourcing surgery to local hospital
Pensacola: losing FP program (in 2 years)
Beaufort: shutting down ER, shutting down UCC. Keeping some inpatient for recruits
29 Palms: not many changes
Pendleton: expanding
Lejune: expanding
Jacksonville: keeping FP program/expanding it

Everybody that matches into FP with this selection board will be able to finish their training there.

The kicker: all of these places shutting down UCCs but keeping any inpatient will now have to have docs stay in-house 24-7 to meet JC requirement for Code Blue call.

There are more, but this is all I can recall.

Thoughts?

Are Bremerton and P Cola losing inpt services/OB as well? How would you like to be the last residency class to go through there covering all the call with no interns for scutwork or rounding?

 

[orbitsurgMD]

I suspect once the commitment to support a residency program ends, current residents will have to be transferred to another program to finish their training. ACGME is not likely to look the other way just because the .mil wants to save a few bucks.

 

[pgg]

Bremerton: Losing ICU (soon), converting ER to UCC (soon), losing FP residency program in 2 years
Lemoore: losing all inpatient (including OB). Will just be a clinic.
Oak Harbor: inpatient will become strictly a birthing center, shutting down UCC, outsourcing surgery to local hospital
Pensacola: losing FP program (in 2 years)
Beaufort: shutting down ER, shutting down UCC. Keeping some inpatient for recruits
29 Palms: not many changes
Pendleton: expanding
Lejune: expanding
Jacksonville: keeping FP program/expanding it

Everybody that matches into FP with this selection board will be able to finish their training there.

The kicker: all of these places shutting down UCCs but keeping any inpatient will now have to have docs stay in-house 24-7 to meet JC requirement for Code Blue call.

There are more, but this is all I can recall.

Thoughts?

That's what they told us today. It's probably the right decision for my hospital.

Time to implement was 5-6 months. I will PCS in 11 ... should be an interesting transition.

 

[IlDestriero]

Looks like you get early release from your remote exile.😉

 

[BigNavyPedsGuy]

That's what they told us today. It's probably the right decision for my hospital.

Time to implement was 5-6 months. I will PCS in 11 ... should be an interesting transition.

7.5 months for me - but yeah, I won't get out before it hits the fan

 

[pgg]

Looks like you get early release from your remote exile.😉

They say no one will PCS early. Depending on how this works out, we may actually end up doing more DOD-beneficiary cases here, or with Navy staff at the local civilian joint. My case load could conceivably go up while my call hours go down.

For anesthesia and OR staff, OB coverage is by far our biggest manpower drain, and provides by far our lowest number of patient contact hours. Outsourcing OB will double or triple the manpower that can be put to work doing ambulatory surgery, something that is cost effective and useful here.

I've been looking for the catch all day but I'm finding little to gripe about. I don't have warm fuzzies about OB being outsourced since the soon-to-be-built birthing center in town won't open until 2015, and their current facility is a dark old building, there are no epidurals offered to patients (!), and some other issues, but there are a lot of details still to be worked out there.

What surprised me most about all this is that they actually intend to implement the changes soon, in months rather than years.

 

[Bernie3144]

Are Bremerton and P Cola losing inpt services/OB as well? How would you like to be the last residency class to go through there covering all the call with no interns for scutwork or rounding?

The last residency class will not be taking all call and will continue until they graduate. The third year residents that final year only have 1 inpatient medicine month which may actually disappear since the required inpatient medicine necessary for ACGME is reached prior to the 3rd year. That rotation may become an additional elective which is nice, especially for those interested in flight or sports medicine (close affiliation with Andrews Institute). As it stands, with our VA patient load, we are already exploring ways to cover the inpatient service which more than doubled over the past year (1 inpatient medicine team average was 3-6, now it is 10-15). Same with the ICU service. OB will continue as is. Any additional questions about PCOLA, please DM me.

 

[backrow]

Anyone else feel like Navy Medicine is trying to pull an Indianapolis Colts and fill up a bunch I semis in the middle of the night?

 

[BigNavyPedsGuy]

Anyone else feel like Navy Medicine is trying to pull an Indianapolis Colts and fill up a bunch I semis in the middle of the night?

But we're still stuck in an abandoned Baltimore stadium trying to maintain safe patient care.