Navy POM20 - Bye Bye to more billets!

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militaryPHYS

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POM20 Navy Medicine Billet Reduction

Well, in addition to MEDMACRE projections for billet changes here comes an additional broad sweep of decreasing billets across all milmed services. This article addresses Navy medicine specifically.

We all knew this was coming, now we are just waiting to see the impact on the end users (us).

Keep us posted if anyone has information regarding impact zones.

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Some musings:
Joel made several interesting claims that he says are BUMED talking points in his post:
1. the line is willing to assume more operational medical risk. I don’t think that’s true at all. I think they will expect the same outcomes for less money
2. He thinks that BUMED can win the battle of the beltway to get some of this back.
3. They acknowledge that GME will have to change. I think this is inevitably the end of IM subspecialty inservice training.

One of the commenters stated that GI and Onc were heavily impacted. That would make sense given our skill set except that the Navy can’t afford civilian me.

I suspect that rather than a budget issue, this is an end strength issue. There are limits on the officer end strength for each service and a MD counts against that total identically to a SEAL. Only one of those jobs can be civilianized.

You have to wonder if this is a response to the formation of the DHA.
 
In my lowly opinion this is everything to do with the Navy recapturing the Capital they are losing with the formation of DHA. If the Service is now only responsible for operational care then why in the world would they expend money on supporting something that is beyond their requirement.

They want to keep that money, just look at the inter-Service fights that happen when new aircraft or other technologies are developed. Nobody ever wants to give up their “piece of the pie” and works to protect their money sources. The same thing is happening here.

Nothing like this happens quickly so I would venture to say that big Navy had this in the works for quite a while. Based on the response so far though I would imagine that this will have significant change prior to final implementation.


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so, after exchanging a couple texts tonight, apparently GI was already hit. They’ve been told about the billet reductions with MTF specific data. Small specialties can get thin really fast if they just turn off the pipeline and have predicatably poor retention.
 
Yeah, I just saw the spreadsheet via a specialty leader of a different specialty. They have very specific numbers from each specialty at each MTF.

Also sounds like these cuts are from big navy (for overal operational purposes) with very little input from navy medicine leadership...as you all are suspecting.
 
I think this is inevitably the end of IM subspecialty inservice training.

Might as well get rid of all GME, the system isn't really built for it. Low volume, low acuity, and now if you take away the sub-specialty services, how are you supposed to train general medicine residents? (or general peds, or general surgery....etc etc).
 
Might as well get rid of all GME, the system isn't really built for it. Low volume, low acuity, and now if you take away the sub-specialty services, how are you supposed to train general medicine residents? (or general peds, or general surgery....etc etc).
I don't think the plan is to get rid of subspecialty care, its to switch all of those billets over to GS or contractor positions. Honestly it would be a better idea to do it that way. The issue is that GS/OB/Peds/IM would need to find a way to make the generalist jobs bearable enough that they can retain people without the subspecialty training.

Its not impossible. FM has a much better track record with retention than the other generalists. It will just require some adaption.
 
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That sounds great in theory but in practice, they can’t hire in my specialty. The salaries are tied to the VA salaries so it isn’t easy to increase.

FM docs want to do primary care. 80% of internists want to subspecialize.
 
Yeah, I just saw the spreadsheet via a specialty leader of a different specialty. They have very specific numbers from each specialty at each MTF.

Also sounds like these cuts are from big navy (for overal operational purposes) with very little input from navy medicine leadership...as you all are suspecting.

Is that FOUO or can you share?
 
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That sounds great in theory but in practice, they can’t hire in my specialty. The salaries are tied to the VA salaries so it isn’t easy to increase.

FM docs want to do primary care. 80% of internists want to subspecialize.
Same. The kind of people you attract withbthe type of salary they offer is (usually) not the type of person you want. I’ve seen that process in action.
 
FM docs stay in because their military salaries are competitive. Cardiologists get out because they make so much more outside. If training opportunities become limited less medical students will sign up and hurt retention too.
 
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It would really be great to know how this affects those in the pipeline already.
 
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It would really be great to know how this affects those in the pipeline already.

I have a feeling that the results of the JGMESB that will come out next month will give some ideas as to what to expect.

For now nobody really knows and much is still in flux. If the current plan holds then I think you will see an emphasis on training in critical wartime specialties and creating GMOs.


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I think you will see an emphasis on training in critical wartime specialties

Which is what? The Navy seems to think the critical wartime specialties are critical care and anesthesia, and so we have a lot of training opportunities in those specialties (IM had 5 spots for PCC this year, I think only 1 for Cards, 1 for Heme Onc).

But you don't have to be trained in critical care or anesthesia to deploy. If you look at it historically over the past 70 years (Gulf War I and II, Afghanistan, Vietnam, Korea), the vast majority of physicians deployed in theater were not trained (formally) in critical care. Moreover, its not fair to ask any one subspecialty to continuously deploy its folks multiples times, while others sit stateside. When the stuff really hits the fan, all specialties can/should be expected to deploy. This is all misguided.
 
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Curious to know if this policy is implemented and the changes y’all are talking about actually come to pass, if militaryPHYS will actually change his opinion of military medicine?

My multi-surgical specialty practice is within 25 miles of the largest post in the army. We already don’t accept Tricare Prime (or whatever fancy new name the military calls it these days). If this policy also applies to the army, dependents of active duty soldiers are screwed.

They can always hurt you more and when it comes to the military, they will definitely make their best effort to do so.
 
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TRICARE is a negative line of business for civilian practices. It’s only slightly better than Medicaid. We don’t accept it either.

It’s not clear to me what the changes mean. I suspect this will turn out to be another flesh wound. They won’t allow a clean kill but they will squeeze until it fails and then blame whoever is holding the bag.
 
Curious to know if this policy is implemented and the changes y’all are talking about actually come to pass, if militaryPHYS will actually change his opinion of military medicine?.

Change my opinion from "Make sure you want to be a military officer first and expect that at some point the big bureaucratic system will screw you?" No. I don't think my opinion will change. I do, however, put a lot more emphasis on critical wartime specialties. Even though you never know what your med student self will change to regarding specialty choice, I still think that you have a higher chance of being satisfied in MilMed if you are already considering a critical wartime specialty. If not, you have no idea what your opportunities for GME training will be when that time comes.

We already don’t accept Tricare Prime (or whatever fancy new name the military calls it these days). If this policy also applies to the army, dependents of active duty soldiers are screwed

I agree that if changes are being made without first verifying that dependents and beneficiaries will be properly served in the civilian community is a big mistake. Having dependable healthcare for families is what service members need if they are being required to deploy and therefore have little control over what happens back home.
 
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For a view on impact to ancillary -

Navy Pharmacy is set to lose 15 additional billets due to this. We already lost 30 or so from MedMACRE. So we go from 120ish to under 80 active duty billets.

Hospital pharmacies (like many other services) cannot actually function without per diem support. Active duty officers fill that role right now. When you remove every active duty pharmacist from the majority of your hospitals, and the one GS pharmacist working overnight decides to call out on Thanksgiving an hour before their shift, what is the plan?

But I know that the MTFs are secondary to operational support role. I just don’t think anyone above DCSS in MilMed even understands what we do or the impact we can have not just in the hospital, but when that CSG is getting underway in 4 hours and the carrier didn’t get their crew’s meds and the contracted pharmacist on duty at the local MTF refuses to fill their scripts, so the CDO calls in the pharmacy officer to take care of the fleet. I also think we’re underutilized on the operational side of things but that’s just my opinion.

Oh well. Just keep on keeping on.
 
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It’s a hell of a gamble to think you’ll know what you want to do as a premed. Beyond that, many critical wartime specialties are relatively competitive so even if you “know” you want to be a bone fixer, what will happen when you don’t get the right Step score?
 
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Also, if the MHS really wanted to reduce billets but keep services, they’d close the incredibly redundant service headquarters. There are more people at BUMED than a MTF all going to work to tell other people how to work. Add in the Army and AF HQs and it’s absurd. They should have taken all the pain.
 
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Also, if the MHS really wanted to reduce billets but keep services, they’d close the incredibly redundant service headquarters. There are more people at BUMED than a MTF all going to work to tell other people how to work. Add in the Army and AF HQs and it’s absurd. They should have taken all the pain.

The problem with that idea is this wasn’t the DHA that directed this reduction. From everything that has come down neither BUMED nor DHA were even consulted on this and were simply told by Navy Personnel. It appears that “big Navy” simply looked at a spreadsheet of capabilities/platforms and said we don’t need X, Y, and Z anymore so slash those billets in order to give us the room to do X, Y, and Z on the Line side.

The rumor mill has similar changes for the Army and Air Force coming down at some point as well.


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The problem with that idea is this wasn’t the DHA that directed this reduction. From everything that has come down neither BUMED nor DHA were even consulted on this and were simply told by Navy Personnel. It appears that “big Navy” simply looked at a spreadsheet of capabilities/platforms and said we don’t need X, Y, and Z anymore so slash those billets in order to give us the room to do X, Y, and Z on the Line side.

The rumor mill has similar changes for the Army and Air Force coming down at some point as well.


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This is an OSD level change in programming. All MilMed is being similarly cut per the Navy SG’s email.
 
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The Army is already looking for civil servant anesthesiologists at Landstuhl Germany. When I was there about a decade ago anesthesia was all AD staffed.

Physician (Anesthesiology)

For what they (DoD) want to pay, they won’t even be able to entice nurse anesthesists.

We had a single contractor come on during my 7 years at Ft. Bragg despite advertising the entire length of my assignment.

He lasted about 2 months and was quickly booted after he admitted lying about a previous DUI conviction on his application.

Very few US medical graduates want to work for the DoD. Those that do frequently have “issues” that won’t allow them to be hired elsewhere.
 
Very few US medical graduates want to work for the DoD. Those that do frequently have “issues” that won’t allow them to be hired elsewhere.

This is actually my biggest concern. Agree with the difficulty in finding professionals (physicians, nurses, CRNAs, optometrists, etc) at the current GS/GP rates. Some contract positions are a little better, but overall it is very difficult to fill the positions.

I worry that the main hospitals will end up filled with various folks who aren’t as competent as the current standard. Just as there is massive variability in the VA system you will likely see this variability introduced into the DoD system.



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the better VAs are able to use university appointments to pay the docs from a second source. That won’t be the case for DoD. NMCP tried to hire a GI for years with no success.

DC, SD, Tripler, Madigan and...I’m not sure where else will probably be fine given the desirability of the location. Maybe add Landstuhl. Otherwise, it won’t be easy
 
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My (totally unfounded) prediction is that military medicine will be slowly deprogrammed by DOD and active duty military medical personnel will be replaced with Public Health Service uniformed personnel, doing nothing but shifting the exact same costs to the DHHS. Because these positions aren’t going to be filled by the private sector at the rate of pay offered.
 
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My (totally unfounded) prediction is that military medicine will be slowly deprogrammed by DOD and active duty military medical personnel will be replaced with Public Health Service uniformed personnel, doing nothing but shifting the exact same costs to the DHHS. Because these positions aren’t going to be filled by the private sector at the rate of pay offered.

Anything is possible but this would require the Services (really the DoD) to shift money out of the DoD budget to a different executive level Department. Every move so far has been to recapture lost money (i.e. folks not necessary for, in their thought, combat medicine) back to their coffers and away from DHA. I don’t see them going for anything that reduces their budget.


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My (totally unfounded) prediction is that military medicine will be slowly deprogrammed by DOD and active duty military medical personnel will be replaced with Public Health Service uniformed personnel, doing nothing but shifting the exact same costs to the DHHS. Because these positions aren’t going to be filled by the private sector at the rate of pay offered.

From my uninformed perspective, I thought PHS was primarily epidemiology/population health/primary care to isolated groups (Indian Health Service, Federal prisons, etc). Do they have commissioned personnel in hospital-based specialties?
 
the better VAs are able to use university appointments to pay the docs from a second source. That won’t be the case for DoD. NMCP tried to hire a GI for years with no success.

DC, SD, Tripler, Madigan and...I’m not sure where else will probably be fine given the desirability of the location. Maybe add Landstuhl. Otherwise, it won’t be easy

Lemoore, Polk, Irwin, Cherry Point, Twentynine Palms ... :lol:
 
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Anything is possible but this would require the Services (really the DoD) to shift money out of the DoD budget to a different executive level Department. Every move so far has been to recapture lost money (i.e. folks not necessary for, in their thought, combat medicine) back to their coffers and away from DHA. I don’t see them going for anything that reduces their budget.


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Yeah, I don't see this one either. Why would the PHS pick up that work?

Here's what I would do if I were king: Shunt as much as possible to TRICARE and eventually close all the CONUS hospitals (put TRICARE under the purview of Medicare with equivalent compensation so its not just a tax on the rest of society). Keep a small cadre of AD medical administrators and nurses to handle the fitness for duty process with civilian MDs (those docs do DODMERB, MEPS and C&P exams now, its not that hard). They would coordinate with the enlisted medical staff for CONUS care for the AD members. Turn the rest of the medical system into a reserve function. Keep HPSP to pay for the training of these reservists. Close USUHS. If you do a specialty that isn't surgical, you function as a primary care physician (GI = IM, etc) and you join the deployable unit during the last stages of work-ups. If you do a truly useless specialty, you just owe back the money. Pay the surgical specialties way more with all the money you've saved by getting rid of infinite bureaucrats so that its actually worth sticking around. Over time, if we are paying enough to keep the right kind of physicians, get rid of HPSP and accession only the properly trained doctors with loan-repayment and a meaningful paycheck. Fill OCONUS hospitals with GS physicians.

This wasn't possible 10 years ago but most physicians are now employed rather than business owners.

What do I think will happen: nothing. This is another of the 1000 cuts that are slowly killing military medicine. They will muddle along providing mediocre care gradually closing fellowships and squeezing everyone a little harder. The proliferation of the DO puppy mills will continue to provide desperate candidates who will take their chances. Its going to be a continued slow and painful decline.
 
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Orrrr until it all collapses irreparably, whichever comes first.

¯\_(ツ)_/¯
images-01.jpeg
 
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Here's what I would do if I were king:

You would be a great King.

I will add that SG says having an "all reserve" military medical force isn't feasible because we need to be able to "fight tonight". Not sure why a reservist can't be able to fight tonight. We could all be practicing civilians on 3 or 6 month rotations during which we understand that we could be called up at a moments notice. You maintain your civilian practice and if you get called up, you mobilize. It would be similar to the European military medical scenario of getting dropped in for 1 to 3 months at a time and then getting pulled right back out and back in clinic or your civilian OR the following week. We would then do away with the 3 to 6 months of hurry up and wait "trainups" with our operational units just to go somewhere and either do nothing medical or do basic wartime casualty care. A 6 month deployment turns in to 12 months when you add trainups and demobe to the front and back end. Instead of inefficient war trainups we could utilize our two weeks every summer for hardcore operational training instead of just getting paid to travel to some hospital and barely check in to said hospital and doing NO work before you have to check out and head back home.

Complete dissolution of an active component is tough to imagine. Super small component? Maybe. Perhaps whatever is left of the active component maintains the overseas billets which are strategic to "areas of concern" who might need to fight tonight. Then the reservists can back fill those hospitals within 24 to 48 hours or be sent on to the real fight. But to be honest, you want your civilian (reservists) who are practicing regularly at shock trauma or other Level I centers on the regular to be the ones treating our wounded.

Could we require reservist medical personnel to live/work within 6 hours of a major military base allowing them to be on the flight line within 24 hours ready to deploy? Just spit-balling here for when one of us gets heard:whistle:

(put TRICARE under the purview of Medicare with equivalent compensation so its not just a tax on the rest of society)

This is essential. If we aren't going to maintain AD docs and MTF's to treat our dependents and beneficiaries (let alone our AD guys/gals) then Tricare needs to be a well respected program within the civilian world...otherwise our military members and families will be treated like dirt.
 
Can you give a list of which specialties where cut and where? Will there be more specialties cut? Will the billet reduction work by attrition or will there be a severance or RIF scenario.
 
If we aren't going to maintain AD docs and MTF's to treat our dependents and beneficiaries (let alone our AD guys/gals) then Tricare needs to be a well respected program within the civilian world...otherwise our military members and families will be treated like dirt.

The devil's in the details as I see it.

1. As long as Tricare pays less than per-patient office overhead, beneficiaries are going to have an increasingly difficult time finding quality off-base clinics to treat them.

2. Some smaller MTFs have successfully turfed L&D downtown. Off the top of my head I'm thinking Beaufort, Lemoore, Cherry Point (although it's a bit of a drive, almost 30 miles I think). Others (Oak Harbor for instance) have converted from full hospital to simply being a birthing center. But several places were exempted from the 2013 small hospital study, which required downsizing by 2015, due to insufficient/non-existent local civilian network. Polk and Irwin come to mind, as well as I believe Twentynine Palms.

3. So what is the MHS to do? Attempt a one-size fits all? I don't think that will work. Too many variables, and all politics is local. Maintain full service MTFs at a few in-CONUS isolated Forts Nowhere, while trying to turf everything downtown at larger bases near a good network (but again see comment #1 above re Tricare)? Maintaining a few full service MTFs at isolated bases would mean AD hospital-based providers are potentially spending their entire career rotating between podunk, nowhere, and not on the map.

4. And let's face it. In CONUS, the MHS is essentially a huge OB practice, with occasional hernias, rotator cuffs, and ACL reconstructions thrown in for good measure. Young soldiers/sailors are generally healthy and excel at making babies. How does the MHS reconcile the bulk of in-CONUS CPT code generation with operational combat medicine requirements and personnel/budgetary challenges? Should DOD realize that having a properly-staffed, properly-equipped, and appropriately distributed MHS is simply the "cost of doing DOD business," and that comparing the MHS business/financial attributes to those of the civilian medical world is apples to oranges?
 
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I agree that if changes are being made without first verifying that dependents and beneficiaries will be properly served in the civilian community is a big mistake. Having dependable healthcare for families is what service members need if they are being required to deploy and therefore have little control over what happens back home.

Unfortunately, this is exactly what's happening. I am the only subspecialist of my type for an entire installation and even the surrounding community, and I treat ONLY family members. Demand far exceeds what can be provided by an n = 1. Yet, I am now under the constant threat of being pulled from my clinic -- despite a sizable active panel -- at any moment and moved to seeing active-duty. I'm a known loss in less than 6 months and there are no plans to replace me with active duty. They finally decided to axe the civilian position since it has gone unfilled for almost 6 years, which makes sense given I could make 100k more than they were offering.

The assumption is that my panel and anyone I may have treated in the future can simply get it outside the gate. Apparently I'm the only person in this system who knows how stupid that idea is. There isn't anyone outside the gate. The nearest subspecialists of my kind are an hour away and only accept cash.

All of this is going to be a cluster of epic proportions. I'm glad I'm separating soon.
 
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Unfortunately, this is exactly what's happening. I am the only subspecialist of my type for an entire installation and even the surrounding community, and I treat ONLY family members. Demand far exceeds what can be provided by an n = 1. Yet, I am now under the constant threat of being pulled from my clinic -- despite a sizable active panel -- at any moment and moved to seeing active-duty. I'm a known loss in less than 6 months and there are no plans to replace me with active duty. They finally decided to axe the civilian position since it has gone unfilled for almost 6 years, which makes sense given I could make 100k more than they were offering.

The assumption is that my panel and anyone I may have treated in the future can simply get it outside the gate. Apparently I'm the only person in this system who knows how stupid that idea is. There isn't anyone outside the gate. The nearest subspecialists of my kind are an hour away and only accept cash.

All of this is going to be a cluster of epic proportions. I'm glad I'm separating soon.

Classic military medicine giving lip service about being “patient centric” when, in fact, they could care less. Hospital commanders are just looking for another bullet point on their OER and “taking care of dependents” is not viewed the same as feeding the war machine and kissing the a$$ of brigade/division commanders.

I mean what hospital organization would change their leader EVERY 2 YEARS and expect to be a success?

What. A. Joke!
 
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Classic military medicine giving lip service about being “patient centric” when, in fact, they could care less. Hospital commanders are just looking for another bullet point on their OER and “taking care of dependents” is not viewed the same as feeding the war machine and kissing the a$$ of brigade/division commanders.

I mean what hospital organization would change their leader EVERY 2 YEARS and expect to be a success?

What. A. Joke!
It is just a slogan. Sounds good. I work as a chief in sub specialty care in hospital and I never saw commander come by. He is in a different universe and wants to pin a star. If you want to pin a star you need to make senior rater happy.
 
MTF are metric machines. The metrics surrounding patient care are the priority and what's considered to be important. The stuff that actually happens during the provision of care is irrelevant. So long as you're meeting the metrics, you could spend the entire encounter with a patient doing a recitation of Old Norse sagas and still be lauded as an excellent clinician.
 
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You would be a great King.

I will add that SG says having an "all reserve" military medical force isn't feasible because we need to be able to "fight tonight". Not sure why a reservist can't be able to fight tonight. We could all be practicing civilians on 3 or 6 month rotations during which we understand that we could be called up at a moments notice. You maintain your civilian practice and if you get called up, you mobilize. It would be similar to the European military medical scenario of getting dropped in for 1 to 3 months at a time and then getting pulled right back out and back in clinic or your civilian OR the following week. We would then do away with the 3 to 6 months of hurry up and wait "trainups" with our operational units just to go somewhere and either do nothing medical or do basic wartime casualty care. A 6 month deployment turns in to 12 months when you add trainups and demobe to the front and back end. Instead of inefficient war trainups we could utilize our two weeks every summer for hardcore operational training instead of just getting paid to travel to some hospital and barely check in to said hospital and doing NO work before you have to check out and head back home.

Complete dissolution of an active component is tough to imagine. Super small component? Maybe. Perhaps whatever is left of the active component maintains the overseas billets which are strategic to "areas of concern" who might need to fight tonight. Then the reservists can back fill those hospitals within 24 to 48 hours or be sent on to the real fight. But to be honest, you want your civilian (reservists) who are practicing regularly at shock trauma or other Level I centers on the regular to be the ones treating our wounded.

Could we require reservist medical personnel to live/work within 6 hours of a major military base allowing them to be on the flight line within 24 hours ready to deploy? Just spit-balling here for when one of us gets heard:whistle:



This is essential. If we aren't going to maintain AD docs and MTF's to treat our dependents and beneficiaries (let alone our AD guys/gals) then Tricare needs to be a well respected program within the civilian world...otherwise our military members and families will be treated like dirt.


I think eventually they will just cut specialties by attrition active duty and civilian DOD by not hiring or filling open slots for certain specialties and expecting the private sector to take active duty soldiers and their family members out of patriotism and wanting to help them out and ignore the crap reimbursement, but we know that's not what will happen because it isn't happening now with Tri-Care and it isn't happening now with CHOICE in the VA. The crap reimbursement (if you can even get reimbursed!) attracts some poor takers and many of them refuse to do the work required.

I foresee more reserve billets to pick up specialties and those poor souls being deployed more often in areas they can't get private sector specialists.

The problem is going to be people being over deployed especially highly trained specialists will make people bail pretty quickly.

Just my thoughts. I just hope someone wakes up and realizes this is a bad idea.
 
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