There once was this unwritten understanding that the discrepency in pay between military physician and civilian pay was offset by professional and personnal benefits of military service. For example, work hours were generally less, hassles (insurance, billing etc) less, and the system worked much like a traditional academic medicine system with time for CME, GME and research.
Then the HMO craze started becoming the norm in the civ sector so the government started to try to apply civilian performance metrics on military providers with providing them with any of the resources and incentives that HMO's provided their docs.
Roughtly the same time the bean counters figured, hey let's unload the retirees - and make them use medicare and go civilian - not a good move for residencies or for subspecialists who need old people with old people diseases.
They started collecting bogus metrics ala UCAPERS, RVU's, whatever which were based on totally erroneous data. With flawed data, they started to cut positions since it was so apparent to them that we (military docs) were a bunch of inefficient dolts. Panels increased, and life got really bad for the primary care docs in particular. Time for research disappeared and lifestyles were degraded....
JCAHO then became this plaque that appeared and administrative requirements went through the roof. As we increasingly lost sight of the real mission PATIENT CARE, we started to alot days for sexual harrassment training, Consideration of other training, NO FEAR training, Ethics, Customer service, Sex abuse responder training, HIPAA, CBRNE and a zillion other training requirements which only served to degrade patient care further. We have closed my clinic several times this year to try to get this generally useless training accomplished.
Guess what? The "benefits" of military service - quality of life, access to training, research etc, disappeared and people started to head for the exits. The exodus wasn't really noticed because we had like 8 years worth of docs in the pipeline either in residency, or obligated through HPSP or USUHS. Adding the "War on Terror", to the mix further demoralized staff especially as deployment decisions were in many ways not equitable, and the increased workload required on nondeployed staff ballooned. Then, more headed for the exits (more than could be filled by HPSP and USUHS accessions). Add to that the decrease in HPSP enrollment in the past 2 years and in 4-5 years you face a cataclysmic collapse in the system.
So where are we? In a very bad place.
Attempts to privatize military healthcare or high civilian contractors is almost uniformly a failing enterprise. Let's face it, the civilian job marked it very tight and pay higher there, so who do we end up hiring? A bunch of FMG's who have no buy-in to the system and don't feel any particular ownership or appreciation for the military beneficiary.
I wish I had reason to be more optimistic but our rating systems do not allow for the best and brightest to become policy makers and GO's, thus in some respects the crap floats to the top. Lastly because we do not have a seperate funding stream distinct from that where beans and bullets are procured, there will always be attempts to raid medical funds to support ongoing combat ops - further degrading care and morale.
My solution - a unified medical command, a competely seperate budget stream, a rating scheme which is based on clinical skills/excellence, bedside manner, in addition to administrative skills. Protected and dedicated funds to each doc for CME. Reasonable work hour guidelines, taking into account mission creep - "do more with less".
