More than 17,000 uni­formed med­i­cal jobs eyed for elim­i­na­tion

The Progress-Index - - CLASSIFIED - Tom Philpott To com­ment, write Mil­i­tary Up­date, P.O. Box 231111, Cen­tre­ville, VA, 20120 or email milup­[email protected] or twit­ter: Tom Philpott @Mil­i­tary_Up­date

The Army, Navy and Air Force are fi­nal­iz­ing plans to elim­i­nate over the next few years more than 17,000 uni­formed med­i­cal bil­lets – physi­cians, den­tists, nurses, tech­ni­cians, medics and sup­port per­son­nel.

The re­duc­tion will al­low those bil­lets to be re­pur­posed as warfight­ers or com­bat-sup­port skills to in­crease the lethal­ity and size of op­er­a­tional units. An­other goal is to deepen the work­load of re­main­ing med­i­cal bil­lets at base hos­pi­tals and clin­ics to strengthen their wartime med­i­cal skills and also to im­prove qual­ity of care for ben­e­fi­cia­ries, de­fense of­fi­cials ex­plained.

One se­nior ser­vice of­fi­cial shared the lat­est fig­ures he has seen show­ing the uni­formed Army med­i­cal staff fall­ing by al­most 7300, the Navy by al­most 5300 and the Air Force by just over 5300.

Spread across a com­bined med­i­cal force of 130,000, both ac­tive duty and re­serve, the planned cuts would lower uni­formed med­i­cal strength by roughly 13 per­cent, a drop steep enough to alarm some health care lead­ers as well as ad­vo­cates for mil­i­tary health care ben­e­fi­cia­ries.

“If the goal is to tear down the mil­i­tary health sys­tem, this would be a rea­son­able way to do it,” warned one ser­vice health of­fi­cial who asked not to be iden­ti­fied.

Given the num­bers in­volved, said re­tired Navy Capt. Kathryn M. Beasley, di­rec­tor of gov­ern­ment re­la­tions for health is­sues at Mil­i­tary Of­fi­cers As­so­ci­a­tion of Amer­ica, the staff cuts eyed are wor­ri­some for pa­tient ac­cess, par­tic­u­larly to physi­cians young fam­i­lies rely on such as pe­di­a­tri­cians and ob­ste­tri­cians.

“We need to see the fi­nal num­bers to un­der­stand the im­pact,” she said.

But se­nior de­fense of­fi­cials, who say they col­lab­o­rated closely with the ser­vices on over­all staff re­duc­tion plans, con­tend the cur­rent force is larger than needed to meet to­day’s op­er­a­tional mis­sions and is over­loaded with skillsets not use­ful for de­ploy­ment and de­liv­er­ing of bat­tle­field care. Also, they con­tend, the over­sized staffs harm qual­ity of care be­cause at too many bases hos­pi­tals and clin­ics these care providers don’t treat enough pa­tients to keep skills sharp.

“So, part of this drill is to realign our peo­ple to the ap­pro­pri­ate level of work­load so that their skills, both for bat­tle­field care and for ben­e­fi­ciary care, im­prove,” said one De­fense Depart­ment of­fi­cial.

Top de­fense of­fi­cials agreed to dis­cuss rea­sons be­hind the planned staff cuts for the mil­i­tary health care sys­tem, but de­clined to con­firm any num­bers for med­i­cal slots tar­geted, which some ser­vice of­fi­cials did share, be­cause no fig­ures will be firm un­til the fis­cal 2020 de­fense bud­get re­quest is ap­proved by the White House and sent to Con­gress in Fe­bru­ary. If Con­gress ap­proves the cuts, to be pre­sented bil­let by bil­let, the re­duc­tions would be­gin to take ef­fect in fis­cal 2021.

Pre­lim­i­nary Navy doc­u­ments show uni­formed staff at Wal­ter Reed Na­tional Mil­i­tary Med­i­cal Cen­ter fall­ing by 534 per­son­nel, with, for ex­am­ple, 82 taken from di­rec­tor of clin­i­cal sup­port in­clud­ing 28 of 39 corps­men, 5 of 12 ra­di­o­log­i­cal di­ag­nos­ti­cians, 4 of 7 phar­ma­cists, 8 of 19 phar­macy techs and 9 of 45 med­i­cal lab tech­ni­cians.

De­fense of­fi­cials de­scribed a year-long col­lab­o­ra­tion be­tween ser­vice med­i­cal de­part­ments, the Joint Chiefs, the De­fense Health Agency and CAPE, the Cost Anal­y­sis and Pro­gram Eval­u­a­tion Of­fice of the Sec­re­tary of De­fense. The force cuts are just one part of an enor­mous trans­for­ma­tion oc­cur­ring across mil­i­tary medicine.

Con­trol of all med­i­cal fa­cil­i­ties is be­ing trans­ferred to the De­fense Health Agency, where func­tions of the three sep­a­rate ser­vice med­i­cal de­part­ments al­ready are be­ing con­sol­i­dated to stream­line health care op­er­a­tions, slash sup­port costs and stan­dard­ize prac­tices and pro­ce­dures, from sched­ul­ing ap­point­ments to re­port­ing on provider er­rors. Mean­while the mil­i­tary health sys­tem is adopt­ing MHS Ge­n­e­sis, a new elec­tronic health record sys­tem.

Just as Con­gress di­rected these changes, it told the Sec­re­tary of De­fense in its fis­cal 2017 Na­tional De­fense Depart­ment Au­tho­riza­tion Act to col­lab­o­rate with ser­vice branches on defin­ing med­i­cal and den­tal per­son­nel re­quire­ments to en­sure op­er­a­tional readi­ness, and to con­vert mil­i­tary med­i­cal po­si­tions to civil­ian po­si­tions if deemed un­nec­es­sary to meet op­er­a­tional readi­ness needs.

The med­i­cal force re­duc­tion ef­fort, how­ever, isn’t be­ing funded for a mass con­ver­sion of mil­i­tary bil­lets to civil­ian med­i­cal po­si­tions. In­stead the em­pha­sis is on pro­vid­ing more ef­fec­tive and ef­fi­cient care, on bat­tle­fields and through mil­i­tary treat­ment fa­cil­i­ties to troops, fam­i­lies and re­tirees, us­ing smaller staffs that are sized to gain more ex­pe­ri­ence and be bet­ter trained for mil­i­tary op­er­a­tions.

To un­der­stand what’s about to hap­pen, said a se­nior of­fi­cial fa­mil­iar with the staff cut plans, it is help­ful to grasp a no­tion that sounds coun­ter­in­tu­itive: “Re­duc­ing the num­ber of peo­ple pro­vid­ing a par­tic­u­lar ser­vice within a fa­cil­ity does not mean a degra­da­tion of care within that fa­cil­ity.”

A “tru­ism in the med­i­cal arena,” he added, “is that the more times a provider per­forms a pro­ce­dure, the bet­ter that provider is at per­form­ing that pro­ce­dure.”

If a mil­i­tary hos­pi­tal now staffed with five or­tho­pe­dic sur­geons per­forms ten knee re­place­ments a month, that’s only two op­er­a­tions per sur­geon. If staff is cut to one sur­geon able to still com­fort­ably per­form 10 pro­ce­dures a month, both qual­ity of pa­tient care and the readi­ness of that sur­geon for war will im­prove.

That ar­gu­ment for a care­ful re­duc­tion of staff isn’t per­sua­sive for some ca­reer med­i­cal per­son­nel. One said he is wor­ried that staff cuts this deep could leave hos­pi­tals short of per­son­nel to de­ploy or to re­ceive pa­tients if old wars es­ca­late or new ones break out in Ko­rea, East­ern Europe or the South China Sea. He also wor­ries about find­ing civil­ian re­place­ments when needed, not­ing chronic staff short­ages within the VA med­i­cal sys­tem that can’t even be filled in peace­time.

“I don’t be­lieve it’s doable when you take your plat­forms down to this de­gree and you’re still putting peo­ple on [for­ward] de­ploy­ment sched­ules,” said this se­nior ser­vice of­fi­cial. “You can ar­gue on the mar­gins whether you need quite as many peo­ple here or there. But these hos­pi­tals sup­port train­ing as well as pro­vide care and [they] keep peo­ple in op­er­a­tional units,” he added. After deep staff cuts, “you’re are go­ing to have a very hard time keep­ing docs, es­pe­cially in uni­form.”

Iron­i­cally, he added, these staff cut plans arise near the end of wars in Iraq and Afghanistan where U.S. mil­i­tary medicine pro­duced “the best out­comes in com­bat ca­su­alty care in the his­tory of the world.”

Se­nior de­fense of­fi­cials an­swered such con­cerns with as­sur­ances DHA and the ser­vices are giv­ing care­ful con­sid­er­a­tion to readi­ness needs in­clud­ing wartime re­quire­ments. Mil­i­tary fa­cil­i­ties still will have ro­bust civil­ian staffs, they added, and will be able to back­fill with re­serve med­i­cal per­son­nel and civil­ian con­tracts.

Of­fi­cials con­ceded the staff cuts, and re­fo­cus­ing on de­ploy­able skills, over time will change the mix of providers de­liv­er­ing care on base, forc­ing more fam­ily care off base and onto TRI­CARE provider net­works.

“We will ex­pect to see an in­crease in cer­tain skill sets [and] a de­crease in other skill sets. More trauma sur­geons, fewer pe­di­a­tri­cians, for ex­am­ple. Those kinds of changes are right at the heart of what Con­gress has di­rected us to do,” said one of­fi­cial.

The same shift in med­i­cal skillsets for hos­pi­tal staffs will be­gin to re­shape grad­u­ate med­i­cal ed­u­ca­tion pipe­lines.

“The rea­son why we do grad­u­ate med­i­cal ed­u­ca­tion is to be able to sup­ply that ready med­i­cal force,” said an­other se­nior of­fi­cial. “We need to ex­pand our ca­pac­ity in some ar­eas” but will see them “con­tract” in oth­ers.

Some crit­ics of the staff cuts sug­gest a de­sire for bud­get sav­ings is a key fac­tor. Navy doc­u­ments iden­tify “ex­pected to­tal sav­ings of $1.14 bil­lion” from that ser­vice’s uni­formed med­i­cal “end-strength di­vesti­ture” plan.

Se­nior de­fense of­fi­cials deny that’s the case, cit­ing an “un­wa­ver­ing com­mit­ment” to im­prov­ing med­i­cal readi­ness and qual­ity of care.

“How do we get higher lev­els of med­i­cal readi­ness for the next ma­jor con­flict? That cen­tral ques­tion is go­ing to drive a lot of changes through­out the mil­i­tary health­care sys­tem.”

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