September 25, 2006
Medical merger
Panel aims to put all health workers under one command in a hurry. But how will it work?

By Gayle S. Putrich
Staff writer

The most sweeping overhaul of the military’s medical system in more than 60 years would combine all Navy, Army and Air Force hospitals, clinics, doctors and staff under a single joint medical command.

And it would do all that in the next three months.

The Defense Business Board, a panel of senior business executives who act as advisers to Defense Secretary Donald Rumsfeld, recommended Sept. 6 that Rumsfeld immediately appoint a transition team and pull together the unified medical command by Jan. 1, 2007.

The Navy and Army support the concept, which, according to the Center for Naval Analyses, could save $344 million or more. But the Air Force is vigorously opposed to a wholesale combination of medical assets, fearing that wing commanders would lose control of a vital support function on their bases.

Some Defense Department officials, as well as lawmakers, are advocating a cautious, incremental approach.

But board members said there is no reason to delay.

“We’re saying, don’t wait until fiscal ’08 to begin,” said Henry Dreifus, founder and CEO of Dreifus Associates Limited Inc., a business consulting firm. Dreifus headed the DBB task group that studied the unified medical command concept. “There is no reason not to do this sooner.”

Under the plan:

• Tricare would need to be realigned to work alongside the new unified command.

• The Pentagon’s Office of Health Affairs would take over policy control, budget authority and accountability and oversight of all medical activities.

• All fixed military clinics and hospitals would come under the unified command, including research, contracting, logistics and training.

• Emergency and operational field care would stay under the individual services, at least for the time being.

“The whole idea here is to continue to provide outstanding health care to the active and the retiree,” said William “Gus” Pagonis, head of the Defense Business Board and a retired Army three-star who served as logistics chief in the 1991 Persian Gulf War.

What a unified medical command means to the average Joe or Jane is not yet clear, but redundant medical facilities serving different military populations likely could be eliminated as those medical facilities start to look more purple and serve multiple military communities in the Air Force, Navy, Army and Marine Corps instead of being focused on just one, board members said.

Training of medical personnel could also be streamlined.

“Part of the unification will then bring the way we educate and train these people to common standards,” Dreifus said. “Common logistics means you will be able to have better force projection across the services with the delivery of that medicine and not have people working with incompatible equipment or procedures.”

All of this could change manning within the medical community — but it does not necessarily mean shrinking medical personnel within the military, Pagonis said.

“I don’t think anybody is concerned we are going to shrink the medical support,” he said.

Pentagon officials acknowledge that such areas as logistics, operations and purchasing are replicated in triplicate within each service, said Dr. David Tornberg, deputy assistant secretary of defense for clinical and program policy.

Consolidating communications, data sharing and personnel management would save money — and perhaps, lives — by making delivery of care quicker and more efficient, Tornberg said.

Still, Pentagon officials are far from ready to jump onboard. Tornberg said combining some or all of the military’s medical efforts into a joint command is something the Pentagon has been seriously considering for nearly a year — and it’s still not done.

Tornberg said combining medical commands will move forward slowly.

“This is an evolutionary process,” Tornberg said. “I’m a proponent of the concept, but I think it has to be done in a very deliberate way.”

Rep. John McHugh, R-N.Y, chairman of the House Armed Services military personnel panel that has jurisdiction over military medical issues, agreed, saying unification seems inevitable but should not be rushed.

“It is important we have the best information available so we do this right because we are, after all, talking about the health of service members, retirees and their families,” he said.

McHugh said there are some obvious needs for more cooperation, such as a problem discovered in Iraq with military medical units deploying with incompatible ventilators. “There are interoperability issues that have to be worked out, which is one of the major concerns expressed by the Army and Navy,” he said.

McHugh suggested a joint medical command could be based on the same model as U.S. Special Operations Command.

Operational mission orders come from the joint command and units work together jointly, but troops still keep all of the benefits, promotion regulations and traditions of their individual services. The command has a joint headquarters planning and budgeting staff but also has lower-level commands for service-specific capabilities.

McHugh said Congress won’t move on this immediately, but “we need a decision by the fiscal 2008 budget.”

The BRAC effect

Tornberg said he is not operating under any sort of time line to set up a fully functioning joint medical command, but there is an expectation that some changes will have to come sooner rather than later.

Some of that will be spurred by decisions made in the 2005 base realignment and closure process, which is already pushing the services toward increased “jointness” in the health care arena, if not a fully unified medical command.

The Bethesda campus also will continue to be the home of the Uniformed Services University of the Health Sciences.

The most recent BRAC round also will create the joint San Antonio Regional Medical Center at Brooke Army Medical Center, where enlisted medical technicians from all services will train. Medical specialty training for the Army is now done at Fort Sam Houston in San Antonio, the Air Force at Sheppard Air Force Base, Texas, and the Navy at three locations across the nation.

Such moves are part of what Tornberg and other Pentagon officials refer to as the “evolutionary nature of the process,” where there are no sudden and sweeping changes that send panic into the ranks of military medical professionals. Pentagon officials said the incremental process began years ago and is expected to continue in much the same way.

The services have already proved they can work well together at joint facilities abroad. Landstuhl Regional Medical Center in Germany has been a cooperative Army/Air Force effort for more than 10 years. Balad Hospital in Iraq is also an Army/Air Force joint facility.

Rep. C.W. “Bill” Young, R-Fla., the House defense appropriations subcommittee chairman and close confidant of active and retired military medical officers, said some unification of military medical command structure is inevitable.

“I think there are pros about it but also a lot of cons,” he said. “There are a lot of military people very concerned about what might happen, and I think reasonably concerned.”

Air Force objections

Meanwhile, the Air Force strongly opposes a unified medical command for fear it would lose some of its service-specific capabilities.

Air Force Secretary Michael Wynne said he is unwilling to cede control to a centralized medical command, and added that the culture of the Air Force would suffer if he did.

“Telling me that I have to forgo a unity of command on an individual air base, from where I fight, and cede that command responsibility to somebody else so that the wing commander no longer has cognizance over his pilots’ health, is a nonstarter for the Air Force,” Wynne said in an interview.

The Navy and Army, Wynne said, “don’t fight from the bases they live on,” which makes them more willing to cede command authority in this instance.

Under the unified command approach, Navy ships would deploy with Navy doctors and corpsmen, Army units would deploy with Army doctors and medics, but Air Force pilots flying bombing runs from their home bases would return to hospitals manned by all manner of medical personnel.

“We are culturally set up differently in that we fight from the bases that we live on,” he said. “We do not want to … give up our base responsibility and consideration of unity of command.”

Air Force Surgeon General Lt. Gen. (Dr.) James Roudebush made it clear, however, that his service does not oppose the entire idea of a joint medical command.

“We very strongly agree that there are opportunities for savings,” Roudebush said, in such areas as eliminating redundancy and reducing costs on graduate medical education, information technology, logistics and acquisitions systems.

“But we also feel that the Defense Business Board went beyond their purview in recommending organizational changes,” he said.

In that regard, he said, “One size really does not fit all.”

But Vice Adm. Donald Arthur, the Navy surgeon general, said the services really have nothing to lose and everything to gain by working together more on the medical front.

“I think we would gain a lot of efficiencies by standardization of equipment and training and things like that,” he said. “What we would gain is the ability to interoperate in combat service support with the other services a lot better. So our communication would be better, we would be able to swap people and equipment, and the flow of patients would be facilitated.”

The main advantage, Arthur said, would be in standardizing “the people that we have, their training, the equipment, the supplies, the financial management systems, the metrics, the communication, so that we are more like a single operating medical system to support the joint war fighter.

“We don’t deploy as a single service anymore,” Arthur said. “We deploy jointly.”

Col. Bernard DeKoning, the Army’s assistant surgeon general for force protection, said his service supports a unified medical command concept, which he described as an outgrowth of joint efforts that have gone on for some time.

“The services have worked together for years in many areas of health care, such as research, education, training and in certain geographic areas where it makes sense to share health care services,” he said.

In congressional testimony earlier this year, Army Surgeon General Lt. Gen. Kevin Kiley was quite candid in his Army-to-Air Force medical comparisons.

“They have care in the air; we have care in the dirt,” Kiley told the Senate Appropriations Committee in May. “I very strongly support a unified medical command.”

Congress, for its part, has shown interest in a unified medical command, but no one is rushing its creation.

The House Appropriations Committee said in its May report on the 2007 defense funding bill that the first thing to be cleared up is whether the move will save significant money or simply form another level of bureaucracy. The committee wants a report from the Pentagon by Dec. 15 on the feasibility of a unified command and the potential cost savings.

More important to the committee is the creation of a Military Health Office of Transformation to look at the future of military medicine, including possible integration with the Department of Veterans Affairs.

The House Armed Services Committee has expressed interest in any plan that improves the effectiveness of military medicine, while noting that the current health system has provided “superior, high-quality health care.”

Change for the sake of change is not going to win lawmakers’ approval, the committee said in its May report on the 2007 defense authorization bill.

But the report acknowledges that improvements are possible. “Efforts to improve and streamline care have been hampered by the lack of standardized equipment and process,” it said.

Contributing to this report are staff writers Erik Holmes, Rick Maze, Gordon Lubold, William H. McMichael and Kelly Kennedy.