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DoD Moves Toward More Joint Medical Services While Avoiding a Unified Command

By U.S. Medicine

By Sandra Basu

WASHINGTON — Faced with growing pressure to consolidate medical services to control skyrocketing costs, DoD has endorsed a middle-ground measure that moves the department toward greater consolidation without dramatically changing the structure within the military services.

The proposal to reorganize MHS as a Defense Health Agency (DHA) will allow the services to operate more jointly while causing the least amount of disruption during implementation, according to Assistant Secretary of Defense for Health Affairs Jonathan Woodson, MD.

“It is the department’s position that this is the responsible, iterative way forward that will produce the maximum efficiencies with the least disruption,” Woodson told a House subcommittee recently.

The new plan, released last month, calls for absorbing the functions of the TRICARE Management Activity into the new DHA, as well as common clinical and business process across the MHS, including medical education and health information technology.

It would not eliminate separate medical commands for the Army, Navy and Air Force and  establish a Unified Medical Command, as called for in 2006 recommendations by the Defense Business Board.

The new plan was based on a recent DoD task force report recommendations and other factors. DoD agreed with the task force that the DHA model is the best way to move forward, rather than taking more drastic options the task force had considered and rejected, including the proposed Unified Medical Command.

The DHA would, however, institute new business processes and appoint market managers in areas with multi-service medical facilities in an effort to streamline operations. It also would seek to reduce redundancies among the services’ medical commands in areas such as purchasing, logistics and information technology. The position of director of the DHA would be a general or flag officer in the grade of Lieutenant General or Vice Admiral.

As part of its recommendations, DoD also is calling for a new directorate within the DHA to succeed the Joint Task Force National Capital Region Medical in managing military-treatment facilities within the National Capital Region, including Walter Reed National Military Medical Center and Fort Belvoir Community Hospital.

A Way Forward

Reorganizing the MHS has been a controversial issue, with numerous prior reports examining the issue, but with little change resulting. Cost is one of the reasons why examining reorganization is pertinent, the recent report points out.

“Overall trends in American medicine, coupled with increases in both beneficiaries and health benefits in military medicine, drove MHS costs from $19 billion in 2001 to $53 billion in 2011,” the task force report states. “The dual imperatives of ensuring superb medical support for current and future military operations and instituting enduring healthcare cost-containment measures require that the DoD continue this momentum of military-health transformation. The DoD needs to operate the most efficient health system possible, elevating cost containment as a priority objective and increasing unity of effort as an implementation capability.”

The task force stated that one of the strengths of the DHA model is that it would reduce duplication and variation, thereby achieving significant cost savings. Its ease of implementation also was noted.

“This organizational construct would retain those elements of the existing MHS governance structure that do not require major organizational upheaval, as would any Unified Medical Command model or more comprehensive DHA option. [It] would place a general or flag officer, of any medical corps, as the director, creating a fourth military-led entity of the MHS,” the task force wrote.

A weakness of the DHA proposal cited is that it “would not establish undivided MHS authority, direction and control over the entire system and would add complexity to the coordination of deployments between Services and the DHA.”

For the task force, the strengths of the DHA outweighed the value of a single line of authority, which would be offered by a Unified Medical Command, especially because the latter would be difficult to implement.

Implementing a Unified Medical Command “would represent a significant departure in governance for all existing organizations (Health Affairs, TMA, Military Department Secretaries, Military Service Chiefs, Service Medical Departments). For the Air Force, this includes creating a medical component command for operation of Air Force medical-treatment facilities; the Navy would need to redesign how garrison billets are mapped to operational requirements,” the report explains.

Transforming the MHS

Woodson told the House Appropriations Subcommittee on Defense that a Unified Medical Command would also be a more expensive option to establish and that current DoD recommendations would not preclude a move to greater joint operations down the road.

“The issue is that this is an iterative approach, a sequential, reasonable approach to producing greater unity of effort, greater efficiency, particularly with the shared entities without causing major disruption at this time,” he said. “It doesn’t prevent us from doing other things, if the timing is right or the conditions become right for doing those things.”

One question posed by Rep. C.W. Bill Young, (R-FL), chairman of the House Appropriations Defense Subcommittee, was how the changes recommended for the National Capital Region would impact the Walter Reed National Military Medical Center and the National Capital Region.

“I see it as an extra layer of governance over and above the Army and the Navy that has done this for years. What will that extra layer of governance do to enhance what the Surgeons General and their medical professionals do to protect our kids? What will it do to enhance medical care,” Young asked.

Woodson responded that it would make for “better command and control of coordination” to the National Capital Region and the oversight of WRNMMC and the Fort Belvoir Community Hospital.

Before DoD can move forward in implementing the report, the GAO has 180 days to review it, and Congress then has 120 days to review the report.

DoD Task Force on Military Health System Governance

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