Perennial Issue of Combining Military Medical Services Comes Up Again

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Editors Note: Since this story went to press, DoD announced it is recommending a Defense Health Agency be established as part of a new model of governance for the MHS. This option was chosen in favor over a Unified Medical Command and other options considered. For more information please read breaking news item “DoD Plan Calls for Changes to MHS Structure.” Please also stay tuned for the April issue that will also include an article on this topic.

By Sandra Basu

WASHINGTON — Combining military medical services, a controversial issue that first came up more than 60 years ago, is being debated again, with a Pentagon task force examining the governance issue, and the topic being discussed at a recent legislative hearing.


Vice Adm. John Mateczun, MD

At the House hearing, military medical officials explained that, while delivery of care to patients may be similar among the services, differing business and accounting practices can make it difficult to work jointly off the battlefield.

“This is a maturation process that we have to identify what are all of those business processes and standards that are different. Delivery of care is not different, but the way that we manage it is different, and we have to find that commonality for sure,” said Army Surgeon General Lt. Gen. Patricia Horoho, RN, who testified recently with the surgeons general of the Air Force and Navy before the House Committee on Appropriations Defense Subcommittee.

Meanwhile, a report from a recent Pentagon task force examination of the MHS governance issue has yet to be published. Past studies have suggested that military medical services should be combined, and members of a key House subcommittee expressed dismay that administrative issues stand in the way, using Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD, as an example.

One lawmaker commented that the issue of how the services were working together to deliver healthcare jointly became “muddier and muddier” as the surgeons general explained some of the administrative challenges in working together.

Walter Reed

Much of the discussion at the hearing centered on whether the administrative structure at WRNMMC, a joint medical center considered a test case for combining the services’ medical operations, is falling short of expectations.

WRNMMC’s governance is unique in the MHS. Before the Walter Reed Army Medical Center and National Naval Medical Center combined, the command and control for the facilities rested with their respective services. Now, the new combined medical center’s operational oversight is provided by the Joint Task Force National Capital Region Medical (JTF-CapMed). The Task Force was created in 2007 and reports directly to the secretary of defense through the deputy secretary of defense, rather than Army or Navy leadership.

Rep. C.W. Bill Young (R-FL), chairman of the subcommittee, wanted to know what qualifications, experience or training of JTF staffers makes them uniquely qualified to perform the oversight responsibilities of the medical center over the “surgeons general who have been running military medicine for years.”

Vice. Adm. John Mateczun, MD, commander of JTF-CapMed, said that JTF staff have “no different knowledge, skills or experience” but a command and control authority that allows them to execute the mission they have been given.

“When you are able to execute across the Army, Navy and the Air Force and do it effectively, you can find efficiencies,” he said. “We don’t have any more knowledge. It’s not a special secret. It’s purely a matter of the authorities and how you exercise them.”

Still, Air Force Surgeon General Lt. Gen. Charles B. Green, MD, acknowledged to the subcommittee that there is “friction,” because the JTF would like the services to operate more jointly there, though the lack of joint policies and guidance among the services sometimes makes it difficult.

“From my own personal perspective, because we don’t have joint credentialing guidance and joint nursing policy and joint patient registration, we need to really operate the hospital today by one service’s rules,” Green said. “So, there is friction, because the JTF would like for us to move toward more joint oversight and, because that doesn’t exist yet, trying to move in that direction is difficult.”

Rep. Jim Moran (D-VA), pointed out that prior studies have concluded that the military medical services should be combined. WRNMMC is supposed to be the “national example” of how this would be done, he said, but it seems to be “falling short.”

“It is a bit frustrating when we hear reports from folks who allege to know and would have reason to know what they are talking about, and, I put it in quotes, a ‘dysfunctional leadership arrangement,’ at the combined Walter Reed campus,” he said.

Navy Surgeon General Vice Adm. Matthew L. Nathan, MD, explained that the format is “a new chain of command format that presently has not been precedent in military medicine.” He acknowledged there have been “growing pains” in putting this new chain of command together but also said they were “finding their way through it.”

Joint Governance

The Pentagon Task Force report on MHS governance referenced at the congressional hearing was also touched upon at the recent 2012 MHS Conference. Assistant Secretary of Defense for Health Affairs Jonathan Woodson, MD, told an audience there that, in 2011, a Pentagon task force examined the question of a unified medical command.          

The issue of whether a Defense health agency or a unified medical command would lead to more savings has been examined in multiple studies in the past 40 years. A GAO report released last year found that realigning DoD’s military medical command structures and consolidating common functions could increase efficiency and result in projected savings ranging from $281 million to $460 million annually.

The idea remains controversial, however. The GAO report last year pointed out that, while most studies that have been done since the 1940s had either favored a unified system or recommended a stronger central authority to improve coordination among the services, “DoD has taken limited actions to date to consolidate common administrative, management and clinical functions within its MHS.”

Rep. Norm Dicks (D-WA), noted at the hearing that “governance and military health is a topic that has been widely studied and discussed, but is difficult to change.” Last year some House members tried to bring change about through a provision in a bill that would have reorganized the MHS under a unified medical command, but the provision was ultimately rejected by the Senate.

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