Top AF doc: Hospital commands keep critical role amid reforms
At the direction of Congress, the Department of Defense is implementing sweeping reforms to how the military's direct health care system is administered, with the Defense Health Agency gaining authorities that long have resided with the surgeons general of the Army, Navy and Air Force.
Lt. Gen. Dr. Mark A. Ediger, Air Force surgeon general since June 2015, agreed to share his perspective on the "extensive changes" underway. In a phone interview last week, he predicted that the reforms will succeed in "providing a more standard experience of care" across the military health system, in focusing uniformed medical forces more on readiness and operational requirements, and, "of course, in producing some savings."
But, he added, hospital commanders will remain "essential" to preserving the three primary functions of base hospitals and clinics: to provide excellent care to beneficiaries, provide medical support for the day-to-day mission, and keep that medical force ready for war.
"As we approach reform … in the interest of achieving greater standardization and more consistent experience in care, but also more efficiency, it's going to be very important that we work very hard to keep those three purposes fully integrated at each hospital and clinic," Ediger said.
"Where the mission happens," he added, there must be "one commander responsible and accountable for seeing that the support to the mission, the care to beneficiaries and the readiness of medical teams are all appropriately balanced."
Reforms Congress enacted in the fiscal 2017 National Defense Authorization Act include making the Defense Health Agency, which was established in 2013, responsible for management of all military hospitals and clinics by Oct. 1, 2018.
Patients will see processes across base facilities streamlined, Ediger predicted, standardizing how pharmacies operate, medical appointments are set, health records are maintained and laboratory tests processed and shared. Beneficiaries will see the same processes "whether they get their care in an Army, Navy or Air Force facility," he said.
Patients also will see certain clinical services shifted from base facilities to TRICARE civilian provider networks. And across Air Force medicine, Ediger said, he anticipates a changing mix of military and civilian medical staffs.
"And then, at the headquarters level, we're going to see some reductions in staff supporting health care operations, as responsibilities are shifted or consolidated in the Defense Health Agency," Ediger said.
What the reforms will not change, he emphasized, "is the focus on keeping airmen medically ready and sustaining a ready, deployable medical force. Also, the focus will stay on trusted care for those we serve."
The Defense Health Agency is working closely with the Army, Navy and Air Force on implementation plans. A progress report to Congress is due next March.
Congress has been pressing the military for several years both to improve wartime medical readiness and to use base hospitals and clinics more efficiently, by caring for more patients and reversing a steady exodus of patients to TRICARE civilian provider networks. Contractors now provide 65 percent of beneficiary care.
Ediger said addressing the two goals is a balancing act because readiness demands can make base hospitals less efficient than private sector facilities. They not only must provide good health care, he said, but be "platforms for keeping a ready medical force so we have skilled and clinically current military clinicians to deploy to support combat operations or provide humanitarian assistance."
To keep wartime skills sharp, "we heavily leverage partnerships with private-sector health care institutions that provide trauma care and critical care," Ediger said. Schedules of deployable specialists at base hospitals are managed to ensure "opportunities to go to a trauma center or to a busy critical care platform."
To lessen the impact on hospital efficiency, Ediger said, the "first preference" of base hospitals is "to pull as much specialty care as we can into our own hospitals to help keep them ready. And that's where partnerships with organizations such as the VA are so important to our readiness."
The Department of Veterans Affairs cares for a population that needs more specialty care and more complex care than military hospitals routinely provide.
"And so, through agreements (with VA])we can sustain the readiness of our military forces in our hospitals, use the capacity in our hospitals to a greater extent but also give those veterans good access to excellent health care," Ediger said.
That initiative has been slowed for the past two years by the VA Choice program, Ediger said. Congress enacted Choice to improve access to private-sector care for veterans who live far from VA facilities or face long waits for VA care. As Choice broadened access to VA-funded provider networks, it also crimped the flow of complex cases to military hospitals.
"We're now seeing some rebound increase in the VA referrals, but they are primarily outpatient," Ediger said. "We really need more inpatient admissions from the VA. We can provide care to those veterans at a savings to the taxpayer, and it will help keep our teams ready" by handling more complex specialty care.
Ediger said he expects the mix of Air Force physicians in base clinics and hospitals to change, "driven by the requirements of the combatant commands" for more teams of providers trained in critical care medicine.
The Air Force will need more officers trained in "emergency medicine, some surgical specialties, some internal medicine specialties, but also in critical care nursing. On the enlisted side, we will see an increase in cardiopulmonary technicians" driven by a rising need of combatant commands "to move critical care patients through the aeromedical evacuation system."
More critical care specialists will mean a reduction in other providers, Ediger said, because "this is a zero-sum game. We know that the Air Force is not able to pour more military end strength into the medical capability. And so, to make that change to force structure, there will be some offsets."
"We are still in the process of analyzing what specialties they would be," Ediger said. "It could be, to some extent, in primary care, pediatric or obstetric areas. We do need those skill sets for deployable ops. It's just a matter of do we need all we currently have, or may there be an opportunity to convert some of those requirements to civilian positions?"
The Defense Department is urging Congress to adopt higher pharmacy fees and to raise co-payments and deductibles for working-age retirees. Those are cost-saving moves that, in Ediger's view, won't improve health care choices by patients.
The Air Force flat out opposes calls by some lawmakers and beneficiary associations to save more money by eliminating the surgeons general and merging three separate uniformed medical services into a single "purple suit" medical corps.
The military requires medical support tailored to the mission, Ediger said.
"By having an Air Force medical service, we're able to tailor our medical support to the mission airmen are asked to perform," he said. The Air Force's strong focus on aerospace medicine allows airmen to meet performance demands unique to the flight environment with its special physiologic and psychologic challenges.