Friday, September 04, 2009

Funding Health Care Reform - The Military Option

Every year of my 13 and a half years of active duty service in the US Navy it sat in the corner. Dark. A symbolic reminder of our mission. To protect and defend the Constitution of the United States. And the President.

'It' was the coronary care unit bed reserved just for the President. In my 13.5 years of service, I saw it used one morning: when preparations were made to perform cardioversion on then George Bush, Sr. after he developed atrial fibrillation while at Camp David. Remarkably, the room never was used since the President reportedly converted to sinus rhythm after an overnight loading dose of Procainamide. I remember the country breathed a collective sigh of relief that Dan Quayle wouldn't have to assume command of the country for those brief seconds of unconsciousness. (Politics is funny like that.) So the room was darkened again, just in case.

Recall that Washington had three military hospitals at the time: Walter Reed, Bethesda Naval hospital, and Andrews Air Force base. Why? Egos. Never mind that any serviceman would receive excellent care at any one of the facilities. Commanders fought to preserve their branches health care facilities tooth and nail. Commanders knew that relinquishing control of this benefit was a sign of weakness.

Things are a bit better now. In 2005, the Base Realignment and Closure committee recommended Walter Reed be closed. Presently, construction is underway to expand Bethesda Naval Medical Center so it can consolidate Walter Reed's Army care in the new facility. Tons of tax-payers money, but hey, it's needed for our military medicine mission.

Or is it?

This is not a small question in this time of great concern over where we get the money to pay for our nation's health care reform. Do we really need the duplicity of health care services offered by our military medical centers? Washington DC already has tons of civilian medical centers. Because of challenges the military has is recruiting subspecialists (neuroradiology was short-staffed when I was there), they often contract out services from civilian counterparts to fill staffing requirements - often at greater cost to them than their military equivalents. Other shortcomings exist as well: Bethesda is not even a Level 1 trauma center - mostly because of the security detail that limits access to the facility. (Imagine: a military center that doesn't see much trauma!) So they send their surgical residents to do rotations at the city's trauma centers. I, too, had to attend a civilian facility to learn my craft on the government's nickle. And at least six civilian medical centers are within a stone's throw of Bethesda.

Military medicine permits some interesting military-specific training, like biologic and chemical warfare training with all it's MOP gear. (Looks like fun, right?) But is there really a need for these facilities and all the personnel infrastructure they require as we struggle to find a way to fund our nation's health care? The government already has the glacially slow, underpaying Tricare and Tricare Prime insurance for our military members so they can receive care at civilian facilities when military medicine cannot fulfill the servicemen and servicewomens' needs.

The bottom line is, we should carefully reevaluate all our options for spending our precious health care resources wisely, and this includes greatly reducing or shuttering our military health care facilities.



Dharma said...

Hmmm, contemplative article. Good points. However, I think as a veteran, all that can be done to care for our military, especially in recovery of trauma and lose, horrific injuries; that an environment that is exclusively involved in the care of our soldiers should not be short changed or spread out in the multiples of others. It is the least we can do to have a place to concentrate on the recovery needs of our soldiers and support for their families.

I think more attention should be made to encourage government to consolidate these medical facilities into one without compromising their care or recovery and have other medical personnel resources available when needed from other medical institutions, until there is an active interest after medical training to work and specialize in areas needed for the military medical facility. Now, if we could just get Congress to get their heads on straight it would be a plausible cost effective feet for those that risk their lives to keep our country free.

Anonymous said...

As a military doc, I think it is time we put this organization out of its misery. All I can say is wow, this is one messed-up, horridly inefficient dystopia and we could be spending our military medical money in a much better fashion.

Chris said...

In the poli sci literature, there has been an attempt to explain why South American democracies have had problems with military coups while the US has not. One book I read ripped apart a variety of theories ranging from "machismo" to command structures and concluded that it was only traditions within the US military culture that kept commanders from trying to usurp power and lower ranking officers from following them.

While I am not a pacificist, isolationist, or progressivist, I think we have to realize that the military is a special sector of society that takes part in marginal activities and is an intrinsic threat to society. This is why they stay partially isolated (ie, quarantined) by their own sets of values and habits.

In recent years, from the increased use of private contractors in combat theatres to the "normalization" of military life as a recruiting/retainment tool, I see the lines between civilian and military blurring, and it is not a direction I like to see us moving in.

As a taxpayer, I am happy to pay a higher rate, if necessary, to preserve separate military facilities and lifestyles.

Furthermore, I am not sure about th logic of this post. If the military has to pay more when it sends troops for civilian treatment or HCPs for civilian training, I don't see a big potential cost savings by outsourcing all the military health care.

Anyhow, there couldn't that much savings to begin with. Military spending is only high if you discount entitlements. When entitlement programs are added in, the military doesn't look so expensive.

preparations were made to perform cardioversion on then George Bush, Sr. after he developed atrial fibrillation while at Camp David. Remarkably, the room never was used since the President reportedly converted to sinus rhythm after an overnight loading dose of Procainamide

Uh oh, HIPAA violation!

Keith said...


And while we maintain a bed for the president on standby, which is more wasteful; paying an insurance company CEO hauling in 20 mil a year or having this room sitting empty 365 days a year? Your example shows again that waste is identifiable in both systems and often most egregious at the upper levels of management. This applies to both goverment management and corporate management. I find the more significant waste to be on the corporate side.

But the bottom line is did these servicemn get good care? I would think physician input as to cost savings would be more influential in the goverment structure (maybe naive on my part) than it has been in on the corporate side where the objective is to make more money. Attempts to improve efficiency in terms of cost reduction to the health care system are not likely to be favorably received unless there is alignment with the profit motive. Currently this alignment is non existent, which accounts for why many medical students are opting for speialties vs primary care fields. Studies time and again show lesser costs of health care with a proportion of primay care providers to specialists more along those in Europe an Canada and no change in most measures of health.

As I mentioned in an earlier post, Medicare spends 5% on managemnt and administration vs 20-30% for private insurers. Yes, Medicare is underfunded and will eventually go broke under the current set of rules, but is still highly efficient in comparision. No fighting over your claim, no 20 mil per year CEO, no preauthorization of your MRI or referral to a specialist, no shareholder to pay dividends, etc. etc.. And 95% of your dollar goes to meical care. Giv me a private plan that will garanty this medical loss ratio and I will snap it up in a minute. the problem is that big insurance realizes this and knows if they have to compete with a goverment plan that say can offer the same product and pay 90% of its money out as claims (thats money going to providers of health care; not all the profit merchants that have lure to the health care bisiness by all the dollars involved) then they will either make much less or go out of buisiness. That is why you see them figting so hard against the public option.

DrWes said...


Uh, oh, HIPAA violation

Not. This was common knowledge reported in the news (see the link I referenced).

Keith -

As I mentioned in an earlier post, Medicare spends 5% on managemnt and administration vs 20-30% for private insurers.

Cost savings? Maybe, maybe not.

Keith said...


You will not that I pegged Medicare administrative costs at 10%, even though the current estimate is closer to 5. This is because I suspect that a goverment run plan will need to act more like a for profit insurance company and perform preauthorization of some more expensive procedures in order to guard against fraud. But how does this protect against fraud anyways (as mentioned in the piece you referred me too). If providers ar going to commit fraud, the ar simply going to lie in the pre-authorization process.

The layers of expensive administrators and shareholder dividends ar where the real savings are. And some will b obtained from simplified rules and the fact the goverment program is unlikely to make providers chas their tail trying to get paid like for profit insurance does. I know that in my office, I could reduce my personnel overhead at least 25% if I was paid by all insurrs like I am by Medicare.

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