Extraordinary steps in the evolution of military medicine are occurring in the Washington, D.C., area where new medical facilities are being built to consolidate services, and a joint command is being readied to adopt cutting-edge concepts to improve quality and efficiency of service health care.

Two famed medical facilities – Walter Reed Army Medical Center and Bethesda Naval Medical Center -- are being combined into one “world class” medical center, the biggest in the military, said the project’s top officer.

Two nearby community hospitals also are being merged into one large new hospital at Fort Belvoir, Va., a facility will cover as much ground as a local shopping mall with its length equal to that of two aircraft carriers.

At both facilities military staff will be Army, Navy and Air Force health care providers and serve in joint billets. The proportional mix of service staff has not been set but will be influenced by medical deployment needs.

Overseeing the $2.4 billion project, the largest capital infrastructure investment ever made in the military health system, and struggling to mesh three service cultures under a single command is Navy Vice Adm. John M. Mateczun, commander of Joint Task Force National Capital Region Medical.

In an interview, Mateczun said National Capital Region Medical will be a test bed not only of joint staffing but for “transformative business practices” and new approaches to military health care delivery.

In the NCR, for example, officials will strive to improve integration of health care service provided through military facilities and through purchased care from the TRICARE network of civilian physicians or health insurance.

NCR Medical has decided to run a single civilian workforce structure for all of its medical facilities, including 37 clinics. It will be organize to eliminate other cross-service redundancies and to centralize specialty care services.

It is here too that differences in service practices and approaches are being revealed, with the weakest to be discarded and the best embraced as standard procedures. The National Capital Region also will continue to serve as the primary casualty reception site for wounded returning from war, Mateczun said, and care of the wounded will remain its top priority.

Orders to “recapitalize” and consolidate military medical facilities in the D.C., area came down in BRAC 2005, the most recent round of base closures and realignments ordered by Congress. This was the first BRAC to include a comprehensive review of medical infrastructure.

The medical region’s realignment is to be completed by Sept. 15, 2011. By then service at Walter Reed will be transferred to an expanded medical center at Bethesda and to the new hospital at Fort Belvoir. The medical center at Andrews Air Force Base will become a clinic and its inpatient capability added to Belvoir or Bethesda depending on care required.

The consolidated facilities are to have the same total patient capacity as area facilities had before BRAC. Mateczun said reorganization and construction plans are progressing on schedule.

He has led the task force since it was established in September 2007. Mateczun calls it a privilege and challenge to reorganize a region with the “largest collection of military medical forces we have any place in the world.”

Considering the medical school on the Bethesda compound, called the Uniformed Services University of the Health Sciences, and the experience of clinicians in the region, “we have the opportunity to bring together some of the best capabilities…to come up with some of the solutions I think everyone is looking for” to improve quality and efficiency in the system.

The region has a combined military and civilian medical staff of 12,000. Eligible beneficiaries total 545,000, but only about 282,000 of them are enrolled in managed care through one of the military facilities. The rest rely on civilian providers for care, mostly in the TRICARE network.

Mateczun said it makes sense to move from four hospitals to two, explaining that consolidation, especially of specialty care, is a trend in the private sector too.

“One of the things we’re learning is that volume counts,” he said, “particularly in the provision of highly specialized and technical services. Something like transplants or amputee services…are best done in places that do a lot of them. Quality tends to be higher.”

Putting all regional facilities under one command is perhaps the bolder move. He predicts closer coordination of primary care, fewer underserved areas for beneficiaries and a more efficient regional health system. When patients can’t fully use military facilities, they drive up costs by using civilian providers. The region last year spent $588 million on private sector care.

“We have an opportunity to take a look at the money we’re spending on purchased care and try to find the right mix for our population,” Mateczun said. Some higher costs are unavoidable. As military medical personnel are sent to Iraq and Afghanistan, fewer patients at home can get care in military facilities. But productivity can be improved through tighter oversight.

Mateczun said the task force’s biggest challenge has been cultural differences between services. Some are merely style and easy to address. Others are mission-related and must be accommodated. For example, medical support in the Army and Marine Corps are maneuver-capable units. But “deployable” Air Force support is still intended to be next to a runway.

To combine the medical centers alone, more than 160 working groups are deciding what assets and services will be at Bethesda or at Belvoir or at both.

Mateczun said judgments the task force makes in taking control of all medical assets in the region, and how that command operates, will inform a long-running debate over whether to establish a joint or unified medical command to oversee all military medical personnel and resources.

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