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HEIDELBERG, Germany — More than a decade ago, U.S. soldiers and families stationed in Europe received nearly all their medical care at 11 U.S. military hospitals and 54 clinics.

But as 2007 begins, with just two remaining U.S. Army hospitals — Landstuhl and Heidelberg — and 24 clinics, more and more medical care is being referred to local European physicians. That has been an adjustment for many Americans.

“The biggest problem we have is meeting the expectations of our beneficiaries. For many soldiers and families, that expectation is to be seen in an Army hospital or clinic,” said Brig. Gen. David Rubenstein, commander of the European Regional Medical Command.

The majority of the more than 5,000 daily outpatient visits are in Army clinics or the two hospitals, which specialize, he said, in “babies and bones.”

But about half of the 60 in-patients, on average, in Germany every day are in German hospitals. In Italy and Belgium, where there are no U.S. Army hospitals, (although a birthing center opened in 2005 in Vicenza, Italy) the percentage is much higher.

“For the past 10 years, as we’ve been closing hospitals, more and more of our patients are being admitted into local hospitals,” he said. “My biggest challenge is to ensure that they’re comfortable with where and how they receive health care.”

Rubenstein says that’s being managed with such things as patient liaisons, bilingual workers assigned to every U.S. patient in a European hospital, and he lauds the care provided by European doctors. Although he also says, “I would put an Army physician up against any physician, anywhere.”

As the number of U.S. Army Europe soldiers becomes fewer with transformation and as bases scattered throughout Germany have become centralized into several hubs, one of Rubenstein’s jobs is to figure out which facility to close when, how to avoid gaps in care, and where to expand — all in a financially responsible way while paying attention to people’s medical needs.

“Transformation to me is knowing when to close a facility. Ideally, the last building to close is the clinic,” Rubenstein said. “If there are still soldiers and families in the community, we use our network of German providers and provide that care.”

And there are other concerns.

“The other big mission we have is to stay in business,” Rubenstein said. “If we’re not being efficient, it becomes cheaper for the big system to just shut us down and send everybody downtown” to local doctors.

So, for instance, in deciding how best to provide orthopedic surgery in Bavaria, should he ask for another surgeon? Or base the one he has at one clinic and send him out to provide care monthly at other bases?

The latter idea was chosen last summer after the Würzburg Hospital, by then with a very low patient census because the 1st Infantry Division had been repositioned in the U.S., closed down, along with three clinics.

But it’s not all closings. Landstuhl is expected to be expanded, hinging on congressional approval, with construction expected to begin in about four years, he said.

Other areas where troops will remain — Grafenwöhr, Vilseck in Germany and Vicenza — are getting new and renovated clinics. In 2005, a birthing center opened in Vicenza because American mothers-to-be were not all comfortable delivering in Italian hospitals.

“That was a tremendous dissatisfier,” Rubenstein said. “General B.B. Bell (former USAREUR commander) heard it over and over, and he decided women in Italy would have that.”

“English-speaking is a big deal,” said one expectant mother when the center opened. “I want to know what’s going on. And I don’t want to have to wait for a translator to tell me.”

Rubenstein, who took command of ERMC last summer and held previous postings as Landstuhl commander, 30th Medical Brigade commander and ERMC chief of staff, said challenges in staffing and closing facilities don’t change his goal as commander.

“When I walk away from here, I want it to be a compassionate military health-care system with trained and ready-to-deploy units, competent, values-driven people and informed, self-sufficient families,” he said. “All our decisions, effort, money and time are focused on that.”

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Nancy is an Italy-based reporter for Stars and Stripes who writes about military health, legal and social issues. An upstate New York native who served three years in the U.S. Army before graduating from the University of Arizona, she previously worked at The Anchorage Daily News and The Seattle Times. Over her nearly 40-year journalism career she’s won several regional and national awards for her stories and was part of a newsroom-wide team at the Anchorage Daily News that was awarded the 1989 Pulitzer Prize for Public Service.
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