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The surgeons general of Army, Navy and Air Force have criticized defense officials for imposing $650 million in phony “efficiency wedges” on their medical budgets that will not produce real efficiencies but will only mean cuts in on-base medical services for beneficiaries.

The feud between the services’ top medical officers and the office of the undersecretary of defense for force readiness and personnel got its first public airing at a February meeting of the Task Force on the Future of Military Healthcare. They continued (and perhaps intensified) their criticism March 27 before the House armed services subcommittee on personnel.

To illustrate the impact of a $343 million cut to Navy medicine, Vice Adm. Donald Arthur said it’s comparable to closing a large family practice hospital at Camp Lejeune, N.C., or the naval base in Pensacola, Fla.

To capture the cynicism of the maneuver, Arthur quoted Portia in Shakespeare’s “Merchant of Venice”: “You may have your pound of flesh but draw nary a drop of blood.” The same sort of impossible circumstance exists here, Arthur said, with defense officials telling military medicine to handle the budget cuts simply by being smarter managers.

“There is no more flesh to be gained without drawing the blood of [medical] services from our family members and our active duty,” Arthur said. Unless Congress intervenes, he continued, “we will have to have a serious conversation about what services we can provide at 16 percent less funding than the year before.”

Maj. Gen. Gale S. Pollock, acting Army surgeon general, said her cut is the “budget equivalent” of losing a large Medical Department Activity (MEDDAC), which means a community hospital plus support elements.

“Basically it means we’re going to take an entire MEDDAC out of our ability to contribute to the health care of the men and women in uniform and their families,” Pollock said. “There is no way I can salami-slice that. … [W]e will need to make a decision about what we are going to stop doing.”

“So it’s not efficiency. It’s a flat-out cut in service at a time when our nation’s at war?” asked Rep. Vic Snyder, D-Ark., chairman of the personnel subcommittee.

“Sir, it will be a cut in service,” said Pollock.

The Air Force faces its own $190 million efficiency wedge for the fiscal year that begins in October. Lt. Gen. James G. Roudebush said there are ways to handle it besides cutting patient services but none will produce real savings. Patients who can’t be treated on base simply move to the private sector, which means even higher Tricare costs, said the Air Force surgeon general. But before that happens, the service will slow spending on facility maintenance, on new medical equipment, on research and training.

“Your seed corn?” Snyder asked.

“Yes sir,” said Roudebush. “You push things downstream,” creating “a bow wave of obsolescence, a bow wave of risk.”

The efficiency mandates imposed by defense officials are in addition to $1.86 billion withheld from the 2008 defense health-care budget on the assumption that Congress will approve the Bush administration’s plan to raise Tricare fees on military retirees under age 65 and their families.

Arthur told the military health-care task force Feb. 20 that, in his opinion, the efficiency wedges directed by Dr. David Chu, undersecretary of defense for personnel and readiness, are just one more way to show lawmakers the consequences of not raising Tricare fees.

“I don’t like it,” Arthur said, “but I think we’re being squeezed in the middle of the politics of that.”

Defense officials want money shifted from military direct care to help pay for burgeoning Tricare support contracts for networks of physicians and other providers who treat beneficiaries off base, Arthur said.

“If we are going to make these kinds of cuts we will be delivering care to active duty only; we’ll be having pharmacy services provided not in military treatment facilities but in private sector care. This, in my opinion, will increase the bill overall because it will force more care out into the private sector where, on the margin, it is more costly to provide.”

The surgeons general also warned of plans to convert another 2,700 military medical billets to civilians starting in October, on top of 5,500 already converted since 2005.

When conversion plans were set, said Pollock, “we did not take into consideration that we could truly be in a long war and some of the elimination we’ve done are for staff we now realize are absolutely critical.”

It’s not only a physician-nurse issue either, said Pollock.

“I’m also concerned about our enlisted soldiers [who] have been converted to civilians. We’re unable to get the mental health specialists that we’re able to train and use as part of that care team. We’ve not been able to do the hiring for those positions that were eliminated,” she said.

The Navy, Arthur said, has been able to fill only 83 percent of health care billets converted to civilian positions. If that pattern holds, the 2008 conversions will leave the Navy short 136 more medical staff, he said. “I was at Bethesda [Naval Medical Center] this week and was told of a problem with overtime pay to the civilians we had [converted], because it’s already an issue. They [work] no nights, no weekends, 40-hour-weeks, no deployments. And they sit right beside a lesser-paid active-duty member who is doing the same job,” Arthur said.

Army medicine has asked for a hold on more military-to-civilian conversions, Pollock said, “so we’re making better decisions and not breaking health care as a result of a personnel change.”

The Navy will have to reverse course on cutting 900 more corpsmen, Arthur said, because the Marine Corps will need more as it grows by 28,000.

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