The Air Force, the only service opposed to creation of a Unified Medical Command, saw its arguments get strafed, rocketed and bombed during a Sept. 6 meeting of the Defense Business Board, a group of outside management experts that advises Defense Secretary Donald Rumsfeld.
The board unanimously recommended that Rumsfeld immediately appoint a task force to oversee establishment of a Unified Medical Command by Jan. 1, 2007, a year sooner than Defense officials had planned.
The command would take charge of all direct-care health services of the Army, Navy and Air Force. It would streamline medical logistics, purchasing, information technology, research and development, facility operations, and the education, training and assignment of medical personnel.
The services would continue to control medical care in support of front-line units and field hospitals. But Level III operational medicine, which includes all fixed military hospitals and clinics, would be run by the new command which would report directly to the defense secretary.
The board, which endorsed the most sweeping reorganization of military medicine in 60 years, also recommended that:
The Tricare Management Activity, which oversees the triple-option health plan for military families and retirees, be realigned to function alongside a unified command, with a new focus on policy and oversight. Management of the Tricare benefit in time would be “outsourced” to the private sector.A transition team for establishing the unified command be created and given milestones of 30, 60 and 90 days to ensure a Jan. 1 start-up. The board believes legislation is not required because the Department of Defense already has authority to streamline health services.Dr. Stephen Jones, principal deputy assistant secretary of Defense for health affairs, said after the meeting that the board’s time line is “very optimistic.” But a consensus is building toward a unified command “or a similar organization” to merge service medical systems, he said.
Lt. Gen. James G. Roudebush, who became Air Force surgeon general last month, said his service opposes a unified command. It would take control only of the direct care system, he noted, which has seen only modest cost growth in recent years. It is expansion of the Tricare benefit that “has driven costs upwards at a very alarming rate,” Roudebush said.
Also, he argued, service missions and cultures are different, and those differences justify having separate medical staffs and resources.
Finally, he argued, the services are responsible under Title 10 of the U.S. Code to provide a fit and healthy force. That’s a mission “we take very seriously, Roudebush said. A unified command “begins to move that away from the purview of the services,” he said.
The services should consolidate some responsibilities to lower costs, such as graduate medical education and perhaps information, acquisition and logistical systems, he said. These steps alone would save a lot of money and not put “at risk” service responsibilities to care for their own forces.
The Defense Business Board is an advisory panel, governed by sunshine laws, so the meeting Wednesday was open. Though held in a small Pentagon conference room, it offered a rare public look at a hotly contested issue between services.
Vice Adm. Donald C. Arthur, the Navy’s top medical officer, challenged Air Force arguments. He was joined by members of the business board, as well as a two-star admiral on the Joint Staff and a two-star Army general who is the deputy director of Tricare.
Arthur said the services separately recruit, train and assign medical staff and operate three separate systems for logistics, for the purchasing of supplies and equipment, and for budgeting and quality assurance.
As a result, they waste up to $500 million annually, according to the Center for Naval Analyses, he said. Henry Dreifus, a board member who led its medical task force, said the CNA figure is probably much too low.
“We are not interoperable, interchangeable or even interdependent,” Arthur added. The problems this creates aren’t obvious when operating separate hospitals in peacetime. But they arise in war zones such as Iraq and Afghanistan, Arthur said, when the medical services learn they “can’t interchange people, equipment, supplies or doctrine.”
Army Maj. Gen. Elder Granger stood to say he saw such difficulties firsthand while a senior medical commander and surgeon in Iraq. For lack of compatible gear, he said, Army medical staff could not communicate with Air Force colleagues regarding wounded arriving in medical evacuations. Also, he said, patient ventilators were not interoperable. Consequently, patients had to be taken off ventilators for brief periods during transport back home.
The wounded still got “world-class care,” said Granger, now deputy director of Tricare. “But it’s all like piecemealed together.”
Arnold Punaro, another business board member and chairman of a commission studying National Guard and Reserve issues, challenged the notion that a unified command would encroach on service legal obligations to provide medical care to their own forces. It’s more likely, he said, that by maintaining separate medical departments, the services are violating laws that mandate consolidation of common functions.
Retired Army Gen. William “Gus” Pagonis, chairman of the business board, led U.S. logistical operations during the first Gulf War. He said he would brief Rumsfeld on the board’s recommendations as soon as possible.
“The key is this transition team,” Pagonis said. “It really has to decide what’s doable, what’s not doable.” But he predicted to Jones that if board recommendations are adopted, “you will see all kinds of savings.”
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