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Air Force opposition has scuttled Army and Navy plans to merge the three services’ large medical bureaucracies, led now by three surgeons general, into a single Unified Medical Command.

Deputy Defense Secretary Gordon England decided this month not to endorse such a major streamlining of the military health care system with Air Force leaders so strongly against it.

Instead, England approved a more modest “new governance plan” for the health care system that directs joint oversight over four “key functional areas.” Dr. William Winkenwerder, assistant secretary of defense for health affairs, explained England’s “conceptual framework” in a recent phone interview.

Areas targeted for joint oversight are:

¶ Medical research. The Army Medical Research and Materiel Command, headquartered at Fort Detrick, Md., would oversee all military medical research. Winkenwerder said a process would be established “to ensure that the interests and equities of all three services are represented in setting priorities and ensuring that appropriate research gets done.”

¶ Medical education and training. The 2005 Base Realignment and Closure legislation already directs creation of a joint center for enlisted medical training at Fort Sam Houston in San Antonio. England embraces that change and wants more common training, standards and approaches. At the same time, said Winkenwerder, England recognizes that certain aspects of medical training will have to remain service-distinct.

¶ Health care delivery in major military markets. Starting with San Antonio and Washington, the services are to shift toward a single service being in charge of care delivery in areas where there are large beneficiary populations and multiple hospitals.

¶ Shared support services. The services are to consolidate certain support services including information management and technology, facilities construction, contracting and procurement, and perhaps some logistical and financial functions.

Whatever entity is created to oversee shared support services, it will report directly to his office, Winkenwerder said. But just as the Army will control medical research, a single service will be responsible for medical education and training, and for health care delivery in major markets.

The details are left to a transition team that soon will be named to review options and recommend steps to implement England’s concept. Winkenwerder said he doesn’t know yet who will be on that team. He predicts it will require a minimum of two years to implement the changes.

The Tricare Management Activity will remain, but it will focus on health insurance, support contractor management and benefit delivery. TMA will lose other joint support responsibilities such as information technology. Those duties will shift to the new shared support services organization.

Though the course that England has set is less ambitious than a unified medical command, it still “needs to be planned and implemented in a very careful, detailed, thoughtful way,” Winkenwerder said.

Everyone recognizes, he added, that the military health care system delivers care anywhere in the world, achieves “incredible results” in saving lives and treating wounded, and provides “a benefit highly prized by beneficiaries.” Therefore, “an underlying theme in all of this is we did not want to break anything that was working well.”

Army and Navy plans for a Unified Medical Command seemed to gain momentum in September after receiving a vigorous endorsement from the Defense Business Board, a group of business leaders who advise the secretary and deputy secretary of defense. Economists with the CNA, a think tank that does a lot of Navy work, had projected savings of at least $500 million a year and the business board said that was conservative.

How much England’s revised plan will save isn’t known. But Winkenwerder said it will “create greater efficiencies and cost savings, improve coordination of medical care, improve support to our warfighters, better leverage medical research and create greater ‘jointness’ and standardization in our training and education of … medical personnel.”

Lt. Gen. James G. Roudebush, Air Force surgeon general, had argued against a unified command on the grounds that service missions and cultures were just too different and those differences justify keeping separate medical staffs and resources. In a recent interview, Roudebush was gracious in victory, saying the debate had been important for military medicine.

The Air Force, Roudebush said, “has its medical support intertwined and woven into the mission and the line of the Air Force” and “is something we feel very strongly contributes to our ability to support the joint war fight.”

Vice Adm. Donald C. Arthur, Navy surgeon general, conceded he had “a different concept” for the future of military medicine. But it came down to “what could realistically get done without a lot of disruption to the system.”

“The point was to get us talking about what are things we could be doing together” to achieve “more collaborative, more interoperable combat service support. I think the new construct that the deputy secretary of defense has signed out … does get us talking about common logistics, common information management and information technology and doing some things together that get us to be more interoperable … That’s a good thing.”

Many hurdles remain. The new guidance to streamline care delivery in major markets, for example, “challenges us to do things uniformly without a uniformed command,” Arthur said. It can be managed, Arthur suggested, but the medical departments clearly have a lot negotiation ahead of them.

To comment on this column, e-mail milupdate@aol.com or write to Military Update, P.O. Box 231111, Centreville, VA, 20120-1111

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