Doctor Skills Factor in Plan to Streamline Inpatient Care
The number of surgeries and other inpatient procedures done on base by military physicians trails the inpatient workloads of private sector peers by wide margins, according to data comparisons run in support of a Defense Department study on modernizing the military health system.
The inpatient workload at many bases is a readiness concern, which the surgeons general of Army, Navy and Air Force are trying to address with a variety of initiatives to broaden the experience of active duty physicians.
The workload comparison data helped to shape a Pentagon plan in spring 2014 to downsize at least eight and possibly 16 base hospitals to outpatient clinics and move many doctors billets to larger base hospitals and medical centers where they might recapture more challenging cases.
Congress, however, has put a hold on that shift until the MHS Modernization Study is complete, so lawmakers can review that workload data and other factors that drove the call to rebalance inpatient care.
Data highlighting the very low volume of inpatient care on base with productivity of civilian peers also was shared with the Military Compensation and Retirement Modernization Commission, and influenced its recommendations to improve medical readiness including establishing a new four-star medical readiness command, which the surgeons general oppose.
As the commission learned, the department two-and-a half years ago began to measure workloads at military treatment facilities including number of inpatient procedures done by each provider. Results were compared to data from the Medical Group Management Association, which tracks the median of inpatient procedures performed by providers nationwide.
For example, military emergency medicine physicians in the busy National Capitol Region performed only 31 percent of the median number of procedures done by civilian emergency medicine doctors. Another way to express that is these emergency docs carried caseloads at the 15.5 percentile of civilian peers (31 percent of 50 percent), commissioners found.
Overall, the workload comparisons show military providers exceeding only one percent of civilian providers on inpatient procedures performed. For commissioners, the issue raised wasn’t physician efficiency but whether doctors get the cases needed to prepare for wartime missions.
Commissioners, in their visits to scores of military bases, reportedly heard from many doctors who said they had to moonlight in civilian facilities just to maintain their skills. They learned too that the services increasingly assigned physicians to some city shock trauma units for the same reason, or to land just-in-time critical training before wartime deployment.
That reinforced the commission’s view that many military treatment facilities might be inadequate training platforms, as configured today.
In an interview Dr. Jonathan Woodson, assistant secretary of defense for health affairs, said the precise numbers shared here on inpatient workload procedures didn’t sound familiar to him. But he acknowledged workload comparisons did show military physicians, particularly in surgical specialties, below civilian caseload averages. He also agreed it’s desirable to have them do more procedures and of greater complexity.
“So what we’re doing is refining the model. And what we are getting answers to is what level [of cases] do you need to really remain skilled and competent and current. And it’s going to be different if you’re fresh out of a residency program or you’ve been in practice for 30 years and have done a lot of these procedures.”
He described the caseload comparisons that raised alarms with the commission as an “attempt at self analysis, to define what we needed to do to ensure we had a ready medical force, which means practitioners that could go as enablers in harm’s way for whatever operation was around the corner.”
Woodson noted military physicians must do some training not required of civilians, which accounts for some the disparity in procedures performed. Also, he said some base hospitals have low patient volumes but must be maintained, for example to support dangerous training at the Fort Irwin National Training Center in the Mojave Desert where no other care is nearby.
“Those hospitals are always going to be needed and we’re going to have to send experienced practitioners there,” Woodson said. The challenge, he said, is not to keep physicians there so long that their skills erode.
“The small [military treatment facilities] and the ones with low volumes are not expected to, and will never be…allowed to do complicated procedures like cardiac surgery or transplantation. But they do need to exist for routine care of the troops and making sure we have a medically fit force.”
In some instances preserving medical readiness “means devising plans to redistribute personnel to [hospitals] where they are busier and importantly can recapture care, and the complexity of care, that will ensure their readiness,” Woodson said.
He said the draft plan to convert smaller hospitals to outpatient clinics is not driven solely by a need to preserve skills but also the changing nature of health care, which has been migrating to more outpatient care.
“Understand that the exact decisions require deeper analysis and input from the services and line” on “which hospitals are necessary for providing care to troops who are training or in austere environments versus hospitals considered medical force readiness platform,” Woodson said.
Why carry the overhead of anesthesia, respiratory and x-ray support at base facilities that largely provide ambulatory care, he asked. Regarding the facility downsizing list now blocked by Congress, he said, “the whole idea was to ask the question again: Was there a readiness case issue for maintaining an inpatient facility and…a business case for doing it.”
The study of workload comparisons provided information that needs to be combined with the latest force structure plans and “other line-driven priorities to define what is the right solution for military treatment facilities.”
Another factor weighed, said Woodson, is that some base health facilities were established 40 or 50 years before communities off base grew to provide enough medical capability to support troops and their families.
“So all of these things are going into the analysis to decide how and where to right size the MTFs,” Woodson said.
Next week: The surgeons general react to inpatient caseload data and to commission recommendations for improving medical readiness. And more too on the base hospitals eyed for downsizing.
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Tom Philpott has been breaking news for and about military people since 1977. After service in the Coast Guard, and 17 years as a reporter and senior editor with Army Times Publishing Company, Tom launched "Military Update," his syndicated weekly news column, in 1994. "Military Update" features timely news and analysis on issues affecting active duty members, reservists, retirees and their families.
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