Three health care options considered

By Tom Philpott: Military Update

The Defense Department is shaping a final decision document to reorganize the military health care system around a new unified medical command, say senior officials.

The command would be led by a four-star medical officer given unprecedented authority. He would take charge of what now are service-unique responsibilities for medical staffing, training, purchasing, operations and medical readiness across the Army, Navy, Air Force and Marine Corps.

Service and Defense leaders in early May received, for review and comment within 30 days, three options for a new command structure.

Under the first, which enjoys strong support from the Army and Navy surgeons general, the new medical command would be a major combatant command similar to the U.S. Special Operations Forces Command (SOCOM), and reporting directly to Defense Secretary Donald Rumsfeld.

A four-star general or admiral would command all medical personnel, equipment and facilities, just as SOCOM controls combined special forces. Medical personnel still would be trained for service-unique missions and in the culture of their parent service. But overall medical training, assignments, procurement and operational support would be centrally controlled. Medical staff would be assigned according to command needs.

Perhaps the most controversial feature of this option, at least as envisioned by the Army, would be absorbing the TRICARE Management Activity (TMA), including $11 billion a year in regional support contracts. The contracts run vast networks of civilian health care providers and represent 70 percent of dollars spent for care to the military’s 9 million beneficiaries.

“It’s where the money is. I think that’s where the risk is,” said Lt. Gen. Kevin C. Kiley, Army surgeon general. He added, “If you’re going to hold a unified combatant commander for medical accountable for end-to-end health care — from the battlefield to Walter Reed (Army Medical Center) — he shouldn’t be beholden to another agency for a significant portion of health care purchased, particularly from outside markets.”

Kiley and Vice Adm. Donald C. Arthur, the Navy surgeon general, were interviewed for this column after a May 3 hearing of the Senate defense appropriations subcommittee. Both men are such strong advocates for a unified medical command they seemed to complete each other’s thoughts in discussing a shared vision. Combining three medical commands into one would save $334 million the first year, said Arthur. And that estimate, produced by the Center for Naval Analyses, “is probably low,” he said.

U.S. forces could have used the enhanced “interoperability” created by a unified command from the start in Iraq and Afghanistan, Arthur said. “As soon as we can get on to doing this, we’ll have tremendous financial, organizational, infrastructural and interoperable advantages,’’ Arthur said.

“It really has to be transformational,” added Kiley. “We need to take somebody like Don Arthur and promote him to four stars, and make him the new flight commander. Let him immediately begin to build the command structure, begin to take charge of health care. I don’t mean wrestle it away from civilian control; that is not the issue. You mold to civilian controls.”

Referring to unspecified problems he faced while in charge of the Army Medical Command, Kiley said they would have been fewer “if we had a unified command. That’s not because you’re bad or I’m bad,” he said, turning to Arthur. “It’s that we had service priorities. We had service issues.’’

But in truth, he added, “we are more alike than we are different.”

Arthur said he agrees with Kiley on the desirability of absorbing TRICARE and its contracts under any unified command. “But I’m just looking at what we can reasonably, politically accomplish,’’ he said.

TRICARE now is the responsibility of Rumsfeld’s own senior staff of political appointees, including David S.C. Chu, under secretary for personnel and readiness, and Dr. William Winkenwerder, assistant secretary for health affairs. These officials are likely to favor a second command option review. This one would establish two separate unified medical commands, one to oversee private sector care, which means TRICARE and its contracts. A second, military-led command would oversee all operational medicine.

The third command option being reviewed is a long shot. It would concentrate responsibility for medical care under one only of the services, to be decided later.

Correction: Last week I wrote that both the House and Senate defense authorization bills support extending the military pay chart out to 40 years of service. In fact, the House-passed defense bill does not.

Tom Philpott can be contacted at Military Update, P.O. Box 231111, Centreville, Va. 20120-1111, or by e-mail at: