Make over DOD healthcare

[TurtleDO2012]

Rethinking The United States’ Military Health System

Too bad this guy doesn't have more pull to make some of his suggestions happen.

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[ijustwannasaveppl]

really interesting read, thanks for sharing! Couldn't help but notice that the author is the Dean of USUHS.

 

[Atlas Shrugged]

Yeah, obviously biased, but I always enjoy Dean Kellerman's talks. He seems like a stand-up dude that really cares and wants to improve the system. He really emphasizes the global ties, and I think we all agree (well, those who actually care about good medicine) with doing that at home with civilians to increase case complexity. I'd also add that I'm only 3 years in and sick of the EMR situation; it is a HUGE burden on physicians and the system in general. It's not as big of a deal when other staff is on top of things, but the quality of nurses and techs has been so broad.

 

[HighPriest]

Its well thought out. Clearly biased, but that's ok. He's not trying to hide that. There's a bit of a disconnect, I think, between what his presumed goals are and what most providers in the military (Army, at least) think are the problems with our system. That's ok too. He's clearly keyed in to the command side of things rather than the clinical side, and command doesn't -have- to listen to its people. Their primary goal isn't to make people happy, it's to fight wars, and I get that. Although I still think it wouldn't be that hard to do both.

I have an issue with a couple of his bullets.

#1 is just a terrible @&$king idea for a huge number of reasons, and to my reading is basically just throwing in the towel in the fight for better healthcare. Period. "We don't have enough qualified people, so let's just use unqualified people because they work in a pinch."

#2 is ok in theory. I'm not exactly sure how much more trauma that would net us. I also don't think it addresses the case complexity issues that everyone at every place that isn't WR would still face.

#3 is a good idea, although I foresee it just @&$king surgical providers at small centers even more than they already get @&$ked. The only decent case you do here is a colectomy? Well, guess what? Those are all going to SAMC now. So piss off.

#4 is s good idea, but...is it really that much of a problem? I've worked at 4 military facilities so far, and I just don't find it that hard to get used to the minor differences. Especially things like OR layout. It's....just not that big a deal...I'm sure it's a bigger deal down range, and so I imagine changes there might help, but I think it's more likely they'll just keep asking people to operate in blown out husks...

#5 wait....isn't that already what we're doing? No? Damn, I've been on the wrong page this whole time...

#6 is interesting. Might be good. Might cause problems (I know that trauma just came in, but you can't bump a soldier for a civilian trauma...)

#7 you would think that this would already be SOP, but it isn't. But frankly we need more complex cases, and more trauma, at all facilities. Not just select referral centers. Unless you're going to completely do away with homesteading and make sure everyone gets some time at WR.

8-9 yeah, sure ok.

10 - NO $#!T. THAT.

 

[Gastrapathy]

I read #1 and stopped. He's the dean of the medical school and wants to abdicate the practice of medicine to IDCs. Pathetic.

 

[HighPriest]

I read #1 and stopped. He's the dean of the medical school and wants to abdicate the practice of medicine to IDCs. Pathetic.

You got it all wrong. He's the dean of a military medical school who has drunk so much kool-aid his skin is turning green.

 

[Gastrapathy]

If he really thinks that "primary care technicians" are the answer, it's time to wake up Al Gore to go close USUHS. There is no chance any member of his family will ever see a "technician" instead of a physician.

 

[Perrotfish]

I read #1 and stopped. He's the dean of the medical school and wants to abdicate the practice of medicine to IDCs. Pathetic.

You're misreading it. And IDC is a provider to this guy, which is already equivalent to a physician. He wants to create an even lower level of care by using 18 year old HNs as 'technicians', which I assume are functionally the same as providers but which will require you to cosign the note and take all the liability.

FWIW I did think the other 9 points were much more intelligent.

 

[Perrotfish]

10 - NO $#!T. THAT.

Why? I'd love it if credentials were standardized. The worst abuses of military medicine occur when providers are locally credentialed to do things they aren't really qualified to do.

 

[TurtleDO2012]

Overall I prefer that at least he takes more of a stance to continue to have military providers rather than trying to have civilian providers assume all roles at the smaller MTFs or have their care farmed out to the local market. Breakdown of costs and arbitrary chasing the RVU metrics was also interesting I thought.

From primary care stand point I think active duty FM/IM need to be at every MTF because typically I feel we provide better care then some of our civillian counterparts and save money overall. If the inpatient side isn't demanding at this point I'll accept that since I don't need to work a full week in clinic and also spend another third on the wards. I'll moonlight for those skills. We also typically care a little more about identifying those that need to be separated. I have seen too many people on a regular basis who should have been separated years ago. Opinions of course based on my own limited experience.

I do wish that the design of clinics was consistent. Ones I was at previously were designed pretty nicely for the whole team concept and PCMH with computers in the rooms, everything wall mounted. Team rooms were large to hold 4-6 people. Go to my next duty station and nothing is wall mounted, small carts in rooms, no real supply room, room sizes vary dramatically, not enough office space so exam rooms converted to hold 2 desks with wasted space taken up by sinks, drapes, and etc. Both places started and finished construction the same year yet they couldn't be more different in their execution. Quality of speed with ahlta and frequency of downtime has varied widely across by locations.

I don't think evey single battalion needs a doctor though or that every single tasker calls for a doctor to fulfill a role. How often during a sick call visit have you thought maybe this could of been done through a telemedicine video chat?

Trying to bring IV pumps to the poorest areas of Afghanistan with instructions in English and runs on a US 110 outlet doesn't require a doctor to say this was a poor use of resources again or to tell the afghans the 5000 amoxicillin tabs they just got was for the year and not the month.

With the rate at which people seek care and the requirements to meet current access metrics the DOD will have to dramatically increase the availability of providers at some point if nothing changes. Better triage of the problems or institute some cost to the patient. I have seen people for simple STD check, signing travel paperwork, PCS paperwork, PHAs, profiles, confirm I don't have strep because my neighbor has it, "just want this documented" crap where a medic or similar is more than capable of taking care of all of that. Maybe if not willing to have them see low acuity issues then we should st least elevate our expectations on how they can help us. They should be better scribes and better trained at using the EMR so I can spend less time checking boxes and more time talking to patient and educating them. Last civilian article I saw indicated on average for every one minute spent with a patient you typically spend a minute on the computer as well, and they have usually better quality speed and EMRs.

 

[Gastrapathy]

@Perrotfish
2-10 could have cured AIDS and cancer. He's still a total sellout to his profession and, even worse, he can't really care about servicemembers if that's the standard of care he will accept on their behalf.

Primary care technician. That should send chills down your spine.

 

[nolapsych]

I like the research he pulled on unnecessary stents in civilian sector vs military, but this is a younger population...Now if MTFs could cut down on unnecessary ortho procedures too then some bigger money could be saved. Where I am the non specific shoulder and knee scope rate is obscene and probably relates to his point about surgeons needing to "get practice"


Sent from my iPhone using SDN mobile

 

[Homunculus]

I applaud him for at least putting some ideas to paper. but his lack of military background and career in the ivory tower slants his piece.

BDE/WTU Surgeon tours are completely glossed over. I'd love to see how he feels about these given his EM/IM/MPH background. my current BDE surgeon is EM. he has made the best of it but it is an extraordinary waste of resources.

I 100% agree with having the medical assets downrange do medical stuff in garrison. I could replace 4-5 LPNs with 2-3 medics at a fraction of the cost, infinitely less b*tching and drama, zero union concerns, and a better trained and more knowledgeable medic. currently they spend their deployments training and getting reasonably proficient only to go back to garrison to be tasked out to the orderly room, arms room, motor pool or any other non-medical labor that they need someone to do. BUT, to expand their scope of practice is ludicrous. he obviously has not spent a significant amount of time with newly graduated medics.

as mentioned above by @HighPriest, to feed the "consolidated centers of excellence" your small MTFs will lose more cases. and flying/housing patients would probably cost more than having the military doc credentialed locally at a place that actually can do X procedure and having them do it there. I don't know how they'd be able to keep both parties happy.

which bring me to my next point-- seeing civilians is a Pandora's box. trauma care when they have no other option, sure. I don't have the ability to see my own patients the way I want, so why would I bring civilians into the mess? further, lets say you build civilian capacity, they are seeing docs, then because of retirements/PCS/deployments their doc is gone without a replacement. now they have to go back to the civilian side? are we still covered under the tort claims act when we treat these civilians? do they waive their right to sue? I can maybe see the VA angle but if he thinks we can see any amount of non-emergent civilians on a regular basis he hasn't gotten out enough.

--your friendly neighborhood "all my plans require the continued presence of USUHS" caveman

 

[deuist]

My preference would be to shut down all of the MTF's and move all of the active duty healthcare doctors and nurses into the reserves--- similar to the British model. Soldiers and sailors should go see civilian doctors using Tri-care is a PPO. During times of war, the reservist physician or nurse would be called to deploy. A few GMO's might need to stick around, but on the whole I really don't see what value I provide by seeing hundreds of people each month with coughs, colds, bug bites, gastroenteritis, and other elements that could be handled by over-the-counter meds and a day of rest.

 

[McCheese]

"....High-quality training and strict adherence to procedures—an approach first championed by military aviation—can largely compensate for smaller case volumes."....
Really?!
So if I go from performing 300 cases a year to 30 cases, I'm going to do the cases as quickly and efficiently, and have the same outcomes, if I adhere to "procedures"?
Sure, there is a saturation point for bread and butter cases where you don't need to do any more to continue to be proficient.
But for more complex cases?... I guess we're better off sending those to the "centers of excellence" then?
(...that already have a 6 month OR wait time because they can't staff their ORs properly?).
Surgical muscle memory aside, I'm all about the "Checklist Manifesto" (see Gawande's work on this), but you also need the volume to practice the process and make it second nature in an OR or trauma bay setting.

 

[HighPriest]

Why? I'd love it if credentials were standardized. The worst abuses of military medicine occur when providers are locally credentialed to do things they aren't really qualified to do.

Yes so would I. That's what I want that $&!T

 

[HighPriest]

I applaud him for at least putting some ideas to paper. but his lack of military background and career in the ivory tower slants his piece.

BDE/WTU Surgeon tours are completely glossed over. I'd love to see how he feels about these given his EM/IM/MPH background. my current BDE surgeon is EM. he has made the best of it but it is an extraordinary waste of resources.

I 100% agree with having the medical assets downrange do medical stuff in garrison. I could replace 4-5 LPNs with 2-3 medics at a fraction of the cost, infinitely less b*tching and drama, zero union concerns, and a better trained and more knowledgeable medic. currently they spend their deployments training and getting reasonably proficient only to go back to garrison to be tasked out to the orderly room, arms room, motor pool or any other non-medical labor that they need someone to do. BUT, to expand their scope of practice is ludicrous. he obviously has not spent a significant amount of time with newly graduated medics.

as mentioned above by @HighPriest, to feed the "consolidated centers of excellence" your small MTFs will lose more cases. and flying/housing patients would probably cost more than having the military doc credentialed locally at a place that actually can do X procedure and having them do it there. I don't know how they'd be able to keep both parties happy.

which bring me to my next point-- seeing civilians is a Pandora's box. trauma care when they have no other option, sure. I don't have the ability to see my own patients the way I want, so why would I bring civilians into the mess? further, lets say you build civilian capacity, they are seeing docs, then because of retirements/PCS/deployments their doc is gone without a replacement. now they have to go back to the civilian side? are we still covered under the tort claims act when we treat these civilians? do they waive their right to sue? I can maybe see the VA angle but if he thinks we can see any amount of non-emergent civilians on a regular basis he hasn't gotten out enough.

--your friendly neighborhood "all my plans require the continued presence of USUHS" caveman

I don't think he's talking about replacing LPNs with medics. If he is, then I agree that would actually be a better option. My impression was the medic as a semi-autonomous provider. A mid-mid-level. Maybe I misread it.

 

[Homunculus]

I don't think he's talking about replacing LPNs with medics. If he is, then I agree that would actually be a better option. My impression was the medic as a semi-autonomous provider. A mid-mid-level. Maybe I misread it.

medics working in MTFs would be a compromise and something I think is a good idea (and would save us a lot of money)-- his idea is totally using them to be a stopgap filler PCM kind of thing. which is why I said him thinking this is ludicrous and shows he's probably never spent any meaningful time with combat medics. even with the ADTMC (algorithm directed troop medical care) manual they still don't recognize things that are important to know. the algorithms are reasonable, and if anything other than OTC or reassurance is required they are supposed to go to their PA or Doc. left alone to do their own bidding is a really, really bad idea. I've already seen medics given too much leeway do some flat out wrong things. their heart is in the right place but basic training and AIT does not prepare someone to be a PCM. their physical exam skills alone are woeful. they simply don't have the tools. Christ, we can barely beat it into residents over a 3 year span lol

--your friendly neighborhood "you gave him flagyl for a sore throat because 'it was an antibiotic?' what exactly do you think he was infected with?" caveman

 

[WernickeDO]

When I read #1, I wasn't sure exactly what the author meant, because surely he doesn't mean that the 68W examines, treats, and dispos the patient independently. But I'm not understanding what a "primary care technician" is.

Here's an idea: instead of giving more power to unqualified people, the military either expands GME or allows deferments so that we can actually have board certified docs taking care of soldiers.

 

[Gastrapathy]

1. Make greater use of enlisted providers—Overseas and aboard ships, the military health system relies on its corpsmen, medics, and med techs to deliver routine care under supervision, as well as save lives in combat. However, the moment these skilled providers come home, they are relegated to minor clinical or clerical tasks because no comparable role exists in civilian health systems. If the military health system allowed them to function as “primary care technicians,” it could expand access to care, reduce use of emergency departments and urgent care centers, and strengthen readiness for future deployments.

His words are very clear. He means replace doctors with low-level providers and he comes up with a new name for them. I posted the same thing on the blog but my comment was removed.

"no comparable role exists" because its a terrible idea. Our patients would be better off if he was replaced by an "administrator technician" and he can fly home on a plane flown by a "aircraft technician." Meanwhile, medicine should be practiced by doctors.

I'd love to see what the AAFP and the ACP think of "primary care technicians."

 

[dr zaius]

"....High-quality training and strict adherence to procedures—an approach first championed by military aviation—can largely compensate for smaller case volumes."....
Really?!
So if I go from performing 300 cases a year to 30 cases, I'm going to do the cases as quickly and efficiently, and have the same outcomes, if I adhere to "procedures"?
Sure, there is a saturation point for bread and butter cases where you don't need to do any more to continue to be proficient.
But for more complex cases?... I guess we're better off sending those to the "centers of excellence" then?
(...that already have a 6 month OR wait time because they can't staff their ORs properly?).
Surgical muscle memory aside, I'm all about the "Checklist Manifesto" (see Gawande's work on this), but you also need the volume to practice the process and make it second nature in an OR or trauma bay setting.

This x1000. The "primary care technician" bullet was enough to nauseate me, but this put me over the edge. This concept has been paraded about over recent years to the dismay of the people who actually want to operate and provide good surgical care to patients. Oh, you aren't seeing enough trauma? That's OK, we're working on this simulation program that you'll deploy with to keep your skills up. We're also going to have you take a written test before deploying! [Actual proposition from a surgical grand rounds]

I see you are probably at the same "center of excellent" as I am based on your OR staffing comment. What a joke.

Let's not even talk about taking civilian trauma here. The occasional street trauma that wanders in takes HOURS to get a simple plain film. Not to mention the poor performance of the majority of physician civ contractors that staff the ED.

I've seen so many people using this article to say hey look! Milmed is actually really good and just needs some gentle tweaking! ****ing WRONG.

 

[Clap MD]

medics ... left alone to do their own bidding is a really, really bad idea. I've already seen medics given too much leeway do some flat out wrong things. their heart is in the right place but basic training and AIT does not prepare someone to be a PCM. their physical exam skills alone are woeful. they simply don't have the tools. Christ, we can barely beat it into residents over a 3 year span lol

This made me think of when I was explaining to an E-6 IDMT that we would need to get weight-bearing films and he told me we couldn't because we didn't have any dumbbells. Can't make this stuff up. A gap in knowledge would have been fine, whatever, you can teach through that... but then he argued with me about it. Fortunately it was one of my early experiences with IDMTs so I knew right off the bat to listen carefully about any patient they see and present to me.

 

[Gastrapathy]

He also didn't touch the real waste of the bloated headquarters staffs and all the people walking around his campus working 9-3.

 

[deuist]

He also didn't touch the real waste of the bloated headquarters staffs and all the people walking around his campus working 9-3.

The last time I checked, my own hospital had 31 full-bird colonels. That's 31 medically trained people collecting $200,000+ a year to keep paperwork flowing instead of seeing patients. That number does not include all of the E-7 through E-9 and O-4 and O-5 middle managers who also do not see patients. I cannot imagine a civilian hospital paying its chief medical officer a full doctor's salary to not see patients.

 

[Homunculus]

He also didn't touch the real waste of the bloated headquarters staffs and all the people walking around his campus working 9-3.

careful or the USUHS mafia will pay you a visit some night.

"no comparable role exists" because its a terrible idea. Our patients would be better off if he was replaced by an "administrator technician" and he can fly home on a plane flown by a "aircraft technician." Meanwhile, medicine should be practiced by doctors.

I'd love to see what the AAFP and the ACP think of "primary care technicians."

succinct. surprised they deleted your comment, it's not inflammatory and is an excellent analogy-- especially since they are always throwing the "this is what the airline industry does" when shoving high reliability and checklist upon checklist at us. hell, if primary care technicians are ok, why not surgical ones? lap appys aren't that hard. . .

--your friendly neighborhood pass me the bovie caveman

 

[AFlightdoc]

While I respect Dr. Kellerman I completely disagree with some of his points. “High-quality training and strict adherence to procedures—an approach first championed by military aviation—can largely compensate for smaller case volumes”. This is so far off the mark. I fear Dr. Kellerman has partaken of the mil kool-aid. The “More sim training, more checklists will fix everything” attitude. Nothing is a substitute for real patient volume and case load. This is a typical mil solution- let’s ignore the difficulty problems that we don’t think we can fix and instead promote things that further degrade skill and physician morale. Hey at least we can cover our ass on paper…
“Make greater use of enlisted providers—Overseas and aboard ships, the military health system relies on its corpsmen, medics, and med techs to deliver routine care under supervision, as well as save lives in combat.” Are you kidding me? More smoke and mirrors with mil med. Yes in deployed settings we utilize non-physician providers. This is out of necessity due to a critical lack of physicians. Punting more medical care out to undertrained and under qualified personnel is a glaring problem in mil med- NOT a solution.(BTW-I’m not talking about Spec ops medics- who are very good at what they do, but occupy a very unique niche). I work in the trenches of mil medicine and I can tell you this is not working. Mil med is broken- likely beyond repair. I’ve spent my entire career in the system and can tell you it needs to die. I’m very disappointed to see Dr. Kellerman promoting fixes that are already failing.

 

[pgg]

In one breath it seems he gets it:

Is the military health system less productive? That depends on how productivity is defined. Because most civilian hospitals rely on fee-for-service billing, their staffs have a strong incentive to see lots of patients and order large numbers of tests and treatments. This translates into the appearance of productivity as measured by “relative value units” (RVUs)—the most commonly used metric of clinical workload. There are two problems with this approach, however. First, RVUs measure the volume of care, not its value. It doesn’t even matter if a procedure helped the patient; it only matters that it was done. Second, RVUs undervalue primary care and overvalue procedures performed by specialty providers. As a result, keeping patients healthy looks less “productive” than filling hospital beds and performing lots of complex procedures.

Value, not volume. Well said, sir.

But then he advocates this "primary care technician" idea:

Make greater use of enlisted providers—Overseas and aboard ships, the military health system relies on its corpsmen, medics, and med techs to deliver routine care under supervision, as well as save lives in combat. However, the moment these skilled providers come home, they are relegated to minor clinical or clerical tasks because no comparable role exists in civilian health systems. If the military health system allowed them to function as “primary care technicians,” it could expand access to care, reduce use of emergency departments and urgent care centers, and strengthen readiness for future deployments.

Volume, not value.

 

[Homunculus]

In one breath it seems he gets it:


Value, not volume. Well said, sir.

But then he advocates this "primary care technician" idea:


Volume, not value.

wow, when you distill it down like that the hypocrisy is obvious. well done. well done, indeed. I swear if we got the mil and ex-mil hive mind of the forum together we could probably come up with a pretty decent plan ourselves that would at least be internally consistent.

--your friendly neighborhood listening to queen's "I want it all" in honor of your post caveman

 

[HighPriest]

In one breath it seems he gets it:


Value, not volume. Well said, sir.

But then he advocates this "primary care technician" idea:


Volume, not value.

Of course, there is a balance between volume and value that makes it to that people aren't waiting 6 months from the onset of a problem to get to my office...or where I can do more than four minor cases in a full day so that it actually makes sense to see patients in clinic.

My point being: you can argue volume vs value, but the volume still sucks at every MTF I've ever worked. Value is....not as good as I would have hoped either....considering the lack of volume you would think we could do better...

If his argument is that we don't see many patients, but we provide better value, I'd refer him to...well, 80% of the consults I get in which patients are treated against standard or to the other thread regarding the ORs as SAMC being shut down. Seems like we could use all that extra volume time to read a manual.

In any case, using medics as primary care providers is just pure, extracted idiocy.

 

[Vandalia]

I cannot imagine a civilian hospital paying its chief medical officer a full doctor's salary to not see patients.

Your imagination is very limited.