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Florida Clinic Showcases Quality Medicine

By Douglas J. Gillert
American Forces Press Service

PATRICK AIR FORCE BASE, Fla., March 31, 1999 – Two years ago, Col. William S. Swindling faced a difficult decision. The Air Force told him to cut the 45th Medical Group staff by 24 percent. He had to decide when to make the cuts and how to continue delivering quality health care to a growing population with fewer medics.

At the same time Patrick Air Force Base faced cuts, the Navy was closing its base in nearby Orlando. That meant thousands of retirees dependent on the Navy for health care would turn to Patrick, particularly its pharmacy. Swindling figured the time was right for wholesale changes in the way the Patrick hospital provided health care.

"We switched to a customer service culture," the medical group commander said. Meeting customer needs would steer all future actions. How the group restructured to meet beneficiary requirements reveals how much military health care as a whole has changed since DoD adopted TRICARE as its primary health care system.

With a smaller staff, Swindling knew his group couldn't provide all the services it had in the past. First to go were inpatient and emergency services. Next went the ambulance service. But in most cases, Swindling said, civilian contractors in nearby communities replaced the lost services with even better services.

For example, the base ambulances were staffed by emergency medical technicians who could provide only basic life support. Patrick established a 911 service with the Harbor City Volunteer Ambulance Service, whose ambulances are staffed with paramedics trained in advanced life support.

"By cutting us out of the loop," Swindling said, "we actually improved services to our people."

Swindling first put together an interdisciplinary team to steer the many changes the group faced. He empowered the team to design and implement right-sizing initiatives and to market the changes to the base population and nearby communities. The team initially decided to offer walk-in surgical care, but this year opted to close it, as well. An abundance of high-quality civilian health care facilities near the base gave the Patrick group the leeway needed to keep costs down while still providing patients a high level of care.

To meet patient needs on base, the clinic extended its hours, providing evening and weekend access to primary care. Same-day appointments were initiated for acute and urgent care, while most other patients can be seen within 24 hours of calling for an appointment.

Some of the biggest changes were saved for the pharmacy. With the closure of the Navy pharmacy in Orlando, the Patrick pharmacy's annual prescription output rose from $3 million a year to more than $5 million. To help recoup costs, the clinic hired a contractor to set up the Patrick Pre-emptive Prescription Payment Program, or P5. Using a common database, the P5 searches for billable prescriptions in DoD's Composite Health Care System.

In fiscal 1997, before P5, Patrick posted 3,252 claims against beneficiaries' insurance companies and collected $65,000. In fiscal 1998, with P5, the clinic posted 13,741 claims and collected $258,621.

Now, the clinic is assigning each patient to a specific primary care team with its own appointment phone line.

Amid all these changes, clinical staff put together information packets and went door-to-door in family housing on a Saturday morning to advise their primary customers of the restructured services. As a result, Swindling said, the clinic has received no major complaints and no congressional complaints despite eliminating many services it previously provided on base.

Swindling said the clinic is a prototype for other DoD clinics facing staff and service cuts. Other command and installation medical staffs frequently visit or call the Patrick clinic for advice and information on how to improve their services. They want to find out how the 45th Medical Group made an ill system well.

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