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Military Medicine Strives for Customer Satisfaction and Trust
Prepared statement Dr. Edward D. Martin, assistant secretary of defense for health affairs, National Security Subcommittee, House Appropriations Committee, Thursday, November 06, 1997

Defense Issues: Volume 12, Number 54-- Military Medicine Strives for Customer Satisfaction and Trust Trust in military physicians and DoD's health care system is vital to readiness. The system must be evaluated for weaknesses and necessary changes made to retain confidence in the system.


Volume 12, Number 54

Military Medicine Strives for Customer Satisfaction and Trust

Prepared statement by Dr. Edward D. Martin, assistant secretary of defense for health affairs, before the National Security Subcommittee, House Appropriations Committee, Nov. 6, 1997.

The mission of military medicine is to provide care for the active duty force wherever and whenever they may need health care. In addition, the military health system cares for the families of active duty members, retirees and their families.

This responsibility is significant, and it is personal. Recent media reports called into question the health care delivered to our beneficiaries. While I believe our system continues to provide excellent care overall, the stories demanded an intense re-evaluation of military medical systems and processes. Re-evaluation is healthy in any organization.

My intent this morning is to briefly identify the problems and then detail for you how we have resolved or plan to resolve them. The cases portrayed in the articles are tragic and should not have happened. However, in all systems of health care, these kinds of events do happen. Events of this nature need to be carefully analyzed to determine specific causes and to identify and implement measures to prevent future occurrences.

It is vitally important that beneficiaries retain confidence and trust in military physicians and in our health care system. Such trust is a readiness imperative.

The military health system has markedly improved since the 1970s and early 1980s. With the end of the physician draft and the Berry Plan [military service obligation for medical school graduates] in 1973, military medicine had to rely on direct accessions. During this period, some providers brought to active duty were not the caliber we should expect. The advent of the Health Professions Scholarship Program and the Uniformed Services University of Health Sciences has allowed the services to become much more selective. For example, in 1982 the Army's total accessions were 407, with 164 of them coming from direct recruiting.

Today, Army's accessions are 300, with only three coming from direct recruiting, and each of these required a letter of exception. Figures are similar for the Navy and the Air Force.

Our ability to "grow" our own has markedly improved the quality of the entire medical system.

Civilian health care organizations advertise board certification as a mark of quality. We actively encourage our providers to obtain their boards with pay incentives. Today, 67 percent of our providers are board certified.

Our hospitals meet the same standards as civilian organizations and exceed the average scores in most all areas of inspection. Nevertheless, military medicine strives to achieve continuous improvement to fulfill our duty to our beneficiaries to offer them the best health care in the world.

Over the next three to four years, we will phase out our use of general medical officer physicians. The GMO designation is given to providers who are recent medical school graduates with only one year of postgraduate training. Historically we have used these physicians to fill medical requirements in line units and positions in adult care outpatient clinics within our medical treatment facilities. Medical training today assumes a requirement for three years of postgraduate medical education to produce a fully trained physician. Physicians with less training will not be able to assume the comprehensive duties of a primary care manager under our TRICARE program, especially for areas of increased attention such as women's health. A plan to limit future active duty accessions to physicians with three years of postgraduate training will be developed and implemented.

We have established policies which will limit the number of medical treatment facilities performing complicated surgical procedures to those with a large enough case load to establish an expectation of excellence in performing the procedure in question. A good example would be hip replacement surgery. Although smaller facilities may have a qualified surgeon who is competent to perform this procedure, he/she may not achieve the same level of good outcomes from the procedure as a physician working in a large medical center which routinely performs many of these procedures every month.

The medical community has found that the best outcomes for complicated procedures are directly related not only to the experience of the surgeon but also to his/her support staff and that a certain "critical mass" of cases are necessary to maintain specialized surgical skills. Toward this end, we have established "centers of excellence" for approximately 20 complicated surgical procedures.

Facilities must apply for this designation for each procedure by demonstrating their track record with respect to case load and outcomes and their dedication to continued performance improvement. Facilities which cannot meet this standard will not be permitted to perform these procedures.

The articles criticized the military health system for not reporting to the National Practitioner Data Bank all providers when money was paid on claims.

The argument was advanced that this process was different from the civilian standard and therefore reduced quality. The National Healthcare Quality Improvement Act in 1986 established the National Practitioner Data Bank as a tool to monitor providers and to prevent problem providers from moving from state to state without identification.

DoD established a memorandum of understanding with the Department of Health and Human Services two years prior to the actual start date of the data bank because we believed in its purpose and we were committed to improving the quality of care we provide.

DoD policy is quite specific on the National Practitioner Data Bank reporting requirement. We report all providers on whose behalf a claim was paid and who failed to meet the standard of care. We have found, as did the articles, that implementation of the policy has not been consistent.

Early this year, we requested that the DoD IG [inspector general] audit compliance of data bank reporting and recommend systems improvements. While the audit has not yet been completed, we have taken actions to improve reporting.

First, services will eliminate their backlog of cases as soon as possible, but no later than the end of the calendar year.

Next, cases will be reported in which a provider fails to meet the standard of care. In every instance where the service determines the standard of care was met or determines the fault was a systems problem, the cases will go to an external civilian panel for review. When the civilian review concurs with the service, no report will be made. When the civilian review disagrees with the service, the service surgeon general will make the final disposition.

I will receive a regular report on the results of every review. It is my hope that this process will help restore public confidence that our primary concern is for the health and well being of our patients.

The specific problem with Oklahoma licenses was unknown to us prior to the series of newspaper articles. We immediately took steps to eliminate this problem. Providers with this type of license no longer practice clinical medicine or do so only under direct supervision of a fully licensed physician. All three services have agreed to treat these providers identically. These providers will have the minimum time required to pass the United States Medical Licensing Exam and to obtain a valid, current, unrestricted state license.

Failure to meet this requirement may result in administrative separation from active duty. The Oklahoma licensing problem has caused DoD to review all elements of its policy and to re-establish the annual quality management report to further aid in earlier identification of compliance problems.

I believe that we will decrease criticisms concerning continuity of care with full implementation of TRICARE. The history of the military direct care system is one of multiple providers. One of the basic tenets of TRICARE Prime, our health maintenance organization option, is the primary care manager or team of managers who ensure continuity of care for the beneficiary.

Now, instead of seeing a different physician every time beneficiaries visit the clinic, they will have assured access to a teams of providers who know their health care problems. Additionally, advances in automation capabilities will enhance our providers' ability to readily access patient records, lab and X-ray reports.

An area of particular focus will be the efficient processing of specialty consultations, ensuring they are legible and provide timely feedback to the primary care provider. This is a critical requirement for not only continuity but quality of care. Over the last six years we have made substantial investments in automation and business practice initiatives. We plan to continue on this course.

Other actions under way will open our communication with beneficiaries regarding our hospitals and clinics. We will direct that comprehensive information on quality be available to our patients. This will take the form a public "report card" or a newsletter and be issued on a quarterly basis as well as being posted on the web. These reports or newsletters will couple health care quality information with important points for improving personal health and for obtaining the best care from the military health system.

Military treatment facility commanders will establish committees of health care consumers, who will meet with the community on a regular basis. The committee will pay special attention to the needs of enlisted personnel and their families. These committees will have an active role in problem solving and in making recommendations to the facility commander. Representatives from beneficiary groups in the military community will be included in the committee membership.

We are discussing the requirement for each facility to publish a directory of providers in a patient information handbook. These directories will include basic information about each provider, such as medical school, licensure and board certification. This information will assist our beneficiaries in regaining confidence in the quality and training of military physicians.

Finally, we plan to strengthen our National Quality Management Program in several ways. We will re-establish the annual quality management report to facilitate the collection and sharing of information systemwide. We will give greater emphasis to best clinical practices and expedite their dissemination, and we will direct use of clinical guidelines whenever appropriate. Further, we have joined the Department of Veterans Affairs and other civilian health groups in pursuing efforts to improve the quality of care in America.

The criticisms of the military health service system mirror in many ways the history of quality of care within the U.S. health care system. At best, it is a study in contrasts. Many individuals and organizations have labored hard, creatively and successfully to improve the quality of care and service they provide. Major advances in technology and science have raised the hope that medicine will continuously improve.

On the other hand, there is continued and growing skepticism about health care in the U.S. Some are concerned about its deterioration. Many voices cry for a return to the "good old days," back to the cottage industry of medicine. There is frustration over waits in physicians' offices or emergency departments, poor access to care and increasing management control over the process of health care delivery.

Media accounts of the growth of aggressive for-profit health care companies have raised concern that a financial focus will erode basic benefits in all our health care systems. Managed health care suffers from these criticisms. Within military medicine, our beneficiaries and our providers are learning about managed care with the implementation of TRICARE.

The belief persists that "more" care is better care and that management may mean limitation of benefits. TRICARE's goal is to provide the best, most appropriate care, in the correct setting and at the correct time.

Correct application of managed care has significantly reduced costs, but cost containment can never be the ultimate goal. We must evaluate our system weaknesses and change them. We must improve customer satisfaction, communication and education.

We must support our providers by giving them automation tools, identifying the best clinical practices and offering the educational support so they can produce the best outcomes possible for their patient, which after all is the final and most important benchmark.

In closing, our system of health care and its providers have been cited by some critics as dangerous. These citations go to the heart of patient care -- credibility and trust. I believe the actions we have initiated will bolster that trust and credibility.

From my view of this health care system, I am compelled to say that the care provided is excellent and the providers are some of the finest in the world. I can point to statistics regarding board certification rates and facility accreditation, for these are the objective measures of quality. But, instead, let me tell you that even with a choice of military or civilian hospitals and providers, I take my two young sons to the military health system. I take them there because I know the care they will receive is the highest quality, considerate patient care.

That is the care that I want every military patient to receive and we have initiated the actions I just described to help achieve that goal.


Published for internal information use by the American Forces Information Service, a field activity of the Office of the Assistant Secretary of Defense (Public Affairs), Washington, D.C. Parenthetical entries are speaker/author notes; bracketed entries are editorial notes. This material is in the public domain and may be reprinted without permission. Defense Issues is available on the Internet via the World Wide Web at