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Military Medicine: In Step, Adept, Flexible
Prepared remarks Dr. Stephen Joseph, assistant secretary of defense for health affairs, DoD TRICARE Convention, Washington, Monday, January 22, 1996

Defense Issues: Volume 11, Number 11-- Military Medicine: In Step, Adept, Flexible Military medicine, as a supporting service to the line forces, must also be organized as flexible, agile and technologically adept.


Volume 11, Number 11

Military Medicine: In Step, Adept, Flexible

Prepared remarks of Dr. Stephen Joseph, assistant secretary of defense for health affairs, to the DoD TRICARE Convention, Washington, Jan. 22, 1996.

Good morning. It is a pleasure to see so many gathered together here. I want to add my welcome to those already offered. We have a terrific line-up scheduled for this week. This conference is a bit different from our past conferences in that we have invited more people from outside the MHSS [military health services system] to give us their perspectives on TRICARE and to perhaps give us some pointers on how we might improve our approach. These are people from our congressional oversight committees, our beneficiaries represented by the military coalition, the media and our watchful advisers, the GAO [General Accounting Office], CBO [Congressional Budget Office] and DoDIG [Department of Defense inspector general]. Please find time to meet and speak with some of these individuals, listen to them, and tell them what you are doing with TRICARE. ...

As I look out toward the horizon of 1996, I see a number of challenges, challenges that carry potential obstacles to mission achievement. These expected events we can plan for, accommodate and turn to our advantage. There are other events, however, which will appear unexpectedly, and they too will present obstacles for us. In this category I would include natural and man-made disasters, such as our recent Blizzard of '96 or the shootings at Fort Bragg [N.C.]. However we are involved, we must be prepared to deal with unanticipated events. How well we deal with them is a reflection of our leadership and the underlying quality of our system.

In addition to the events that will occur in 1996, there will be a variety of decisions made by others quite apart from the military health services system. Many of these decisions will assist us in pursuing our mission and goals. Others will pose difficulties for us. Consider the effects of the recent government furloughs or of our participation in the NATO force in Bosnia.

These decisions were not made with military medical operations in mind, yet they carry significant influence on our operations. Again, we must recognize that such decision making occurs and that we can and must plan for it. Solid leadership, guided by an understanding of our primary mission, will not only handle the effects of such decisions, it will find the means to capitalize on the situation.

For example, in Operation Joint Endeavor, in addition to Job No. 1 -- taking care of our people -- we will have an opportunity, and will take that opportunity, to demonstrate and develop advances in epidemiologic surveillance and the newest use of telemedicine cubed in that theater.

No matter where you sit within the military health services system, there are events and decisions that affect what you are doing and how you do it. Your mission responsibilities continue regardless of obstacles placed in your path; you will exercise your leadership to reach your goals.

This underscores for all of us the very real need for growing well-experienced, flexible, knowledgeable leaders for the MHSS. I say that particularly for those of you who are now experienced lead agents, experienced leaders in our system. Remember the importance, the capital importance, of the people who come behind us, who will be smarter than we are.

Our conference this week is about being prepared and about having the ability to achieve our goals -- it is about readiness and leadership.

What I want to do this morning is to take a look at the landscape of military medicine. Just what does it look like all around us? Then I will examine some of the steps we are taking to ensure that the MHSS is prepared to fulfill its obligations. Finally, I want to discuss what military medicine is doing that demonstrates its leadership within the community of health care delivery and in some ways within the military itself.

Ten, even 15 years ago, there began a hue and cry in this country about the steeply rising costs of health care delivery and about increasing dissatisfaction with the state of that delivery.


  • Corporate America became increasingly aware of and involved in the health benefits offered by its companies for its employees.
  • Unions held up labor negotiations until the health benefit was a comprehensive one.
  • Debates raged about where the blame rested for these increasing costs of health care.

Many suggested solutions. Early in this administration, President Clinton offered a solution. It was considered too complex, threatening to some, and it did not gain congressional approval. Emerging from this decade of debate, with no comprehensive answer to the issues of cost, came a proliferation of managed health care plans. Though around for a number of years, their ability to control health care costs was not a necessity. Today, it is.

Managed care gradually is taking hold in all parts of the U.S. And when it is well done, managed care:


  • Enhances the care patients receive;
  • Focuses on personal involvement in one's own health;
  • Guards against unnecessary care;
  • Enables a clearer projection of annual costs; and
  • Controls the costs of health care delivery.

At the same time, it necessarily limits, or defines, the choice of providers from whom care may be sought and, without a good quality program, managed care can become more concerned with the immediate costs of care rather than the long-term health of its patient population. I mention that to deplore the rapidly increasing shift from the original not-for-profit shape of the managed care industry to an increasingly for-profit array.

Practicing within a managed care organization clearly is different from independent practice. There are guidelines and rules to follow, there is accountability, and in staff models the providers are salaried. For many, this change in practice habits is difficult to accomplish. For many more, it is an alternative to the tremendous costs involved with setting up and operating one's own practice. The growth of managed care, with its emphasis on accountability and effective practice, is influencing the delivery of health care across the nation.

With managed care's emphasis on patient health, it has the potential to greatly assist the public health capabilities in the nation today. Clearly, public health and our organizations that monitor, detect and offer preventive advice and measures need greater attention and assistance.

Infectious diseases are resurgent around the world due to a variety of factors. The mobility of our national population raises the risk of exposures. The increased resistance to antibiotics for some diseases, such as TB [tuberculosis], malaria and many common bacterial strains, is another example of why strong public health programs in this country are very important, and managed health care delivery systems can contribute to these programs.

Another public health factor, very important to military medicine, is the ability to gain a clear picture of disease patterns and disease trends in all parts of the world. Our forces must be prepared to rapidly deploy anywhere in support of our national security interests.

Being prepared includes being knowledgeable about all potential threats, including health threats, and having the means to protect the force in the face of those threats. U.S. military medicine is unique in that we have medical capabilities spread around the globe, and these capabilities are linked to the larger military health care delivery system for communication, discussion and consultation.

We are positioned to contribute in a major way to a worldwide system of disease surveillance, and we also would be a clear beneficiary of such a system. Such a capability would assist as we embark on any one of the continuum of missions now emanating from the National Security Strategy of our nation. Turning to the environment within DoD, we all recognize that there has been significant change in the past few years. The National Security Strategy is now one of engagement and enlargement. We want to be globally involved to help spread the tenets of democracy and to assist countries and regions to stabilize and become productive economic participants in the world marketplace.

Our military missions range from disaster assistance to peacekeeping to peacemaking to conflict and war. The way we carry out those missions is to rapidly project the appropriate force to the area of need. In most instances, the size force required is small compared to the force mobilized for Operation Desert Storm or to that we planned for the defense of Western Europe.

The thrust of the department today is to assemble and train the U. S. armed forces as flexible, highly mobile, technologically expert units prepared to deploy anywhere in the world. This involves creating a smaller forward footprint. Military medicine, as a supporting service to the line forces, must also be organized as flexible, agile and technologically adept.

As the forces have downsized to meet the new strategic objectives, the requirements for manpower, infrastructure and dollars also have downsized. There is much debate within the department on such questions as

how much of which weapon systems should we have, should one service have full functional responsibility for a given system, where research dollars ought to be spent and whether one of every four O-6s on active duty should be in the health care community?

These are extremely difficult issues facing the leadership of the military services and DoD.

A false, but seemingly simple fix to the MHSS facet of these issues would be to privatize or outsource those military functions which can be most easily accomplished by the civilian sector. It is this line of thinking that leads to suggestions for severely scaling back the military health services system -- manpower, infrastructure and dollars.

We have been successful thus far in articulating the inseparability of our everyday health care delivery responsibilities from our operational support responsibilities and therefore, establishing the requirement for a very robust military health care delivery system. In fact, we are in the process of looking again at medical personnel requirements, the minimum number of active duty physicians required, and the number and size of our medical treatment facilities here in the U.S.

This re-examination is known by many names, but it is the update to the original 733 Study. The most significant difference in this evaluation is the recognition by those outside the medical community that counting only deployed manpower does not represent the true requirement. We expect to see some study results toward the end of March.

As the armed forces are downsizing, they are also becoming significantly more advanced in their use of technologies: The digital battlefield involves sophisticated imagery, worldwide video communications, global positioning, precision bombing. In some ways, these technologies ease the difficulties produced by downsizing.

Military medicine, too, is using many of these technologies in applications designed to enhance our capabilities to project sophisticated, specialized, health care forward to the patient, even to the point of injury. They provide us the means to ensure rapid, high-quality care. They enable injured or ill manpower to remain on the job and avoid the costs of medical evacuations and replacement processing.

Naturally, all health care cannot be delivered via telemedicine and the many other advanced technologies that we have begun to analyze and test. We will continue to require medical support units, hospital complements aboard ships and aeromedical evacuation systems. And there will never be a substitute for what [Vice] Adm. [Harold M.] Koenig [Navy surgeon general] calls "care at the deckplates." These units, complements and systems must be prepared to deploy with little or no notice, and they increasingly have to be able to communicate with one another.

I want to spend a few minutes describing for you just how we are building the readiness of our medical forces to be prepared to deploy rapidly, to have the resources they need to maintain the health of our service members and to be able to communicate seamlessly with medical personnel of another service in the theater and beyond.

It is my belief that the most important accomplishment we have achieved within military medicine over the past two years has been the solid ability to work together -- Army, Navy, Air Force medicine and [Office of the Assistant Secretary of Defense for] Health Affairs. This ability is expressed in a number of forums, but the result is a crumbling of the territorialism, the parochialism, and a realization that our unity -- or jointness -- has become military medicine's strength.

The surgeons general, and [Dr.] Ed Martin [principal deputy assistant secretary of defense for health affairs] and I meet weekly to discuss and decide the policies that will direct the operations of the military health services system. I think of us as DHP [Defense Health Program], Inc., very much like a corporate board. And as many of you know, we have now expanded the TRICARE Executive Committee to the TRICARE Readiness Executive Committee with the strong participation of J-4 [Office of the Joint Chiefs of Staff, Logistics].

It is the Medical Readiness Strategic Plan 2001 that is our blueprint for ensuring a jointness in our planning, training and doctrine. This long-range plan supports execution of the full array of defense strategic planning documents and addresses how, jointly, military medicine will achieve that smaller forward footprint.

There are today over 1,000 action items being worked and implemented by military and civilian medical personnel throughout the military services in support of this plan. DHP, Inc., in cooperation with the Joint Staff, identified six highest-priority action items. Each of the six is under way, and each is a building block for follow-on actions. These first six deal with doctrine, information support systems, readiness reporting, medical evacuation, medical personnel fitness and readiness oversight within the military health services system.

Within the Medical Readiness Strategic Plan 2001 are specific issues focused on our reserve components. It is important to recognize the essential role these units and personnel play in our ability to meet our medical mission responsibilities. Should our commitments to peacekeeping and peacemaking operations continue to increase, we must consider the increased use of our Reserve and National Guard personnel.

In view of this, the assistant secretary for reserve affairs, Debbie Lee, and I have established a Joint Reserve Health Coordinating Committee, which is tackling the role of our reserves and the issues that arise from such roles. In addition, the TRICARE Readiness Executive Committee includes the reserve affairs principal deputy.

What is the relationship between TRICARE and readiness? A fair question. TRICARE is the military health services system. It includes everything and incorporates the dual responsibilities of our military medical mission -- what [Air Force Maj.]Gen. George[K.] Anderson [deputy assistant secretary of defense for health services, operations and readiness] calls "Big TRICARE."

The transformation of our system of health care delivery to managed care brings a new flexibility to military medicine that enhances its ability to meet its readiness responsibilities. This flexibility is generated through the regional organization and planning for health care to a defined population.

In that planning is a dependence upon interservice resource sharing. This sharing in the everyday delivery of care not only makes it possible to have our military personnel gain essential readiness training; it also builds familiarization among the personnel who work together.

Second, the managed care support contracts bring a supplemental capability to our military medical treatment facilities. It is a capability and a partnership that can support our beneficiary population in the event of a deployment of hospital staff or of a readiness exercise.

TRICARE changes our health care delivery system to make it more accessible to our beneficiaries and more cost effective for the department. Both accessibility and cost effectiveness are essential in order to retain the delivery structure. And that delivery structure is vitally important as the source of training and skills maintenance for our medical personnel. TRICARE makes enhanced medical readiness possible.

TRICARE also promises to make the military health services system a leader within the defense establishment and within the national medical community.

Many of the initiatives and characteristics of TRICARE that I have mentioned are goals among other communities of the armed forces. Jointness and the ability to use one another's resources places military medicine ahead of those who continue to vie for aircraft, vehicles, weapons. We are planning together, developing policy together, creating systems together.

Civilian-military partnerships are clearly reflected in our managed care support contracts. Our delivery system improvements have come to depend upon these partnerships in order to accomplish our health care responsibilities. Our improved business practices, such as use of Prime Vendor, have significantly increased our relationship with and reliance on the civilian sector to meet our needs. And we have a number of partnerships, affiliations or agreements with civilian medical facilities and medical schools for specialized education and training. TRICARE has us actively engaged in civilian-military partnerships, equal to or surpassing other functional proponents within DoD.

One of our significant accomplishments is our National Quality Management Program. This program encompasses personnel readiness certification, facility accreditation, practitioner licensure, clinical credentialing and privileging, the National Practitioner Data Bank and special studies leading to "best practice" models.

The Centralized Credentials and Quality Assurance System is a single data base which provides the means to rapidly assess the credentials of about 200,000 privileged providers throughout our military health services system, including members of the reserve components. Having this information readily available to all of our facilities, lead agents, major commands and service headquarters facilitates the transfer and sharing of personnel among facilities and across services.

Supporting the quality management program is a comprehensive contract designed to ensure uniform application of utilization management criteria and to monitor the quality of health care delivered throughout the system -- in military medical facilities and by civilian network providers -- with the goal of discovering and implementing "best clinical practices."

An example of the benefit of these best-practice guidelines for how we use our resources is the recent study on hysterectomies. We found that we could avoid $1 million in costs annually by using our resources in a more effective way.

The last area I will mention that I believe places us out ahead, both in the defense and in the national medical sector, is strategic planning. Our process to look ahead, to identify what we need to get under way today so that it will be there tomorrow, to create a framework for evolving our whole system has been a very energizing one.

It began about a year ago with the surgeons general and myself and now involves an ever-growing number of our personnel throughout the military health services system and even a good number from other organizations, such as the assistant secretary for reserve affairs, the Joint Chiefs of Staff and representatives of the surgeons of our unified commands.

It is a tremendous accomplishment that we have all facets of military medicine and those who have a stake in military medicine working together on how we should jointly plan and approach our future.

We have published a strategic plan for the military health services system, we have articulated our five goals, and we have begun to identify the metrics by which we can determine the progress we are making in achieving those goals. The measures will differ for each organization.

For example, hospital commanders will need finer, more detailed information about their own facility than the lead agent or the surgeon general. And members of the health affairs staff will need greater detail than I on a given facet of the system. So this task of determining metrics is one we are working with diligence, finding the right set of measures and not collecting information for the sake of having it available. As you go about the task of developing your own metrics, I encourage you to make these rather fine distinctions.

In closing, it seems appropriate to borrow from President John F. Kennedy. These were his words when he addressed the University of California at Berkeley in March of 1962:

"The wave of the future is not the conquest of the world by a single dogmatic creed but the liberation of the diverse energies of free nations and free men."

That thought can be interpreted to apply to our participation in the operational missions designed to implement our National Security Strategy of engagement and enlargement -- striving for democracy around the world and the regional stability that would accompany that achievement. Our participation presents challenges to our readiness posture, of our inclusion of the reserve components, and to everyday health care for all of our beneficiaries.

A second interpretation could be applied to the significant dialogue we, together, are accomplishing within the military health services system. This open dialogue has created the atmosphere which encourages the "diverse energies" of all of you to help face our challenges, learn from them and move on to prepare for the next century.

This year of 1996 does indeed pose challenges. We expect to award the remaining managed care support contracts this year. We will continue to close medical treatment facilities identified in the BRAC [base realignment and closure] process. We will redouble our efforts to explain the details of our TRICARE triple option benefit plan to our beneficiaries and those who retain an interest in military medicine. And we will continue our initiatives to meet the five goals of our strategic plan for the military health services system.

Thank you. ...


Published for internal information use by the American Forces Information Service, a field activity of the Office of the Assistant to the 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 Stephen C. Joseph TRICARE: Readiness & Leadership