View Full Version : Military Medicine and HealthCare Reform
olhamada
01-09-2009, 10:36
In order to facilitate discussion at the appropriate level, when you post for the first time in this forum, please provide a brief introduction with your level of training, experience, and current medically-related position as applicable.
I am an MD (Family & Sports Medicine, and Obstetrics & Gynecologic Surgery). I was Director of Predoctoral Affairs while on faculty at the University of TN College of Medicine from 1995-2002, and am now an Associate Clinical Professor at Vanderbilt University's School of Medicine. I currently serve at Pfizer in the position of Director, Pfizer Global Medical, Pain & Inflammation. I have served as a national level speaker for the American College of Obstetrics and Gynecology, and for Marcus-Evans, and am currently a speaker for the American Academy of Family Physicians and the Christian Medical and Dental Association.
On the military side, I was in the 230th MASH from 1989-1994, and then in the 1/20th SFG, (A) from 1994-2004. Training included Combat Casualty Care, Medical Management of Biological and Chemical, Flight Surgeon, Hyperbaric Medical Officer, and Diving Medical Officer. Of course, ABN and SCUBA as well.
So, my question is - A couple of days ago, I received an invitation to be the anchor speaker at Duke University's Fuqua School of Business on the topic of HealthCare Reform from a military perspective. We are still flushing this out in terms of topics, pertinent questions, etc.... I would love to have any input you might be willing to share given the vast experience on this board.
Given the recent failures of the VA system to provide adequate and ongoing care for our troops, and given the recent and worsening failures of our civilian healthcare here in the US, this is a very timely topic and should generate great discussion.
Here's the "tickler" from Duke:
At the April 16-17, 2009 Health Sector Advisory Council meeting, Duke University, we will address health care reform focusing on Military and Combat Medicine. Speakers such as MAJ Omar L. Hamada, MD will consider pre-deployment requirements and logistics, in-theater functionality, past and present mechanisms and survivability of battlefield injuries, acute and chronic care and rehabilitation secondary to Traumatic Brain Injury, amputations, blast injuries, etc. The need to prepare soldiers for deployment, potential in-theater injuries, and post-deployment care has created opportunities for public and private sector innovation. All observers agree soldiers fighting in Afghanistan and Iraq have greater survivability due to innovative devices and therapeutics. Yet this improved survivorship has increased the challenge to make post-injury care accessible, high quality, affordable and sustainable. The discussion will focus on a variety of issues including delivery of services through private sector versus government sponsored models (VA). Speakers and panelists will also suggest how reforms for Military and Combat Medicine may foreshadow broader health care reform issues facing the new Obama administration and the 111th Congress.
The target audience will be C-level executives from GE, P&G, HCA, BCBS, Aetna, etc..., a couple of US congressmen, Duke Fuqua Business School faculty and students.
A few pertinent questions to help guide discussion:
- What specific things would you think about and want to have covered regarding the delivery of medical care in the pre-deployment phase?
- What changes have occurred in the past 50 years in terms of mechanisms of injury on the battlefield?
- What has improved the survivability of our soldiers?
- What are the implications of increased survivability with regard to chronic medical care and rehabilitation?
- How do we best prepare our soldiers to deal with their own and other soldiers' injuries on the battlefield?
- How do we maintain high quality and accessible care once the injured soldier has returned to CONUS?
- How can this translate into new paradigms for civilian healthcare delivery on a global scale?
Of course, any other thoughts or questions you have are certainly welcome!
I look forward to your input!
olhamada
01-15-2009, 18:03
Ok, I see this has really generated a ton of interest! :)
I know it's a long post, but most of it's background and intro. If any of the questions at the end spark any interest or thoughts, please let me know in a post or PM. Or if you know of anyone who might have the experience, background, and interest to contribute, please let me know. (Just spoke to D2 about it - prev USASOC Surg).
What we're trying to do is raise the visibility of Military/Combat Medicine, the plight of our wounded veterans, and figure out a way to help reform the civilian healthcare system.
Thanks for your time and attention!!:lifter
My experiences are limited to those gained as a member of the ARNG with a LOD injury, but I would say the provider network of Tricare needs to be addressed if you want to ensure good pre- and post-deployment healthcare for reserve component soldiers outside the catchment area of a major MTF.
While MMSO attempts to coordinate our care, this involves paying for services received from a Tricare network provider. In some areas, the physician quality is excellent. I had a surgery performed in the Portland area last spring, and the network included most of the specialists offered by my private health insurance.
However, here in Dallas, TX, the situation is very different. Because no qualified specialists were available in-network, I recently spent $13,000 out of pocket for surgical revision rather than going to an unqualified provider. How many troops can do that?
In fact, I was recently looking at the Reserve Select health insurance offering, given its very low premiums, and decided not to go that route because of the network quality. From a list of 17 physicians whom I or a close friend have used, exactly zero accept Tricare. It's a pretty sad state of affairs.
Ok, I see this has really generated a ton of interest! :)
What we're trying to do is raise the visibility of Military/Combat Medicine, the plight of our wounded veterans, and figure out a way to help reform the civilian healthcare system.
Thanks for your time and attention!!:lifter
Doc
I am not in the health care business, so I will not attempt to add.
My observations are based on your note.
1)Your asking for input from BTDT people that are at the start of the process, yet your attempting to fix the other end,, VA care???
2)Your audience for the presentation does not include the very people that own the problem,, the VA??
3)The other target "will be C-level executives from GE, P&G, HCA, BCBS, Aetna, etc..., a couple of US congressmen, Duke Fuqua Business School faculty and students" have very little to do with the problem nor the solution, with the exception of a couple of US congressmen
Given your target audience and the fact that they will have probably ZERO background in war zone medicine.. I can only conclude,, and again,, based on your initial post, that the meeting is more based on money and less on actual care given. The lack of care giving medical professionals in your audience,, and the abundance of business, insurance, managerial professionals,, asks the question,, WHY???
Another point, you appear to have a bias view of both the VA and national medical system. Not a good way to start an open-minded conversation about change.
Given the recent failures of the VA system to provide adequate and ongoing care for our troops, and given the recent and worsening failures of our civilian healthcare here in the US, this is a very timely topic and should generate great discussion.
If I have misunderstood your post, sorry...
Here is my small 2 cents worth on the VA where I happen to work. Although the people down in trench's who actually care for and treat our veterans are tremendous. The VA as whole and our government are just covering their behinds with all this Brain Injury stuff, PTSD, and Wounded Warrior care. Here is what I witness. A veterans checks in and is registered with the VA which is what you are suppost to do once you have been discharge. They are given a survey to cover the above mentioned and this is done so they can put a check in the box when the VA reports back that they caring for the servicemen returning home. They are set up for a physical and little is done after that. All the VA is required to do is that initial exam after the veteran registers. Something needs to be put in place to make sure that we are not just checking the box's for some governement report and our veterans are getting continious care.
I don't think this is the type of response you were looking for but like I said this is what I see happening to our veterans that are returning from harm's way.
Red Flag 1
01-16-2009, 11:06
below
greenberetTFS
01-16-2009, 11:55
What is YOUR goal at this talk? Or is that what you are looking for from this board?
Given the venue, this looks to be a dollars and cents issue, and not so much medical care from any arena. If you condider that Med care in the military is socalized medicine with civillian back up, it suggests that your audience wants to learn about high energy socalized medicine.IMHO.
The VA system generally gets a bum rap. The VA is socalized medical care. I agree with JJ in presuming that the VA is a failing system is a hole you may have to dig yourself out of, IMHO.
Lastly, do you believe that Medicine practiced by the military is applicable to general health care in the USA? Active military populace is generally healthy and "in shape". Very little chronic issues in active duty military population. If you want to examine long term care for the military patients, I give you the VA. On a nationwide level, I give you Canada.
Perhaps an MBA, along with your other quals, would be plus at your upcoming event. Have you vetted with TS yet?
RF 1
Good points RF1.............
GB TFS :munchin
I said I'd not discuss the medical side as I am not in the profession..
I am a receiver of services,, in that I have a 30% service connected, combat disability,, for 39 years. I was also active in the VFW and made many monthly visits to the VA hospital in Miami.
Let me be very clear,, I hate socialized anything to include medicine. I also think the VA system needs a lot of work.
A major part of VA failure is the fact that we have let it become a bureaucratic monster incapable of delivering it's intended mission.
Like all socialized institutions, it has built a hi-archy based on unfitted consumption of money and resources, with little or no care for it's targeted product, and it festers unabated..
Why?? Because the VA is responsibly for a small portion of the population with little political clout.
Additionally, socialists, who can care less about Vets,, are more than willing to use it as a stepping stone for the nationalization of the US medical system..
The Veteran is only used in the context of appropriations,, not the services rendered.
When the VA was initiated, there was a need to help returning veterans integrate back into a society that would shortly fall into world depression.
www.va.gov/facmgt/historic/brief_va_history.asp
Congress established a new system of veterans benefits when the United States entered World War I in 1917. Included were programs for disability compensation, insurance for service persons and veterans, and vocational rehabilitation for the disabled. By the 1920s, the various benefits were administered by three different Federal agencies: the Veterans Bureau, the Bureau of Pensions of the Interior Department, and the National Home for Disabled Volunteer Soldiers.
It has turned it's back on the veteran. The VA slinks thru the halls of the capital buildings in DC, with it's hand out. It provides just enough feed-back to curry favors from the Congressman & Senators responsible for funding, who in turn, spew great verbiage to the populace, while raising our taxes...
If you target is national socialized medicine,, we will end up like the UK and Canada,, a bureaucratic morass that can only consume and will not die...
My $00.0002
end of rant..... :mad:
Well almost,,, I should also add that ALL veterans with service connected disabilities, whether it was combat related or not, are not in a welfare line. These people had a contract with the US government for medical insurance for services rendered.. They deserve nothing but the best... They are not getting what they deserve... :mad:
Red Flag 1
01-18-2009, 17:44
if it worth saying, it will be quoted.
olhamada
01-19-2009, 18:21
However, here in Dallas, TX, the situation is very different. Because no qualified specialists were available in-network, I recently spent $13,000 out of pocket for surgical revision rather than going to an unqualified provider. How many troops can do that?
In fact, I was recently looking at the Reserve Select health insurance offering, given its very low premiums, and decided not to go that route because of the network quality. From a list of 17 physicians whom I or a close friend have used, exactly zero accept Tricare. It's a pretty sad state of affairs.
jatx, I feel your pain - and that's one of the issues we are trying to deal with. The costs of healthcare have become completely uncontrollable and irrational. We have to find a way to provide high quality healthcare with reasonable access to our citizens without breaking either their budgets or the national budget while preserving choice, autonomy, and quality. With tens of millions unable to afford insurance and the costs of healthcare approaching 18% of GNP, something's got to be done, but no one knows how to fix it - yet.
olhamada
01-19-2009, 18:37
1)Your asking for input from BTDT people that are at the start of the process, yet your attempting to fix the other end,, VA care???
2)Your audience for the presentation does not include the very people that own the problem,, the VA??
3)The other target "will be C-level executives from GE, P&G, HCA, BCBS, Aetna, etc..., a couple of US congressmen, Duke Fuqua Business School faculty and students" have very little to do with the problem nor the solution, with the exception of a couple of US Congressmen.
Given your target audience and the fact that they will have probably ZERO background in war zone medicine.. I can only conclude,, and again,, based on your initial post, that the meeting is more based on money and less on actual care given. The lack of care giving medical professionals in your audience,, and the abundance of business, insurance, managerial professionals,, asks the question,, WHY???
Another point, you appear to have a bias view of both the VA and national medical system. Not a good way to start an open-minded conversation about change.
If I have misunderstood your post, sorry...
JJ BPK, great questions.
1) The focus is really to start a discussion with the hope of helping to fix both the civilian and VA systems through dialogue.
2) True - this is targeted more at the civilian sector who want to learn from the VA - both from the good and the bad.
3) Again true - if we're talking about the VA alone. However, in this, the VA system will be used as a model from which we hope to learn from both the failures and the successes. On the civilian side, these are the decision makers.
4) WHY? Because doctors and other healthcare providers no longer run anything. It's the pharma companies, the insurance agencies, the hospital corporations, and the government that hold the reigns, spend the money, allow and disallow services, etc... Healthcare is funny - it is both a right and a commodity - sort of a hybrid. Without buy-in from those that make the profits and control the bank we are hopelessly adrift in a very deep sea that will sink our economy if not controlled.
The thing driving healthcare right now are the enormous profits these companies are making on the backs of our ill. Another problem is that we have made doctors double minded by telling them to treat patients, but document and code appropriately so that they get reimbursed for the services they provide. So we have taken physician's eyes off the patient and put them on billing and collecting. That can't be good for the patient or the doctor.
Re bias - I worked in the VA system for several years through med school and residency, and I'm sure we all remember the issues at Walter Reed from a couple of years ago. The VA has incredible systems and processes in place, but also suffers from a lack of efficiency and has a few quality issues.
olhamada
01-19-2009, 18:39
I said I'd not discuss the medical side as I am not in the profession..
I am a receiver of services,, in that I have a 30% service connected, combat disability,, for 39 years. I was also active in the VFW and made many monthly visits to the VA hospital in Miami.
Let me be very clear,, I hate socialized anything to include medicine. I also think the VA system needs a lot of work.
A major part of VA failure is the fact that we have let it become a bureaucratic monster incapable of delivering it's intended mission.
Like all socialized institutions, it has built a hi-archy based on unfitted consumption of money and resources, with little or no care for it's targeted product, and it festers unabated..
Why?? Because the VA is responsibly for a small portion of the population with little political clout.
Additionally, socialists, who can care less about Vets,, are more than willing to use it as a stepping stone for the nationalization of the US medical system..
The Veteran is only used in the context of appropriations,, not the services rendered.
When the VA was initiated, there was a need to help returning veterans integrate back into a society that would shortly fall into world depression.
It has turned it's back on the veteran. The VA slinks thru the halls of the capital buildings in DC, with it's hand out. It provides just enough feed-back to curry favors from the Congressman & Senators responsible for funding, who in turn, spew great verbiage to the populace, while raising our taxes...
If you target is national socialized medicine,, we will end up like the UK and Canada,, a bureaucratic morass that can only consume and will not die...
My $00.0002
end of rant..... :mad:
Well almost,,, I should also add that ALL veterans with service connected disabilities, whether it was combat related or not, are not in a welfare line. These people had a contract with the US government for medical insurance for services rendered.. They deserve nothing but the best... They are not getting what they deserve... :mad:
I completely agree with everything you said. It looks like you share my bias. :)
I would hate to see us convert to a socialized medical system, but I don't see any other option. Do you? if we could get all external parties disengaged from the heart of healthcare and plug them into the periphery, then we'd go a long way in fixing the problem. We need to return the physician-patient relationship to the center. However, there are too many parties interested in making $5000/ER visit (for example) to fix this.
olhamada
01-19-2009, 18:48
What is YOUR goal at this talk? Or is that what you are looking for from this board?
Given the venue, this looks to be a dollars and cents issue, and not so much medical care from any arena. If you consider that Med care in the military is socalized medicine with civillian back up, it suggests that your audience wants to learn about high energy socalized medicine.IMHO.
The VA system generally gets a bum rap. The VA is socalized medical care. I agree with JJ in presuming that the VA is a failing system is and may be another hole you may have to dig yourself out of, IMHO.
Lastly, do you believe that Medicine practiced by the military is applicable to general health care in the USA? Active military populace is generally healthy and "in shape". Very little chronic issues in active duty military population. If you want to examine long term care for the military patients, I give you the VA. On a nationwide level, I give you Canada.
Perhaps an MBA, along with your other quals, would be plus at your upcoming event. Have you vetted with TS yet?
In that you have come to this board for advice, perhaps you could share with us the position of your employer Pfizer. What is their goal for your presentation at the Duke School of Buisness?
RF 1
In terms of my goal, I hope to utilize the successes we've had in healthcare delivery through the VA system, and make suggestions that would assist those in attendance in reforming the civilian sector.
Re your second point - EXCELLENT. You may be correct. I hadn't thought about that.
i don't think the VA system is a failing system, though I do think it has many areas which could be strengthened. Our civilian system is failing and cannot be sustained in it's present state. How do we fix it? That's the question. How do you handle something that's both a right and a commodity?
Re your fourth point about health status of civilians versus military - also an excellent factor to seriously consider. Thanks!
The MBA - Hmmmmm. That's something I've been trying to convince my wife of for years. :)
Re Pfizer's position - I was not invited nor am I speaking as a Pfizer employee, but as a physician with experience in healthcare reform as well as academic medicine, private practice, industry, and the military. So, though they are aware of the fact that I am speaking, they have not tried to influence my opinions or talking points.
jasonglh
01-20-2009, 01:11
My fathers doc has retreated back to working through the VA clinic because of the high cost of malpractice for surgeons. Can't say we are overly impressed with the VA clinic but he has seen the same surgeon for 25 years and does not wish to change. If he has not gone back to operating out of the VA he said he would have been forced to retire as he couldn't afford his malpractice any more. That is not something I have heard from just him my own doc is on the fence about continuing his practice next year. Every year the govt and insurance takes a larger bite so why keep working?
Tort reform is needed but most politicians are lawyers so what are the odds?
Lawsuits are driving malpractice insurance up and these billion dollar payouts by the drug companies are why my copays are now $60 per script.
As I understand it America is one of the few places that allows direct marketing of prescription drugs to consumers?
I see lots of elderly cardiac patients suckered by new drugs that combine their 2 old pills together in an easy to take single pill. Now this new pill is going to cost them when they could get the old ones as generic for $4 each at Walmart.
I'm just an RN in Kentucky and have only worked at 2 ICU's but both hospitals I worked for do not turn away any patients. Maybe in the bigger cities that is a problem but not here the patient comes first and they worry about billing later. Granted a few months ago we got a memo saying were using too many trashbags so money is tight but....
I wonder what the ratio of bean counters/managers to MD/RN runs at the VA vs private hospitals.
Red Flag 1
01-20-2009, 12:24
if it worth saying, it will be quoted.
I suspect that if each VA complaint was followed up on, the real story would be different. I have done this a few times and was impressed with the VA care system each time. I do think that the patient load is just overwhelming much of the time.
Concur. I've worked with VA providers and know a few more. They are all outstanding. I'm sure there are also exceptions. While the VA has many admirable qualities, I'd be extremely cautious about extrapolating from the VA model to a civilian system. There are many confounding variables--RF1 has pointed out just a few. Sounds like you are wading into unknown waters; tread with care.
...I would hate to see us convert to a socialized medical system, but I don't see any other option. Do you? ......
Yes, I do. Make health insurance similar to car insurance. Once again government has tied the hands of the everyday people.
Make your health insurance deductable off your taxes. The self employed get stiffed on that one. Why should a 30 year old male be forced to pay full coverage for insurance that covers breast implants?
The government has made health care the monster it is and now wants to fix it? Yeah, right, want to buy a bridge?
Yes, I do. Make health insurance similar to car insurance. Once again government has tied the hands of the everyday people.
Make your health insurance deductable off your taxes. The self employed get stiffed on that one. Why should a 30 year old male be forced to pay full coverage for insurance that covers breast implants?
The government has made health care the monster it is and now wants to fix it? Yeah, right, want to buy a bridge?
Pete's suggestion is something I have though about for years..
As I stated earlier. The VA system is a contract between the US Gov & Veteran's. As such there is no reason that a health plan could not be developed to cover the Vet and executed at any doctor's office or hospital available to anyone.
Certain aspects would need new systems. Like rehab, prosthetics, and ambulatory care after initial release.
If the active military hospital systems took care of the patient during the initial phases, and was available for specialty care (prostitutes), the rest can be handled by any and all in the med profession??
Issue a vet an industry accepted insurance card.. We have the process & system in place,, it's called Medicare.
This would need a couple things to happen:
- eliminate the VA hospital system, move the head-count resources to the active duty military system,, where needed.
- release the current VA hospitals to the civilian network. Turn them over to the states.
- substantially augment the active military hospital system so a wounded vet is not shuttled out the door like a chunk of meat at a packing plant.
- keep vets on active duty until they are reasonably fit for duty or retired, with their consent.
- made the military realize that a disabled vet is still an asset. He/she may not be a combat asset, but they can contribute. Ref: Cpt Ivan Castro
- tweak the "insurance" plan (Medicare) to allow NON-contributory, ZERO COST, & 100% coverage for service connected care.
With the above system, a veteran with a service connected disability could go to any doctor and get the care they need. No more 150 mile trips to the NEAREST VA clinic, No more shuffle between hospitals looking for doctors with specialized talents, No more bureaucratic maze..
My $00.0002
JJ,
That is essentially what the Military Medical Support Office does - it contracts for care of RC soldiers with line of duty injuries who are not within the catchment area of a major MTF. Once you file the docs substantiating your claim of injury, your home unit calls to get authorization for you to visit Tricare-network providers. You never see the bill and there is no copay.
Issues:
In areas with higher medical costs (i.e. major cities) or fewer vets, the network is very weak. In these areas, the reimbursement rate for many procedures/visits is less than half what a non-profit health insurer like Blue Cross pays. Consequently, quality providers and specialists refuse to join the network.
Second, MTF can mean a podunk TMC where you might be limited to seeing a PA, or waiting for hours to be seen. You may not receive the same standard of care as if you were on a post with a base hospital, let alone a major medical center. If you need a type of specialist that is not in-network for Tricare - tough luck soldier!
Third, coverage of care ends when soldiers ETS, and the individual enters the VA system.
So, MMSO is similar to what you're suggesting, but not exactly a model.
The thing driving healthcare right now are the enormous profits these companies are making on the backs of our ill. Another problem is that we have made doctors double minded by telling them to treat patients, but document and code appropriately so that they get reimbursed for the services they provide. So we have taken physician's eyes off the patient and put them on billing and collecting. That can't be good for the patient or the doctor.
Wow, these 4 sentences are amazing for someone with your published credentials. :confused: I'm not trying to be disrespectful, but, these comments express not only a certain political persuasion but also lack a fundamental understanding surrounding the basic issues of health care management, economics and human psychology. Just my 2 cents.
olhamada
01-27-2009, 20:16
Wow, these 4 sentences are amazing for someone with your published credentials. :confused: I'm not trying to be disrespectful, but, these comments express not only a certain political persuasion but also lack a fundamental understanding surrounding the basic issues of health care management, economics and human psychology. Just my 2 cents.
FILO, Sorry for my delay - my harddrive went up in smoke. Got an iMac less than a year ago and it's already dead. Trying to recover data.
Anyway, no disrespect taken. Care to expound? I'm not sure I follow.
Thanks.
FILO, Sorry for my delay - my harddrive went up in smoke. Got an iMac less than a year ago and it's already dead. Trying to recover data.
Anyway, no disrespect taken. Care to expound? I'm not sure I follow.
Thanks.
Sucks when that happens. Anyway, regarding your comments, I found them to be politically bent, uninformed and what I would expect coming from a Nancy Pelosi or Harry Reid.
Now, as I interpreted your comments, the high cost of health care is directly resulting from the greed of the insurance companies and that the poor patients and doctors are victims in this unjust system. Is that correct? If so, please back up your comments with credible statistics and analysis.
I can spend a significant amount of time talking about health care and how there are many factors involved in determining the costs, but, before I do, at least check these website out: http://www.meps.ahrq.gov/mepsweb/; http://www.nchc.org/ and http://www.nhcaa.org/eweb/StartPage.aspx. It's just a start and there are many other sites you can visit which can educate you with real statistics and analysis on why going to the doctor is expensive.
After you check it out, I'm willing to continue the discussion, but it should probably go to PM since we'd more than likely bore the hell out everyone here.
olhamada
02-02-2009, 11:33
Sucks when that happens. Anyway, regarding your comments, I found them to be politically bent, uninformed and what I would expect coming from a Nancy Pelosi or Harry Reid.
Now, as I interpreted your comments, the high cost of health care is directly resulting from the greed of the insurance companies and that the poor patients and doctors are victims in this unjust system. Is that correct? If so, please back up your comments with credible statistics and analysis.
I can spend a significant amount of time talking about health care and how there are many factors involved in determining the costs, but, before I do, at least check these website out: http://www.meps.ahrq.gov/mepsweb/; http://www.nchc.org/ and http://www.nhcaa.org/eweb/StartPage.aspx. It's just a start and there are many other sites you can visit which can educate you with real statistics and analysis on why going to the doctor is expensive.
After you check it out, I'm willing to continue the discussion, but it should probably go to PM since we'd more than likely bore the hell out everyone here.
OUCH!! Pelosi and Reid?? HA! Not quite. Actually, I'm on the other side of the spectrum.
Thanks for the links - they look great. I'll check them out and get back to you via PM.