A Tale of Two Systems: The Search for Relevant Military Health Care
Congress fractured the Military Health System in 2018 when it moved military health care under the Defense Health Agency. Ever since, the Defense Health Agency has centralized resources and civilianized military health care to save money and provide care to more dependents and retirees. In turn, operational military leaders, facing a mission-ignorant health care system, have started paying for embedded medical care out of their operational budgets. Embedded at the unit level and outside the military treatment facility, this innovative care blends primary care, psychological health, and human performance in an interdisciplinary team approach. It helps get military members the care they need at a fraction of the Defense Health Agency’s budget. This decentralized health care system is mission-centric, having been used by Special Operations Command for the past 20 years.
In the current Military Health System, the warfighter is asked to schedule a 15-minute primary care appointment at the clinic. If the system works as designed, the member is sent to the correct network specialist weeks or even months later, while the unit and the operational mission are without the mission-ready teammate.
Hence, there is a discrepancy between the two systems. This is because operators prioritize relationships, access, cost savings, risk, and morale in ways the Defense Health Agency has not. The embedded model provides the agility and decentralized execution needed to support the warfighter and the future fight in a proactive approach.
Military health care is a vital part of the joint force. It should be held to standards Chairman of the Joint Chiefs of Staff Gen. C.Q. Brown, Air Mobility Command leader Gen. Mike Minihan, and former Air Force Special Operations Command leader Lt. Gen. Jim Slife have all called for. Currently, Defense Health Agency’s centralized bureaucracy lacks the concepts the joint force is striving to achieve: a department-wide disruption narrative emphasizing flexibility, autonomy, innovation, adaptation, collaboration, accepting risk, advancing mission command, and empowering execution. Instead, the current Military Health System is focused on financial efficiency and meeting administrative metrics. This dueling tension has led military medical professionals to question the agency’s priorities and support to the operational mission. As warfighting leaders clamor for the rapid, low-cost expansion of integrated operational support, their demand signal is a leading indicator of the military’s need. Is the Military Health System willing to accept the operational and medical risk of meeting medical needs outside the walls of the clinic to meet this growing demand?
Bandages, Beans, and Bullets
In the early 2000s, U.S. Special Operations Command led a paradigm shift in military health care, reclassifying warfighters as tactical athletes. This decision was driven by an understanding that “musculoskeletal injury accounts for the greatest number of medical visits and lost duty time in military populations.” By embedding comprehensive health care teams across the force to care for their operators, the special operations model spread across the conventional force. Today, multiple health care models exist across various bases and military branches because the effectiveness of multidisciplinary human performance support continues to earn operational adherents. One of the most apparent indications of effectiveness is the funding stream: operational leaders are paying for these programs out of their operational budgets. The Defense Health Agency, in contrast, has centralized resources. They have done so — undoubtedly with the best of intentions — to improve access to care for dependents and veterans. However, what is happening is that operations-ignorant medical leaders are now focused on the wrong thing: bureaucratic demands for efficiency. This, in turn, has harmed operational survivability, resilience, lethality, and readiness.
Former Chairman of the Joint Chiefs of Staff, Gen. Mark Milley, has expressed specific concerns about this disconnect. When the Defense Health Agency proposed to cut nearly 13,000 military health care jobs, transitioning many active-duty billets to nondeployable civilian positions, “Milley raised questions over whether there would be a sufficient number of doctors, nurses, corpsmen, and medics to man combat hospitals and fighting units.” The Military Health System–led COVID-19 response, according to the Department of Defense Inspector General’s report, answers Milley’s question with a resounding no. The COVID-19 response denuded military treatment facilities of all but crisis caregivers, essentially terminating affirmative care to build survivability, resiliency, and readiness.
The bureaucratic Military Health System remains focused on health care delivery within hospitals and clinics mimicking the civilian hospital environment. As a result, hospital rank and file know little about novel integrated operational support concepts. Further distancing medical personnel, funding for the integrated medical model has come from nonmedical operational budgets at a fraction of the cost — using “bullets and beans” money to pay for bandages, to use a colloquial phrase. According to my correspondence with Air Force Special Operations Command A1Z, Mr. James Beaty and Chief of Sports Medicine, Lt Col Jordan Richardson, the 2023 human performance budget in U.S. Special Operations Command is a mere $100 million, while Air Force line commanders have requested nearly $76 million to support the integrated health care their missions demand. Round $176 million up to $200 million, and the combined “ask” for operationally focused medical care is still right of the decimal of the Military Health System’s fiscal year 2023 $55.8 billion portfolio.
The core concept of integrated health care teams is not new. Athletes at the collegiate and professional levels have had the advantage of this model for more than 100 years: first “trainers,” then sports medicine physicians (e.g., team doctors), physical therapists, nutritionists, sports psychologists, and the other supporting health care providers. Early aviators similarly had this advantage, exemplified by the career of Maj. Gen. Dr. Malcolm Grow, who entered the United States Army Medical Service in 1917. Dr. Grow studied the effects of the aviation environment on the human body. All that’s new is that more operational leaders are spending more operational dollars on integrated operational support to make up for the gaping holes in health care for warfighters. Five core principles of integrated operational support underpin its success: relationships, access, cost savings, risk, and morale.
The first principle is relationships. In the integrated operational support framework, teamwork between the multidisciplinary provider team and the operational command is foundational. This teamwork relies on relationship development and the trust that comes from it. Trust comes most quickly through shared experiences inside operational units. Embedded health care programs integrate caregivers, enabling relationships to grow and trust to develop. Trust enables a preventative approach to health care that is directly relevant to the operational environment. By understanding operational requirements before, during, and after military engagements, integrated medical teammates provide ready, relevant, reliable care to the warfighter. The Military Health System must value no higher priority than trusting relationships between the providers and the operational command team.
The second principle is the need to provide unfettered access to a multidisciplinary health care team. This contrasts with the standard goal of providing efficient care via “primary care referrals, 15-minute appointment slots, and tedious specialty appointing.” Even with the best care under this model, many servicemembers go outside the system to get the medical support they need. Rigidity and centralization exist to enable the Military Health System to meet the needs of warfighters, family members, retirees, and other beneficiaries despite resource gaps, access barriers, and the inevitable ignorance that comes from disconnection from the warfighter. Documenting the observed importance of access, a 2020 RAND study found access to be the key ingredient shared in the various integrated operational support model programs. In this regard, operational priorities, not budget or efficiency priorities advanced by the Defense Health Agency, must determine access to care.
The third principle is cost savings. These programs formerly relied on subjective anecdotes, but current research overcomes the difficulty of measuring success with tools built to measure hospital compliance. Imagine a physical therapist at a large hospital with a patient population of 4,000 who must see 15 patients a day (warfighters, family members, retirees, etc.) to meet Defense Health Agency access and cost metrics. In the integrated model, a physical therapist might only have a patient population in the hundreds, yet each member of that population represents over $1 million in military investment needed for warfighting missions. The hospital-model physical therapist can’t compete with this ratio of direct support to the warfighting mission. The integrated-model physical therapist can’t compete with hospital population access and cost metrics. The integrated model loses when measured with hospital tools, but if the metric is warfighting lethality, the integrated system wins big. Military leaders and Congress debate and legislate this balance, sometimes with contradictory language on either side. Fortunately, research continues to provide insight into the question of priority. A 2021 Air Force study of recruit training found that every dollar spent on an embedded integrated operational sports medicine team saved $10 in injury-related attrition. A similar but much larger 2022 Army study found every dollar spent on integrated medics saved $4. The third priority, then, is measuring cost savings not in the suburban dependent and retiree clinics but at the bleeding edge of the spear.
The fourth principle is assuming risk. This paradigm-shifting integrated health care model provides unit-level medicine in keeping with senior military leaders’ “intent to decentralize and transform.” Like their operational counterparts, medical leaders should focus on mission execution risk, with bean-counting risk clearly subordinated. Despite the Defense Health Agency’s tendency to be risk-averse, operational commanders tend to welcome risk if it can be mitigated and if they have a validated recommendation from medical leaders they trust. Can the Military Health System assume more risk with our operational colleagues to improve care? Basic standards and medical credentialing are critical, of course. But a civilian-heavy suburban outpatient clinic differs vastly from what is needed within an operational unit. The priority must remain focused on the warfighter.
Finally, the fifth principle is morale. The improved morale of members receiving agile, relevant, multidisciplinary care at the unit level makes connections that builds trust, encourages injury reporting, and increases retention, which saves money and time. For example, the Air Force Special Warfare Training Wing, in an unpublished human performance report that I have access to from 2022, notes that 70 percent of people exposed to the integrated model reported having human performance optimization services available influenced their decision to stay in the military. Ninety percent responded that the presence of integrated medical care led them to seek care for injuries and concerns they might otherwise have left unreported. Morale matters to providers as well. A study of burnout in a military medical center noted 56 percent of medical providers recorded emotional exhaustion, 30 percent expressed depersonalization, and 91 percent cited a feeling of a lack of personal accomplishment. Regardless of profession, military members want to be valued, trusted, and connected to a team connected to the mission. An expanding body of research shows the integrated model provides these opportunities — and it is why I’ve stayed in the Air Force while many other medical colleagues have separated.
An additional positive aspect of the model is its potential impact on recruiting. The Department of Defense is struggling to meet its national recruiting goals as a record-low number of individuals are eligible to serve, and few of those eligible desire to. An internal Department of Defense survey noted that “more than half of the young Americans who answered the survey — about 57 percent — think they would have emotional or psychological problems after serving in the military. Nearly half think they would have physical problems.” The integrated health care model could potentially influence recruitment if it is highlighted and advertised appropriately to counter this prevailing narrative.
Medical leaders face ongoing challenges, including the impossible task of balancing the Military Health System support to warfighters, family members, veterans, and other beneficiaries as congressionally directed. But if everything is a priority, nothing is a priority. The tensions I’ve laid out should trigger discussions that lead to deliberate prioritization through the integrated operational support model’s medical agility and autonomy needed to support the current demands of strategic competition and to get ready for the future near-peer fight. This model can be developed and expanded across U.S. Special Operations Command and the Air Force at 0.3 percent of the Military Health System budget. For a total force initiative, it shouldn’t exceed 2 percent. Scaling up the integrated multidisciplinary model will distribute some hospital and clinical assets into operational units under the service medical departments. Transitioning the Defense Health Agency to focus on beneficiary care will also provide service medical departments with a clear focus to serve the warfighter population in a more relevant and effective manner.
Accelerating change will require difficult decisions and a clear understanding of operational priorities. As the Defense Health Agency centralizes resources and civilianizes the force, operational leaders are creating ways to integrate medical professionals into their formations. The integrated operational support model is relevant and cost effective and provides positive outcomes across multiple domains, including relationships, access, cost savings, risk, and morale. The Military Health System and the Defense Health Agency must innovate and transform their approach to operational medical support — or operational leaders will increasingly spend funds on bandages that are needed for bullets and beans.
Lt. Col. Philip M. Flatau is the deputy commander, 51st Medical Group, Osan Air Base, Republic of Korea. As the deputy commander, he supports leadership and direction to personnel across three squadrons in the Air Force’s most forward-deployed permanent wing.
The conclusions and opinions expressed herein are those of the author and do not necessarily reflect the official policy or position of the U.S. government, Department of Defense, or Air University.
Image: U.S. Army