Military Health System Transformation

Administration and management of all U.S. military medical facilities are shifting to the Defense Health Agency.

By J.R. Wilson

In the most significant development in military health care since its founding in 1775, the National Defense Authorization Act of 2017 (NDAA 2017) directed the Defense Health Agency (DHA) to bring all U.S. military medical treatment facilities for all service branches together under a single Department of Defense (DOD) organization. It was an action that had been recommended by several studies since World War II to reduce duplication and redundancy and increase proficiency and health care solutions.

Until NDAA 2017, each service was responsible for ensuring a ready medical force and its own medically ready force. As a result, there were no inter-service standardization processes, just a great deal of variation. The transition to DHA is intended to standardize all aspects of health care and ensure consistency throughout the U.S. military.

That transition began on Oct. 1, 2018. A year later in October 2019, an article on the Military Health System’s official website by DHA’s director, Army Lt. Gen. Ronald J. Place, addressed what the transition means to Army, Navy, and Air Force hospitals and clinics.

“Many are questioning what this change really means. Let me first tell you what it’s not about: It’s not about ownership. It’s not about control. It’s not about one Service is better than another. As a matter of fact, it’s because of the great work the Services have done to advance and elevate the quality of care for our warfighters and their families that bring us to this day,” he wrote.

Sailors and staff observe morning colors at Naval Health Clinic Corpus Christi prior to a CO’s call with Capt. Eric Evans to commemorate the command’s official transition to the Defense Health Agency (DHA) on Oct. 1, 2019. All U.S. military medical treatment facilities will transition to the Defense Health Agency by the end of September 2021.

“This is all about the patient. It’s about harvesting decades of best practices from across the Army, Navy, and Air Force – along with what we can learn from the civilian community – to build a global standard with one focus: Make our system better to improve health outcomes that matter to our patients.”

DHA originally was stood up on Oct. 1, 2013, as the nation’s military medical combat support agency – a joint, integrated organization enabling the services to provide a medically ready force and ready medical force to combatant commands in both peacetime and war. Working with the Joint Staff Surgeon and military department medical organizations, DHA maintains a global network of military and civilian medical professionals at nearly 450 military hospitals and clinics, supporting health care delivery to 9.5 million active-duty service members, retirees, reservists, National Guardsmen and women, and their families.

The movement of all military health care delivery to DHA – both CONUS and OCONUS – is scheduled for completion by October 2021. A primary goal is to standardize the business side of health care delivery while improving patient experiences, such as making the process for scheduling appointments or getting a referral for specialty care the same across all facilities.

DHA has assigned military health care facilities to individual markets, based on size: 21 large markets; 16 small markets; and 66 facilities which, because they do not fit into either of those segments, are being designated as a “stand-alone” segment and will be managed by the same office that manages the small markets.

Some 75 U.S. military treatment facilities (MTFs) in Europe and the Indo-Pacific region eventually will be placed into similar markets and transitioned to DHA no later than Sept. 30, 2021.

“Common patient safety and clinical quality policies mean the very best practices in one clinic become the norm within every clinic, raising our performance across the board. A single agency accountable for all the health care we provide – whether in one of our facilities or through a civilian provider in our TRICARE managed care network – means we will be more effective in finding the best possible source for the best care for each patient,” according to Place.

U.S. Army Lt. Gen. Ronald Place, DHA director, addresses members of the 99th Medical Group at Nellis Air Force Base, Nevada, Feb. 28, 2020. During the visit, Place discussed the future of military health care and new advances such as MHS GENESIS, the military’s new electronic health record.

“In the months ahead, we’ll set up market organizations in regions across the country, allowing hospitals and clinics in the same geographic area – regardless of Service – to share and target resources where our patients need them. In the next year, our work focuses on getting this right in the United States and [preparing] for the transition of overseas facilities.”

The transition also will make the new military electronic health records (EHR) system – MHS GENESIS – available across the full spectrum of both DHA-run military health care facilities and those run by the Department of Veterans Affairs. This seamless availability of EHRs to both patients and caregivers, regardless of service, status, or location, not only relieves the patient of the need to copy and carry their records with them when visiting a new facility, but also ensures different providers will not need to repeat the same tests multiple times because they can’t access earlier test results.

U.S. ARMY

At a Jan. 28 forum of 350 Army medicine leaders at Fort Belvoir, Virginia, Army Surgeon General Lt. Gen. R. Scott Dingle warned the attendees they had to rapidly gain “a better understanding of the breadth and depth of change” from the transition.

“Things are changing at the speed of relevance,” he said. “As leaders, it is imperative that we understand the changes that are going on, and that we are also responsive to these changes, because if you are not responsive to the changes, you lose the relevance. And so, fasten your seat belts, batten down the hatches, be ready to make these supersonic speed changes.”

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Dingle’s office, in a statement on the Army’s medical website, assured service members the transfer of Army hospitals to DHA is designed to create a more integrated health care system, improve patient outcomes, and enable the readiness of the Army to support the Joint Force by ensuring medical readiness, supporting wartime requirements, and enhancing the quality of care for soldiers and their families.

“As we reform and reorganize, we are committed to providing ready and responsive health services and force health protection,” Dingle told the House Armed Services Committee’s Subcommittee on Military Personnel in December 2019, speaking on behalf of the Army’s 130,000 health care providers. “The Army is continually assessing the risks with changes to medical end strength. Personnel changes currently under review are a necessary part of our modernization and our force shaping,” he said. “For the service and sacrifice of our soldiers and their families, we must get this right. This is our solemn obligation to our nation,” he added.

At the Defense Committee on Trauma (DCOT), Committees on Surgical and En Route Combat Casualty Care (CCC) Conference in San Antonio, Texas, on Nov. 13, 2019, Dingle also said the transition is an opportunity to bring real change to combat trauma care. That is a major goal of the Army Ready Surgical Force Campaign Task Force (ARSFC TF).

U.S. Army and Ghanaian medical professionals discuss medical practices during Medical Readiness Exercise (MEDREX) 19-3 at Accra, Ghana, on June 10, 2019. MEDREX exercises in support of U.S. Army Africa allow U.S. forces to train in an alternatively resourced environment, share medical practices, and build lasting relationships with medical professionals from participating African partner nations.

ARSFC TF wants to ensure larger roles and training opportunities in military exercises such as the Medical Readiness Exercises (MEDREX) in support of U.S. Army Africa (USARAF), Expeditionary Resuscitative Surgical Team (ERST) in support of U.S. Africa Command (AFRICOM), Expeditionary Health Readiness Platform-Honduras (EHRP-H) in support of U.S. Army South (ARSOUTH), and Global Health Engagement (GHE) Medical Readiness Training Exercise (MEDRETE) in support of ARSOUTH.

“Things are moving at the speed of relevance and if we aren’t relevant to today’s fight, then we’ll become extinct,” Dingle told the conference. “I can’t change the past, but together we can change the future. We can get it right, but it’s not me – it’s we. It’s going to take all of us to bring change.”

U.S. AIR FORCE

“The Air Force is fully committed to the vision of an integrated system of military health and making that process as seamless as possible,” according to Lt. Gen. Dorothy A. Hogg, Air Force surgeon general. “DHA will have responsibility for the administration and management of military treatment facilities operations related to delivering the health care benefit. The Air Force Medical Service retains our readiness mission, ensuring airmen are fit to carry out their mission and delivering deployable medical assets to meet combatant commander requirements.”

Maj. Nicole Ward and Capt. Matthew Muncey are program managers with the Air Force Medical Service (AFMS) Transition Cell, which serves as an information clearinghouse, facilitating communication and collaboration within AFMS as well as externally to the Army, Navy, and DHA.

Air Force Maj. Nicole Ward (left) and Air Force Capt. Matthew Muncey, program managers with the Air Force Medical Service Transition Cell. The Transition Cell interfaces with DHA and represents the Air Force position on the development of policy and plans for the transition of military treatment facilities (MTFs) to DHA.

“We work closely with DHA and the TIMO [Transition Intermediate Management Office] program management offices to ensure clear communication flows to build support and deliver guidance to Air Force and our service partners’ MTFs. Each service brings its own best practices and approaches to make this process possible. This collaboration furthers the MHS high-reliability organization journey, reflecting and enhancing our own Air Force Trusted Care principles,” Ward said in a January 2020 interview with the Air Force Surgeon General Public Affairs Office.

“It also means the Air Force lends its expertise to the transition process and DHA’s implementation efforts,” Muncey added. “The first example to demonstrate the value of our partnership is the AFMS memorandum of agreement with DHA to provide direct support to the MTFs. This agreement allows us to maintain uninterrupted operations supporting Air Force MTFs, freeing up DHA to develop and mature its processes. Air Force’s early and frequent engagement with the DHA yielded positive results for the Air Force and the entire enterprise.”

The Transition Cell was created by AFMS in 2018 to be the primary interface with DHA and represent the Air Force position on the development of policy and plans in transition of the MTFs to DHA, according to Muncey. The cell has representation from both the Air Force Medical Readiness Agency (AFMRA) North in Falls Church, Virginia, and AFMRA South in San Antonio, Texas.

“DHA recognizes it doesn’t have all the answers to these questions and is very open and transparent about that. So it relies heavily on the services to lend our time and talent toward trying to figure out these problems,” Muncey said.

“That’s really where the Transition Cell offers up a lot of the benefits of this productive partnership. We focus on making the transition as seamless as possible by working with DHA to make sure we meet Congress’ intent, while preserving what we already do well at the MTF.”

Hogg said the transformation will “provide us an opportunity to really shape the future of the Air Force Medical Service. Our core mission continues to be paramount – providing exceptional, high-quality trusted care and improving the readiness of our airmen.”

U.S. NAVY

The newly established Navy Medicine Readiness and Training Command (NMRTC) is assisting the transition of health care delivery and business operations to DHA, while enabling Navy Medicine to retain command and control of the uniformed medical force and responsibility and authority for the operational readiness of sailors and Marines, as well as the clinical readiness of the medical force.

Naval Medical Center Portsmouth (NMCP) hosted the Future of Military Medicine panel on Nov. 14, 2019, to discuss the MTFs’ transition to DHA. The panel participants were, from left to right: Capt. Joel Schofer, deputy chief of the Medical Corps at the Navy Bureau of Medicine and Surgery (BUMED); Capt. Lisa Mulligan, NMCP’s commanding officer; and Capt. Guido Valdes, Navy Medicine East’s deputy commander.

“The transition is going well,” Capt. Joel Schofer, deputy chief of the Medical Corps at the Navy Bureau of Medicine and Surgery (BUMED), told a Nov. 14, 2019 Future of Military Medicine panel at Naval Medical Center Portsmouth (NMCP), Virginia, the Navy’s oldest continuously operating military hospital since 1830. “DHA is building its bench. What BUMED is doing is taking personnel and putting them into what is called the direct support cell … the portion of BUMED that is helping DHA run MTFs.”

BUMED’s position is simple: The readiness of the Navy Medicine team is paramount to combat survival in the future. The focus will be on getting and keeping the team ready.

“The way we think about our mission has changed more than the actual mission,” said Capt. Lisa Mulligan, NMCP’s commanding officer. “We need to start thinking, in the terms of Navy Medicine, the mission is being more focused on readiness, but still includes the things that we have been doing all along,” Mulligan said.

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“DHA transition is a big change, but we have the culture to deal with change,” added Capt. Guido Valdes, deputy commander of Navy Medicine East. “If anybody can get through the new journey, Navy Medicine can.”

“Military Health System (MHS) transformation has provided Navy Medicine an unmatched opportunity to refocus on our true mission – the reason why we have uniformed medical personnel – which is achieving maximum future life-saving capabilities and survivability along the continuum of care,” according to Rear Adm. Bruce L. Gillingham, Navy surgeon general, in his statement to the House Appropriations Committee Subcommittee on Defense on March 5, 2020.

“When a sailor or Marine goes into harm’s way, Navy Medicine is with them. The CNO [Chief of Naval Operations] and CMC [Commandant of the Marine Corps] have expressed a sense of urgency for Navy Medicine to meet the demands of the rapidly changing security environment. Our commitment: Optimizing Navy Medicine for the warfighter.”

Carl R. Darnall Army Medical Center (CRDAMC) emergency medicine (EM) resident Capt. Katey Bettencourt examines a simulated casualty while Air Force Maj. Chris Pitotti, EM residency program associate director, University of Nevada, observes during CRDAMC’s Joint Emergency Medicine Exercise held May 28-31, 2019. The exercise tested the Tactical Combat Casualty Care readiness of Army, Air Force, and Navy EM residents in a simulated real-world, joint operational medicine environment. The transition to DHA will facilitate the implementation throughout the Military Health System of best practices in military medical care from all the services.

In a Feb. 19, 2020 report to Congress, DOD announced it had concluded a review of 343 U.S. military medical facilities and is now beginning to restructure 50 of those “to better support wartime readiness of military personnel and to improve clinical training for medical forces who deploy in support of combat operations around the world.”

Of those being restructured, 37 outpatient clinics now open to all beneficiaries eventually will see primarily only active-duty personnel. Active-duty family members, retirees, and their families who currently receive care at those facilities will transition over time to TRICARE’s civilian provider network, a process MHS said may take several years as each is assessed for individual requirements and alternative providers.

Place said the MHS transition also requires a change of mindset within DHA.

“We’ve largely been an agency that is a legacy of TMA – TRICARE Management Activity – and we’re very good at that. We’re very good at carefully and slowly looking at information and coming up with the right answer. That mindset doesn’t work as we support hospitals, medical centers, and clinics in action. When a question arises, we need to respond quickly,” he said.

“We have to transition from being good at thoughtful, deliberate work, to also being an organization of action that takes in information and rapidly gets the right people involved. We still have to be absolutely accurate managing the TRICARE benefit, but we have to be nimble, agile, flexible, and supportive on the direct care delivery side. So, in our culture, we have to transition to balancing both of those things.”

Place also tried to dispel some rumors that have swirled around the transformation.

“The reason for this transformation has nothing to do with this idea that Army Medicine, Air Force Medicine, or Navy Medicine weren’t doing a good enough job,” he said. “That’s not what this is about. This is about taking the great work that people have been doing and finding those best practices across the entirety of the military health care system and bringing everyone up to that level. We have to find ways to make the process user friendly, irrespective of service, for every single beneficiary that we have,” he said.

“Every single person in senior leadership across the services, everyone in Congress who is writing these laws, fundamentally understands the great work that is happening in military medicine, and the whole idea behind this is how to take that great work and make it better. Our ultimate goal is to strengthen our ability to provide ready medical forces to support global operations and improve the medical readiness of combat forces.”