21 Aug 06

The time and care evidenced in your memorandum is appreciated. I spent some time on your web site with particular interest in the excerpts from your forthcoming book. I also took the liberty of sharing your memo with the Society's leadership.

My president's letter in the May newsletter used the term "astonished" in reference to the FY2007 plan given the current operation tempo. SMCAF has been fully informed over the past several years by the leadership of the services and by the ASD (HA) of the reductions in active duty physician positions, increasing use of physician assistants and nurse clinicians, the disruptions caused by the contracting process and the increasing use of the civilian health care system for care that was once the province of the military health care system. The past two years have accelerated the need for repetitive deployments with the expected impact on continuity of care and retention. The number of physicians such as yourself that have left active duty within a few years of retirement eligibility is higher than anyone can remember, the major cause being the increased recalls of retired physicians who are eligible for such involuntary recall for life. Recruitment is down significantly: the HPSP program did not fill this past year.

Some of the changes make sense: the closure of very small hospitals with less than enough inpatient workload to preclude quality care; avoiding duplication of high cost technologies in military treatment facilities (MTFs) geographically near each other; using nearby civilian facilities for services where the volume in the MTF is small, e.g. neonatology. Many are not fiscally responsible but are driven by limitations in active duty strength and civilian employment caps. The civilian leadership of DOD and the services appointed by the current administration favor outsourcing and privatization. The military leadership has allocated personnel positions to perform the current and expected missions thus special forces increase and dependent health care in the direct health care system decreases. Additionally, there have been errors in estimates of demand not dissimilar to the proclaimed glut of physicians, now being reversed. All this has placed stress on the clinical leadership at MTFs. The measurable quality of care by outcome criteria has not suffered, but the quality of life for patients and providers alike has. Moreover, the military health care system and the individuals serving therein cannot sustain the unpredictability.

The Society has worked with the civilian leadership of DOD and the services with some effect, but sorry to say, more in blunting the process rather than reversing it. We also meet monthly with the Military Coalition (TMC), an umbrella organization for 34 military associated non-profit associations from the American Legion to the Gold Star Wives. The TMC has a strong lobbying presence in Washington, and they are speaking up. While we will continue, my own belief is that great progress will not be made under this administration. I believe that working through the political process is the best option. An informed electorate is essential; your work is directed at that end.

It is essential to address physician issues, but not sufficient. Patients, commanders, other health care disciplines and support services have important issues as well. Physicians cannot work alone. While there are non-physician health care providers that behave in ways that do not result in the optimal care for the patient, the overwhelming majority want what you want.

I hope I have seriously responded to your memorandum. Please continue to work positively to a common objective.

Mike Scottti

Some of this

Michael J. Scotti, Jr., MD