Health Care Foibles – A Personal Tale

An example of the stupid things even doctors do when it comes to health care. 

In March of 2013 I wrote Healing the Health Care Cost Conundrum. Four years later, in March of 2017, I have retired from the US Army and am practicing medicine in Memphis, TN. My practice is in the inner city, and our focus is serving the Medicaid population. Our patients are impoverished and often very sick, with chronic diseases frequently showing up 20 years earlier than in their more affluent counterparts. Many live in dangerous communities, have no reliable transportation, and have unhealthy food. Obesity is the norm, violence is taken for granted, and serious mental illness is widespread. It comes as no surprise that many patients abuse drugs, citing chronic pain that may or may not be real. Some come to the clinic for no other reason than to feed their drug habit, and try to get narcotics to generate a little extra income. It is the toughest medical environment I have encountered since my combat tour in Iraq.

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The Future of the Military Health System

What will the Military Health System look like in the future? The operational forces will be more military, and the CONUS facilities will be more civilian. 

In the book Retribution: The Battle for Japan, 1944-1945, Max Hastings described how ships’ crews took on the characteristics of their commanders. One captain was not well liked but was respected because “he had a mind like a slide rule.” Most good commanders took care of their sailors.

One characteristic of all effective commanders was that they communicated all that they knew about the strategic situation to their crews. In December 1944 the US Navy had 1100 warships and 5000 support ships. Most sailors never saw the big battles and instead spent the war shipping cargo between ports. For example, it is 5100 nautical miles from Honolulu, Hawaii to Darwin, Australia. Cargo ships took 21 days each way to make the trip. Temperatures in these all-metal ships reached 110 degrees, the odor of fuel and sweat was ubiquitous, and the noise was deafening. Men swabbed, repaired, ate, slept and repeated the process endlessly. They saw nothing but the sea, the sky, their ship, and each other. Few knew how their part, no matter how small, fit into the overall plan for victory.

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Healing the Health Care Cost Conundrum

A prescription for making US health care better quality, more accessible, and less expensive for all of us. 

The military health care system is different in many ways from the civilian system, but a primary difference is the income incentive. Simply put, health care providers and other medical professionals are not paid based on the number of patients that they see or the number of procedures that they do. Instead they receive a fixed salary with few if any bonuses for productivity or quality. The budgets for military health care institutions, and many others in the Federal government, are based on Congressional appropriations, not on productivity. This has been changing in the past decade but remains largely true today.

Civilian medicine is not so. They are paid for what they did, patients seen and procedures done, and everyone on staff is usually highly motivated to do more. Some have described such fee-for-service reimbursement arrangements as “you eat what you kill.” In some practices, that can equate to more visits and more procedures, even if some are not medically required.

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