Board recommends TRICARE be realigned

By Tom Philpott: Military Columnist

The Air Force, the only service opposed to creation of a Unified Medical Command, saw its arguments get strafed, rocketed and bombed during a meeting last week of the Defense Business Board, a group of outside management experts that advises Defense Secretary Donald Rumsfeld.

The board unanimously recommended that Rumsfeld immediately appoint a task force to oversee establishment of a Unified Medical Command by Jan. 1, a year sooner than Defense officials had planned.

The command would take charge of all direct-care health services of the Army, Navy and Air Force. It would streamline medical logistics, purchasing, information technology, research and development, facility operations, and the education, training and assignment of medical personnel.

The services would continue to control medical care in support of front line units and field hospitals. But Level III operational medicine, which includes all fixed military hospitals and clinics, would be run by the new command, which would report directly to the defense secretary.

The board, which endorsed the most sweeping reorganization of military medicine in 60 years, also recommended that:

• The TRICARE Management Activity, which oversees the triple-option health plan for military families and retirees, be realigned to function alongside a unified command, with a new focus on policy and oversight.

Management of the TRICARE benefit in time would be “out-sourced” to the private sector.

• A transition team for establishing the unified command be created and given milestones of 30, 60 and 90 days to ensure a Jan. 1 start up. The board believes legislation is not required because the Department of Defense already has authority to streamline health services.

Dr. Stephen Jones, principal deputy assistant secretary of defense for health affairs, said after the meeting that the board’s timeline is “very optimistic.” But a consensus is building toward a unified command “or a similar organization” to merge service medical systems, he said.

Lt. Gen. James G. Roudebush, who became Air Force surgeon general last month, said his service opposes a unified command. It would take control only of the direct care system, he noted, which has seen only modest cost growth in recent years. It is expansion of the TRICARE benefit that “has driven costs upwards at a very alarming rate,” Roudebush said.

Also, he argued, service missions and cultures are different, and those differences justify having separate medical staffs and resources.

Finally, he argued, the services are responsible under Title 10 of the U.S. Code to provide a fit and healthy force. That’s a mission “we take very seriously, said Roudebush. A unified command “begins to move that away from the purview of the services,” he said.

The services should consolidate some responsibilities to lower costs, Roudebush said, such as graduate medical education and perhaps information, acquisition and logistical systems, he said. These steps alone would save a lot of money and not put “at risk” service responsibilities to care for their own forces.

The Defense Business Board is an advisory panel, governed by sunshine laws, so the meeting last Wednesday was open. Though held in a small Pentagon conference room, it offered a rare public look at a hotly contested issue between services.

Vice Adm. Donald C. Arthur, the Navy’s top medical officer, challenged Air Force arguments. He was joined by members of the business board, as well as a two-star admiral on the Joint Staff and a two-star Army general who is the deputy director of TRICARE.

Arthur said the services separately recruit, train and assign medical staff and operate three separate systems for logistics, for the purchasing of supplies and equipment, for budgeting and quality assurance.

As a result, they waste up to $500 million annually, according to the Center for Naval Analyses (CNA), he said. Henry Dreifus, a board member who led its medical task force, said the CNA figure is probably much too low.