future of medicine in the United States Air Force, The

Military Medicine, Sep 2003 by Carlton, Paul

It is a pleasure to be here to share a few thoughts with you. I would like to start with a little bit about mission capabilities and how can we respond as a nation. One of my burning concerns right now is that I think this is the best war we've ever fought on the medical side. I'll give you some of that data.

We've got more than a hundred ventilated rides in Air Force airplanes, and none of these patients would have survived in previous times. I'm reasonably happy with that, but I'm very concerned about the nation and how can we prepare it [for this war on terrorism].

We are building a virtual medical center right now. We clearly have got to lower overhead costs. Why do we [have the structure that] we do today? Because that's the way we always have been. And the question is: is that the way we should be? We have an opportunity in [Colorado], where Fitzsimmons [Army Medical Center] closed in 1997, and the Department of Defense opened up a new base, Buckley, [where there had been] a small National Guard base. A managed care support contractor owns the business in Denver and [the contractor] is owned by the University of Colorado as a principle shareholder, if you put all of these entities together, I think you can build a virtual medical center. I'm going to take you through [from] the in-patient [to] a full-up medical center. Bricks and mortar is how we've always thought about units of medical capability, but there are limitations to bricks and mortar. The four pillars that hold up every medical center include patient care, readiness research, and training or graduate medical education. To do [all four,] you must have a balanced system in a bricks and mortar world. Traditionally about 30% of the people will be able to deploy and 70% will not. If you could have a system without bricks and mortars that does all of the same things, couldn't you pay for what you use? Could you really do all of these things? The answer is yes, if you let your imagination go a little bit. The University of Colorado took over the old Fitzsimmons Army Medical Center and they are building a $4.5 billion medical complex there, which is about 2 miles from our base at Buckley. We have rented active duty space right now that's half a mile from the old Buckley, we have some inherent capability in each of these locations, and we're getting ready for a pharmacy just off base. What we'd like to do in 2003 is to move the active duty to the new seventh floor of the [former] Fitzsimmons complex, which would enable us to pick up active duty family members and their care within a year vs. a construction project of many years. We would be able to build block units of medical capability. No bricks. No mortar. The University says, "This is a great idea. Let's go. You already have the patients, and, if you're a vascular surgeon or an orthopedic surgeon, and you want to do every hip in the world, they bill Medicare." You avoid the issues of Medicare subvention.

How far you would go with this? Clearly, there are a lot of ways to look at it. Interestingly, the [university] dental school has [recently requested that they be allowed to participate.] We would consolidate a lot of things on Buckley. The [university] plan is to then build a trauma center, and we could continue to put our units of medical capability, or deployment capability, into this complex.

We could have world-class health care, access to world-renowned specialists, and state-of-the art activities, leveraging the partnership between managed care contractor, Veterans Affairs, and the university. Right now, there is political pressure for the Department of Defense and the Veterans Affairs to work more closely together. This would answer that pressure. All of these things are beneficial as we talk about preparing the nation [for the war on terrorism]. Exercises [will maximize] the level of capability for the state. If there is conceptually something wrong with this, we haven't figured it out.

[The events of] September 11, 2001 have muddied our traditional thinking. We have said the military's mission is to go to war and they must prepare for it. We have considered peacetime health care as what everybody except the military does, while we also do part of it. But the reality is that as of September 11, 2001 we have a new major war theater, and it's called the United States of America. How do we, the military, help our civilian friends [cope], because now there is considerable overlap between what the military and civilians [realms]. In fact, we have to prepare our civilian friends for mass casualties from chemical and biological agents, for example. I would suggest, as you think about 50% of our academic health centers right now are in the red and dying, that if we can come up with funding for this, we would be the absolute heroes.

This morning, [at] a U.S. Medicine Institute, we looked at surge capacity. Right now the United States of America is [emphasizing] efficiency in every aspect of health care, but if the measure of merit is surge, we are totally ineffective. We have gone too far, and we lack balance. We need to seek balance in our system somehow or our families are not going to be taken care of. How we do this is a huge issue. That is why I started off with the Denver initiative, [which can serve as a template]. Everybody recognizes that surge [capability] is important, but we have to focus on efficiency and cost-effectiveness.