Through the years, I’ve had the honor of speaking to groups after they heard from notables like Michael J. Fox, Sammy Hagar, Jeff Immelt, U.S. Secretaries of Health Tommy Thompson and Mike Leavitt, Warren Buffet and others. They’re the headliners and I usually follow them with a less celebrated presentation about the current issues and future in healthcare.
Last week, in Arizona, I spoke to 3M’s annual healthcare conference following Lt. Colonel Justin Constantine, a Marine who served from 1997-2013. Justin’s story is profound: he was plying his trade as a military lawyer in the Al Anbar province of Iraq on October 18, 2006 when a sniper’s bullet tore through his head. After an emergency tracheotomy by Navy Corpsman George Grant, scores of surgeries and years of treatment, he survived and now shares his story as an inspirational speaker, crediting the Military and Veterans Health Systems for saving his life.
His message was riveting: Leaders lead. Never give up. Don’t be afraid. His scarred face and slurred speech commanded the rapt attention of the 250 in the audience. As he concluded, we all stood in a spontaneous expression of appreciation for this man, his message and his courage.
Later that day, he shared more about his decade-long climb experience as we traveled together back east. And through this week, I found myself reflecting on his ordeal and the roles of our Military and Veterans systems about which I confess I’d given little thought prior.
Each serves a unique purpose with a scope of operations that is substantial:
- The Military Health System operates under the oversight of the Assistant Secretary for Defense of Health Affairs with a $50 billion budget. It serves about 10.3 million beneficiaries including active duty personnel, their families, and retirees over the age of 65 and their dependents, employs 137,000 in 65 hospitals, 412 clinics, and 414 dental clinics in facilities across the nation and in combat-theater operations worldwide. But in combat zones, military health caregivers also offer care to civilians caught in the line of fire and enemy combatants where their care can be given safely. So, its “patient population” can vary widely.
- The Veterans Health Administration is a major part of the U.S. Department of Veterans Affairs which was elevated to cabinet level status in 1988 by President Reagan. With its $65 billion budget, it serves 8.9 million of the country’s 22 million veterans who use its services primarily, employs 298,000 and operates 168 hospitals and 1053 outpatient clinics. Innovations in primary care, care coordination, performance measurement, infrastructure and efficiency have been its focus in recent years led by two physician leaders: Under Secretaries of Health: Ken Kizer and the current Under Secretary, David Shulkin.
The two operate interdependently with distinct missions. And they face similar challenges:
Clinical complexity: Just as the mechanisms of war have transitioned from ground combat to chemical warfare and terrorism, the range of war wounds for our active military continue to change. Arguably, the complexity of their medical problems and the circumstances of their diagnoses and treatments are unlike any other setting. The same is true for our vets: they are young and old, bound by military experiences which take a heavy toll physically and mentally. A disproportionate number are sick and homelessness and depression are major struggles: 22 choose to end their lives daily accounting for one in five suicides in our country. There are no correlates in the private sector to these circumstances: the “population health management programs” are truly unique necessitating the purposeful integration of health and human services, physical and mental health treatment, and care for whole families.
Financing: The Military Health and Veterans Health programs are largely funded through taxpayers as part of the federal budget. For active duty personnel, there are no co-pays, deductibles and premiums. And for vets who use the VHA’s services almost exclusively, modest co-payments are collected on its means testing methodology. Thus, like Medicare and Medicaid, Congressional authorization is the key to their funding and political oversight is intense.
Transparency: The news media follow the MHS and VHA closely frequently drawing comparisons between their performance and the private sector. Example: in 2014, for instance, lapses in care in Phoenix were reported to be associated with 40 avoidable death. Public outrage and political indignation followed. A closer examination showed the actual number was likely 8: though unfortunate, far less than first reported. Media attention is the new normal for the Military Health System and Veteran Health.
Candidate Trump vowed support for our active military and veterans. President-elect Trump announced his choice of Dr. Shulkin to be his new Secretary of Veterans Affairs and telling reporters at last week’s news conference that Cleveland Clinic CEO Toby Cosgrove would also be key advisor. And at Friday evening’s Inaugural Concert, headliners Toby Keith, Lee Greenwood and the U.S. Army Band received a shout-out from the new Commander in Chief who pledged his support. No doubt, the Military and Veterans health programs will be in the spotlight as the new administration steps in.
The challenges they face may sound familiar-- funding, clinical innovation, workforce effectiveness, operational efficiency and so on. But what’s done in these two systems is vastly different than what’s done in the private sector. There are similarities but vast differences. I’ve known Drs. Shulkin and Cosgrove for many years: they know it, but often it’s not understood by outsiders who think private sector solutions are a quick fix.
The inconvenient truth is this: the MHS and VHA face challenges that are unique. There are no quick fixes. The solutions will be discovered through the persistence of their performance improvement processes under the watchful eyes of leaders who are empowered to implement changes.
Justin Constantine is a hero, and so are the caregivers in the Military and Veterans Health programs who saved his life. The inconvenient truth is that these programs don’t get enough recognition for the good they do and more than their share of flack when they fall short.
This week, details of how elements of the ACA Repeal will become more clear as key Congressional Committees make recommendations that align with the parameters of their expected Reconciliation vote soon. The individual and employer mandates are expected to get the ax, and speculation I swirling that subsidies for those purchasing coverage through the exchanges might be channeled thru states. Also on tap: confirmation of Rep. Tom Price as Secretary of Health and Human Services. More to come.