Salute to military medicine as key to improving U.S. healthcare
I have a rather unique perspective on American healthcare having spent more than 33 years working as an Armed Forces clinician –an optometrist - and health care administrator, serving everywhere from remote battlefield hospitals to the nation’s capital.
It has become almost fashionable of late to bash our healthcare system. American healthcare however, is world class in many respects, featuring the best-trained doctors, dentists, optometrists, nurses, health scientists and support staff. We have the finest university-based teaching hospitals and lead the world in healthcare research, which results in generally better outcomes. The FDA's comparatively shorter drug approval processes lead to having availability of leading-edge drugs and treatments faster than elsewhere. That’s my short list of attributes.
Unfortunately, we are not always the picture of best practices from that point forward. Data reveals Americans spend approximately 17.6% of GDP on healthcare, which equates to $8,233 per year and is more than 2.5 times more than most developed nations in the world. Life expectancy increased by almost nine years between 1960 and 2010 in the US, in contrast to an increase of over 15 years in Japan and more than 11 years in other developed countries. In 2010 the average American lived to 78.7, more than one year below the average of 79.8 years; not a great return on our healthcare dollar investment. Of the 40 developed countries surveyed by a leading international non-governmental agency for life expectancy, the U.S. ranks 29th. This is unacceptable.
I believe that among our most significant institutional shortcomings is that too many healthcare systems lack integration, access, adequate case management assets and the proper emphasis on maintaining fundamental health and wellness. This is compounded by the fact that the majority of the American population has grown accustomed – and not by choice - to seeking care only when they get sick rather than focusing on wellness and disease prevention. While there are no quick and easy solutions, I strongly suggest we look to the Military Health System (MHS) for guidance and improvement.
The MHS, which collectively dwarfs most health systems (it includes a network of 65 hospitals, 412 clinics, and 414 dental clinics) provides healthcare to both active duty <http://en.wikipedia.org/wiki/Active_duty> and retired <http://en.wikipedia.org/wiki/Retired> U.S. Military <http://en.wikipedia.org/wiki/U.S._Military> personnel <http://en.wikipedia.org/wiki/Personnel> and their dependents <http://en.wikipedia.org/wiki/Dependant> . It provides health support for the full range of global military operations and sustains the health of all entrusted to MHS care. This extraordinary international effort involves medical testing and screening of recruits, medical treatment of troops involved in hostilities, and the maintenance of physical standards of those in the armed services.
The MHS patient-centered, multi-disciplinary, prevention-focused delivery model works very well, and I believe can also succeed outside the military. Long before the Affordable Care Act (ACA) was proposed, the MHS was working to manage expenses and improve clinical outcomes by creating efficiencies through combining like services such as Information Technology, Facilities Management, Education and Training, and others under one administrative entity.
In contrast, the non-military American healthcare system is neither integrated nor designed to promote wellness and sustainable good health. It is driven by incongruous incentives for reimbursement and an antiquated medical tort system that tends to inflate healthcare costs and has the potential to drive down overall quality. Countries such as Japan and France, that tend to spend the least for healthcare, use a common fee schedule so that hospitals and health services are paid similar rates for most of the their patients . In the US, hospital reimbursement depends on the patient’s insurance type. Healthcare organizations can choose patients with an insurance policy that pays them more generously than other patients with lower-paying insurers, such as Medicaid.
That is the current reality we face. To ensure better access, integration, and change the culture from intervention to prevention and wellness, I strongly support a shift to the Patient-Centered Medical Home (PCMH) model. As our military medical experience demonstrates, we can do this if we focus on putting the patient first. We also need to develop an integrated approach to professional, health science education to train our next generation of providers. At Salus, we’re squarely focused on efforts to develop such a model
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The Author: Michael H. Mittelman, OD, MPH, is a recently retired Rear Admiral and Deputy Surgeon General in the United States Navy and the newly appointed President of Elkins Park-based Salus University, formerly the Pennsylvania College of Optometry. He may be contacted through www.salus.edu