Reforms Prescribed for Military’s Health Care System

Angered by “horror stories” of bungling doctors, million-dollar negligence awards and an unresponsive bureaucracy, officials in the Pentagon and Congress are prescribing heavy doses of reform to cure the military’s ailing health-care system.

Obvious changes, such as checking the credentials of doctors being hired, and revolutionary proposals, such as letting GIs sue for malpractice, are bubbling forth at a rapid rate to fix a system that is supposed to care for 8.7 million persons but doesn’t always.

“It is not a mess,” asserted Dr. William E. Mayer, the assistant defense secretary for health affairs. But he acknowledged that important changes are needed to help restore the confidence of military personnel and their families in their level of care.

Second to Civilian Care

Complaints about military health care are as old as armies themselves.

But, according to a Pentagon questionnaire sent to 19,630 users of the system, military care comes out second best to civilian treatment in every category, including thoroughness of care, the adequacy of hospitals and the supply of doctors.

Evidence of chronic problems began surfacing last year with a dramatic rise in the number of negligence suits and fault-finding internal audits that cast doubt on the qualifications of some of the Defense Department’s 13,000 physicians.

From 689 malpractice claims filed in fiscal year 1982, the number rose 24% to 854 in 1984. During the same period, the amount of money won each year by claimants jumped from $28 million to $41 million. Army, Air Force and Navy audits also turned up cases in which unqualified and unsupervised doctors were operating in military hospitals, requiring investigations and dismissals.

This month, a federal judge awarded $6.3 million to an Army wife whose brain-damaged baby was born at Madigan Army Medical Center in Tacoma, Wash. Lawyers submitted evidence that even though the woman was bleeding when she arrived at the maternity ward, she was told to walk around for several hours before being admitted to a labor room, and no measurement of fetal heartbeat was taken for 70 minutes.

In other recent developments:

- The chief heart and chest doctor at Bethesda Naval Hospital--the “hospital of presidents”--was ousted from surgical practice last month after the Navy said he had demonstrated “professional behavior contrary to medical staff bylaws.”

- The Defense Department found that nearly 5% of the doctors checked in a recent audit were involved in such irregularities and misconduct as moonlighting at other jobs during duty hours.

- Armed services audits indicated that many military hospitals failed to check the credentials of doctors, allowing some physicians who had lost their state medical licenses to treat military patients.

- Women delivering babies at Air Force hospitals in 1982 suffered severe cuts and tears at a rate twice the national average, according to Defense Department audits.

Mayer, who took over as head of the system in 1984 after a 20-year career as a military doctor and a top job in health administration in California, said in an interview that he is taking decisive action to correct the problems.

He said a major recruiting drive to get the best medical school graduates into the military is expected to eliminate a doctor shortage that he said was “partly responsible for the horror stories.”

In a blitz of directives, Mayer has ordered the military to require state licenses for any new doctors coming into the system.

The services also will be required to set standards for a long list of medical procedures and hold their doctors to them. They must ensure that nurses and interns are more closely supervised by experienced physicians and they must constantly review doctors’ credentials to perform tasks to which they are assigned.

Working to Build Control

Mayer also is working to strengthen his office’s control over the surgeons general, the uniformed chiefs of the Army, Navy and Air Force medical services who have traditionally enjoyed huge measures of autonomy in running their departments.

Mayer said he will soon be forming “medical strike forces” composed of investigators reporting directly to him within hours or days of incidents that may indicate a major problem in the system.

Such teams would be used in highly publicized cases, such as in the death of a 6-year-old boy who entered Madigan Army Hospital for treatment of a cut lip earlier this year and died of a heart attack apparently caused by an improperly administered sedative.

“That was a terrible tragedy.” Mayer said. “I want to satisfy myself that I have all the facts in such cases immediately. Unfortunately, no directive is ever going to guarantee that an incident like that won’t happen again.”

Mayer also is planning a study of obstetrics and gynecological care and is looking into the possibility of major improvements in military medical records, including the possible use of a computer-strip ID card that each patient would have with him at all times.

Poor Record System Cited

Sen. Jim Sasser (D-Tenn.), whose interest in the military health system was prompted by a series of complaints by constituents, said the lack of a good record system is a major problem.

Because soldiers and their families are transferred from post to post, they need the best records possible to make sure chronic conditions are treated consistently.

“Unless the current system is changed, the military will continue to be plagued by horror stories that have recently been reported and will not be able to determine if the quality of care is being improved.”

Sasser lauded Mayer’s new directives, but added: “As audits conducted by the Department of Defense revealed, steps have been in place previously to properly credential doctors and other health-care providers. These directives have simply been ignored.”

He said that unless civilian control over the military services is strengthened, “the current system of everyone being in charge, but no one is, will continue.”

An idea sponsored by Sasser and Rep. Barney Frank (D-Mass.) is to repeal rules forbidding soldiers, sailors and airmen from bringing malpractice suits in civilian courts. Dependents can sue, but military personnel must appeal to their services to redress malpractice complaints.

Frank Deutscher, a civilian attorney who has won several lawsuits brought by dependents at Madigan Army Hospital, said such a law would make military doctors more careful about the way they treat patients in uniform.

Mayer denounced the proposal, saying: “It’s based on an absolutely false perception that the fear of lawsuit is the major motivator for providing good care. If that’s the case, we’re in a lot of trouble in this country.”

He acknowledged, however, that he would like to change the current disability system that pegs compensation for disabling injuries to a serviceman’s rank.

“There are real tragedies as a result of the low level of disability payments that some servicemen receive,” Mayer said.

Mayer also supports the thrust of a recent General Accounting Office report suggesting that the military should close some of the smaller, outmoded hospitals in its 168-hospital system.

Citing several studies that showed the most efficient hospitals have between 200 and 300 beds, the GAO questioned the Defense Department’s need to operate 69 hospitals that were admitting 50 persons or less.

Mayer also supports experiments to test improvements in the $1.5-billion system that permits dependents to occasionally seek care in non-military hospitals.

Despite the reforms, important differences will always remain between military and civilian medicine.

The highest salary a doctor can earn in the military is about $70,000, contrasted with a $100,000-a-year average for civilian physicians. Military hospitals are supported by tax dollars and budgets are tight.

In addition, the military health system for peacetime care of servicemen and their families operates in the shadow of the Defense Department’s traditional medical mission: treating the casualties of war.

“In an emergency, all bets are off,” Mayer said. “We have to worry about medical readiness for war all the time.”