June 1, 2013  

Unified medical command: An old idea whose time has come

The idea of merging the uniformed medical corps of the U.S. military’s service branches has come under serious discussion “about every 20 years” since 1880, as Air Force Col. John Kirk wrote a few years ago. It’s time to have the discussion again and, this time, do something about it.

Decades of joint in-theater operations and the successful mergers of major DoD medical centers mean that today, the uniformed medical services provide “end to end” medical support nearly seamlessly, both in joint medical facilities and in the day-to-day trauma, surgical and medical care in combat areas of operation.

Yet the services continue to fund and maintain separate medical commands. This is fiscally irresponsible in an era when budget realities demand the elimination of unnecessary redundancies from DoD operations. Past rationales and parochial defenses cannot justify the status quo. The benefits of continuing and completing the transformation from redundant to joint to unified operations and a uniform medical command far outweigh the challenges and pain.

Various Options

In 2005, Army Surgeon General Lt. Gen. Kevin Kiley proposed a unified medical command led by a four-star at the Joint Chiefs of Staff level. He suggested this might allow a decrease in medical end strength. The idea was quashed the following year by the Air Force surgeon general, Lt. Gen. G. Peach Taylor and his successor, Lt. Gen. James Roudebush. They argued that a unified medical command would not work for the Air Force because the services have different missions, cultures, organizations and processes.

In 2008, Rear Adm. David Smith, Joint Staff surgeon to the Joint Chiefs of Staff, proposed three “courses of action” for a unified medical command.

å COA 1: Unified Medical Command. This SOCOM-like model would put readiness and beneficiary missions (these can be loosely defined as care for troops and for dependents and retirees) under a single authority. The individual services would retain responsibility for recruiting, military development, and providing organic and embedded medical forces for combat care. For Levels 1 and 2 (emergency and urgent) medical care, the services would provide support through a Component Command structure, while for levels 3, 4 and 5 (nonurgent care), medical support is joint under the UMC.

å COA 2: Dual Medical and Healthcare Commands. This option would create two joint commands — one for readiness and one for beneficiary health care. As in COA 1, the services would recruit, develop and field organic and embedded medical forces for Levels 1 and 2, which would be provided through a Component Command structure. All other medical support would be joint, under the two commands. The Medical Command would manage readiness, receive clinical personnel for deployments, and provide command and control of deployed “theater-level” medical units. The Healthcare Command would train military clinical personnel, provide beneficiary health care services and operate the Tricare Medical Treatment Facilities and purchased care system.

å COA 3: Single-service Navy/Marine Corps model. One service would take over all Title 10 health care functions (recruit, organize, train, equip and sustain medical forces), would provide all operational medical capabilities for all services, and would provide direct and purchased care. Each service branch would keep a surgeon general and staff for planning, coordination and integration of its health care requirements.

Of Smith’s three options, COA 3 is the most cost-effective and efficient model. It eliminates redundant commands and parallel tracks for training and mission support. Theater commands would have “a single-source vendor” for physicians, nurses, technicians and medical support personnel, similar to the end-product support line in the Armed Services Blood Program. Specialized medical services could be further consolidated in a regional or centers of excellence model.

But as great an improvement as COA 3 would be over today’s redundant setup, we can do even better by mixing in aspects of Kiley’s proposal.

A New Department

The vision proposed here would create a Department of Defense Health Service (DDHS), commanded by a surgeon general, a four-star member of the Joint Chiefs of Staff, responsible for all health care provision, planning and operations of the unified medical command.

In a process similar to the creation of the Air Force, the new department would absorb the medical and medical support officers and enlisted personnel from the departments of the Army, Navy and Air Force. Later, qualified personnel would be able to transfer between services (e.g., between the DDHS and Army), as they do today among active-duty and reserve components.

Instead of a surgeon general for each service, the new department would have three “service line” roles: Terrestrial Medicine, Maritime Medicine and Air and Space Medicine. Roughly approximating the current Army, Navy and Air Force Medicine responsibilities, these new roles would eliminate duplications of effort and allow these broad special areas of military medicine to focus on the unique characteristics of the supported missions. Like many current major commands (e.g., AFRICOM, EUCOM, PACOM), the service line chiefs would draw trained and qualified medical personnel from the DDHS pool and assign them as needed.

Terrestrial Medicine would be the most complex service line and, like today’s Army Medical Command, would have the most assets to manage and facilities to maintain. With the exception of USNS Mercy and USNS Comfort, hospitals are terrestrial activities. (The hospital ships would operate as part of the Maritime Medicine department.) All land-based hospitals, medical research facilities and existing joint medical functions (e.g., the Armed Services Blood Program) would come under the Terrestrial Medicine surgeon general, who would report to the DDHS surgeon general.

Following the Army’s model, the Terrestrial Medicine service line would have regional medical commands that would oversee day-to-day operations in military treatment facilities and exercise command and control over the medical treatment facilities in their regions.

Under the unified medical command, there would be no “joint” medical facilities other than operations with other agencies, such as the Department of Veterans Affairs’ Veterans Health Administration.

The Terrestrial Medicine surgeon general would draw appropriate manning for operational terrestrial medicine from the DDHS personnel pool of physicians, nurses, nonphysician scientists, medical administrators, technologists and technicians.

Maritime Medicine can be defined as the surface and submersible vessel provision of medical care and the unique specialty of dive medicine. The medical personnel who provide care in those unique environments would obtain specialized training and qualifications under the direction of the Maritime Medicine Surgeon General, whose office would draw appropriate manning for operational maritime medicine (including for Coast Guard vessels) from the DDHS personnel pool. Although the TMSG would be responsible for research facilities, the MMSG would be responsible for research and development for Maritime Medicine.

Aviation and space medicine (ASM) training, operational assignments, research and development would fall under the Air and Space Medicine Surgeon General. ASM would include medical support for the military (and NASA) space and missile operations, airborne medical transportation and fixed- and rotary-wing operations, including remotely piloted aircraft. A single ASM school would train flight surgeons, physician assistants and technicians. The ASMSG would draw appropriate manning for operations from the DDHS pool.

Under the direction of the DDHS Surgeon General and with the guidance and advice of the three service line surgeons general, there would be a single and consistent implementation of DoD directives and instructions pertaining to medical (including mental health) issues. The redundant service-specific medical commands would be eliminated, and a single headquarters would stand up (with Regional Medical Commands as noted above).

The offices of the Maritime Medicine and Air and Space Medicine service lines might be located at or closer to their respective functional training centers, but they would not re-create the current service medical department structures, since neither would have facilities or personnel to manage.

Reserve Component

A reserve component would be created for the DDHS: the National Guard Health Service, which would absorb today’s reservists in medical roles and whose structure would parallel the service lines described above. Assignments would be by the facilities and functions supported within each state; redundant positions would be eliminated.

As part of a National Guard component, NGHS personnel would be assets of the governor of the state or territory in which they were commissioned or enlisted. The state surgeon would serve as the agent of the National Guard Bureau surgeon to fulfill the military requirements and directions of the DDHSSG and the TMSG, MMSG and ASMSG for the service lines represented in each state.

Nonmedical reserve units would obtain medical support (periodic health examinations, pre- and post-deployment health assessments, dental and mental health screening and support, immunizations and occupational health evaluations and examinations) from the reservists of the unified medical command.

Uniforms for the Unified Medical Command

The pain of merging medical branches with long heritages might be eased by reaching across all services for the unified medical command’s uniforms. The working uniform for environments not requiring surgical scrubs, a flight suit or other specialized gear would be the Army combat uniform. The service dress (officer and enlisted) would be khaki. (Neckties, which can transmit disease, would only be worn with the service dress jacket.) The formal dress uniform would be the Navy’s blue formal dress. Rank, rank insignia and specialty badges would follow the Air Force, though unique badges such as the Combat Medical Badge and Dive Medical Officer Badge would be retained. The DDHS would use the Rod of Asclepius as the symbol of the new medical service (associated with healing and medicine) instead of the staff of Hermes (caduceus).

This proposal is far from perfect, and compromises will be necessary in the implementation. But there is no justification for parochial defense of programs or processes that are redundant and fiscally wasteful. AFJ