An unprecedented Pentagon review of the military health system — prompted by the VA hospitals scandal — concluded that military hospitals and clinics overall provide health care on a par with private-sector programs, despite longstanding complaints by troops, retirees and their families frustrated by long wait times and inadequate care.
The review, ordered in May to determine whether the Pentagon provides safe, effective care to its 9.6 million beneficiaries, acknowledged that some facilities still fall short in serving their patients. Disparities in appointment wait times and quality of care depend largely on where patients live and which facilities they use, according to the report, the Military Health System Review, released Oct. 1.
The report offers a comprehensive review of the sprawling, $51 billion military health system, encompassing 56 hospitals and 361 clinics operated by the medical commands of the services, as well as Tricare.
Defense Secretary Chuck Hagel said the findings clearly indicate there is room for improvement within the system.
"The bottom line is that the military health care system provides health care that is comparable in access, quality and safety to average private-sector health care. But we cannot accept average. ... We can do better," Hagel said.
Read the full DoD report: www.militarytimes.com/healthreview
The review looked at three measures of health care performance: access to care, quality of care and patient safety, and ranks the medical facilities in a number of categories, including access to care, quality of care and customer satisfaction.
High performance often translates to quality health programs that serve patients best, according to the report, and results of the review in these areas guided recommendations for improvements.
Access to care
Regarding access to care, the review found that "access to care meets the defined standards."
In military hospitals and clinics, standards are that patients get an appointment within 24 hours for urgent care, a week for routine care and four weeks to see a specialist.
According to data in the review, medical groups at Ellsworth Air Force Base, South Dakota, and Fairchild Air Force Base, Washington, rank at the top for patient appointment access. At the bottom were a medical group at Misawa Air Base, Japan, and Darnall Army Medical Center, Fort Hood, Texas.
But even though the report found that a majority of military hospitals and clinics met requirements for access to care, patients continue to express extreme dissatisfaction with access to care.
In a Military Times poll of readers conducted this summer, appointment wait times were the top complaint among active-duty service members who said they were dissatisfied with their health care benefits.
At town hall meetings held as part of the military health system review, Pentagon officials heard similar complaints.
"Every time ... I go to make an appointment, it's, 'No, I'm sorry we don't have anything for 4-6 weeks.' I could go to the emergency room, but I would like to have my appointment before 4-6 weeks," one patient said, according to the report.
"Every time I try to schedule an appointment with my primary care manager, it seems like he is fully booked for like the whole month and you can only get an appointment next month," another patient said.
Defense officials said the discrepancy between the report's findings and customer complaints warrants further investigation.
"Even though we are meeting our own standards, there is some variation, and we have to dig down deep into this," said Deputy Defense Secretary Bob Work, head of the review team.
The report also noted that data on wait times were unavailable for beneficiaries who get their care at private facilities through Tricare, and more oversight was needed on that issue.
Quality of care
In December 2011, Navy Cmdr. Alan Abshear fell from a ladder and injured his back. What began as routine care at Portsmouth Naval Hospital, Virginia, for nerve damage and a compression injury quickly developed into severe illness, including a systemic blood infection.
Abshear spent six weeks in the facility's intensive care unit and doesn't have a bad word to say about the care he received.
"They saved my life. I know there are problems in the system, mainly because of the overwhelming number of people who use it. But our health insurance benefit is great," Abshear said.
Others have not been so lucky. In an interview with the New York Times in September, Navy wife Raquel Bradshaw discussed the death of her 6-year-old son, Kristian, from severe dehydration — a condition stemming from gastroenteritis not properly treated at Lemoore Naval Hospital, California.
"I kept telling the doctor, this is not normal," Bradshaw told the Times. "She told me to give him Gatorade."
In terms of quality of care, the review reflects what many military beneficiaries already know: Quality is "mixed," with "considerable variation across the system."
The review found variances in meeting the standards of accreditation bodies and said that while the system in general meets or exceeds targets, it needs improvement.
According to the report, surgical complication rates were all over the map, with eight hospitals of 17 closely reviewed having higher than acceptable surgical complication rates while several ranked among the top nationally and others had persistent poor performance.
Some hospitals displayed a need for improvement in ensuring that patients don't get sicker or contract additional complications after receiving surgery within their walls — a measure known in the health care industry as morbidity.
The review noted that some of the military's top facilities, including Naval Medical Center San Diego, and Naval Medical Center Portsmouth and Fort Belvoir Community Hospital, Virginia, need to improve their morbidity rates.
And surprisingly, the review also found that military hospitals and clinics do not include a key measure of quality of care — unexpected deaths, also known as the standardized mortality ratio.
While mortality often is not seen as an accurate reflection of care quality, civilian health care organizations now believe that risk-adjusted mortality measures can help identify positive and troubling trends in hospital settings.
For the review, the Pentagon conducted a brief study of standardized mortality ratios — the predicted number of deaths for a military treatment facility — against the observed number and found four facilities with worse than expected ratios that need further investigation: Naval Hospital Guam; Tripler Army Medical Center, Hawaii; 60th Medical Group at Travis Air Force Base, California; and 81st Medical Group, Keesler Air Force Base, Mississippi.
The review also found disparities in data keeping and reporting of military facility performance measures — not surprising, given that the system is made up of individual medical commands of the Army, Navy and Air Force, and the Defense Health Agency, which also manages the contracts for private treatment provided under Tricare.
Officials found that in some cases, military hospitals and clinics failed to provide required reports on patient complications and preventable deaths.
According to defense officials, the lack of information made it difficult for reviewers to draw conclusions or even measure facilities against one another or against the civilian health system.
"The self-reporting of events related to patient safety is a key concern for all health systems," noted the review.
Hagel ordered the comprehensive review partially in response to the scandal over patient appointment wait lists and data manipulation at Veterans Affairs Department hospitals and clinics — a federal system separate from the DoD medical system — to determine whether similar or other issues existed in the Defense Department, the secretary said in May.
The military health system has been the subject of a yearlong investigation by the New York Times into malpractice and deaths at its hospitals and clinics and also has had some high-profile scandals related to patient care, including questions of neglect at Walter Reed Army Medical Center in 2007 and the death of retired Marine and Pennsylvania congressman John Murtha, who died in 2010 from surgical complications following gallbladder removal at National Naval Medical Center, Bethesda, Maryland.
In response to the review, Hagel has ordered a number of changes across the military health system:
■ All military treatment facilities not meeting access standards develop action plans to improve appointment times at military facilities and through Tricare in 30 days;
■ A yearlong study be undertaken to review appointment access for Tricare beneficiaries;
■ All military hospitals failing to meet quality and safety standards develop a plan for fixing their problems in 45 days;
■ The Defense Health Agency provide a plan in 90 days for better assessment of quality and safety in private care and establish a performance management system that will monitor measures, and:
■ DHA develop a plan to make available all statistics on quality and safety for each military treatment facility.
Hagel said the Defense Health Agency would work swiftly to resolve discrepancies and focus on quality and care, emphasizing the importance of patient safety across the system.
"Even small lapses in care can lead to devastating, heartbreaking losses and injuries, so today I'm directing that the military health system take steps to ensure that the system is not 'just average,' " Hagel said.
While some military and veterans service organization executives have raised concerns that the military health review was conducted largely by military officials and edited and reviewed for publication by those with a vested interest in protecting the Pentagon's reputation, others expressed gratitude that the review was conducted and hoped that it would foment change.
"I was extremely heartened to read the statement in the secretary of defense memorandum that 'no patient should be told to call back the next day for an appointment,' " said Joyce Raezer, executive director of the National Military Family Association.
"Our biggest concern is for the military families who often have no choice where they receive care. What happens if their hospital is identified as performing at a less-than-satisfactory level? These families need to be assured improvements will be made where the review found quality problems," she said.
Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.