The Army's Office of the Surgeon General (OTSG) and U.S. Army Medical Command (MEDCOM) oversee the staffing and operations associated with their missions to support military operations and provide care to a wide range of beneficiaries. These services require different types of medical and auxiliary personnel and are provided in both deployed and garrison environments. Army medical professionals must acquire and maintain the high level of proficiency required to fulfill the Army's medical missions. The medical care demands in a combat setting often do not mirror those in U.S. medical treatment facilities (MTFs). Further, the demands of beneficiary care sometimes outweigh the capacity of MTFs in garrison. Although the Army takes MTF capacity and beneficiary demand into account in assigning medical personnel to MTFs, MTFs sometimes enter into agreements with civilian organizations in local communities to meet shortfalls in proficiency training and to provide beneficiary care. One type of agreement allows for MTF-based care providers, mostly physicians, to provide direct care to Military Health System (MHS) beneficiaries at civilian hospitals; there are similar resource-sharing agreements with U.S. Department of Veterans Affairs (VA) medical centers; and, at some locations, Army MTFs share medical resources with other services in multiservice markets (MSMs). These arrangements are largely intended to improve the timing, quality, and efficiency of care for beneficiaries, but they also help military medical professionals maintain clinical proficiency. Yet another type of agreement, which is intended solely to enhance proficiency, enables such military medical personnel to provide care to civilian patients, in a training context.
Research Objective and Methods
The Army Surgeon General asked the RAND Arroyo Center to assess current Army medical practice in civilian facilities, including those that VA operates, and suggest opportunities for greater synergies. To address these objectives, the research team reviewed relevant statutes, military guidance, and published papers. The four U.S.-based regional medical commands (RMCs) provided data from all 28 MTFs under Army command to RAND Arroyo Center.1 The research team used those data to produce summary statistics and for analyses that drew from the full range of information sources. The research team also reviewed the structure and content of 30 agreements, including 26 identified from a cataloged list of agreements held in a MEDCOM repository and four more that were provided during one site visit. The team conducted interviews with subject-matter experts in the Army, Navy, Air Force, and Office of the Secretary of Defense to better understand the context in which agreements are created and implemented and the purposes for such agreements; determine what authorities and guidance are relevant, existing, or needed; describe how the agreements are executed; and better understand the benefits and challenges of these agreements.
Finally, the research team visited four representative MTF sites and interviewed both military health leaders and their local civilian counterparts for more in-depth review:
- Dwight D. Eisenhower Army Medical Center (AMC) at Fort Gordon, Georgia, part of Southern RMC
- Guthrie Ambulatory Health Care Clinic at Fort Drum, New York, part of Northern RMC
- Evans Army Community Hospital (ACH) at Fort Carson, Colorado, part of Western RMC (WRMC)
- William Beaumont AMC at Fort Bliss, Texas, also part of WRMC.
The study found that management of external medical practice is largely decentralized and context-specific: Each MTF develops its own business plan, taking into account the local profile and alignment between MTF supply (assigned personnel, facilities, services), beneficiary demand (at the MTF and in the broader local catchment area), medical readiness and other training needs of MTF personnel, and cost considerations. The relevant statutes indicate that the goals of resource-sharing agreements with both the VA and non-VA civilian facilities are to provide care to beneficiaries more effectively, efficiently, and economically and, in the case of VA sharing agreements, to increase access to care. Training agreements help military professionals enhance or maintain clinical proficiency. With these foundational premises, highlights of the findings related to Army MTFs, agreements, and stakeholder interviews follow.
Information from Army Medical Treatment Facilities
Of the 28 Army parent MTFs distributed across the four U.S.-based RMCs, 13 indicated that military medical personnel under their commands, most commonly surgeons, provide care in VA or other civilian facilities, mostly at non-VA civilian facilities (Table 1). The most frequently reported reasons are to serve beneficiaries and to meet routine proficiency maintenance needs. MTFs also offered further justifications for providing care at civilian or VA facilities; these included types of care that are not available at the MTF or when external practice serves as an incentive for retention of Army medical talent. All outside practice is through formal agreement.
Table 1. Types of Facilities, Providers, and Reasons for Care Outside an Assigned Medical Treatment Facility
|MTF||Type of Facility||Service||Reason for Care|
|VA||Non-VA Civilian||Affiliated MTF||Another DoD MTF|
|Keller ACH, West Point, N.Y.||1||1||1||Surgery (general, orthopedics, podiatry)||Beneficiary care|
|Ireland ACH, Fort Knox, Ky.||1||1||1||Surgery (general) (pending)||Beneficiary care|
|Guthrie Ambulatory Health Care Clinic, Fort Drum, N.Y.||1||Surgery (orthopedic, obstetrics and gynecology)||Beneficiary care|
|Womack AMC, Fort Bragg, N.C.||1|
|McDonald Army Health Center, Fort Eustis, Va.||1||1|
|Kenner Army Health Clinic, Fort Lee, Va.|
|Kimbrough Ambulatory Care Center, Fort George G. Meade, Md.|
|Tripler AMC, Fort Shafter, Hawaii||1||Not specified||Beneficiary care|
|Winn ACH, Fort Stewart, Ga.||1||1||1||Surgery (general, orthopedic)||Beneficiary care|
|Reynolds ACH, Fort Sill, Okla.||1||Surgery (general, orthopedic, ENT)||Beneficiary care|
|Dwight D. Eisenhower AMC, Fort Gordon, Ga.||1||1||x||Surgery (obstetrics and gynecology, thoracic, plastic); family medicine, neurology||Beneficiary care, routine proficiency|
|San Antonio Military Medical Center, Joint Base San Antonio–Fort Sam Houston, Texas||1||1||1||Surgery (thoracic, ENT)||Routine proficiency, pre-deployment|
|Blanchfield ACH, Fort Campbell, Ky.||1||Not specified||Beneficiary care, routine proficiency, pre-deployment|
|Moncrief ACH, Fort Jackson, S.C.|
|Martin ACH, Fort Benning, Ga.|
|Lyster Army Health Clinic, Fort Rucker, Ala.|
|Fox Army Health Clinic, Redstone Arsenal, Ala.|
|Carl R. Darnall AMC, Fort Hood, Texas|
|Bayne-Jones ACH, Fort Polk, La.|
|William Beaumont AMC, Fort Bliss, Texas||1||1||Surgery (general, orthopedic, ENT, obstetrics and gynecology, urology, ophthalmology)||Routine proficiency|
|Madigan AMC, Joint Base Lewis-McChord, Wash.||1||Surgery (obstetrics and gynecology, thoracic)||Routine proficiency, beneficiary care|
|Evans ACH, Fort Carson, Colo.||1||1||Surgery (urology)||Routine proficiency|
|Bassett ACH, Fort Wainwright, Alaska||1||Surgery (general); family medicine, internal medicine, psychiatry||Routine proficiency|
|Weed ACH, Fort Irwin, Calif.|
|Raymond W. Bliss Army Health Center, Fort Huachuca, Ariz.|
|Munson Army Health Center, Fort Leavenworth, Kan.|
|Irwin ACH, Fort Riley, Kan.|
|General Leonard Wood ACH, Fort Leonard Wood, Mo.|
|Total (n = 28)||5||11||6||6|
NOTE: DoD = U.S. Department of Defense. ENT = ear, nose, and throat.
Nine of the 13 MTFs reporting no external practice (in VA, non-VA civilian, or other MHS) indicated that their routine and deployment-related medical readiness needs were met at the MTF; the four others did not specify a reason, although one indicated that it had sent personnel to the local VA medical center in the past and was developing a new agreement to do so again.
At the time of the data call to request information from MTFs, discussion with OTSG staff and review of documents and published papers had indicated that training for medical readiness needs, especially deployment-related needs, was likely to be the major reason for outside practice; there was little indication at that time that external practice to provide beneficiary care would prove to be as prevalent as it was. The data request had not specifically solicited information on the MTFs' assessments of the alignment between MTF capacity and local beneficiary needs or whether the MTF had consciously considered the potential need to send professionals to provide beneficiary care in a local civilian facility. No MTF backfilled staff during their time away.
Information from Review of Agreements
The team reviewed 30 relevant agreements that were available from the repository or site visits (Table 2). Nearly all MTFs that reported any kind of external medical practice reported external resource-sharing agreements (ERSAs), which cover beneficiary care by military providers in civilian facilities. Far fewer reported VA–DoD sharing agreements (which cover military providers in VA facilities or vice versa); gratuitous training agreements (GTAs), which cover training; or memoranda of agreement (MOAs), which do not specifically commit resources.
Table 2. Different Types of Agreement Identified and Available for Review
|Type of Agreement||Number Available from Repository or Site Visit||Number Reported by MTF but Not Available from Repository or Site Visit||Total|
The 19 ERSAs we reviewed did not follow a standard format, and the information contained in them was not uniform. For example, only six of them provided information on the type and specialty of provider that the agreements included; most were more general in nature, not specifying the type or specialty of personnel. Both ERSAs and the one MOA specified inpatient or outpatient services in general terms, while the GTAs were more specific and standardized. During the four site visits, interviewees reported preferring generic agreements (referring mostly to ERSAs) that cover a broad spectrum of opportunities and provider types rather than an agreement that specifies providers by name or specialty, which could become outdated more quickly. All agreements had clear statements on statutory or DoD authorities, responsibility of parties, term of agreement, liability coverage provisions, and funding. VA–DoD resource-sharing agreements and GTAs were the most standardized and complete types of agreement.
Finally, although we found generally good correlation between agreements in the central MEDCOM repository and those that the MTFs reported, not all reported agreements are in the MEDCOM repository, and there is some evidence that MTFs' reporting of agreements was incomplete.
Themes from Stakeholder Discussions, Including Site Visits
Our analysis of the stakeholder interviews and the four site visits resulted in the categorization of findings into common themes, including the benefits and challenges of Army medical practice in VA and non-VA civilian facilities. Although the MTFs find the guidance for such agreements to be outdated, insufficient, and in need of updating, MTFs that use one or more types of agreement for medical practice outside their MTFs (which were mostly ERSAs for providing beneficiary care) and the counterpart civilian institutions universally find such arrangements mutually beneficial. Both military and civilian stakeholders cite many dimensions of benefit, including access, quality, and continuity of care they can provide to MHS beneficiaries; opportunities for Army medical practitioners to be exposed to industry best practices in civilian facilities; and access to sophisticated medical technologies that might not be available or justifiable in the MTF and are more productively used in civilian facilities. Military personnel cite good community relations as another benefit.
Most current Army medical practice outside MTFs involves physicians (mostly surgeons) who, usually as individuals rather than as part of a team, provide care to beneficiaries. Very few agreements involve nurses, medical technicians, or other medical personnel. However, in at least one location that already uses ERSAs extensively for physicians, both MTF personnel and their civilian counterparts indicated that they had not given sufficient thought to enlarging the range of Army medical personnel who take advantage of opportunities to provide beneficiary care in the civilian facility but that they intend to consider such expansion in their future planning. Related to this is their indication that expansion of types of personnel might also include their participation in such agreements as teams, rather than just as individuals.
Stakeholders cited only a few challenges to such agreements. Given the attention to liability considerations and the U.S. Department of Justice rulings documented in materials reviewed, we had anticipated that malpractice liability, as well as credentialing of physicians in a local civilian hospital, might pose challenges; however, as various stakeholders reported, credentialing does not appear to pose a major barrier, nor do liability issues, because the Army has provided Department of Justice–approved standard language for liability coverage for the major types of agreement. One of the greatest challenges is the lack of interoperability of patient medical records across systems, both MTF–VA and MTF–civilian, which creates inefficiencies, including delays in care delivery and time-consuming manual transfer of patient information. Still, some sites are creating workarounds to address these issues. Systemic fixes that apply more broadly, within a local area or even across the country, would be highly desirable. The Army can leverage ongoing efforts, which mostly aim to standardize electronic health records across the MHS, to address these challenges in the future.
Another perceived challenge raised at one site and in other interviews is the lack of uniformity of clinical care standards and procedures between DoD and VA. However, at that one site, both MTF and VA personnel interviewed noted that they recognized this and are working to standardize these satisfactorily, upward through the chain of command on each side.
An administrative challenge is clarifying who gets “credit” (for TRICARE reimbursement and productivity monitoring purposes) for care that military practitioners provide in facilities outside MHS.
Conclusions and Recommendations
MHS continues to enhance the efficiency and quality of care to meet its two missions of supporting military operations and providing beneficiary care and to meet its four aims of readiness, population health, experience of care, and cost of care. In doing so, it grapples with balancing direct and purchased care. Although Defense Health Agency policy is increasingly oriented toward “recapturing” beneficiaries for care within MTFs, different types of agreements enable some degree of direct care outside Army MTFs, in facilities that might be better equipped to both serve beneficiaries and offer opportunities to maintain clinical proficiency—in the MTFs of other services (in the enhanced MSMs), in VA medical centers (through VA–DoD sharing agreements), and in non-VA civilian facilities (through ERSAs). Other types of agreement are intended to provide training, whether for purposes of deployment or routine maintenance of clinical skills. Planners at each MTF develop their business plans taking into account (1) the local supply (the personnel and volume and types of capacity and care available at the MTF and at other local facilities, including other MTFs, other federal facilities, and non-VA civilian facilities); (2) the local beneficiary demand at the MTF and in its broader local catchment area; (3) MTF medical personnel needs for training; and (4) cost considerations.
Figure 1 summarizes the MTF business planning landscape (MTFs' centrality is indicated by the bold red outline in the figure): the clinical skill requirements to meet the MHS missions, the care settings in which those requirements could be met, the mechanisms that Army MTFs can use to access those settings, and the requirements for such facilities (patient mix, infrastructure, services available, equipment, and cost optimization). All of these contribute to MTFs' decisions about where and how they can best meet their various mission-related requirements. For example, civilian hospitals, including trauma training centers, typically have adequate patient mixes in terms of numbers and complexity; infrastructure (e.g., operating room, intensive care); services available (e.g., emergency, obstetric delivery, inpatient); and equipment (e.g., diagnostic, surgical), all reflected as “+” in the figure. For GTAs with civilian facilities, cost considerations are also favorable (such agreements involve no exchange of funds). Each Army MTF might or might not meet the full complement of facility requirements—reflected as “±” in the figure. An MTF that can meet all needs within the MTF might not need to seek civilian partnerships. However, those that lack critical features might need to meet shortfalls through one or more mechanisms described in this study. Their choices of partners will depend on the presence and characteristics of other local facilities, as well as cost considerations.
MTF resource utilization and decisions about sending medical personnel outside the assigned MTF are determined at the MTF level, as described above. The most commonly reported type of external practice was through external and VA resource-sharing agreements, which enhance access, quality, and continuity of beneficiary care, and are perceived as cost saving (to TRICARE, for provider costs in non-VA facilities), while also exposing military providers to industry (civilian) best medical practices in such facilities and helping them maintain their technical proficiency. Thirteen of 28 Army MTFs reported one or more professionals who provide care under such arrangements—mostly physicians and, among them, mostly surgeons. MTF personnel and their counterparts at the four sites visited universally consider such agreements mutually beneficial, including multiple specific benefits to the Army.
Although most of the 15 MTFs that did not report such practice indicated that their routine and deployment-related medical readiness needs were met at their MTFs, we did not ask them specifically about their assessments of the alignment between MTF capacity and beneficiary needs beyond those that can be met at the MTF, and therefore about any need for resource-sharing agreements to address the latter. Moreover, we did not specifically ask the 13 MTFs that do engage in such agreements about whether they had considered the need to extend external practice to disciplines beyond physicians.
As noted above, MTFs that use one or more types of agreement for medical practice outside their MTFs and the counterpart institutions universally find such arrangements mutually beneficial. They cite as benefits the better access, quality, and continuity of care they can provide to military beneficiaries and opportunities for Army medical practitioners to be exposed to industry best practices in civilian facilities and have access to sophisticated medical technologies that might not be available or justifiable in the MTFs. They note also that such agreements contribute to good community relations. The benefits and broad acclaim that the parties accord to such agreements suggest that any untapped opportunities should be identified and that an MTF should be encouraged to take advantage of them if they are justified in the MTF's business plan. Thus, this study sets the qualitative foundation for more-focused analysis in this direction, including a thorough economic analysis that takes opportunity costs into account, as well as more easily documented costs to TRICARE and MHS as a whole.
Regardless of the magnitude of any untapped opportunities, the guidance documents for two important types of agreement (ERSAs and GTAs) warrant updating because they are outdated and less than comprehensive. Even MTFs that already use these mechanisms noted the insufficiency of current guidance and recommended updating. We found limited guidance for ERSAs. The OTSG/MEDCOM memo originally issued as policy memorandum 14-059 in July 2014 (Fiore, 2014) and most recently reissued as policy memorandum 15-022 in April 2015 (Fiore, 2015) updates the guidance for VA–DoD sharing agreements; this memo might be a good model for updating guidance on these other agreements and might, thus, help to raise attention about such agreements (and the use of them) across more of the Army medical community.
Stakeholders did identify some challenges associated with external medical practice, such as the lack of interoperability of patient medical records across systems and the lack of uniformity of clinical care standards and procedures across systems that share medical resources.
The conditions that favor Army medical practice outside the assigned MTF appear to derive mainly from the local profile and alignment between each MTF's supply (of assigned personnel and available facilities and services), local beneficiary demand (at the MTF and in its broader catchment area), training needs of MTF personnel, and cost considerations that might favor (or at least do not disfavor) such practice. The MTFs that use ERSAs do so when they have excess personnel capacity that can help meet local beneficiary demand that cannot be met at the MTF, such as when facility space (such as operating room or intensive care unit), medical service (such as obstetric delivery), or a specific technology (such as robotic surgery apparatus), is not available at the MTF. All 13 MTFs use resource-sharing agreements mostly for physicians and, among them, mostly for surgeons across multiple surgical specialties. This is not surprising because surgical practice tends to have facility and technology requirements that might not be available (or justifiable) at the MTF, which are more complex than what the practice of many non-surgical specialties requires. MTFs enter into resource-sharing agreements with local VA medical centers when a business case analysis on both sides justifies the mutual benefits, such as reducing VA patient backlog in medical specialties for which MTF volume and mix are insufficient for the number of providers. We conclude that military and civilian users and leaders share strong consensus regarding the benefits of external medical practice and that such practice is warranted when the MTF and partner institution can justify a military–civilian agreement in their respective business plans.
These conclusions suggest some recommendations for enhancing military–civilian medical synergies:
- Update OTSG/MEDCOM policy guidance for ERSAs and GTAs.
- Identify appropriate proponents for ERSAs and for GTAs.
- In the short term, identify potential untapped opportunities for external practice, especially ERSAs, and encourage their use when justifiable in MTF business plans.
- For longer-term policy purposes, conduct a quantitative assessment of the costs and potential efficiencies associated with care provided in MHS compared with different civilian options, such as those examined in this initial qualitative study.
- If warranted following such analysis, encourage the expansion of agreements to include a wider range of Army medical professionals and medical teams.
- Maintain the current decentralized management scheme, but consider a mechanism for central visibility of agreements.
- Facilitate mechanisms to share experiences and learn lessons about different types of sharing and training agreements.
Fiore, Uldric L., chief of staff, Office of the Surgeon General and U.S. Army Medical Command, “Department of Veterans Affairs (VA)/Department of Defense (DoD) Health Care Resource Sharing Agreement Approval Process and Delegation of Approval Authority,” Office of the Surgeon General and U.S. Army Medical Command policy memorandum 14-059, July 29, 2014.
———, “Department of Veterans Affairs (VA)/Department of Defense (DoD) Health Care Resource Sharing Agreement Development, Renewal and Maintenance Process,” Office of the Surgeon General and U.S. Army Medical Command policy memorandum 15-022, April 10, 2015.
1 RMCs were in effect during the study period but were subsequently changed to regional health commands, with realignment of MTFs.
This research was sponsored by the Office of the Surgeon General of the U.S. Army and conducted within the Personnel, Training, and Health Program, a part of the RAND Arroyo Center.