Enhancing Military–Civilian Medical Synergies

The Role of Army Medical Practice in Civilian Facilities

by Melinda Moore, Michael A. Wermuth, Gary Cecchine, Paul M. Colthirst


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Research Questions

  1. What is the state of Army medical practice in civilian facilities, including those that the U.S. Department of Veterans Affairs operates?
  2. What opportunities are there for greater synergies?

Army medical professionals must maintain the high level of proficiency required to fulfill the Army's medical missions of supporting military operations and providing beneficiary care. Because beneficiary care demands in a U.S. medical treatment facility (MTF) do not mirror those in a combat setting and sometimes can exceed the MTF's capacity, some MTFs enter into agreements with local civilian facilities to meet shortfalls in beneficiary care or training. The study's objective was to assess Army medical practice in U.S. Department of Veterans Affairs and non–Veterans Affairs civilian facilities and suggest opportunities for improving military–civilian synergies.

Key Findings

Stakeholders Widely See Resource-Sharing Agreements as Beneficial

  • MTFs and local counterparts that use such agreements universally find them mutually beneficial, although the MTFs find the guidance documents outdated, insufficient, and in need of updating.
  • Military stakeholders reported benefits to the Army that include better access, quality, and continuity of care for beneficiaries; proficiency maintenance and exposure to industry best practices for military professionals; and perceived cost savings to TRICARE.
  • Benefits that local civilian counterparts cited included revenue generation (TRICARE payment for beneficiary care) and more-productive utilization of their infrastructure by military personnel.
  • The strong consensus among military and civilian users and leaders regarding the benefits of external medical practice suggests that such practice is warranted when both the MTF and local partner can justify it in their respective business plans.


  • Update Office of the Surgeon General and U.S. Army Medical Command policy guidance for external resource-sharing agreements (ERSAs) and gratuitous training agreements.
  • Identify appropriate proponents for ERSAs and for gratuitous training agreements.
  • 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 the Military Health System compared with those of 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.

Table of Contents

  • Chapter One


  • Chapter Two

    History and Authorities for External Medical Care and Training

  • Chapter Three

    Information from the Medical Training Facility Data Call

  • Chapter Four

    Types of Agreement and Review of Selected Agreements

  • Chapter Five

    Findings from Stakeholder Discussions, Including Site Visits

  • Chapter Six

    Conclusions and Recommendations

  • Appendix A

    Organizations Consulted

  • Appendix B

    Office of the Surgeon General and Army Medical Command Policy Guidance on Department of Veterans Affairs — Department of Defense Sharing Agreements

  • Appendix C

    Office of the Surgeon General Policy Guidance on Gratuitous Training Agreements

  • Appendix D

    Details of Findings Related to Medical Treatment Facilities

Research conducted by

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.

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