Military Health System stabilization: Rebuilding health care access critical to patient's well-being

On Dec. 6, 2023, the deputy secretary of defense signed a memo directing the stabilization of the Military Health System. The memo requires that the MHS add capacity to reattract patients and beneficiaries, improve access to care in military hospitals and clinics, and increase opportunities to sustain military clinical readiness for medical forces. 

The need to stabilize the MHS is clear. The realignment of medical personnel and the volatile health care economy of the past three years, created challenges in the  care of beneficiaries. Further, the ability to efficiently generate and sustain ready medical forces was also affected. 

"Coming out of COVID-19, there were capacity constraints across all health systems in both the United States and peer nations," said Dr. David J. Smith, the deputy assistant secretary of defense for health readiness policy and oversight, who is leading a task force charged with implementing the memo's directives. "Health-seeking behaviors changed as well as the demands on the war fighters and readiness … health systems worldwide could not keep up."

Aligning with the recently released MHS Strategic Plan for fiscal years 2024 through 2029, the memo primarily addresses the need for the MHS to continue providing medically ready forces and ready medical forces while simultaneously delivering quality care to beneficiaries. Doing so effectively, "requires a stable, predictable workforce sufficiently staffed, trained, and routinely available to provide health care to our beneficiaries," the memo states. 

"A big piece of this memo was about providing that stability: creating more stability for our staff so that they can provide more stability for our patients," Smith said. "This leads to better access to care and more clinical capabilities."

Rarely have issues in the MHS become so front-and-center. Recognizing the lasting impacts of the COVID-19 pandemic and reorganization, the undersecretary of defense for personnel and readiness began relying heavily on the MHS executive review board to oversee and implement major improvement projects. Moreover, the board began referring issues to the senior most military and civilian leadership in the DOD through the deputy secretary's workforce council. 

"The board is chaired by the undersecretary of defense for personnel and readiness, with official representation from the Army, Navy, Air Force, joint staff and Marine Corps … all of the major components of the United States DOD," Smith said. "This is so important to our senior leadership, as we are actively discussing and updating this effort at the Deputy's Workforce Council, the most senior governance forum in the department covering personnel issues. 

"This is a massive commitment of time from our senior-most leadership because we know that medical is critical to the war fight," Smith said. He added, in reference to the four-years-long reorganization of the MHS, "The [Defense] Department has undergone a tremendous transformation to deliver more effective and efficient health care. This is critical to the well-being of our patients and the well-being of our families." 

The reorganization realigned all military clinics and hospitals from the Army, Navy and Air Force to the Defense Health Agency. Doing so leverages economies of scale and standardizes care for our warfighters and beneficiaries in the long-term, but the transition was enormous. Smith said the organization has been characterized as the largest reorganization and transformation in the DOD since the establishment of the Air Force in 1947. Major transitions often take time to stabilize and realize improvements, especially for organizations as large and diverse as the MHS. 

Upcoming Steps to Stabilize the MHS 

The DOD will prioritize military and civilian staffing and uniformed personnel management at military hospitals and clinics, incorporating the memo's guidance into programming and planning activities. The focus is increasing medical personnel delivering care at military hospitals and clinics to optimize capacity for beneficiaries and mission requirements. "The [Secretary's] goal of taking care of our people is about investing in our workforce," Smith said, and that is exactly what the Deputy Secretary's memo does in the short and long term. 

First and foremost, by June 30, 2024, the undersecretary of defense for personnel and readiness will complete a comprehensive review of all medical manpower and staffing. The review will inform how best to increase capacity to improve access to care for service members, their families and all MHS beneficiaries while maintaining and improving readiness capabilities. 

The memo also directs the DOD to rethink policies on the assignment of military medical personnel to hospitals and clinics. In the short term, there will be a limited redistribution of medical personnel to boost capacity at a few key locations to begin no later than July 1, 2024, "to stabilize health care delivery and mitigate risk to operational forces and missions."

"We'll begin PCSing [permanent change of station] a number of health care professionals," said Smith. "From there, we're going to a phased progression of assigning these providers to military hospitals and clinics." Assigning military medical forces primarily to military hospitals and clinics will provide more predictability and continuity for patients and increase capacity for day-to-day health care. 

"Another big change will be on civilian personnel staffing," Smith said. "We are going to implement authorities allowing us to recruit and retain our civilian employees better. This will include facilitating paying our civilian employees at rates commensurate with the [Department of Veterans Affairs] and the private sector."

As Smith stated, one critical, key initiative is implementing the authorities under chapter 74 of Title 38 opens NIH.gov to improve pay for civilian health care personnel. The Department recognizes the need to be a more competitive employer and pay civilian health care personnel at rates equal to the Departments of Veterans Affairs and Health and Human Services.   

Boosting Staff to Bring Back Beneficiaries 

The DOD wants to reattract beneficiaries back to military hospitals and clinics where possible. Many have turned to the private sector for health care as fewer military and civilian personnel were available to deliver care in the Defense Department's hospitals and clinics. The DOD also recognizes that burnout in health care workers is a serious challenge in the United States. Recruiting and making more medical personnel available at military hospitals and clinics reduces burnout, improves the workplace environment and enhances the experience of care for patients. 

"If we have more people in military hospitals and clinics, we won't be burning out people as much. We also know that burnout is correlated with the experience of care for our beneficiaries," Smith said. "In doing so, we can reattract beneficiaries to MHS."

Based on an economic model that optimizes the future state of the MHS around warfighters and military families, the memo directs, "reattracting at least 7 percent of available care from the private sector back to MTFs on average." Reattracting 7% of patients from the private care system is an ambitious yet realistic goal given the time it takes to close gaps in medical personnel staffing. For patients, coming back to military hospitals and clinics should be easy and limit any out-of-pocket costs. 

"We want to bring beneficiaries back to the MHS  … and truly make the MHS the place you want to receive care," Smith added. "We are going to rebuild that capacity first to earn trust from our beneficiaries."

The Defense Department does not plan to ask any patients to change their health plan or their doctor. The goal is to make the MHS more accessible to make getting care at military hospitals or clinics the easiest, simplest choice. 

"We remain focused on readiness and health care for all our beneficiaries," stated Dr. Lester Martínez-López, the DOD assistant secretary for health affairs, in the strategic plan. "The two are inseparable: When our people take care of people, we increase the readiness of the total force. I look forward to this work, knowing that it will lead to a stronger MHS capable of meeting the challenges we inevitably face." His message to the MHS is this, "I hear you. I know we have serious issues, and we have a plan to fix our situation. I am asking for your support during the time it will take to make the changes we need."

Ultimately, the MHS exists to support the military and the nation. Doing so is the highest calling, and the Deputy Secretary's memorandum stabilizes and makes whole the MHS to provide better access to care for the DOD's 9.6 million beneficiaries in the United States and around the world.