Put in aeronautical terms, the military health care system is an aircraft in level flight over rising terrain. That is the grim analogy used by Lt. Gen. Charles H. Roadman II, surgeon general of the Air Force, to characterize the profound challenges that now face military medicine.

Roadman predicts downsizing and resource constraints will continue for years, making it difficult to do more than maintain today's level of services. Even so, DoD's network of hospitals, clinics, and professionals face ever-increasing expectations for quality care, Roadman and others told an Air Force Association military health symposium held April 28 in San Antonio.

"We cannot wait until the mountain is on us," Roadman told symposium attendees. "We must begin to lead turn ... to identify problems, set a strategy, lead turn so that we avoid the ramifications."

All the services now recognize that there is a handful of critical tasks at which they must succeed in order to navigate between the peaks into which military health care could crash, according to the Air Force's top doctor.

Their No. 1 goal is to be ready to take care of combat forces on a moment's notice. That includes being ready to respond instantly to the use of chemical or biological weapons against US troops anywhere in the nation or the world.

Goal No. 2 is to deploy a managed health care system. For all of the services, that means Tricare. "There isn't another plan other than Tricare," warned Roadman.

Goal No. 3 is learning to "right-size." In other words, the services must wring inefficiencies out of their medical systems. The Air Force currently has 21 facilities that average fewer than 10 patients in beds per day. If service leaders have their way, such inefficient infrastructure will become things of the past.

Breaking Habits

Finally, the military needs to break free from ingrained habits of waiting for diseases and injuries to occur, rather than trying to prevent them. Officials said the services need to build healthy communities, which means an emphasis on prevention.

Roadman said Air Force ground crews do not just wait for an F-15 to break before they touch it; they carry out preventive maintenance to keep the airplane in the air, and the service needs to think about its people in the same way.

"It means that we don't spend $1.3 billion on smoking-related illness, but ... put that money into preventing that ahead of time," said Roadman.

At the same time, the Air Force, Army, Navy, and Marine Corps must maintain their culture of taking care of their own. Medicine remains a big quality-of-life issue for the current force. Within the Air Force, access to quality care is a major retention issue.

"When one of our young people is flying at 500 feet over the terrain just below the speed of sound, he should not be worried about whether his child can get into the pediatric clinic back at home base," said Roadman.

Health care has also become a huge problem for retirees. The Pentagon has simply delayed in dealing with the consequences of decisions made in past years. Now that retirees outnumber active duty troops, problems are coming home to roost.

For Medicare-eligible military retirees, space-available care in Military Treatment Facilities has become difficult to find. Plans for Medicare Subvention, a process whereby Medicare reimburses the Pentagon for a portion of care provided to older retirees in MTFs, might be one solution. At the insistence of Congress, the Pentagon now has undertaken a subvention test in six sites.

Of Medicare Subvention, Roadman said, "We have high hopes." He added, "I think it is going to be a close-run thing," because it might entail new costs for the Defense Department.

Some lawmakers are eager to open the Federal Employees Health Benefits Program to military retirees, as well. The FEHBP solution sounds good, said Roadman, but it could also founder on the issue of increased cost to DoD accounts.

"I think [FEHBP] holds [Medicare Subvention] at risk," the Air Force doctor said. "It holds at risk space-available care, both for over 65 and under 65. ... If you are already in level flight with rising terrain, raising the terrain is not the strategy to use."

A Process, Not a Place

Still, said Roadman, the Air Force will continue working as hard as it can to provide and broker care for retirees. It will continue with its commitment to take care of its own. It will build a mosaic of care that meets people's requirements, said the service's top doctor. "But it won't be a place," he warned. "It will be a process."

Joining Roadman were a number of senior active duty participants, including Gen. Lloyd W. "Fig" Newton, commander of Air Education and Training Command; Lt. Gen. David L. Vesely, assistant vice chief of staff of the Air Force; Vice Adm. Harold M. Koenig, surgeon general of the Navy; Lt. Gen. Ronald R. Blanck, surgeon general of the Army; Maj. Gen. Earl "Wynn" Mabry II, commander of Air Force Medical Operations Agency; Brig. Gen. Linda J. Stierle, director of Air Force Medical Readiness Doctrine and Planning and Nursing Services; Lt. Col. Mark Ediger, chief of aerospace medicine, Air Force Medical Operations Agency; and Maj. John Bulick, Air Force Surgeon General's Office.

Speakers from private industry and other federal entities were Maj. Gen. George K. Anderson, USAF (Ret.), of the Koop Foundation; David W. Forslund of Los Alamos National Laboratory, N.M.; Dr. John P. Howe III, president of the University of Texas Health Science Center at San Antonio; Julie Turner, member of the staff of Rep. Charles W. Stenholm (D-Texas), and James E. Woys, COO, Foundation Health Federal Services.

The Air Force surgeon general's colleagues from other services agreed that the nation's military health system is at a crossroads. Lower budgets must be assessed in the context of increased expectations from patients at all levels, said Lt. Gen. Ronald R. Blanck, surgeon general of the Army.

"Patients want now the same level of care, whether they are at Ft. Irwin, [Calif.] ... or in Bosnia, or Kuwait, or on board ship, or here in San Antonio," said Blanck.

Teamwork between the services is one way to meet these expectations, said Blanck. At the Navy hospital in Okinawa, Japan, for instance, the Air Force runs the neonatal intensive care unit. At Tripler Army Medical Center in Honolulu, the deputy head of the facility is a Navy captain.

Tricare will be another expectations-enabler, said the Army surgeon general, as it will allow leverage of the Pentagon's direct-care dollars into a wider network.

Technology will also help stretch scarce dollars in the future. The Navy, for instance, has focused on trying to move information instead of people.

Medical evacuations off a ship are expensive, after all, at some $4,400 per case. So the Navy has worked hard at digital camera­based telemedicine. Sixty telemedicine consultations were conducted on board USS George Washington during a recent six-month deployment to the Persian Gulf. The consultations, transmitted by satellite back to the National Naval Medical Center, Bethesda, Md., helped avoid 20 medical evacuations.

The 60 consultations involved 10 different medical specialties, though half were dermatological in nature. Surprisingly, a few involved mental health.

"There were five sailors on that ship who didn't think they were going to make it," said Vice Adm. Harold M. Koenig, surgeon general of the Navy. "These were all first-term enlistees. ... We were able to hook up, real time, with a psychiatrist at Bethesda to work with each of those patients, and every one of those sailors was able to complete that cruise."

The Navy even has a baby bonding program, which allows mothers on shore to transmit digitized newborn photos to dads at sea. At the Navy hospital in Naples, Italy, newborn pictures are all posted on a Web page so that stateside family members can share in the experience.

"Navy medicine is trying to re-engineer how we deliver health care," said Koenig.

Ignore the Unessential

Other speakers warned that, as all the services move into the new world of health care information systems, they need to keep their focus on truly important items: patients and medical personnel. They said it was easy to get swept away in the technology and build systems which satisfy the needs of computer professionals but are less than satisfactory for physicians.

"As long as people use the term 'telemedicine' it is a failure," said David Forslund of the Los Alamos National Laboratory, N.M. "[My] personal view is [that] we have to get rid of the term 'telemedicine' and have just one [term]: 'medicine.' "

From the Air Force perspective, maintaining the current state of readiness for combat medicine capability all starts with recruiting and training, said Gen. Lloyd W. "Fig" Newton, commander of USAF's Air Education and Training Command.

The need is considerable and constant. Of the service's officers, one in five has a health care specialty. For enlisted, the figure is one in seven. Yet recruitment of health care professionals, said Newton, "has been-and we suspect will always be-a significant challenge for us."

Exploding demand in the civilian health care sector, plus the continued decline in the number of military hospitals, has only made this task more difficult. It has meant that recruiters have to work a bit harder for medical workers, said Newton.

Recruits come from three sources: working physicians attracted by the military lifestyle and opportunities; residents, who are eligible for a military financial assistance program; and the Pentagon's health professional scholarship program.

The latter program is a primary conduit for physicians coming into the armed services. The Air Force awards over 200 medical scholarships a year.

In 1997, the recruiting goal was 99 physicians. That represents a 50 percent drop from the early 1990s goal of more than 200 a year. The Air Force met its physician goal in 1997, said Newton, and is likely to do so again in 1998.

Air Force recruiters have also consistently met their goals for attracting nurses into the service. In 1997, they recruited 396 nurse candidates--one more than their goal.

Fleeing Dentists

However, dental care is another story. The field is plagued by a high attrition rate, among other things. The Air Force recruiting goal for dentists has increased from 60 in the early 1990s to over 125 for 1996 and 1997. Actual accessions were about 70 for both years, despite such inducements as a signing bonus of upwards of $30,000. "Dental recruitment has been a tough nut to crack," said Newton.

The deployment of USAF health care recruits who are now entering the Air Force mirrors that of personnel service-wide. In today's era of expeditionary air operations, most forces are concentrated at bases in the United States and make extended TDY deployments overseas. In the medical field, too, more troops will be based in the continental United States.

Already, cutbacks in forward deployed medical forces have been considerable. At the time of the fall of the Berlin Wall in late 1989, the Air Force had some 40 Military Treatment Facilities spread across the European theater, for instance. Today, there are fewer than a dozen.

This shrinkage has profound implications for the military's theory of combat medical care.

In the past, planning called for most treatment to be done in theater. Today, all the services "are just looking at that care that absolutely has to be done in theater and then moving that individual to more definitive care which is usually going to be in the continental United States," said Brig. Gen. Linda J. Stierle, director, Air Force Medical Readiness Doctrine and Planning and Nursing Services.

That means the fixed-wing air medical evacuation airplanes of the service have become an even more important national asset than they were in the past, according to Stierle. The Air Force still counts on flying in medical care for forward-based units. Due to today's fast pace of operations, the Air Force can anticipate that every month three or four air transportable hospitals and, at any given time, 300 medics will be on deployment somewhere in support of a contingency.

In the past, injured personnel would not have been evacuated from a theater if doctors anticipated that they would return to duty within 30 days. Today, the policy is seven days.

Stierle said, "If you are injured in a combat zone ... [and] we cannot return you to do duty within seven days, then you will be evacuated."

If doctors do not anticipate that the injured person will be well enough to fight again in 15 days, then the patient will be air evacuated, likely to the United States.

The reason for the change: It is easier to move people back than to move more medical equipment forward. Lift capacity defines everything. "We are talking about having to move stabilized patients, not stable patients, ... patients [who] could deteriorate in flight," said Stierle.

Air Force medical officials tested this concept during Patriot Med Star, a 1995 air medical evacuation exercise. The Air Force converted a C-141 to critical care capability, through adding oxygen and electrical support for 12 vent-dependent patients.

"We were able to demonstrate that we could use the C-141 in that capacity," said Stierle. "But as we look to the future, even for us, information superiority and emerging technology is very important."

Unconventional Problems

Better air evacuation equipment is not the only new medical equipment on Air Force priority lists. The potential rise of unconventional weapons has created some burning issues that need to be addressed through R&D, said Lt. Col. Mark Ediger, chief of aerospace medicine, Air Force Medical Operations Agency.

Current anti-laser eye protection is inadequate, for instance. It alters color vision significantly, perhaps rendering warning lights invisible. Better protection against toxins, heat, and cold are high on Ediger's wish list, as are fatigue countermeasures.

Expeditionary pilots will face tremendous jet lag as they begin combat operations. "Even though we may be able to help them sleep at certain times, we don't have the means right now to adjust their circadian rhythm," said Ediger.

Caring for the wounded is not the sole purpose of the Air Force medical network. The health readiness of all Air Force personnel is becoming an increasing emphasis for service doctors, noted Maj. Gen. Earl "Wynn" Mabry, commander of the Air Force Medical Operations Agency.

One lesson learned from the Gulf War was that the Air Force did not have a good information base on the health of its people before deployment to the Kuwaiti theater of operations. That has made the evaluation of Persian Gulf illness syndrome, and any possible proximate cause, much more difficult.

"Part of our commitment as we put people into harm's way in the future is we will know their health status and risk factors going in, while they are there, and coming back," said Mabry.

As a result, every active duty individual is now supposed to have an annual health assessment and risk appraisal. Results will be tracked by computer-a difficult assignment considering it will involve such variables as status of immunization against anthrax, a process which takes six shots over 18 months.

Another Gulf lesson learned was that many in theater casualty producers are avoidable. While the war against Iraq was far from typical in its low battle casualty count, the main cause of troop air evacuation was not bullets, shrapnel, or even disease. It was sports injuries.

"We lost a lot of our people unnecessarily through unstructured athletic and sports events while they were in a combat environment," said Mabry. "Those are things that are preventable."

With a smaller force available to fight, troops will have to be more fit than ever before. Commanders cannot afford the daily kinds of illnesses and injuries they have tolerated in the past.

From the top down, said Mabry, Air Force leaders should do their best to eliminate superfluous risk factors. Anti-smoking and anti-alcohol campaigns could provide major benefits in this regard, he said, noting that DoD spends a billion dollars a year to take care of illnesses related to tobacco and alcohol. He added that alcohol alone accounts for an estimated $12.7 million in lost productivity every year.

Health centers, using one-on-one or mixed-group counseling, have proven effective against these problems. With respect to smoking, said Mabry, "we are down below 25 percent over all, and some bases ... are even below 20 percent."

Focusing on Fatties

Aerobic fitness remains a concern, as well. About 72 percent of Air Force personnel are now judged in moderate to high aerobic shape. "We are targeting to work hard on the 20 percent in the low-fit category," said Mabry.

The Air Force has been the butt of jokes by the other services for switching to bicycles from the 1.5-mile run for fitness testing, but the change has been a success, in this sense: During running tests, a certain percentage of the most unfit personnel collapsed and died of cardiovascular failure.

"We're not saying it is the absolute ultimate, because it is expensive, ... but we've been doing this for five years, and I can tell you we have not lost anybody," said Mabry.

As befits its importance to the force, military health care is a hot topic for the nation's lawmakers. Retirees and current service members alike contact their members of Congress with concerns about access to and availability of care, said Julie Turner, a staff member in the office of Rep. Charles Stenholm (D-Texas).

Rumors, particularly about possible closing of more military hospitals, spread among constituents like wildfire.

There is concern not only about the actual access to care "but about the perception that there is some kind of loss, that there is a decrease and less availability of care," said Turner.

Cost to the federal government is another lawmaker concern.

"The money, at this point, is not there for the next couple years to do any type of increase ... in military spending overall and in military health care in particular," said Turner.

Congress approved a test of Medicare Subvention despite opposition from the Republican House leadership, said Stenholm's aide. Lawmakers will insist that the test be budget neutral-not cost the government a dollar extra-she added.

FEHBP is now the legislative military health issue of the day. While there would be obvious benefits to opening the federal employee health plan to military retirees, there are downsides as well, said Turner.

"It is a different kind of system, one where you have to contribute through your full lifetime," she said.

And the co-share cost can be substantial. Blue Cross costs some $603 annually for a single person, for instance, with a 5 to 25 percent co-payment for each doctor visit.

"Dicey"

While an FEHBP demonstration would likely pass if it reached the House floor, the complicated process of committee approval means the legislation's success "is still a little dicey," said Turner. However, some tinkering with Tricare is likely, she said, such as raising of some reimbursement rates.

Tricare implementation has not exactly been a success in all areas of the country. James E. Woys, chief operating officer of Foundation Health Federal Services, admitted that working in health maintenance organizations in general and Tricare in particular makes him something of a target these days.

Foundation Health Federal Services has won three of the Tricare regional contracts. While implementation has gone smoothly in some areas, in one-the south-central Region 6, and particularly in areas of Texas--it has not.

"Abilene [Texas] was a disaster," said Woys. "We didn't do a very good job in claims and processing when we brought up Region 6."

Hopefully, a lot of money and attention has solved these problems, he said, but attracting full provider networks in some rural areas remains difficult.

Part of the reason is simply regional acceptance of managed care, said Woys. In California, where such plans are widespread, he can get providers to give him a 15 to 20 percent discount on rates to qualify for Tricare business.

In Texas, where managed care is still in its infancy, and primary care physicians make more than they do in California, resistance to such discounts is widespread.

Woys said he is aware of the widespread suspicion that managed care means slowing down or denying medically appropriate treatment. However, he said, "I have never once ... been in a meeting where anybody has suggested denying care."

The Air Force health care strategy rests on four pillars: medical readiness, Tricare, right-sizing, and building healthy communities, concluded Lt. Gen. David L. Vesely, USAF assistant vice chief of staff.

Readiness is both a peacetime and a wartime function. It means everything from a flexible organization for health care professionals, to physical exams and current vaccinations for the force as a whole.

Tricare, the peacetime health program, is essential to the force quality of life. "Many of the problems with Tricare have been identified, and I know that all of you are working to resolve those problems," said Vesely.

Right-sizing means concentrating the active medical force on military unique missions, and privatizing or outsourcing other capabilities when necessary.

Building healthy communities means encouraging healthy life styles and enhancing availability of preventive health services.

"It does no good to advise a patient to obtain a mammogram or a cholesterol screening if she or he can't get that service in a timely fashion," said Vesely.