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Last November, the Navy began overhauling its health-care system, based °n recommendations made by the Medical Blue Ribbon Panel. Proceedings editors Laura Johnston and Mark Gatlin interviewed Vice Admiral James A. Zimble, Surgeon General of the Navy and Director, Naval Medicine, on the changing course of Navy medicine.
Proceedings: Did you find the recommendations made by the Blue Ribbon panel helpful?
Zimble: Yes. I am very encouraged by the findings of the Blue Ribbon Panel.
Proceedings: What recommendation sticks out in your mind?
Zimble: That GME [graduate medical education] will have top priority. That without question, the lifeblood of Navy medicine, because that endeavor !P>lls over into every area of medicine. *° do GME right, we have to see the tull spectrum of patients. That means elder patients, dependent and retired Patients. Largely healthy young sailors hon’t provide the training our doctors need to be proficient. We have to pro- v*de opportunity for the post-resident Practice; we have to make sure that we nave the right types of technical sup- P°rt, including people, which means We have to have continuing medical education in order to make sure that GME is right, and we have to nurture faculty. The endeavor in education is fhe absolute assurance of quality. With- °ut one, we lose the other.
Proceedings: Have you begun any new Programs as a result of the report? Nimble: Yes. The report was approved only recently, but we are truly using 1'Cthesda as a flagship, a ship that other hospitals will steer by in the sense of being a prototype for improvement and progress. We’ve put a Rapid Implementation Team of line and staff corps experts at Bethesda to look for areas where we can improve. What we do there we will be able to share with our other facilities.
Proceedings: How soon?
Zimble: The team has been out there since November, and its members found some things that they want to do. The VCNO [Vice Chief of Naval Operations] has reviewed these recommendations and he has told us to make them happen. So the process is moving.
Proceedings: Will such teams be deployed to other hospitals?
Zimble: We have Medical Assistance Teams that are going to our other teaching hospitals, and they will look at the lessons learned from the Rapid Implementation Team and take those things on board that are applicable. We also have some retention teams that are going to facilities.
The reorganization is on a relatively fast track. By the end of February, the Center for Naval Analyses will come back with a report on implementing a TyCom [type commander] concept, in which the control, resourcing, and accountability for all of our direct care treatment facilities will be under the cognizance of the fleet CinCs [commanders-in-chief]. I think that’s where it will be.
Proceedings: You said you liked all of the recommendations. Were there any conclusions that you took exception to? Was anything left out?
Zimble: There was very little left out. The only area that the panel didn’t really explore in great depth was our research and development work.
The only caveat I have regarding the Blue Ribbon Panel is that its major emphasis, which has been my major emphasis, has been to be more frugal with appropriated funds. That means being a good fiduciary of the taxpayers’ dollars, saying that I can do it less expensively in the direct care system.
A lot of the emphasis is directed at recapturing the CHAMPUS [Civilian Health and Medical Program of the Uniformed Services] workload. We can do it less expensively, and we can assure quality. I think that’s great, and I’ve been pushing that.
But by the same token, I am very concerned that we will be looked at as a “for-profit” health-care system in that we can cause economies for the Navy, without the Navy recognizing that we have a cost. That cost is the rest of our mission, which entails maintaining readiness, operational support of the fleet, and a posture that will allow us to respond in any contingency, especially in a non-mobilization contingency, where we become the extra ready reserve force and move to some other location to do our job.
We need the fleet hospital platforms, the hospital ships, and the training for them. Those things don’t offset CHAMPUS costs. Those things have a price tag: it’s the price of military medical readiness. In these days of budgetary constraint, that may tend to be deemphasized.
Proceedings: With regard to the command changes that are taking place at Bethesda, we understand you’re putting Navy and Marine Corps line officers into the command structure?
Zimble: Not true. That was a misquote in Navy Times. We have some line people at Bethesda, but they are in the Rapid Implementation Team; they are not in the executive suite.
We’re working toward combining Bethesda and the National Capital Region into a single command headed by a flag officer. That flag officer will be responsible for running the hospital and will have a Medical Corps executive officer and a full directorate of Medical Department officers. In addition, the Bethesda commanding officer will also head up the Rapid Implementation Team. His number-two man on that team will be a post-major command line officer. The other members of that team will be very experienced in their disciplines of supply, personnel, contracting, etc.
Proceedings: What’s the most important information that the team at Be- thesda has come back with?
Zimble: I think its number one concern is with validating the level of nursing support that we have at Bethesda and looking into the detailing endeavor to accommodate a better mix of nurses and numbers. We have a significant number of very junior nurses there who have an important teaching role.
Proceedings: How do you keep your doctors’ experience in the profession satisfying?
Zimble: You know as well as I do, we haven’t done that. Why? Because doctors don’t have enough secretarial or clerical support. They find that they’re being slowed down by a lot of paperwork that should be done for them. We can’t open all of our beds, so patients are turned away. One service may be chock-a-block, while another service isn’t. One doctor wants to refer a patient for consultation and can’t get his patient in for consultation. That’s frustrating.
Doctors who can’t get an operating room because there’s no ICU [intensive care unit] bed for post-op, or because we don’t have enough technicians in the operating room, are frustrated. We need to give them the technical support; nursing support in the intensive care units, the special units, and in regular units; and the secretarial and clerical support that will allow them more time to see more patients.
Proceedings: Are these the reasons doctors are leaving?
Zimble: Sure!
Proceedings: Not so much money? Zimble: Money, too. The average salary of physicians in this country is $125,000 a year. Some make two to three times that. We don’t have average physicians in the Navy; the great majority of our physicians are well above average. They are all very competitive, but we don’t have one military doctor in any of the services that makes anywhere close to $125,000, or even $100,000. We must provide those compensation incentives we can in order to recognize their contribution and to help keep good people on the team.
Proceedings: Is there a question we haven’t asked that you would like to address?
Zimble: 1 am concerned that we address marketplace issues. The line understands that supply and demand is where the action is, but we have some marketplace issues that we have to look at beyond physicians, specifically nurses, some of the more specialized disciplines within the nursing community.
There’s a terrible shortage of nurses in the civilian sector. The military has been able to offer nurses a better status in terms of becoming officers, but we have let them down by not adequately assessing the value of their talent and their contribution. The civilian sector has done the same thing, but it is starting to repair that, which means that the military will be facing an even greater supply and demand problem.
Proceedings: How’s the retention rate for nurses?
Zimble: Not good right now, because the promotion opportunity has been worse in that community than in any other community in the Navy, and they feel it. They’re hurting. When I promote lieutenant commanders and leave in the zone and above zone 100 nurses who are eminently qualified for promotion to lieutenant commander, I’ve got a problem. When the promotion opportunity is 60% for lieutenant commander, I’ve got a problem. The flow point is 12.5 years for lieutenant commander; that’s a problem.
Proceedings: What can be done? Zimble: DOPMA [Defense Officer Personnel Management Act] relief will help. We’re also looking at a billet scrub of the Nurse Corps to see whether we need to ratchet it up a little bit in terms of grade strength. We need to attract and retain nurses, or we don’t get good patient health care. There’s a 300,000-nurse shortfall in this country. I’ve got 200 empty billets; that’s my shortfall. I want to fill those.
We also have to look at some marketplace issues that deal with some of the disciplines in the Medical Service Corps, where, again, the disparity in pay is great and we have difficulty retaining our people. In the dental community, there are some disciplines in which we have a problem recruiting, too. Addressing these issues will save money in the long run, because what we have to pay in the CHAMPUS bill is much, much higher.
We’re taking initiatives now to try to better use our CHAMPUS balance—• things like the new Catchment Area Management project, planned for
Charleston, South Carolina, in which we will enroll our patients, have health care finders, and establish and negotiate some networking with physicians, HMOs [health maintenance organizations], the university, the VA [Veterans Administration], and the Air Force. If we cannot accommodate patients inside the hospital, we’re not going to use that terrible pejorative term of “disengaging” them to CHAMPUS. We’re going to keep patients engaged and put them in the civilian sector in an area that we know, where we can assure quality and where we can get a better bang for the CHAMPUS buck, in addition to saving patients some money, too, because we can negotiate some reductions in the co-pay and the deductibles for patients and increase services.
Proceedings: When you were Medical Officer of the Marine Corps in the early 1980s, you pushed hard to get hospital ships to make sure that combat care was available for potential Marine casualties in crisis. How do you feel today about the hospital ship program? Zimble: Well, we got them! We’ve got two beautiful hospital ships. They’re the best and largest trauma centers in the United States. I would like to use them more. I know that takes resources, but I would like to see those ships exercised. I’d like to see us do more humanitarian missions, using active and reserve personnel from all services. But we don’t have the necessary funding. We have them in a ROS [reduced operating status]-5 category. In five days, the personnel, equipment, and supplies come together and the ships are ready to sail. They’re sponsored; we train on those ships.
The [USNS] Mercy [T-AH-19] went to the Philippines and the South Pacific for a four-month humanitarian mission in 1987. We tried to get the media to notice; no one was interested in all that good news. We took care of 2,000 major surgical cases—60,000 patients in all. Can’t tell you how many teeth we pulled. It was a very positive image: beautiful pictures, good will.
We went to several ports and trained their physicians to do things. We made the blind see and the lame walk with relatively easy procedures. We corrected disfigurements, took out cataracts—unbelievable! I mean miracle workers! I’d like to do more of that.
At the same time, I’d like to exercise with the fleet. I’d like to explore good, sound medical support doctrine using those ships. The problem is that it costs big money.