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On Oct. 1, the Defense Health Agency will take on more than half of the military’s medical facilities. It’s also preparing for the possibility of losing about 18,000 medical staff over the next few years.

The further transition of medical facilities from the military services to DHA and the erosion of the workforce will be a job for the next DHA director, however. Current Director Vice Adm. Raquel Bono, who oversaw much of the preliminary work for the military treatment facility (MTF) changeover, is retiring next week.

In a final roundtable with reporters on Monday, Bono said DoD is considering hiring contractors to fill in gaps of medical care if treatment facilities are unable to provide the specialized care patients need if the medical staff downsizes.

DoD wants to transfer the 18,000 medical billets to other military functions to make the force more lethal.

DHA has yet to make the determination if it needs contractors, though. It is currently assessing how it will operate with a smaller staff.

“In some of those areas where we don’t have that much representation from the MTFs, we are going to be evaluating if we will be hiring or contracting or seeing what our managed care support contractors can do to help meet the patient demands for care,” Bono said at the DHA Headquarters in Falls Church, Va.

DoD currently does not have any funds budgeted for that purpose in its 2020 plan.

Bono said that would come later as staffing decreased.

“This is something that the military departments have decided on in their efficiencies,” Bono said. “We are looking to see where the patients are and where the optimal places are to draw those personnel and billets out. About 25% of those billets are currently unoccupied now. We don’t expect to see very much change here in the first year, which is good because it gives us time to do the analytics to understand where the best places are to reduce those billets.”

Areas that may need contractors would be ones that do not have robust medical communities. Somewhere like Alaska or Idaho may need to contract out for a specialist, for instance.

Privatizing some medicine brings to mind a recent military failure when turning to companies to handle benefits. The military privatized its housing decades ago, but now it’s finding out there are substandard living conditions in those homes. In some cases those conditions made service members and their families sick. The companies also allegedly falsified maintenance records to receive bonuses for work they didn’t do on those homes.

When asked how Bono would ensure privatized medicine in the military wouldn’t take this turn, she said DHA’s unified structure would help.

“If you look at the housing situation, there was no centralized oversight and it was very much driven by either locality or a particular department’s approach,” Bono said. “There wasn’t a collective or uniform approach to that. This is the benefit I believe DHA will bring to the military health system. Because DHA already manages a large part of health care, which is TRICARE, we are already seeing everything through a very large lens.”

Currently DoD’s plan to cut billets is up in the air.

The House version of the 2020 defense authorization bill prohibits DoD from realigning or reducing military medical end strength until the military services and Joint Chiefs of Staff “conduct a review of the medical manpower requirements of the military department of the secretary that accounts for all national defense strategy scenarios.”

The bill requires an analysis of each military treatment facility to mitigate potential gaps in health care.

It also requires DoD develop a standard measurement for communities that will be affected by a reduction. DoD will need to provide each member of the military and covered beneficiary in an affected area with a transition plan for continuity of care and set up a public forum to discuss concerns.

Finally, DoD must provide Congress with a report of the reviews and analysis and a description of the plans for reduction of realignment.

The services already have their plans ready in case the provision does not make it into the bill.

The Air Force will decrease its medical billets by nearly 5,000 positions over the next three years as part of the effort.

MTF transition

At the beginning of October, all eastern MTFs will move from the military services to DHA.

The move was mandated by Congress in the 2017 defense authorization act.

The goal is to standardize care and to give patients a uniform way to make appointments and conduct other administrative activities.

It is the second phase of the MTF transition. Next October the MTFs on the western side of the United States will come under DHA jurisdiction and in October 2021 all MTFs worldwide will be under DHA.

The first phase only encompassed a small batch of MTFs under the agency.

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