EXPANDING MILITARY OPERATIONAL CAPACITY

With an emphasis on quality of service and cost containment, military medical-management systems are evolving to build collaborative systems with other healthcare partners. Ongoing initiatives to consolidate services and reduce redundancy are improving efficiency while maintaining the unique mission requirements of military healthcare.

Specifically, sharing agreements between DoD and the Department of Veterans Affairs (VA) aim at building on the strengths of the VA to optimize federal healthcare. The VA and DoD are engaged in sharing agreements for buying or selling services, joint ventures, TRICARE, pharmaceuticals and medical/surgical supplies, shared staffing, advanced technology, education and training, and consolidated procurement. As efficiencies improve and redundancy is eliminated, interdependence provides opportunities for improved asset visibility. The downside of reducing redundancy is the threat of overreliance on the same assets to fill critical needs in times of emergency.

In addition, the VA/DoD Contingency Hospital System and the National Disaster Medical System (NDMS) provide healthcare backup to DoD in the event of war or national emergency (U.S. DoD 2001). DoD maintains medical operational plans that coordinate the receipt, distribution, and treatment of returning military casualties. The VA/DoD Contingency Hospital System plan describes how VA-staffed hospital beds would be made available to treat returning military casualties (U.S. VA 2001). NDMS, described in Chapter 7, is a mutual-aid program that supports both military and civilian needs when medical systems are overwhelmed. The different systems were designed to support specific needs of returning military casualties as they relate to priority of care and fiduciary responsibility. For example, if a soldier returns as a military casualty to be treated in a VA medical center, the priority under the VA/DoD Contingency Hospital System plan is higher than if treated under TRICARE. Additionally, the funding allocation differs, affecting the facilities’ bottom line. As the systems evolve, issues related to the priority of care and fiduciary responsibility must be clearly defined.

Appropriate Use of Military Medical Assets
During the initial use of the Federal Response Plan in 1992, the Army’s 44th Medical Brigade was called on to support civil authorities when those authorities were overwhelmed during Hurricane Andrew. The military medical response provided significant organizational structure and clinical support to the civilian medical response. As civil authorities regained capability, the 44th Medical Brigade redeployed to ready itself for its next military mission.

Military doctrine dictates that military assets should never be the first option in a civilian domestic response; the military’s significant medical capability is organized to support combat operations. DoD recognizes the obligation for domestic support but is not organized, staffed, or equipped for initial domestic support.

As commander in chief of the Armed Forces, the president can order the military to provide domestic support in national emergencies. However, until or unless the military mission changes, the forces are organized around projected requirements for specific military contingencies. Having the capability to provide support should not be equated with the responsibility for initial support. All military assets, active and reserve, exist to support projected military missions. If needed for civil support, current planning dictates that the military is the last support in and the first out. Access to military support is addressed later in this chapter.

Coordinating Local Military and Community Medical Assets
When military assets are located in the community, as in the case of military treatment facilities or military medical reserve units, what role exists for them in community planning? Coordination and synchronization begin with communicating existing capability and recognizing existing constraints. The first responsibility of the military is to support operational missions. As such, they may not be initially available to the community.

Military commanders, however, are a community asset and should be involved in community disaster planning. Supporting arrangements and memoranda of understanding may be appropriate, with the requisite review of senior command and legal counsel. On the other hand, the needs of the military community for civilian support are often overlooked. Disasters involving military facilities may require significant civilian assets; thus, the needs of the military should be considered and addressed in local planning. Every military commander has the authority to direct his or her assigned forces to support imminently serious situations to save lives, prevent human suffering, or mitigate great property damage. That authority must follow proper procedure and cannot be used to subvert the routine, albeit “emergency,” requests.