Military Doctors In Crosshairs Of A Budget Battle
The U.S. military is devising major reductions in its medical corps, unnerving the system’s advocates who fear the cuts will hobble the armed forces’ ability to adequately care for health problems of military personnel at home and abroad.
The move inside the military coincides with efforts by the Trump administration to privatize care for veterans. The Department of Veterans Affairs last month proposed rules that would allow veterans to use private hospitals and clinics if government primary care facilities are not nearby or if they have to wait too long for an appointment.
Shrinking the medical corps within the armed forces is proving more contentious and complex. In 2017, a Republican-controlled Congress mandated changes in what a Senate Armed Services Committee report described as “an under-performing, disjointed health system” with “bloated medical headquarters staffs” and “inevitable turf wars.” The directive sought a greater emphasis for military doctors on combat-related needs while transferring other care to civilian providers.
Details of reductions have yet to be finalized, a military spokeswoman said. But within the system and among alumni, trepidation has increased since Military.com, an online military and veterans organization, reported in January that the Department of Defense had drafted proposals to convert more than 17,000 medical positions into fighting and support positions — a 13 percent reduction in medical personnel.
“That would be a drastic first cut,” said Dr. David Lane, a retired rear admiral and former director of the Walter Reed National Military Medical Center in Bethesda, Md.
At most risk in the current planning are positions that aren’t considered essential to troops overseas, such as training spots for new doctors and jobs that can be outsourced to private physicians and hospitals — obstetricians and primary care doctors, for example. The reductions may also limit the military’s medical humanitarian assistance and relief for foreign natural disasters and disease outbreaks.
Even in war zones, Lane warned, it would be a mistake to downplay the importance of contributions by doctors who do not specialize in trauma. In the 1991 invasion of Kuwait, for instance, cases of diseases and non-battle injuries rather than combat injuries created the most medical work, he said.
Doctors who train in the military’s highly regarded medical school — who have committed to serve in the armed forces after training— and those who do military residencies account for much of the staff serving troops overseas. A major deployment could leave the military flatfooted, said Dr. John Prescott, a former Army physician.
“The majority of folks in the military don’t stay in for their whole career, they stay in for a few years,” Prescott said. “I’m concerned there will be a very small cohort that will be available for deployment in the future.”
The military health system is responsible for more than 1.4 million active-duty and 331,000 reserve personnel, with 54 hospitals and 377 military clinics around the world. Split among the Navy, Army and Air Force, each with its own doctors and hospitals, the service has been targeted for years for overhaul to reduce redundancies and save costs.
The department has already started moving administrative functions under one bureaucracy, called the Defense Health Agency, which is slated to take over the service branch hospitals in 2021.
The budget for the next fiscal year is still being developed and final decisions have not yet been made, a Department of Defense spokeswoman, Lt. Col. Carla Gleason, said in an email. “Any reforms that do result will be driven by the Department’s efforts to ensure our medical personnel are ready to provide battlefield care in support of our forces, and to provide the outstanding medical benefits that Service members, retirees and their families deserve,” she said.
For years, critics of the broad role of the military health services have argued that many medical corps services — such as maternity care and pediatrics on bases — could be provided more effectively by civilian doctors and hospitals.
But Lane said there is too much focus on the high-profile trauma cases on the battlefield “that at the end of the day are a small portion” of medical care. “When we’re trying to put things back together that got broken during a war,” he said, “that’s what you need the most of — pediatricians, public health doctors, primary care doctors.”
Some studies commissioned by the department have concluded private hospitals could deliver less costly care, in part because doctors at hospitals take care of more patients. But the Congressional Budget Office said savings were not at all certain and that military hospitals might be less expensive if the government arranged for greater use of them.
Brad Carson and Morgan Plummer, who held senior jobs in the Department of Defense during President Barack Obama’s administration, argued in a 2016 essay that the military isn’t the best training for surgeons because it doesn’t provide them with a sufficient number of cases to develop expertise.
The military health system “has too much infrastructure, the wrong mix of providers, and predominantly serves the needs of beneficiaries who could easily have their health care needs satisfied by civilian providers at far less cost and with equal or better quality,” they wrote.
The government this year is spending $50 billion on the military health system, including Tricare insurance for more than 9 million active-duty service members, veterans, families and survivors, according to Congress’ budget office. That is roughly a tenth of the military budget. The CBO projected costs are on track to increase to $63 billion in 2033.
Defenders of the system reject the idea that non-wartime jobs can be eliminated without it hurting that core mission.
“Military health care providers between deployments maintain their clinical skills by treating service members and millions of beneficiaries,” Dr. Arthur Kellermann, dean of the school of medicine at the Uniformed Services University in Bethesda, wrote in a 2017 Health Affairs article. “Military hospitals provide valuable platforms for teaching the next generation of uniformed health care professionals and standby capacity for combat casualties.”
Prescott, the former Army doctor, said that the military may have trouble turning to civilian doctors in some regions given physician shortages, which he said the military cuts would exacerbate.
“Most hospitals are already pretty full, most health care providers are pretty busy,” said Prescott, now chief academic officer at the Association of American Medical Colleges.
Doctor shortages would increase if the military cut the slots it now has to train doctors, because there wouldn’t be new civilian residencies created to compensate. “Those positions basically disappear,” he said.
Kathryn Beasley, a retired Navy captain who is director of government relations for health affairs at the Military Officers Association of America, said she was also concerned with unforeseen consequences of dramatic cuts.
“Everything’s tied together, there’s a lot of interdependencies in these things,” she said. “You pull a string on one and you might feel it in an area you don’t expect.”
Feb. 14, 2019
Washington is often disconnected from the veterans communities, and that division can lead to ineffective policies, former Air Force officer Michael Haynie told Hill.TV.
“The extent to which we have conversations in D.C. about the social, economic, wellness concerns of this community without connecting those conversations back to the communities in which veterans are going to live, work, raise families I think is pretty short-sighted,” Haynie told Hill.TV’s Krystal Ball and Shermichael Singleton this week on “Rising.”
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Click link below to view the 2018 meeting highlights !
- HG Stevenson Award for outstanding support and dedicated service to the SGSU and urology residency programs. Presented to: Gerald Jordan, MD
- Honorary Lifetime Membership Award for lifetime dedication and service to the SGSU.
Presented to: John M. Barry, MD
- Prince Beach Award for best paper (#65) presented by a society member staff physician as judged by chief residents. Presented to: Thomas Rozanski, MD
- Clare Scanlon Award for outstanding administrative work on the organization of the Mock Oral Boards for many years. Presented to: COL Inger Rosner, MD
- Clinical Research Award Winners:
- 1st Place: #9 – Capt Theodore R. Saitz, MC, USAFR
- 2nd Place:#11 – MAJ Dantae Bowie, MC, USA
- 3rd Place: #1 – Maj Pansey Uberoi, MC, USAF
- Basic Science Award Winners:
- 1st Place: #2 – LT Chad Pusteri, MC, USN
- 2nd Place:#5 – CPT Joseph Fantony, MC, USA
- 3rd Place:#20 -CPT Karmon Janssen, MC, USA
- People’s Choice Award: #12 – Leah Williams, Ms3
- Honorable Mention: #22 – LT Ryan Gillis, MC, USN
- Poster Session Winners:
- 1st Place: #55- CPT Alexandria Hertz, MC, USA
- 2nd Place: #62-LCDR Eric Biewenga, MC, USN
- 3rd Place: #52- CPT Karmon Janssen, MC, USA
Job Opportunity Available
Immediate opening at Lexington VAMC for a full-time VA Urologist. A faculty appointment is available with the affiliate institution (University of Kentucky) and competitive salary/benefits come with the position. Lexington, Kentucky is a very desirable location with affordable housing, good schools and it is a safe city to raise a family. Not to mention, it is the Horse Capital of the World and for Bourbon enthusiasts, this is the center of it all. The preferred candidate would be an early to mid-career Urologist with minimally invasive experience or minimally invasive surgery fellowship training who would, after 2-3 years, transition to the Chief of Urology (VAMC) position, however, all applicants will be considered (including graduating residents in 2019). The DaVinci Xi Robot is available and owned by our facility. All subspecialties are represented at Univ. of Kentucky and our VA has an excellent working relationship with the affiliate institution such that our Veterans receive world class, subspecialty and general urology care. If you are looking for a change, a great place to live and work, and a gratifying job, look no further. Also, Urologists leaving the military before a retirement (short of 20 years) are eligible to transfer/purchase your years of military service into the VA retirement system! This is a huge benefit. Please share this with colleagues/residents/fellows in your programs. Please send application/CV to David M. Preston, MD, Chief, Urology Service, VAMC Lexington – email (firstname.lastname@example.org < Caution-mailto:email@example.com > ) and by phone, please text 859-396-3323 identifying your interest and contact number and Dr. Preston will reply back.
Urological Society for American Veterans
Success at the AUA San Francisco!
I would like to personally thank all of this year’s USAV annual meeting organizers and sponsors for their contributions in producing an outstanding meeting at the AUA. We were able to complete our business objectives for the organization, have professional interactions with our meeting sponsors and an excellent scientific program on Sunday afternoon May 20, 2018 .
DeSantis Management Group (organizer)
Some highlights from the meeting re USAV accomplishments:
- AUA recognition as an independent specialty society with inclusion in the annual meeting agenda
- USAV- request to participate in congressional advocacy with AUA on capitol hill in March, 2018
- SCSAUA- creation of a board of directors representative position for government urology
- SGSU- creation of a board of directors representative position for USAV and VA urology
- Consensus building activity on NMIBC management to develop white paper for VA acquisition office
We have many future projects to organize and engage in and will be soliciting your participation.
We want to engage each of the AUA sections to have representation and scientific program elements engaging USAV membership.
We want to have national research and quality projects aimed at improving GU practice in VA facilities nationwide.
We also want to provide standardized processes for making necessary equipment and resources available to execute our jobs well.
We need the members to step up, pay their dues (very nominal) and volunteer to participate- we need and want you to GET INVOLVED.
We as a group are in a unique position to influence the health a large population of our veteran’s health, and there are great opportunities for leadership and coordination of important efforts within our organization.
With kindest regards,
Your humble President,
SGSU 2018 Kimbrough Meeting
VA Representative Report by Jeffrey Jones, MD – USAV President
- Dr. Jones thanked SGSU for the opportunity to become a Chapter of the SGSU and for their support.
- USAV was financially successful in the past year, having a gain of over $3,300 in its fund.
- He said they are gaining new members and industry support, thanks to strong efforts by the DeSantis Management team.
- He noted that the USAV will have a program at the AUA and hopes to have a representative talk about the merits of SGSU membership and merits of being a member of both organizations.
- He noted that the USAV was asked to present at the AUA Advocacy Summit, and will plan to participate.
- He hopes to establish/continue with a Resident/ Young Urologist Simulation workshop working with industry partners like BSC.
- There may be opportunities for hands-on sessions at future Kimbrough meetings for the Manthos lunch, if rated positively.
- Dr. Jones noted there was a separate break-out session for VA/military medicine at the SCS-AUA in Florida this year. He will ask that each AUA Section allow time for VA/DOD urologists to have a forum for Government Urology in order to increase visibility and recruitment.
- He wishes to expand participation in section leadership with a government urology representation to the Board of Directors.
Many thanks to Dr. John Barry for his diligence in taking the time to provide SGSU members these insights.
- Ten minutes of mindfulness exercises (or simply sitting in an empty quiet room) may reduce anxiety and pain associated with urodynamic procedures. It was a prize winner.
- Decellularized placental membrane grafts may turn out to be a useful matrix for spread-fixed dorsal urethroplasties.
- Microscopic hematuria is normally gone by the 3-month follow-up visit after robotic-assisted radical prostatectomy. If it isn’t, it’s worth a work-up.
- Prolapsed ureteroceles are rare in adults.
- Synergistic immune-photothermal nonotherapy (SYMPHONY) works in a murine model of bladder cancer. Another prize winner.
- Cryotherapy, radiation therapy and radical prostatectomy for localized prostate cancer have slightly different long-term quality-of-life issues; choose wisely.
- Newly diagnosed prostate cancer patient distress is reduced with a 4-hour multidisciplinary approach.
- PSA screening is beneficial.
- A “Hole-in-a-Box” model for estimation of prostate size by Foley balloon palpation turned out to be a successful teaching tool, and it confirmed the expertise of faculty. It was a prize winner.
- Cytoreductive radical prostatectomy for local management of metastatic prostate cancer may be a valid concept.
- Shared decision making for prostate cancer treatment was associated with patent satisfaction across all races. Another prize winner.
- A perioperative anesthesiology consultation service reduced opioid use, extended hospital stays and readmission rates. This was a People’s Choice Award – the presenter was a medical student.
- 30% of orchiectomy patients chose replacement with testicular prostheses; some had to be removed for pain, infection or cosmetic disappointment.
- A pathway was presented for management of Fournier’s gangrene.
- Urethral injury during penile prosthesis surgery is rare, but it happens, even to fellowship-trained urologists. Management is by common sense approach.
- Chronic scrotal content pain is relieved just over half the time by microsurgical denervation.
- Patient compliance with recommended post-vasectomy semen analysis isn’t very good.
- Semirigid ureteroscopy as a sole dilator for ureteroscopy works, but it’s debatable if it’s more cost-effective than other methods.
- The Lean Six Sigma DMAIC process improvement method resulted in a flexible –scope readiness of 89% -from 38%.
- Ultrasonic propulsion of kidney stones is almost ready for prime time. Another prize winner.
- Components of urinary stones activate the NLRP3 inflammasone in female rats.
- Children with ADHD, Asperger syndrome, autism and ODD seem to have a greater risk of eliminating dysfunctions.
- Fibroepithelial vaginal polyps are rare.
- The top three factors resident applicants use to rank residency programs are resident satisfaction, faculty/resident relationships, and mentoring.
- International peace-keeping and combat deployment missions for military physicians are challenging -and rewarding.
- Antimicrobial prophylaxis for TURP appears to be unnecessary if the urine is sterile before the procedure.
- Al Squitieri gave an interesting talk about the German War cemetery in Glencree, Ireland.
- BG Turlington described Colonels John Wettlaufer and John Weigel as “Gurus of Combat Urology.” John Wettlaufer signed my copy of their book, Urology in the Vietnam War on 27 March 2008; it’s on the bookshelf next to my four volume set of Campbell-Walsh Urology.
- Failed exstrophy closures are best managed by an experienced team.
- Most patients with cloacal exstrophy achieve urinary continence at a median of 11 years, but only after multiple procedures.
- Subcutaneous leuprolide works.
- Telecystoscopy for bladder cancer surveillance by allied health professionals with transmission for live interpretation by a urologist is successful.
- FlexDex is a hand-held laparoscopic needle holder that mimics the functions of a robotic needle holder.
- Renal denervation is a treatment option for chronic renal pain.
- Think of lumbar and sacral spinal-mediated pathology for cases of not-so-obvious neurogenic sexual dysfunction when the neurogenital exam is positive.
- Corporal erectile tissue fibrosis can be seen on tumescence B-mode grayscale ultrasound exam.
- Does finasteride sometimes cause corporal fibrosis?
- Clomiphene works in many cases of male factor infertility and testosterone deficiency.
- Automated flow cytometry may become the new standard for the diagnosis of microscopic hematuria. It will need to be standardized for each lab. Prize winner.
- The combination of Peyronie’s disease curvature and indentation have been successfully treated with placation and onlay tunica albuginea grafts of cadaveric fascia.
- Collagenase and interferon injections have been used to treat Peyronie’s disease; the latter is quite a bit cheaper.
- There was a nice historical review of the principles guiding the use of intestine in urologic surgery.
- Check “interstitial cystitis” patients for vestibulodynia with a Q-tip exam; they may not have IC.
- Clitoral adhesions can cause sexual dysfunction in women.
- Vastus lateralis fascia is being rediscovered as a mesh substitute for the repair of female pelvic floor descensus.
- A labia minora island flap can be used for female urethroplasty.
- Patients don’t seem to mind if their teleurology practitioner is a urologist or not, as long as the practitioner is competent.
- A screening PSA of 1.5 probably doesn’t need to be repeated for 5 or 10 years.
- If the Select MDx, a two-gene urine test, is positive, consider Bx.
- The Confirm Dx will give one and estimate of the probability of prostate cancer after a negative biopsy.
- An indication for the Oncotype DxGPS is a Gleason 6 or 3+4 on Bx.
- AR-V7 is a blood test to help predict response of androgen receptor (AR)-targeted therapy.
- The purpose of the ABU is to protect the public. The purpose of the AUA is to support the profession.
- Maintenance of Certification (MOC) is being changed to Life-long Learning Program (LLP). The Wright Map concept is being applied.
- Watch Simon Sinek’s TED talk on the Golden Circle. It’s a classic.
- Best functional studies for pediatric urodynamics = PVR and Uroflow EMG.
- TENS pads are replacing fine needles for neuromodulation treatments.
- There are now five approved anti-PD-L1 agents for bladder cancer.
- Inflatable penile prosthesis (IPP) reservoir complications are not rare. One-third of sub-Scarpa’s fascia reservoirs are visible. Modeling for Peyronie’s disease seems to work most of the time when an IPP is placed. If there is an hour-glass deformity, it will get better in 6 months; any curvature of 30 degrees or less is OK. Don’t put in a sphincter and an IPP at the same time. Get under Scarpa’s fascia by scraping it off the pubic tubercle. Wait 3 months before doing IPP revision surgery.
- Premature ejaculation (one definition is <1 minute intravaginal latency) can be treated with the oral selective serotonin uptake inhibitors (SSRIs) paroxetine and dapoxetine, or Emla cream (wash it off after 5 minutes, then have intercourse). An oxytocin antagonist is being studied. A risk of the SSRIs is suicidal ideation.
- Therapeutic options for delayed ejaculation are vibrators, oxytocin nasal spray and carbergoline and ergot derivative.
John M. Barry, MD
by Evan Sweeney |
A bill introduced by two senators on Monday designed to modernize the Department of Veterans Affairs includes a provision that would allow physicians to practice telehealth across state lines.
Introduced by Sens. John McCain, R-Ariz. and Jerry Moran, R-Kan., the Veterans Community Care and Access Act of 2017 (PDF) would consolidate community care authorities into a single program, implement data-driven access and quality standards, improve walk-in care and ensure safe prescribing practices, among a slew of other requirements.
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From FierceHealthCare by Joanne Finnegan |
A neurosurgeon has been barred from performing any surgeries at a Veterans Affairs medical center in Mississippi but has continued to collect his salary as a legal battle goes on.
The G.V. (Sonny) Montgomery VA Medical Center in Jackson barred the doctor, Mohamed Eleraky, from seeing patients years ago, but Eleraky continues to collect his $339,177 annual salary, according to the Clarion Ledger.
Eleraky filed an amended court complaint earlier this month against the VA seeking injunctive relief and monetary damages in a jury trial.
by Jeff Jones, President
Urological Society for American Veterans – an affiliate of the SGSU
Thanks to all who attended, and contributed to, the May 2017 meeting of the USAV in Boston, during the AUA. We had an excellent scientific program put together by the program and abstract committee of Robert Grubb, Justin Parker, Jennifer Taylor, Chris Filson and chaired by Dan Makarov. The meeting was well supported by industry partners, and included review talks on genetic analysis tools for prostate cancer and new technology for bladder cancer diagnosis, in addition to the institutional VA-derived abstracts.
In the business meeting the executive committee announced our formal affiliation with the SGSU, and our acceptance as a recognized professional society by the AUA. Deb Moore, as our secretary, is working on the approved changes to our bylaws submitted by Rob Moore, and Muta Issa, our VP, and Krish Gaitonde, our treasurer has already put the organization well into the black in our first year- great job all! We have already been contacted by the AUA outreach regarding the upcoming AUA Congressional Advocacy day on capitol hill in March 2018, and the USAV will be contributing. Thus, we have made great strides to establish ourselves as the “go to” organization for veteran health in urology.
We are already planning our meeting in San Francisco in May 2018, and we hope our agenda will be published in the AUA program book for the first time this year.
In additional to our open member’s forum and national email roster, we are building a member-only page to place VA-specific items like SOP’s, personnel and equipment justifications, etc. to assist urology at each geographic location get the support they need to execute the VA urology mission, without having to locally “reinvent the wheel” every time.
We hope all of you will be encouraged to join both the USAV and SGSU, so we can grow our organizational infrastructure, capability, and influence. The dues are really very modest, so please sign-in and join- the organization is here to serve you, its membership.
WASHINGTON – Department of Veterans Affairs Secretary David Shulkin argued Tuesday that a House plan for veterans’ health care was too restrictive and wouldn’t offer enough veterans the choice of private-sector care.
House lawmakers and VA officials hashed out details Tuesday of two proposals outlining major changes to the VA’s community care programs. Both would effectively end the Veterans Choice Program that was created in 2014 following the VA wait-time scandal to extend VA care into the private sector. The plans do away with a rule that allows veterans to seek private sector care when they are forced to wait more than 30 days for an appointment or live more than 40 miles driving distance from a VA facility.
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- Military Doctors In Crosshairs Of A Budget Battle March 11, 2019
- Former Air Force officer calls Washington’s approach to veteran health care ‘short-sighted’ February 20, 2019
- Outlook Newsletter – March 2018 August 31, 2018
- Congratulations 2018 Kimbrough Award Winners August 24, 2018
- Job Opportunity Available – Immediate opening at Lexington VAMC August 20, 2018
- USAV – President’s Report 2018 June 19, 2018
- VA Rep to SGSU 2018 Report June 19, 2018
- John Barry’s Meeting “take aways” – 2018 Scottsdale April 13, 2018
- Senate bill aimed at modernizing VA health system includes telehealth licensing provision December 5, 2017
- A VA surgeon barred from operating on patients since 2013 still collects an annual salary—and he’s not alone November 27, 2017