Outsourcing of primary care: satisfaction level in the Israeli Defense Forces

OBJECTIVE: To examine the effect of outsourcing primary care services on satisfaction levels among career soldiers in the Israeli Defense Forces (IDF). METHODS: Data were acquired via self-administered satisfaction questionnaires during the visits of soldiers and civilians to primary care clinics in military bases, hospitals, and HMO settings. Multivariable analyses (GLM) used the SAS statistical program. RESULTS: Two hundred thirty civilians and 618 soldiers (200 in hospital clinics, 277 in military clinics, and 141 in HMO clinics) completed 848 questionnaires. Gender did not influence satisfaction level (alpha < 0.05). Age and rank influenced two parameters: surroundings (p = 0.0277) and availability of the medical service (p = 0.0368). Location (hospital clinic, HMO clinic, and military clinic) was the primary variable influencing and predicting satisfaction level (11.6%). "Quality of medical care" predicts only 4% of satisfaction level. Soldiers in HMO settings expressed a higher degree of satisfaction particularly in availability of service, quality of service, general satisfaction, and courtesy. CONCLUSIONS: Career soldiers in Israel value all aspects of primary care given by a civilian HMO and are willing to accept a change (outsourcing primary care to a civilian provider). As a result, decision makers should expand the provision of these services to all career soldiers in Israel. Outsourcing of medical services can serve as a model to military corps worldwide.     

Satisfaction among soldiers with secondary medical services within military and civilian clinical settings

The medical services system of the Israel Defense Forces (IDF) is founded on a principle that by definition considers it the military's role to maintain the health of its personnel in uniform. The 1994 Compulsory Health Insurance Law, Section 55 addresses health services for soldiers, stating that a soldier is entitled to health services from the Medical Corps of the IDF or an agent operating on its behalf. In the implementation of its responsibilities, the IDF Medical Corps operates an array of medical services, including secondary care. This study deals with the scope of utilization of secondary medical services by IDF personnel visiting military medical clinics and civilian hospital outpatient clinics: their character, the subjective health status of the respondents, and their degree of satisfaction with medical services. The results indicate that most of those seeking medical treatment at military and civilian clinics are not chronically ill. Most consider their health status to be good to excellent, but many of those referred for secondary care--more than half of the respondents who visited military specialist clinics-visited the clinics many times and even visited other clinics. No problem of access to clinics was found, but availability was problematic. There was a marked preference among patients to receive secondary health sevices from outside civilian agents rather than the military system.     

Gaps in expectations among clients of secondary medical services in the military system compared with the civilian system as a satisfaction index

The Israel Defense Forces Medical Corps operates a health network for Israel Defense Forces soldiers. Secondary medicine is included in the services to which soldiers are entitled. It is provided to military personnel through two parallel systems: within the Medical Corps specialists' clinics and through the auspices of a number of civilian hospital outpatient clinics. The military medical system, like the civilian medical system, is designed to serve its clientele. One of the indices for ascertainment of satisfaction with medical services is compatibility of client expectations with the service actually received. In this study, we present a gap index that demonstrates that there is gap in satisfaction among soldiers receiving secondary medical services from the military network compared with soldiers who receive secondary medical services from the civilian network. We designed a questionnaire administered to 1,532 soldiers and used 1,359 (89% response rate) for our analysis. The military system provides soldiers with services fully in synch with military regulations. Consequently, in most cases, there is a gap between soldiers' expectations from military medical service and the service they receive in practice-a phenomena that impairs soldier satisfaction. On the other hand, soldiers receiving medical services and treatment from the public civilian system receive, for the most part, service and treatment that meets or even exceeds their expectations because the system operates according to other regulations.     

Early pregnancy confirmation--the role of urine pregnancy test in military primary care clinics

Pregnancy detection is a common procedure in primary care and can be challenging in the setting of military primary care clinics. The objective of this study was to determine whether the introduction of urine pregnancy tests to military primary care clinics is associated with earlier pregnancy detection. We conducted a cross-sectional study using data from female soldiers, aged 18 to 20 years. Pregnancy was diagnosed using urine pregnancy tests. Ultrasonographic gestational age at presentation was compared between pregnant soldiers diagnosed in primary care clinics and pregnant soldiers diagnosed in gynecology secondary care clinics. A total of 150 female soldiers performed urine pregnancy tests in 5 different primary care clinics, from which 28 (19%) were pregnant. Mean gestational age at diagnosis was significantly lower among patients diagnosed in primary care clinics as compared with patients diagnosed in gynecology secondary care clinics (41.07 days (SD, 6.72) vs. 48.42 days (SD, 21.94), p < 0.001). In conclusion, the availability of urine pregnancy tests in the setting of military primary care clinics was strongly associated with early pregnancy detection at a time point in which presentation for both antenatal care and abortion services potentially improve maternal and neonatal health.     

Financial management using a computerized system for evaluating health care invoices

The Medical Corps of the Israel Defense Forces (IDF) provides health care services for hundreds of thousands of soldiers in IDF clinics and by purchasing services from civilian institutes. Monthly invoices from civilian institutes are so numerous that most are paid with insufficient scrutiny and valuable information regarding soldiers' health care is lost. Our objective was to develop a computerized system for reviewing invoices and gathering data. Based on Oracle software (Oracle, Redwood Shores, California), the system stores the terms of agreements with medical institutes, enters billing data, calculates invoice totals, manages information, and generates reports. It automatically checks for duplicate invoices and confirms payment. The system allows users to view data for decision-making, creates insurance claim files, identifies incorrect charges, assists in quality assurance, and maintains personal patient records. With the system in operation since 2001, savings significantly increased, to approximately 5% of the IDF health care budget. On the basis of information gathered by the system, changes in medical procedures were implemented that are expected to generate even greater savings.     

The Combat Trauma Life Support course: resource-constrained first responder trauma care for Special Forces medics

OBJECTIVE: In response to advances in civilian trauma care and changing military priorities, the United Kingdom Special Forces (SF) community undertook a complete review of its medical support in 1992 and developed a mission-orientated prehospital trauma care program known as the Combat Trauma Life Support (CTLS) program. METHODS: The course was developed dynamically, using a faculty of civilian trauma experts and military doctors to allow both medical and military doctrine to be included. RESULTS: Three scenarios were developed to cover all aspects of SF operations and civilian hospital practice. CONCLUSIONS: The CTLS course provides an evidence-based adaptable model to teach trauma care to SF soldiers operating in austere environments with limited medical equipment and prolonged evacuation times. It allows military and medical priorities to be balanced in a structured format. We believe that the development process may provide the basis for other specific needs-based prehospital trauma care.     

Managing health and finance: challenges, outcome, and control in the Israel Defense Forces

BACKGROUND: The Ministry of Defense budget constitutes 16% of the state budget. The budget for the Ministry of Health and for civilian health care is derived from the state budget. The health care funds receive their budgets from several sources. The capitation formula, which is determined by law, is the main factor that affects the size of the budget each fund receives. OBJECTIVE: The objective of this study is to describe the manner of planning, managing, monitoring, and controlling the budget allocated to medical services, which is a public budget for soldiers. METHODS: Several parameters are suggested for comparison, including the interface with the civilian health system, the method for budgeting a health care system, possible results of managing a medically centered budget, and the possibilities for monitoring the provided services. We also examine the potential for decentralization of authority. CONCLUSIONS: Managing the budget and locating appropriate alternatives, as well as the availability and accessibility of medical services, are important for procurement and for forming contracts with both military and civilian systems. Turnover based on updated information might serve to improve future health services.     

A model program: stress management unit--a clinic run by army nurses.

People suffering from stress and stress-related disorders are a great challenge to our already depleted military health care system. Early identification and separation of soldiers not able to adjust, immediate intervention for temporarily stressed soldiers, and stress management for dependents and retirees help decrease visits to military hospitals and clinics. Immediate intervention for salvageable soldiers also helps improve work performance and productivity. A Stress Management Unit has been open for two years at Brooke Army Medical Center (BAMC), Texas. This article identifies the need for stress management clinics in the military and briefly describes the nurse-run program at BAMC.     

Effect of an imaging-based streamlined electronic healthcare process on quality and costs

RATIONALE AND OBJECTIVES: A streamlined process of care supported by technology and imaging may be effective in managing the overall healthcare process and costs. This study examined the effect of an imaging-based electronic process of care on costs and rates of hospitalization, emergency room (ER) visits, specialist diagnostic referrals, and patient satisfaction. MATERIALS AND METHODS: A healthcare process was implemented for an employer group, highlighting improved patient access to primary care plus routine use of imaging and teleconsultation with diagnostic specialists. An electronic infrastructure supported patient access to physicians and communication among healthcare providers. The employer group, a self-insured company, manages a healthcare plan for its employees and their dependents: 4,072 employees were enrolled in the test group, and 7,639 in the control group. Outcome measures for expenses and frequency of hospitalizations, ER visits, traditional specialist referrals, primary care visits, and imaging utilization rates were measured using claims data over 1 year. Homogeneity tests of proportions were performed with a chi-square statistic, mean differences were tested by two-sample t-tests. Patient satisfaction with access to healthcare was gauged using results from an independent firm. RESULTS: Overall per member/per month costs post-implementation were lower in the enrolled population (126 dollars vs 160 dollars), even though occurrence of chronic/expensive diseases was higher in the enrolled group (18.8% vs 12.2%). Lower per member/per month costs were seen for inpatient (33.29 dollars vs 35.59 dollars); specialist referrals (21.36 dollars vs 26.84 dollars); and ER visits (3.68 dollars vs 5.22 dollars). Moreover, the utilization rate for hospital admissions, ER visits, and traditional specialist referrals were significantly lower in the enrolled group, although primary care and imaging utilization were higher. Comparison to similar employer groups showed that the company's costs were lower than national averages (119.24 dollars vs 146.32 dollars), indicating that the observed result was not attributable to normalization effects. Patient satisfaction with access to healthcare ranked in the top 21st percentile. CONCLUSION: A streamlined healthcare process supported by technology resulted in higher patient satisfaction and cost savings despite improved access to primary care and higher utilization of imaging.     

Quality assessment in primary military clinics of the Israel Defense Forces Northern Command

OBJECTIVE: To assess the quality of care provided in primary military clinics. METHODS: A standardized assessment tool was used, with medical record audits and tracers (minimal clinical criteria for proper care of common conditions), peer-review observations of medical encounters, assessments of organization and administration, and patient satisfaction and physicians' occupational stress questionnaires. RESULTS: Forty-three clinics and 113 physicians were assessed. Tracers were high for management of upper respiratory infections and low for low back pains and mental problems. The average encounter time was 9 minutes, and 25% of medical encounters resulted in referrals to specialists. Regular physicians performed better than reservists. Surgeons performed worst as primary health care providers. Female physicians did better than male physicians. The integration of new immigrant physicians was successful, and they expressed less occupational stress. Smaller clinics were better, with longer encounter times and better patient satisfaction scores. CONCLUSIONS: Quality assessment of primary health care is feasible in the military system, providing useful information for future improvement.     

Primary care enrollment levels in staff- and group-model health maintenance organizations: a standard to compare military enrollment with civilian organizations

A literature review was conducted to determine civilian staff- and group-model health maintenance organization (HMO) primary care provider staffing. Civilian staff- and group-model HMOs enroll an average of 1,473 members per primary care physician. When physician extenders are considered, the average enrollment is 1,156 members per primary care provider. Despite the similarities between the staff- and group-model HMO and military medicine, military medical care is significantly different and may decrease the capability for enrollment as a result of mission support, occupational medicine, and other military-unique factors. Comparisons between military and civilian enrollment should be tempered with these considerations.     

Optimization of the system of medical service of students of Cadet Schools of the Ministry of Defense of the Russian Federation

One of the factors of the successful military career guidance Cadet schools students is preserving and promoting their health. Medical support of children and adolescents aged 10-17 years should include the full range of medical and preventive measures defined for this group. The state of providing outpatient care for pupils at the Cadet School in St. Petersburg was studied. These results show that full medical care in accordance with the standards can be based only on children's health clinics. It is important that the organization of medical support pupils cadet schools should be cooperate with civilian health care.     

Tracking the implementation of medical referrals: responsibility versus benefit

According to the court's position, an absence of procedure that flows the medical information between the specialists and the family doctors is considered malpractice on the part of the fund that insures. In the medical practice of the Israel Defense Force, there is an uncompromised system to deal with this issue because of the special responsibility for the soldiers. In this study, we proposed changing the military system in a way that will limit the amount of resources used, as well as to track directly only to those referrals for which the primary care physician has predetermined to be important for the purposes of patient risk management. The results have shown that the new method not only better stands the test of medical malpractice but also is just as effective, and possibly even more so, than the previous method.     

The Managed Military Health System for Force Generation-project

In summary, the Managed Military Health System for Force Generation will: Allow better understanding of health issues and illness patterns in the Armed Forces. Ensure optimum health and medical fitness of service personnel throughout their military careers by: Promoting health. Protecting health. Providing timely, properly co-ordinated, healthcare from military and civilian providers. In conjunction with DMICP, provide a seamless system of patient care and administration involving all healthcare providers. Enable all military personnel to make good health decisions. Ensure a smooth transition to NHS care on completion of Service. Improve the morale of those in the Defence Medical Services through working in a high quality organisation.     

Medical treatment and costs of sports-related injuries in a total population

A prospective study of acute injuries from sports and physical exercise was carried out during 1 year in a total population of a municipality with 31,620 inhabitants. The medical treatment and the services required for the injuries have been calculated and related to the total consumption of medical care in the municipality. A total of 571 injuries (17% of all injuries) occurred in 28 different sports: 65% of the injured were males. Sports injuries accounted for 3% of all acute visits and there were altogether 1,083 outpatient visits, which yields a mean of 1.9 visits per injury. Related to the total consumption of outpatient visits to the five clinics in the municipality sports injuries also accounted for 3%. Forty-four patients were hospitalized; the proportion of inpatient care due to sports injuries was 0.7% and the mean length of stay in hospital 3.9 days. The total amount of sick leave compensated for sports injuries (3,477 days) was 1.2% of all days compensated in 1984. The overall mean cost per injury was US$ 335. Individual sports (motorcycling, downhill skiing and equine sport) were by far the most costly in the Falk?ping survey, the dearest of the team sports ranking only fifth (handball followed by soccer).     

Colonoscopy by a family physician: a case series demonstrating health care savings

Army community hospitals (ACHs) without gastroenterologists require civilian referrals for colonoscopy. The purpose of this study was to determine whether a colonoscopy-trained, military family physician (FP) saved health care dollars at an ACH by decreasing outside referrals. We present a chart review of all 182 colonoscopies performed by a FP at an ACH from September 2003 to May 2005. The total facility cost was determined using the cost of personnel, lost clinic hours, equipment, supplies, medications, continuing medical education, missed diagnoses, procedure complications, and need for additional studies. The potential referral cost was determined using local civilian colonoscopy billing codes and TRICARE reimbursement rates for 2004. The total facility cost was $53,517.14 ($294.05 per colonoscopy). The total referral cost would have been $156,197.60 ($858.23 per colonoscopy). Using a FP saved the hospital $102,680.46 ($564.18 per colonoscopy). A colonoscopy-trained FP saved significant health care dollars at an ACH.     

Trends of stress fracture prevalence among Israel Defense Forces basic trainees

Stress fractures (SFs) are a common type of overuse injury encountered in training soldiers. High rates of SF may cause a tremendous negative effect on the military unit capability to perform its missions. In this study, we reviewed the medical registry of Israel Defense Forces (IDF) soldiers assigned to combat basic training programs between the years 1998 and 2007. SF rates among IDF combat basic trainees were as high as 20% in several companies during the first years of the study. Amendments in training programs were targeted to fit the different capability and the qualifications required from combat soldiers. As a result, a steady decline of SF rates was observed, with a yearly average of 5% in the later years of the study. Increasing awareness of both medical and commanding personnel to SF and their prevention led to the gradual decline in their frequency observed in IDF basic training programs during recent years.