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.     

Various contract settings and their impact on the cost of medical services

OBJECTIVES: This study analyzes the effect of outsourcing healthcare on career soldiers in the Israel Defense Forces (IDF) in different settings, so as to develop a model for predicting per capita medical costs METHODS: Demographic information and data on healthcare utilization and costs were gathered from three computerized billing database systems: The IDF Medical Corps; a civilian hospital; and a healthcare fund, providing services to 3,746; 3,971; and 6,400 career soldiers, respectively. Visits to primary care physicians and specialists, laboratory and imaging exams, number of sick-leave days, and hospitalization days, were totaled for men and women separately for each type of clinic. A uniform cost was assigned to each type of treatment to create an average annual per capita cost for medical services of career soldiers. RESULTS: Significantly more visits were recorded to primary care physician and to specialists, as well as imaging examinations by Leumit Healthcare Services (LHS), than visits and tests in hospitals or in military clinics (p < 0.001). The number of referrals to emergency rooms and sick-leave days were lowest in the LHS as compared to the hospital and military clinics (p < 0.001). The medical cost per capita/year was lowest in LHS as well. CONCLUSIONS: Outsourcing primary care for career soldiers to a civilian healthcare fund represents a major cost effective change, lowest consumption and lower cost of medical care. Co-payment should be integrated into every agreement with the medical corps.     

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.     

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.     

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.     

Finally "deliberate by design": milestones in the delivery of health care for U.S. military family members

The development of medical care for U.S. military families and retirees was serendipitous, a fortunate accident. The formal development of military family medical care required the evolution of three factors: the emergence of a standing army, frontiers to guard, and a peace to defend. These factors were first realized in the late 19th Century, and beginning at that point in U.S. history, seven key years highlight major milestones in the history of military family member medical care. At the same time, these years exemplify changing ideas of disease and of health care and how the physical design of clinics and hospitals reflects and impacts these ideas. The Fort Belvoir Community Hospital, which opens in 2011, exemplifies the Nation's best example of green hospital construction, patient and family centered care, and evidence-based design in a Culture of Excellence that demonstrates that military family medical care is finally "deliberate by design."     

A psychometric comparison of military and civilian medical practices

BACKGROUND: Our purpose was to compare the psychometric properties of military and civilian ambulatory internal medicine care. METHODS: Military data came from two cohorts of patients presenting for primary care. Variables collected included mental disorders (the PRIME-MD study), previsit symptom-related concerns and expectations, functional status (Medical Outcomes Study SF-6 and SF-20 scales), postvisit unmet expectations, satisfaction with care (Medical Outcomes Study five-item survey), and physician-perceived "difficulty" (Difficult Doctor-Patient Relationship Questionnaire). This data set was compared with data abstracted from several civilian studies of ambulatory primary care. These studies used the same instruments and took place during the same period. RESULTS: Military and civilian patient populations were equally likely to have mental disorders, with no differences in the prevalence of disorders within the broad categories of mood, anxiety, somatoform, eating, or alcohol disorders. Civilian populations had a slightly higher rate of some specific diagnoses, including major depression, panic disorder, and generalized anxiety disorder. There was a similar distribution of previsit expectations of care and in the types of postvisit unmet patient expectations, with military patients having slightly lower rates of unmet expectations. Patients in both practice settings had similar self-reported ratings in the six domains of functioning (role, social, pain, emotion, physical, general health), with civilian patients reporting slightly worse overall self-rated health. Both settings had high rates of fully satisfied patients (40% "excellent" for both), with patients with unmet expectations in both groups much less likely to be fully satisfied. There was also a similar proportion of encounters rated as difficult by the clinician (military, 11%; civilian, 15%; p = 0.99). The correlates of difficulty in both groups were similar, with mental disorders and multiple symptoms increasing the likelihood of a difficult encounter. CONCLUSIONS: The psychometric properties of patient care in military and civilian internal medicine ambulatory settings are remarkably similar. These data support mutual generalizability of primary care research findings with respect to psychometric properties between military and civilian populations.     

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.     

Diagnoses, demographics, and utilization of care as encountered by three U.S. Navy general medical officers

U.S. Navy general medical officers (GMOs) are physicians serving as general practitioners. Although exceptions exist, most GMOs are not board-certified in a specialty. They are post-graduate year 1 (PGY-1)-trained, state-licensed physicians analogous to civilian general practitioners. We conducted a retrospective study using data generated from patient visits with active duty males and females from June 1 to 30, 1998, to describe diagnoses, demographics, and utilization of care patterns encountered by three PGY-1-trained GMOs at an ambulatory clinic. A total of 781 patient encounters with 123 diagnoses from a patient population of 3,178 were recorded. This is an average of 260 patient encounters per GMO, at a rate of 2.52 patients seen per patient-care hour. Fifty-seven consultations/referrals were requested (7.3% of encounters, 1.8% of the patient population). Personnel assigned to the clinic accounted for 4.2% of visits (2% of the patient population). Patient satisfaction was rated as "excellent" to "satisfactory," and no significant morbidity was observed at 1.5-year follow-up. With PGY-1 training, GMOs provide primary care to a substantial volume of prescreened patients and treat patients with a majority of diagnoses without referral or unacceptable complications. The role of GMOs, and perhaps other physicians without specialty training (i.e., general practitioners), in selected settings seems valid and may have advantageous medicoeconomic implications for military and civilian managed care systems.     

Quality assessment of primary health care in a military setting

PURPOSE: The aim of this study was to analyze the quality of primary care in Israeli Defense Forces primary care clinics and physicians (PCPs) and to test the hypotheses that: (1) the quality of primary care provided in battalions is higher than that provided by other primary care providers and (2) the evaluation of a specific PCP within the framework of the quality assessment program results in an improved score during a second evaluation. METHODS: Teams of two physicians carried out the control process. Each primary care clinic is evaluated in a standardized manner by filling a prospectively established form. Five parameters are examined: (1) direct inspection of the PCP, (2) medical record audit, (3) high-risk patients' management evaluation, (4) evaluation of secondary health care characteristics, and (5) medical staff guidance evaluation. The various clinics and physicians evaluated were classified as: battalion clinics, division and brigade clinics, training center clinics, and home-front clinics. RESULTS: Between the years 1999 and 2001, 149 primary care clinics and 250 PCPs were evaluated. Seventy-four PCPs (29.6%) were evaluated twice. Battalion clinics scored higher than the other clinics. PCPs evaluated twice had significantly better quality assessment results at the second encounter. CONCLUSIONS: Quality of primary health care is the highest in battalion troops clinics. We interpret the increase in quality assessment scores from one examination to the other as an index of improvement resulting from the feedback given to the providers.     

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.     

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.     

A comparison of MEDRETE practice content to U.S. ambulatory care

A U.S. military medical team spent 2 weeks providing medical care in a rural area in Bolivia. Records of presenting complaints and physician diagnoses were kept for 2,169 patients seen during the exercises. Patients seen in Bolivia were younger than in typical U.S. clinics, with 53% being less than 15 years old. Digestive system complaints were the reason for 35% of the visits, compared to 5% in U.S. clinics. Diagnoses made more often than expected on the Bolivian expedition included gastroenteritis, peptic diseases, low back pain, and headaches. Supply and personnel needs are greatly influenced by these patient characteristics.     

Effect of a computerized online grading system on patient satisfaction in a military primary health care setting

Patient satisfaction is gaining recognition as an important determinant of the quality of medical care. We conducted an analysis to evaluate the effect of a computerized online system that comparatively displays grades of patient satisfaction among primary care military infirmaries. Fifteen Israel Air Force primary care infirmaries served as the intervention group, and 130 Israel Defense Force infirmaries were the control group. Baseline patient satisfaction was surveyed in all infirmaries. In the intervention group only, infirmaries were resurveyed at 3-month intervals during a 1-year period. Satisfaction scores were continuously displayed on an intranet site in a comparative graphical manner by using the computerized system, available only to the intervention group. At the endpoint, patient satisfaction improved in both groups. However, the magnitude of improvement in the intervention group was significantly greater, in comparison with the control group. The most pronounced improvement was noted in availability of service (intervention group, 57.9% at baseline vs. 66.0% at endpoint, p < 0.001; control group, 67.5% vs. 69.6%, p < 0.025). We conclude that the use of this computerized system in conjunction with promotional efforts resulted in significant improvements in patient satisfaction.     

BATLS/BARTS training in Lithuania

OBJECTIVE: In order to train medical personnel properly for future international missions the Lithuanian Armed Forces decided to adopt BATLS/BARTS as a basic course for military pre-hospital trauma care. This decision was based upon the increasing Lithuanian participation in international missions as a part of multinational units. Another important reason was the personal experience of the course concept acquired in Sweden in 2001 by five Lithuanian medical officers. METHODS: Similar to the way BATLS/BARTS was introduced in Sweden, a regular Swedish course (as given in Sweden for own units prior to international missions) was given in Lithuania. The faculty consisted of three experienced instructors from Sweden, and the two Lithuanian medical officers who had previously taken the BATLS course and the BATLS instructor course in Sweden. RESULTS: Two BATLS/BARTS courses have been given in Kaunas, Lithuania. A total number of eight medical officers, nine military nurses, five medics, three civilian doctors and four medical students have taken the course. Some of these (four medical officers, two military nurses and two medics) have later been deployed to Afghanistan, Iraq and Kosovo, where the Lithuanian units have been collaborating with British, Danish, Polish and Czech-Slovakian units. CONCLUSION: As international missions become multinational, it is essential there is full confidence in the level of training and preparedness among all units working together. One way to achieve this is through bi- or multinational training as described in this paper.     

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.     

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.     

Evaluating delivery of primary health care to military personnel during low-intensity conflict using a patient satisfaction survey

The delivery of medical health care to soldiers serving in active front units in the Israeli Defense Forces requires the ability to adjust to different military activity settings. This study was conducted to compare patient satisfaction, as a tool for assessing quality of care, in different activity settings: training and Low-intensity conflict setting. A patient satisfaction survey was conducted simultaneously in battalions during low-intensity conflict and training activities. Data analysis showed that patients' perception of the quality of care they received and of medical staff attitude was higher in the conflict setting. Correlation analysis revealed that patients during conflict perceived outcome of care and accessibility as most important in evaluating overall satisfaction. We suggest that perception of high-quality medical care can be obtained during conflict conditions. Interestingly, in the conflict setting, the physical environment of the clinics appears to be less crucial to patient satisfaction than physician availability and medical outcome. These results may serve as a basis for changing health delivery systems by health policy makers.     

Patient-centered medical home: an emerging primary care model and the military health system

The patient-centered medical home (PCMH) is a primary care model that aims to provide quality care that is coordinated, comprehensive, and cost-effective. PCMH is hinged upon building a strong patient-provider relationship and using a team-based approach to care to increase continuity and access. It is anticipated that PCMH can curb the growth of health care costs through better preventative medicine and lower utilization of services. The Navy, Air Force, and Army are implementing versions of PCMH, which includes the use of technologies for improved documentation, better disease management, improved communication between the care teams and patients, and increased access to care. This article examines PCMH in the Military Health System by providing examples of the transition from each of the branches. The authors argue that the military must overcome unique challenges to implement and sustain PCMH that civilian providers may not face because of the deployment of patients and staff, the military's mission of readiness, and the use of both on-base and off-base care by beneficiaries. Our objective is to lay out these considerations and to provide ways that they have been or can be addressed within the transition from traditional primary care to PCMH.