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I N T E R V I E W :
W I N K E N W E R D E R  &  G A L V I N
 
4 August 2005  
  

The Complex World Of 
Military Medicine: 
A Conversation With 
William Winkenwerder

The assistant secretary of defense for health affairs
discusses health care under pressure in the
Defense Department in a time of war.


by Robert Galvin


ABSTRACT:

Starting as assistant secretary of defense for health affairs just ten days after the 9/11 terrorist attacks, William Winkenwerder has probably the most complex and challenging leadership role in health care. In this interview he talks about the innovations taking place in battlefield medicine; the cost pressures and consolidation that exist in the military health system; the challenges of reporting to his notoriously demanding boss, Secretary of Defense Donald Rumsfeld; and the need to deal with a questioning, skeptical media. Trained in internal medicine and business administration, Winkenwerder came to the Defense Department after stints at Emory University and Blue Cross of Massachusetts.

Working In The DoD

Bob Galvin: As assistant secretary of defense for health affairs in the Department of Defense (DoD), you have a range of responsibilities as big as any other job in health care. Yet few people understand the various aspects of the role. Can you give us an overview of the job?

Bill Winkenwerder: I’d be glad to do that. Our responsibilities do, indeed, span a broad range of activities. Our core responsibility is to ensure that we have a fit and healthy military force and that we can support all military operations worldwide. So it’s first and fundamentally supporting the Department of Defense. Second, our mission is to ensure that we are providing a world-class health care system for military service members, their family members and dependents, and military retirees who qualify for a lifetime health benefit.

Those are our two fundamental missions, and within those missions are a broad range of activities. For example, we have the health insurance coverage program, TRICARE, which pays for care provided through our military hospitals and clinics and military pharmacies, and it also pays for care that we contract for with the private medical community across the United States. Those contracts are through private health insurance plans that bid for our business and that are awarded long-term contracts to provide those services.

We also have other responsibilities. For example, we train large numbers of physicians, nurses, pharmacists, medical technicians, and laboratorians. These individuals come to us through their initial entry into the military service; or they come to us through scholarship programs, where we finance their education, and they have a commitment in return; or through our own university, the Uniformed Services University in Bethesda, Maryland.

And then finally, we have a significant set of programs in the area of medical research and development. In this area, our work ranges all the way from activities that would relate to trauma and casualty care to biodefense to more regular types of medical problems—for example, prostate cancer or breast cancer.

Galvin: You report to Secretary of Defense Donald Rumsfeld. Having reported myself to a strong leader—Jack Welch—I have found that the reporting relationship is like a contact sport. Would you describe your experience as being similar to mine?

Winkenwerder: [laughs] Secretary Rumsfeld is a great boss, in my judgment. He is a very strong leader. He is extraordinarily astute about a wide variety of issues. He’s exceptionally experienced. Everybody who pays attention to the things he says and does knows that. He’s also a very disciplined manager who has high expectations for the people who work for and around him. He’s tough. He’s direct. He’s unambiguous. I enjoy that type of leader. He is very much as he has appeared to millions of Americans on television in his briefings and meetings. So what you see is what you get. But he does take an interest in people, and I’ve found him to be a great boss and a good mentor as well.

Galvin: What would you say have been the top two or three surprises between what you thought the job was going to be and what it has been?

Winkenwerder: Even though I was fully aware that the relationship with Congress was important, I’ve learned that Congress is involved not just in oversight but in the way in which our program is managed, and the various policies that we develop, to a greater extent than I had expected. What this means is that it has been a big undertaking to keep the staff of the various committees informed and to stay in communication with members of Congress, to keep them informed but also to help them understand what our issues and problems are, and where we’re trying to lead the program.

The other area would be with respect to dealing with the media. Again, I had some sense of that challenge and some experience with it. However, there is almost not a day that goes by when there isn’t a media question to respond to, an “issue” to deal with or manage. So one of the challenges has been to better inform the media about our activities and responsibilities and the programs we’re pursuing, not merely to be in a reactive stance—that is, just responding to questions that come in. We see our role as to inform people about what we’re trying to accomplish.

I’ll give you an example. When we were initiating our anthrax and smallpox vaccination programs, we felt that it was important to reach out not just to the general media but to the scientific community, so that all understood what we were doing and why, and could in turn help the media understand our message.

I’m sure this will come as no surprise, but for the most part, the general stance of most of the media seems to be one of skepticism. So at times this is rather frustrating.

Galvin: These are certainly skills that neither of us learned in medical school.

Winkenwerder: No, we didn’t learn anything about that.

Medical Care In Wartime

Galvin: Let’s move to the broader topic of wartime medical care. Most readers will be most familiar with battlefield care from what they remember from the TV show M*A*S*H, or perhaps war movies from the Vietnam era. How have strategies for clinical care changed, and what would M*A*S*H look like now?

Winkenwerder: We believe that care for our service members has much improved since the days of Vietnam or M*A*S*H. Obviously what was done at that time was an honest best effort to take care of people, but there are many ways in which we’ve markedly improved the way we take care of people. First, we pay a lot of attention to the health status of all of our service members before they deploy. We are diligent about assessing all service members’ health on a regular basis, as a matter of routine. In addition to that, every service member has a pre-deployment health assessment, at which point they’re assessed for the state of their mental and physical health, vaccinations, and other things that you’d want to check off to make sure that they’re ready to go.

During deployment, we pay a lot more attention today than in the past to what I’ll call environmental medicine or environmental surveillance—looking at the soil, the water, and the air and testing all of those, and managing the risks associated with things like insects or other naturally occurring environmental threats. So there’s a lot of effort to keep people healthy.

Then we have a postdeployment health assessment process that goes through a similar set of questions and face-to-face interaction. We’re expanding that process to include a required visit at about three to six months after deployment that focuses both on physical health and mental health, things such as post-traumatic stress disorder, adjustment issues, and the like. All of that is new. All of it represents things that were not done even during the first Gulf War in the 1990s.

Galvin: Could you comment on medical care on the battlefield?

Winkenwerder: On the battlefield, the medical care system is also very different than it used to be. We are placing forward surgical resuscitative capabilities—small teams of doctors, nurses, anesthetists, and anesthesiologists—in places where surgery can be performed, ideally within just a few minutes of an injury, to stop hemorrhage or to perform a life-saving procedure. Then, from that point, we look to rapidly transport the individual—many times by helicopter—to a combat support hospital, where additional stabilizing surgery can be performed.

What’s different today from the past is that wounded combatants might have been in that particular location for days or weeks. Today we bring them back to the United States very soon. And we transport them on aircraft that are retrofitted to become intensive care units or hospital wards. A person could be wounded today in and around the area of Fallujah, in a combat support hospital later this afternoon, on an airplane tomorrow to Landstuhl Regional Medical Center in Germany, and at Walter Reed [Army Medical Center in Washington, D.C.] within three days. That whole air transport capability is very different than in the past.

Lessons For The U.S. Domestic Health Care System

Galvin: Given these dramatic changes, even since Desert Storm, it speaks of a delivery system that’s adaptable and flexible—the opposite of the U.S. health care system, which you know from your prior roles is notable for its resistance to change and its slowness to adopt new innovations. Are there lessons that could apply to the U.S. delivery system?

Winkenwerder: Yes, I think that there are. One advantage we have is that everybody who works as part of the military health system is focused on the mission, which is to protect and save people’s lives and to restore their health as quickly, effectively, and efficiently as possible.

If you talked to some of our providers, I think you’d hear that they don’t worry so much about things like reimbursement and they’re not competing with other providers. Their mission is very clear. When you’re in those battle situations, everybody comes together as a team and works to get the job done.

The team aspect is another element that I think some of our providers would point to if they were asked that question. There’s not a great deal of hierarchy or differences between the status of a doctor or nurse or technician. Everybody’s just part of the team. Obviously, the team has leadership in terms of command and control. But they really function very well, and I’ve seen this myself, out visiting our combat support hospitals and some of our forward operating medical units. It’s a great thing.

Maybe we’re also benefiting from the fact that people didn’t look at us too closely during the years of evolution and improvement. There was great focus on what we were doing twelve, thirteen years ago in the first Gulf War. Now there’s a focus again. In between, there was a period of time during which we could make a lot of these improvements.

Wartime Policies

Galvin: Let me switch to a couple of policy issues. The first is, now that the military hospitals in Iraq are being pressured with large numbers of Iraqi civilians because of problems with the Iraqi medical care system, how do we want, and how are you directing the hospitals, to respond? Are we going to treat Iraqi patients just like U.S. military personnel, or are you loath to spend our resources that way?

Winkenwerder: We’re responding to this using our humane instincts. If an Iraqi civilian or even a combatant is injured because of warfare or violence, and that person comes into our custody, we take care of them, with the same level of care that is offered to our own service members or American civilians. That’s just a basic obligation, and I’ve been impressed with the way in which our medical professionals have responded to that challenge. In many situations, the numbers of Iraqi civilians or detainees may represent over half of all the occupied beds in one of our combat support hospitals.

Historically, there hasn’t been much doctrinal guidance about this, and we’re working with the line leadership of the military to assess this issue and to plan for it. We’ve been able to respond to the tasks we’ve been given, but historically taking care of civilians has not been part of the mission. But because the local native health systems in both Afghanistan and Iraq have significant problems, in many cases the task really falls to us. So we’ve responded and we’ve done the right thing, and I’m very proud of our people for having done that.

Galvin: Let me move on to another policy issue: Given a war with a high burden of wounded, and given medical recruitment that I understand is falling short of your goals, how long can we sustain this war without a medical draft? And how is that going to happen?

Winkenwerder: There is absolutely no need for a medical draft. We have plenty of capability within our current active-duty force, not to mention our guard and reserves. Today we have a total force of about 134,000 trained medical personnel. About 12,000 of those are physicians. I can’t give you, off the back of the envelope, how many are nurses or medics, but we could probably find out. There’s also another 45,000 medical personnel in the guard and reserves. So that’s really quite a large number. In the three and a half years of engagement worldwide with the global war on terrorism, something in the range of one-third of those personnel have deployed into operations. So we clearly have not even tapped our potential capability. The bottom line is, we do not think that there’s any need to consider a draft.

Galvin: Let me press you a little bit on this point, because my question was not about current capacity. I was thinking of the issue of replacement. Some data indicated that only fifteen surgeons volunteered for the reserves last year. If that number is correct, it seems that the future issue of keeping up with need is one that might need to be addressed.

Winkenwerder: That doesn’t sound accurate to me. We have a significant number of people moving into active-duty positions who are graduates of residency programs, who are graduates of our own Uniformed Services University Medical School, who have obligations. So I don’t think there’s an issue there.

Have we had, in one surgical specialty or another at one point in time, fewer people than we wanted? Yes, that has happened. But we believe that those issues might be more related to pay, or personnel management issues, or things that can be addressed managerially, rather than some broad response out there in the medical community about unwillingness to serve in the military. In fact, we’ve seen a good response of people signing up and joining the guard and reserves, and I expect that will continue.

Armed Services Medical Personnel And Prisoner Abuse

Galvin: The Washington Post and the New York Times recently reported that there have been numerous allegations that armed forces medical personnel have been involved in or failed to report episodes of prisoner abuse. My question for you is twofold: First, given some of the government’s policies on what’s acceptable with prisoner interrogation, how can medical personnel distinguish between when abuse has occurred and when it’s allowable interrogation? Second, how will you monitor repercussions for those personnel who do report abuse? I would think that because of military culture, being a whistleblower, in effect, could make life very uncomfortable.

Winkenwerder: On the first part of your question, if a physician treating a detainee observes bodily injuries, the physician can be sure that those were not the result of any approved interrogation technique. If a physician observes anything at all that the physician thinks is a problem or possible abuse, the policy is that the physician is to report that to the chain of command. Then, if there is still concern, the physician is called on to also report up through the medical chain. That report can come to the command surgeon or surgeon general, who can make sure that the issue is reviewed at senior levels to ensure that proper standards are understood and followed.

On part two of your question, the senior leadership from President Bush on down has made clear that detainees must be treated humanely, that violations of this standard are a discredit to the U.S. Armed Forces, and that violators will be held accountable. I think that the overwhelming number of military members—and certainly medical personnel—understand this and want to prevent violations of the long-standing policy of the U.S. government.

Galvin: Let me press you on this. Reporting on members of one’s team is very, very difficult. Some companies in the private sector have addressed this by establishing confidential, anonymous ways to report. How do you plan to make it easier for people in the military to do the right thing?

Winkenwerder: We rely on our medical personnel, reinforced by proper guidance and training, to always do the right thing. We expect the command climate to be such that any person should feel comfortable to report suspected abuse.

The Military Health System At Home

Galvin: Let’s move away from the war and discuss the U.S.-based portion of the military health system. A brief summary is that this system covers more than nine million active-duty personnel, family members, and retirees, with about 60 percent of the care delivered in your own facilities and about 40 percent through the typical U.S. delivery system. This all adds up to an overall expenditure of more than $36 billion a year.

The first question is, given that there is the nonmilitary delivery system, the veterans’ health system, and yours, how much excess capacity do you think there is, and how are you addressing it?

Winkenwerder: Where we overlap most with the Veterans Health Administration is for our retirees with twenty years of service, who have a lifetime health benefit that gets them access to military hospitals and clinics and the TRICARE network. We sought, over the last three years, to work as closely as possible with the VA [Veterans Affairs] to avoid areas of duplication and to improve communication and coordination between our two systems.

Let me point to a couple of examples. In the area of information systems, we’ve made a lot of progress so that today we can transfer electronically the clinical records of separating service members to the VA so that they have those records in full and don’t have to be reconstituted or transferred by paper to the VA. That’s a real advance. So we’ve got emerging, robust, two-way communication with respect to clinical health records.

As another example, we’re working, wherever possible, to not build two hospitals if they’re in the same area but to build one, either a Department of Defense or a VA hospital, and utilize that one hospital as the source of care for both populations. And then in the area of business practices, again we’re seeking to do more things, so that together we procure hundreds of millions of dollars worth of medical materials, pharmaceuticals, and supplies. This is an unknown area to the general public, but I can assure you that we save many tens of millions, if not hundreds of millions, of dollars on an annual basis through this joint purchasing with the VA. There are a number of other things we’re doing together. Our goal, really, is to make our care systems as seamless as possible when people transfer from one to the other.

Galvin: Overlap and excess capacity are certainly no stranger to the nonmilitary U.S. delivery system. What actions are you taking in terms of physical infrastructure?

Winkenwerder: We’re taking action to reduce excess capacity where it occurs and to partner with the VA or with community-based heath systems. For example, in the base realignment and closure effort, we stated that we will be closing, I believe, twelve community-based hospitals and two tertiary hospitals out of the roughly fifty-five that we have in the United States today. So a significant number will be closing, for the very reason you cite.

The most significant example is here in the national capital area, where the plan will have Walter Reed coming together with the Bethesda National Naval Medical Center to create the new Walter Reed National Military Medical Center. It will become a joint triservice tertiary medical center for all military medicine. As part of that set of changes here, we will be—if the Base Realignment and Closure Commission approves this—building a new community-based hospital in northern Virginia and also closing the hospital at Andrews Air Force Base, the Malcolm Grow Hospital. So we’ll be closing two institutions, building one new one, and combining two others. We’ve really put a lot of effort into looking at our infrastructure and better aligning it to our needs, and to where our population resides.

Galvin: Will physicians, or any clinicians, be losing their jobs because of the consolidation?

Winkenwerder: Some physician positions will be eliminated as a result of these changes. However, the implementation time frame is several years. So there will be plenty of time to plan for and adjust to those changes.

Galvin: If you’re really going to get at infrastructure, shouldn’t you ask whether the military really needs its own delivery system for nonwartime medicine?

Winkenwerder: We have ongoing discussions about all that we do, and we certainly believe that it’s important to be clear with ourselves and with the leadership of the military about why we do things the way we do them. But what I would say is that we have a fixed infrastructure of military hospitals and clinics, and all of the personnel associated with those, and we believe that it’s very important to sustain this, to effectively support military operations around the world.

Now, the question really is the degree to which we need to own and operate fixed facilities—that is, hospitals and clinics—and the degree to which we can partner with others using our own personnel in their facilities. A number of new models have emerged in which military personnel, through these partnerships, are taking care of military beneficiaries but doing it in community-based hospitals, VA hospitals, or academic health centers.

We have a new emerging partnership with the University of Colorado in which we will have a significant outpatient client on campus at the University of Colorado, partnering with its new academic health center, and inpatient services will be provided there. We will do this instead of building a hospital on the Buckley Air Force Base.

Galvin: Interesting. I don’t think that this is widely known.

Winkenwerder: In Chicago—and this was announced in the base realignment and closure announcement earlier this year—we’re closing the Naval Hospital at Great Lakes, and our inpatient care will be provided by the North Chicago VA, and then we will jointly have a large, ambulatory clinic that will be managed together, with VA and DoD medical personnel working out of the same facility. So what’s critical for us is the medical professionals who are trained and equipped, and ready to go and ready to operate and work as a team. However, we believe that we cannot perform as we would desire to perform unless we have a certain amount of fixed infrastructure that we really own and operate ourselves.

Clinical Quality

Galvin: The VA has impressed everyone with its clinical transformation. It now scores higher than any other known delivery system on quality metrics. Do your hospitals have similar data? And if so, how do they score?

Winkenwerder: We do track similar data, and I’m not able to provide that for you today, because I don’t have it in front of me, but maybe we can get it for you and follow up. We do very well on these comparative metrics, and we place a real importance on them.

Again, I think because of the teamwork aspect that we alluded to earlier, as well as our investment in information technology, we’re getting better at this as time moves on, because our systems are getting better and better. We have a Patient Safety Office that started about three or four years ago. There are a number of priorities associated with that office. One area we really have focused on—because we do quite a lot of obstetrical care—is on reducing bad outcomes associated with normal deliveries, both vaginal and cesarean. We use the same system that’s been developed to look at those outcomes and compare those statistics. There are a handful of different areas, around the new AHRQ-sponsored measurement system that have been established. We do pretty well on all of those, but we really believe that we ought to be at the top of the pack, so we’re working hard to do that.

Galvin: It’s always interesting to me how “pretty well” in medicine has so frequently been 80 or 90 percent of achievable, whereas outside the health care world, that would be looked at less than two sigma and be considered unacceptable.

Health Care Benefit Costs

Galvin: With the reorganization you mentioned, it sounds like there is a common theme of trying to deal with overall costs relative to other issues that Defense is facing. At recent hearings of the Senate Armed Forces Subcommittee on Personnel, where you testified, the point was made that rapidly rising health costs in the military are threatening to claim budgeted dollars that would otherwise upgrade equipment or be used for other objectives. How are you specifically addressing this issue, in addition to the infrastructure rationalization that you described?

Winkenwerder: The rising cost of health services for the military is a significant problem, and left unaddressed it will become a very significant problem in the medium to longer term. We’re addressing the challenge of our rising health expenditures in a variety of ways. We’re making a number of important decisions with respect to our facilities and our fixed infrastructure, as I just spoke about. We are implementing a drug formulary and utilizing our market power to negotiate favorable prices with the pharmaceutical industry. Just recently, we made the first decision that comes out of our formulary process. And I say “we”—it was our Pharmacy and Therapeutics Committee that made this recommendation, which I approved, to eliminate among the class of proton pump inhibitors the drug Nexium, because it was, relative to the others, not the most cost-effective. That decision will save the department many tens of millions of dollars. We’ll be making more of those decisions on many other drug classes.

Another way in which we’re seeking to better manage our costs is through changing the payment system for our military hospitals and clinics. Until very recently, the military hospitals and clinics were reimbursed on a cost-plus basis, and as you know, that’s generally what was done in the civilian community up until the mid-1980s, with the implementation of DRGs [diagnosis-related groups in Medicare]. We are now implementing, albeit a bit late, a DRG system and a prospective payment system so that we won’t be rewarding those who are inefficient in the way that they provide hospital care. We’re doing that internal to the direct care system for military hospitals and clinics.

So we’re making some really important changes to better manage our resources. In addition to that, we believe that it’s very important that we now also look at our benefit structure and make sure that it better aligns with the benefit structures that are now seen in the private employer-based health insurance community, and make sure that cost sharing is appropriate so that our beneficiaries are incentivized in appropriate ways.

Galvin: A recent article in the New York Times pointed out that the increase in spending for your retirees is clearly the area in which costs are growing the most. The article noted that those retirees have close to first-dollar coverage.

Winkenwerder: That’s correct.

Galvin: Those of us in the private sector understand what those kinds of incentives do. But you’re facing a similar problem with having people expect a certain level of health care, and in some cases it’s stronger in the case of the military, because these are people who put their lives on the line for their country. That is called “the Promise” in certain circles. What’s your strategy for addressing the retiree issue?

Winkenwerder: One thing is clear: We will always have a superior health benefit for our military service members and their families and for military retirees. I am quite comfortable in saying that it would be my objective that that benefit always be better than the benefit that individuals would be offered by civilian employers. That’s not the issue. The issue is just how much better, or how different, in terms of the costs that individuals share as part of their health plan, this can be without creating perverse incentives. Frankly, this makes it very difficult for us to manage and sustain our medical benefit over the long term. So we have to look at these issues in a constructive way, in a careful way, and engage not only our leadership in the Department of Defense, which we have done, but also leaders of Congress and representatives of all of the military service organizations that are concerned about the future of the medical care benefit.

Galvin: Because you are one of the largest purchasers of care outside of Medicare and federal employees, your procurement practices can have a powerful impact on the U.S. health care system. I’m aware that you’ve recently consolidated your suppliers, which is a move that many employers made over the past several years as well. Yet most of the changes that we talked about in terms of benefit design, drug formularies, and supplier consolidation are the same ones that private purchasers will tell you do not address the root causes of cost increases and are unlikely to make a big impact beyond the short run.

The Leapfrog Group and other initiatives to drive more transparency and payment reform are thought by leading-edge buyers to be necessary to affect costs. Despite membership in Leapfrog, the DoD has not been a leader in these areas. Why not, given the enormous impact you could have with your interaction with the nonmilitary health care system?

Winkenwerder: The honest answer for why we have not been more active is probably that we’ve been really busy the last three and a half years with all that is on our plate, supporting operations in Iraq and Afghanistan and around the world. We’ve been very busy in taking care of the hundreds of thousands of mobilized reservists and guardsmen and their families, and, by the way, implementing a new health benefit for them. We’ve implemented a new pharmaceutical and other health benefit for our retirees over age sixty-five called TRICARE for Life [TFL]. And we’ve restructured all of our TRICARE contracts. So it’s not that the issue you bring up is not important, because it is very important, but it is something that, unfortunately, has not reached the top of our priority list, I think principally because of the very unusual circumstances we’ve faced in the last three and a half years. That said, I think we’re now prepared to delve more aggressively into the issue and to focus on some of the things that you bring up.

Bill Winkenwerder has served as assistant secretary of defense for health affairs since October 2001. He came to the Pentagon after thirteen years of executive leadership positions in the health care industry. Bob Galvin (robert.galvin{at}corporate.ge.com) is director, Global Health Care, for General Electric in Fairfield, Connecticut.

DOI: 10.1377/hlthaff.w5.353
©2005 Project HOPE–The People-to-People Health Foundation, Inc.