Navy Medicine Introduces Value-Based Health Care.

In 2016 the newly appointed surgeon general of the Navy launched a value-based health care pilot project at Naval Hospital Jacksonville to explore whether multidisciplinary care teams (known as integrated practice units, or IPUs) and measurement of outcomes could improve the readiness of active duty personnel and lower the cost of delivering care to them, their dependents, and local retirees. This article describes the formation of the project's leadership structure, the selection of four conditions to be treated (low back pain, osteoarthritis, diabetes, and high-risk pregnancy), the creation of the care team for each condition, outcomes and costs measured, and the near-term changes in outcomes during the twelve-month pilot period. Patient outcomes improved for three of the four conditions. We describe factors that contributed to the project's success. After the pilot concluded, the Navy combined the back pain and osteoarthritis IPUs into a single musculoskeletal clinical unit and established a similar IPU at another naval hospital and its clinics. The diabetes IPU was continued, but the high-risk pregnancy IPU was not. We offer several observations on the elements that were key to the success of the project, explore challenges and opportunities, and suggest that the pilot described here could be taken to greater scale in the Military Health System and elsewhere.

A historical review of the U.S. Navy's busiest recompression chamber in the Pacific theater with a current perspective on caring for civilian divers within its area of responsibility: short communication.

On the island Nation of Guam, the United States Department of Defense has stationed military personnel from every service branch. Guam is utilized as a strategic waypoint for the U.S. military in the Pacific theater. As the largest service branch in the region, the Navy has placed a few Diving Medical Officers in Guam to collectively manage and treat patients with recompression therapy. Guam is also a popular tourist destination, with multiple recreational diving companies certifying individuals who are looking to take advantage of the beautiful warm water and exotic marine life. Unfortunately, with an increase in training and certifying inexperienced divers, came an increase in the operational tempo of the U.S. Navy's recompression chamber on Guam. The recompression chamber on Naval Base Guam (NBG) has been treating patients since 1971. With the only multiplace chamber in the Mariana Islands, Diving Medical Officers, with the accompanying chamber staff, treat military personnel, active-duty sponsored patients and civilian patients. Treating civilian patients by military providers through military treatment facilities presents multiple issues that must be addressed in an effort to provide efficient quality medical care. This article reviews the records, documents, and activity of the NBG chamber over the last four decades. Through the obtained data the information provides projected financial reimbursement from civilian patients. The article also sheds light on areas of needed improvement with regard to data collection, third-party financial collection efforts and the necessity of an inclusive electronic health record (EHR) for military and civilian patients.

Legal aspects of cruise medicine - can a non-US ship's doctor be sued for malpractice in Florida?

An English ship's doctor treated a non-US female patient for abdominal discomfort on a foreign-flagged cruise ship off the coast of Haiti. In Mexico the patient underwent abdominal surgery, followed by complications, for which her lawyers wanted to take the ship's doctor to court in Florida, USA. A trial court granted their wish, but this decision was reversed on appeal as the factors discussed were insufficient to establish Florida jurisdiction over the ship's doctor. The decision is not about whether malpractice occurred; it is about limiting the possibility of taking the ship's doctor to a court in a location preferred by the plaintiffs' lawyers. The appeal court ruling is important for non-US doctors working as independent contractors on cruise vessels that visit US ports, and it will hopefully prevent some of the more frivolous law suits from being filed in the future.

The business case for telemedicine.

BACKGROUND AND AIM: Following the coming into force of the International Labour Organisation Maritime Labour Convention (ILO/MLC) and International Maritime Organisation Standards for Training, Certification and Watchkeeping, Manila 2010 (IMO/STCW) amendments, the objective of this article is to provide the shipping community with an initial assessment of the economic reasons and business case, in support of both publicly financed and private telemedicine being implemented on board commercial vessels. MATERIALS AND METHODS: It provides the global scale of the requirement, the number of Telemedicine Assistance Services (TMAS) calls handled by participating TMAS, the average direct and indirect costs incurred by both TMAS and ship operators, responding to medical emergencies, and also provides a calculation of the market size of about 760 million Euro/year. It estimates a return on investment per ship, of implementing telemedicine on board to meet the MLC and STCW requirements at less than 1 year. RESULTS AND CONCLUSIONS: 1. There are both financial and soft benefits, such as crew retention and being perceived as a quality employer offering a telemedicine service on board. 2. It is quite possible to obtain a 20% savings to the industry of perhaps 152 million Euro/year from the deployment of telemedicine on board. 3. The deployment of a telemedical service on ships is an opportunity to encourage further cooperation between TMAS and also with the private TMAS sector. 4. There is clearly a great need, on a global basis, for more cooperation, particularly in standardisation of pre-boarding medical files available, the equipmentrequired on board at a minimum, and level of service quality provided. 5. A collection of a common TMAS annual set of normalised statistics from the stakeholders in the maritime industry is needed. Should someone not be tasked with collecting this? 6. Open registries and countries where the private sector only providestele medicine, should be encouraged to work with the global public TMAS system and contribute to its costs?

[Medicine aboard cruise ships--law insurance specifics]. / Versicherungsrechtliche Betrachtungen zur Tätigkeit des Arztes an Bord von Kreuzfahrtschiffen.

The booming cruise industry, associated with ships with more passengers and crew on board, results in growing medical needs for the ship doctor. The ship's doctor insurance policy includes different jurisdictions, namely national law, international law, tort law, insurance law and labor law. In addition, international agreements must be taken into account, which complicates the design of an adequate insurance policy. Equally high are the costs and defense costs for the ship's doctor in case of liability. In order to limit the liability for all parties is to ask for appropriately qualified medical staff, hired on board.

A cost analysis of training expenses versus the value of medical care provided during West Africa Training Cruise 2004: Senegal.

A medical civic assistance program (MEDCAP) visit was conducted by naval reservists in eight villages in Senegal, West Africa. More than 6,000 patients were treated by MEDCAP team members. Medical and dental care, eyeglasses, vitamins, medications, educational material, and mass casualty training were provided. Major challenges confronting the mission were to provide care in makeshift clinics in remote villages in an arduous sub-Saharan climate, where more than one-half of the population lacks adequate public health funding to address basic medical and dental needs. To estimate the economic costs and benefits of the mission, as a guide to future planning, we calculated the total costs of the mission and its economic benefits. Total costs were found to be $502,500. We estimated that the monetary value of the medical services provided was $730,090. Additional nonquantifiable value was created through training and development of military and professional partnerships. In a post-September 11 world, the MEDCAP is an important and cost-effective vehicle to advance U.S. foreign policy in a nonthreatening manner. Countless lasting friendships can be won with bandages and medicines.

[Healthcare at water transport].

The timely restructuring of healthcare at water transport is an issue of special importance under the social-and-economic conditions of today. The paper mirrors positive and negative aspects of the present state medical care provided to those occupied at water transport system of the North-West Okrug of the Russian Federation. The virtually identical standard of medical care rendered to the discussed category of employees is observed in other Okrugs of Russia. A model of medical care for seamen for the at-sea and on-shore conditions is put forward. In order to preserve and to promote the discussed sphere of healthcare it is necessary to preserve the positive traditions of the past and, jointly with the interested branches, departments and public and other organizations, to apply the modern methods healthcare organization, i.e. to reorganize some of the sectors, to introduce a strict Register of institutions and organizations preoccupied with medical are at water transport and to develop and to introduce new technologies in all spheres of medical care within the branch.

A comparative analysis of amlodipine and felodipine in a military outpatient population: efficacy, outcomes, and cost considerations.

BACKGROUND: This retrospective study compared the efficacy, tolerability, and cost of two dihydropyridine calcium channel blockers. METHODS: Charts of patients who had been on continuous antihypertensive therapy with amlodipine or felodipine for at least 6 months were reviewed. Analyses include mean changes in blood pressure, percentage of patients achieving blood pressure (BP) < 140/90 mm Hg, average dose, and cost per day of the two calcium channel blockers, average cost of additional medication, total medication cost per day, and cost to achieve BP control. RESULTS: Eighty-seven percent of amlodipine-treated patients achieved BP control compared with 33% of felodipine-treated patients. Total medication cost to achieve BP control was 0.87 dollars per day for patients on amlodipine compared with 1.79 dollars per day for patients on felodipine. CONCLUSIONS: Amlodipine produced BP control in a greater percentage of patients than did felodipine at a lower total cost to achieve BP control. When evaluating the total cost of antihypertensive treatment, the cost of a drug alone can be misleading.

"Tip of the spear" physical therapy during a 6-month deployment to the Persian Gulf: a preliminary report.

When a U.S. Navy aircraft carrier battle group deploys overseas, the ship's medical department is responsible for more than 10,000 personnel and their numerous musculoskeletal injuries. This paper reviews the effectiveness of having a U.S. Navy physical therapist and physical therapy technician onboard the USS Carl Vinson during its most recent deployment to the Persian Gulf. Physical therapy had 3,373 patient visits during the ship's 1998-1999 Western Pacific deployment. Having physical therapy personnel onboard resulted in fewer patient visits to sick call for musculoskeletal problems and fewer evacuations compared with other similar carrier deployments. Providing physical therapy at the "tip of the spear" is an effective, beneficial, and cost-saving landmark improvement in providing quality medical care to the fleet. The lessons learned from this experience will assist in clarifying the role of physical therapy in future military support operations and sustained deployments.

Obesity-related hospitalization costs to the U.S. Navy, 1993 to 1998.

The objective of this work was to estimate the cost to the U.S. Navy for obesity-related hospital admissions by examining (1) inpatient utilization associated with obesity; (2) the rank order, probability, and total facility costs of obesity-related diagnosis-related groups (DRGs); and (3) expected inpatient expenses. The frequency and probability of inpatient events in the Navy's active duty population were derived from the Department of Defense's Retrospective Case Mix Analysis System. Medicare-based facility costs per DRG were estimated. These measures were combined in a decision-analytic model. Expected facility costs per obesity-related admission for active duty Navy personnel increased by age group from $3,328 for 18 to 24 year olds to $5,746 for 45 to 64 year olds. The annual avoidable inpatient cost for the Navy was estimated to be $5,842,627 for the top 10 obesity-related DRGs. Improvements to the Navy Physical Readiness Program and other interventions that may reduce obesity, obesity-related health care use, and the public economic burden should be pursued.

A cost-benefit analysis of the effect of shipboard telemedicine in a selected oceanic region.

Data from a selected oceanic region, the UK search and rescue region, were used to establish the average annual of ship diversions and emergency service call-outs arising from urgent medical problems of passengers or crew. During the period 1997-8 there were 228 medical evacuations. An attempt was made to estimate the extent to which some or all of the diversions and call-outs could have been averted if telemedical facilities had been available on-board the ships. The analysis showed that telemedicine would be an expensive alternative to existing evacuation methods, but did not allow for the fact that helicopter and lifeboat evacuations cannot be carried out in bad weather or at distances over 200 nautical miles (370 km) from land. Taking into consideration the cost of ship diversions in such circumstances produces completely different results. Telemedicine could clearly provide substantial cost-savings for the shipping industry, and a separate analysis focused on the shipowner alone would make an overwhelming economic argument for investment in a telemedicine service simply on the strength of diversion avoidance.

Surgery aboard ship: is it safe?

A retrospective review was performed on 684 surgical procedures done aboard U.S. Atlantic Fleet ships during a 3-year period from 1994 to 1996. These procedures were compared with similar procedures performed at the Naval Medical Center in Portsmouth, Virginia. Morbidity and mortality rates were calculated and compared. A very low morbidity rate (0.43%) was reported for surgical procedures performed while deployed compared with 1.69% for procedures at the Naval Medical Center. One mortality was reported. These extremely low rates are felt to be attributable to multiple causes, including a highly selected, healthy patient population, performance of only low-risk procedures, early presentation of surgical problems, and early medical evacuation of patients with complex medical and surgical problems. We feel that elective surgical procedures such as vasectomy, circumcision, inguinal hernia repair, and hemorrhoidectomy can be performed safely aboard ship. This would increase the training opportunity for all members of the medical department and at the same time decrease the costs and risks associated with medical evacuation.

A cost analysis: general endotracheal versus regional versus monitored anesthesia care.

A prospective study was conducted to compare the total cost of all consumable products used to perform a general endotracheal anesthetic (GETA), a regional anesthetic, and a monitored anesthetic (MAC). For 1 month, providers completed a survey for each anesthetic rendered identifying type and quantity of consumables used. The mean cost of each type of anesthetic was identified. Analysis of variance was conducted using SPSS (version 7.5.1) to compare the mean costs of the three groups. Of 936 anesthetics performed, 536 surveys were returned (57%). The breakdown by type was GETA, 60% (N = 319); regional, 35% (N = 189); and MAC, 5% (N = 28). The mean cost per case type was GETA, $61.74; regional, $34.99; and MAC, $26.27. The cost of rendering a GETA was significantly greater (p < 0.0005) than that of either regional or MAC. Clinical practice guidelines were established to address areas in which cost savings could be realized and were provided to all anesthesia practitioners to assist in providing the safest and most cost-effective method of rendering an anesthetic.

A cost-effectiveness analysis of shipboard telemedicine.

BACKGROUND: The U.S. Navy is considering the installation of telemedicine equipment on more than 300 ships. Besides improving the quality of care, benefits would arise from avoiding medical evacuations (MEDEVACs) and returning patients to work more quickly. Because telemedicine has not yet been fully implemented by the Navy, we relied on projections of anticipated savings and costs, rather than actual expenditures, to determine cost-effectiveness. OBJECTIVES: To determine the demand for telemedicine and the cost-effectiveness of various technologies (telephone and fax, e-mail and Internet, video teleconferencing (VTC), teleradiology, and diagnostic instruments), as well as their bandwidth requirements. METHODS: A panel of Navy medical experts with telemedicine experience reviewed a representative sample of patient visits collected over a 1-year period and estimated the man-day savings and quality-of-care enhancements that might have occurred had telemedicine technologies been available. The savings from potentially avoiding MEDEVACs was estimated from a survey of ships' medical staff. These sample estimates were then projected to the medical workload of the entire fleet. Off-the-shelf telemedicine equipment prices were combined with installation, maintenance, training, and communication costs to obtain the lifecycle costs of the technology. RESULTS AND CONCLUSIONS: If telemedicine were available to the fleet, ship medical staffs would initiate nearly 19, 000 consults in a year-7% of all patient visits. Telemedicine would enhance quality of care in two-thirds of these consults. Seventeen percent of the MEDEVACs would be preventable with telemedicine (representing 155,000 travel miles), with a savings of $4400 per MEDEVAC. If the ship's communication capabilities were available, e-mail and Internet and telephone and fax would be cost-effective on all ships (including small ships and submarines). Video teleconferencing would be cost-effective on large ships (aircraft carriers and amphibious) only. Teleradiology would be cost-effective on carriers only. Telemedicine's bandwidth requirement is small-1% of a month's time. However, if the ships' medical departments need to resort to a commercial satellite, E-mail and Internet would be the only telemedicine modality generating enough monetary benefits to offset the costs.

Users' evaluation of the Navy Computer-Assisted Medical Diagnosis System.

U.S. Navy Independent Duty Corpsmen (IDCs) aboard small ships and submarines are responsible for all clinical and related health care duties while at sea. During deployment, life-threatening illnesses sometimes require evacuation to a shore-based treatment facility. At-sea evacuations are dangerous, expensive, and may compromise the mission of the vessel. Therefore, Group Medical Officers and IDCs were trained to use the Navy Computer-Assisted Medical Diagnosis (NCAMD) system during deployment. They were then surveyed to evaluate the NCAMD system. Their responses show that NCAMD is a cost-efficient, user-friendly package. It is easy to learn, and is especially valuable for training in the diagnosis of chest and abdominal complaints. However, the delivery of patient care at sea would significantly improve if computer hardware were upgraded to current industry standards. Also, adding various computer peripheral devices, structured forms, and reference materials to the at-sea clinician's resources could enhance shipboard patient care.