Objective: To describe the background to the provision of medical support to enemy prisoners of war (EPW) and the clinical activity undertaken at the EPW medical treatment facility. Methods: Data were recovered from operational diaries and individual patient records to show EPW attendance rates at routine sick call, diagnoses made, and medications prescribed. Results: EPW presented at an average rate of 1.2 cases per 100 EPW per day. Trauma, musculoskeletal, and dental problems accounted for 52% of presentations. Medications for mild/moderate pain and broad-spectrum antibiotics accounted for nearly 65% of prescriptions. Cultural and security issues presented additional challenges to medical staff members. Conclusions: Provision of medical support for EPW is an enduring task covered by the Geneva Conventions. EPW present a wide range of ailments at routine sick call that require suitable medications, all provided in a culturally appropriate and secure environment.

OperationTelic was the United Kingdom’s contribution to the combined joint military action to enforce Iraq’s compliance with U.N. Security Council Resolution 1441 concerning the identification and destruction of its research, development, and deployment program of weapons of mass destruction. This was the largest deployment of British troops since Operation Granby, which saw U.K. forces deployed to the Middle East in 1990-1991, although the time frame for Operation Telic, compared with Operation Granby, including planning, deployment, and commencement of offensive operations, was compressed into 13 weeks rather than 6 months.

Medical planning concerning enemy prisoners of war (EPW) was initiated before deployment. and further refinement of the plan was conducted in theater. Working from first principles and using the Geneva Conventions1 and current doctrine2-4 as a framework, a medical estimate was completed to identify tasks and begin to allocate resources and priorities. There was little information available concerning what the basic health status of EPW might be. This made allocating troops and priorities difficult, and there was a risk that medical coverage for EPW might be inappropriate to the level of need encountered.

The evidence base concerning the management and treatment of EPW is limited. What had been published before the last Gulf war was focused on the experiences of Western (and mainly American) troops from World War II, the Korean War, and the Vietnam War. However, the experiences of the 46th Combat Support Hospital5 and the 300th Field Hospital6,7 generated some data concerning clinical activity and general management of EPW. Additional work from Operation Desert Storm described malingering among EPW,8 combat stress reactions,9 provision of pharmaceutical services,10 the continuing importance of the provision of environmental health support to EPW holding areas,11 and ethical concerns of deployed military physicians.12

Only the 300th Field Hospital published data relating to uptake of primary care-type services, using information generated from routine sick call. The article described average weekly percentages of those reporting sick (10.26-27.45% per week during the air campaign and 1.71-3.32% per week during the ground campaign). The most common conditions seen and medications prescribed were also described.

Dental disease, upper respiratory tract infections, headache, gastrointestinal conditions (diarrhea and constipation), urinary tract infections, and dermatological conditions accounted for approximately 75% of consultations. Simple analgesics and broad-spectrum antibiotics were the most commonly prescribed items but methyldopa, nitroglycerin, prochlorperazine, and phenytoin sodium were also prescribed. Communication problems and the provision of security in the hospital were also discussed. The aims of this article are to describe the organization of medical assets, present a synopsis of the clinical work of the medical facility deployed to the Corps EPW handling area, and discuss some the issues that arose during the operation.

Initial Planning and Operations

Planning

Under the terms of the Geneva Conventions, there was a requirement to provide EPW with the same levels of medical support as friendly forces, with access being decided on the basis of need alone. This would require provision of NATO role/ echelon 1, 2 and 3 medical care.13 Table I summarizes the capabilities of each NATO role/echelon medical treatment facility.

At the point of capture, EPW would be treated by medical personnel from the capturing unit. At the Corps EPW holding area, there was a requirement to provide NATO role 1 and 2 care (with the exception of resuscitative surgery), and this was organized from an area medical support troop (AMST), a mobile primary care facility with a limited holding capability of up to 15 personnel for 48 hours. The complement was eight officers (four medical, two dental, and two nursing) and 25 personnel of senior and junior ranks. Medical staff members had no formal training in the provision of medical services in a transcultural setting, although some personnel were able to call upon previous experiences to assist the younger, less experienced staff members.

WITH HEADLINES proclaiming another medical malpractice crisis, it’s a good idea to take stock of how physicians conduct business with patients.

Let’s face it, in malpractice cases the trouble doesn’t begin with lawyers, it begins with doctors’ interactions with patients. Patients who feel well cared for and have an amicable relationship with their physicians rarely sue, even when there may be a poor outcome to some element of a care plan.

In medical practice for 38 years, I’ve seen the malpractice concerns of physicians rise from minimal to, sometimes, almost hysterical. The scope of our problems accelerated in the early 1970s.
I believe our risks for litigation grew as individuals dispersed away from their core family groups after World War II. The close, long-term contacts with which many of us grew up in our well-defined communities were disrupted. Trust became a victim of that dispersion. People did not have the family ties and, due to frequent moves, did not develop new ones.

That mobile pattern continues to increase today. In addition, the highly publicized scientific developments in medicine began to make the public believe that medicine could cure almost anything and expectations became unrealistic in many cases.

This combination of lost trust in physicians and publicity surrounding miracle cures played a large part in the development of the litigious society in which we live. Of course, this litigious attitude is not limited to physicians, but it hits us hard when we see our insurance premiums rise each year and our coverages reduced.

Age 55 no longer means retirement is on the horizon. From the recent downturn in the stock market, which has taken a bite out of many people’s 401(k) retirement savings, to the prospect of living longer, people are staying in the workforce beyond the traditional retirement age.

If they have already retired, a decline in their investment portfolios or the desire to be more active may prompt these individuals to return to the workforce. The increase in the number of older workers is not a temporary phenomenon. It is a trend likely to continue into the future.
“Many baby boomers will have no choice but to stay on for two reasons: One, they are going to need the money and, two, too much of their life is ahead of them–physically, emotionally and motivationally,” says Bruce Douglas, a consultant on aging workers and an oral and maxillofacial surgeon who recently returned to practice after 14 years in retirement.

Demographic changes will continue to have a major impact on the U.S. workforce. Government statistics show that while there were 18.4 million workers over age 55 in 2000, older individuals in the workforce will jump to 31.9 million by 2015. In addition, older workers will make up an increasing proportion of the overall workforce as there are fewer younger workers entering the job market to fill vacancies from retiring workers.

More older workers on the job is ultimately good news for employers that face a likely “experience shortage” as boomers–the largest demographic in the population–age.

When I wrote “My Mother’s Haunting End,” about the health care system’s failings during my mother’s last hours, I knew that by telling her story I would be expressing the sentiments of many. But I could not have imagined the flood of e-mails I would receive. They were full of anger and insight, pain and compassion — and above all a desire for change in a medical system that had caused lingering harm.

“The local hospice had no room for my mother. I drove around town checking out alternate facilities. Then she was transferred by ambulance to a nursing home where a full month’s basic charge (not including ‘non-essentials’
Jeanne Ramage Green’s husband died on Feb. 4, 2007. “No one told us how bad the cancer in his lungs was. … Not one doctor in the four months after the cancer was discovered to have recurred told him that his cancer was terminal until four days before he died,” she wrote.

Just as pained were those charged with caring for such patients. Susan Johnson, a geriatric care manager in Bethesda, wrote: “I hope it is some small consolation that your story will impact many who have read it and we, who feel some passion for our work, will be motivated to get it better the next time. No, we could not have changed your mother’s diagnosis or her prognosis, but surely we could have gotten her a peaceful death with dignity and good pain management.”
“I now have cancer,” wrote a former hospice worker in Virginia named Nancy. “Like Elizabeth Edwards, I am ‘incurable’ but not yet ‘terminal.’ Having seen what I have seen of what cancer does to you at the end, and the hell patients and their families go through with the medical establishment, as well as the inadequacies of even hospice care. … I don’t plan on riding the disease till the end. When it gets close, I will find somewhere peaceful and end it on my own terms, and save us all the ordeal of the American way of death.”

Medical Savings Accounts (MSAs) now occupy center stage in the continuing healthcare reform debate. Title III of the recently enacted “Health Insurance Portability and Accountability Act of 1996″ provides for a limited national “demonstration” of MSAs. But no one doubts that MSAs will continue to be an issue not only in the political debate but also in the planning formulas healthcare financial managers must employ.

What are MSAs and what do they mean for you and me? When I use the term I am referring to health insurance plans that combine a catastrophic insurance policy, a “savings” account an individual can use to pay medical bills not covered by an insurance policy, and preferential tax treatment.
MSAs are intended to take the place of traditional indemnity insurance or managed care plans. They contain a catastrophic insurance component to cover healthcare costs after an out-of-pocket deductible amount has been paid. Deductibles under the new law range from $1,500 to $2,000 for individual coverage and $3,000 to $4,500 for family coverage. Once the deductible has been met, the “catastrophic” insurance is either fully comprehensive or contains further copayments and other restrictions.

To help pay for the deductible out-of-pocket expenses, an individual sets up a tax-free savings account, with the amount in the account being deducted from gross income before Federal income taxes. If established through an employer, the employer and/or employee can both contribute to the account. Money unspent in any year can be carried into future years, creating a larger cushion against future healthcare expenses, or withdrawn for nonmedical reasons. Withdrawals for nonmedical reasons are taxed and a penalty is imposed if the account owner is under 65.

FORGET “MANAGED” COMPETITION. ORDINARY COMPETITION DOES NICELY, THANK YOU. NOW THAT THE FEVER OF OUT-OF-CONTROL HEALTH-CARE COSTS HAS BROKEN, DOES THIS MEAN THE HEALTH-CARE CRISIS IS PAST? NOT ENTIRELY. CEOS OF BOTH PROVIDERS AND EMPLOYER-USERS DEBATE POSSIBLE PRESCRIPTIONS FOR WRINGING OUT FURTHER COSTS AND UPGRADING THE QUALITY OF CARE.

Last year for the first time ever, annual growth in corporate America’s health-care costs declined to 12 percent from 6 percent the previous year, although overall spending hit 14 percent of GDP. To some degree, private-sector reform has been so widespread that government reform seems moot. Why? Health care is at last starting to be run like other businesses. The surge of HMOs and the increasing variety in managed-care vendors are due, in part, to recent moves toward standardization, outcomes measurement, and performance data collection. There’s an increasing emphasis on accountability that was absent 10 years ago.
So if U.S. health care is no longer on the respirator, is the patient recovering? It depends on who you talk to. Facing acute overcapacity, hospitals are losing money. Doctors and other providers say they are unhappy with managed care and the industrialization of the care industry. HMOs are continuing to consolidate almost as fast as banks. In 1994, the industry saw 1,100 mergers and acquisitions worth $60 billion. Through an aggressive acquisition strategy, Columbia/HCA Healthcare, for example, turned itself into a $15 billion juggernaut with operating margins close to 20 percent in less than eight years. Big pharmaceuticals have moved with lightning speed to pick off rivals and merge. Consumers are frustrated and continue to worry about quality and availa
The history of the health-care crisis is riddled with short-lived victories over escalating costs. In 1984, then-Secretary of Health and Human Services Margaret Heckler asserted that the rise in healthcare costs was at an end. Events proved otherwise (see chart). Many experts claim that recent evidence of a decline in average costs reflects one-time savings from moving out of high-cost indemnity plans. A Foster Higgins survey, for example, noted that HMO premiums increased 9.7 percent in 1994 for large employers and 6.2 percent for small employers. To counter this, employer coalitions - notably in Minneapolis and San Francisco - have sprung up in an effort to push HMOs to lower prices and let employers monitor care provided by doctors and hospitals.

Some employers are considering Medical Savings Accounts for the same reason others have turned to managed care (see sidebar). It puts the buyer-user of health care in direct contact with the seller-provider. In exchange for indemnity coverage with a high deductible, employees keep any MSA money they do not spend. They have a financial incentive to shop around to buy prudent first-dollar health care. According to Michael Tanner, director of health and welfare studies at the Cato Institute, a variety of companies that use some version of MSAs - flexible savings accounts or incentive savings plans - including Dominion Resources, Quaker Oats, Indresco, and Forbes, have found them highly effective in reducing costs, despite the fact that they face a bias in the present tax code.

In the following roundtable, held in partnership with Deloitte & Touche LLP, CE gathered CEOs of both providers and users to discuss cost and quality trends that will affect employers. Will costs continue to decline? As buyers exert more power over providers and government defers more to market competition, uncontrollable costs should be a thing of the past (the Heckler effect notwithstanding). The challenge will be to measure efficiencies and quality of care in ways that employer-buyers of health care can use. Beyond hospital utilization rates and inpatient care days, the industry is at the nascent stage of developing metrics that can help employers buy higher-quality care at lower cost.

- J.P. Donlon

AN “UNFULFILLED PROMISE”?

Robert A. Go (Deloitte & Touche LLP): Many people, including policy-makers, say managed care is the solution to the high cost of health care. Others argue it is only part of the solution. Let’s look at the facts.

There has been a slowdown in healthcare inflation. As recently as 1988 or ‘89, increases in HMO premiums were between 15 percent and 17 percent. This year, the average is near 0 percent. Yet the inflation rate for health care since 1960 has remained fairly consistently between 50 and 100 percent higher than the overall U.S. inflation rate for GDP (see chart). This year, GDP was rising at approximately 2 percent or 3 percent, and health care was increasing at approximately 4 or 5 percent.

So what’s going on? The actual promise of managed care - the creation of new ways of managing patients - is still largely unfulfilled. While managed care has created financial incentives and some cost containment, actually managing care - developing clinical protocols and so forth - is just beginning.

Marc Richmond, MD, MMM, didn’t exactly plan to move into medical management; it happened to him gradually.

Frustrated with the early forms of managed care that emerged in the early 1990s, Richmond–then a full-time family physician in Irvine, Calif.–wanted a better understanding of the business of medicine.

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“I had been reading medical management literature for a little while, and in 1993 I received a mailer from the University of California at Irvine announcing a weekend certificate program for health care executives,” Richmond recalls
He wondered how he could ever manage to juggle his clinical work with weekend studies, thinking he’d be exhausted. Nevertheless, he decided to check out the program.

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“There were about 20 people in the class from various occupations–the CEO of an ambulance company, a lawyer who specialized in health care, an architect who did health care design, a few physicians and nurses,” he says.

And while the schedule was demanding, “after the first several classes, it became very evident to me that these sessions recharged my batteries. The different venue for thinking, interacting with different people and getting a different perspective about health care was really stimulating.”

The classes, mainly introductory courses on medical management, energized Richmond. “When I was sitting in these classes, I would think, ‘Oh, the hospital board would want to know that. I wish somebody from the board of directors was here.’”
Soon, he took the initiative and began making presentations about what he was learning in class to the board of his hospital.

“I had become friendly with the hospital’s CEO who truly valued what I was doing,” Richmond says. “So one day he asked me if I would be interested in being a half-time physician director of integrated health services for the hospital. That was my first real management opportunity.”

Intrigued by the offer, Richmond took the job.

“I was the clinical liaison between the hospital administrative team, the local IPA and the medical community. I was working with the hospital to evaluate opportunities to merge or buy practices, identify service gaps, identify areas for quality improvement and assess activities that the hospital might want to get involved in.”

After completing the UC Irvine course, Richmond continued his management studies with ACPE courses and a Leadership for Physician Executives program at Harvard University. His hospital footed the bill for his studies. Richmond paid for his travel and lodging.

Out of the blue, in 1997, a recruiter called and offered Richmond a job as the chief medical officer for an emerging health delivery system in Little Rock, Arkansas. “The timing was terrible because our youngest child had just started high school. My wife and I talked about it quite a bit and ultimately decided it was one of those opportunities for a full-time management job that probably wouldn’t present itself again,” Richmond says. “Everything was right except the fact that it was in Little Rock and I was in Irvine. We agonized for a while, but ultimately I took it.”

Richmond helped form a consortium of five entities to bring managed care to the area, a developing network of about 3,000 doctors and roughly 40 hospitals throughout Arkansas and some nearby states.

In Little Rock from 1997 until 1999, Richmond continued his education by enrolling in the Masters in Medical Management program at Tulane University. “So I was commuting from Little Rock to New Orleans every three months for a week at a time,” Richmond recalls. “But the courses helped me do the management job, and the management experience helped me in the courses.”

For example, “One of the things that we had to do in the MMM was to write a business plan. I used the company that I was working for as the model for doing that. And once I did the plan, I was able to present it back to the executive director of the company, where it was well received.”

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Richmond earned his MMM in 1998 and soon received another offer from a recruiter, this time for a job back in Northern California as CEO and executive director for Napa Valley Physicians, a group of 150 doctors and 2 hospitals.

“My wife said, ‘I don’t know about you, but I’m moving back to California,’” so Richmond took the job.

One of his duties was dealing with insurance companies–PacifiCare, Healthnet, Blue Shield, and others–and that eventually led to another job opportunity. “One of PacifiCare’s medical directors mentioned that a position would be coming available as their regional medical director for the San Francisco Bay area and the Napa Valley position was the most difficult job that I’d ever had, and appeared to be in increasing financial difficulty. So, at the end of a year I accepted the job at PacifiCare in San Francisco. Eventually, another opportunity arose within PacifiCare in Southern California, and I was able to move my family back home.”

Michael Lumpkin, PhD, specializes in studying the impact of stress on brain hormone systems. “I actually started off studying viral stressors such as HIV/AIDS, but it turns out that all stress, whether it’s viral or physical or psychological stress, does pretty much the same thing,” he says.

Now, as Professor and Chair of the Department of Physiology and Biophysics at Georgetown University School of Medicine, he is teaching a generation of medical students to use mind-body methods to limit their own stress, and also to help their patients.

Lumpkin specializes in the hypothalamus. This part of the brain makes master hormones that regulate pituitary gland hormones, and they in turn circulate to other glands and organs and tell them how to function.
“When we’re stressed, those systems are activated, allowing us to mount defenses that contribute to our survival,” he explains. While the body systems that respond to stress are helpful in a short term emergency, they create new problems if they keep going indefinitely. “During chronic stress, these stress hormones elevate your blood sugar (making you more susceptible to diabetes), retain water (making you susceptible to hypertension), and reduce the effectiveness of your immune system, making you more vulnerable to infection,” Lumpkin says.
Because he was professionally interested in the impact of stress on brain hormones, Lumpkin wanted to learn more about mindbody medicine. In 2001 he took the professional training program at the Center for Mind Body Medicine in Washington, DC. In a small group, with a facilitator, he learned to be more aware of his emotions. “I’d never had any type of psychotherapy so the whole experience was somewhat foreign to me,” he recalls. Once participants in the training program became more aware of key emotional issues, they learned coping and stress reduction skills such as biofeedback, meditation, guided imagery, and breath control.

There are many different mind-body methods. Students may learn to keep their attention on the flow of breath, or picture themselves at the seashore, or visualize small dragons eating up cancer cells. Those seem to be different methods, but physiologically, Lumpkin says, they all tap into the same basic mechanisms.

“As you reduce the rate of respiration, you change the ratio of oxygen to carbon dioxide in the blood, bringing in more oxygen, which has a favorable effect on your brain. Certain nerves send information from your lungs to your brain, so when you breathe more deeply, that has a calming effect on stress centers in the hypothalamus. Or when you relax and meditate, that shuts down the activity of the sympathetic nerves, and allows your immune cells to perform their functions more efficiently.” In all these different mind body methods, Lumpkin says, you use your conscious brain (your cerebral cortex) to quiet the emotional centers (in the amygdala and hippocampus). When you enhance positive emotions, that reduces stress hormone activity in your hypothalamus.

Teaching Medical Students Mind Body Methods

Once he’d experienced mind body training himself, Lumpkin wanted to share it with his students. He introduced lectures on relaxation methods, biofeedback, and stress management into the physiology and endocrinology courses he teaches. In addition, some first year medical students at Georgetown now take a course in “Mind Body Medicine: an Experiential and Didactic Introduction,” taught by several different faculty members. They meet in small groups to study and practice mind body methods including relaxation skills, meditation, nutrition and physical exercise. Eventually this course will be required for all first-year Georgetown medical students (and will be taught by 24 faculty members).

You can measure stress hormone levels by taking saliva samples. The Georgetown physiology department now has a research study underway, looking at students’ stress hormone levels before and after they learn mind-body skills. “We’ll follow them for several months afterwards to see how well they manage stress, compared to the other students who aren’t taking mind-body training,” Lumpkin says.

Being a physician is stressful. Some MDs develop depression, or become alcoholics or drug addicts. They have a higher suicide rate than the general population. “Society invests a great deal of money in training physicians, but it hasn’t given them coping skills,” Lumpkin says. “Medical students don’t receive any instruction on how to manage their own stress.” He hopes the mind-body training Georgetown medical students now receive will help them avoid depression, stress related hypertension, and other health problems. In addition, once they learn how to use these methods for self care, they’ll be more likely to share them with their patients, or refer patients to mind body classes.

The Supreme Court of Iowa held that a workers’ compensation claimant could recover lost wages incurred by his spouse while transporting him to and from medical treatment.

Here, Sands suffered several on-the-job injuries while working for various seed companies. During treatment for his injuries, his wife drove him to some of his doctors’ appointments and attended some appointments to learn how to assist in his care. After a hearing on Sands’s petition for workers’ compensation benefits, the deputy commissioner ruled that he could recover as medical expenses die wages his wife lost as a result of driving him to and from the doctors’ appointments. The commissioner reversed, denying the request for reimbursement of lost wages, and a trial court affirmed.
Reversing, the state high court noted that Iowa Code § 85.27, which addresses an employer’s obligation to provide for reasonable medical services, states that the employer “shall allow reasonably necessary transportation expenses incurred for such services.” Noting that the issue was one of first impression for the jurisdiction, the court cited Florida case law interpreting a similar statute providing that a claimant is entitled to reimbursement of the “reasonable actual cost of transportation.” There, the court held that lost wages are reimbursable provided the claimant can prove that the manner of travel was the most reasonable and economical under the circumstances and the amount was reasonable in terms of the quality

Even in the United States, some aspects of life are too precious, intimate or corruptible to entrust to the market. We prohibit selling kidneys and buying wives, judges, and children.

How far should such prohibitions extend? In recent years entrepreneurs and their friends in government have privatized many publicly-funded services previously provided by government or nonprofit agencies–including interrogating Iraqi prisoners. Even in liberal Cambridge, our school superintendent proposes enlisting a for-profit firm to set up a new “public” high school.
Health care epitomizes this trend. Tax dollars account for 60 percent of U.S. health spending (counting as government spending not just Medicare, Medicaid, and Veterans Administration hospitals, but also the costs of health benefits for public workers and the tax subsidies for private coverage). (Indeed, on a per capita basis, public funding for health care in the United States exceeds total health spending in nations with national health insurance.) Yet investor-owned firms have come to dominate kidney dialysis, nursing homes, psychiatric hospitals, rehabilitation facilities, and HMOs. They have made significant inroads among acute care hospitals (they own about 13 percent of such facilities), as well as outpatient surgical centers, home care agencies, and even hospices.

Market theorists argue that the profit motive optimizes care and minimizes costs. But a growing body of evidence indicates that this dogma has no clothes.