Military vows extensive improvement in maternity care

By Tom Philpott

Maternity care has been a weak spot in military medicine.  Surveys show too many patients dissatisfied with continuity of care, scheduling of appointments, availability of ultrasound, limited pain management options, and even a lack childcare services or close-in parking for doctor visits.
Enhancements in all of these areas are on the way.
The Department of Defense Aug. 27 unveiled a new “family-centered care initiative” for expectant mothers. Dr. William Winkenwerder, assistant secretary of defense for health affairs, said it will deliver “a world-class standardized” obstetrics benefit across the military.
A few factors drive the initiative. One is the loss of authority, effective Dec. 28, for military hospitals to force maternity patients who use TRICARE Standard, the military fee-for-service insurance benefit, to seek care first from service hospitals if they live within 40 miles, the hospital’s “catchment area.”
Some active duty dependents could even decide to disenroll from TRICARE Prime, the managed care network, if dissatisfied with maternity care. That’s because, under an exception to law that Congress has declined to change, active duty family members are exempt from the usual TRICARE Standard cost shares when seeking maternity care.
The “loss of our discretionary power” to capture Standard patient is forcing military obstetric care to be more competitive, said Dr. David N. Tornberg, deputy assistant secretary for clinic and program policy.
Another factor behind the initiative, Tornberg said, is the need to evolve military medicine toward a family-centered approach to care delivery.
“If you look at the military health system, our No. 1 activity is maternal/infant care. Thirty percent of our admissions are maternity-related visits,” Tornberg said. “If you expand that to the outpatient pediatric services through adolescence, it composes 45 or 50 percent of the care we extend.”
Private sector health networks long have viewed quality maternity care as the way to win a family’s loyalty. Using a retail marketing term, Tornberg described maternity care as a “loss leader.” If a hospital makes new mothers happy, it wins their families for years to come.
So private sector networks use “many inducements to attract expectant mothers into their networks,” Tornberg said. “Well, we felt we had to compete also.”
Defense health officials and the three surgeons general, of the Army, Navy and Air Force, began a year ago to develop a strategy to upgrade and standardize maternity care. The resulting family-centered care concept means shifting focus, from what’s convenient for physicians or hospitals to what’s important to patients.
It emphasizes patient empowerment. Clinics will help women develop a “birth plan,” which will sort out type of delivery, anesthesia desired, if any, and even how involved other family members will be in the birth.
“What we wanted to establish was a uniformed service (and) uniformed expectations across our health system,” Tornberg said.
Women who begin treatment at one military facility and have to transfer during pregnancy to a new assignment should be assured of the same type and quality of care. Toward that end, the services are adopting uniform clinical practice guidelines for uncomplicated pregnancies and uniform treatment protocols for “problem-focused” visits.
The commitment to improved maternity care will require more spending by the services to upgrade obstetric facilities and staff. Precisely how much, Tornberg couldn’t say. The trend for all services will be up but the depth of improvements will vary by service and facility.
Navy and Marine Corps clinics have the lead in “cutting edge” maternity care, he said.

Tom Philpott can be contacted at Military Update, P.O. Box 231111, Centreville, Va. 20120-1111, or by e-mail at:
milupdate@aol.com