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Distributing the Army’s Medical Department Officers

To meet the needs of a transforming Army, the authors believe that the Army Medical Command’s Officer Distribution Plan process must evolve to include human resources assets of the other services and the civilian workforce.

The Army is undergoing a dynamic process of transformation while it simultaneously supports the Global War on Terrorism. The military healthcare system (MHS) and the Army’s component of that system, the Army Medical Command (MEDCOM), are not exempt from the changes associated with this massive transformation. Managing critical human resources processes while participating in both a global armed conflict and a major transformation is a daunting task. Corporate human resource strategy, including the management of scarce human resource assets, is a complex endeavor in the best of times. This article will discuss how MEDCOM manages one of its most vital human resource assets—its officer corps—during this challenging time.

Our purpose is to describe the MEDCOM Officer Distribution Plan (ODP) and its importance to MEDCOM’s human resource strategy as both a decisionmaking tool and a predictive analysis tool. Our hope is to demystify what some have deemed a “smoke and mirrors” process and provide a glimpse of the future for both leaders and human resource managers. We will briefly discuss the history of the ODP and its development and maturation over the years, the current ODP process, and some future perspectives.

Managing the Army’s Medical Officers

The Army’s medical enterprise is a complex and highly diverse organization, consisting of 6 separate officer corps (career management branches) and more than 90 areas of concentration (AOCs). These 6 corps currently have more than 13,900 assigned officers. Managing the annual distribution of these medical professionals is both challenging and time-consuming, but it is also of vital importance.

The MEDCOM ODP is a synchronized and dynamic process that “commits” to the distribution of human resource overages and shortages approximately 15 to 18 months before they take effect. The annual MEDCOM ODP ensures that senior medical leaders have the opportunity to analyze and approve the distribution of vital healthcare officers. The final approval authority for each fiscal year’s ODP is the Surgeon General of the Army, who also is the Commanding General of MEDCOM.

Historical Evolution of MEDCOM’s ODP

The Army’s overall ODP process began in 1947 in an effort to equitably distribute the Regular Army officers remaining on active duty after the post-World War II drawdown. MEDCOM’s ODP process began in the mid-1970s, when the end of the draft-deferred medical residency programs after the Vietnam War resulted in an acute shortage of physicians in the Army. By the late 1970s, the MEDCOM ODP process was similar to the Army Competitive Category ODP system. However, MEDCOM had little in the way of a corporate distribution strategy, little involvement by the most senior MEDCOM leaders, no system for validating personnel requirements, and no link between the distribution shortage and the need for increased funding to acquire personnel with the required capabilities from the civilian market. This system remained virtually unchanged through the 1980s and into the 1990s.

In the mid- to late-1990s, MEDCOM began formulating its ODP during an annual 3-day conference held in the national capital region. Attendees included career management officers from the Total Army Personnel Command (now called the Army Human Resources Command-Alexandria [AHRC–A]; AOC-specific consultants to the Surgeon General; regional medical command (RMC) chiefs of administration, clinical services, and nursing; and human resources subject-matter experts from the Army’s Office of The Surgeon General (OTSG) and MEDCOM headquarters. The conference was strictly limited to the discussion of Medical Corps (physician) officer distribution. The other five corps of MEDCOM—Dental, Medical Service, Medical Specialist, Army Nurse, and Veterinary Corps—were rarely discussed and thus not truly considered in the greater scheme of officer distribution.

The ODP process was very simple. AHRC–A initially distributed MEDCOM officers by unit and specialty based on the authorized strength of each specialty and the available distributable inventory of officers in each specialty. Career managers at AHRC–A used the Personnel Manning Authorization Document (PMAD) as the authoritative space requirements document.

The PMAD is a human resources (Army G–1) tool that is derived from two separate operations (Army G–3) files—the Master Force (MFORCE) list and The Army Authorization Documents System (TAADS). The G–3 Force File, reflecting documented and programmed force structure positions for each unit in the Army, produces the MFORCE. TAADS is a Headquarters, Department of the Army (HQDA), automated system that contains all unit authorization documents, maintains quantitative and qualitative human resources and equipment data for individual units and the entire Army force structure, standardizes authorization documents for similar parent units, and interfaces with other HQDA automated systems. In creating the PMAD, personnel system staff officers at Army G–1 overlay the MFORCE and TAADS to resolve differences. They then input the results into the Correctable Automated Unit Database (CAUDB). The Army G–1 staffers load senior Army leader decisions at the specialty level of detail into CAUDB. When combined in CAUDB, the output from the MFORCE and TAADS overlay and the senior leaders’ decisions result in the PMAD.

The fundamental goal of the MEDCOM ODP has always been to provide support to the warfighter. Historically, units in the deployable force were allocated officers to their respective levels of authorization. Essentially, MEDCOM served as the force provider of medical officers to non-MEDCOM units. What actually happened was the distribution of shortages—MEDCOM determined which Army medical treatment facilities would have a deficit due to a lack of distributable inventory.

At the annual ODP conference, the AOC consultants and RMC representatives discussed which MEDCOM medical treatment facilities were best able to absorb a shortage of any given specialty. If contentious issues arose among the RMCs, the Deputy Surgeon General arbitrated and made a final recommendation to the Surgeon General. In most cases, few shortages resulted from the assigned strength of the Army during that time. So the ODP conference was essentially an opportunity for the AOC consultants to share the state of their specialties and for senior medical leaders to discuss specific assignments for a select group of officers. Business metrics to guide decisionmaking and a controlled process for RMCs to submit formal disagreements with AHRC–A’s proposed MEDCOM officer distribution were lacking. The disjointed nature and stovepiped approach left many senior leaders with the sense that the MEDCOM needed an ODP process that was more inclusive and synergistic.

Changes in 2002

Over time, senior MEDCOM leaders and medical treatment facility commanders expressed the desire to gain a more holistic view of the ODP process by considering possible sources of medical personnel that might be able to supplement MEDCOM’s organic capabilities. Areas for consideration included the Army’s ability to hire civilian physicians from other Federal agencies; the availability of civilian contract physicians in a particular area; the ability of the TRICARE network (the Department of Defense’s version of a health maintenance organization) to absorb the Army’s medical workload if the local Army medical treatment facility was unable to handle it; the availability of Air Force and Navy physicians assigned to nearby sister service medical treatment facilities; and the expanded capabilities created by cooperation among assigned physicians, physician extenders (such as physician assistants and nurse practitioners), and associated support staff (such as radiologists, laboratory technicians, pharmacists, and nurses).

Three significant improvements emerged to dramatically change the MEDCOM ODP process in 2001 and 2002: the introduction of business-related metrics, the creation of an automated ODP system, and the creation of multispecialty, multibranch “team packages.” Not only was it apparent that an automated information technology solution was required, but ODP participants also realized that a more structured administrative process was needed to ensure an equitable distribution of MEDCOM officers.

The OTSG and MEDCOM human resources community quickly realized that an automated method was needed to capture data at a level sufficiently detailed to meet the requirements of the Army’s senior medical leaders. The Medical Operational Data System (MODS), a mainframe computer-based information technology system developed in the 1980s to manage physician special pay contracts, was the system chosen for developing an ODP support module. The MODS was transformed from a simple database, in which ODP and assignments data were stored in a retrievable form, to a web-based system that contains interactive decision-support tools specifically designed to assist in the ODP decision process.

Unlike the process of the late 1990s, the 2002 ODP process began months before the ODP conference. In June 2002, the Decision Support Center, a data analysis cell within the OTSG staff, produced data on business variables to help measure the cost effectiveness and workload production at the physician level of detail at each Army medical treatment facility. These business variables included such metrics as population served, average number of available full-time-equivalent (FTE) personnel by work center, population per average available FTE, productivity measures, purchased care workload by specialty, purchased care amount paid by provider specialty, benchmark replacement cost (the mean annual civilian compensation cost by specialty for the medical treatment facility), and replacement availability.

The Decision Support Center divided the business variables into two categories: relative value units, which are associated with outpatient care, and relative weighted products, which are associated with inpatient care. These data became invaluable as benchmarks for comparing one medical treatment facility’s medical productivity to another’s. However, a noted constraint was the business variables’ focus on physicians, to the exclusion of other medical career branches. Taking that constraint into consideration, the ODP conference participants nevertheless relied on the business variables as decision-support tools.

Working collaboratively and leveraging the MODS database, AHRC–A, OTSG, and MEDCOM developed an Internet-based view of the ODP process. The initial document, the ODP “strawman,” displayed the previous year’s ODP at the medical treatment facility- and specialty-level of detail for each AOC—not just for the Medical Corps but for all medical career branches. The strawman compared previous and proposed ODPs to authorizations. It aggregated the ODP at the RMC and MEDCOM levels. This tool allowed senior medical leaders to ascertain the overall MEDCOM personnel picture in a single, simple snapshot view. Arguably, the highest value derived from the strawman was the common operating picture it afforded to all ODP participants.

In previous ODP conferences, participants noted that decisions influencing physician distribution also affected other medical specialties, such as nurses, and other clinical specialties, such as pharmacists and laboratory technicians. So the Deputy Surgeon General directed OTSG and MEDCOM, in conjunction with the AOC consultants, to produce certain clinical staffing teams. An example of a clinical staffing team is the orthopedic team, which consists of orthopedic surgeons and physiatrists [specialists in physical medicine] from the Medical Corps; physical therapists, occupational therapists, and orthopedic physician’s assistants from the Medical Specialist Corps; and podiatrists from the Medical Service Corps.

Other teams are anesthesia, aviation medicine, critical care, pathology and laboratory, obstetrics-gynecology, optometry and ophthalmology, emergency medicine, preventive medicine, primary care, and psychiatry and mental health. These teams allowed senior leaders to substitute for a shortage specialty. For example, in the anesthesia team, if there was a deficit of anesthesiologists (Medical Corps), senior leaders may have decided to substitute a certified registered nurse anesthetist (Nurse Corps). Often, AHRC–A career managers made these substitution recommendations to the AOC consultants as they produced the ODP strawman.

Two months before the annual ODP conference (normally held in early December), career managers at AHRC–A entered data into the ODP strawman. These data were aggregated and then displayed in MODS for medical treatment facility clinical leaders and human resources managers to analyze and make business-related decisions. Each medical treatment facility had approximately 2 weeks to conduct its business case analysis and determine its next course of action. One option was for the medical treatment facility to accept the strawman as written and then expect distribution at the proposed level of fill during the next fiscal year’s assignment cycle. The other option was for the medical treatment facility to submit a “reclama,” or a formal disagreement with the proposed distribution. In order to submit a reclama, the medical treatment facility was required to submit a business case analysis to justify their disagreement.

The RMC human resources chiefs aggregated the reclamas at the RMC level and, after review by the RMC commanders, forwarded them to MEDCOM for the ODP conference. In the last few weeks leading up to the ODP conference, career managers at AHRC–A again scrutinized the available distributable inventory to see if they could support a medical treatment facility’s reclama. AHRC–A might be able to redistribute inventory by moving an allocation from one medical treatment facility to another based on the latter facility’s better business case. If this occurred, the losing facility could argue against its loss at the ODP conference. At the conference, each AOC consultant presented the status of his specialty, including any problems (such as shortage of distributable inventory or recruiting and retention issues).

Based on the business variable data, the business case analyses presented by the medical treatment facilities in support of their reclamas, and the input from the AOC consultants, the RMC commanding generals adjudicated the reclamas. The group determined which facilities would gain or lose distribution allocations. If the group was unable to reach agreement, the Deputy Surgeon General would make the final decision. Approximately 1 month after the conference, the Surgeon General approved the ODP and AHRC–A released the MODS-based results to the field.

Impact of War and Transformation

This process sufficed until the Army became decisively engaged in the Global War on Terrorism and Army Transformation. These two signal events changed the face of medical human resources management and required MEDCOM to again rethink its approach to officer distribution. Rapidly changing events have caused AHRC–A to quickly move officers from nondeploying units and assign them to the deploying force. Changes in Army structure resulting from transformation also have caused human resources authorizations to shift from one unit to another, often very quickly. This has made managing the MEDCOM ODP particularly challenging.

In 2006, the MEDCOM ODP used a more comprehensive set of business variables, including variables for inpatient nursing and nonphysician providers. The ODP conferees also considered the impact of base realignment and closure recommendations on medical treatment facilities and the installations they supported. For example, if an installation was slated to receive a 5,000-Soldier brigade combat team, the ODP conferees were required to consider the associated rise in healthcare requirements—and not only for the Soldiers themselves but also for their associated family members.

The 2006 ODP conference also saw the addition of representatives from the Navy and Air Force Surgeon General offices. The decision to invite attendees from the sister services had two rationales. The first was to ascertain the availability of clinical support in multimarket areas. For example, Wilford Hall Air Force Medical Center and Brooke Army Medical Center are both located in San Antonio, Texas. If the Army medical center experienced a decrease in distributable inventory, perhaps the Air Force facility would be able to pick up the clinical workload. Having a member from the other services’ surgeon general offices in attendance made this coordination infinitely easier and timelier. The second rationale was to help the other services to better understand the Army’s process, with an eye on future joint possibilities.

One aspect of the MEDCOM ODP revolves around fiscal resourcing for manpower support. Currently, the ODP process allows the MEDCOM Resource Management Directorate to increase budgets (“plus ups”) when the projected distribution of physicians does not meet the previous year’s distribution or the projected distribution must be changed to reduce the number of physicians at a specific medical treatment facility. The basic premise is that the MEDCOM enterprise must support the local medical treatment facility’s healthcare mission, either by providing a uniformed healthcare provider or by providing the financial resources to contract for that specialty or purchase the service from the local economy. One shortcoming in current practice is the focus on budget plus-ups only for physician specialties. Several senior MEDCOM leaders have recognized that the enterprise must address this concern by including all medical career branches in budget plus-up considerations.

The 2006 ODP conference demonstrated that attendees made less use of business variable data than in previous years. However, this revelation was not bad news. It reflected the fact that, even though the data were more readily available because of improvements in technology, senior leaders made decisions based on clinical needs and requirements in support of the Global War on Terrorism rather than relying strictly on business variable metrics. When queried, the leaders confirmed that medical treatment facility commanders and senior staff were making better use of business variables at the local level before deciding to submit reclamas to their higher headquarters. This development fulfills the intent behind introducing the use of business variables.

The Future of the MEDCOM ODP

Having seen past initiatives become reality, the human resources community intends to improve the ODP process and product each year. In the short term, we will make routine improvements in the overall human capital distribution process covering data quality, agency coordination, business variable development, the reclama process, inclusion of the other services, and inclusion of civilian FTEs into the ODP process. This list is not all-inclusive, but it demonstrates the complexity of the concept.

We believe the ODP process will evolve into more of a joint process that we will dub the “joint medical human capital strategy” (J–MHCS), which will comprehensively incorporate the personnel of our sister services and our civilian workforce. This strategy will likely be necessary both from an inventory and a financial standpoint. The J–MHCS could potentially serve as the MHS staffing tool for many, if not all, Department of Defense military and civilian medical specialties. For example, as we staff medical treatment facilities within multiservice markets, a more collaborative exchange among the services on how we distribute our medical shortages would reduce duplication of resources and allow for duplicated resources to be placed somewhere else. In terms of applying the J–MHCS to civilian distribution, we have in recent years, through the current ODP process, accounted for civilian physician and nurse FTEs, but only after the fact. We intend to incorporate them up front.

As good as the current ODP process has become, it is still much too rigid and cumbersome. As an annual process, it is not as flexible as it could be. Even after the staff has finalized the ODP and the Surgeon General has approved the distribution of personnel, we have seen that requests to change the ODP begin immediately (albeit at a minimal number). We deal with the requested distribution changes on a case-by-case basis. However, the process has no structure.

So what changes might help to make the future MEDCOM ODP process more flexible? First, we likely will need to adjust our timeline so that we conduct a “midyear” review of the future 15- to 18-month distribution contract the leaders approved the previous December. During the midyear review, the senior MEDCOM leaders will have an opportunity to adjust both current J–MHCS needs and the just-approved J–MHCS (against which AHRC–A will begin making assignments 15 to 18 months in the future). The tools for those personnel working on the J–MHCS will include a current manning document (PMAD or the Updated Authorization Document), updated information on the specialty inventory, projected losses, input on civilian specialties, and input from the other services.

Second, the future J–MHCS process must have a better means of tying funding to distributed human capital. In other words, our MHS enterprise leaders must ensure that adequate funding is fairly distributed to each organization based on documented productivity and other metrics. Similarly, all funding allocation and reallocation processes and procedures associated with the J–MHCS must be flexible and responsive.

Third, we clearly must have a mature J–MHCS process that incorporates our civilian workforce and our sister services’ military and civilian workforces into the future distribution equation. The sharing and systematic accounting of these human capital assets must be implemented. As an initial step, MEDCOM will need to develop an enterprise civilian human capital strategy that enables us to recruit and place our civilian personnel where we truly need them. In other words, we must better tie the civilian workforce to our military workforce needs and shortfalls. We also will need to develop a “mobile” civilian workforce that can be integrated and “plugged” into our facilities to supplement our military workforce.

With forethought and creativity, we are confident that we can design a flexible and synergistic joint medical human capital strategy that will effectively and efficiently distribute our vital medical human capital assets. The times ahead will be fraught with many challenges for senior medical leaders and medical human resources managers, but we believe the Army medical enterprise will rise to the occasion.

The annual MEDCOM ODP distribution plan is a dynamic, synergistic process that has matured over the years. It helps to provide predictive analysis and indepth synchronization to our human resource management system and serves as a foundation for decisions that will affect military healthcare into future years. The process itself results in the assignment of officers at the tactical levels of Army medicine (field medical units and local medical treatment facilities). However, the impact of the process is strategic by its very nature. We believe that some form of the MEDCOM ODP process will migrate into a joint human resources management process that will be better linked to our sister services’ support to Army organizations. Similarly, we see ODP as including the Army’s civilian healthcare staff in a more relevant and more predictable way.

The Army has made many changes in the ODP process, and we realize that further improvements are both possible and needed. The very utilitarian nature of the MEDCOM ODP process allows it to change as requirements change. Our endeavor is to make the process as adaptive and flexible as possible while maintaining its usefulness.

It is an exciting and challenging time for human resources management within MEDCOM and the Army Medical Department. The ODP is a great tool that must be understood and then executed by all of our leaders. We must be willing to push forward with new ideas, policies, and practices to meet the daunting personnel challenges that lie ahead.

Colonel Larry S. Bolton is the Director of Human Resources in the Office of The Surgeon General and the Assistant Chief of Staff for Human Resources of the Army Medical Command. He holds a B.S. degree in health and safety studies from California State University at Sacramento, an M.A. degree in health services management from Webster University, and an M.S. degree in national resource strategy from of the Industrial College of the Armed Forces.

Lieutenant Colonel R.G. Dickinson is the Chief of the Force Management Division in the Office of The Surgeon General. He is a graduate of the Command and General Staff Officers Course. He holds a doctoral degree in human resources and a master’s degree in education administration.

Major Vernon Wheeler is the Assistant Executive Officer for the Surgeon General in the Office of The Surgeon General. He has a B.A. degree in sociology from the University of Kansas and an M.A. degree in public administration from the University of Oklahoma. He is a graduate of the Army Medical Department Officer Basic and Advanced Courses and the Combined Arms and Services Staff School. Major Wheeler served as the MEDCOM ODP project officer for 2006.