The Doctor Supply Problem

Expected shortages in health care professionals primarily physicians have been viewed by many as one of the most difficult problems associated with the all-volunteer concept. Though comprising a small fraction of total officer needs (about 13 percent), it has traditionally been among the most difficult problems confronting the services, even under draft conditions. At present, two-thirds of these medical officers serve because of the "doctor draft." Of the remaining third, about one-half are volunteers, while the other half are fulfilling obligations stemming from training sponsored by the Department of Defense (DOD).

With the end of conscription, the military services will have to rely on a combination of voluntary enlistments and, for several years, those still liable for duty under the draft-motivated Berry Plan. In that program, draft-liable doctors could register with the Department of Defense and negotiate for the service of their choice and their date of entry; an intern could defer his obligated service until completing specialty training (a period of five or more years).

Below are DOD estimates of shortages in the supply of military physicians for fiscal 1974-76, assuming that those remaining in the Berry Plan will be required to meet their obligations after the expiration of induction authority.

Based on these projections, the Department of Defense has proposed legislation to increase the special pay for medical officers with two years of service from $150 to $350 per month and to provide a retention bonus of up to $15,000 per year. The total costs of this proposal per fiscal year are estimated at $75 million for 1974, $95 million for 1975, $105 million for 1976, and $112 million for both 1977 and 1978.

The Department of Defense has also initiated several programs aimed toward using physicians more efficiently. These include using paraprofessional and clerical personnel to relieve doctors of timeconsuming nonprofessional details, and the testing of a tri-service military coordination concept. Partly as a result of these programs, the stated requirement for military physicians declined from 14,500 in fiscal 1972 to 11,300 in fiscal 1974.

There are several alternatives to the bonus proposal that merit examination:

Increasing the Supply of Military Physicians: The Scholarship Plan

The Armed Forces Health Profession Scholarship Program, passed by the 92nd Congress, allows up to 5,000 medical and dental scholar

3 In addition to regular military pay and allowances, qualified medical officers have been authorized additional monthly special pay; the amount depends on the number of years of medical service. Presently, a medical officer does not qualify for the maximum $350 per month until reaching 10 years of service. The proposed legislation would provide the maximum amount to all of those authorized with at least 2 years of service.

ships at any one time at civilian schools. These scholarships, which pay all educational costs plus $400 per month, are in exchange for obligated service on a one-for-one basis (one year of military duty for each year paid by the scholarship). Expansion of this program (in which over 40 percent of the scholarships have been filled in the first seven months) presents a possible option for increasing the future supply of physicians; however, evaluation of such a project would not be possible for several years.

Decreasing the Demand for Military Physicians: Civilianization The need for military physicians can be reduced by transferring some of the patient load to the civilian medical community or by substituting civilian doctors for military physicians in military medical facilities.

The first alternative would call for the wider use of the Civilian Health and Medical Programs of the Uniformed Services (CHAMPUS), a coinsurance program in which dependents and retired military personnel obtain health care in civilian facilities. Under current policy, retired personnel and their dependents are afforded care in military facilities on a "space available" basis. Where space is not available, these patients use the CHAMPUS program. Dependents of active duty personnel residing with their sponsors cannot use the program unless care is not otherwise at hand. Insisting that a larger fraction of nonuniformed personnel use the CHAMPUS program would substantially reduce the patient load on military facilities.

The legal requirement to provide medical care in military facilities extends only to uniformed personnel. As a matter of policy, however, the services feel obligated to provide medical care to nonuniformed personnel. In 1972, Assistant Secretary Richard Wilbur gave the following reasons: 1) it would be professionally unattractive for career physicians to see only relatively healthy young males; 2) in order to obtain recognition of military residency training programs from civilian accrediting bodies, a proper mix of patients is necessary; and 3) there is a moral obligation to retired personnel stemming from the implied guarantees for military medical care.*

Criticism of the wider use of CHAMPUS takes three forms. First, it is claimed that the shortage of physicians is universal; in many areas, particularly around military bases, adequate care is not available. CHAMPUS would thus not provide dependents with adequate care. Second, some have charged that the diversion of a greater share of the patient load to CHAMPUS would result in dramatically increased health care costs. Finally, it is argued that a reduction in the staffing level of military facilities, and possibly a reduction in the number of facilities, would decrease the surge capacity of military health services needed during periods of national emergency.

On the other hand, an alternative that replaces military physicians with civilians in military medical facilities overcomes these objections. It would not lead to a reduction in current health services; it would preserve surge capability; and it might also help to reduce total costs through increased productivity and lower overheads. Substitution on the scale required would probably call for contracting, on a geographic

"Statement of Hon. Richard S. Wilbur, Assistant Secretary of Defense for Health and Environment," in House Armed Services Committee No. 92-70, pp. 16285-86.

basis, with organized self-governing groups of doctors. According to the Gates Commission, such hospital-based group practice (for example, the Kaiser Plan) has proved an efficient form of medical organization in the civilian economy. Further advantages would include: (a) less duplication of facilities in areas where more than one service maintains facilities; (b) where military facilities are underutilized, provision of care for otherwise ineligible civilians; (c) less turnover among doctors and use of more female doctors; and (d) easier and less expensive hospital staffing because physians would not have the disadvantages associated with military service.5

How many medical billets could be "civilianized" and what would be the extent of the cost savings? Both aspects of the question need careful analysis. Career progression, assignment rotation, and mobilization surge potential would need to be considered in establishing minimum billets for military professionals. Also, to provide valid comparisons of military and civilian health care, uniform cost-accounting techniques need to be developed. Since the projected shortages of health professionals under current policies do not reach the critical stage for at least two years, sufficient time is available to examine each option more carefully.

Conclusions

How these three issues-possible shortages in critical skills, reserve forces, and health professionals are resolved is important for several reasons. First, the financial implications-$225 million in fiscal 1974 and growing to about $400 million by fiscal 1976-will further complicate the already serious manpower cost dilemma. Second, increased financial incentives, which should be used only as a last resort, could become a substitute for lower cost alternatives. Finally, how these initial shortages are resolved could set the pattern for the long-term approach to all-volunteer force problems in the future.

Some of these concerns might be mitigated by placing constraints on the broad authority requested by the administration in the proposed Uniformed Services Special Pay Act of 1973. Among the limitations that the Congress should consider are: 1) to enact the legislation for a one-year trial period only; 2) to establish a maximum dollar authority; 3) to restrict payments for specific skill categories; 4) to pay bonuses only for longer than normal enlistments, and 5) to require that the funds be reprogrammed from less productive incentives.

The proposed use of bonuses raises an even more fundamental issue: the need to evaluate the military compensation system. A complex patchwork of over two hundred elements of pay, allowances and fringe benefits, the current system is a legacy from an era with a strikingly different military establishment. The military pay structure is already so complex that military personnel understandably have difficulty in evaluating accurately the various compensation elements. Adding the additional elements included in the proposed Uniformed Services Special Pay Act would compound the problem.

5 The Report of the President's Commission on An All-Volunteer Armed Force (1970), pp. 91-92.

CHAPTER THREE

LONG-TERM PROSPECTS

Can this nation sustain an all-volunteer force? With a zero draft achieved this longer term question comes to the fore. Answers vary, depending partly on different estimates of how many people the services will need to attract and how many they can expect to attract. Moreover, different interpretations of what constitutes "acceptable" quality yield different assessments of success.

One common conclusion is that the future of the all-volunteer armed force is highly uncertain. For one thing, there is no precedent; no nation has ever attempted to maintain a force of close to three million volunteers (active and reserve). For another, it is extremely difficult to attempt any projections based on the current period of sharply changing political, social, and economic patterns-all of which have important implications for the structure and content of U.S. military forces. Such considerations led former Secretary of Defense Melvin Laird to conclude in his last appearance before the Congress ". that we are breaking new ground and that no one at this point in time can guarantee absolutely that the United States will be able to maintain an All-Volunteer Force for the indefinite future." 1

Future prospects are assessed in this chapter by comparing longterm estimates of the demand for, and supply of, volunteers. The discussion focuses on enlisted military manpower because it comprises the largest proportion of total military manpower and the greatest challenge to the success of the all-volunteer concept. The annual accession requirement for officers (other than health professionals) is less than 20,000 per year. With the services having a greater pay comparability with the private sector, the future supply of officers-both quantitatively and qualitatively is expected to be adequate to meet perceived needs, with the possible exception of limited critical skills. This exception and the health professional problem were discussed in Chapter Two.

The estimates to follow assume no changes in military and civilian compensation comparability or in existing service personnel management policies and practices. They also assume that there will be no change in the attitude of American youth toward military service

as a career.

With these assumptions in mind, there are two mitigating factors that facilitate the determination of long-term estimates. First, as volunteers replace draftees and draft-motivated enlistees over the next few years, the average duration of initial enlistments will tend to lengthen, thus reducing overall turnover and decreasing the average

1 "Final Report to the Congress of Secretary of Defense Melvin R. Laird, before the House Armed Services Committee," (January 8, 1973; processed), p. 68.

annual demand for new volunteers. At the same time, the male population group those aged 17 to 22-will be growing at a rate of about 2 percent per year through 1978, thus increasing the potential supply of volunteers.

The Demand for Volunteers

The effectiveness of U.S. military forces depends, in large measure, on the quantity and quality of available military personnel. A primary concern, already voiced with respect to the volunteer concept, is whether, in the absence of draft pressure, the military services will be able to attract indefinitely personnel of sufficient quality to man the for ces considered necessary to meet U.S. national security objectives without prohibitive cost.

How many volunteers will have to be recruited? The number of new entrants needed each year is one of the most critical variables in the volunteer problem, and at the same time, one of the most difficult to estimate. As a general rule, the fewer enlistees needed each year, the less their average cost for a given quality level or, conversely, the fewer enlistees needed, the higher their average quality will be for a given cost. The fewer people to be recruited, in fact, the easier it will be to attain and maintain—an all-volunteer armed force.

The number of new personnel needed each year depends on the difference between military manpower requirements (the jobs to be done) and the number of personnel available to fill those jobs.2 Manpower needs are derived from a set of interrelated decisions about foreign policy, national security strategy, military force structure, and manpower policies. Table 3-1 shows total active military manpower requirements requested for fiscal 1974 which, when compared with some recent years, suggests that a post-Vietnam equilibrium has been reached. There is informal evidence that the military manpower requested for fiscal 1974 represents the minimum considered necessary by the administration to support national security strategy for the next few years. On that basis, it is assumed that the fiscal 1974 distribution of military manpower requirements (about 2.2 million) will remain constant, with perhaps minor changes, until the end of the decade.

TABLE 3-1.-TOTAL ACTIVE FORCE MILITARY MANPOWER REQUIREMENTS, BY SERVICE, FISCAL YEARS 1971-74

Sources: 1971, "The Budget of the United States Government, Fiscal Year 1973." (1972), p. 84; 1972–74, "The Budget of the United States Government, Fiscal Year 1974" (1973). p. 79.

2 This is an oversimplification. In addition to the jobs to be done ("structure spaces") the military services are authorized additional "pipeline" billets to accommodate personnel in training, transient, patient, and prisoner status. These extra personnel ostensibly are used to keep units fully manned.