A former Surgeon General of the Navy, Vice Adm. Harold Koenig, M.D., is a senior partner with the health care consulting firm Martin, Blanck & Associates, Inc., and chief medical officer for Awarepoint, a manufacturer of real-time location systems in the health care setting. He is currently chairman of the board of the Veteran’s Village of San Diego, which provides shelter and rehabilitation services for homeless veterans, and is a member of the board of directors of the Rostropovich-Vishnevskaya Foundation that provides health services to children in the former Soviet States and Palestine. Koenig also serves on the Scientific Steering and Advisory Committee of the Millennium Cohort Study of the DoD Center for Deployment Health Research, and is a corporate board member in the medical device sector.

The Year in Veterans Affairs and Military Medicine: In your writings and speeches, you’ve identified an “operational culture” that distinguishes military medicine.

Vice Adm. Harold Koenig, M.D.: There is a much stronger camaraderie between people in the military health care system than in the private or nonmilitary health care system, a sense of teamwork and having to help each other in their various roles. Many of my friends and I look at our time in the military as our greatest contribution, the best thing we ever did during our health care careers. There’s something distinctive about serving the country and serving in uniform and taking care of the people who are defending the country and doing the wishes of the administration. There’s something about that that pulls people together. You sometimes work under some rather arduous conditions.

You mean in the field?

Yes, or at sea.

The armed forces do a lot of humanitarian missions. Right now, one of the Navy hospital ships is out on a humanitarian mission in the southern hemisphere. Something like that is constantly going on, if not a hospital ship, than some other ship, or the Army or Air Force is doing it in field hospitals or dispensaries in various parts of the world.

Those are really unique experiences where people go out and help folks who may have never seen a doctor before in their lives. They see a lot of strange and exotic diseases and conditions that they only read about in textbooks here in the United States.

They get to do definitive work for a lot of people. A lot of conditions that can be fixed permanently – there’s an awful lot of cleft lip and palate surgery done and ophthalmologic surgery for kids with crossed eyes, basic things like that. It makes a whole world of difference for people. So I think those opportunities combined make for a unique experience for health care professionals in the armed services.

It seems there is a renewed interest on the part of physicians, both military and civilian, in that kind of work.

When the hospital ships go out, there are many civilians who volunteer to go on those missions; that’s generally coordinated through Project Hope. There’s a certain minimum length of time they have to agree to go, usually at least two weeks. There’s usually more volunteers than can be accommodated on those missions – doctors and nurses, technicians, and so forth. It’s neat that people want to do that.

As for combat situations, I’m not really aware of any non-uniformed personnel being involved in Afghanistan or Iraq right now. Those people are, as far as I know, uniformed people. But I know there are reservists who volunteer to go, and go for extended periods of time. They’ll button up their practice, or turn it over to partners or colleagues, and take off and do those things. There are many people interested in doing this.

That’s a big change from the looming shortage of military physicians you identified about a decade ago.

There was a period in the early part of this decade, after 9/11, when the number of people signing up for the Health Profession Scholarship Program was less than the number of slots available. That became an issue of great concern for the armed forces, but it seems to have corrected now. There was a lot of effort put into recruiting, speaking to people starting college and medical school, people who were aiming at a medical career.

What do you think was behind the shortage?

I don’t know. I can’t put my finger on it. I think one problem we have nationally is that there are not many faculty in medical schools with military backgrounds now because we’ve shrunk the size of the military so greatly that there are not a lot of professors who have served. For instance, I started medical school in 1962. There were a lot of professors who had served in World War II or Korea. So they all had war stories to tell, stories about their military experience. Following that, we had Vietnam, and some of those guys came back and went into professorships. I think many of them had interesting medical experiences to relate. But then that cadre of people began to thin out.

Part of it, also, may have been the all-volunteer force. Before we had the all-volunteer force, when we had a draft, people knew they were going to probably have to go in. So they took the best deal they could get, and then that went away. So there were probably several factors contributing to the military doctor shortage. But the bottom line is we had the problem and it seems to have gotten better.

The all-volunteer force has been an incredible success for this country. I was in the service when the all-volunteer service started, and it was rough for the first several years. Then it started to get better. People adjusted to it. It’s been a wonderful success, but it’s also created some new problems.

You mean the costs of recruiting and retaining an all-volunteer force – especially health care and pension costs.

Yes. You’ve got this professional force now that’s served, and many of the people from the earliest years are now entering retirement. As they get older, they require more health care. They were promised these benefits, and now it’s time to deliver.

The cost of health care is going up [at] three times the rate of inflation, generally speaking. So the military faces the same cost escalations that the rest of the health care sector does. There are more people getting older with chronic conditions that need management, and there are things that we can do for them now that we couldn’t do in the past – but those things cost money.

Physician compensation is not going up in this country; if anything, it’s flattening out or coming down relative to many other professions. So it isn’t the cost of doctors’ salaries that are driving up costs. It’s technology, pharmaceuticals, and the cost of hospital care.

Why does hospital care cost so much today? Well, if you look at the people who are in our ICUs now, those people used to die. The people who are on our general wards, they’re the people who used to be in our ICUs. The people who used to be in our general wards are being managed as outpatients. We are able to do a lot more for a lot more people now than we were able to do even two or three decades ago. But it costs a lot of money to do that.

Is it more expensive for military personnel?

Not necessarily. But if you look at the life expectancy of military people, it’s equal or better than the average for the nation. That’s pretty phenomenal. People would think it would be shorter because of the exposures they have. It isn’t. Some of the early data from the Millennium Cohort Study is showing us that the health of the first cohort who enrolled a decade ago – over 50,000 people – the health of these people is as good or better than their peers who haven’t served in the military.

Why do you think that is? Is it the quality of military medical care?

In part it is, but I also think it’s the kind of people we get into the armed forces. People say, “Oh, the armed forces is a cross-section of American society.” It is not. It’s better. These are good people. They’re well educated, and their education continues in the armed forces. They’re taught things that a lot of people aren’t. When I was in the Navy, half the recruits coming into the Navy or the Marine Corps had never seen a dentist in their lives before they arrived in boot camp. And the first thing we did was look in their mouths. Then we taught them how to brush their teeth and made them do it. We looked in their mouth every year. They could not deploy, they could not go out on their ship if they had not seen the dentist in a year. If they had corrections that needed to be made to keep them in good dental health, they had to have it done before they could deploy. So when you start doing things like that, you make people healthier, because poor dental hygiene contributes to shorter life expectancy. There is a direct connection between poor dental hygiene and cardiovascular disease. So all those kinds of things have been imbued in our service members.

We are also more aware of the problems of alcohol and tobacco. In the past, there was hardly a promotion ceremony that was not accompanied by alcohol, and often in large quantities. That’s pretty much gone from the culture now. We used to practically give tobacco away to service members, and now it’s banned in virtually all indoor spaces, and it’s even banned on board ships, except outside, and the prices match those in the private sector.

So there are all these things we’ve done that have helped people live healthier and longer lives with a better quality of life. But when you do that, you’re going to have more medical expenses simply because they’re around longer.

Obviously, nobody thinks that the way to drive the costs of health care down is to start educating people less, or rationing care. But doubling costs every 10 years, as is happening in the Department of Defense, is not sustainable.

Absolutely it is not sustainable. I think a lot of the issues with cost escalation are rooted in the model we built, starting during World War II, for financing health care. During World War II, President Roosevelt imposed a wage-price freeze, and businesses could not increase salaries. But they could increase benefits. So the benefits they increased were health care and pensions. We got to the point where 65 percent of our population had health care that was paid for at least in part by their employer.

And when somebody else is paying the bill, utilization goes up. Estimates today are that about a third of health care is unnecessary. About a third of surgical procedures nationally are not necessary. They’re done because of patient preference. One procedure that is cited a lot is Cesarean section.

It seems the obvious answer for decreasing the likelihood of that one-third of unnecessary procedures is to shift some of their costs back to the patient. But it’s proven a political impossibility. Congress has been unable to raise the premium payments for TRICARE members since the program was established.

I was a deputy assistant secretary of defense from 1990 to 1994, when the TRICARE benefit was being developed.

In the original design, we put a cost escalator into the premium. We proposed that every year, the premium ought to go up along with the COLA. There were people who objected to that. So the decision was made – not at our level but in congress – that the premium escalator wasn’t going to be put in there then. The fight would be too hard and they wanted to get the TRICARE benefit in place. So here we are, 15 or 16 years later, and there’s been no change in the premium. So people look at the $230/$460/year premium as an entitlement.

Now that 15 or 16 years have gone by, maybe we should look at that again and ask if that was the right thing to do. I think people in the end are going to say, “No, it’s not, and we need to change it.” Now do you change the whole thing all at once? No, you can’t. But you’ve got to start some place and build it in. The Servicemembers’ Group Life Insurance premiums change, and so does the amount of coverage.

You think the amount of TRICARE coverage per dollar is increasing? Benefits seem to be constantly added in.

Benefits keep getting added, and once added they never get taken away. Something added this year is going to be covered forever. But the premium has remained unchanged.

Here’s an example: When Pfizer was getting ready to release Viagra, I was a deputy assistant secretary of defense. The question was asked: “Should DoD cover this and make it part of the benefit?” The answer out of the assistant secretary’s mouth was, “Hell, no.” Well, let me tell you, the echo of his, “Hell, no,” hadn’t even resounded back down the hall before the response came back: “Yes, you are.”

So then we had to consider the next question: How many of these little blue pills are we going to give to a patient each month? They weren’t cheap, about $10 each. We decided we’d give them 10 a month. Well, 10 might be too many for one guy and not enough for another. But now it’s all covered. You see the same debate occurring right now on a national level about birth control pills for women. There’s a big push to make it free for everyone. In the military, it is.

I’ll bet I could walk through military retirees’ homes – if they would let me – and look through their medicine cabinets, and in some places I would find hundreds of Viagra tablets. This is what happens. You expand the benefit. You never contract the benefit, and it gets it more and more expensive, and people come to expect it as an entitlement.

You make the idea of lowering health care costs seem sort of hopeless.

It has been, to this point, but I think we’re coming to a point of national awareness now where people are beginning to understand we can’t keep this up. I think what will contribute to decreasing the rate of escalation of health care costs – note my choice of words there, “decrease the rate of escalation”; I don’t think we’re going to lower them – will be education. A lot of the expensive part of the benefit is about lifestyle choices – like Viagra. Lifestyle choices aren’t necessary for your well-being or for relief of pain – and they aren’t cheap.

By the way, Pfizer just got its patent for Viagra extended to 2019. A generic manufacturer wanted to release a generic equivalent, and was told no. There’s a lot of power in the big pharmaceutical companies. When you’re doing 80 percent of the world’s pharmaceutical research, somebody has to pay for it, and as Americans we’re the people who have to do that. It gets folded into our health care bill, but that’s part of the game. When you’re the guy on top, you’re expected to pay more. And we do.

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.