The Defense Department is taking a four-pronged approach to improve military hospitals and clinics following a drop in patient load that has caused providers' skills to deteriorate.

Assistant Secretary of Defense for Health Affairs Dr. Lester Martinez-Lopez said Tuesday that, with roughly 60% of Defense Department medical care now provided through the civilian Tricare^[1] network, the DoD is working to attract staff and bring back patients.

Deputy Defense Secretary Kathleen Hicks issued a memo last December directing the Defense Health Agency to bring at least 7% of patients back to military health facilities by 2026, largely by regaining trust and building a dependable, high-quality workforce.

Read Next: Military Jobs with High Deployment Pace, Blast Exposure Correlated with Higher Suicide Rates, Data Shows^[2]

During a webinar Tuesday hosted by the Association of the United States Army^[3], Martinez-Lopez said that effort is underway, beginning with an overall assessment of the force needed to provide direct medical care to more beneficiaries.

The evaluation of the requirements currently doesn't exist, according to Martinez-Lopez.

"We have no requirements for force generation in the Military Health System. And we have no requirements for what I call military essential billets, which is the guys in Japan ... the guys in [Fort] Irwin [California]. We're not hiring civilians there; I need to assign military people there ... so we're in the midst of doing the overall study to sort out what we have in hand," Martinez-Lopez said.

After completing that assessment and a related risk evaluation, the Defense Health Agency can move with step two, hiring civilians, attracting providers to DoD with incentives that would make pay and benefits comparable to those offered by the Department of Veterans Affairs^[4] and other federal agencies, Martinez-Lopez said.

To do that, the DoD must reduce the time it takes to onboard personnel -- currently, an average of 179 days between a job offer and the start of employment -- and ensure that there are military personnel in DoD hospitals and clinics to round out the staff, he said.

"If you need to be in operation in Poland, so be it. If you need to be in a ship in the Atlantic, so be it. But if otherwise, you're going to be taking care of our beneficiaries in the MTFs [military treatment facilities]," Martinez-Lopez said.

The Defense Department awarded a contract in May worth up to $43 billion to 11 health care companies to provide dental, nursing, physician and medical support to military treatment facilities in the U.S., Guam and Puerto Rico through 2034.

In a panel discussion in May shortly after the contract award, Martinez-Lopez said the agreements were needed because civilian providers remain the "steady force" within the military health system.

"The military guys are moving around every three years; these guys are holding the fortress," Martinez-Lopez said during a lunch event at the National Press Club on May 22.

By 2026, the DoD will begin the third step, heavily investing in what Martinez-Lopez called "critical MTFs" -- those with large populations of active-duty members, retirees and families -- to attract patients back to the system.

He believes that, as the department succeeds with the efforts, more will return, given the low-cost care and ease of access to services at military facilities -- in most cases, no or low copayments and a one-stop shop for primary care, specialty care and medications at zero cost to the patient.

The fourth leg of the transformation of the direct-care system, he said, will be technology.

The DoD has been slow to embrace user-friendly interfaces that allow patients to make appointments online, message providers or refill prescriptions. The department rolled out an app earlier this year called "My Military Health," similar to widely used civilian interfaces such as MyChart or HealthLife, at five military health facilities in Georgia, Florida, Virginia and Ohio, but such modern conveniences aren't available to all who get their health care at a military hospital or clinic.

Martinez-Lopez said the app, improved information technology and telemedicine should bolster the capabilities of military treatment facilities and entice patients.

"Patients call because they have a problem they want to fix. How do we provide that fix? Most patients don't care. All they care is [that] their problem is fixed. So, we can provide that through technology, we can provide it face-to-face, we can provide it through telemedicine. ... We're going to give the patient the option and make it attractive," Martinez-Lopez said.

The fiscal 2017 National Defense Authorization Act gave the Defense Department flexibility in reorganizing the military health system, which serves 9.6 million beneficiaries.

Initial reforms called for realigning staff, consolidating health facilities and shedding some 200,000 retiree and family member beneficiaries, as well as 12,800 military health billets in an effort to curb rising health care costs and streamline the uniformed medical corps so its members could focus on active-duty personnel.

At the time, the defense health budget was $48.8 billion, including personnel and construction costs.

The plan immediately received pushback by the services' top health officers, who said the reorganization was "extremely difficult" and affected care. But their concerns were dismissed largely as turf battles with the Defense Health Agency, the organization now responsible for managing the military health facilities once operated by the services that currently provides administrative, management, training and logistics services for the military health system.

With the level of care declining in military treatment facilities and costs ballooning -- the military health budget is now at $55.8 billion -- the decisions to shed patients and military providers have been abandoned, however.

Last November, the DoD Inspector General published a management advisory warning the Defense Health Agency that it needed to resolve issues within the system, recommending that the agency review its provider network and survey Tricare beneficiaries and providers to understand where the system may be shortchanging patients.

The DoD IG's office did not receive a response from Defense Health Agency Director Army Lt. Gen. Telita Crosland "by the time of publication, despite providing an extension of our original deadline for the director to respond," according to the report.

Martinez-Lopez said he is optimistic that the DoD can build a high-quality health care system that can also train clinicians for battlefield needs.

"It's a huge elephant, so we have to [take] one bite at a time, small, and then chew it and swallow it," he said.

Related: Tricare Patients Would See Lower Mental Health Care Costs Under Bill Introduced in Congress^[5]

Members of the military's combat specialties experienced higher suicide rates than other troops -- and the broader American public -- in the waning years of the War on Terror, according to numbers delivered by the Pentagon to Congress this month. The worst-hit jobs included career fields with high operational tempo and occupational exposure to explosions.

Between 2011 and 2021, the enlisted job groupings with the highest suicide rates were armored and amphibious vehicle crew members, infantry, combat engineers, explosive ordnance disposal and divers, combat operations control troops, and artillerymen assigned to both guns and rocket units, according to the data. All of those specialties saw suicide rates at least 50% higher than the general population during that period.

The numbers were contained in a report the Defense Department submitted to Congress comparing suicide rates across military career fields. The report, dated July 23 and delivered to lawmakers seven months after a congressional deadline, represents the military's first official by-job suicide data since a 2010 task force report^[1]. It was publicly released Wednesday.

Read Next: The Army Bet $11M on The Rock and UFL Ginning Up Enlistments. It May Have Actually Hurt Recruiting Efforts.^[2]

To calculate suicide rates for 2011 to 2022, Pentagon researchers combined data for military specialties based on a master list of career fields. Active-duty and reserve deaths were included, and the rates adjusted by sex and age in order to allow meaningful comparisons with the general U.S. population. For their comparisons to the broader civilian population, the report excluded 2022 military numbers as the authors didn't have access to broader general population suicide data for that year.

What Congress received was mostly a data dump, according to Katherine Kuzminski, a defense expert at the Center for a New American Security, or CNAS, think tank.

"[The authors of the report] didn't really provide any analysis or storytelling," she said.

But Kuzminski, who heads CNAS' Military, Veterans and Society program, said there was an obvious theme: Jobs where troops are deployed more frequently and face greater exposure to low-level blasts experienced higher suicide rates between 2011 and 2022.

Chart depicting the six occupational groupings with the highest suicide rate.

The data alone cannot prove that those factors are causing the increased suicides, she cautioned, noting that those fields may also have experienced higher rates of casualties.

In recent months, lawmakers have intensified their scrutiny of the Pentagon's suicide prevention efforts, questioning whether the military has adequately accounted for some suicide risk factors, such as occupational blast wave exposure and operational tempo.

Concern over the role of brain injuries in military suicide rates -- fueled in part by reports from Military.com^[3] and The New York Times^[4] -- led to hearings on Capitol Hill and a series of legislative proposals^[5] meant to address the issue. In May, lawmakers asked a government watchdog agency^[6] to investigate what Pentagon officials knew about brain injury risk, when they knew about it, and what they did to reduce the risk.

Similarly, a March 2024 Army Times^[7] investigation that discovered high recent suicide rates in the Army^[8]'s overworked armor community inspired Congress to double down on demands for Wednesday's suicide data. Although the Army quickly announced changes to its deployment^[9] model for tank units, the House Armed Services Committee directed the DoD to study its force structure in Europe, where the service's armor brigades regularly deploy due to a lack of permanently based armor units.

Sen. Angus King, I-Maine, said in a phone interview that the report "is not a panacea, but it gives [the Pentagon] a way to target resources and understand where the higher risks are." He added that the information will also help Congress provide critical oversight of military suicide prevention work.

"We can have all the studies in the world. We can have all the data. We can have recommendations," the senator said. "Implementation is as important as vision, and I want to see how this is going to be executed, and I'm going to keep on them to be sure it is executed properly."

The report falls short of the standard set by Congress in its 2023 defense policy bill. Lawmakers ordered the Pentagon to provide suicide data dating back to Sept. 11, 2001, broken out by year, specific job code, and duty status. The data provided in the report only covers 2011 through 2022, and it fails to analyze the numbers by year, specific occupational specialty, and active or reserve component membership.

The report's authors claimed they could not provide authoritative data predating 2011 because the Pentagon "did not have a standardized reporting methodology," and restrictions on analyzing suicide data with small sample sizes led them to decline to assess the by-year, by-component, or by-job code rates. The report argued these figures "are highly sensitive to small changes over time, and are unreliable for comparison."

Their approach contrasts with that adopted by the 2009-10 DoD Task Force on the Prevention of Suicide by Members of the Armed Forces, the last major effort to carve out job-specific data. The congressionally chartered task force's final report provided suicide data detailing annual deaths for every military occupational specialty across the different branches.

Kuzminski, the CNAS expert, argued the new report's consolidation of data could mask critical trends. She said that lumping together personnel generalists and recruiters^[10], for example, "doesn't tell me what is the individual rate of the 'recruiting and counseling' [subgroup]. There's probably far fewer recruiters than broader personnel [specialists]."

The Senate's draft defense policy bill for fiscal 2025 includes a King-authored provision to make Wednesday's report a permanent annual requirement for the Pentagon.

King described the report's numbers as a starting point, saying that "what [DoD] produced is still significant," and the numbers will accumulate over time if his proposal to make the report a permanent annual requirement becomes law.

Now, the senator wants to see results.

"My concern on this suicide study is that I don't want it to just be interesting data," said King. "I want it to guide action."

The full report containing data on suicide by specialty can be found here^[11].

Veterans and service members experiencing a mental health emergency can call the Veteran Crisis Line, 988 and press 1. Help also is available by text, 838255, and via chat at VeteransCrisisLine.net.

-- Davis Winkie is an investigative reporter who focuses primarily on the military and veterans. Davis, a Military Times and CNN alum, was a finalist for the 2023 Livingston Award for Local Reporting and shared the Society of Professional Journalists' 2023 Sunshine Award with colleagues from The Texas Tribune, ProPublica and The Marshall Project.

Related: Overall Military Suicide Rate Dropped, But Active-Duty Deaths Increased Slightly, Pentagon Reports^[12]

Civilian federal employees, contractors and family members identified as having "Havana Syndrome" -- mysterious symptoms that began, for many, overseas after hearing a loud noise, accompanied by instantaneous earaches and headaches -- face difficulties receiving medical care in the military health system as allowed by law.

For a report published Monday, Government Accountability Office analysts interviewed 65 of the 334 people who qualify for Defense Department medical care for their condition, referred to as "anomalous health incidents" by the U.S. government, and found they've faced troubles navigating the system, scheduling appointments, and receiving medical hardware, medications and support.

According to the Government Accountability Office, the affected CIA, State Department and FBI employees and others have not received clear guidance from the DoD about their medical care and often rely on one another to navigate the maze of facilities, including the National Intrepid Center of Excellence for traumatic brain injury^[1] in Bethesda, Maryland; Walter Reed National Military Medical Clinic; and regular military hospitals and other facilities.

Read Next: Indiana Staff Sergeant Identified as Marine Killed in Humvee Rollover During Training at Twentynine Palms^[2]

Many of those interviewed for the GAO review said they had little support and faced difficulties getting appointments at military hospitals as they qualify for care only on a space-available basis. They added they couldn't reach anyone to make appointments at the National Intrepid Center of Excellence.

"Some patients stated they had waited so long for a response from the [National Intrepid Center of Excellence] that they had essentially given up on the military health system and were pursuing treatment in the civilian sector," GAO analysts wrote in "Havana Syndrome: Better Patient Communication and Monitoring of Key DoD Tasks Needed to Better Ensure Timely Treatment."^[3]

Several State Department employees at the U.S. Embassy in Havana, Cuba, began suffering in 2016 from headaches, tinnitus, hearing loss, vertigo and cognitive dysfunction after hearing a loud noise that came from one direction, according to sufferers.

Reports from other U.S. government employees, contractors and family members followed after similar incidents and experiences in China, Russia, Poland, Colombia and elsewhere overseas, as well as in the U.S., including Washington, D.C.

Studies into the possible causes have reached differing conclusions. In a report declassified in February 2022, a panel of intelligence community experts said that pulsed radiofrequency energy could be responsible for symptoms, while an Intelligence Community Assessment published in March 2023 found that most federal agency members believed it was unlikely the incidents were targeted energy attacks by a foreign adversary. That report concluded the symptoms likely were the result of a conventional illness or preexisting condition.

In 2022 and 2023, Congress passed two laws that required the DoD to furnish medical treatment to affected employees and family members at locations that included the National Intrepid Center of Excellence and certain military treatment facilities.

According to the report, 34% of those eligible for health care were either CIA or worked in the Office of the Director of National Intelligence; 29% were with the Defense Department; 16% were State Department; and 11% were FBI employees. The remainder were classified as "other" and included some 15 children.

Those who received care through the U.S. military -- 50 patients -- and were interviewed by GAO told officials that they were grateful for the treatment from providers familiar with their experiences. Nearly half said their symptoms had improved as a result of treatment.

But many said they never received guidance on how to access care and faced challenges getting onto base, receiving medications and making timely appointments.

By law, the DoD also was to maintain a registry of affected patients, collect data and information that would be used to help drive treatments, and establish processes for caring for patients through a network of specialty facilities, the Intrepid Spirit Centers, at U.S. military bases across the country.

But those tasks have not been completed, according to the GAO.

"DoD has created a plan to address some access concerns of [anomalous health incident] patients, but it contains uncertain time frames and lacks monitoring provisions," the report states.

The GAO noted that, because its analysts interviewed only volunteers from the patient community, the findings may not represent the experiences of all those affected.

The watchdog recommended that the DoD provide written guidance such as a handbook, as a way to educate patients on their care; develop a small cadre of health providers and administrators to manage cases and care for patients; and work to fill provider vacancies by shortening the length of time it takes to onboard new employees such as nurse navigators.

The Defense Department agreed with the recommendations, with Seileen Mullen, principal deputy assistant secretary of defense for health affairs, writing in a response to the report that the DoD is piloting a handbook to guide patients and will finalize it by early fiscal 2025. She said it also is developing monitoring capabilities and maintains a "coordination cell" at the National Intrepid Center for this group of patients.

According to the report, the patients feel stigmatized by their conditions, and many are reluctant to seek care, given the reaction they have received at work after disclosing that they were affected. Nearly half the patients GAO analysts interviewed said they faced difficulties at work -- losing assignments, being placed on leave, having their security clearance renewals delayed, or being referred for psychological care.

Several patients said they did not tell their supervisors of their exposure out of concern that it would negatively affect their careers.

Studies published in March by the National Institutes of Health found that affected patients had no evidence of brain injury. Using magnetic resonance imaging and blood biomarkers for brain injury, researchers examined more than 80 patients with Havana Syndrome and compared them with a control group, finding "no significant differences."

In an accompanying editorial, Dr. David Relman, a professor at Stanford University School of Medicine who also has engaged in research on anomalous health incidents, said that drawing conclusions from this study that "nothing happened" would be "ill-advised."

Noting conditions such as Gulf War Illness, chronic fatigue syndrome and long COVID-19 that initially were viewed with skepticism and suspected to be psychological, not physiological, Relman said institutions must examine their own biases, address shortcomings in research and treat patients.

"Prejudice and poorly supported assumptions must be set aside. Clear and timely public communication is essential. The delivery of appropriate nonjudgmental care must be initiated without delay," Relman wrote.

Related: New Study Finds No Brain Injuries Among 'Havana Syndrome' Patients^[4]