MILITARY MEDICINE, 172, 1:75, 2007
Civilian Doctors in Military Clinics—Outsourcing for
Better Medicine
Guarantor: Rachel Dankner, MD MPH
Contributors: Rachel Dankner, MD MPH*†; Jonathan Rieck, MD‡; Ariel G. Bentacur, MD†‡; Yaron Bar Dayan, MD§;
Amir Shahar, MD MPH†‡
Objectives: To determine whether outsourcing of medical con-
sulting services could improve the quality of medical treat-
ment in military primary care clinics. Methods: Data were
collected prospectively over 2 months in two regular army
clinics manned by ordinary army doctors and in two interven-
tion clinics also staffed with senior civilian doctors. The
causes for doctor visits, diagnoses, and other patient data
were collected. Results: Information was recorded from 4,970
soldier visits in the four clinics. Although a prescription of
rest days was similar in both types of clinics, the level of
tertiary referrals was lower by one-third in the intervention
clinics compared to the regular clinics. Surrogate markers for
quality of care, such as increased use of planned follow-up and
reduced antibiotic use, were significantly better in the inter-
vention clinics, and so was overall patient satisfaction. Con-
clusions: Integration of specialist civilian physicians in the
military primary care system is highly beneficial and provides
better care and saves costs.
Introduction
raditionally, military doctors in the Israeli Defense Force
T (IDF) have been the exclusive providers of primary care in
army bases to soldiers in service. This has required extensive
organization of the medical and administrative personnel, and
the maintenance of suitably equipped clinics. Whereas in many
Westernized countries, military hospitals treat members of the
military, in Israel, there are no military hospitals and soldiers
requiring acute medical care are referred to the civilian health
system only when advanced medical treatment or hospitaliza-
tion are necessary.
The military medical system of the IDF is torn between its
commitment to provide high-quality medical care to its person-
nel and its constraints of using relatively young inexperienced
doctors and limited resources. There is an essential and deep
conflict regarding the utilization of professional medical man-
power in the military system: the limited manpower resources
should be positioned in the field forces and not in rear, semici-
vilian bases. Therefore, services which can be given by civilian
providers should be outsourced. In addition, improvement in
the quality of care can be best achieved by the introduction of
well-experienced civilian doctors into the military primary care
1
system or by privatization of services, and, indeed, in recent
*The Gertner Institute for Epidemiology and Health Policy Research, Tel-
Hashomer, 52621 Israel.
†Sackler School of Medicine, Tel Aviv University, Tel-Aviv, 69978 Israel.
‡Department of Emergency Medicine, Sheba Medical Center, Tel-Hashomer, 52621
Israel.
§The Medical Corps, Israeli Defense Force, Ramat Gan, Israel.
This manuscript was received for review in January 2006 and was accepted for
publication in May 2006.
Reprint & Copyright © by Association of Military Surgeons of U.S., 2006.
75
years, military ambulatory medical services were outsourced to
civilian medical service providers. Furthermore, better access to
specialists and quick definitive plans of treatment are important
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determinants of patient satisfaction.2
For the last several years, members of the staff of the emer-
gency department (ED) of Sheba Medical Centre have been prac-
ticing in primary care clinics of two military permanent rear bases.
These senior clinicians treat soldiers and consult army doctors.
Our objective in the present study was to determine whether the
introduction of civilian physicians into the military primary care
system has improved the quality of care provided to soldiers.
Methods
A prospective nonrandomized interventional study compared
four army clinics during a 2-month period (March–April 1999).
Regular army physicians staffed the two control clinics, while
the two intervention clinics included also senior civilian consult-
ants working in parallel to the military physicians. The included
clinics were matched by the type of soldiers, type of activity, and
the crude turnover of the clinic. The civilian physicians were
board certified internists, a surgeon, an orthopedist, a derma-
tologist, and emergency medicine physicians.
Demographic and clinical information was obtained from the
clinics’ log for every soldier visiting a doctor. Research nurses
stationed in each of the bases recorded it consecutively and
continuously. The causes for the doctor’s visits were categorized
as: acute illness, request for tertiary referral, administrative, or
follow-up. Diagnoses were drawn from the IDF coding system,
developed specifically for epidemiological purposes and based
on the body systems affected.
A questionnaire on customer satisfaction was filled by a ran-
dom sample (n ⫽ 303) of visitors to the intervention clinics. The
Statistical Analysis System software3 was used to analyze the
tabulated data. Differences between the groups were assessed
by the Student t test for parametric variables, and the ␹2 test for
frequencies. The significance level was set at p ⬍ 0.05.
Results
During the 24 days of clinic activity, 4,970 visits were re-
corded in the studied clinics. The baseline characteristics of
soldiers in the intervention and control groups were similar in
their demographic makeup (Table I), and they matched 95% of
the general population of conscript soldiers, adjusted for type
of service and age group. Civilian physicians managed 47.4% of
the soldier visits in the intervention clinics and 9.2% in the
control clinics, the latter attributable to senior physicians on
reserve duty at the control group clinics.
Military Medicine, Vol. 172, January 2007
76 Civilian Doctors in Military Clinics

TABLE I TABLE III

BASELINE CHARACTERISTICS OF VISITS TO MILITARY CLINICS, BY PROPORTION OF OUTCOME MEASURES (PER 100 VISITS) BY
TYPE OF CLINIC CLINIC TYPE

Interventiona (%) Controlb (%) p Intervention Control p

Gender Consultant referral 18.9 27.2 ⬍0.001
Male 1,860 (63.1) 1,313 (64.9) 0.19 Referral to ED 1.3 3.7 ⬍0.001
Female 1,080 (36.6) 707 (34.9) 0.21 Sick leave (total days) 17.3 17.6 0.86
Unknown 6 (0.2) 4 (0.2) 0.8 Imaging 4.9 4.4 0.59
Service type Laboratory 4.8 7.0 0.03
Conscript 2,346 (79.6) 1,564 (77.3) 0.04 Antibiotics prescribed 3.5 10.3 ⬍0.001
Career 509 (17.3) 353 (17.4) 0.9 Planned follow-up consultation 2.2 2.5 0.66
Reserve 54 (1.8) 97 (4.8) ⬍0.001 Other 2.1 3.7 0.03

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Other/unknown 37 (1.2) 10 (0.5) 0.01
Physician type
69.1%; p ⬍ 0.001). The use of ancillary laboratory tests in the
Civilian 1,396 (47.4) 186 (9.2) ⬍0.001
Military 1,534 (52.1) 1,837 (90.8) ⬍0.001
intervention clinics was lower by one-third relative to the control
Unknown 16 (0.5) 1 (0.0) 0.001 clinics.
Reason for visit The soldiers in the intervention group expressed significantly
Acute illness 1,729 (58.7) 1,145 (56.6) 0.15 higher overall satisfaction from the standard of received care
Referral request 286 (9.7) 430 (21.2) ⬍0.001 and, particularly, from its improvement after intervention, com-
Follow-up 183 (6.2) 43 (2.1) ⬍0.001 pared to those in the control clinics. They have not assessed
Administrative 710 (24.1) 395 (19.5) ⬍0.001 differently the quality of care or its accessibility and were indis-
Unknown 38 (1.3) 11 (0.5) ⬍0.001 tinguishable on the response to the control clinics on their
a
n ⫽ 2,946. working environment and interpersonal relations (Table IV).
b
n ⫽ 2,024.
Discussion
The reasons for visit (Table I) already suggest the influence of
the specialists, with fewer soldiers in the intervention group Military service is mandatory in Israel and most civilians serve
seeking referral to consultants or special laboratory tests, fewer for 2 to 3 years as conscript soldiers. Military doctors are either
arriving for administrative reasons, and more showing up for military personnel conscripted after having completed army
follow-ups initiated by the treating physician. The number of sponsored medical training immediately after their internship,
soldiers examined due to acute illness was similar in both and reserve physicians, from all medical specialties, who are
groups, averaging 57%. The spectrum of the major complaints mobilized for approximately 3 weeks annually.
prompting the visit to the clinic is listed in Table II. There was a This study is the first of its kind. A change in policy by the
higher rate of primary complaints of fever, abdominal pain, Medical Corps allowed us to assess the impact of the introduc-
musculoskeletal pain, headaches, and back pain in the control tion of specialists into the military primary care system on the
group than in the intervention group. quality of care. Optimal organization of resources to provide
Analysis of the outcome data indicates an apparently similar timely access to quality care while meeting cost considerations
rate of sick leave given in both types of clinics (Table III); how- is the main challenge of the military health care system.4 The
ever, the rate of various medical exemptions was higher in the integration of civilian specialists into the military system5 and
control group than in the intervention group (11.3% vs. 6.3%, the outsourcing of dental services to civilian contractors1 have
respectively, p ⬍ 0.001). The level of tertiary referrals in the been suggested as effective means of meeting these challenges.
intervention group was one-third less than that of the control Our findings suggest that the more experienced civilian phy-
group, with 10 fewer referrals for every 100 visits. Prescription of sicians who are not part of the military environment, are less
antibiotics was three times more frequent in the control clinics defensive, and that their clinical decisions are of a higher stan-
than in the intervention clinics (10.3% vs. 3.5%, respectively, dard. The defensive behavior of ordinary military physicians was
p ⬍ 0.001), and the rate of antibiotic use for sore throat and
TABLE IV
fever was notably lower in the intervention group (39.7% vs.
RESPONSE TO A QUESTIONNAIRE RELATED TO INDIVIDUAL
SATISFACTION FROM THE MEDICAL CARE PROVIDED (%)
TABLE II
MAJOR COMPLAINTS IN THE STUDY GROUPS (PER 100 VISITS) Intervention Control
(n ⫽ 157) (n ⫽ 146) p
Presenting Symptoms Intervention Control p
Working environment 76.6 75.1 0.80
Sore throat 8.3 6.6 0.15 Interpersonal relations 73.1 71.1 0.70
Musculoskeletal pain 7.1 10.7 0.004 Quality of care 71.1 66.9 0.43
Back pain 4.5 7.5 0.004 Accessibility of care 64.3 55.8 0.13
Headache 4.4 7.9 0.001 Care improvement noticeable 65.7 54.4 0.04
Rash, acne 4.4 5.7 0.22 Overall satisfaction from care 79.0 63.3 0.003
Abdominal pain 3.8 7.3 ⬍0.001
Control questions included satisfaction from the working environment
Fever 1.7 4.2 ⬍0.001
and interpersonal relations.

Military Medicine, Vol. 172, January 2007

Civilian Doctors in Military Clinics
already suggested in a previous study that found military pri-
mary care physicians keep medical records better than army
reserve physicians.6
The most significant contribution of the intervention is the
drastic reduction in tertiary referrals. The potential cost saving
from the reduced rate of referrals originates from the reduction
in loss of workdays from fewer hospital outpatient visits and
from the fewer sick leaves prescribed by specialists. The fewer
laboratory tests used by the civilian physicians may also con-
tribute to reducing costs.
Although acute viral and bacterial pharyngitis can be clini-
cally differentiated in ambulatory care,7 antimicrobial drugs are
often indiscriminately prescribed for upper respiratory tract in-
fections.8 Our finding of a 3-fold increase in antibiotic use in the
control group relative to the intervention group cannot be jus-
tified just by the different frequency of fever as the primary
complaint in both groups, since a significant large difference in
the rate of antibiotics given per 100 soldier visits was observed.
Headaches and back pain are mostly subjective complaints
that are frequently used to avert workload or to obtain better
service conditions. Therefore, it is not clear whether the ob-
served difference in these complaints was inherent or the result
of the intervention, but the difference in tertiary referrals is
clearly a consequence of the intervention. What is surprising is
the overall high rate of tertiary referral in a population repre-
senting young and fit individuals.
Medical systems all over the world face increasing costs of
curative medicine and are required to contain expenditures9,10;
military medical systems are no exception. The IDF medical
system is fundamentally similar to other military medical orga-
nizations, but dissimilar in several aspects. Primarily, the ma-
jority of soldiers is comprised of compulsory conscripts between
ages 18 and 21 who had been medically screened, implying a
preselected healthy population. Second, by IDF regulations, a
doctor’s appointment is guaranteed within 48 hours. Third,
military physicians are relatively young and inexperienced (im-
mediately postinternship), which explains the overuse of spe-
cialists and ancillary tests. Finally, shortage of military medical
manpower creates a dilemma of allocation, with the best physi-
cians deployed in combat units while the bulk of the army is in
other units. However, beyond specific military priorities, it, as in
other medical systems, is challenged by the expectation of high
quality of care.
Several models have been proposed to deal with these de-
mands because the traditional medical service to the soldiers
was deemed unacceptable. Few civilian physicians joined the
professional army; health maintenance organizations were
granted a global budget to perform some medical services for the
army and night service providers and hospitals received respon-
sibility for aspects of medical care in certain bases and regions.
Under this arrangement, the ED of the Sheba Medical Center, a
university affiliated center, was contracted to operate multidis-
ciplinary clinics in several military bases. Both partners bene-
fited from this arrangement–the ED enlarged its staff, resources,
and its recruitment potential for in-house services, and the IDF
upgraded its medical care.
It was suggested that quality of care is composed of two
principal dimensions–access and effectiveness.11 Individuals
with a regular doctor have better access to primary care than
77
those with a regular site but no regular doctor, unless report to
the clinic is mandatory. This suggests that policies that promote
the doctor-patient relationship are those that increase accessi-
bility.12 We observed that the number of visits per servicemen in
both groups was comparable, but the number of follow-up vis-
its, which reduces early disease relapse,13 was significantly
higher in the intervention group, reflecting improvement of the
access dimension of quality.
Effectiveness is much more difficult to assess, but indicators
such as the increased use of planned follow-ups and the lower
use of antibiotics in the intervention group suggest that better
care was provided there. Fewer laboratory tests also improved
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the quality of care by decreasing the volume of unnecessary
tests. No difference was found in the rate of steroid use, and in
the future, different markers may have to be considered for
comparison. Since the treatment rendered by the civilian phy-
sicians is more holistic, it could influence the future attitudes of
this young soldier population toward the medical system in
future medical encounters.
Health care systems that are constantly challenged by high
costs or quality demands seek strategic tools that can provide
effective solutions. Outsourcing, where organizations delegate
part of their functions to other providers, is such a strategy. It is
an effective way to reduce costs, update technologies, and main-
tain quality patient care.14 It, however, demands careful partner
selection and partnership development, clearly delineated con-
tractual responsibilities, a monitoring system, pre-established
cures, and a system to manage potential dysfunctions.15 Many
noncore services such as laundry,16 laboratory,17,18 informat-
ics,19 radiology,20 and pharmacy20 have been outsourced with
reportedly significant reduction of costs. Recently also, blood
product services21 and complex condition management22 have
been included in this expanding list.
In summary, this study supports the belief that specialist
civilian doctors in primary care military clinics can improve the
quality of care delivered, benefiting the present and future
health consumer behavior of young servicemen.
Acknowledgment
This study was supported by a grant from the Medical Corps of the
IDF.
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