Nearly a year into his job as the Navy's top doc, Vice Adm. C. Forrest Faison III wants to make wide-ranging reforms designed to better heal millions of sailors, Marines, military retirees and their families.
The 38th surgeon general of the Navy wants to wage war against complacency on three fronts -- making health services more convenient for troops and their families; ensuring positive, "friction-less experiences" with Navy medical providers; and using technology to connect troops with the best physicians.
But he doesn't want his reforms to bear unacceptable costs, like destroying a medical culture that saved 97 percent of America's wounded service members during the wars in Iraq and Afghanistan -- the highest survival rate in military history -- or adopt private-sector practices that won't work in a military constantly churning with new recruits coming aboard and veterans returning to their hometowns.
"There's a great temptation to look at Navy medicine through a civilian lens," Faison, 58, said during an interview last week with The San Diego Union-Tribune.
"We have a 28 percent turnover rate because people move every three years to support the Navy. People also deploy. Unlike one of the marquee civilian health-care institutions in the nation -- (where) they're not going to empty their hospital and send that staff into harm's way -- I am. And I'm going to do it on a moment's notice."
The Navy is younger than the U.S. civilian population, which is why Faison's proposals focus on a millennial generation of Marines and sailors that he believes is "fundamentally changing health care."
Three out of every four sailors and their families were born after 1986. They're digital natives -- more than 80 percent of them fall asleep with their mobile phones -- and their fingers can choose from 16,000 apps related to health care, few of which have been tested for accuracy by the Navy or linked to the service's physicians.
They demand convenience, and the federally subsidized health system -- called Tricare -- lets them choose "minute clinics" and urgent-care providers outside the traditional military medical system.
But their need for speed has unintended consequences: When sailors and Marines desert the traditional sick bay system for off-base care, Navy medical teams lose both "visibility on the health of the force" and proficiency in their craft because they have fewer patients to practice on, Faison said.
He wants to fix that by pushing Navy medicine onto smartphones and integrating that health care more seamlessly into service members' daily lives, wooing sailors and their families back to direct military treatment while taking advantage of technology already in the fleet to make their experiences better than they would find in most private-sector clinics.
Faison points to early efforts that promise to use high-tech "virtual medicine" to link patients with his 63,000 physicians, nurses, corpsmen, dentists, government civilians and contractors.
"We're in the early stages of discussing a pilot program that would develop corpsmen-led clinics that might be in our commissaries or in our exchanges, connected by telemedicine to doctors at the hospital," he said. "So if you're a patient, while you're in the commissary you can get your health-care needs met by a corpsman, and that corpsman is getting the opportunity to keep his skills up.
"More importantly, because he's the guy there, he's developing the confidence he's going to need to save lives on the battlefield -- but in a structured way that we're providing good, safe health care using telemedicine links to experienced physicians in the rear."
For example, the Navy's new hospital in Guam links to specialists in Hawaii and San Diego. Similar systems connect to warships at sea or surgical teams saving Marines on remote battlefields.
More than 70 percent of clinical care doesn't require a trip to the doctor, so putting a corpsman in the commissary could very well be a smarter and cheaper option for taxpayers than pushing patients into emergency rooms or physicians' offices.
Controlling expenses is important in a Navy that spends $9.6 billion annually on health care -- about a fifth of the Department of Defense's overall medical budget.
Accounting for inflation, military health costs rose 130 percent between 2000 and 2012, according to the Congressional Budget Office. In 2000, medical care consumed 6 percent of the Pentagon's base budget. A dozen years later, it gobbled up a tenth of all military spending. It could reach 11 percent by 2028, the federal analysts warned.
Rising expenses are mostly tied to Tricare. In the past two decades, Congress has expanded Tricare access to growing numbers of military retirees, active-duty service members' families, National Guardsmen and reservists.
Today, the Navy directly treats or funds the health care of 2.8 million beneficiaries, but three out of every four patients aren't active-duty sailors or Marines. They're mostly military spouses, children and working-age retirees.
Federal lawmakers have been reluctant to force military families to share a larger portion of health-care expenses by significantly hiking co-pays, enrollment fees and other charges -- even in Tricare Prime, the managed-health-care option that's designed to contain costs.
In 2010, the typical Tricare Prime enrollee garnered $4,800 in yearly federal subsidies, according to the Congressional Budget Office analysis.
With low out-of-pocket costs, Tricare Prime beneficiaries use 50 percent more outpatient services than civilians of the same age who are enrolled in health-maintenance organizations.
But beyond the financial savings for military enrollees, Tricare surveys have shown that many service members and their families believe they get seen faster, and by better physicians, in the private sector.
Marines are the most disgruntled. In the 2015 Military Compensation and Retirement Modernization Commission report, 54 percent of them expressed dissatisfaction with their overall health-care experiences and 56 percent said they didn't like their choice of medical providers.
The Navy is using a customer-service surveying system modeled on Delta Airlines' to get rapid feedback from those dissastisfied Marines so Navy medicine can respond nimbly to their needs. But in general, Faison said military care suffers from a perception problem.
"Our access for primary care and specialty care is well below the civilian average. So when people are sick, we take it to heart to get them in quickly and get them seen," he said.
Faison believes private-sector health networks artificially boost satisfaction rates by offering valet parking, gourmet meals and other non-medical perks that taxpayers wouldn't tolerate for the Navy.
"It's very easy to confuse the experience of care with the quality of care," he said. "So you see nice waterfalls and pavilions and that sort of stuff and you say, 'Well, that place has all of this so it must be high-quality care.'"
The one program Faison won't revamp is the Navy's cutting-edge medical research.
Faison's teams are experimenting with a potential malaria vaccine in the jungles of northern Thailand, exploring the cause of sepsis in an Egyptian hospital and working to unravel the mysteries of the Zika and other epidemics -- medical breakthroughs that could save millions of lives worldwide, help preserve stability in troubled places and safeguard American service members from disease if they're deployed overseas.
"Look at the force you can say confidently will get out the door tonight to save lives, wherever called upon, that can build strategic partnerships and alliances around the world and that's leading the nation -- and sometimes the world -- in battling infectious diseases in our research labs. That's a pretty darned good investment," he said.