MADIGAN ARMY MEDICAL CENTER, Joint Base Lewis-McChord, Wash. -- What does military medicine look like in the future? What does it mean to the individual military treatment facilities to have the Defense Health Agency assume command of medicine throughout the services?Maj. Gen. Lee Payne, the assistant director of combat support for the DHA, visited Madigan Army Medical Center on Joint Base Lewis-McChord, Wash. and tackled these questions in a town hall on Dec. 12.Payne, an Air Force officer, came to Madigan as an emergency physician in 1987. He has seen many changes since that time."There's a lot of things happening simultaneously across the military health system. It's probably the most challenging amount of change I've seen in my whole 33-year career," said Payne.The development of the DHA is one of the biggest drivers of change currently.In the hour and 15 minutes that he spoke to a packed house in Letterman Auditorium, Payne explained some of the structure of the DHA's organization.All medical entities will be grouped into 21 large markets of all of the facilities within a geographic, across the different services. There will then be some smaller markets and two regions, one in the Pacific and one in Europe.Payne said DHA Director Lt. Gen. Ronald Place likes to use the orchestra in illustrating his thoughts on how the markets should work, describing that they sing with one voice, but every once in a while, you will hear individual instruments."There is a complex interplay and that's kind of what the market is going to need to be as well," added Payne.Some of what that will mean in the long term will be more flexibility in placing staff where they are needed, regardless of service."The market is the lynchpin and the cornerstone to our success," said Payne.DHA headquarters is currently doing an exercise to determine if it's ready to support the National Capital Region market."There's a whole list of objective criteria that have to be met," Payne said.When Place is convinced that checklist of requirements is met, he will certify the market and move forward across the country in a similar manner.Payne stated, and reiterated when asked for a specific date this will happen for Madigan's market, that this will be a conditions-based process, not a time-based one. Though he does expect, if all goes well, Place will be looking to certify the Puget Sound Military Health System market in mid-2020.Considering the types of conflicts the military will likely face in the future is expected to change, the provision of military medicine will also transform.Payne expects that direct care for many specialties will continue, both to keep the force medically ready to deploy as well as the medical force ready to treat, more patients and services will likely move to the local, civilian networks supported by TRICARE."We've seen this transition across our careers where the amount of patients- the Medicare patients, the retirees- the volumes have shrunk," noted Payne. "My experience over the last 33 years, tells us the reform we're going through is necessary; we have to make some changes."Payne made it clear that Madigan is vital in the mix saying, "You are instrumental; you're one of the most important hospitals in keeping us medically current and competent."Given its size and scope, Madigan impacts all of military medicine. This can be seen when countless visitors, Payne included, start their town hall presentations by telling of their time stationed at Madigan.As the DHA moves to bring all forms of medicine within the armed services under one umbrella, Madigan's model is appreciated."The thing I love about a place like Madigan is you're training the whole team," said Payne.Payne stressed that he wants both Soldiers and civilians to see a future with military medicine, saying the DHA is committed to no reduction in the civilian workforce. Expanded authorities coming to the agency will allow it to move personnel across services, which the separate services cannot do now.He explained that the opportunities for staff to work in a variety of organizations- from MTFs to the DHA- will be included."There will be more opportunities for you," he said.