Many Military Treatment Facilities just don't have the patient volume to support complex general surgical cases. For the most part, this is a young, healthy, patient population, as well as their families. Centers that have a large retirement community around them, such as Camp Lejeune, tend to get more complex surgical cases. If that MTF is located near a major city with larger hospitals, many patients, including active duty, may opt to seek treatment at those civilian facilities, and with the changes to Tricare they are free to do so.
As a former Navy surgeon, I can only speak to my own experiences, but I will tell you that I'm very concerned about this focus on "combat care" and "combat readiness". That is a push that has come from the Army and has resulted in many "noncombat" oriented specialties being pushed out of active service, namely medical subspecialties, Ob/GYN, and Peds. Without a referral base, surgeons are left to rely on the cases that come in from the active duty side and often times these are less complex and more simple cases, which skews the data in this study to "less substantial" KSA numbers. During my time on active duty between 08-13, I had no issue with getting adequate numbers of cases or diversity of cases, but I was at NH Camp Lejeuene and we had a great base of patients and no large civilian center near us.
One of the weaknesses in military medicine, frankly, is that they are quick to put young, inexperienced surgeons into billets where they will be seeing limited surgical cases but have to perform those cases under difficult circumstances. For example, in the Navy, young surgeons are often placed into carrier billets or on fleet surgical teams which support amphibious assault ships. Those are usually one to two year billets and I can assure you that their surgical volume is minimal during that period, but they are like a fire extinguisher behind glass and may be required to step up and perform complex cases should the situation arise.
As for combat surgery, I am diametrically opposed to using contract labor for wartime combat surgery. Combat surgery is unlike any civilian trauma and, although the principles of sound trauma care remain, the intensity of that trauma can not be replicated. As such, it should be military providers who share a vested interest in the care of their soldiers, sailors, airmen, and marines caring for the wounded. That's a personal opinion and one that comes from personal combat surgical experience so I readily admit my bias. I believe there can be ways to improve trauma training without shifting to contract work. Plus, what cost are they willing to put on that care? Contract labor isn't cheap and forward combat surgery often takes place in austere environments where the war is literally going on outside the flaps of your OR, that was certainly true in my case.
All of that being said, we are transitioning into a peacetime military, and that's a good thing. Perhaps in order to keep up skills, all branches of the military need to invest in peacetime medical support of their MTFs, promote treatment within those facilities for active duty as well as retirees, and allow active duty surgeons to have privileges at neighboring civilian hospitals and allow for rotations on a regular schedule at civilian trauma centers to keep up skills.
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