[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
[H.A.S.C. No. 114-39]
THE DEPARTMENT OF DEFENSE VIEWS
ON THE MILITARY COMPENSATION
AND RETIREMENT MODERNIZATION
COMMISSION'S RECOMMENDATIONS
FOR MILITARY HEALTH CARE REFORM
__________
HEARING
BEFORE THE
SUBCOMMITTEE ON MILITARY PERSONNEL
OF THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
HEARING HELD
JUNE 11, 2015
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
___________
95-314 U.S. GOVERNMENT PUBLISHING OFFICE
WASHINGTON : 2015
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SUBCOMMITTEE ON MILITARY PERSONNEL
JOSEPH J. HECK, Nevada, Chairman
WALTER B. JONES, North Carolina SUSAN A. DAVIS, California
JOHN KLINE, Minnesota ROBERT A. BRADY, Pennsylvania
MIKE COFFMAN, Colorado NIKI TSONGAS, Massachusetts
THOMAS MacARTHUR, New Jersey, Vice JACKIE SPEIER, California
Chair TIMOTHY J. WALZ, Minnesota
ELISE M. STEFANIK, New York BETO O'ROURKE, Texas
PAUL COOK, California
STEPHEN KNIGHT, California
Jeanette James, Professional Staff Member
Craig Greene, Professional Staff Member
Colin Bosse, Clerk
C O N T E N T S
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Page
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
Davis, Hon. Susan A., a Representative from California, Ranking
Member, Subcommittee on Military Personnel..................... 2
Heck, Hon. Joseph J., a Representative from Nevada, Chairman,
Subcommittee on Military Personnel............................. 1
WITNESSES
Ediger, Lt Gen Mark A., USAF, Surgeon General, United States Air
Force.......................................................... 6
Faison, RADM C. Forrest, III, MC, USN, Deputy Surgeon General,
United States Navy............................................. 7
Horoho, LTG Patricia D., USA, Surgeon General, United States Army 5
Woodson, Dr. Jonathan, Assistant Secretary of Defense for Health
Affairs, Department of Defense................................. 3
APPENDIX
Prepared Statements:
Heck, Hon. Joseph J.......................................... 29
Woodson, Dr. Jonathan, joint with Surgeons General of the
Military Departments....................................... 30
Documents Submitted for the Record:
Statement of the National Association of Chain Drug Stores... 53
Witness Responses to Questions Asked During the Hearing:
[There were no Questions submitted during the hearing.]
Questions Submitted by Members Post Hearing:
Mr. Jones.................................................... 65
Mr. Walz..................................................... 66
33
THE DEPARTMENT OF DEFENSE VIEWS ON THE
MILITARY COMPENSATION AND RETIREMENT
MODERNIZATION COMMISSION'S RECOMMENDATIONS
FOR MILITARY HEALTH CARE REFORM
House of Representatives,
Committee on Armed Services,
Subcommittee on Military Personnel,
Washington, DC, Thursday, June 11, 2015.
The subcommittee met, pursuant to call, at 3:00 p.m., in room
2212, Rayburn House Office Building, Hon. Joseph J. Heck
(chairman of the subcommittee) presiding.......................
OPENING STATEMENT OF HON. JOSEPH J. HECK, A
REPRESENTATIVE FROM NEVADA, CHAIRMAN,
SUBCOMMITTEE ON MILITARY PERSONNEL
Dr. Heck. Good afternoon.........................................
I want to welcome everyone to this hearing to discuss the
Department's views on the Military Compensation and Retirement
Modernization Commission's recommendations for reforming the
military healthcare system.....................................
I apologize for our tardiness. We understand there will be
another vote coming up somewhere between 3:30 and 4:00. So we
will try to get through as much as practically possible........
We ask the witnesses to bring their statements down to 3 minutes
so that we can get to questions. And then, once the vote is
called, we will determine whether or not we need to come back.
It is only one vote. So it should take no more than walking
time there and back if we need to continue.....................
As we studied the Commission's recommendations over the past 5
months, we considered the views of our current and retired
service members through the organizations that represent them..
We heard mixed reviews about TRICARE and the military health
system. However, the consistent viewpoint is that TRICARE can
and should be improved. We take their concerns seriously and
will consider all views before undertaking any changes to the
military healthcare system.....................................
That being said, I do believe that we can all agree that the work
conducted by the Commission identified weaknesses in the
current system that give us an opportunity to focus our efforts
as we discuss reforming the Military Health System.............
It is our duty, as the Military Personnel Subcommittee, to get to
the root cause of the issues and help determine the best course
of action to fix them. Today is the first hearing where we will
receive specific testimony from the Department of Defense [DOD]
on their reaction to the Commission's recommendations to
improve health benefits for our service members and their
families.......................................................
I am interested in hearing from our distinguished panel if they
agree or disagree with the Commission's recommendations or if
they have alternative suggestions for addressing the perceived
shortfalls identified by the Commission........................
In addition, I am interested in hearing the Surgeons General's
views on how the recommendations would specifically affect the
future of the military treatment facilities and the direct care
system.........................................................
As I said before, guiding consideration for our work is to ensure
that we can continue to recruit and retain the best and
brightest in order to maintain the viability of the All-
Volunteer Force and ensuring that we do not break faith with
our service members, retirees, and their family members........
[The prepared statement of Dr. Heck can be found in the Appendix
on page 29.]...................................................
Dr. Heck. I would like to take this opportunity to ask unanimous
consent to enter a statement from the National Association of
Chain Drug Stores into the record..............................
Without objection, so ordered....................................
[The information referred to can be found in the Appendix on page
53.]...........................................................
Dr. Heck. And before I introduce the panel, let me offer the
ranking member, the distinguished woman from California,
Congresswoman Davis, an opportunity to make her opening
remarks........................................................
STATEMENT OF HON. SUSAN A. DAVIS, A
REPRESENTATIVE FROM CALIFORNIA, RANKING MEMBER,
SUBCOMMITTEE ON MILITARY PERSONNEL
Mrs. Davis. Thank you very much. Thank you, Mr. Chairman.........
And welcome to all of you, all of our witnesses, particularly
those who I have known from San Diego..........................
And it is great to see you here, Admiral Faison..................
This topic, as we all know, is very important. It is very
important to the committee. It is very important to the men and
women and their families who serve our country. So as we move
forward toward reforming TRICARE, we have to really hold on to
this, I think, and really explore it well......................
We have a responsibility to ensure that we provide a cost-
effective world-class healthcare system for our military. And
while we have had several hearings and briefings on the
Commission's recommendations, this is really the first time
that we have had to hear from the Department of Defense with
their thoughts on the healthcare piece.........................
And, more importantly, this is an opportunity to begin discussing
the best way to improve TRICARE and military readiness. The
Department obviously has to balance medical readiness with the
rising cost of health care while at the very same time
improving access, improving choice, and quality care for
beneficiaries. We know that this is no easy task...............
I look forward to hearing from the witnesses on how they propose
that we move forward...........................................
Thank you, Mr. Chairman..........................................
Dr. Heck. Thank you, Mrs. Davis..................................
We are joined by a distinguished panel representing the offices
of the Secretary of Defense in the military departments. We
will give each witness the opportunity to present his or her
testimony and each member an opportunity to question the
witness........................................................
Again, we would ask the witnesses to keep their spoken testimony
down to 3 minutes. Your entire written testimony will be made
part of the hearing record.....................................
Now let me welcome our panel:....................................
Dr. Jonathan Woodson, Assistant Secretary of Defense for Health
Affairs and my former senior rater.............................
Lieutenant General Patricia D. Horoho, Surgeon General of the
United States Army.............................................
And I understand this is probably the last time that you will be
appearing before our subcommittee..............................
General Horoho. I hope so........................................
Dr. Heck. I want to say thank you for your lifetime of service
and looking out for the men and women in uniform and for your
passion and leadership on championing the Performance Triad....
General Horoho. Thank you very much..............................
Dr. Heck. Lieutenant General Mark A. Ediger, Surgeon General of
the United States Air Force, newly appointed...................
Congratulations and welcome......................................
And Rear Admiral C. Forrest Faison III, Deputy Surgeon General of
the United States Navy.........................................
Welcome, sir.....................................................
With that, I turn the floor over to you, Secretary Woodson.......
STATEMENT OF DR. JONATHAN WOODSON, ASSISTANT
SECRETARY OF DEFENSE FOR HEALTH AFFAIRS,
DEPARTMENT OF DEFENSE
Dr. Woodson. Thank you very much. Chairman Heck, Ranking Member
Davis, members of the committee, thank you for the opportunity
to appear before you today.....................................
The Military Compensation and Retirement Modernization Commission
has performed a valuable service to the Department and the
Nation. We agree with their overarching findings regarding
challenges facing military medicine. We concur with many
recommendations and have already moved to implementation.......
In fact, some members of this committee may recall that, when I
testified in this room in February of last year, I talked about
the need to ensure an agile, relevant, and forward-leaning
Military Health System [MHS]. I stated that, to meet our
mission in these changing times, I had outlined for the MHS six
strategic lines of effort......................................
These include modernize the Military Health System management
with an enterprise focus, the successful establishment of the
Defense Health Agency and the development of enhanced multi-
service market represent signature initiatives; two, define and
deliver the medical capabilities needed in the 21st century;
three, invest and expand the strategic partnerships; four,
assess and refine the balance and needs of our medical force;
five, modernize TRICARE health program; and, six, define the
MHS's requirements in terms of global health engagement........
These strategic lines of effort will help us deliver on our
overarching quadruple aim of readiness, improving the health of
the population we serve, improving the experience of care in
our system, and responsibly managing our costs. Our written
testimony provides a more comprehensive summary of our
positions on the Commission's recommendations..................
For my remarks today, I would like to focus on all of the
strategic efforts underway to make the Military Health System
stronger, better, and more relevant for the future.............
Here is what we have been working on to address the readiness
requirements, ensure quality, and serve as effective stewards
of the resources you have provided us:.........................
Over the last 2 years, we have undertaken a comprehensive review
of our medical infrastructure and resources and presented a
modernization plan that proposes to place our most skilled
professionals in the military communities where they are likely
to keep those skills sharpest..................................
We have reformed governance and established the Defense Health
Agency and have provided a collaborative and affordable way for
the Department to leverage economies of scale for those
functions that are common among the service medical
departments....................................................
And, third, our system is implementing recommendations that
emerged from the Secretary's review of the Military Health
System and culminated in the Secretary's action plan of 1
October 2014. We are making it easier for access to care in our
system. We are focusing on key measures of quality and safety
and participating in national quality improvement initiatives,
such as the Partnership for Patients. And we are making our
performance data more transparent for our beneficiaries and the
public to see..................................................
Similar to achieving historical survival rates on the
battlefield, our leadership team will be relentless in our
efforts to be a national leader in quality and safety in all
that we do.....................................................
And, finally, we are reforming our health benefit. TRICARE is an
exceptional health benefit tailored to meet the unique needs of
military families. Elements of TRICARE can be improved and must
be improved, and that work is underway.........................
We have released an RFP [request for proposal] to recompete the
national TRICARE contracts, and we have included provisions
that reward innovation and simplify administration of the
contracts......................................................
In summary, the Military Health System is a unique and
indispensable instrument of national security. Our mission is
supported by some of the most respected medical professionals
in the world and attracts an extraordinary pool of young
medical professionals who understand how compelling and vital
this system is to others.......................................
We are fortunate to be entrusted with serving as stewards of this
system, and we take this seriously. So I am grateful for this
opportunity to be here today and to answer your questions......
[The joint prepared statement of Dr. Woodson and the Surgeons
General can be found in the Appendix on page 30.]..............
Dr. Heck. Thank you..............................................
General Horoho...................................................
STATEMENT OF LTG PATRICIA D. HOROHO, USA, SURGEON
GENERAL, UNITED STATES ARMY
General Horoho. Chairman Heck, Ranking Member Davis, and
distinguished members of this subcommittee, thank you for this
opportunity to provide the Army and Army Medicine's perspective
on the healthcare forum recommendations........................
After 13 years of war, the Army remains globally engaged. Any
changes to the compensation and benefits must not only honor
their sacrifices, but preserve the long-term viability of an
All-Volunteer Force. The Army supports the underlying
objectives of the Commission's health-related recommendations.
However, we do have concerns regarding certain elements that
threaten readiness and our medical skills......................
It is critical to understand that our direct healthcare system
connects with the battlefield and exists to provide health
readiness to our soldiers and their families. This is what
separates us from the civilian healthcare system. Our hospitals
are our readiness training platforms which produce a ready
medical force and a medically ready force. It is a system that
performed so well over the last 13 years of war................
We concur that a comprehensive list of essential medical
capabilities, or EMCs, should drive our training and
resourcing. However, those EMCs must address the whole spectrum
of health rather than focusing solely on combat trauma and
surgical capabilities..........................................
For instance, less than one out of every five service members
evacuated from Iraq and Afghanistan were injured in battle.
During Operation United Assistance, the major threats to our
soldiers were endemic infectious diseases. The Army already
utilizes joint structures and mechanisms to identify, monitor,
and report on medical readiness. We are working to integrate
EMCs into these processes; therefore, the Army does not support
establishing a four-star readiness command.....................
The Army supports the Commission's objectives of affordable
health care and increased choice for our beneficiaries.
However, the Commission's recommendation to establish TRICARE
Choice would negatively impact our readiness of our entire
healthcare team and present financial challenges to both Active
Duty families and retirees.....................................
Currently, non-Active-Duty beneficiaries comprise 67 percent of
our total beneficiary population, 83 percent of our inpatient
care, and 79 percent of our high-acuity inpatient workload.
These patients are vital to the sustainment of our 148 graduate
medical and health professional education programs. The loss of
these beneficiaries from our direct system would pose
tremendous risk to our training programs and negatively impact
our medical force's readiness posture..........................
The Army sees financial risk to soldiers and to families and
injured in the Commission's recommendation to offset TRICARE
Choice costs through a basic allowance for health care. Year-
to-year healthcare expenses are unpredictable, and many areas
of our country are medically underserved.......................
In conclusion, the Army needs a medically ready force. When the
gate on the Stryker opens, commanders need to know that it will
be full of soldiers that are ready to deploy. And the Army
needs a ready medical force. When the wounded soldiers hear the
rotor blades of a medevac [medical evacuation] helicopter, they
need to continue to have confidence that our providers are
trained and ready. Any radical departure presents significant
risk to a system that has produced record levels of both combat
casualty survival and readiness................................
I would like to thank the Congress for your continued support.
Army Medicine team is proudly serving to heal and honored to
serve..........................................................
Dr. Heck. Thank you..............................................
General Ediger...................................................
STATEMENT OF LT GEN MARK A. EDIGER, USAF, SURGEON
GENERAL, UNITED STATES AIR FORCE
General Ediger. Chairman Heck, Ranking Member Davis, and
distinguished members of the subcommittee, thank you for
inviting us to appear before you today.........................
The Air Force is truly grateful for the hard work of the Military
Compensation and Retirement Modernization Commission. Many
parts of the Commission's recommendations will enhance and
facilitate programs that serve our airmen, their families, and
our veterans...................................................
Today I will speak to impacts in two areas of primary importance
for the Air Force based upon our analysis of the Commission's
recommendations. I will begin with the impacts on the readiness
of our medical force...........................................
We appreciate the Commission's focus on the linkage between care
provided in our hospitals and the readiness of our medical
force. We found their proposal to identify and quantify
readiness-related essential medical capabilities helpful to
focus efforts on the capture of specialty care for our
hospitals. That concept builds upon the Readiness Skills
Verification Program we have utilized in the Air Force for over
15 years to set clinical standards for the readiness of our
medical force..................................................
However, we do not see the need for a joint readiness command, as
existing processes jointly utilized by the services enable us
to measure and assess the readiness of our force...............
We have significant concern about the impact the Commission's
health plan recommendations would have on the readiness of our
force. We believe the proposal would shift family member and
retiree care significantly to the private sector and thereby
move care essential to our readiness out of our medical
facilities.....................................................
We also believe the proposal to place our medical facilities into
competition with the private sector would drive up
administrative costs and significantly detract from the focus
on the operational mission in our medical facilities...........
The second area of primary concern centers on our support to
Active Duty families. We believe resilient families with
excellent health service support greatly enhance the resilience
of all of our airmen. We support changes in the President's
budget to improve TRICARE while enhancing our readiness........
Additionally, significant progress in the strategic line of
efforts referenced by Dr. Woodson has occurred, and we are a
progressive system of health and readiness as a result.........
We are concerned that the Commission's proposed change to the
health plan would increase stress on airmen and families by
requiring them to navigate a complex insurance marketplace on a
recurring basis. We are concerned that the Commission's
proposal would shift family care significantly into the private
sector, thereby creating a hole in the safety net commanders
depend upon for Active Duty families under stress..............
Proper balance in the mix of our medical force is important to
maintaining a ready medical force while providing safe and
high-quality health services. The National Defense
Authorization Act of 2010 permanently prohibited the services
from converting non-military essential Active Duty medical
positions to civilian positions. Relief from this prohibition
would enable the Air Force to judiciously increase the
proportion of civilians in its force mix.......................
I thank the committee for your continued support for Air Force
medicine and the opportunity to answer your questions today....
Dr. Heck. Thank you..............................................
Admiral Faison...................................................
STATEMENT OF RADM C. FORREST FAISON III, MC, USN,
DEPUTY SURGEON GENERAL, UNITED STATES NAVY
Admiral Faison. Chairman Heck, Ranking Member Davis,
distinguished members of the subcommittee, thank you for the
opportunity to appear before you today.........................
The Navy appreciates your leadership in establishing the
Commission and commends the Commission for their thorough and
independent assessments. We remain guided by our Navy
Medicine's strategic priorities of readiness, value, and
jointness......................................................
We note that the Commission recognized the importance of these
imperatives and many of their overarching objectives are
largely aligned with our strategic priorities..................
Following the release of the Commission's final report in
January, Navy Medicine participated in the DOD-led rapid and
comprehensive review of the healthcare recommendations. While
there is general support for the underlying objectives of the
recommendations, I will briefly highlight some of our
perspectives and concerns regarding them.......................
In relation to medical readiness, we do support establishing
common and service-specific essential medical capabilities, or
EMCs, as they could be an effective means to monitor readiness
and guide resourcing decisions.................................
We note, however, that EMCs must be developed for more than just
surgical trauma skills. Military medicine supports a wide range
of operations, including treating disease and non-battle
injuries during military operations as well as providing
humanitarian assistance and disaster relief when called upon in
crisis.........................................................
While there is general agreement to the Commission's objective to
provide an affordable health benefit with additional choice, we
must recognize that our medical centers, hospitals, and clinics
are our most important readiness training platforms for our
military medical personnel and critical to sustaining vital
skills and clinical competencies of them. The availability of
case mix, volume, complexity, and diversity is vital to having
a trained and ready medical force..............................
In this regard, care of our beneficiaries is inextricably linked
to our readiness mission. Patient enrollment is fundamental to
our approach to maintaining the health of our patients. The
Military Health System is working hard to recapture workload
into our direct care system and leveraging initiatives like our
Patient Centered Medical Home program to improve access and
care...........................................................
Navy Medicine is leading forward in these areas as they continue
to show progress. We believe that the Commission's approach to
offer greater choice through the use of commercial insurance
plans presents risk by reducing patient volume and case mix in
our system and positioning MTFs [military treatment facilities]
at a significant disadvantage in attracting patients when
competing against commercial insurance plans...................
The careful assessment of the recommendations for exceptional
family members requires additional time. We agree with the
objective of expanding services to help family members with
specific needs, but more work is needed to identify which
specific services among the many State Medicare waiver programs
most meet their needs..........................................
Regarding the DOD and VA [Department of Veterans Affairs]
recommendations, we support the goals of the Commission, but we
believe that the current joint executive committee has
sufficient authorities to realize the outcomes desired by the
Commission.....................................................
Throughout Navy Medicine, we work closely with the VA in
assessing opportunities to collaborate and cost effectively
share services to meet the needs of service members and our
veterans, and we have several unique collaborations, sharing
agreements, and partnerships already in existence that benefit
both Department beneficiaries..................................
We are working with the Assistant Secretary of Defense for Health
Affairs, the Defense Health Agency, as well as our sister
services to incorporate many of these opportunities in the MHS.
Some changes can be accomplished within existing policy, while
others may require legislative changes for which we would
appreciate the Commission's and the committee's support........
In summary, we recognize we need to recognize what sets us apart
from civilian medicine, that we are a truly rapidly deployable,
fully integrated medical system. This capability allows us to
support combat casualty care with unprecedented battlefield
survival rates, to meet global health threats as we recently
did in deploying labs and personnel to Liberia in response to
the global Ebola crisis, and to our hospital ships, Comfort and
Mercy, deployed today and underway supporting missions around
the world......................................................
We must also understand that our readiness mission is directly
linked to the training and skill sustainment our personnel do
every day in our hospitals, in our clinics, in our labs, and in
our classrooms. We cannot expose our direct care system to risk
that could negatively impact our readiness posture. Thank you
very much......................................................
Dr. Heck. Thank you all for your testimony.......................
We will now begin a 5-minute round of questioning from each
member. I will defer my questions to the end and recognize the
junior member of the subcommittee, the gentlelady from New
York, Ms. Stefanik, for 5 minutes..............................
Ms. Stefanik. Thank you, Mr. Chair...............................
And thank you to all of our witnesses here today.................
I wanted to focus and address my question to General Horoho. I
represent New York's 21st District, which is home to Fort Drum,
and part of the 10th Mountain Division is based at Fort Drum...
Later this summer I plan on hosting a listening session with
various service members and their families to hear their
feedback on the Commission's reports and healthcare plans going
forward........................................................
And Fort Drum is unique, as you know. There is no hospital on
post and we have a very strong partnership with civilian
hospitals like Samaritan and River Hospital. I think you
visited Fort Drum recently to assess----.......................
General Horoho. Yes, ma'am.......................................
Ms. Stefanik [continuing]. That partnership......................
Could you talk about whether there will be an impact for Active
Duty service members because of that unique relationship,
because there is no on-post hospital...........................
General Horoho. Thank you, ma'am.................................
If I understand the question correctly, are you asking whether or
not there would be an impact if we move towards the
Commission's recommendation on Fort Drum?......................
Ms. Stefanik. Correct............................................
General Horoho. Okay. I do believe there will. And the reason why
I say that is that right now many of the readiness skill sets
even though we have a unique capability there with the clinic
and then we have a strong partnership with the civilian
facilities, we still rely on a large family member and retiree
population getting their care at Fort Drum proper..............
That allows us to enhance our readiness skills of our medics as
well as our clinicians, our orthopaedic surgeons, and the
entire healthcare team. If that population goes out to one of
the 11 different plans that are out there, then we become
competition with the healthcare plans and it is an
unpredictable population that we would be able to treat........
Ms. Stefanik. Great. Thank you very much.........................
And then I just wanted to ask broadly: Can each of you talk about
the kind of listening sessions that DOD has done to understand
the concerns directly from the service members. I know this is
a large question. Just broadly, if you can answer that.........
Dr. Woodson. Sure. Let me start, and I will let the Surgeons
General follow on..............................................
Just, you know, briefly, coming out of the MHS review, we
conducted town halls. Of course, we routinely, in fact, use
survey techniques to find out what is going on.................
And for the sake of brevity, I would just say that the Evaluation
of the TRICARE Program: Access, Cost, and Quality, the 2015
report to Congress, contains a lot of good information about
what we do to survey our population to adjust the program and
understand where we are at and where the improvements are
needed. And I would just recommend that to you.................
General Ediger. Yes. In addition to what Dr. Woodson referenced
from the MHS review, which was very valuable and helpful, each
of our medical group commanders has a panel in which they
conduct regular listening sessions of people who consume their
health services in the local community.........................
We have a process by which the findings and the trends from those
sessions are fed up and centrally analyzed for trends, and we
found that to be a very helpful process........................
In addition, each of our medical groups uses social media to
solicit input and feedback from the people that consume their
health services, and we also use social media centrally for
that purpose...................................................
Ms. Stefanik. Great. Thank you very much.........................
Did you want to add?.............................................
Admiral Faison. Yes, ma'am.......................................
Same in the Navy. We conduct regular town hall meetings. We have
an expectation that all of our COs [commanding officers] will
regularly attend the healthcare consumer councils at each of
our bases. And whenever we travel, we make a point of meeting
with every line commander to solicit their input. We also are
very active on social media to get feedback in.................
General Horoho. If we are going to go all the way, I will do the
same thing, then, because we are very similar in our
approaches.....................................................
The other is are virtual town halls that actually are conducted
from the Chief of Staff of the Army on down to get the feedback
from our beneficiaries and being able to hear their voices and
the concerns...................................................
We have also had high-reliability summits to be able to educate
our Active Duty professionals in the healthcare business. And
then we take that back to the commands and then they share
information with the beneficiaries as well.....................
Ms. Stefanik. Great. Thank you very much.........................
I yield back.....................................................
Dr. Heck. Thank you..............................................
Mrs. Davis.......................................................
Mrs. Davis. Thank you, Mr. Chairman..............................
And I appreciate, again, all of you being here...................
I am not sure if my questions are related. Probably are..........
But, first, you did talk a little bit about the loss to the
beneficiary because, if--in the Commission's recommendations,
we had a different system, and training of medical personnel
was critical to that...........................................
So I wanted to ask about that, but also about the fact that the
Commission determined that EMCs, the essential medical
capabilities, are not clearly defined and they suggested that
the DOD had not established the clinical proficiency standards
for military medical personnel in facilities based on widely
accepted metrics...............................................
So, you know, you may not agree with that assessment, but I
wanted to know how you see that assessment and what you would
propose. And if you can attach it to training, that would be
great, but maybe that is a totally different question. So----..
Dr. Woodson. Yeah. Maybe I can start and, again, the Surgeons
General can add on.............................................
From a context point of view, one of the things we have to
understand is that medicine really has evolved. So four decades
ago a doc [doctor] may have been a doc and a nurse may have
been a nurse and today, with sub-specialization, the idea of
what the competency is and how to maintain that competency is
radically different............................................
And so the issue, really, that we got to, again, as part of the
modernization study and some of the self-analysis we were doing
is identifying what the specifics of the skill set should be by
specialty and military occupational skill set. And this is a
really big work, but important work to do so...................
We self-identified, prior to the Commission, that we needed to
focus on this issue of better defining readiness, competency,
and being able to measure that. I think the Surgeons General
have done a great job, and the Air Force, I think, has a great
matrix that they use. And the other services have their metrics
as well........................................................
General Horoho. Thank you, ma'am.................................
We have looked at this over the last 3 years--this has been a
culture shift across Army Medicine--and really looked at our
hospitals as being our readiness training platforms because
that is where we house our graduate medical education programs
and our health professional education programs.................
So we rely on a constant beneficiary population that gives us the
complexity and the case mix. We evaluated where we had our
Active Duty, that there was a mismatch a couple of years ago
where our green-suiters were. They were in more of the smaller
areas, and then we had contract personnel and civilians more in
the medical centers............................................
Those medical centers are where we need that complex capability
and readiness skill set training. So we have started migrating
and shifting where our Active Duty population is...............
We have also looked at it from not just combat casualty care, but
actually the readiness skill sets that are needed for every
single one of our service members that are part of the medical
team. And so I will give a good example. We looked at
substitutability...............................................
So we may have rheumatologists that we need for our day-to-day
healthcare beneficiaries, but for deployability, we are
identifying what are the wartime skill sets that are needed for
that specialty so that they can be substituted for a surgeon on
the battlefield. And so we are now down to that level of detail
of really looking at it........................................
And, in addition to that, we now have standards in place where I
can assess the readiness of my military treatment facilities, I
can assess the individuals. And now we have just rolled out,
with all three services using it together, a surgical tool that
allows us to look at every one of our operating rooms, the
number of cases that are needed, the complexity, and then being
able to look at that in addition to assessing our surgeons.....
Mrs. Davis. Thank you............................................
I think I will go ahead and have the Surgeons respond............
And I think part of my question around this, too, and the whole
issue I know Admiral Faison will and I talked about this a lot
in San Diego because, you know, there is this concern--and it
is partly why the Commission addressed this--in the mix in
terms of the patient population and the ability of medical
professionals to have access to be able to help those and treat
those who are coming from a more diverse and a larger
population.....................................................
And so I guess I am just trying to get at that as well in terms
of whether the mix that you have is adequate to do that, since
we also are looking at the general public to help with that. We
know that military medicine is not going to be able to support
that always and----............................................
General Ediger. Yes. An important point is that, when we talk
about essential medical capabilities and clinical currency, we
are talking about that within the context of readiness, the
clinical skills that are needed in a deployed environment,
which don't always exactly match up with our day-to-day
practices at home station......................................
And so, in the Air Force, we have had a process that, by
specialty, we actually define case volume and mix and skills
that actually translate into the deployed environment, and then
we keep records and we track the extent to which we are able to
meet those requirements and keep clinicians ready..............
In some cases--you are right--our population doesn't really have
the demand in certain procedures that would support our
readiness requirements. And so, in the Air Force, we have used
strategic partnerships in some cases--and the other services
have as well--to send selected clinicians to other places under
training agreements to make sure they are current in those
types of skills................................................
I think what we have all decided to do together is to actually
incorporate these standards for clinical readiness into the
measurement of the preparation and readiness of our forces and
present that jointly the same way our combatant partners in the
line present the readiness of their forces.....................
Mrs. Davis. Thank you............................................
I know my time is up. Thank you, Mr. Chairman, for those
additional minutes. Thank you. We will get it later............
Mr. Jones. Mr. Chairman, thank you very much.....................
And, Dr. Woodson, I read your letter on May 19th, and I would
like to make reference to that.................................
First, I would like to share with you and the panel an email from
a marine's wife down at Camp Lejeune, which is in my district,
and I will start with this from her email. ``2 weeks ago, on
April 13 of 2015, he attempted suicide. He has severe PTSD
[post traumatic stress disorder], a TBI [traumatic brain
injury] because of an IED [improvised explosive device]
explosion, and has severe physical ailments associated with the
blast. He was placed on a ventilator for about 12 hours as a
precautionary while the pills he had overdosed on worked their
way through his body while he was sedated and unresponsive.''..
The reason I wanted to bring that forward is because many of us,
not all, but in Congress, including Senator Vitter, have been
very supportive of an option that we would hope that the
Department of Defense would give to the medical doctors in all
services, should the doctor decide that maybe hyperbaric oxygen
treatment [HBOT] might be a way to treat PTSD and TBI..........
I asked in the letter I wrote you that you respond and not
Admiral Wagner. We had written Admiral Wagner and asked that
the hyperbaric oxygen treatment--that Admiral Mullins himself
go to Camp Lejeune, remain there and be put in the Intrepid
Spirit Concussion Recovery Center at Camp Lejeune. Obviously,
his response back was not very encouraging. So let me go to
this paragraph.................................................
``How much money was expended by DOD on medication in 2014 to
treat PTSD and TBI for Active Duty military? As we note,
certain medications have been implicated in the suicidal
epidemic in our veterans. Are you aware that Dr. Harch
published a statistical significant reduction in suicidal
ideation in the HBOT-treated veterans and this was accomplished
in veterans with the combined diagnosis of TBI and PTSD? Do you
have any DOD studies showing the same with any other therapy?''
I don't expect you to answer that today, but I am looking forward
to your answer.................................................
What is so ironic to marines down at Camp Lejeune is that, in
this Intrepid Center, they can be treated with yoga and
acupuncture, but they can't be treated with hyperbaric oxygen..
To many of us in both parties, House and Senate, we just don't
understand why and how that the Department of Defense in their
studies say that they do not see where hyperbaric oxygen
treatment would be a positive..................................
And, yet, Dr. Harch, who is a foremost expert at LSU [Louisiana
State University] on this treatment, has even offered--and I
have written to Secretary Mabus--that he will take 12 marines
from Camp Lejeune at no charge to DOD and LSU will absorb it to
treat them for 8 weeks. And I hope that you will take the time
to read carefully what we are asking you.......................
As you know, Senators Vitter and Landrieu asked on Inspector
Jones' investigation as to how the Department of Defense--the
different studies have studied hyperbaric oxygen and why they
do not think this would be helpful to those with PTSD and TBI..
So I hope that you will answer this letter. Again, it was May the
19th. And I want to give you, as I would anybody, 6 to 7 weeks
to respond back................................................
But when you read--I have never heard of any, any, soldier or
marine or anyone that had the treatment of hyperbaric oxygen
that committed suicide. Yet, when they are medicated, we are
averaging maybe 20 or 21 a day committing suicide..............
I don't understand, sir, why this treatment will do no damage--if
it doesn't do any good, it doesn't do any damage. I guarantee
you it will do more good than yoga or acupuncture..............
Will you promise me today and this committee that you will
respond back to this letter that we have written here?.........
Dr. Woodson. Absolutely..........................................
Mr. Jones. Thank you, Mr. Chairman...............................
Dr. Heck. Mr. MacArthur..........................................
Mr. MacArthur. I pass............................................
Dr. Heck. Okay. So we had a briefing from the current TRICARE
administrative service organizations [ASOs] on how they viewed
the Commission's recommendations. Obviously, they all have a
non-military health insurance option that they also provide,
and they stated that they felt that there would be opportunity
for them to address some of the shortfalls or deficiencies
identified by the Commission if they were just allowed to
utilize some of the best practices that they have on their non-
military side on the military side. This is moving away from
fee-for-service to value-based care............................
So, Dr. Woodson, I know we have had this discussion a little bit
offline. You know, as the TRICARE 2017 contracts, RFP, is out,
what would be the pathway to be able to, one, provide the
authorities necessary to allow some of what is being done on
the civilian side to come into the military side as far as
managing health care?..........................................
And how would that happen if the TRICARE 2017 contracts are let
prior to those changes being made? Would it be a mod? Is there
a benefit to just extending current contracts till we figure
this out? What do you believe is the best way forward?.........
Dr. Woodson. So thank you very much for that question. And we
fully endorse moving toward utilizing value-based care in the
management of both the TRICARE contracts and our patients to
their betterment...............................................
As we move to 2017, again, we have approached it in a more
disciplined way. And, in fact, we are looking for the authority
to use value-based care........................................
Now, as it relates to the flexibility, remember, there is a
common misperception about the contracts that they are kind of
5-year locked-in entities. They are not. In fact, they are 1
year with yearly options. And we modify contracts all the time.
Continuing the extension of current contracts is costly and, in
fact, it just maintains sort of antiquated systems. And so, as
we move more to trying to use utilization management tools, big
data to better define and manage our populations, it is very
important that we modernize the contracts. But we can
incorporate all those things and fully anticipate incorporating
all of those issues into the 2017..............................
And, lastly, we have already moved out in terms of value-based
care. We have a demonstration project right now in Maryland in
which we have a pay-for-performance model......................
And, lastly, we are working very closely with Medicare on their
work group, but to define particularly those outcome parameters
that are important in making sure you have success with value-
based care.....................................................
Dr. Heck. Great. That is very encouraging........................
I look forward to continuing to work with you to make sure that
DOD has all the authority it needs to be able to capitalize on
some of these proven strategies that are currently forbidden or
prohibited from being utilized in the military healthcare
system.........................................................
One of the other areas that was brought up is, of course, the
importance of patient data and data analytics. And, you know,
it seemed like there was a disconnect in being able to have all
the data to adequately manage a patient's care when the
prescription part of TRICARE is not part of any one of the
ASO's service lines............................................
And it was brought forward that perhaps and, as I understand it,
prior to my arrival here, it was Congress that said, ``Go ahead
and go out and get us a separate PBM [pharmacy benefit
manager].''....................................................
But the idea of bringing prescription service back within the ASO
contracts, thoughts on that?...................................
Dr. Woodson. Well, I think it is very important, I guess, to
address the central point of making sure there is single point
of accountability for the coordination of all of the benefits
and care, and that is one of the issues that concerns me about
the Commission recommendation..................................
So if you look at what would have to happen, we would have to
disestablish the DHP [Defense Health Program], disestablish
TRICARE. We would have to have OPM [Office of Personnel
Management] establish this choice network with navigators
because it would be very important. They would have 250
programs which the service members and beneficiaries would have
to negotiate...................................................
We would have to expand the MERHCF [Medicare-Eligible Retiree
Health Care Fund] fund to cover the healthcare and pharmacy
programs for non-Medicare-eligible retirees. Funds from the
services' MILPERS [Military Personnel] would have to be
transferred to the employees' health benefit fund managed by
OPM for Active Duty family members, Reserve Component and
family members.................................................
For gray-area retirees that is non-Medicare, funds should also be
transferred from MERHCF to the employee health benefits fund
managed by OPM. We would have to establish a new trust fund
which would be managed by DOD to finance existing pharmacy and
dental programs for Active Duty family members and Reserve
Components.....................................................
MTFs would be funded through a revolving fund and using
reimbursements that they receive for care. And the services'
O&M [Operations and Maintenance] accounts would be at risk for
shortfalls, and we estimate that would be about $2.4 billion a
year. And we would have to establish a catastrophic fund for
Active Duty family members.....................................
Now, the key here, though--and then DOD would still be
responsible for pharmacy, dental, vision, the basic allowance
for healthcare, the networks for Active Duty service members,
the networks for overseas Active Duty service members, which
there is no mention of how we would handle that in the
Commission report, ECHO [Extended Care Health Option]..........
And so the important issue here is that, if you take it from the
point of view of the beneficiary--and let's just say, for
example, we take an Active Duty family with an exceptional
family member, a child with autism, let's say..................
They are going to have to deal with these private insurers for
the health care and then they are going to have to deal with us
for other things. And if they have cost overruns, then they are
going to have to try and get into this catastrophic fund.......
That is a lot of touchpoints. And then, if you add to that the
highly mobile population we have, I think that there is
substantial risk when you don't have a single point of
accountability for the entire health benefit, substantial
education for retirees, substantial education for
beneficiaries..................................................
So I think there are some risks, and I think there are easier
approaches to reforming TRICARE to make it exceptional. And I
think that is where we would love to work with Congress........
Dr. Heck. Great..................................................
We will go for a continued round until we get called for votes...
Mrs. Davis.......................................................
Mrs. Davis. Thank you, Mr. Chairman..............................
And perhaps, Dr. Woodson, I can pick up on that. And I hope the
others will join in, too.......................................
One of the things that we heard with the Commission was I think
they were a little displeased, actually, when they heard that
there was a kind of protectionism coming through, that surely
our military families might not be able to navigate on multiple
systems like this. And I think you all said as well that, you
know, it is harder to navigate a more complex system...........
So I wonder if you could respond to that a little bit because I
understand exactly what you are saying, how important it would
be to have a point of accountability. But at the same time
there was a sense that somehow we couldn't provide the support
system to enable families to be able to utilize that to the
best of--you know, to serve their needs........................
And if you can expand on having more options for families, more
choices, as they talked about, that seems to be a good thing,
and maybe we shouldn't get caught up in whether or not they can
navigate it....................................................
So help me out with this a little bit because I don't think that
is really the reason to not do this, of course, but----........
Dr. Woodson. I am sure the Surgeons General will have--that is a
great question, and the Surgeons General will certainly want to
say something about this.......................................
But let me just say this, that when I go out and talk to folks
and when I look at surveys, choice is not about wanting to
navigate through 250 health plans..............................
Choice, as expressed to me, is ensuring that I have a robust
health benefit that will take care of my health needs when I
want it, and then the real choice is about being able to see
the provider that I want when and where I want them............
And so if you look at PB [President's budget] 2016 and 2015
proposal, it was about giving more choice to the family member
so that they wouldn't have the hassle of authorizations and
referrals and they could choose when and where they wanted to
see, you know, the doc or the provider. That is, I think, the
choice that they want, not necessarily a lot of programs.......
By the way, when you boil it down and you go into the commercial
market, you really find three types of programs. Right? You
find health maintenance organizations, which is similar to our
Prime. You find fee-for-service programs of two types. One is
preferred provider and one is, again, more open fee-for-
service. We have those, basically..............................
So they are not going to have really different choices in terms
of types of plans. They are just going to have to navigate
through more insurance programs and not have a single point of
accountability.................................................
Admiral Faison. Ma'am............................................
General Horoho. Yeah. Go ahead. And we will go backward..........
Admiral Faison. I will address the most difficult case for the
Navy. Thirty-five percent of the Navy is deployed in any given
day, and 75 percent of our sailors were born after 1986. They
are very young.................................................
And so the typical sailor is married with two children. So they
are stationed, let's say, in San Diego. The ship is out at sea.
Right now, if that family member has a problem with their
health care, they call the CO [commanding officer] of the
hospital. It is one point of contact...........................
So I want to distinguish between navigate versus advocate. And
so, if there is an issue, they call one person. If we allow
them the choice, they are navigating several hundred health
plans, as a CO of a hospital, having just been one, I have no
leverage over those plans. So how do I advocate for that mom
and her children?..............................................
And if one of those children is a special needs, she is dealing
with the health plan for part of her healthcare needs, she is
dealing with DOD for the special needs part, she is dealing
with DOD somewhere else for pharmacy. It is overwhelming while
you are trying to balance two kids as a single parent and your
grandparents are back in Texas, as an example..................
So we are worried that we are adding to the plate of our service
members to get a benefit where right now they have got kind of
a single point of contact to pick up the phone and help them...
Mrs. Davis. And, of course, we know a lot of those are ombudsman
as well----....................................................
Admiral Faison. Yes, ma'am. Absolutely...........................
Mrs. Davis [continuing]. That single point of contact. And it is
wonderful in San Diego.........................................
Sir..............................................................
General Ediger. I would agree with that completely. It is not
that we think the families are incapable of navigating. We just
see the complexity of it as another source of stress for
families that we know are already under stress by virtue of the
service and the OPSTEMPO [operations tempo] that they are a
part of........................................................
I think the other thing that would be challenging in that venue
is that, if we have families who have a variety of different
health plans that they have chosen on the marketplace, those
plans come at different prices. They will have different ranges
of benefits....................................................
And so we have a remarkable system between all three services of
employing the medical home concept in the way we provide
primary care. And so with that comes timely prevention in a
coordinated team-based approach to care........................
That becomes more difficult to apply if you are dealing with a
patient population that has got a variety of different types of
health coverage................................................
And so we think we can do a better job of providing continuous
support to their health and performance over the time of their
service to the Nation if they are getting their care
continuously in our MTFs.......................................
General Horoho. And, ma'am, in addition to that--because we are
pretty similar in all of our responses--I think the importance
of the care coordination can't be understated, especially when
service members are deployed...................................
And when we looked at the area with behavior health, one of the
things that we realized is we had to be very unique in the way
that we supported families or children that had stressors due
to the deployment. So we took our behavior health and we are
able to embed them into the school-based programs..............
When they are out into the civilian sector, those types of unique
options are not going to be available to respond to really
timely needs...................................................
And I think the other piece of it is, as we realize when health
care is changing or opportunities to be able to be much more
responsive in the area of health, that allows us to employ all
of our capabilities together using tele-capabilities to really
reach our patients where they need their care..................
Mrs. Davis. Yeah. Thank you......................................
Thank you, Mr. Chairman..........................................
Dr. Heck. Mr. MacArthur..........................................
Mr. MacArthur. Thank you, Mr. Chairman...........................
I am sorry I missed your opening remarks. I would have been very
interested in hearing them. But a lot of the discussion on this
part of the Commission's recommendations has been around the
quality of health care to our military families, and rightfully
so. And that is why the four of you are here with that focus...
But some of the Commission's focus was on the financing of health
care, and that has given rise, I think, to a lot of the
recommendations................................................
And as I think about that, the financing of it, the creation of a
structure, and they have gone down the private route, and I
think there are other views that fixes to TRICARE would be a
better approach to that, I worry about the next iteration......
So we make fixes now and then the broader marketplace continues
to evolve and new programs allow the non-military healthcare
world to make changes and get efficiencies and TRICARE is stuck
in whatever new model we create. And so my question has to do
with how we create a self-evolving TRICARE.....................
Let me explain what I mean with that. Something that doesn't
require an act of Congress every time we want the program to be
able to keep pace with what is going on in the marketplace. And
I think this concept is essential, and this is why I have been
somewhat supportive of the private market idea, although I
think there is problems with it................................
And so I am now back in my thinking to what do we do to TRICARE
so it can evolve. Without you coming and getting 435 members,
you know, half plus 1, to agree to that, I would be interested
in your insights on that.......................................
Dr. Woodson. So let me start again, and the Surgeons General can
follow on......................................................
That is an excellent question. That really is the heart. So one
of the things I think we all need to consciously understand is
that TRICARE is not an insurance program. It is a defined
Federal benefit program in which it is guided by laws and
statutes and the like. And that was probably very appropriate
two decades ago................................................
What we need to, again, I think partner on is giving the
flexibility to the administrators of the program to evolve the
program in real time to take advantage of what's occurring in
medicine.......................................................
So I was very thankful to Congress when last year they gave me
the ability to look at evolving medical technologies and
implement them without coming to Congress right away, and that
was just new. That is new. But it is that kind of thinking.....
You know, I had this discussion with some folks, and it had to do
with something we wanted to do with TRICARE. And the lawyers at
the time were telling me, ``No. You can't do that. No. You
can't do that.'' And they were well meaning--don't get me
wrong--about this..............................................
But I said to them, you know, ``Someone once said that the law
should be stable, but never static. But medicine is neither
stable nor static. And so we have to understand that and build
in the flexibility.''..........................................
Now, you, as Congress, in your rightful authorities and position,
should have oversight. And so what we owe to you is a mechanism
for bringing to you what we have done and being accountable for
what we have done, but we need to have the flexibility to
modify and approve the program to make it, again, the
exceptional program that the beneficiaries deserve.............
Mr. MacArthur. If any of you know, how many lives are covered by
TRICARE today?.................................................
Dr. Woodson. 9.5 million.........................................
Mr. MacArthur. I mean, that is bigger than many, many health
insurers. That is a lot of lives. One would think that we
should be able to create a form of TRICARE that is competitive
with anything----..............................................
Dr. Woodson. You bet.............................................
Mr. MacArthur [continuing]. That the private market can offer and
that can evolve just like the private markets evolve...........
And I would encourage a continued dialogue because I think there
is the potential for that that could possibly overcome some of
these hurdles that--and, as I said, I started as--we have had
these discussions--I started as an advocate for change, but
sometimes the--you know, sometimes the cure can be worse than
the illness. And so I think maybe we need to explore this more.
I yield back. Thank you..........................................
Dr. Heck. Thank you..............................................
And I want to go back. Dr. Woodson, thanks for, you know,
pointing out all the things that the Commission would require
you to do to set up this new program...........................
And as we move towards the idea of value-based care and having
that single point of accountability and contact for a patient
in a medical home, it goes back to the previous question that I
had, which is: Is there, you know, benefit in looking at--do we
bring pharmacy benefits back in-house to the TRICARE ASOs, the
nurse advice lines, which right now don't go to the ASOs, so
you have somebody calling for nurse line advice that is
unrelated to the actual healthcare provider they are going to
wind up seeing?................................................
So I think, as my colleague said, as we evolve and try to
maximize the benefits of what has happened on the outside of
the military healthcare system, again, we need to come up with
how do we give you the authority to be as flexible and agile as
you need to be. Right?.........................................
And to the Surgeons General, a topic we haven't discussed yet:
Your opinions on the idea of a unified medical command. What do
you think are pros versus cons, in 3 minutes 58 seconds?.......
General Horoho. Let me go quick..................................
The Commission actually recommended a joint readiness----........
Dr. Heck. We have taken that one off the table...................
General Horoho. You have taken that off. Okay....................
Dr. Heck. We are just taking about specifically--kind of like a
TRANSCOM [Transportation Command] for medicine.................
General Horoho. You know, I think right now we have spent so much
time and energy and we are starting to see some progress in the
10 shared services.............................................
I think we need to allow that to continue to progress. We have
really worked with standardizing our capabilities and looking
where we need to be more interoperable.........................
And so I think there is some goodness in cost savings and, also,
just standards that will be common across the board to decrease
unwarranted variance...........................................
So I support the direction of refinement of where we have been
going with the Defense Health Agency and then common business
processes across the board.....................................
General Edinger. Yes, sir. I agree...............................
I think, if you look at what has happened over the past 3 years,
there have been substantive change in the Military Health
System. We have worked together jointly under a new governance
process........................................................
We have stood up the 10 shared services with the Defense Health
Agency to gain efficiencies and effectiveness in what we do in
common. We train our enlisted out of a joint platform. We have
a medical school where our physicians train together. And we
have a lot of our hospitals now, more than ever, that are
jointly staffed................................................
So I think what you are seeing is a significant evolution in the
way we work together jointly in our home station medical
support........................................................
Admiral Faison. Sir, I would agree with that.....................
You know, we have been doing this for a long time. All our IT
[information technology] systems are architected jointly so
that, no matter where you go and what facility you are in, your
healthcare record is available.................................
We deploy our staffs together. You know, when I was deployed in
theater running a combat hospital, I was commander of a joint
task force. I had Army and subordinate Air Force units working
for me. We worked together side by side........................
In San Diego, when I was in garrison, all the wounded warrior
care physical medicine rehabilitation was provided by Army
physicians. We trained Air Force pediatricians.................
We have been doing this. And now we have evolved to these shared
services. I would recommend we give these an opportunity to
mature and then step back and say, ``What problem are we
solving?''.....................................................
Dr. Heck. And, General Edinger, thanks for putting out a plug for
Uniformed Services University, one of the finest medical
schools in the country and no better military medicine school
in the world. I was on faculty there for 4 years...............
Mrs. Davis.......................................................
Mrs. Davis. Thank you, Mr. Chairman..............................
I might just ask if you are seeing any outstanding cultural
issues in that integration as you move forward with jointness..
Admiral Faison. Ma'am, I will address that.......................
I had the privilege of visiting San Antonio for our combined
enlisted training program that we run for all our ``A'' school
corpsmen, our medics, our technicians, and they all get their
training together now. And although we preserve our service
cultures, we teach our corpsmen how to salute and the different
signal flags and things like that..............................
What really impressed me the most was, when I looked down into
the courtyard, I saw Army, Navy, and Air Force young, junior
enlisted folks working together, making friendships and bonds
that were going to carry them throughout their careers. I have
not seen service cultures, you know, we have the banter that
goes back and forth where I am trying to learn how to say
``Hooyah'' and at the same time how to teach my Army colleagues
how to say ``Ooh Rah.'' But when push comes to shove, when we
are at the bedside, we are taking care of the patient as one
team. I haven't seen cultural issues...........................
General Horoho. If I could just give an example, when the issue
came up with the capabilities that needed to deploy in support
of the Ebola mission, it was all three services coming together
and saying, ``Let's look at how do we do this jointly.''.......
We looked across our facilities, as Surgeons General, and
identified the capabilities that were needed. It was a tri-
service effort. We went down to San Antonio. It was all
services coming together, developing the training plan.........
And then they were ready to support that mission. That is a whole
different way in which we have approached those types of
missions.......................................................
General Edinger. I agree.........................................
We have learned that culture is important because we are part of
a mission. And so, when we deploy our medical folks out to work
within our missions, they need to be able to work within the
culture of our service.........................................
But at the same time we have learned that culture should not and
does not get in the way of the way we take care of our
patients. And so I think we have learned how to strike that
balance appropriately..........................................
Mrs. Davis. Thank you............................................
Dr. Heck. Mr. MacArthur..........................................
Mr. MacArthur. I would like to continue that discussion that I
suggested a few moments ago, and it is how can we give you more
flexibility today..............................................
In broad strokes, are there two or three things that we could do
now structurally that would give you the flexibility not to
propose programs that we then approve, but give you the freedom
to explore, to act, to try things without an act of Congress,
you know, those broad changes? Are there things we could do
today that would allow you to change the current program?......
Dr. Woodson. So thank you again for what I think is an
extraordinarily important question.............................
So in the spirit of, again, medicine isn't stable, we need to
develop legislation that gives authority, I think, to the
Assistant Secretary of Defense to define a process for
evaluation involving medical technologies for inclusion in the
program and then include them, even if it requires subsequent
follow-up evaluation of their efficacy at some point in time in
the future.....................................................
And that ought to be broad. I think that is really very important
because, again, medicine isn't stable. New ways of treatment
evolve every day. And the way the language reads now, it is
pretty rigid about the requirements for evidence, and that sort
of stalls us a little bit......................................
I think there are some other things that we need to deal with to
synchronize our efforts. One of the things that the Surgeons
General and my office have come together on is looking at new
models in which we can manage markets, optimize the use of the
military treatment facilities, and optimize the use of the
purchase care market...........................................
And so there are going to be some new, I think, authorities that
we'll need to allow patients to flow from the market to the
MTFs to ensure we have the proper case mix, this to include new
ways of attracting Medicare-eligible or -aged patients, whether
or not we actually define and establish a sort of Medicare
Advantage within the MTFs......................................
We need to be given broader authorities, I think, that relate to
taking care of veterans. I think, in fact, there is even an
opportunity for us to take care of DOD civilians. And, in fact,
you know, we have a lot of dual-eligible folks who, in fact,
work for the Federal Government and they have TRICARE benefits.
Well, why not allow them to use the TRICARE benefits within the
MTFs?..........................................................
See, I think this would lead to proper utilization of the MTFs,
proper market management, meet the case mix-skill mix issue and
actually allow us to deliver extraordinary service to the
beneficiary population.........................................
So those are some of the things. There are other things that we
could talk about, but off the top of my head, that would be
some of the things we would look forward to....................
Mr. MacArthur. Let me explore one other. And I am happy to have
any of you answer..............................................
In the private sector, you have a constant dynamic interaction
between the provider of health care and the financier of health
care. It is largely how the private sector healthcare system
has evolved, that tension between high quality of care and
affordability. And everyone hates it, but it works well. You
don't have that................................................
As you observed earlier, TRICARE is not insurance. We are the
financier of health care on behalf of the American taxpayer,
and you don't have that same daily dynamic interchange.........
Can you achieve what I am talking about, what we have been
talking about--can you achieve that without this two-party
negotiation going on a day-to-day basis?.......................
General Horoho. I will take that one and share it down the road..
Each of us have to be fiscally solvent to be able to manage and
run our healthcare facilities. And so we have very well-defined
business plans. We have incentives where we incentivize our
providers and clinicians for patient satisfaction for their
care experience, for health outcomes, and then we also
incentivize them for readiness.................................
So we have moved as we improve readiness. That is something that
they get incentivized and financial rewards for that and moving
even more so in a complicated system of looking at how do we
really move towards outcomes and functional health.............
So this movement from health care to a system for health is a
huge culture change that your financial system has to be able
to drive it and support it.....................................
General Edinger. Yes. I think really the answer to the question
you pose is really the value-based approach to providing health
care. And I think to do that we have got to define and consider
and measure and manage the performance and value in all of its
aspects. And so that is quality, that is safety, that is
patient experience, but it is also cost and efficiency.........
The performance management system that we built in the direct
care system and the action plans that followed up the MHS
review last summer are really focused on all the aspects of
value, including cost and per-member per-month cost, those kind
of things. We are now managing to that as a metric. So I think
really the answer is value-based approach to providing care....
Admiral Faison. And, sir, also adding into that flexibility,
flexibility, as we had talked about earlier, and agility.
Health care is dramatically changing and it is impacting the
military because, as I shared earlier, 75 percent of our
uniformed force were born after 1986...........................
How they make their healthcare decisions and what influences
those decisions is fundamentally different than what influences
us, as Baby Boomers. And so they pursue convenience and the
experience of care and increasingly technology, having the
agility to pursue value-based options..........................
Using those things without requiring them to come to a hospital
for their care is fundamental to our success and really an
operational imperative. So the things that you could do to help
to give us that agility is where success is going to lie.......
Mr. MacArthur. Thank you, Mr. Chairman. I appreciate your
indulgence. I was making up for lost time earlier..............
Dr. Heck. I appreciate your very informed questions..............
So I agree with Secretary Woodson's comments about trying to
attract more consumers of health care into our MTFs to provide
a better training platform for our military healthcare
providers to be better ready...................................
And I think that was really one of the places where the
Commission missed the mark. Certainly, when they presented to
us, they seemed to be focused on the idea of the MTFs being
training platforms solely for combat casualty care, not
realizing, as you well pointed out, General Horoho, that the
vast majority of folks we treat are not traumatic injuries.....
So the question is: If you get the authorities and the
flexibility and the marketing campaign is successful to bring
more lives into the MTFs, is there capacity within the MTFs to
be able to absorb a higher patient volume, whether it is the
may we go to a Medicare Advantage-type TFL [TRICARE for Life]
product or we go out and try to allow DOD civilians to
participate and receive care at the MTFs? Are you going to be
able to absorb that increased patient volume? And will the cost
associated with caring for those new patients keep your
business plan in the black?....................................
Dr. Woodson. So let me start again. I think the Surgeons General
really need to weigh in on this................................
So, first of all, within the MTFs, we have fixed cost. So if we
take care of one patient, the cost of care for that patient is
extraordinarily high. If we take care of more patients, of
course, the costs go down. And there are some built-in costs of
readiness, which is the issue we are talking about in terms of
maintaining skill and the graduate medical education program...
So the bottom line for me is that there is capacity. I think what
we have been working on is retooling how we are thinking and
how we are managing to make the system clearly more efficient
and to make us a preferred provider. And I will stop there and
let the Surgeons General talk..................................
General Horoho. And, sir, just in two areas with that, it would
be very helpful to be able to have a diverse population that we
could care for, but it is going to have to be tied to our
readiness: What is the complex cases that we need to really to
support our training programs and increase our medical
readiness of our providers and the support staff?..............
With that, though, it is going to require a commercial financial
system and a business intelligence system because both of those
are capabilities that we don't have right now and we would need
to be able do that so that we could bill for certain services..
General Edinger. So the care that is needed to help enhance and
support our readiness is specialty and inpatient care. And in
Air Force hospitals, yes, sir, we do have capacity.............
I think, as we potentially gain the ability to more effectively
capture care, that is the kind of care we would want to
capture. And so I think we would need to go about it in a way
using the business intelligence systems where we were capturing
the kind of care that is most relevant to our readiness........
And that is the kind of care where we have capacity. Our
hospitals are fully enrolled and growing. Our primary care
workforce is really not what we need so much on the readiness
side as it is to pull in specialty and inpatient care..........
Admiral Faison. Sir, I would agree with the other panel members.
We not only see unit costs go down as you see more patients,
but there is an inherent efficiency in the staff so that you
see more patients much more efficiently and you get better
outcomes.......................................................
And so long-term costs are down because you are getting better
outcomes and keeping people healthy. Short-term costs are down
because you are not using as many things to take care of them
in the short term. So I think there are inherent efficiencies
to that........................................................
We have capacity to do that. But, as General Edinger and General
Horoho said, we have to be selective. So we don't want to
recapture all of one thing. We only need to look at what
exactly do we need for our mission and then go after those.....
Business intelligence is critical for that, and we don't have
that right now. And so I think that will be an important tool
that we will need in our toolkit to go after those things......
Dr. Heck. Perfect timing.........................................
Well, I want to thank all of you, one, for staying with us even
though we started late, and for your answers to the questions
here today. Obviously, we look forward to continuing to work
with all of you to make TRICARE the premier healthcare provider
in the Nation..................................................
I want to again hail Lieutenant General Edinger to our group.....
And farewell to General Horoho. It has been a pleasure working
with you, and I am sure we will be talking to you soon.........
This hearing is adjourned........................................
[Whereupon, at 4:16 p.m., the subcommittee was adjourned.].......
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A P P E N D I X
June 11, 2015
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PREPARED STATEMENTS SUBMITTED FOR THE RECORD
June 11, 2015
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[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
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DOCUMENTS SUBMITTED FOR THE RECORD
June 11, 2015
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[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
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QUESTIONS SUBMITTED BY MEMBERS POST HEARING
June 11, 2015
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QUESTIONS SUBMITTED BY MR. JONES
Mr. Jones. In response to a congressional inquiry addressed to you,
the Army reported that, in May 2014, General Horoho's office approved a
business case analysis (BCA) submitted by HDRL to take all HIV testing
services ``in-house.'' In the months following this decision key
assumptions of the BCA have proven to be incorrect. Current facilities
have proven to be inadequate, test equipment, supplies and Army
resources unavailable. These significant lapses led to the Army's delay
in pursuing this for up to 3 years. It's also seems that the Army's
effort to do this would result in sole sourcing with a company that has
been heavily fined by the Justice Department, for bribing foreign
government officials in order to obtain government business, in
violation of the Foreign Corrupt Practices Act. (That company is Bio-
Rad.) Bottom line, fundamental assumptions of the BCA have proven to be
incorrect and the decision to take testing ``in-house'' needs to be
reviewed as the evidence appears to indicate increased costs. Just as
troubling the inferior performance of the proposed equipment, HDRL's
track record on shipment and turn around and the inevitable
uncertainties and inefficiencies associated with transition are cause
for serious concern.
Secretary Woodson, General Horoho; are you reviewing this decision
and if not, why not; and will you provide the committee with a copy of
the original BCA, along with analysis addressing those areas mentioned
above and any other areas where the BCA's assumptions have proven to be
incorrect, as well as, provide details of the estimated costs
associated with those changes. Thank you
Dr. Woodson. The basic requirements of HDRL's BCA, which support
the change in the Army's acquisition strategy for HIV testing, have not
been significantly altered. Delays to date have been due to ensuring
compliance with applicable policies and regulatory guidance, adherence
to current contractual requirements, and addressing solicitation
protests by the current contractor. The Army's current acquisition
strategy is resourced, and is proceeding according to schedule barring
any additional solicitation protests. HDRL's final costs within the BCA
are currently under revision due to several procurement actions that
are still out for bid. The Government's final cost for 4th Generation
HIV testing is projected to be lower than the current contracted cost
per test, which is based on a sole-source procurement to the incumbent
contractor. All Army Procurements are done in accordance with the
Federal Acquisition Regulations (FAR) and the Defense Federal
Acquisition Regulation Supplement (DFARS). This includes ensuring that
contract awardees are not currently suspended, debarred or otherwise
ineligible from receiving any Government contracts.
HDRL is fully accredited by the College of American Pathologists
(CAP), and has served as the DOD/HA HIV reference lab since 1987. HDRL
performs all OCONUS HIV testing (60K HIV screen tests/year), 6K HIV
viral loads/year of USA/USN infected personnel for confirmatory testing
and clinical monitoring, and 1.2K HIV resistance genotypes/year for all
DOD HIV infected Soldiers and beneficiaries. Under the current contract
all CONUS HIV testing that screens POSITIVE must be shipped to HDRL for
supplemental, confirmatory testing.
Under HDRL's BCA, greater efficiencies would be achieved with the
Army's HIV testing algorithm through performance of both screening and
confirmatory testing at a single location. This would facilitate a
quicker turnaround time for the Government for confirmed results as
HDRL would not have to wait for a contractor to ship samples that
screen positive to HDRL for confirmation. There are no known systemic
issues with quality or performance of either Bio-Rad or Abbott's 4th
Generation HIV testing method. A review of the Safety and Effectiveness
data submitted to the US Food and Drug Administration by Bio-Rad and
Abbott for their 4th Generation HIV test methods demonstrates
comparable analytic performance for both manufacturers that meets or
exceeds the FDA's sensitivity (>99%) and specificity requirements
(>99%) for HIV assays.
Currently, there are four open procurements actions. As the BCA
contains contractor bid and proposal information, commercial vendor
sensitive information, and source selection information related to
these ongoing procurement actions, the release of the full BCA prior to
final award would violate the Procurement Integrity Act (PL 111-350,
Section 2102 and FAR 3.104). Final award of the open actions is
anticipated in mid-August 2015, and the BCA will be releasable at that
time.
______
QUESTIONS SUBMITTED BY MR. WALZ
Mr. Walz. Dr. Woodson, do you agree with the MCRMC Conclusion that
``As evidenced by the similarity in benefits authorized under the HCBS
and ECHO programs, as well as the directive to use state and local
services before accessing ECHO, the Congress intended ECHO as an
alternative to unavailable waiver benefits. Yet ECHO benefits, as
currently implemented, are not robust enough to replace state waiver
programs when those programs are inaccessible to Service members and
their EFMs. With the exception of home health care services and ABA
therapy services, the ECHO program is not highly utilized. This is due
to a lack of needed services.''?
Dr. Woodson. The ECHO program, as currently implemented, offers a
robust range of integrated services and supplies beyond those offered
by the basic TRICARE health benefit program. These services and
supplies include, but are not limited to, assistive services (e.g.,
from a qualified interpreter or translator), durable equipment
(including adaptation and maintenance equipment), expanded in-home
medical services (through ECHO Home Health Care (EHHC), rehabilitative
services, respite care, training to use special education and assistive
technology devices, limited transportation services to and from
institutions or facilities, etc. The ECHO program was not designed to
serve as a full replacement to state waiver programs, and as a result,
there are significant differences between benefits authorized under the
HCBS and ECHO programs. To assist DHA in better aligning ECHO services
with HCBS, DHA has initiated an analysis of HCBS waivers and
eligibility criteria, and is in the process of designing a beneficiary
survey to identify current gaps in ECHO services and to evaluate which
HCBS services should be added to the ECHO program to better support our
military families.
Mr. Walz. Dr. Woodson, do you agree with the MCRMC's recommendation
that ``Services covered through ECHO should be increased to more
closely align with state Medicaid waiver programs, to include allowing
for consumer-directed care.''? If so, what is the implementation plan
and timeline? If not, what alternative would you propose?
Dr. Woodson. DHA is currently developing a beneficiary survey to
identify current gaps in ECHO services and to evaluate which state
Medicaid waiver services should be added to the ECHO program to better
support our military families. Consumer-directed care (which is legally
limited to respite and attendant care) is one avenue of service
delivery that will be considered after the survey has been completed
and the needs have been identified. To better understand how consumer-
directed care might be effectively implemented under the ECHO program,
DHA has met with the MCRMC research group to review the process for,
and the impact of, the implementation of consumer-directed care in
several states. Additional research in this area will occur over the
next 4-6 weeks.
Mr. Walz. Dr. Woodson, how can DOD in the immediate term, address
the underlying objectives of increasing access, choice and value in
military health care, specifically for families and children under
TRICARE? Do the steps require legislation or does DOD already have the
authority?
Dr. Woodson. The Military Health System (MHS) is addressing access,
choice and value in military health care through initiatives in primary
and specialty care. The Patient Centered Medical Home (PCMH) model of
primary care is our foundation for enhancing access, improving health
and increasing quality. Currently, over 310 of our primary care clinics
are recognized by the National Committee for Quality Assurance (NCQA)
as meeting the highest PCMH standards. The PCMH model of evidence-based
care supports the patient's continuous relationship with his or her
primary care manager (PCM) and healthcare team, who coordinates and
integrates the patient's care needs. PCMH also enhances access to care
by offering alternatives to face-to-face medical appointments including
walk-in clinics for common acute conditions, a Nurse Advice Line
available 24 hours a day and secure messaging, which allows patients to
email their PCM and healthcare team. To further improve access to care,
the MHS has embedded specialty providers for commonly occurring medical
issues directly in the PCMHs; these providers include behavioral health
specialists, clinical pharmacists and physical therapist. PCMH is
supported by two new access initiatives to ensure patient medical needs
are addressed in a timely manner.
First, MHS is implementing policies, which identify standard
processes for patients calling for appointments to ensure patients'
needs are resolved on the first phone call. The MHS also is
implementing Simplified Appointing Guidance, which will better match
primary care appointment supply by patient demand, especially for
appointments available within 24-hours. Simplified Appointing guidance
also identifies processes to appoint patients based on their preference
for when they want to be seen rather than on the acuity of their
medical condition. Simplified Appointing is based on best practices
recognized by the Institute of Medicine. By leveraging the success of
the Tri-Service PCMH program, the MHS is now developing standard
processes and goal to improve access to specialty care in the direct
care system. Finally, to expedite our patients' access to specialty
care in the direct care system or in the TRICARE network, the MHS is
now developing a streamlined specialty appointing process. DOD has the
authority to accomplish required actions and steps do not require
legislation.
Mr. Walz. Dr. Woodson, one of the key recommendations in the MHS
Review that was completed last summer stated ``The Department will
expand its collaboration with external health care organizations to
improve as a learning organization''. It is my understanding that
senior leadership within the Defense Health Agency will be meeting with
pediatric stakeholders, including the TRICARE for Kids Coalition, which
includes, among others, the American Academy of Pediatrics and the
Children's Hospital Association on the 24th of June. Using that meeting
as an example, can you explain how you intend to take their input as it
relates to pediatrics to improve ``as a learning organization''? I
would appreciate an out brief after the meeting, helping the committee
understand what their recommendations are, and how you plan to
incorporate their suggestions into ensuring we are providing excellent
medical care for our military connected children.
Dr. Woodson. The June 24, 2015, meeting did occur and we had great
attendance with representation from about 10 different groups, to
include the American Academy of Pediatrics, National Military Family
Association, and the National Association for Children's Behavioral
Health. Attendees were provided information on: (1) compound drugs, and
informed that TRICARE is dedicated to getting safe, effective, and
appropriate compound drugs to all beneficiaries, to include our
pediatric population. (2) Pediatric Program Updates (e.g. changes
planned for the Extended Care Health Option (ECHO) program (e.g.
respite care and adult diapers for incontinence, breastfeeding supplies
and services), and (3) TRICARE's benefits regarding mental health care
for children.
We are committed to hosting two meetings a year with the group and
will work to address their recommendations as they arise. We trust this
will ensure we continue to provide excellent medical care to our
military children.
Mr. Walz. Dr. Woodson, similarly, when it comes to children, we
hear that Medicaid and CHIP are the gold standard, in terms of the
comprehensive coverage and the attention to pediatric health and
development. What can you learn or adopt from those programs that will
enhance and protect children's health coverage, particularly in order
to create a program that responds to and develops in alignment with
best practices and technology and treatment options as they are
emerging and developing, so that the DHA is not always playing catch up
in the children's health care arena. Do the steps require legislation
or does DOD already have the authority?
Dr. Woodson. Medicare and CHIP are not designed as specific uniform
standards but rather are health insurance plans underwritten by the
states for children in families with income up to 200 percent of the
federal poverty level ($48,500 per year for a family of four). Eligible
children and teens can receive regular check-ups, immunizations, doctor
and dentist visits, vision care, hospital care, mental health services
and medications. These services are different in each state with
different requirements of income and necessity. All the medical
services in Medicaid and CHIP are available and some more robust within
the TRICARE entitlement programs. The alignment with emerging best
practices, technology and treatment options require evaluation of the
cost and legislative authority (Well Child Care defined up to age 5).
With the statutory permission received from Section 704 from NDAA 2015,
the DHA has been able to begin to design an enhanced approach to adopt
and review emerging and developing technologies. This will continue to
be strengthened through use of the governance system to review,
evaluate and recommend benefit changes to address evolving beneficiary
needs.
Mr. Walz. Dr. Woodson, has the DOD calculated any comprehensive
comparison of benefits and costs, including cost-shares and
catastrophic caps, between the recommended TRICARE Choice plans and the
current TRICARE plans? This is a big concern for families with special
healthcare needs, active duty and retired. Does DOD have a plan to
ensure that it can provide benefits (comparable to private plans and
MA/CHIP as they relate to pediatrics) without increased or variable
cost shares and catastrophic caps?
Dr. Woodson. The current TRICARE Prime and TRICARE Prime Remote
plans for Active Duty family members involve very minimal out of pocket
costs (primarily for prescriptions which would be unaffected by the
Commission's recommendation). Our analysis indicates that while the
proposed Basic Allowance for Health Care (BAHC) equals or exceeds the
average out-of-pocket costs, the financial risk for active duty family
members varies considerably by eligibility status, family size, choice
of plan selected, and health status (including for families with
special health care needs). According to the Commission's report,
nearly 1 in 6 Service member families will be negatively impacted
financially. 50,000-100,000 families will experience unreimbursed out-
of-pocket expenses of more than $1,000 above the BAHC,
disproportionately affecting those paid the least. In addition, unlike
housing expenses covered by BAH, health care expenses are unpredictable
and highly variable. Without controls to ensure BAHC is saved for
health care-related costs (deductibles, co-insurance, premium cost-
shares, etc.), it is highly likely that some members will face
significant financial hardships without the resources to meet them. As
for non-Medicare eligible retirees, the Department estimates that in
the steady state (20% of premiums) the average retiree family of three
will experience an increase of $3,600 (FY 2014 dollars) in out-of-
pocket expenses, significantly more than current out-of-pocket and much
more than Department proposals that have been rejected in the past. The
Department's proposals for PB 2016 allowed active duty family members
to continue with an MTF managed option with the same low out-of-pocket
costs as today. In addition, the proposal for retiree health care was
estimated to increase the out-of- pocket cost for a family of 3 by less
than $300 per year.
Mr. Walz. How does DHA intend to monitor the ECHO plan to ensure it
maintains this alignment with state Medicaid waiver programs as
technology and best practices change in the future?
Dr. Woodson. DHA already has expertise in the area of medical
benefit policy development, which includes a well-established process
for continually monitoring reliable evidence for evolving medical
benefits and technology. DHA will establish a similar process to
continually monitor future changes to state Medicaid waiver programs
and to assess whether ECHO policy or benefit revisions are indicated.
Mr. Walz. A recent study by DOD stated ``Overall, 37% of military
families with a special needs child reported they had heard of the
TRICARE ECHO program.'' Why is reaching these families difficult and
what are you doing to improve your outreach to these families?
Dr. Woodson. DHA currently utilizes a wide range of contemporary
communication techniques to inform beneficiaries and providers about
all aspects of the TRICARE program. However, this study suggests a need
for additional emphasis on the TRICARE ECHO program to ensure that
military families are fully informed of the process for participating
in the ECHO program so that a family member with special needs can
receive integrated services and supplies beyond those offered by the
basic TRICARE health benefit program. DHA will explore options for
providing focused ECHO messages under the current and future TRICARE
contracts. These outreach efforts will include military families,
primary care managers and other providers in the Military Treatment
Facilities (MTFs), and network providers participating in TRICARE
Managed Care Support Contracts. Additionally, DHA will reach out to the
Services to ensure that Exceptional Family Member Program (EFMP)
program coordinators are familiar with the ECHO program and can advise
military families accordingly.
Mr. Walz. The same report noted ``72% of military families whose
child was enrolled in TRICARE ECHO were satisfied or very satisfied
with the program''. What is the trend in satisfaction since the ECHO
program was created? Is this a high number or a low number? Do you
think the MCRMC recommendation would improve satisfaction with the ECHO
program?
Dr. Woodson. DHA regularly conducts various inpatient and
outpatient beneficiary satisfaction surveys; however, ECHO program
satisfaction is not routinely tracked by the agency. Therefore, DHA is
unable to provide information on ECHO program satisfaction trends, nor
can DHA state with certainty whether 72% represents a high number or a
low number. However, Gallup researchers conduct annual surveys on a
wide range of health care satisfaction metrics, including overall
patient satisfaction with their health care coverage. Based on survey
results from 2001 through 2012, between 63% and 72% of patients who
were surveyed rated their overall satisfaction with their health care
coverage as ``excellent'' or ``good'' (the other rating options were
``fair'' and ``poor''). Although these surveys are not limited to
patients with special needs, as an indicator of overall program
satisfaction, it would appear that a 72% ECHO program satisfaction
rating is consistent with the upper range of overall patient
satisfaction with their health care coverage. DHA is committed to
quality improvement and is currently developing a beneficiary survey to
identify gaps in ECHO services. The results of this survey will be used
to evaluate which HCBS services from the MCRMC recommendation should be
added to the ECHO program to better support our military families. This
identification of coverage gaps and the subsequent implementation of
necessary policy and program changes to better align the ECHO program
with the MCRMC recommendation should lead to improved beneficiary
satisfaction.
Mr. Walz. What actions is DOD taking or contemplating to increase
access to specialty care--which the MCRMC identified as a big challenge
for families? Do the steps require legislation or does DOD already have
the authority?
Dr. Woodson. The Military Health System (MHS) is improving access
to specialty care in both our direct care system and in our TRICARE
network. The MHS Review of Access, Quality and Safety recommended
leveraging the success of the Tri-Service Patient Centered Medical Home
(PCMH) program to develop standard processes and goals to improve
access to specialty care in the direct care system. Recapturing
specialty care to the direct care system supports our goals of
maintaining a ready military medical force, which is able to respond
quickly and effectively in support of National Strategy. Our direct
care PCMHs using evidence-based clinical practice guidelines (CPGs) to
deliver more comprehensive, coordinated care in primary care without
having to refer the patient to specialty care, which frees up specialty
care access. In addition, the MHS has embedded specialty providers in
PCMHs for commonly occurring medical issues directly so patients can be
seen quickly without a referral; these providers include behavioral
health specialists, clinical pharmacists and physical therapists. Our
telehealth program also is expanding the reach of direct care
specialists by providing tele-consultations to remote PCMHs, which do
not have in-house specialty care capabilities.
To achieve the goal of improving access to specialty care and in
support of our integrated delivery system, the MHS has developed a new
Tri-Service Specialty Care Advisory Board. Our direct care specialties
are increasing the number of available appointments as well as
maximizing the availability of operating rooms and other support
services. If specialty care is not available in the direct care system,
patients will be referred to high quality specialty care in our TRICARE
network. Our specialty care access standard is for patients to be seen
for an appointment within 28 days and care in most specialties is
available well within this access standard in both the direct care
system and in the TRICARE network. Some specialties are in short supply
nation-wide; however, the MHS ensures patients needing care are seen as
quickly as possible. Finally, to expedite our patients' access to
specialty care and in response to patient feedback, the MHS is now
developing a streamlined specialty appointing process so patients know
when and where they will be seen more quickly. DOD has the authority to
accomplish required actions and steps do not require legislation.
Mr. Walz. Children's behavioral health care seemed to be a
particularly difficult area, due to the unavailability of outpatient
providers, the obsolete model of residential treatment that TRICARE
imposes, and the lack of some intermediate service levels. How is DOD
addressing this shortfall? Do the steps require legislation or does DOD
already have the authority?
Dr. Woodson. Many of the challenges TRICARE faces regarding
behavioral health care for children parallel the nationwide problem of
appropriate care for this population, to include the shortage of
outpatient providers, child psychiatrists and psychologists; access to
residential treatment and partial hospital programs for substance use
disorders; and appropriate services in between the two levels of care.
TRICARE has several efforts underway to improve behavioral health care
for our beneficiaries. In 2014, TRICARE regulations were finalized to
add TRICARE-Certified Mental Health Counselors as authorized
independent providers of mental health care. Also in 2014, the
Department sought legislative relief to remove statutory quantitative
limits on inpatient psychiatric and residential treatment center care
for children in the TRICARE program. As a result, the National Defense
Authorization Act for Fiscal Year 2015, Section 703 ``Elimination of
inpatient day limits and other limits in provision of mental health
services'' amended section 1079 of Title 10 United States Code to
remove these quantitative limits, and we are currently revising our
TRICARE program manuals to implement these changes. Additionally, the
Defense Health Agency is in the process of drafting proposed regulatory
changes to ensure our mental health benefit has parity with the
benefits for medical/surgical procedures, is consistent with current
industry standards of care, and facilitates access to qualified
institutional and professional providers of mental health services. We
anticipate that a proposed rule outlining these changes will be
published in the Federal Register in the near future, and we will
encourage stakeholders to provide feedback during the public comment
period.
In addition to medical services, non-medical services continue to
be available to all TRICARE eligible beneficiaries. Non-clinical
counseling programs and resources are sponsored by the Services (such
as the Army's Strong Bonds program and the Navy's Project Focus) and by
Deputy Assistant Secretary of Defense for Military Community and Family
Policy (such as Military Family Life Consultants, Military OneSource
Programs, and the Joint Family Support Assistance Program). These
adjunct programs, in addition to Military Health System behavioral
health care, help ensure that children and families have access to a
broad range of psychological services.
Mr. Walz. If DOD does not agree with the MCRMC recommendations,
what are some of the elements of private health plan design and
administration that can be adopted to address the concerns so
compellingly set forth in the MCRMC report? Do the steps require
legislation or does DOD already have the authority?
Dr. Woodson. The Department believes that adopting the proposal set
forth in the 2016 President's Budget has many of the elements of most
private health plans. That proposal would replace the two TRICARE plans
(PRIME, Standard/Extra) with a simplified Preferred Provider
Organization (PPO) plan. In 2014, 58% of beneficiaries covered by
employer-sponsored insurance were enrolled in a PPO. In a PPO,
beneficiaries have the choice to choose their providers. There are no
requirements for referrals and authorizations, which is a source of
many access-related complaints associated with TRICARE. Also, co-pays
will differ to steer patients to the lower cost providers. In the PB
2016 proposal, co-pays were lowest for military treatment facilities
(where patients are needed for our active duty providers), low for
network providers (where the Department has lower costs) and highest
for out-of-network care. Furthermore, copays are zero for preventive
services, lowest for primary care, higher for specialty care and
highest for emergency room visits.
While the PB 2106 proposal does require legislation, we are looking
at options to address other aspects of the MCRMC report that will not
require legislation, including implementing value based purchasing. The
Department is reviewing those options now.
Mr. Walz. The 2013 NDAA, Sec 735 directed ``The Secretary of
Defense shall conduct a study on the health care and related support
provided by the Secretary to dependent children.'' The report was to
include the (1) the findings of the study; (2) a plan to improve and
continuously monitor the access of dependent children to quality health
care; and (3) any recommendations for legislation that the Secretary
considers necessary to maintain the highest quality of health care for
dependent children. The findings of the study were published almost a
year ago, in July 2014, but we still don't have a plan or
recommendations for legislation. When do you anticipate providing this
information?
Dr. Woodson. Defense Health Agency began a Pediatric Integrated
Project Team (IPT) in March to address the gaps and areas of
consideration in the 2013 NDAA, Sec 735. This team is addressing each
of the areas in the nine original elements in a multidisciplinary
collaborative group from direct care, purchased care and other
Department of Defense Agencies. The group is reviewing advocacy group
responses to the 2013 NDAA Sec 735 for additional input and
recommendations. The report from this group is anticipated to be
reported to DHA governance in December 2015.
Mr. Walz. General Horoho, one of the reasons the commission
recommended changing the Military Health Care system is because
military families and retirees told them they wanted choices. If your
members do want more choice, is the Commission's recommendation what
the members of your organization want? Do they believe choice will
improve medical care? What are your concerns with the recommended
change? Are there ways to improve the TRICARE program instead? If so
how?
General Horoho. The Army supports the Commission's objectives to
increase choice for beneficiaries; however, we believe the DOD
proposals in the 2016 President's Budget will achieve these goals
without jeopardizing the ability to maintain a ready and deployable
medical force and a medically deployable force. We are concerned that
the Commission's proposal to establish a Federal Employee Health
Benefit type program for beneficiaries risks loss of beneficiaries from
the direct care system that provide the volume and complexity to
sustain the skills of our military healthcare providers. The PB16
proposal offer Active Duty Family Members and Retirees the choice of
using Military Treatment Facilities or network providers and
incentivizes use of the direct care system. This creates choice as
recommended by the Commission while preserving the case load required
to sustain skills for our military providers. Additionally, Army
Medicine must maintain the ability to provide critical healthcare
services not available to our beneficiary population in the civilian
market, for example, School-based Behavioral Health Care. Many of the
Commission's goals are currently being achieved through initiatives
such as patient-centered medical home, nurse advice line, shared
services, Defense Health Agency, and MHS governance. In order to
improve the TRICARE program, the Army recommends expanding authorities
to increase patient populations and therefore the case mix to keep
military providers ready to deploy; seeking cost effective solutions to
improve healthcare coverage of Reserve Component Families impacted
during activation of Reserve Component Soldiers; and exploring
strategies to transition from a fee-based health plan to a value-based
health plan that incentivizes preventive care, improves health
outcomes, and encourages healthy behaviors.
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