    [House Hearing, 114 Congress]
    [From the U.S. Government Publishing Office]

                             [H.A.S.C. No. 114-72]

                   STAKEHOLDER VIEWS ON MILITARY HEALTH CARE

                                   __________

                                    HEARING

                                   BEFORE THE

                       SUBCOMMITTEE ON MILITARY PERSONNEL

                                     OF THE

                          COMMITTEE ON ARMED SERVICES

                            HOUSE OF REPRESENTATIVES

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  HEARING HELD

                                DECEMBER 3, 2015

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                       ______

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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

                                  ----------
                                                                       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

    Bousum, Scott, Legislative Director, Enlisted Association of the
      National Guard of the United States............................     3
    Raezer, Joyce, Executive Director, National Military Family
      Association....................................................     6
    Ryan, VADM Norbert R., Jr., USN (Ret.), President and CEO,
      Military Officers Association of America.......................     4

                                    APPENDIX

    Prepared Statements:

        Bousum, Scott................................................    28
        Heck, Hon. Joseph J..........................................    27
        Raezer, Joyce................................................    71
        Ryan, VADM Norbert R., Jr....................................    47

    Documents Submitted for the Record:

        Slide displayed by VADM Ryan.................................   102
        Statement of the National Association of Chain Drug Stores...    95

    Witness Responses to Questions Asked During the Hearing:

        Mr. MacArthur................................................   105

    Questions Submitted by Members Post Hearing:

        Mr. Walz.....................................................   109

                   STAKEHOLDER VIEWS ON MILITARY HEALTH CARE

                                  ----------

                      House of Representatives,
                           Committee on Armed Services,
                            Subcommittee on Military Personnel,
                            Washington, DC, Thursday, December 3, 2015.
        The subcommittee met, pursuant to call, at 11:37 a.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. Okay. I would like to call the hearing of the
    Military Personnel Subcommittee to order. I want to welcome
    everyone to the hearing.
        I thank the witnesses for their flexibility.
        Just to say at the outset, we are probably going to have
    another vote series at 12:30, which will be a one-vote vote
    series. So my plan is that when the bell rings whoever is
    speaking will finish what they are saying, we will depart, go
    vote that one vote, and come immediately back if we have not
    yet concluded the hearing.
        So again, I want to thank everyone for coming to the
    subcommittee hearing to get the stakeholder views on proposed
    military health care reforms. This hearing is part of the
    committee's ongoing project to comprehensively review the
    current state of the Military Health System and military health
    care and, based on this information, identify areas that need
    improvement.
        I want to be clear that this process is not being driven by
    budgetary concerns. We are using the same format that we used
    in the successful review of the military retirement changes,
    which were not driven by budget but driven by what will produce
    the best possible benefit to be able to recruit and retain the
    best and brightest into our All-Volunteer Force.
        The overarching goal of the project is to ensure the
    Military Health System can sustain trained and ready health
    care providers to support the readiness of the force while
    providing a quality health care benefit that is valued by
    beneficiaries. To that end, the committee has heard from
    several experts, including current and former Surgeons General,
    the Under Secretary of Defense for Health Affairs, and civilian
    health care programs, regarding the current and future
    challenges of providing health care.
        Today we look forward to building on the knowledge by
    hearing from military service organizations regarding their
    members' views on military health care. These incredibly
    important perspectives are crucial to understanding this
    multifaceted and complex issue.
        Our purpose today is to discuss both what works and what
    needs to be fixed in the military health care system.
        We are keenly aware that military health care is an
    extremely important benefit and any reforms must be thoroughly
    analyzed from multiple perspectives and structured to prevent
    unintended consequences. Our discussion today is an integral
    part of that process.
        Before I introduce our panel, let me offer the ranking
    member, Congresswoman Davis, an opportunity to make her opening
    remarks.
        [The prepared statement of Dr. Heck can be found in the
    Appendix on page 27.]

        STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM
     CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL

        Mrs. Davis. Thank you. Thank you, Mr. Chairman.
        And I also want to welcome, of course, all of you to this
    hearing. Your perspective and your views have always been very
    important to us, and particularly as we have been engaged in
    the health care reform discussion.
        And, Admiral Ryan, I understand you will be stepping down.
    Is that correct? Yes--as President and CEO [Chief Executive
    Officer] of MOAA [Military Officers Association of America],
    and we just want to thank you so much for your service. I know
    that everyone in the organization feels the same and we
    appreciate very much the work that you have done.
        We have had the opportunity to hear from some of you this
    past spring as we began working through many of the
    recommendations of the commission, and you know that we did
    address retirement reform as well as several other commission
    recommendations in the NDAA [National Defense Authorization
    Act]. And we have made progress in health care reform by
    instituting a pilot program on urgent care requiring the DOD
    [Department of Defense] to publicly post access standards and
    requiring DOD to improve TRICARE enrollment during duty station
    changes.
        And I think we can all agree that there are areas of the
    health care system that work very, very well. And yet, there
    are some areas that we can improve. And so that is the
    challenge before us, I think, to try and make these
    improvements while maintaining a superior standard of care.
        I know each of your organizations represent particular
    constituencies and particular concerns, so we are eager to have
    your insight and your thoughts. Thank you so much, again, for
    being here.
        And I might say, Mr. Chairman, that I believe with the
    votes kind of got us off schedule that I may need to leave in
    the middle.
        But I am hoping that we will be able to hear from all of
    you before that, and even some of the questions.
        Thank you so much.
        Dr. Heck. Thank you, Mrs. Davis.
        We are joined again today by an outstanding panel. We will
    give each witness the opportunity to present his or her
    testimony and each member an opportunity to question the
    witnesses.
        Respectfully remind the witnesses to summarize, to the
    greatest extent possible, the high points of your written
    testimony in 5 minutes or less. Your written comments and
    statements will be made part of the hearing record.
        Let me welcome our panel: Mr. Scott Bousum, Legislative
    Director of the Enlisted Association of the National Guard of
    the United States [EANGUS]; Vice Admiral (Retired) Norbert
    Ryan, President and CEO of the Military Officers Association of
    America; and Ms. Joyce Raezer, Executive Director, National
    Military Family Association [NMFA].
        I also ask unanimous consent to enter a statement from the
    National Association of Chain Drug Stores into the record.
        [The information referred to can be found in the Appendix
    on page 95.]
        Dr. Heck. Without objection, so ordered.
        Who is going to go first?
        Mr. Bousum. Okay. You are recognized for 5 minutes.

       STATEMENT OF SCOTT BOUSUM, LEGISLATIVE DIRECTOR, ENLISTED
         ASSOCIATION OF THE NATIONAL GUARD OF THE UNITED STATES

        Mr. Bousum. Well, Chairman Heck, Ranking Member Davis,
    esteemed subcommittee members, my opening statement is part of
    my written testimony, and since we have a--kind of a tight
    schedule with votes I am willing to just submit it for the
    record and not read.
        Dr. Heck. Well, can you give us a quick summary in 5
    minutes of what your statement says so we can move forward, so
    everybody has an opportunity that made not have read your----
        Mr. Bousum. Sure.
        Dr. Heck [continuing]. Statement in advance----
        Mr. Bousum. Absolutely. Yes, no problem.
        Well, on behalf of the Enlisted Association of the National
    Guard, it is a pleasure to testify on the critical issue of
    health care reform. Our membership represents over 414,000
    enlisted men and women of the Army and Air National Guard,
    their families and survivors, and the tens of thousands of
    National Guard retirees.
        Each and every year one of them is affected by health care
    when the Guard mobilizes in support of our country or when they
    fulfill their strategic missions. We welcome this opportunity
    to submit testimony for the record.
        Our members appreciate the countless hours that you and
    your staff have devoted to ensure that our service members
    receive the best care.
        Under committee leadership, the National Defense
    Authorization Act committed the Military Compensation and
    Retirement Modernization Commission [MCRMC].
        The commissioners made recommendations to ensure--or to
    Congress on how to improve health care access that would
    eliminate problems currently encountered by Guard and Reserve
    members and families. We encourage the committee to consider
    the commission's final recommendations as they explore health
    care reform.
        From the Guard's perspective, it is difficult to discuss
    health care without addressing the complexity of our duty
    statuses. The military's complex personnel system directly
    affects Guard pay, health care, and even burial rights, based
    on what duty status orders are published under.
        The focus of today's discussion does not include National
    Guard duty status reform, but I suggest that the type of health
    care coverage members receive should be separated from whether
    or not they are on Active or Inactive Duty military orders.
        Service members and their families should have one health
    care program regardless of duty status. Separating the two
    would fix the continuity of care issue creating problems for
    members of the Guard and their families.
        As you consider changes next year, please keep in mind that
    access is a problem because most members of the National Guard
    do not live on or near military installations. As a result,
    many of our members drive hundreds of miles for appointments,
    only to be referred to a specialist who may or may not be
    available under TRICARE.
        Additionally, their frustration is compounded because
    appointments may not be scheduled in what you or I would
    consider a reasonable timeframe.
        This association, in conjunction with the Reserve Officers
    Association [ROA] and the National Guard Association of the
    United States [NGAUS], circulated a health care satisfaction
    survey to our members. The results of the survey are enclosed
    with my written testimony. After reviewing the survey results,
    I am not prepared to say that TRICARE is broken.
        I want to recognize Reserve Officers Association and the
    National Guard Association of the United States for their input
    in today's testimony. Together, our membership makes up the
    entirety of the Reserve Component, officers and enlisted, and
    all over 1.1 million members, which includes every mobilization
    category.
        So thank you again for hosting this hearing. As the
    discussion continues, we look forward to working closely with
    you and your staff as you look at military health care reform.
        [The prepared statement of Mr. Bousum can be found in the
    Appendix on page 28.]
        Dr. Heck. Admiral Ryan.

     STATEMENT OF VADM NORBERT R. RYAN, JR., USN (RET.), PRESIDENT
           AND CEO, MILITARY OFFICERS ASSOCIATION OF AMERICA

        Admiral Ryan. Chairman Heck, Madam Ranking Member Davis,
    Congressman Coffman, Congressman MacArthur, Congressman
    O'Rourke, thank you. Good morning.
        First, from my humble perspective as the president of MOAA
    for the past 13 years, this committee's actions have been the
    driving force, I believe, in sustaining the All-Volunteer Force
    while the Nation has been at war. Leaders make a difference.
    You all have made a real difference. Thank you.
        As for today's subject of military health care, MOAA's
    first guiding principle is to do no harm. We think it is
    important to preserve what is working and fix what is not
    working.
        In a category of what is working we would include: combat
    casualty care; the overall quality of military health care once
    it is delivered; TRICARE for Life; pharmacy programs, including
    the mail-order pharmacy; and TRICARE Standard, for the most
    part. On the latter score, MOAA's recent survey of more than
    30,000 beneficiaries found Standard participants had a higher
    satisfaction rate and significantly lower dissatisfaction than
    Prime beneficiaries.
        In the list of things that are not working, MOAA would
    include, first and foremost, the fundamental inefficiency of a
    system built around three separate military service programs
    with no single budget and oversight authority. We fight wars
    jointly, thanks to Congress' insistence in the 1980s, over the
    objection of all the Joint Chiefs.
        Why can't we do the same in medical? In layman's terms,
    there are simply too many cooks in the kitchen.
        As a result of our survey, it confirmed serious
    shortcomings in the TRICARE Prime appointing and referral
    system; the Guard and Reserve TRICARE coverage, as Scott
    alluded to; the patient load in military treatment facilities
    where military providers see far fewer patients per week than
    civilian providers; and inadequate case management of the
    higher cost for at-risk health care users.
        One of the biggest problems is a serious disconnect between
    rhetoric and reality on DOD health care costs. Every year some
    defense officials offer dire budget projections of health care
    costs they say are out of--spiraling out of control. But recent
    history shows these projections have been consistently wrong.
        Slide, please? I don't know if you are going to be able to
    put it up there.
        The chart displayed reflects the reality: DOD health costs
    have been flat or declining for the past 5 years. Figures
    through fiscal year 2014 are actual expenditures; fiscal years
    2015 and 2016 are projections in the latest DOD report and the
    fiscal year 2016 budget.
        As you can see, TRICARE for Life costs have dropped
    significantly and purchased-care costs have been flat or
    declining. A prime source of cost increases has been in-house
    military care, which is mainly a factor of medical readiness
    and system inefficiency.
        [The slide referred to can be found in the Appendix on page
    102.]
        Admiral Ryan. In assessing what changes should be pursued,
    our statement for the record offers a number of guiding
    principles. Four key ones include: First, means testing is
    inappropriate for military health benefits. Reducing benefits
    for longer and more successful service has very negative career
    retention effects.
        Second, readiness costs should not be passed on to
    beneficiaries. When military providers are deployed or military
    facilities are inefficient and more beneficiaries are pushed
    into the private care, that is a cost of doing military
    business, not a personnel benefit.
        Third, the military health benefit should be the gold
    standard: a top-tier program that is substantially better than
    those offered by the best civilian employers.
        And lastly, each similar group of eligibles should be
    provided similar coverage. We are not in favor of an FEHBP
    [Federal Employees Health Benefits Program]-style system that
    means those with more income can buy better coverage.
        Finally, our written statement offers 12 specific
    recommendations, but in the interest of my time and your time
    and the colleagues' time, I will not address those now.
        Mr. Chairman, in closing I can assure the entire committee
    that MOAA stands ready to assist you and your staff in any way
    that would be beneficial. We all want to get this right.
        Thank you.
        [The prepared statement of Admiral Ryan can be found in the
    Appendix on page 47.]
        Dr. Heck. Ms. Raezer.

        STATEMENT OF JOYCE RAEZER, EXECUTIVE DIRECTOR, NATIONAL
                      MILITARY FAMILY ASSOCIATION

        Ms. Raezer. Thank you, Mr. Chairman, and Ranking Member
    Davis, and other members of the subcommittee, for inviting me
    to speak today on behalf of the National Military Family
    Association and the families we serve about what is working and
    what is not working with military health care for families.
        Our written statement submitted for the record contains a
    summary of what we hear most often from currently serving
    military families about their experiences, good and not so
    good, in accessing care and the quality of the care they
    receive.
        We appreciate the provisions that you included in the
    recent NDAA as a step in addressing some of those issues about
    access and quality, but it has been more than 20 years since
    TRICARE was created. It is time for a holistic examination of
    TRICARE and the Military Health System, not tweaks around the
    edges.
        But we remain committed to the concept that the reform
    discussion must start with how to build and deliver the best
    benefit possible for our military families--which I think I
    heard from you, Mr. Chairman--not on how much families should
    pay for that benefit.
        Military health care must meet the unique needs of military
    families, such as frequent moves and deployments, as well as
    address the concerns of families in remote locations,
    individuals with complex health care needs, wounded service
    members, and our National Guard and Reserve members and their
    families. Service members must get the care they need to be
    medically ready.
        Above all, coverage, access, quality, and cost should
    acknowledge the value of the service and sacrifice of troops
    and their families. As Admiral Ryan said, our military families
    deserve nothing less than the best possible health care
    coverage and care.
        We do know that many of our families remain satisfied with
    TRICARE--the care they receive and the low cost of that care.
    Our concern for these families centers on what could happen to
    their care if financial pressures take a greater toll on
    military hospitals or the TRICARE benefit over time.
        When we asked for families' input about their health care
    experiences, they routinely cite difficulty in obtaining timely
    appointments; bureaucratic hassles to obtain referrals; lack of
    continuity of care; difficulties in navigating the system,
    especially when moving from one military community to another;
    a lack of coverage for certain services; and poor customer
    service.
        While most families rate ``poor access'' as their number
    one health care quality issue, some do tell us of experiences
    of less than satisfactory care--examples similar to what was
    found in the 2014 Military Health System Review conducted by
    the Department of Defense.
        But we do know there are models of timely access and
    quality improvements in pockets of the direct care system. But
    there doesn't seem to be a single entity with the power to
    drive implementation of those improvements across the system
    and hold those in need of improvement accountable.
        Based on what we hear from military families, here is what
    we would like you to look at as you begin your review of
    TRICARE.
        Changes in and enforcement of access, quality, and customer
    service standards must apply across the entire Military Health
    System, direct care and what is purchased from the private
    sector. Before initiating additional recapture efforts to bring
    more beneficiaries into the military hospital, military
    hospitals should be required to certify they are meeting
    appointment access standards for current patients.
        Reconsider the concept of a unified medical command to
    provide a single entity responsible for ensuring consistency
    and quality accountability across the system. Ask how private
    sector coverage options, patient engagement efforts, and
    quality standards can inform TRICARE reform.
        Consider the demographics of military families today in
    updating the TRICARE benefit and in managing the balance
    between meeting the readiness mission and delivering an
    employer-provided health care benefit to families. A Medicare-
    based reimbursement system and a focus on troop and provider
    readiness for war don't easily translate into a model of
    coverage and care for a population of young families with kids.
    Here is a statistic for you: Of the 1.1 million children of
    Active Duty service members, almost 50 percent are age 6 or
    younger.
        Questions about any proposed changes to TRICARE should also
    be asked about the current system. How does this structure
    promote military readiness? How does it ensure timely access
    and quality care at the best possible price for both
    beneficiaries and the government?
        In an era of budget constraints when military families see
    any proposed change in their benefits as just another attempt
    to cut costs, it is important to rebuild their trust and to
    show them their service is valued. We hope this hearing is only
    the beginning of a thorough discussion of how to deliver the
    best care benefit to military families.
        Thank you.
        [The prepared statement of Ms. Raezer can be found in the
    Appendix on page 71.]
        Dr. Heck. Thank you. I appreciate all of your testimony.
        And since, Mrs. Davis, you may have to leave soon I will
    defer my time and give you the first 5 minutes.
        Mrs. Davis. Thank you very much.
        And again, thank you all for being here.
        Ms. Raezer, maybe I will--wanted to ask you really just to
    follow up, I think, on some of the discussion, because one of
    the concerns that you stated, and I think has been stated
    often, is about access standards. And what we know is that
    there isn't a whole lot of awareness sometimes of what those
    DOD standards are, which the awareness may be low but the
    standards are high in a number of cases, and yet that is not
    something that I think is--people are able to relate to within
    the service that they are getting.
        And so how would you do that? What are we missing? What is
    not happening to increase the standard so people really can, I
    think, demand, in many ways, that they get the care that they--
    that actually has been developed for them?
        Ms. Raezer. You are absolutely right. There isn't a lot of
    awareness about the standards. And unfortunately, it is not
    just on the military family side; it's on--and this is mostly
    in the direct care system, where there aren't the same kind of
    accountabilities that are in the purchased-care contracts--
    there's not a whole lot of awareness on the--among the people
    who are charged with giving military families an appointment.
        So if a military family member, even if they--who knows
    about an access standard calls for an appointment for a sick
    child and said, ``This is urgent care; the access standard is
    24 hours,'' typically they are going to get the response,
    ``Sorry, there are no appointments.''
        ``Well, can you send me out for urgent care?''
        ``Sorry, we are not doing that right now,'' which is why we
    are so grateful for the pilot.
        A military treatment facility's response to beating access
    standards shouldn't be to tell a military family with a sick
    child, ``Go to the emergency room and wait for 9 hours,'' and
    that's what is happening. So there is an awareness needed on
    the military hospital side across the culture and a commitment
    to meeting those access standards.
        We don't hear a lot from DOD about access standards lately.
    We really did a lot when TRICARE was first created, and that
    was the promise of TRICARE Prime: ``You give up some control
    over your care and we will guarantee low cost and access.'' The
    low cost is still there but the access isn't.
        Mrs. Davis. Yes.
        Any others--do you have a sense, Admiral, about how do we--
    --
        Admiral Ryan. Yes.
        Mrs. Davis [continuing]. Make that better?
        Admiral Ryan. I couldn't agree more.
        What our survey of over 30,000 folks says is that it all--
    that the real issue is with TRICARE Prime. The greatest
    dissatisfaction was meeting the appointment timelines or
    getting specialty appointments. And it is double the
    dissatisfaction rate in TRICARE Prime, and specifically in the
    military treatment facilities is where the--rather than the
    purchased-care part of TRICARE Prime.
        So it is 15 to 19 percent dissatisfaction with the
    appointment--getting the timely appointment or getting a
    specialty appointment. It's half of that in TRICARE Standard
    and even less in TRICARE for Life.
        And so the figures show it, exactly what Ms. Raezer was
    talking about.
        Mrs. Davis. Yes. Because there are some reports that would
    indicate that the MTFs [military treatment facilities] are
    actually meeting this standard. But that is----
        Admiral Ryan. Well, we have had discussions with DOD----
        Mrs. Davis. Why this disconnect?
        Admiral Ryan. Yes.
        Ms. Raezer. We have had numerous discussions with the
    Department on how do they measure access. If I call and ask for
    an appointment for a sick child and I am told, ``Call back
    tomorrow,'' or, ``Go to the emergency room,'' how does that get
    recorded in the system? How does that response, ``Call back
    tomorrow,'' get recorded in the system as meeting or not
    meeting access standards?
        And what we were hearing from the Department is they
    weren't really sure. And that was one of the things that came
    out in the Military Health System Review is that there were a
    lot of questions about how the military was measuring access.
        Admiral Ryan. One of the principal problems--and I know
    that the health care providers and MTFs are really
    professional--consummate professionals and want to do a good
    job, but when you look at the number of appointments that they
    have in a day versus what you have in the purchased care, it's
    not even close to what is in the purchased care.
        Now, that may not be the fault of any of the health care
    providers. Dr. Heck has been in the system. It may be the
    administrative requirements that are placed on them; it may be
    the lack of administrative support so they end up doing
    clerical stuff as well.
        But that is an area, if we could fix one thing it would
    break a lot of this dissatisfaction, I think.
        Mrs. Davis. Well. Okay. Yes. Thank you.
        Mr. Bousum, did you want to comment on that?
        Mr. Bousum. I was just going to interject quickly--I am
    running on a little time here--when guardsmen go onto TRICARE
    Prime and they are called to Active Duty and there is a switch
    in this continuity of care, the--our members are now deployed
    and their family members are left to work this convoluted
    nightmare with them, you know, now thinking of their family and
    it affects readiness, so----
        Mrs. Davis. Okay. Thank you. Thank you very much.
        Thank you, Mr. Chairman.
        Dr. Heck. Thanks.
        So, you know, one of the approaches that we are trying to
    look at from the subcommittee perspective as we tackle this is,
    you know, from the 30,000-foot view, what is the primary
    purpose of the military health care system? What is the primary
    reason that we have a military health care system? And then
    from there, try to bring it all the way down to the tactical:
    How do we provide that care?
        So I would ask each one of you, on behalf of your
    association: To your association, what is the primary purpose
    of the military health care system?
        Mr. Bousum.
        Mr. Bousum. Well, I would say--and in our case it's not
    this way but it should be this way, that a guardsman should
    have the same health care regardless of their duty status, that
    it should be something that fits the needs of the service
    member and their family, and that it is something that they
    have 365 days a year until they maybe opt to change that. But
    it shouldn't change at any point regardless of what happens
    during that year.
        Dr. Heck. Okay.
        Admiral.
        Admiral Ryan. Well, I think you said it in--both of you and
    Madam Ranking Member said it in your opening statement. It is
    readiness.
        But we think an important part of readiness is making sure
    that you can also take care of the family. And so the way you
    phrased it's the right way.
        And that is why when the commission came out with this
    FEHBP proposal we could not see how military--the military MTFs
    could sustain their readiness with that proposal. And that's
    why we would rather--you can't evolve this system; it has to be
    reformed. And it can't be piecemeal.
        But it has got to start with the readiness and making sure
    that all of those MTFs have people that are qualified to do
    what you have done, to deploy and take care of our troops. But
    an important segment of that readiness, as Scott pointed out,
    is when somebody goes over the horizon they want to know that
    their family is being taken care of and seen.
        Thank you.
        Dr. Heck. All right.
        Ms. Raezer.
        Ms. Raezer. I agree with Admiral Ryan. It is readiness
    first. The system has to ensure that service members are
    medically ready to deploy, that they--and that they have the
    best possible care when they are deployed.
        We don't want to mess with the successes that we have seen
    in combatant care. But that's prime important--of prime
    importance to families, as well. They want to know that their
    service member is well taken care of when put in harm's way.
        But the Department of Defense also has an obligation to
    provide a high-quality employer-sponsored benefit, and where we
    are seeing--so there really--it is a dual-purpose, and what we
    are seeing is the conflict between those two goals in the
    Military Health System.
        Too much emphasis on readiness leaves families without
    appointments. And pressure on readiness dollars leaves families
    and sometimes service members without care.
        So I think the challenge for you as you do this work is
    saying, ``How do we get rid of that conflict between those two
    missions of the Military Health System?''
        Dr. Heck. Great. Thank you. I will save my second question
    for the next round since it is going to take longer than a
    minute and a half.
        Mr. O'Rourke.
        Mr. O'Rourke. Thank you, Mr. Chairman.
        I am more familiar with the VA [Veteran Affairs] health
    care system--I have been on the VA Committee for 3 years and on
    this committee for almost a year--than I am the TRICARE and DOD
    system. But you mentioned something that caught my attention
    because we have heard it so often on the VA side, which is
    access standards and accuracy in measuring access standards.
        In the VA it was wait times. And, you know, we were told
    with all certainty by the VA 2 years ago that we were seeing
    everybody within 14 days, and there was a--the infamous wait-
    time scandal in Phoenix.
        So I would love for you to expand on that a little bit and
    tell me what your members are seeing, or what the concerns are,
    or what your recommendations are for assuring that we are
    meeting the standards and that we are measuring those
    accurately.
        In our case in El Paso we bypassed the VA and just asked
    veterans directly and did a survey of veterans in El Paso to
    find out what their real wait times were. And instead of 14
    days we found for primary care it was 81 days on average; for
    mental health care, 74 days.
        So that, and then the second question for you and then
    anyone else who would like to address it, one of the MCRMC's
    recommendations was having greater interoperability between VA
    and DOD. And there is the DOD/VA Joint Executive Committee to
    standardize and enforce collaboration, so any thoughts on that
    would be appreciated.
        And I will start with you, Ms. Raezer.
        Ms. Raezer. Yes. I will start with the access question. We
    haven't heard of families having the same length of wait as
    what some of the worst stories that came out of the VA are.
        But that said, we are hearing from families who not only
    are being told they have to wait for care, where there is no
    mention of an access standard, but there is also what I term as
    ``silly rules''--processes and procedures at military hospitals
    and clinics that vary but that put barriers up between a
    patient and the provider in accessing care from that provider,
    rules about when you are transitioning on a military move from
    one installation to another, what do you--you know, the
    enrollment process from TRICARE contractor to TRICARE
    contractor is pretty seamless.
        Where our families are having problems is getting that
    first appointment with a primary care manager in a military
    hospital. Or if you have come in with an existing health
    condition, we--one of the examples we referenced in our written
    statement was a spouse late term--late in her pregnancy who
    moved from one military community to another, and even though
    she was obviously pregnant, had her records with her showing
    she was high-risk, was told she had to take a pregnancy test
    before she could get an appointment with an OB [obstetrician].
        She came at 28 weeks, didn't see the doctor until 36 weeks.
    That's just wrong.
        And we hear that--we have heard that from other military
    families, that the process they have to go through when they
    move creates a barrier between them and care that doesn't show
    up readily on access standards.
        Just a bit on the other--on your issue about
    interoperability between DOD and the VA, our families who are
    going through transitions say the process has to be seamless.
    Especially if you have a wounded service member it is--there
    are still too many unmanaged processes for that individual, too
    many different case managers, too many barriers.
        You are fixing some with the drug formulary, for example,
    but there's still some other ways that that could be made
    better. So we agreed with the commission on that.
        Mr. O'Rourke. Too many different systems.
        Ms. Raezer. Yes.
        Mr. O'Rourke. Admiral Ryan.
        Admiral Ryan. Well, I go back to the President's first
    term. He cared enough about this that he called about six of us
    into a room, major VSOs [veteran service organizations], and
    said, ``This is important if we get this joint DOD-VA medical
    record, and I want it to be a medical record.'' He called the
    Secretary of Defense and the Secretary of VA out of separate
    meetings to be there to look everybody in the eye and said,
    ``We need to get this done.''
        Unfortunately, there has been--it's been well documented
    that leader after leader on both sides have not been over--able
    to overcome the intransigence of the bureaucrats over there.
    You all have wasted a lot of money on this, and the latest is
    now they are publicizing that you can look at the other
    person's record, but it's really an embarrassment.
        And I see well-intentioned people at the top say, ``We are
    going to be involved in this,'' but they get overtaken by
    events and I think they leave it to other folks and they don't
    have the clout to get it done.
        Mr. O'Rourke. Yes.
        Unfortunately I am out of time, but I would love to get
    your thoughts either offline or on the record.
        And with that, I'll yield back to the chair. Thank you.
        Mr. MacArthur. Thank you, Mr. Chair.
        Thank you for being here.
        We got a lot of hearings now on this subject. We have met
    with the commission, active and retired members of the services
    and the DOD, the Surgeons General, the private sector, the
    public sector, and now stakeholder groups. And I am reminded
    that the purpose of walking is to get somewhere, and we are
    getting to that point where I think we need to come to some
    kind of a landing, and that is what we are working on.
        And as I think about our objectives, it's clearly readiness
    and it's clearly keeping our end of the bargain--family care
    and providing for people. And I think those two are front and
    center to me.
        Rather than asking you detailed questions, I'd actually
    like to lay out a broad framework that is beginning to gel in
    my mind and I would like you to react to it. And that framework
    is a couple of changes to the current system.
        One would be a consolidation of the medical health system
    into a consolidated command, rather than having each service
    run their own hospitals. And then the Surgeons General would
    focus on training, equipping, and supporting, not running a
    system.
        Two would be granting broad authority to this central
    command to change plans, to change delivery within broad cost
    constraints that we would define here.
        Three would be investing in centers--military centers in
    areas of concentration of troops and families and increasing--
    in other areas where there is less concentration, increasing
    access to private health care.
        And then lastly would be ensuring a vibrant military health
    Reserve system so that we can make use of health care
    professionals in the private sector who agree to be on Reserve
    status and go wherever whenever.
        Could you each take--I have only got 3 minutes left. Could
    you each take a few moments to talk about pros and cons to that
    framework?
        Admiral Ryan. You didn't get a chance to talk, so----
        Mr. Bousum. So actually, a part of the--my written
    testimony, my organization would actually support the basically
    FEHBP plan and bringing everything over to OPM [Office of
    Personnel Management]. They manage for Federal employees, and
    that there could be a structure in place that they could
    support that for service members.
        In terms of access--you know, better access to private
    care, we would--from a readiness perspective we would have to
    ensure that doctors understand readiness levels for the
    different services. There are different standards for every
    service member, and so in order to do that, that is asking
    more--putting the onus on them. So if a service member comes
    in, perhaps, with the flu but they look to be overweight, then
    a doctor would say, ``Okay, you know, I am taking care of, you
    know, your flu symptoms but, you know, I also am now
    responsible for reporting this.''
        One thing, and this is, you know, as you are looking at
    reform this is somewhat outside the box, but in order to, you
    know, in order to go that route, perhaps a cost offset for that
    doctor would be that the Federal Government reimburse some
    portion of their Federal student loans.
        Mr. MacArthur. I am going to stop you there because I want
    the----
        Mr. Bousum. Okay.
        Mr. MacArthur [continuing]. Other two--I would invite
    written responses to this, as well. But let me hear from the
    other two of you briefly.
        [The information referred to can be found in the Appendix
    on page 105.]
        Admiral Ryan. Well, thank you, Congressman.
        We would definitely like to explore this with you and the
    committee. Actually, as you know, you were very supportive of a
    unified command and a single budgeting authority. We think that
    makes imminent sense.
        Consolidation, I think, would have to be under DOD. We
    would get nervous if it went--our association--if it went to
    OPM. I am sure they are fine people; they do a good job for
    civil servants. But as Joyce said, we think DOD has the
    responsibility there.
        Access is going to be a problem for everybody. We see it in
    the private sector now, too. It is a big deal. We think getting
    the military treatment facilities more efficient would really
    help with the access.
        And then having a much more collaborative relationship
    between the MTFs, the managed care, and the purchased care. It
    is almost nonexistent now. It is at arm's length. We waste a
    lot.
        Ms. Raezer. Yes. I agree. I think I would make one point. I
    would love to talk to you more about the idea of investing more
    capacity in military centers where large populations are and
    doing that better coordination in other areas. I think military
    hospitals----
        Admiral Ryan. Your mike----
        Ms. Raezer. Oh, sorry.
        I think military hospitals should be staffed not just based
    on readiness needs but the--what the community capacity is or
    isn't. So if you are sending a lot of military families with
    their service member to a remote location then maybe the
    military does have to put in a few more family practice docs
    and pediatricians than they would other places.
        But and so it is not just on, ``We'll let the private
    sector do what the military can't,'' but how does the private
    sector work with the military facility in that location to
    build that capacity in the community?
        Mr. MacArthur. I thank you.
        I yield back, Mr. Chairman.
        Dr. Heck. Thanks.
        So I was going to--my follow-on question was going to be,
    you know, how we kind of look at the three ups and three downs
    of the system. What are the three things you think they are
    doing well? What are the three things, if you could wave a
    wand, you would want to improve?
        Actually, Admiral Norbert, I think you did that, actually,
    in your opening statement, and if I had them right you kind of
    said the ups were combat casualty care, TRICARE for Life,
    pharmacy benefits, TRICARE Standard, and the quality of care.
        Admiral Ryan. Yes, sir.
        Dr. Heck. And the three downs were inefficiencies of three
    separate programs, TRICARE Prime, and TRICARE Reserve Select.
        Admiral Ryan. Yes----
        Dr. Heck. Do you have anything else that you would add to
    either of those two columns?
        Admiral Ryan. I would just say, in relation to Scott, what
    he said, that we think one of the recommendations we have in
    there is if you want to actually look at an FEHB-type of
    program, doing it with the Guard and Reserve might not be a bad
    idea because right now it is so--lack of continuity,
    disjointed, they don't get equal treatment. So that is one of
    our thoughts.
        Dr. Heck. Okay.
        So, Ms. Raezer, what would be your three ups and three
    downs?
        Ms. Raezer. I think my three ups would start with the
    combat care. This has been a success story.
        I think the military families say they want to go to a
    military hospital because they believe the providers understand
    their life, so that cultural competency. And I think for
    military families--for currently serving military families, the
    cost of the care to--it's important for our very young military
    families to have that low, low predictable cost.
        I think the three downs, it is access, inconsistency, and
    access. If you can't get an appointment, everything else is a
    problem.
        Dr. Heck. Right.
        And, Mr. Bousum.
        Mr. Bousum. Yes. I honestly, for the most part I echo that
    sentiment. I have an example from the previous line of
    questioning.
        I have a member filled out our survey. There was room for
    additional comments. They had a torn ACL [anterior cruciate
    ligament]. Took 5 months. Ended up having to do it at a, you
    know, at an outside hospital, a civilian hospital.
        In fact, the doctor--this was someone in the National
    Capital Region, obviously, because a doctor at Fort Belvoir
    actually said, ``With your age being 64 years old, you should
    just wait till closer to 70 and have your knee replaced.'' I
    mean, that is not something that is said.
        Dr. Heck. And then, you know, in one of the previous panels
    we had the former Surgeons General, one of which was Admiral
    Cowan. And, you know, he talked about, you know, obviously his
    longitudinal perspective that he has had from being involved
    for so long that, you know, when TRICARE was originally
    envisioned, you know, the idea was that all of the health care
    actually would be provided in MTFs until the military staffing
    in that MTF had to deploy, and then the care would go to, you
    know, out into the community until those returning physicians,
    nurses, medics were coming back to the MTF.
        And he had this idea, or his thought was that we should try
    harder within DOD to recapture more of the care that we've let
    go outside the gate via TRICARE back into the MTFs.
        Now, I understand the point that you brought up, Ms.
    Raezer, that, hey, if there are no appointments to take care of
    the current beneficiaries, how are they going to provide
    appointments for those outside the gate? But assuming that
    could be fixed--that is a big assumption, but let's say
    assuming that could be fixed--what degree of reticence do you
    believe there would be amongst your beneficiaries, your
    members, of wanting to come back into the gate?
        I mean, would they need to be incentivized to come back in
    if they have been getting care outside the gate? Or how do you
    think we would be able to accomplish that, to get them to
    understand or want to come back into the MTF?
        Ms. Raezer.
        Ms. Raezer. Well, I think it is important to remember that
    most of our Active Duty families are already in the MTF to
    varying degrees. Air Force has downsized a lot of facilities to
    clinics, so there is a lot more care out in the purchased side
    for Air Force families in many locations.
        I think our Active Duty families look to the military for
    care. They believe this is something they have earned. As I
    said, these are providers who supposedly understand their life.
    But you have to convince them.
        We have also heard from a lot of military families that
    they are making the switch to Standard because they want more
    control, they want more access, and so the military hospitals
    are going to have to convince them that they offer the care
    that they need. That includes things like after-hours care;
    that includes other options than waiting with a sick child in
    the emergency room; that includes getting rid of some of these
    silly rules.
        So I think our military families can be convinced, but it
    is up to the military hospitals to show they understand what
    families need.
        Dr. Heck. When you talk about cultural competency and the
    providers understanding the life of the duty member, do your
    members talk about hospitals or military health care facilities
    that are primarily staffed with civilian contractors nowadays,
    versus actually Active Duty health care professionals?
        Ms. Raezer. They actually like the places that have more
    civilian providers because generally hours are better and
    there--it is easier to get an appointment.
        Admiral Ryan. I think we are rowing up the stream and it is
    going to be very difficult. Our survey of over 30,000 indicates
    that with TRICARE for Life, which retirees are very important,
    84 percent say it is not very important to go to a military
    hospital; Standard, 90 percent say not very important; and then
    Prime, 61 percent not very important, including currently
    serving.
        As Joyce said, they're most interested in access and
    choice. So it is not something that is working well right now,
    and it is not going in the right direction.
        Admiral Cowan is a great American, but you know, Dr. Heck,
    and even in your area that purchased care provides 58 percent
    of the care on the west and only 42 percent is done in the
    MTFs. So it's a big hurdle.
        Dr. Heck. Mr. O'Rourke, another question?
        Mr. O'Rourke. Yes. Thank you, Mr. Chairman.
        Admiral Ryan, I just want to tell you that your comments
    are spot on in terms of the need to force interoperability
    between DOD and VA And it is really encouraging, actually, the
    anecdote that you told us of the President calling in the two
    secretaries responsible, and yet deeply disheartening that as
    we enter the final year of his term nothing's happened. And he
    really is the only person who can referee this dispute.
        But I would love to join my colleagues on this committee to
    do everything we can from a legislative perspective to try to
    force this. However, as you probably know, that there has been
    legislation requiring this, mandating it, that the
    administration, for lack of a better word, has just refused to
    implement.
        And there is no excuse for it. And it is, in your words,
    very embarrassing. And the consequence is that you have wasted
    taxpayer resources and you're not maximizing the health
    systems--the two largest health systems in this country.
        And just one last anecdote: We had a hearing on this with
    the Government Oversight Committee couple months back and the
    excuse from DOD's perspective for not doing this is that their
    systems need to work on a submarine, which, you know, to me
    makes no sense. We can have it work on a submarine; we can have
    it work in a VA clinic.
        But, Mr. Bousum, you didn't get a chance to answer that
    question on access and interoperability between DOD and VA and
    where you see some opportunities, so I'd love to give you a
    chance to respond.
        Mr. Bousum. Well, the point I was going to make was
    actually about that ACL surgery, so I was able to work it into
    another answer.
        As far as interoperability goes--and the comment was made
    that I think that there are decisions being made at high levels
    that don't actually make it down to the people who end up, you
    know, at the base level, so that's a particular problem that we
    are seeing.
        I would say that as far as--it is unfortunate that there
    are numerous members of the Guard and their families that
    aren't allowed to use an MTF, and so I think that that should
    be across-the-board access. And I think that our members would
    welcome that because it is a one-stop shop, it is--they are
    around other service members, they are--they would be more
    willing to go, and they feel more comfortable and they would
    like their primary care provider. And so, yes.
        Mr. O'Rourke. Let me ask Ms. Raezer a question, and this is
    slightly dangerous because it is based on anecdote. But my
    sister is an ER [emergency room] nurse in El Paso, and we have
    William Beaumont Army Medical Center, which is an excellent
    Army medical center, and they are just completing a $1 billion
    new William Beaumont Army Medical Center 9 miles east. And she
    said it really struck her the number of military families who
    showed up at the ER to get primary care for non-emergencies
    that I assume TRICARE is paying for, despite there being a
    world-class Army medical facility on base.
        Any thoughts on that, in terms of reforms that could
    address that? If true, it doesn't seem like, perhaps, the best
    use of resources and love to get your thoughts.
        Ms. Raezer. Well, I think it's--when one new hospital that
    I am not going to mention opened, military families who went
    there said, ``Beautiful new building; same old military
    customer service.''
        Mr. O'Rourke. So it is the access----
        Ms. Raezer. It becomes an access issue.
        So the question for me is how late are Beaumont's primary
    care clinics, pediatric clinics open? Do they have after-hours?
    What's the provider workload? Do they--how are they augmenting
    military staff with civilian staff to help promote access?
        But if she's seeing military families for primary care in a
    civilian ER, those families are probably there because they
    didn't feel they had any other options.
        Mr. O'Rourke. That makes sense. And great questions for me
    to ask of William Beaumont, in terms of their hours and
    availability.
        Thank you, Mr. Chairman.
        Dr. Heck. Mr. MacArthur.
        Mr. MacArthur. Admiral, I had a follow-up question for you.
    You mentioned that you thought consolidation should be under
    the DOD, not OPM. I agree with that, but I am wondering,
    briefly, what your reasons for that are.
        Admiral Ryan. Well, because, first of all, with the All-
    Volunteer Force, the people that should have ownership of
    retention should be DOD. And so we start out--we are an officer
    association, but we start out concerned most about what about
    the E-5, 10 years of service, combat experience, sitting around
    a table, family of four--what do they think of this or that?
    And I just think that that member, when they go over the
    horizon, he or she, they want to know that somebody's got their
    back, and that has got to be DOD with the All-Volunteer Force.
        OPM does a great job with the civil service, but DOD ought
    to be responding to DOD.
        Mr. MacArthur. Okay. Thank you. And I think there are
    meaningful cultural changes between the two population groups.
        Admiral Ryan. Yes. One of the things that we have found,
    and it is in regard to the chairman's question too, about what
    should we do in the MTFs, we did a study with UnitedHealthcare
    called ``Ready to Serve,'' and that was done by RAND
    [Corporation], and it shows that the families really do have
    concerns about do the people understand us.
        But guess what? The practitioners have even more concern,
    particularly in the mental health area, that they don't feel
    that they are qualified to help somebody coming from a military
    situation if they come in for a mental health issue.
        So a lot of people are trying to work on that. Some States
    are doing a better job. It is not only the concern of the
    family, but the providers themselves, they are split between
    the 1 percent and the 99 percent. They want to do the right
    thing but they are worried that they don't know what that right
    thing is if that patient comes to see them as a civilian.
        Mr. MacArthur. Yes.
        My other question was for Ms. Raezer and then Mr. Bousum.
    The admiral--admiral, excuse me, mentioned that you polled very
    high--your members polled very high on access and choice being
    the highest priorities. I think that was you that said that.
        And it seems to me as I'm listening that training of
    physicians and other health care professionals is vital on the
    readiness side of the objective, and access and choice is vital
    on the family care side, and how do we balance those two?
        I wondered if your members would--if you have polled them,
    do you think they would poll as high--or maybe you have already
    done that work and you can answer--would they be in the 80
    percentile, as well, that access and choice are the highest
    priorities?
        Ms. Raezer. I think for currently serving--and we are in
    the process of polling. We also sent families to MOAA's survey
    to fill that out, and we are in the process of polling a larger
    sample of military spouses.
        What we hear from military spouses is access. If they can't
    get access then choice becomes important, and that's why we are
    hearing of families who are making the choice to assume more
    out-of-pocket costs for their health care so that they have
    more options under TRICARE Standard.
        Mr. MacArthur. I thank you.
        And, Mr. Bousum.
        Mr. Bousum. So I am flipping through here. Our poll shows
    that, ``Does TRICARE Reserve provide health care in a quick and
    timely manner?''
        ``All the time'' is 46 percent, and ``very little of the
    time'' is about 5 percent.
        And then, let's see, ``Does TRICARE provide a good
    selection of network providers to meet medical needs?'' This
    one's really across the board. It just depends on when it works
    as advertised, which some of our members say, ``TRICARE works
    and it is great when I get it, but otherwise no,'' so I'm
    happy. It should be in front of you on, let's see, it's about
    the fourth question.
        Mr. MacArthur. Okay.
        Since I have a moment, Admiral, I'd like to say that your
    representatives in southern New Jersey, which is what I
    represent, have done a superb job of making me aware of the
    issues that matter to your members. Whether it is concurrent
    receipts or other things, they really have been very, very
    effective in being in front of me on those.
        And, Mr. Chairman, I yield back with that.
        Dr. Heck. Well, I am going to keep going because we have
    got you here and I want to totally exploit the opportunity to
    get your perspective.
        So again, as we have been working through this--and, you
    know, this has been a very iterative process. Each time we get
    another panel before us we pick up another pearl, or at least I
    pick up another pearl that sometimes changes the entire
    calculus that I had before that committee hearing.
        I was impressed that each of you said that, you know, the
    primary goal is to maintain combat casualty care, right, as the
    primary goal of the military health care system. And I would
    certainly agree with that, certainly when we look at the
    advances we've made over the last 14, 15 years.
        So here's, I am throwing out--and I probably shouldn't do
    this on the record, but I am throwing out a concept, okay? So I
    don't want this--you know, this shouldn't be publicized in any
    newspaper article that that's my idea, but a concept. Too late.
    Otherwise my phones are going to start lighting up already.
        So with the idea of trying to maintain combat casualty
    care, right, which basically comes into the idea you need a
    health care provider force that's ready to be able to provide
    that care, and you need a medically ready force to be able to
    deploy. It would seem that the--and that comes at cost--
    readiness comes at a cost, and I think that is one of the
    things that DOD fails to recognize. Well, they recognize it
    when they write the check, but they don't realize that if you
    want to be ready you have got to spend money to do it.
        And I use the analogy of like a civilian trauma center.
    Civilian trauma centers know that they are going to lose money.
    It is because, you know, you have got to have all those
    resources ready to go at the flip of a switch 24/7, whether you
    are using them or not, and that comes at a cost.
        So if we want to say that the primary goal is to have that
    medically ready force, medically trained and ready providers,
    and maintain combat casualty care, that perhaps, as Mr.
    MacArthur said, we focus providing that at centers of--military
    medical centers of excellence. That would be the full impatient
    capability MTF, and those would be located in areas of high
    troop concentration, right?
        If we downscale other facilities, then, to let's say
    outpatient clinics with no inpatient capability and we want
    to--well, the--I should go back. To do that we need to
    recapture all the care in those areas into those facilities so
    that those medical health care providers can get the training
    that they need, not just on combat casualty care but, you know,
    we do humanitarian missions. It is delivering babies, taking
    care of pediatric patients, taking care of, you know,
    asthmatics and everything--heart failure and heart attacks.
        If I'm hearing correctly, in order to do that we've got to
    increase access, which is the hours of operations, the number
    of appointment slots, and the staffing and the specialists
    available within the MTF.
        Outside of those areas of concentration, then, perhaps more
    of the care is provided through military outpatient clinics--so
    on a post, base, or camp there would be an outpatient clinic
    with no inpatient capability and inpatient services would be
    provided on the economy.
        And then to address the Guard and Reserve issue that
    perhaps--so that there's not an issue with changing in duty
    status, that they are allowed to enroll in FEHB or FEHB-type
    equivalent. Honestly, I mean, previously--actually right now
    the law says that if you are eligible for FEHB you are not
    allowed to enroll in TRICARE Reserve Select.
        So perhaps, you know, as a broad framework--and again, I
    know there are a lot of holes in that, but give me your first,
    you know, response to a system that would look potentially like
    that.
        Ms. Raezer.
        Ms. Raezer. I think there's some merit in it. I would have
    just a couple questions.
        My first would be even if you concentrated a lot of that
    readiness care in a few locations, would our population still
    be big enough on its own to allow military medical providers to
    get the skills they need to remain combat-ready? And there is a
    lot of discussion about--and there is a model in San Antonio
    where the military facility is a level-one trauma center,
    helping, you know, supporting the community as well as the
    military. So I think that is one question that would have to be
    considered.
        The other would be, as I said earlier, in designing where
    those smaller facilities, what's the interaction between the
    military system and the civilian provider network? Would there
    be enough civilian capability in the providers and the
    specialties that our families would need to meet the demand
    from the military folks?
        So I think that would be my caution in designing that is
    making sure that capacities and access is still there in those
    smaller facilities. But and then the other is the bigger
    question. I mean, what will it take to keep our providers ready
    and trained?
        Dr. Heck. Okay.
        Admiral.
        Admiral Ryan. It is a very interesting concept and we would
    like to talk to your staff about it some more.
        One big thought: You know, the VA has their polytrauma
    centers at the different geographical areas, and so there is
    kind of a lesson that could be learned maybe about that. Do
    they get enough inflow for the spinal cord and brain injuries
    and all to stay current while they are doing everything else
    and pulling in the regular patients, as you said--not the
    babies necessarily, unless it is one like Chicago where they do
    both. So you have got a little bit of something here you could
    get some experience from.
        I think no question, right now the military does an awful
    impressive job. I would say they are leading the country in
    this type of casualty competency. That part of it is working
    well right now.
        I wonder going forward if we could really get the trust of
    the people to come into the thing when you are going to then
    just deploy them when something happens. And so it would have
    to be--it couldn't be with the three Surgeon Generals the way
    it is now.
        You would have to have a unified command where it is in the
    plan that we are going to have a much more collaborative--for
    example, these six areas of concentration right now, they are
    committees. Nobody has the authority to move the dollars
    around; nobody is really in charge. They try and work together,
    but you have got to have somebody in charge and somebody who
    can move dollars around.
        And then you have got to embrace the community, the
    purchased care, and have, you know, a system where it is
    visible--the appointment system is visible to everybody that is
    trying to meet that need.
        I think it is doable. You almost have it right now, but
    what you don't have is the unity of command to make those
    systems--the incentive for those military systems to be as
    efficient as the purchased care.
        Dr. Heck. Great. Thank you.
        Mr. Bousum.
        Mr. Bousum. Well, you know, we know that this is a
    multiple-year effort and we know that, you know, you and your
    staff are going out in the field and meeting with service
    members, Reserve Component, and Active Component. What I can
    say--I don't really want to speculate. What I would say is I
    will just, you know, continue to work with your staff and to,
    you know, get a better idea of this concept and perhaps tailor
    the survey we are already sending to our members in a way that
    could better get results for you.
        Dr. Heck. Right.
        Admiral Ryan. Mr. Chairman, I would just say based on that,
    our recommendation that 15 other associations in The Military
    Coalition have supported is try it in one of the major six
    areas and give DHA [Defense Health Agency] the authority to
    actually move the dollars and control it, and do the same thing
    with the Guard and Reserve. Try that. And if it works then,
    wow.
        Dr. Heck. Okay. And that is perfect timing on that note, as
    the bell has just rung, and since I am the last man standing.
        So I want to, again, thank you all for taking time to be
    here and to offer your insights and opinions. They are very
    valued and we certainly will take them into deep consideration
    as we move forward. And I am sure you will be back as we start
    moving forward with the actual proposal.
        So again, thank you, and the hearing is adjourned.
        [Whereupon, at 12:38 p.m., the subcommittee was adjourned.]

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                                A P P E N D I X

                                December 3, 2015

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                  PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                                December 3, 2015

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    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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                       DOCUMENTS SUBMITTED FOR THE RECORD

                                December 3, 2015

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    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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                  WITNESS RESPONSES TO QUESTIONS ASKED DURING

                                  THE HEARING

                                December 3, 2015

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               RESPONSES TO QUESTIONS SUBMITTED BY MR. MacARTHUR

        Mr. Bousum. Consolidation of the military health system. In my
    opinion, a medic is a medic, no matter what color the uniform.
    Consolidating the military health system into one command makes sense,
    might provide budgetary efficiencies, and would probably be applauded
    by military members and families alike. And I agree with your
    conclusion about the responsibilities of the surgeons general, although
    I am not convinced that it takes a three star general officer to
    oversee training, equipping, or supporting. Broad authority. In my
    opinion, flexibility in TRICARE contracts allows for dynamic changes
    and not having to wait five to eight contract years to react. Military
    centers. In my opinion, consolidating facilities to provide regional
    coverage for larger concentrations of military troops and families,
    while extending the reach into the private sector for dispersed
    beneficiariesreservists, or specialty care is prudent. Inclusion of VA
    and other federal medical facilities also makes sense--a whole of
    government approach instead of a parochial Defense Department paradigm.
    Military health reserve system. In my opinion, allowing providers to
    contractually affiliate with the Department without having a military
    obligation as an added pool of resources may provide an outlet for
    patriotic service to these providers, or in some cases, allow continued
    service for those providers with previous military or federal service.
    Modeled after the Individual Mobilization Augmentee (IMA) concept
    (without the military obligation), rotations of civilian providers will
    become a valuable manpower and educational resource for the military
    treatment facility. A concern may be in proper compensation for their
    service commitment based on their specialty (nurse, doctor, or
    specialist).   [See page 13.]
        Admiral Ryan. MOAA has long supported a unified medical command, in
    the belief that there can be no system efficiency without a single
    point of responsibility for the health care budget, policy and
    execution. As for giving the command ``broad authority to change plans
    and delivery within broad cost constraints'', MOAA would be reluctant
    to agree to such a general concept without additional specifics and
    guidelines. One thing we believe would be essential would be to
    establish a joint working group, to include reasonable beneficiary
    organization participation, to develop, evaluate, and implement
    proposed changes. This is exactly what was done in the implementation
    of TRICARE For Life. The TRICARE Management Authority (predecessor to
    the Defense Health Agency) provided the working group head and a wide
    variety of agency participants who met weekly with a select group of
    beneficiary association representatives to exchange perspectives,
    identify problems, and propose and evaluate potential solutions. That
    process worked exceptionally well, with positive outcomes (indeed,
    better than expected outcomes) for both the Defense Department and the
    beneficiaries. The military health reserve system could pose the
    greatest challenges, simply because of the general shortage of
    providers. Without more specificity concerning this proposal, it's
    difficult to provide substantive comments.   [See page 13.]
        Ms. Raezer. Our Association supports a unified medical command in
    the hope it would lead to greater policy consistency across the MHS.
    Currently, policy adherence varies across the Services and individual
    MTFs. This makes it hard for military families to navigate the system
    as they encounter new rules, policies and procedures at each new duty
    station.
        We are open to the idea of concentrating military medical assets in
    areas with significant military populations. However, we would want to
    be assured that:
          Military medical facilities outside of the major medical
    centers (e.g., outpatient clinics on remote installations) would
    provide high quality care on par with that received by families at the
    major military medical centers
          There are adequate civilian medical resources in the
    surrounding community to meet military family needs--e.g., are there
    enough civilian providers in Junction City, Kansas (population 25,388)
    to provide for the medical needs of Fort Riley families (family member
    population 24,678)?
          Families living near military medical centers would
    continue to have options for civilian care (e.g., TRICARE Standard)--we
    would not want military families to be ``trapped'' in an
    underperforming direct care system should they encounter problems with
    the MTF Ensuring a vibrant military health reserve system utilizing
    health care professionals in the private sector who agree to be on
    reserve status and go wherever whenever seems like a win from the
    military perspective. However, we wonder what would happen to civilian
    medical facility staffing and civilian health care should a large and/
    or sudden mobilization of health care reservists occur.   [See page
    13.]

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                  QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                                December 3, 2015

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                        QUESTIONS SUBMITTED BY MR. WALZ

        Mr. Walz. One of the reasons the commission recommended changing
    the military health care system is because military families and
    retirees told them they wanted choices. Is this the message you hear
    from your organization members? 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?
        Mr. Bousum. The majority of the members of the Enlisted Association
    of the National Guard of the United States (EANGUS) do not believe that
    TRICARE is broken. When surveyed, EANGUS members are satisfied with the
    care they receive when the system works. Many members of the National
    Guard struggle with continuity of care when activated to Title 10 and
    receive health care coverage under TRICARE Prime. EANGUS members are
    interested in the findings of the congressionally mandated Department
    of Defense assessment to review recommendations made by the Military
    Compensation and Retirement Modernization Commission to consolidate
    duty statuses, section 515 of The National Defense Authorizations Act
    for Fiscal Year 2016 (Public Law 114-92). As a general principle,
    EANGUS members believe that health care coverage should not be linked
    to duty status and that all members of the National Guard should be
    able to stay on the same health care plan regardless of orders.
        Mr. Walz. What are the specific challenges regarding Reserve
    Component forces accessing care?
        Mr. Bousum. Members of the Enlisted Association of the National
    Guard of the United States (EANGUS) recognize that some military
    service organizations are apprehensive about any Congressional or
    Department of Defense action to make changes to TRICARE. However,
    members of the National Guard are often located in rural areas. Access
    to quality health care is limited. Access to specialized care can be
    even harder to find, and where it is found, the quality or knowledge
    base of the providers are limited--it's not the best care; it's only
    the best of the available care, and this can make a difference in
    treatment of certain conditions, like autism and down syndrome. Since
    most members of the National Guard do not live on, or near, major
    military installations, EANGUS members believe that the contract
    requirement for a pre-authorization (i.e. referral) to use urgent care
    clinics should be eliminated. Unlike hospital emergency rooms, urgent
    care clinics have faster response times and less cost. In rural areas
    that don't have urgent care clinics, a simpler process is needed to
    eliminate the need for Reservists to pay upfront costs of emergency
    room visits and have to seek reimbursement from TRICARE. TRICARE should
    effect payment directly to the hospital before exacting co-payments
    from the member.
        Mr. Walz. What aspect of health care matters most to your members
    (ie. Continuity of provider, low cost, flexible appointment scheduling,
    etc.)?
        Mr. Bousum. Members of the Enlisted Association of the National
    Guard of the United States (EANGUS) care most about continuity of
    provider. Members of the National Guard and their family members often
    lose access to their primary care physicians when activated to Title 10
    and receive health care coverage under TRICARE Prime. Too few primary
    care physicians accept TRICARE which is why members and their families
    are forced to change doctors. EANGUS staff recognize that the
    Department of Defense has increased use of 12304b orders to activate
    members of the Guard. 12340b orders provide health care coverage only
    during deployment, not 90 days before and after deployment as with all
    other duty status orders. The overuse of 12304b orders makes it so that
    the family members of the members of the National Guard are left to
    navigate finding a health care provider without the servicemember to
    assist. As a result, forward deployed members of the National Guard are
    concerned for their family members' stressful situation, particularly
    in the cases were family members are injured or ill, and focus less on
    the mission. Readiness suffers as a result.
        Mr. Walz. One of the reasons the commission recommended changing
    the military health care system is because military families and
    retirees told them they wanted choices. Is this the message you hear
    from your organization members?
        Admiral Ryan. The message we hear from our members is that those
    who are dissatisfied with their access to care want another choice that
    will get them access. It's not that they necessarily want multiple
    options to pick from, but that they need to know they and their
    families can get access to quality care on a timely basis. The issue
    here is mostly with TRICARE Prime enrollees. And among that group, the
    most dissatisfied are the ones who are enrolled in military treatment
    facilities. That's where most of the excessive waiting times occur.
    They want DOD to adhere to its own access standards, and if they can't
    be seen in the military facilities within those standards, they want
    and need to be referred to a civilian network provider within DOD's
    timeliness standards.
        Mr. Walz. If your members do want more choice, is the Commission's
    recommendation what the members of your organization want?
        Admiral Ryan. Many members of the Guard and Reserve community would
    see the Commission's recommendation as an improvement over the widely
    varying TRICARE benefits now offered to them at various stages of their
    lives. It would also provide better continuity of care than TRICARE now
    provides when transitioning to and from active-duty callups,
    transitioning from Selected Reserve to gray area reserve status and
    from gray area to retired pay status.
        That said, military technicians--who now are enrolled in FEHBP--
    have been frustrated for years that they are compelled to pay high-cost
    FEHBP premiums and are not authorized to enroll in the much lower-cost
    TRICARE Reserve Select (TRS) available to other Reserve component
    members. So any new option involving an FEHBP-style plan should include
    a significantly more favorable federal subsidy.
        Our survey results did not show any particular indication of
    interest in the Commission's plan from the active-duty or retired-pay-
    eligible population. They simply want DOD to meet its own stated
    standards of timely access, and a strong majority expressed the believe
    that they shouldn't have to be charged more money to get that access.
        Mr. Walz. Do they believe choice will improve medical care?
        Admiral Ryan. Our survey of 30,000 beneficiaries showed the
    significant majority are satisfied with the quality of their medical
    care, once they get access to it. Where they are currently having
    access problems (i.e., mainly in TRICARE Prime and mainly in military
    treatment facilities), they believe they should have an alternative
    option to receive that care in the civilian community, and that
    improved access would effectively mean improved care.
        Mr. Walz. What are your concerns with the recommended change?
        Admiral Ryan. MOAA believes the MCRMC-recommended change to scrap
    TRICARE and implement an FEHBP-style insurance system through the
    Office of Personnel Management is unnecessary to achieve improved care
    access, and almost certainly would carry its own unintended
    consequences.
        First, it would turn over DOD's employer responsibility for this
    unique population over to a civilian personnel agency where the
    military population would, for all intents and purposes, be treated as
    civilians. DOD imposes extraordinary hardships on this population
    through frequent relocations, combat deployments, family separations,
    and more that require unique consideration from the military employer.
        Second, MOAA feels strongly that the military health care benefit
    is earned by arduous military service, and that the same benefit and
    coverage should apply to all, as it does under TRICARE. MOAA believes
    it would be inappropriate to implement an FEHBP-style system where
    getting better coverage depends on one's income level. If choice means
    having tiered healthcare options where higher-ranking people can buy
    better coverage than lower-ranking people can afford, that's not the
    kind of choice we think is appropriate for the military healthcare
    system.
        Third, imposing significantly higher cost shares on uniformed
    service beneficiaries--nearly as high as those associated with FEHBP--
    is an inherent part of the MCRMC proposal. MOAA agrees with the 70+% of
    our survey recipients who said they should not have to be charged more
    to get access to quality care.
        Mr. Walz. Are there ways to improve the TRICARE program instead? If
    so how?
        Admiral Ryan. There are many ways to improve TRICARE rather than
    throwing it out and imposing a civilian-style insurance system. MOAA's
    statement for the record lists more than a dozen specific
    recommendations, some of which include:
        Provider Payments Should Reward Quality Care. MOAA concurs with the
    MCRMC belief that both Medicare and TRICARE need to move to payment
    systems and treatment bundles that reward providers for meeting
    standards of quality and healthy outcomes rather than simply paying
    them for the number of patient encounters they have.
        Focus on the Causes of Problems, Not the Symptoms. If the real
    reason behind a cost increase is program inefficiency, DOD or service
    decision-making, the exigencies of national conflict, or arbitrary
    hiring freezes or other conditions caused by sequestration, that is not
    any fault of the beneficiary, and raising beneficiary fees is not the
    appropriate response. The solution should be to focus on addressing
    those problems rather than making beneficiaries pay more simply because
    it's budgetarily or programatically easier.
        Consider Implementing a MCRMC-Style Insurance System for the Guard/
    Reserve (G/R). The current hodgepodge of makeshift healthcare programs
    for the under-60 G/R community makes it one program where it actually
    is possible to start over from scratch. The subsidy levels envisioned
    by the MCRMC would provide a better deal for many G/R beneficiaries
    than they have today--especially ``gray area'' retirees and those
    drawing retired pay before age 60 because of deployment credit, who now
    have no subsidized care. Selected Reservists who prefer to keep family
    coverage through an employer should be allowed to retain that coverage
    upon activation, with the premium paid or subsidized by DOD.
        Consider Establishing a Joint HASC/HVAC Subcommittee on DOD/VA
    Transition. If the HASC and HVAC can cooperate in a joint
    subcommittee--even a temporary one--to devise joint policy, program,
    and budget solutions on such issues as a joint interoperable electronic
    healthcare record, there is a far greater chance this joint resolve can
    be reflected in DOD and VA programs.
        Require DOD to Implement the MCRMC Recommendation to Expressly
    Allocate Readiness and Benefit Costs. A thoughtful and rational
    dialogue on beneficiary cost sharing absolutely requires an agreement
    on exactly which expenses are a cost of doing national defense business
    vs. a benefit value delivered primarily for the sake of the
    beneficiaries.
        Seek Some Form of Agreement on the Premium Value of a Service
    Career. This issue is at the crux of every disagreement between DOD and
    its beneficiaries over how much the latter should be expected to pay
    for their healthcare benefits, and why. The legislative history of
    CHAMPUS, TRICARE Prime, and TRICARE For Life allows at least some
    starting inferences on this thorny topic. A primary reason for
    beneficiary outrage at proposals for steep fee increases are current-
    year assertions that military beneficiaries are somehow undeserving of
    current benefit levels or that their benefits should be more like
    civilians'. Such arguments fly directly in the face of what the
    military retirees were told in order to induce them to stay for a
    career in uniform and contradict the long history of military
    healthcare programs provided at modest cost in tacit, if not explicit,
    recognition of the extraordinary, in-kind premiums career service
    members and families pre-pay in terms of arduous service and sacrifice
    over multiple decades.
        Test the Concept of Unified Budget and Oversight Authority in MSMs.
    The Defense Health Agency is in an excellent position to oversee
    establishment of pilot project to test the concept of a single
    budgetary/operations oversight authority in at least two of the multi-
    service market areas (MSMs). Such a test should offer some insight into
    the feasibility and potential savings associated with unified vs.
    multiple-service oversight of budget, appointing/referral, and other
    operational and support programs.
        Increase Patient Visits Per Provider in MTFs. Assess and change
    support staffing and other factors that lead military providers to see
    significantly fewer patients per week than their civilian counterparts.
    If, as defense health officials often assert, it is more cost-effective
    to see beneficiaries in MTFs, it should be worthwhile investing in
    whatever is necessary to promote more comparable numbers of patient
    visits per military provider. This should also substantively ease the
    appointing and referral problems reported by Prime enrollees.
        Require Leadership Oversight/Training on Appointment Timeliness. It
    is beyond understanding that the TRICARE Prime appointment process
    apparently ignores DOD access standards on a routine basis at many
    facilities. This is in substantial measure a leadership problem, in
    MOAA's view. It should be made clear to MTF commanders and others in
    leadership positions over appointing offices that it is their
    responsibility to monitor appointment timeliness and take necessary
    corrective action when standards are not being met.
        Focus Managed-Care Outreach Efforts on High-Use/Cost Beneficiaries.
    Under current rules, priority is given in MTFs to active duty members
    and families, TRICARE Prime enrollees, other under-65 beneficiaries,
    and TFL-eligibles, in that order. MOAA believes much greater priority
    for managed care or case management should be given to beneficiaries
    with a history of high-cost care and those with chronic conditions that
    have the greatest potential for incurring high costs in the future. For
    example, a TRICARE Reserve Select family with multiple children
    requiring complex care would have a high incentive to be seen in a
    managed-care environment, but is not eligible for Prime enrollment.
    Similarly, certain TFL-eligibles or other non-Prime enrollees may have
    chronic conditions posing long-term cost risks far higher than a
    majority of Prime enrollees. These high-cost care users are readily
    identifiable from existing cost records. Surely there are savings to be
    realized by shifting to include a care-cost factor and creating
    outreach programs to bring such families into a more active managed-
    care or case management system.
        Pursue Public-Private Partnerships to Reduce TFL and Other Costs.
    Several innovative cost-saving programs around the country have
    potential application to military beneficiaries and facilities. MOAA
    would encourage DOD to investigate the potential for partnerships with
    civilian contractors to establish TFL-specific Medicare Advantage
    programs in locations where there are large retiree populations and
    significant military medical facilities. The partnership agreement
    would establish the military facility as the preferred provider for
    certain surgeries or other conditions to help sustain military
    providers' readiness skill levels. These programs should include
    outreach efforts to identify high-cost users and those with chronic
    conditions to bring them into a case management environment. This
    system would reduce the contractor's cost and allow addition of other
    program elements (e.g., vision or dental) to incentivize TFL-eligibles'
    participation. The military facility, in turn, could be reimbursed at
    some level through the TFL trust fund. This would seem to have a
    winning potential for the government, DOD, contractors, and
    beneficiaries alike. Anthem's Care More program is an exceptional and
    proven model, and Humana and United Healthcare offer similar programs.
    The MCRMC staff cited another successful model in the Las Vegas area.
        Adopt pediatric-centered payment policies that let providers to
    make optimal care decisions for children. Because TRICARE payment
    systems are based on Medicare systems designed for older people, the
    systems often don't work for pediatric care and don't properly
    reimburse providers for needed and delivered care. Reimbursement should
    follow appropriate care, not form the basis for care decisions. In
    situations where emerging technology is clearly providing compelling
    options for patients and families, TRICARE should allow payment to
    follow the needs of the patient instead of driving the type of care the
    patient receives. When there is a known issue with translation of
    policy or payment from Medicare to pediatrics, there must be an
    efficient process for resolving the difference. Continued innovation
    and research will ensure this issue is at the forefront in the coming
    years, with genetic testing, gene therapy, and individualized medicine
    as examples of prevention, intervention, and treatments that will need
    to be covered and reimbursed appropriately.
        Do More to Connect TRICARE Standard Beneficiaries with Providers.
    One way to improve TRICARE Standard beneficiaries' access to providers
    is to educate them that they are not limited to seeing network
    providers. It's preferable if they do, because that saves money for
    both DOD and the beneficiary. But if a beneficiary is having trouble
    getting an appointment with a network provider, there should be a
    method to put them in touch with a non-network provider who is willing
    to accept non-discounted rates payable under Standard.
        Ease the Cost Burden on TRICARE Young Adult (TYA) Beneficiaries.
    Unlike civilian insurance programs, which spread the cost of adding
    children under 26 by raising family premiums slightly across the board,
    TYA requires each TYA-eligible (or the parents) to pay the full
    individual premium cost of his or her care. With the 26% (TRICARE
    Standard) and 47% (Prime) premium increase for 2016, the $2,500 to
    nearly $3,700 annual cost of this program is particularly onerous,
    especially for families with more than one qualifying child. MOAA
    encourages the Subcommittee to explore alternative ways to spread this
    cost across the entire population, in hopes that this could be done via
    a relatively inconsequential increase. As currently implemented, the
    high individual cost of the coverage deters many beneficiaries from
    using it, which defeats the purpose of the program.
        Mr. Walz. During the height of the wars in Iraq and Afghanistan,
    many retirees were transferred from military treatment facility primary
    care providers to civilian treatment facilities. Are there still
    retirees who would prefer to come back to military treatment
    facilities, but cannot because of access issues?
        Admiral Ryan. We believe there likely are some who fall in that
    category, but not as many as some would expect. Among the 3,000 TRICARE
    Prime beneficiaries (the significant majority of whom were retired) who
    responded to MOAA's survey, 17% considered being seen in the military
    facility as being ``extremely important'' and another 21% thought it
    was ``fairly important''. But even larger numbers reported that they
    were, in fact, being seen in the military facility. While there are
    some who would prefer to be seen there, but are not, it would appear
    from MOAA's survey sample that most who prefer to be seen in a military
    facility are being afforded that opportunity. We also hear from many
    retired members and family members that, once they start being seen in
    the civilian community, they are content to remain there.
        Mr. Walz. What aspect of health care matters most to your members
    (ie. Continuity of provider, low cost, flexible appointment scheduling,
    etc.)?
        Admiral Ryan. Our survey found a considerable amount of consistency
    that access (which we took to mean ease of making appointments and
    referrals) was important across all ages and categories (TRICARE For
    Life, TRICARE Prime, and TRICARE Standard. But all categories and ages
    also reported a distinct belief that it would not be reasonable to have
    to pay more in fees.
        Some specific survey results are summarized in the chart below:

    ----------------------------------------------------------------------------------------------------------------
                                                                                 TFL          Prime       Standard
    ----------------------------------------------------------------------------------------------------------------
    How important is picking your provider?                                 99%           93%           99%
    (% answering ``extremely'' or ``fairly'' important)
    ----------------------------------------------------------------------------------------------------------------
    How important is guaranteed access?                                     88%           91%           81%
    (% answering ``extremely'' or ``fairly'' important)
    ----------------------------------------------------------------------------------------------------------------
    Are you willing to pay more for priority access?
    a. Definitely                                                            3%            4%            3%
    b. Probably                                                             20%           22%           16%
    c. Not sure                                                             42%           37%           41%
    d. Probably not                                                         24%           23%           29%
    e. Definitely not                                                       11%           13%           11%
    ----------------------------------------------------------------------------------------------------------------
    Do you think it's reasonable to ask TRICARE beneficiaries to pay more?
    f. Definitely                                                            2%            4%            2%
    g. Probably                                                             12%           14%           12%
    h. Not sure                                                             10%            8%            8%
    i. Probably not                                                         20%           19%           22%
    j. Definitely not                                                       54%           54%           56%
    ----------------------------------------------------------------------------------------------------------------

        Mr. Walz. One of the reasons the commission recommended changing
    the military health care system is because military families and
    retirees told them they wanted choices. Is this the message you hear
    from your organization members? 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?
        Ms. Raezer. Choice is most important to military families who are
    dissatisfied with the quality of care they currently receive through
    TRICARE, as well as the patient experience and access to care. The top
    priority for military families is improved access to care. Greater
    choice, as one possible way to improve access, is therefore important
    to families. There are two main types of access challenges with the
    Military Health System (MHS) that must be addressed with MHS Reform:
          Direct Care System Appointment Challenges: Approximately
    80% of military families are TRICARE Prime enrollees and rely on
    military hospitals and clinics for most of their health care. Too
    often, military families have problems getting appointments at military
    treatment facilities (MTFs) and can't access the right care, at the
    right time, with the right provider.
          TRICARE and MTF Policies: Numerous TRICARE referral and
    coverage policies limit or delay military family access to care
    recommended by their medical providers. TRICARE coverage policy, based
    on Medicare, isn't optimal for families with young children. It has
    also failed to keep up with technological innovations and evolving
    standards of care, leaving military families with substandard coverage
    relative to civilian plans and other government payers.
        While military families don't currently report widespread access
    challenges within the TRICARE private-sector provider network, our
    Association fears attempts to reduce purchased care spending will
    result in erosion of network provider access and questionable coverage
    policies. Provider reimbursement rates will continue to decline,
    resulting in fewer providers participating in the TRICARE network.
    Alternatively, providers might further limit the number of TRICARE
    patients they will see due to low reimbursement rates. The result will
    be diminished access to care for military families. As dissatisfaction
    with access, quality, or the patient experience increases, so will the
    desire for more health care options increase.
        From our Association's perspective, the top priority for MHS Reform
    is addressing the variety of access challenges military families
    currently face as well as future threats to health care access posed by
    continued fiscal constraints on the MHS.
        Will the MCRMC proposal address military family issues with the
    MHS? Our Association believes the Commission's proposal has the
    potential to provide military families with a more robust and valuable
    health care benefit than they have today. Offering military families a
    selection of high quality commercial health plans could provide them
    with better access to high quality care, a more comprehensive set of
    benefits, and the ability to tailor coverage options based on
    individual family needs.
        We also believe the Commission's proposal would address health care
    coverage problems the Reserve Component faces. Switching to TRICARE
    when the service member is activated can result in disruptions in care
    for the National Guard or reserve member's family, while maintaining
    the service member's employer sponsored health insurance in order to
    provide continuity of care can lead to significant out-of-pocket costs.
    We have long advocated giving National Guard and Reserve members more
    flexibility to maintain employer-sponsored coverage for their families
    during activation and believe the Commission's plan is one way to
    achieve this.
        What are NMFA's concerns regarding the MCRMC proposal? While our
    Association supports, in principle, the concept of moving military
    families to high quality commercial health plans, the Commission's
    proposal raises several questions and areas of concern, including:
          Potential for increased out-of-pocket costs. Some
    segments of the military family community will incur significantly
    higher out-of-pocket costs versus the current system. TRICARE Choice's
    catastrophic cap is unspecified. Details are sparse on the Chronic/
    Catastrophic Program and we are not convinced it would sufficiently
    insulate special needs families from high health care costs. We are
    skeptical the Basic Allowance for Health Care (BAHC) formula would
    adequately cover costs for high quality plans for all types of
    families. Finally, working age retiree premiums and out-of-pocket
    expenses will be significantly higher versus current TRICARE retiree
    costs.
          Beneficiary education and financial planning guidance
    needed. TRICARE Choice would require an unprecedented level of
    beneficiary communication and education to help families choose the
    right plans. Medical bills are highly variable in amount and timing,
    requiring more sophisticated budgeting skills and additional financial
    planning training.
          Does not address access and quality issues within the
    MTFs. While we see merit to the Commission's proposal, it is important
    to note that it does nothing to address beneficiary complaints
    regarding the direct care system other than allowing dissatisfied
    beneficiaries to seek care somewhere else in the hope competition will
    incentivize the MTFs to improve.
          Potential impact on military medical readiness. Even
    though the MTFs will remain an integral component of military family
    health care delivery under the Commission's proposal, the report
    contains few details on the potential effect the plan might have on the
    direct care system. There is no analysis of potential impact on MTF
    caseload or consequences of loss of beneficiary caseload on military
    medical personnel readiness.
        Are there ways to improve the TRICARE program instead? We are
    skeptical the existing MHS construct can be tweaked to simultaneously
    achieve cost savings and significant improvements to access, quality of
    care, and the patient experience particularly given the barriers to
    improving the MHS, including:
          The current budgetary environment. It is unlikely that we
    will realize TRICARE program improvements during a period of fiscal
    constraint.
          Entrenched TRICARE reimbursement policies, governed by
    statute, which are difficult to modernize. It literally takes an Act of
    Congress to make substantive changes to TRICARE coverage policy. While
    today's MHS Reform initiative might fix current gaps in coverage, new
    gaps would likely emerge as medicine evolves in the future.
          The Military Health System's dual readiness and benefit
    provision missions make it difficult to focus on improving the
    beneficiary health care benefit.
          Inconsistent policy compliance by the Services and MTFs.
    There is no measure of MTF compliance and no accountability from the
    MTF to the Service to DOD in regard to policy adherence. Without a
    unified medical command and a cultural change emphasizing policy
    adherence, we are skeptical that policy improvements would be
    consistently implemented at the local level.
          DOD's demonstrated unwillingness to address known TRICARE
    problems leads us to believe they will continue to resist program
    changes in the future.
          Fee for service contracts prevent adoption of innovative
    reimbursement models. As commercial health insurance and other
    government payers move toward a greater emphasis on preventative
    services and outcomes, TRICARE contracts are locked in to the fee for
    service model. This prevents military families from benefitting from
    innovations in medical care delivery.
        Given the barriers to improving TRICARE and the MHS, we believe now
    is the time for Congress and DOD to consider a fundamental overhaul of
    military health care.
        Mr. Walz. What aspect of health care matters most to your members
    (ie. Continuity of provider, low cost, flexible appointment scheduling,
    etc.)?
        Ms. Raezer. Given the current state of the Military Health System,
    military families' primary concern is access to care. If you can't get
    an appointment at the MTF, all other factors are largely irrelevant.
    Once basic access to care problems are addressed, military families
    will likely be more focused on improving other aspects of care. They
    recognize many aspects of the current system need improvement, but
    their main focus today is improving access.

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