[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






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                   SUBCOMMITTEE ON MILITARY PERSONNEL

                    JOSEPH J. HECK, Nevada, Chairman

WALTER B. JONES, North Carolina      SUSAN A. DAVIS, California
JOHN KLINE, Minnesota                ROBERT A. BRADY, Pennsylvania
MIKE COFFMAN, Colorado               NIKI TSONGAS, Massachusetts
THOMAS MacARTHUR, New Jersey, Vice   JACKIE SPEIER, California
    Chair                            TIMOTHY J. WALZ, Minnesota
ELISE M. STEFANIK, New York          BETO O'ROURKE, Texas
PAUL COOK, California
STEPHEN KNIGHT, California
               Jeanette James, Professional Staff Member
                Craig Greene, Professional Staff Member
                           Colin Bosse, Clerk
                            
                            
                            
                            
                            
                            
                            
                            
                            
                            C O N T E N T S

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                                                                   Page

              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, Ranking 
  Member, Subcommittee on Military Personnel.....................     2
Heck, Hon. Joseph J., a Representative from Nevada, Chairman, 
  Subcommittee on Military Personnel.............................     1

                               WITNESSES

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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                   DOCUMENTS SUBMITTED FOR THE RECORD

                            December 3, 2015

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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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