August Edition of Health Affairs Focused on Military Health System

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A special August edition of the journal Health Affairs, focused on military medicine and the MHS, is now available.

A listing of articles, with links to abstracts, is available at the journal’s table of contents:

https://www.healthaffairs.org/toc/hlthaff/38/8

Full articles are available to journal subscribers. An introductory article from editor of Health Affairs, available free to all readers, is below:

Date: Aug 5, 2019
Title: Military Health Systems
Source: Health Affairs
Author: Alan R. Weil

This month we examine the health systems that serve 1.4 million active duty
service members; provide care and coverage for another 8.1 million
reservists, retirees, and family members; and provide care for 9.0 million
veterans. As the Military Health System (MHS) goes through a major
restructuring, it also faces pressures and opportunities similar to those in
the civilian sector.

OVERVIEW
Terri Tanielian and Carrie Farmer describe the evolution of coverage for
military service members and their families from the 1880s to the current
TRICARE program. They note that almost 60 percent of those covered by
TRICARE are retirees or their dependents. The authors describe how TRICARE’s
evolution has mirrored that of private insurance, with the growth of managed
care, the adoption of patient-centered medical homes, and the recent
introduction of patient cost sharing.

Terry Adirim discusses the 2017 National Defense Authorization Act
requirement to consolidate the direct care system of “fifty-one inpatient
hospitals and medical centers and 672 ambulatory care, occupational health,
and dental clinics,” currently operated separately by the Army, Navy, and
Air Force, under a single authority. The hope is that a consolidated system
“can more effectively standardize care across the enterprise through the
implementation of standard clinical pathways, standard administrative
policies and procedures, and efficiencies realized by eliminating
redundancies in headquarters personnel and operations.”

An essential component of the MHS is its ability to deploy medical personnel
on a moment’s notice to remote, often austere settings. Paul Hutter and
coauthors describe the challenge of gaining and maintaining the skills
necessary to treat battlefield wounds when most training and medical
practice occurs in traditional clinical settings where patients with fairly
routine conditions are treated. The authors note that the current
consolidation of the MHS’s direct care system creates both opportunities and
challenges for achieving the goal of having a “ready medical force.”

QUALITY
In the United States there are significant racial disparities in the
prevalence of heart disease and the quality of coronary care. Muhammad
Chaudhary and coauthors analyze data from TRICARE and find “no difference in
[National Quality Forum]-endorsed quality-of-care metrics between African
American and white patients receiving coronary artery bypass grafting.” The
authors conclude that universal insurance and equal access can contribute to
reducing racial disparities in surgical care.

Peter Learn and coauthors describe the MHS’s participation in the American
College of Surgeons’ National Surgical Quality Improvement Program.
One-third of military hospitals participated in 2014, with all forty-six
qualifying hospitals participating in 2018. The authors find encouraging
trends of quality improvement in the earlier-adopting hospitals, adding to
the evidence that quality improvement collaboratives can have their desired
effect.

Craig Holden and coauthors examine unplanned readmission rates in military
health facilities. They find a significant reduction in seven-day
readmission rates for medical and surgical services in fiscal years 2011-18
, consistent with broad efforts in the health care system to reduce
readmissions.

CHILDREN
Children of parents who are injured while serving in the military are at
increased risk of various poor health outcomes. Elizabeth Hisle-Gorman and
coauthors examine data for children two years before and two years after
parental injuries and find that these children “received decreased
preventive health care and had increased health care visits for injury,
maltreatment, and mental health care and increased days on psychiatric
medications.” The authors also note “the lack of post-injury change in
visits for maltreatment, injury, and mental health care for children of
parents who sustained their injuries on the battlefield.”

Almost two million children receive coverage through TRICARE. Joseph
Zickafoose and coauthors compare the comprehensiveness of this coverage to
that of Medicaid and Affordable Care Act Marketplace plans in five large
states. Notable limitations of TRICARE relative to Medicaid are in the areas
of well-child visits for children older than age six and developmental
screening. Marketplace plans cover a set of services similar to those
covered by TRICARE, but often with significantly higher cost sharing.

Roopa Seshadri and coauthors analyze access and quality for children covered
by TRICARE. Overall, children on TRICARE are more likely to have complex
medical or mental health needs than children covered by other public or
private insurance programs. Children on TRICARE with special needs could
obtain referrals, but the authors conclude that “our findings suggest that
TRICARE-insured families might not have reliable access to care when their
children have special health care needs or behavioral health needs.”

ACKNOWLEDGMENTS
Health Affairs thanks Gail Wilensky of Project HOPE for serving as issue
adviser. We also thank the Uniformed Services University of the Health
Sciences and the New York State Health Foundation for financial support of
the issue.

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00879

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