A recent JAMA article was published that discusses transforming the Military Health System (MHS). It can be read for free here:
If you prefer PDF, here it is:
This article from the Military Officers Association of America (originally found here) has some interesting medicine related comments:
June 23, 2017
The House Armed Services Committee (HASC) subcommittees released their markups of the FY 2018 defense authorization bill this week, providing milder recommendations than in years past.
The active duty pay raise will match the Employment Cost Index at 2.4 percent. This is a welcome change from the president’s budget request of a 2.1-percent raise, which would have widened the existing pay gap between the military and private sector.
For the first time in many years, the mark includes a provision aimed at supporting military spouse employment. It would allow for reimbursement of up to $500 in expenses when a military spouse must acquire a new license or certification as a result of a PCS to a new state.
On the TRICARE front, unlike the budget the DoD recently proposed, the HASC bill proposes no changes for TRICARE For Life, TRICARE Prime, or last year’s new TRICARE Select, and it maintains the current grandfathered fee structure. The new fee structure begins only for those future service entrants after Jan. 1, 2018. This bill would continue to grandfather currently serving and retired servicemembers and families against the large fee hikes proposed in last year’s defense authorization bill.
Other proposed changes to health care include clarifying the roles of the services’ surgeons general, placing greater emphasis on their responsibility for the provision of readiness training at their respective military treatment facilities (MTFs), and prohibiting DoD from reducing inpatient capacity at overseas MTFs.
All in all, MOAA supports the HASC’s balanced approach to reforming military personnel policies and especially appreciates the committee’s rejection of the large TRICARE fee increases proposed in the FY 2018 DoD budget.
Here is another good article about the NDAA and its impact on the military health system by Tom Philpott:
The National Defense Authorization Act (P.L. 114-328), signed into law Dec. 23, orders an avalanche of changes to the TRICARE health care benefit used by servicemembers, retirees, and their families. It also makes sweeping reforms to how the military direct-care system is organized and operates.
The sheer number of changes and additional studies being mandated, filling 40 sections and 150 pages of the act, is more impressive than any short list of highlights we might be able to review here.
“There’s a lot of good stuff in there. There’s a lot of stuff we’re still puzzling over,” said Dr. Karen S. Guice, acting assistant secretary of defense for health affairs. She will serve in that post only two more weeks, until the Trump administration assumes responsibility for the $50-billion-a-year military health care system and a beneficiary population of 9.6 million.
The authorization act for fiscal 2017 “is full of ideas, concepts, and new things for us to tackle,” said Guice in phone interview. She added that it contains “a remarkable series of provisions that set forth some challenges [and] provides us with new authorities that we’re greatly looking forward to.”
But Guice emphasized many new provisions to modernize TRICARE and improve access will only accelerate reforms that the department already has been piloting or planning to adopt, though perhaps not at the speed Congress desired. The department’s guide has been recommendations of the 2014 Military Healthcare System Review, which then-Defense Secretary Chuck Hagel ordered to take a hard look at performance and outcomes at military facilities and through civilian purchased care networks, Guice said.
Beneficiaries have started to see the fruits of that effort in greater access to care and a nurse advice line. They will see more when the new generation of TRICARE purchased care contracts takes effect this year, and also with gradual rollout of MHS Genesis, the new electronic health records system. All this before many of the new defense bill initiatives kick in in 2018 and years beyond. Associations advocating for beneficiaries wonder how many changes the health system can implement before chaos rules.
Guice doesn’t sound worried for the staff she’s leaving behind.
“We have a lot of very experienced, motivated people who just like to tackle challenges,” she said. “Also, we are looking at this across the enterprise, so it’s the Army, Navy, Air Force all coming together about how we actually do this.”
The Senate version of the defense bill had called for dismantling the medical headquarters of the Army, Navy, and Air Force surgeons general. The enacted law is a compromise that directs a shift of key management functions done by the services to the Defense Health Agency, leaving the surgeons general to recruit, educate, and train their military and civilian health care providers and to advise DHA on medical readiness issues.
“That’s an interesting construct,” said Guice. “And we’re kind of figuring out how best to optimize what Congress is intending to achieve.”
Congress staggered deadlines in the law across a span of years.
“They knew there was a lot of work here and allowed flexibility by pushing out some timelines or saying do this work and then the timeline kicks in,” Guice said. “I think they want us to take our time and get it right.”
There are gems in the law for families seeking more timely care.
One provision ends a requirement that TRICARE Prime users get referrals from primary care providers before using a neighborhood urgent care facility. Another provision mandates that military treatment facilities with urgent care clinics keep them open daily until at least 11 p.m.
Those “are both wins for families,” said Brooke Goldberg, deputy director of government relations for family issues at Military Officers Association of America. Other law highlights she noted require:
- Adoption of a standardized appointment scheduling system across all of military health care and also first-call resolution of appointments.
- New TRICARE contracts incentives to improve beneficiary access, care outcomes, and enhanced beneficiary experiences.
- Adoption of new productivity standards for care providers in military treatment facilities, which should mean more on-base appointments.
- Military providers’ performance reports to include measures of accountability for patient access, quality of care, outcomes, and safety.
Military families will be eligible by 2018 to buy vision coverage through federal employee health programs, explained Karen Ruediseuli, government relations deputy director for National Military Family Association. Retirees and dependents will be eligible for both dental and vision programs.
Some changes touted by Congress are not quite what they seem. For example, the planned narrowing of three insurance options – TRICARE Prime, Standard, and Extra – down to two, with Prime still providing managed care and TRICARE “Select” offering a preferred provider network, is largely a name change push by DoD. Goldberg said it could even be “transparent to families who really don’t know the nuances of Standard vs. Extra.”
Many beneficiaries, she added, “just know they have to pay more if they see one [civilian] provider over another. Many have been using Extra, calling it Standard, and not realizing it.”
Still to be determined “is what the preferred-provider network will look like and will families be able to easily discern which services will result in higher costs? And will they have access to providers who are low-cost?”
For example, current TRICARE provider networks include those who participate in Prime and agree to take a discount from the normal Medicare-based payment. But many providers willing to see Standard patients for its allowable fee will not see Prime patients with its lower fee.
“Will those providers be considered preferred providers under TRICARE Select, or will the Select network only include those who participate as part of the Prime network? If the former is true, then the transition likely will be smooth. If the latter is true, many more people could be hit with out-of-network charges, to the extent they aren’t grandfathered,” said Goldberg.
Adding some confusion is language that grandfathers current generations of military families and retirees from a new schedule of higher fees to hit those who enter service on or after Jan. 1, 2018. But the law will require current beneficiaries to enroll in Select, as they do with Prime, and enrollment will carry a fee for retirees under age 65, beginning in 2020, if a government audit confirms improvements in quality care and patient access.
Guice took exception to one senator’s characterization of the new law as a “first step in the evolution” of military health care from “an under-performing, disjointed health system into a high-performing, integrated” one.
She noted a recent National Academy of Medicine study on military trauma care that found that over a decade of war the U.S. military had made unprecedented gains in survivability rates from battlefield wounds.
“I don’t think that’s reflective of an underperforming system at all,” Guice said. “The people who created that learning system of care are the same people who provide the in-garrison care. That is evidence we really do value constant performance improvement.”
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There are many changes coming our way from the 2017 National Defense Authorization Act. Here is a brief article that summarizes some of the changes:
The 2017 National Defense Authorization Act puts into law new requirements spanning many of DoD’s programs. Most notably, it will entail sweeping changes for the military health care system.
This newly signed legislation puts into law a number of MOAA’s priorities. Specifically, it:
- Secures a 2.1 percent military pay raise vs. the 1.6 percent pay raise proposed by the administration. The 2.1 percent pay raise matches the average American’s, as measured by the Bureau of Labor Statistics’ Employment Cost Index.
- Stops the force drawdown and actually increases manpower levels, especially for the Army, Air Force and Marine Corps.
- Requires an array of reforms to improve beneficiaries’ access to timely and high-quality health care.
- Protects currently serving and retired beneficiaries from a variety of steep TRICARE fee increases proposed in the administration’s budget.
- Rejects a Senate proposal to cut housing allowances by $10,000 to $30,000 a year for dual-military couples and other servicemembers who share housing.
- Provides needed survivor benefit improvements: (a) extending the Special Survivor Indemnity Allowance (SSIA) until May 2018 at $310 per month, and (b) increasing Survivor Benefit Plan (SBP) annuities for survivors of reservists who die during Inactive Duty Training, to match benefits provided for active duty deaths.
The long list of health care improvement requirements are aimed at addressing the systemic and chronic problems MOAA and others have highlighted with beneficiary access (appointments and referrals), quality of care, and safety and consistency of care.
They include changes in contracting, appointment and referral processes, and holding medical providers and commanders more accountable for productivity and consistency of beneficiary-centric care, especially in military facilities.
One major change affecting TRICARE Standard beneficiaries is that program will change, effective Jan. 1, 2018, to a preferred provider organization called TRICARE Select. Another big difference is all non-Medicare-eligible retired beneficiaries will be required to formally enroll every year in either TRICARE Prime or TRICARE Select, starting in 2018. Previously, only TRICARE Prime required a formal enrollment.
The Prime option, though largely unchanged, will be modernized such that the majority of referrals to specialists from primary care managers will no longer be required to go through a cumbersome pre-authorization process. Pre-authorizations for urgent care will also no longer be required.
All in all, MOAA believes the healthcare reforms required in the new law are very positives steps toward our goal of improving beneficiaries’ access to quality health care and elimination of administrative hassles beneficiaries have experienced too often.