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

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

STAKEHOLDER VIEWS ON MILITARY HEALTH CARE

__________

HEARING

BEFORE THE

SUBCOMMITTEE ON MILITARY PERSONNEL

OF THE

COMMITTEE ON ARMED SERVICES

HOUSE OF REPRESENTATIVES

ONE HUNDRED FOURTEENTH CONGRESS

FIRST SESSION

__________

HEARING HELD

DECEMBER 3, 2015

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

______

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SUBCOMMITTEE ON MILITARY PERSONNEL

JOSEPH J. HECK, Nevada, Chairman

WALTER B. JONES, North Carolina SUSAN A. DAVIS, California
JOHN KLINE, Minnesota ROBERT A. BRADY, Pennsylvania
MIKE COFFMAN, Colorado NIKI TSONGAS, Massachusetts
THOMAS MacARTHUR, New Jersey, Vice JACKIE SPEIER, California
Chair TIMOTHY J. WALZ, Minnesota
ELISE M. STEFANIK, New York BETO O'ROURKE, Texas
PAUL COOK, California
STEPHEN KNIGHT, California
Jeanette James, Professional Staff Member
Craig Greene, Professional Staff Member
Colin Bosse, Clerk

C O N T E N T S

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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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[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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DOCUMENTS SUBMITTED FOR THE RECORD

December 3, 2015

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[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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WITNESS RESPONSES TO QUESTIONS ASKED DURING

THE HEARING

December 3, 2015

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RESPONSES TO QUESTIONS SUBMITTED BY MR. MacARTHUR

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

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QUESTIONS SUBMITTED BY MEMBERS POST HEARING

December 3, 2015

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QUESTIONS SUBMITTED BY MR. WALZ

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

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TFL Prime Standard
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How important is picking your provider? 99% 93% 99%
(% answering ``extremely'' or ``fairly'' important)
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How important is guaranteed access? 88% 91% 81%
(% answering ``extremely'' or ``fairly'' important)
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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%
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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%
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