FEBRUARY 17, 2016
Congress is eager. A bipartisan commission has laid a path. And the Pentagon has proposed a step in the right direction. Is this the year to institute meaningful reforms to improve military health care?
Major reform could significantly improve the quality of health care for servicemembers and their families. Unfortunately, too often this discussion revolves around saving money in DOD’s budget. Delivering military health care in an efficient and cost-effective manner is important. But let’s be clear: Military health care reform should not be just about saving money; it should first and foremost be about building a better health care system.
Today the military’s medical system has two primary goals, which can at times be in tension with each other: first, to provide medical care and support for military missions at home and abroad, including in combat; and second, to provide peacetime health care to service members, their families and retirees.
The operational mission, from the combat medic to casualty evacuation to recovery, and the home-station mission, such as routine medical services for servicemembers and their families, are all part of one large system. These two missions are undertaken, and medical care is provided for 9.5 million people, by a complex organization. This organization is comprised of medical providers in each service, service-specific and DOD-wide management organizations, multiple TRICARE health plans, as well as private-sector medical providers.
Unfortunately, this system is not currently accomplishing either of its two primary goals sufficiently. Patient satisfaction and quality of care are consistently lower than civilian benchmarks, and the military medical workforce is optimized for the patients they serve at home, not the patients they would serve in combat. A military health care system that better supports the operational mission and also provides better care for servicemembers and their families is possible. But this can only be done with structural reform.
Last January, the Military Compensation and Retirement Modernization Commission (MCRMC) released a series of recommendations in its final report. Unlike many Washington commissions, the MCRMC has already had a huge impact on policy — its retirement modernization proposal was largely implemented in the FY2016 National Defense Authorization Act. Part of what made that proposal successful was the commission’s focus on providing a better system for servicemembers instead of cutting benefits or increasing fees in an attempt to balance the books. Impressively, the commission was able to develop a system that was more flexible for servicemembers and will also (in the long run) be more affordable.
TRICARE, the military’s health care program, is ripe for the same kind of overhaul. Surveys of servicemembers and their families show that the system trails the private sector significantly in terms of customer satisfaction, the wait time for appointments, and the quality of care received. TRICARE data show that the time it takes to get appointments, particularly with specialists, takes longer than in the private sector. And on a range of specific procedures, health outcomes are worse in the military system. At the same time, the military health system is not designed well to support combat operations. The MCRMC has outlined a proposal that would address the quality of care both at home and in combat, but change is not easy and the Pentagon needs to provide leadership if real improvements are to be made.
Dissatisfaction with Health Care
A major MCRMC survey of active servicemembers found that 47 percent of respondents were dissatisfied or very dissatisfied with their health care provider choices, and 43 percent were dissatisfied with the quality of health care they experience. In other words, almost half of servicemembers are not satisfied with the health care they are receiving from the military. According to TRICARE’s own surveys, the military health system consistently lags five percent or more behind civilian benchmarks in satisfaction measures including getting needed care and getting care quickly.
As you dive deeper into the numbers, it is clear that younger servicemembers are more frustrated with the current system than those with greater time in service. More than half (51 percent) of junior enlisted (E1–E4) and junior officers (O1–O3) say they are dissatisfied or very dissatisfied with their health care provider choices. Meanwhile, 46 percent of junior enlisted and 43 percent of junior officers are dissatisfied or very dissatisfied with the quality of their health care experience.
Field grade officers (O4–O6) report significantly greater satisfaction with their health care, but more than a third (36 percent) are dissatisfied or very dissatisfied with their provider choices — compared with the civilian national average of less than 20 percent. While a number of factors likely contribute to a better experience for more senior officers, what is surprising is that a third of them are still unsatisfied with their health care.
Interestingly, military retirees and their family members are the most satisfied with the current system. According to TRICARE’s 2015 report to Congress, 76.5 percent of military retirees and family members are satisfied with TRICARE, compared to only 53.5 percent of those on active duty. Military retirees and their families are also vastly less likely to use TRICARE Prime, which is the main HMO-like TRICARE plan. Only 53 percent of retirees and family membersunder age 65 use TRICARE Prime, while 83 percent of active duty family members are enrolled in Prime along with 100 percent of active-duty servicemembers. Retirees are either choosing to use TRICARE Standard and TRICARE Extra, which allow for more freedom to access private-sector doctors in exchange for significantly higher fees, or they are using alternate health plans (probably through their current employers).
Lower Quality of Care
But dissatisfaction with care is not the only problem with the current system. According to TRICARE’s own statistics, military hospitals trail civilian hospitals in implementation of 15 out of 16 specific medical best practices, usually by just a few percentage points but sometimes dramatically. In 2014, the New York Times published a series of stories looking at quality gaps in the military health care system, including things like complications after surgeries and after delivering babies. A DOD review of the military health system, apparently initiated in response to the New York Timesinvestigation, concluded that quality data was lacking and that there was “considerable variation across the system” in health care quality. In the stilted language of bureaucratic reports, this is essentially an admission that there are at least some parts of the system where health care quality is subpar. In short, the health care provided at military clinics and hospitals is not as good as it ought to be.
Operational Medical Care
At the same time, the current military health system is not optimized to provide medical support to an active, global military. TRICARE and the military treatment facilities produce doctors who overwhelmingly focus on providing care to military families rather than the types of injuries and health problems seen in combat.
While military medical professionals have done amazing work saving lives in Iraq, Afghanistan, and elsewhere, some of this expertise might be fading, in part because the military medical practitioners at home are not focused on trauma. The top two inpatient procedures in military hospitals, both by volume and by cost, are pregnancy/childbirth and newborn care. In fact, in 2014 there were twice as many pregnancy and newborn care procedures in military hospitals as the rest of the top 20 procedures combined.
An IDA study of military medical staff concluded that the military “understaffs operationally required specialties” and “overstaffs beneficiary care specialties.” For example, the Army had only 126 general medicine doctors in uniform but needs to be able to deploy 378. At the same time, the Army has 232 pediatricians in uniform, but only needs to be able to deploy one. Caring for military families is vitally important, but pediatricians are not in high demand in combat medicine.
MCRMC Proposal
The good news is that there are better options. The MCRMC outlined a proposal that would both provide better health care to servicemembers and their families and enable the military to focus its medical professionals on skills most needed in combat.
First, the commission proposed that DOD identify Essential Medical Capabilities (EMCs). According to the commission, EMCs include skills such as “clinical and logistical capabilities related to combat casualty care; medical response to and treatment of injuries sustained from chemical, biological, radiological, nuclear and explosives incidents; diagnosis and treatment of infectious diseases; aerospace medicine; and undersea medicine.” Once these critical capabilities are identified, DOD can design its medical system to ensure that military has sufficient numbers of medical providers that are proficient in these key areas.
In addition to redesigning the military’s medical system around EMCs, the MCRMC proposed moving military dependents to a health insurance model similar to what government civilians use today. If done properly, this would provide better coverage options and care for servicemembers and their families. Servicemembers would still get their healthcare through the military system directly, but family members and retirees would enjoy greater access to non-military providers while still retaining the option of using military treatment facilities. This change would also allow more flexibility for the military medical system to be refocused on EMCs without disrupting care for military families. Additionally, the MCRMC believes this proposal would be cost-neutral for military families and actually save the military money over time.
Countless details would need to be worked out, and a change of this magnitude cannot be made overnight. The MCRMC has proposed a fairly comprehensive plan, and others have proposed similar ideas in the past. It’s time for the Pentagon to stop focusing solely on dollars and cents and instead work on building a better health care system.
The Path Forward
Over the last year, Secretary of Defense Ash Carter and his senior team have done admirable work on defense reform. Now they need to step up on health care. DOD’s FY2017 budget request contains a significant proposal to change the TRICARE system, but it appears to be focused primarily on cost.
Instead of focusing on keeping TRICARE costs down by increasing fees on military families, the Pentagon should propose a significant reform that focuses the military health system on the unique challenges of supporting servicemembers around the world in combat and peacetime operations. To improve the quality of care and access to care, a new system should make it easy for military families and retirees to use civilian medical providers, but retain the option to access military medical facilities.
Getting the military healthcare system right will not be easy, but all parties must approach it first and foremost with the goal of improving the system for servicemembers in combat or at home with their families. Secretary Carter has eager partners in Congress, but leadership from the Pentagon on this issue is vital.
Justin T. Johnson is the senior analyst for defense budgeting policy in The Heritage Foundation’s Center for National Defense.
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