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Avalanche of enacted TRICARE changes poses challenges

The National Defense Authorization Act (S 2943) signed into law Dec. 23 orders an avalanche of changes to the TRICARE health care benefit used by service members, retirees and their families. It also makes sweeping reforms to how the military direct-care system is organized and operates.

The sheer number of changes and additional studies being mandated, filling 40 sections and 150 pages of the cct, is more impressive than any short list of highlights we might be able to review here.

"There's a lot of good stuff in there. There's a lot of stuff we're still puzzling over," said Dr. Karen S. Guice, acting assistant secretary of defense for health affairs. She will serve in that post only two more weeks, until the Trump administration assumes responsibility for the $50-billion-a-year military health care system and a beneficiary population of 9.6 million.

The authorization act for fiscal 2017 "is full of ideas, concepts and new things for us to tackle," Guice said in phone interview. She added that it contains "a remarkable series of provisions that set forth some challenges (and) provides us with new authorities that we're greatly looking forward to."

But Guice emphasized many new provisions to modernize TRICARE and improve access will only accelerate reforms that the department already has been piloting or planning to adopt, though perhaps not at the speed Congress desired. The department's guide has been recommendations of the 2014 Military Healthcare System Review, which then-Defense Secretary Chuck Hagel ordered to take a hard look at performance and outcomes at military facilities and through civilian purchased-care networks, Guice said.

Beneficiaries have started to see the fruits of that effort in greater access to care and a nurse advice line. They will see more when the new generation of TRICARE purchased-care contracts takes effect this year, and also with gradual rollout of MHS Genesis, the new electronic health records system, all this before many of the new defense bill initiatives kick in in 2018 and years beyond. Associations advocating for beneficiaries wonder how many changes the health system can implement before chaos rules.

Guice doesn't sound worried for the staff she's leaving behind.

"We have a lot of very experienced, motivated peopled who just like to tackle challenges," she said. "Also, we are looking at this across the enterprise so it's the Army, Navy, Air Force all coming together about how we actually do this."

The Senate version of the defense bill had called for dismantling the medical headquarters of the Army, Navy and Air Force surgeons general. The enacted law is a compromise that directs a shift of key management functions done by the services to the Defense Health Agency, leaving the surgeons general to recruit, educate and train their military and civilian health care providers and to advise DHA on medical readiness issues.

"That's an interesting construct," Guice said. "And we're kind of figuring out how best to optimize what Congress is intending to achieve."

Congress staggered deadlines in the law across a span of years.

"They knew there was a lot of work here and allowed flexibility by pushing out some timelines or saying do this work and then the timeline kicks in," Guice said. "I think they want us to take our time and get it right."

There are gems in the law for families seeking more timely care.

One provision ends a requirement that TRICARE Prime users obtain referrals from primary care providers before using a neighborhood urgent care facility. Another provision mandates that military treatment facilities with urgent care clinics keep them open daily until at least 11 p.m.

 Those "are both wins for families," said Brooke Goldberg, deputy director of government relations for family issues at Military Officers Association of America. Other law highlights she noted require:

* Adoption of a standardized appointment scheduling system across all of military health care and also first-call resolution of appointments.

* New TRICARE contracts incentives to improve beneficiary access, care outcomes and enhanced beneficiary experiences.

* Adoption of new productivity standards for care providers in military treatment facilities, which should mean more on-base appointments.

* Military providers' performance reports, to include measures of accountability for patient access, quality of care, outcomes and safety.

 Military families will be eligible by 2018 to buy vision coverage through federal employee health programs, explained Karen Ruediseuli, government relations deputy director for National Military Family Association. Retirees and dependents will be eligible for both dental and vision programs.

Some changes touted by Congress are not quite what they seem. For example, the planned narrowing of three insurance options  TRICARE Prime, Standard and Extra  down to two, with Prime still providing managed care and TRICARE Select offering a preferred provider network, is largely a name change push by the Department of Defense. Goldberg said it could even be "transparent to families who really don't know the nuances of Standard vs. Extra."

Many beneficiaries, she added, "just know they have to pay more if they see one (civilian) provider over another. Many have been using Extra, calling it Standard and not realizing it."

Still to be determined "is what the preferred-provider network will look like and will families be able to easily discern which services will result in higher costs? And will they have access to providers who are low cost?"

For example, current TRICARE provider networks include those who participate in Prime and agree to take a discount from the normal Medicare-based payment. But many providers willing to see Standard patients for its allowable fee will not see Prime patients with its lower fee.

"Will those providers be considered preferred providers under TRICARE Select, or will the Select network only include those who participate as part of the Prime network? If the former is true, then the transition likely will be smooth. If the latter is true, many more people could be hit with out-of-network charges, to the extent they aren't grandfathered," Goldberg said.

Adding some confusion is language that grandfathers current generations of military families and retirees from a new schedule of higher fees to hit those who enter service on or after Jan 1, 2018. But the law will require current beneficiaries to enroll in Select, as they do with Prime, and enrollment will carry a fee for retirees under age 65, beginning in 2020, if a government audit confirms improvements in quality care and patient access.

Guice took exception to one senator's characterization of the new law as a "first step in the evolution" of military health care from "an underperforming, disjointed health system into a high-performing, integrated" one.

She noted a recent National Academy of Medicine study on military trauma care that found that over a decade of war the U.S. military had made unprecedented gains in survivability rates from battlefield wounds.

"I don't think that's reflective of an underperforming system at all," Guice said. "The people who created that learning system of care are the same people who provide the in-garrison care. That is evidence we really do value constant performance improvement."

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