The Link Between Combat Medicine and Managed Care
CPT
Jon Lasell, CPT Steven Shipley, CPT Jay Schwartz,
CPT
Scott Stokoe, and CPT George Zeckler
Paper submitted in partial fulfillment for the requirements of
HCA 5318, Managed Care
March 17, 2004
The assumptions, opinions, or assertions expressed
in this publication are the private views of the authors, and do not reflect the
official policy or position of the Department of the Army, Department of
Defense, or the U.S. Government.
Abstract
The link between the military health system and
managed care is determined by the common bond shared between combat medicine,
garrison medicine or the military treatment facility, and military health
policy. Throughout history the primary
purpose of military medicine is to provide health care services to soldiers
during peacetime and war, stateside or abroad, given the imposition of financial
and utilization constraints. The
management of military health care extends through the nation’s wars, shaped by
health policy, and is apportioned by beneficiary eligibility. Although garrison and combat medicine have
purposefully evolved independent of each other, initiatives in military health
policy have transcended the gap between combat medicine and managed care. Given the progression of managed military
health care, from CHAMPUS to TRICARE, coupled with a changing military
environment, it has evolved to meet the health care demands of today’s military
forces, and alludes to a glimpse of future military health care initiatives.
Introduction
The military health care system (MHS) is a unique managed care organization. Its uniqueness comes from its dual mission of readiness and benefits. Operationally defined, readiness involves providing medical support to the armed forces during military operations, while the benefits involve providing medical benefits to all Department of Defense beneficiaries during peacetime (Rand National Defense Research Institute, 2002). The dual mission of the MHS can be broken down even further to associate readiness with combat medicine and benefits with garrison medicine. Garrison medicine and civilian medicine are almost identical and their link with managed care is easy to see. However, the link for combat medicine is not as readily apparent. The purpose of this paper is to examine the evolution of combat medicine, garrison medicine, and TRICARE to determine if there is a link between the three, particularly combat medicine and managed care, and to determine how strong the link is.
While
researching the history of the military hospital, three factors consistently
emerge: war, policy, and population have
influenced the evolution of military hospitals over the past 300 years. The factor having the greatest impact on the
development of military hospitals is the nation’s involvement in war. Through trial and error
The second
factor influencing the development of the military hospital is the enactment of
legislative health policies. The
government gauges health policies and subsequent funding based on the size,
structure, and mission of military forces.
Failure to allocate funds and/or the inappropriate utilization of funds
will result in the deterioration of soldier health. In addition, the dynamics of health policy
dramatically impact the delivery of healthcare services through the military
hospital and place limitations on beneficiary eligibility.
The third factor that influences military hospitals is
the population served. Population is
defined as eligible military beneficiaries.
The beneficiaries of today encompass active duty soldiers and their
dependents, retired veterans and their dependents, and retired veterans over 65
years of age (Stanley & Blair, 1993).
Future challenges facing the military hospital encompass bringing health
care services to
As a nation in the 1700s,
Following the
war for American independence and the American-Indian Wars, there was a period
of military inactivity, resulting in disbandment of the
Gillette
(1995) highlights that during the Spanish-American War (1898), post facilities
were made of local materials that rapidly decayed, forcing the transfer of
patients from “inferior accommodations to newer and better facilities, which
became known as base hospitals” (p. 361).
Disease and pestilence continued to plague the soldiers throughout all
the wars of the 1800s, continuing to claim more lives than injuries sustained
in battle. A fundamental problem
continued to be the failure of Congress to recognize that an army whose duties
included the garrisoning of small posts scattered throughout the expansion of
the West, rapidly depleted funds and required more physicians than an army
operating exclusively in units of regimental size or larger. There was also a
lack of adequately trained medical staff to care for the sick and injured
(Ashburn, 1929).
In the later
part of the 1800s, Gillette (1995) accounts that the small military outposts
that dotted the nation were gradually consolidated into centralized larger
posts. During this period the Medical Department
closed its small treatment facilities and started building hospitals. This proved to be more cost effective and
efficient as opposed to the continuous funding of loosely dispersed treatment
huts. In accordance with new policies,
every post hospital was to include a room specifically for surgery, isolation
annex for steam sterilization, diet kitchens, and bathrooms. Despite the cost savings in old facility
closures, these new construction mandates exceeded the Medical Department’s
construction budget of $20,000. Also
during this period, as a result of construction costs more than doubling, post
surgeons were forced to use antiquated equipment, work in dilapidated
facilities, or move operations into old troop barracks (Gillette, 1995).
The
wars of the 1800s enabled military leaders of the Army to plan ahead for appropriate types
of hospitals and their management. Plans
were made based on estimations of number of casualties and types of care
needing to be rendered. Gillette (1981)
makes note of the following:
Armed with
this type of information, the Army Medical Department could predict the
number of
general and regimental hospitals needed for the predictable number of
patients. In the management of
the individual hospital, military experts emphasized the
necessity for
good order, good air, and careful sanitation, as well as for the proper staff.
(p. 8)
The 20th
century marked the dawn of the “modern military hospital” and hospital
modernization across the nation. This
was the era of true fixed facilities, offering a full range of services. Along with
National health care is defined through implementation
of the New Deal, Social Security and welfare medicine; the introduction of
health insurance; the Emergency Maternal and Infant Care Program (EMIC)
for dependents of service members; and the Hill-Burton Bill (better known as
the Hospital Survey and Construction Act) funding hospital expansion; Medicare,
Medicaid, and the birth of Health Maintenance Organizations (HMOs) and managed
care; the Balanced Budget Act, Omnibus Reconciliation Acts, EMTALA, and HIPAA;
and the introduction of hospital certification and peer review organizations
all impacting the delivery of military health services in one form or another
(Shi & Singh, 2001).
War veterans
of the 20th century assumed life-long health care as part of a
career’s worth of military dedication.
In 1956, the Dependents’ Medical Care Act was signed into law defining
health care sought at military treatment facilities for retirees and their
dependents on a space available basis only; this act did not guarantee retiree
health benefit entitlements (Stanley & Blair, 1993). Throughout the 1960s, the Department of
Defense continued to provide health care to its beneficiaries through its own
network of military hospitals and clinics.
In 1963, Congress started the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS) to ease the burden of direct care on military
hospitals, by allowing beneficiaries to utilize civilian medical services on a
cost-sharing basis with the government (Stanley & Blair, 1993).
As the Cold
War came to an end, the military faced downsizing and base realignment and
closures (BRAC). The Army transcended
from the height of 20 divisions during the 1980s to the 10 divisions of today,
cutting the force structure nearly in half and along with it more than an
equitable number of military hospitals (DoD Annual Report, 1990). In 1990, there were 168 military hospitals
and over 800 medical and dental clinics deployed worldwide to support
During the last decade of the 20th century, as the dynamics of military operations tried to keep pace with changes in the global environment, the Army had to transform from preparedness for war on two fronts, to humanitarian and peacekeeping operations on numerous fronts. The shape of accountability and delivery of military health care again shifted in order to keep pace with the growth of HMOs and the ever-increasing need to cut costs through balanced budgeting. The military health system transformed with the advent of the TRICARE managed health care program. This program would define military health care for the 21st century.
Based on
events just over the past couple of years, the direction of military health and
expected dynamics of the military hospital in the near future are
foretelling. The current Medical
Department structure of medical treatment facilities will not change much from
its present state, as the existing facilities are not expected to require
remodeling or modernization for another 50 years or more. In 2001, the National Defense Authorization
Act expanded TRICARE benefits to include life coverage of military retirees and
their families beyond 65 years of age.
TRICARE For Life covers the health care costs of dual-eligible, military
and Medicare beneficiaries, and entitles these beneficiaries to the same pharmacy
benefits as military retirees under 65 years of age (DoD Annual Report,
2002). Military treatment facilities
(MTFs) are impacted by the increased benefits of TRICARE, as the new changes
will increase access for a growing beneficiary population. The 21st century marks the era of
military hospitals not only increasing access, but also having to beef up
security and taking appropriate countermeasures to thwart the possibility of
terrorist attacks. While the
Evolution of Combat Medicine
Combat medicine has played an important role in military operations since Roman times. Roman history describes the evolution of combat medicine with respect to two basic military concepts: “Care of the wounded is a military necessity and patriotic duty, and demoralization of the fighting line by the misery of the wounded when the primal duty of evacuation is neglected” (Peake, 1988). Based on these concepts, Napoleon's Army was the first to assign people to help the wounded. His armies left a contingent behind to care for the wounded after a battle until the wounded were able to travel or a safe place was found for them to stay (Peake, 1988).
Our nation’s
concern for the medical care of the American service member dates back to the
earliest days of the colonies. In May
1775, the Colony of Massachusetts ordered competency examinations of physician
candidates to act as regimental surgeons (Peake, 1988). During the Civil War, casualty lists grew
because of poor evacuation policies.
Following the Battle of Manassas in 1862, it took one week to remove the
wounded from the battlefield. The
Surgeon General William A. Hammond appointed Dr. Jonathan Letterman to serve as
the medical director for Major General George B. McClellan’s Army of the
Dr. Letterman's transportation system
proved highly successful. At the battle
of Antietam, a 12 hour engagement and the bloodiest one day battle in the
entire Civil War, the ambulance system was able to remove all the wounded from
the battlefield in 24 hours (Medics, A Brief History, 2004). Dr. Letterman’s evacuation plan remains the
foundation for today’s military medical evacuation system. His experiences suggest that improved
delivery of military medicine can provide resources in manpower and morale to
the battle (Peake, 1988).
World War I required millions of
casualties to be treated at the front edge of the battlefield. Unlike previous wars, battles did not stop to
retrieve the wounded or the dead. World
War I saw, for the first time, medics rushing forward with the troops, finding
the wounded, stopping their bleeding, and bringing wounded soldiers to the aid
stations. In World War I, medics were
well-trained and no longer expendable (Medics, A Brief History, 2004).
World War I also ushered in the age of utilizing Henry Ford’s Model “T” automobile as an ambulance. The automobile provided an advantage over horse draw ambulances when operating near the front lines and in mountainous terrain. If an ambulance was stuck in the mud, the Model “T” was light enough that four soldiers could pick it up and move it. Automobiles also allowed medics to administer first aid during the evacuation process, however, this practice proved detrimental to patient safety due to the spread of infectious disease (Edger, 2004).
After World War I, military medicine advanced. Training became a priority both in fighting and medical care. Medics were trained along side infantry soldiers, learning how to use the lay of the land for their protection and their patients. Medics were also trained in the use of pressure dressings, plasma IV's, tracheotomy, splints, and administering drugs (Medics, A Brief History, 2004).
The main objective of medical evacuation and the World War II (WWII) medic was to get the wounded away from the front lines. Many times this involved the medic climbing out from the protection of his foxhole during shelling to help a fallen comrade. Once with the wounded soldier, the medic would do a brief examination, apply a tourniquet if necessary, clean the wound as best as possible, and sprinkle sulfa powder on the wound followed by a bandage. Then he would drag or carry the patient out of harms way under enemy fire or artillery shelling. During World War II, a wounded soldier had an 85% chance of surviving if a medic treated him within the first hour. This figure was three times higher than World War I survival statistics (Medics, A Brief History, 2004).
Just as the automobile provided
significant advancements for combat medicine, the helicopter, arguably,
provided the biggest advantage in the evolution of combat medicine. It was introduced during the Korean War in the
1950s. Medical evacuation (MEDEVAC)
helicopters allowed the Army to reach injured soldiers who otherwise would have
been unreachable due to inadequate road networks. MEDEVAC aircraft provided quicker transport
time and was less punishing for patients than ground ambulance. Unlike automobiles in WWI, MEDEVAC aircraft
could treat patients while transporting them back from the front lines to field
hospitals (Ginn, 1997). These
advancements in field operation and transportation assets resulted in a 98%
survival rate for soldiers who were evacuated within the first hour (Medics, A
Brief History, 2004).
Today,
advances in medicine and technology, combined with lessons
learned from previous conflicts, fuel a transformation in how injured
Evolution
of TRICARE
Medical
managed care within the military reaches as far back as 1884. It began with a congressional mandate that
directed military doctors and surgeons to care for soldiers and their families
free of charge (TRICARE Fundamentals Course, 2003). In 1945, Congress introduced another program
call the Emergency Maternal and Infant Care Program (EMIC). This government-sponsored program provided
maternity care for the wives of soldiers in the lowest pay grade. EMIC was state controlled program that
provided women with the option to choose their physician and hospital. The program ended after two years (
Since TRICARE’s inception in 1993, significant changes have been made to improve its benefits and abilities to provide quality health care to the nation’s armed forces. TRICARE’s mission is to enhance the Department of Defense and our nation’s security by providing health support for the full range of military operations and sustaining the health of all those entrusted to its care. Four goals employed by the TRICARE program to achieve its mission are to: 1) Improve Force Health Protection and medical readiness, 2) Improve performance of the TRICARE health program, 3) Improve coordination, communication, and collaboration with other key entities, and 4) Address issues related to the attraction, retention, and appropriate training of uniformed services personnel. The program is carried out through three primary options: 1) TRICARE Prime, 2) TRICARE Standard, and 3) TRICARE Extra. Prime focuses on care received in the medical treatment facilities, Standard utilizes copays and deductibles to receive care in the civilian sector, and Extra is similar to Standard, but uses negotiated fees and networked providers. TRICARE is an entitlement provided to all services worldwide throughout the Department of Defense. Projections for 2004 indicate that out of 8.9 million beneficiaries, 4.8 million are enrolled in TRICARE prime. Care for all military beneficiaries is carried out through 88 military hospitals/medical centers and 323 medical clinics (TRICARE Fundamentals Course, 2003).
The primary focus of military medicine is to care for the warfighters and to ensure that they are capable of meeting the rigors of military operations (Carrato, 2001). A review of the evolution of combat and garrison medicine indicates that the two, in large part, primarily grew independent of one another. Combat medicine remained focused on field medicine while garrison medicine focused primarily on providing secular health care services to the many MHS beneficiaries. Although independent of one another, one initial identifiable link between combat and garrison medicine is the exchange of health service professionals through programs like the Professional Filler System (PROFIS). Through PROFIS, garrison health care professionals supplement combat medicine in time of war and contingency operations (How the Army Runs, 2003). When worldwide deployments slow; however, the need for combat medicine decreases. This is when garrison medicine assumes the primary duty of providing health care for military personnel. The link between garrison medicine and managed care is very similar to the link between civilian hospitals and civilian managed care organizations. Both provide the care needed to remain healthy and care received in garrison is very similar to care received by a local hometown doctor.
World missions and deployments have evolved to the point where that clear-cut line between garrison and combat medicine is now blurry. The evolution of combat and garrison medicine, coupled with the MHS’s mission to carry out a readiness/benefits mission leads to one theoretical link that has been developed to meet the demands of today’s medical missions. The evolution of TRICARE and its inception have been introduced to improve military medicine and to establish the link between combat medicine and managed care. TRICARE is a unique managed care organization that is centered on providing support for the warfighter, both directly through readiness and indirectly through benefits (How the Army Runs, 2003). It takes the MHS’s dual mission and molds it into one. The focal point of the link is found in TRICARE’s first goal to improve FHP and medical readiness.
According to Thomas F. Carratto, Executive Director of TRICARE Management Activity, (2001), TRICARE is responsible for providing patient care, for keeping our forces fit and healthy, and for ensuring that our medical personnel are well-trained in all the latest treatments, techniques, and technologies. Such a practice fits in accordance with the three primary pillars of FHP. These pillars are promoting and sustaining a healthy and fit force, illness and injury prevention, and a world-class casualty care and management system (Sculley, 2001). To go a step further TRICARE also complements three key areas within FHP: 1) Full spectrum of health care in support of contingency operations, 2) Deployment of fully trained and equipped medical personnel, and 3) Deployment health support (FHP, 2004). Supporting FHP requires close coordination between combat and garrison medicine. Better health in garrison ensures that troops are prepared for contingency operations and combat medicine is prepared to care for them on the battlefield. Throughout operations, garrison medicine must maintain close contact with combat medicine to ensure that when patients move through the echelons of care, their health care is seamless and not as fragmented as it was in the past. TRICARE is the program that is proposed to mend the gap between the two and to ensure seamless health care is received anywhere in the world. In doing so, it has also drawn together the individual services into one team, hence the prefix “TRI” in the name TRICARE. It is through TRICARE that medics, doctors, and warfighters will meet the demands of worldwide military operations. By supporting FHP, TRICARE maximizes force readiness (Carrato, 2001).
TRICARE’s purpose goes one step further to establish a link with combat medicine. This step involves establishing a medical infrastructure within garrison medicine. TRICARE’s three options are designed to maintain continuity of care in garrison medicine when health care providers are pulled from the facilities to support combat operations. It allows the military health system to meet the demands of combat medicine without compromising care in garrison. TRICARE works to provide a sense of security for deployed soldiers, by caring for their families while they are away. In turn, families can be reassured that, if needed, soldiers will receive the best care available through combat medicine. In theory, the design of TRICARE is geared towards strengthening combat medicine, garrison medicine, and the MHS’s dual role of readiness and benefits. However, in practice, the established link between combat medicine and managed care may not be as strong as presented.
While the evolution of combat medicine continues to bring about vast improvements in battlefield health service support, the increased number of deployments finds providers in a bifurcated role, the role of TRICARE readiness and the role of combat readiness. This bifurcation creates many conflicts. Most providers are assigned to medical treatment facilities (MTF). These fixed facilities provide the training opportunities necessary to hone their professional skills; however, their duties in the MTFs are not conducive to personal combat readiness. In addition to being assigned to a MTF, as discussed earlier, many of the providers are assigned to combat medical units via the professional filler system (PROFIS). As combat medicine and its capabilities becomes more battlefield oriented, the requirement for these providers to train with their combat units becomes more critical.
An inherent conflict with PROFIS is the
assignment methods by which providers are slotted to fill combat unit
positions. Many times providers are
slotted against the manning document of a unit that is not located at the same
installation or even the same state.
This geographic separation further causes several conflicts. The first conflict is availability. Because of the geographic separation, the
provider is not readily available to participate in field training exercises or
day-to-day unit functions. This breeds
an unfamiliarity of operational procedures.
Consequently, the only time a PROFIS provider is able to train with the
unit is during a collective training event such as deployment to the National
Training Center (NTC) in
Combat medicine conflicts with TRICARE readiness. One of the biggest conflicts is training levels and capabilities. The garrison mission of providing meaningful health care services to the military health system beneficiaries often fails to leave the provider with the time to train and become familiar the PROFIS unit’s equipment. The provider spends the majority of his/her day working with state-of-art equipment. This equipment is capable running diagnostics and screenings that the providers use as a crutch. The problem with this crutch is that this level of technological capability is not available on the battlefield. Furthermore, the equipment in combat unit’s inventory is antiquated. Consequently, the providers that deploy to train with their PROFIS unit are unable to perform efficiently, or they are required to learn the art of practicing medicine in combat environment. This learning process is steep and detracts from the overall training experience of the unit.
Another conflict is priorities. For many providers assigned to MTFs their last priority is individual military readiness. The opportunity cost associated with going to the qualification range is too high. As a result, many providers never find themselves on range. They do not qualify on a weapon, or they do not attend nuclear, biological, and chemical training until they on their way to deploy to real-world contingency. This lack of training puts themselves and the patients they are sworn to protect in jeopardy. However, the lack of individual training is not completely the provider’s fault. The table of distribution and allowance (TDA) does not facilitate the training requirements for these providers. The TDA medical companies to which these providers are assigned are not equipped with the correct amount of weapons necessary to train and prepare these providers for combat. However, individual readiness falls low on the totem poll of priorities regardless of the availability of equipment.
Another shortfall in combat medicine is the provider-medic relationship. The providers spend the majority of their time working in a MTF with a set of medics that will not be the medics that deploy with them. Consequently, the medics that they do deploy with them are not familiar with the idiosyncrasies of the providers. Additionally, the providers may expect that the medics have certain levels of knowledge that they do not have. This creates anxiety within the deploying unit that could have been avoided if the providers were afforded the time to train with the unit on a regular basis.
As with any good healthcare delivery system, change is required to increase the effectiveness of the system as deficiencies are discovered and the demands of the system change. Since the evolution of TRICARE, small piecemeal changes have been made so that it can better support the readiness mission of the military. However, larger reforms need to be made to TRICARE so that it can further support the military’s readiness mission and strengthen the established link between combat medicine and fixed facility medicine, with greater impact being in fixed facility medicine. This is the impetus behind the Next Generation of TRICARE Contracts, also known as “T-Nex.” By describing the details of T-Nex and the changes it will bring, it will be evident how T-Nex improves the efficiency and effectiveness of the MHS.
T-Nex’s vision is the following: “Provide a world class health benefit at a reasonable price. Demand customer service at the highest achievable level. Achieve continuous improvement in the health status of our members” (Hanna, n.d.). Beneficiary satisfaction is the cornerstone of T-Nex. Accordingly, T-Nex has several specific goals, which are as follows: deliver high quality health care at the maximum value, making best possible use of the existing direct medical care system and incorporating best commercial practices whenever practicable; support each Services’ readiness and peacetime mission requirements; maintain beneficiary satisfaction at the highest possible level; achieve continuous measurable improvements in the health status of our beneficiaries; develop a transition plan that minimizes disruptions to beneficiaries; achieve a positive, cooperative operational relationship between the government and each contractor, and between contractors; organize contracts, functionally and geographically, in a manner which minimizes administrative burdens on the government and contractor, minimizes risk and makes good business sense, while fully meeting the needs of beneficiaries and providers; maintain ready access to data to support DoD’s needs in financial planning, health systems planning, medical resource management, clinical management, clinical research, and contract administration; and maximize our relationships with other Federal healthcare agencies, such as Department of Veteran Affairs (DVA) and Centers for Medicare and Medicaid Services (CMS) (Wasneechak, 2004).
T-Nex will be an improvement in efficiency of care to the DoD’s 8.7 million beneficiaries. Its most salient characteristics are its multiple contracts, it usage of “carve-outs,” its regional restructuring, and the simultaneous transitions these changes will occur in. Dr. Winkenwerder, Assistant Secretary of Defense for Health Affairs, states that the new TRICARE contracts “…will reward superior customer service, simplify administration of TRICARE, and increase the ability of local medical commanders to best serve their local beneficiaries” (DoD Announces, 2003). TMA will include incentives for superior and measurable performance in customer service, quality of care and access to care. With less prescriptive contracts, TMA can adopt industry practices to improve the TRICARE program. Therefore, T-Nex has established several guiding principles, which are as follows: create RFPs that are simpler and easier to understand, to ensure maximum competition for our business, and contracts that are less complex to administer; establish performance-based requirements, clearly defining our ultimate needs rather than simply listing our expectations; establish separate contracts (carve-outs) and organize work logically by core competencies; and take advantage of lessons learned (Wasneechak, 2003).
T-Nex is restructuring the TRICARE regions from 12 to 3, with three managed care support contracts. They are the following: North (Health Net Federal Services), South (Humana Military Healthcare Services), and West (TriWest Healthcare Alliance Corp.). These contractors will be strategic partners in support of medical readiness; and their added value includes optimizing care in our military medical facilities, ensuring access to the highest quality civilian providers and offering preventive and outreach strategies for our beneficiaries (DefenseLink, 2003). T-Nex will bring about several more contract improvements. The standard for meeting network access standards will increase to 96%. The accreditation requirements for the network will also be increased. The contractor will ensure there are a sufficient number of specialists necessary to meet access standards and more current (within 30 days) up-to-date lists of network providers will be maintained. TMA will require that all claims be submitted electronically, unless a waiver is granted. Referral reports will also have to meet strict time guidelines, 98% within 10 days for specialty care and 98% within 24 hours for emergent care. This will include monthly audits to verify compliance with referral standards. Methods of transmission of medical information are required to be HIPAA compliant. It will ensure MTF capacity is reached before enrolling to the network. Some other beneficial contract changes include: an increased focus on customer service which is linked to performance awards, allowing contractors to establish customer performance standards utilizing commercial practices, and reducing referral requirements to determining if care referred is a covered benefit—with no medical necessity determinations (Lupo, 2003).
The health care/administrative services contract is still the main contract with those going to the 3 regional MCSCs. Their responsibilities include network functions, health care functions, claims processing, enrollment, provider certification and related administrative services. So that contractors can focus on their core competencies, T-Nex has several carve-out elements to it. Some of those contracts include the following: the TRICARE dual-eligible fiscal intermediary contract, which performs the claims processing and customer service for DoD beneficiaries also eligible for Medicare; two pharmacy contracts, a national mail order pharmacy (TMOP) and the integration of all national retail pharmacy services; a single national marketing/education contract to provide a uniform message on TRICARE and its benefits; the TRICARE retiree dental program; a national quality monitoring contract; and local support contracts controlled by MTF commanders. The functions being brought back to the MTF through local support contracts are appointing, internal utilization management, local resource sharing, demand management, health care information line (HICL), and health evaluation and assessment report (HEAR) (DoD Announces, 2003).
T-Nex changes the responsibilities of the MHS’ key players with new governance principles. The service surgeons general are accountable for the performance of their respective MTFs. Therefore, T-Nex will make information much more freely shared and visible throughout the MHS. Regional Directors are responsible for developing regional business plans that integrate the local MTF plans and the contractor plans. With the focus being on local management, T-Nex’s greatly changes the responsibilities of the local MTF commander, making them financially accountable for MTF performance throughout their business plans. It requires MTFs to manage their Prime enrollees and optimize MTF capabilities for other beneficiaries. MTF commanders will develop and submit the business plan for the market, to include developing and implementing joint programs in multiple service market areas. They will establish performance targets in the business plan and then monitor performance against that plan. Additionally, commanders will identify and develop sharing initiatives with the VHA and support and participate in regional activities as requested. Most importantly, MTF commanders will manage the care of all MTF Prime enrollees under revised financing, which includes purchased care for their enrolled population and those not enrolled to the MTF. A number of MTF commanders will be designated by the surgeons general as a senior market manager (SMM) in one of the 13 multi-service markets. In this role, the SMM will lead a collaborative process to develop a consolidated business plan for the market and to jointly work resource issues in his multi-service market. The SMM is empowered to make recommendations concerning short-term operational decisions to augment the MHS’ combat readiness role. This integrated business plan created by the SMM will include appointing services, resource sharing, optimization initiatives and DoD/VA sharing opportunities. T-Nex encourages much more VA sharing than earlier TRICARE contracts in order to further augment and improve the joint contingency/readiness capabilities of the MHS (Wasneechak, 2004).
The revised financing aspect of T-Nex was brought about to provide stronger cost control incentives for managing enrollee healthcare and support for MTFs to maximize their capacity, specifically their enrolled population. It effectively tightens the linkage between performance and financial impacts and motivates greater monitoring of cost controls by the MCSC. It eliminates the complicated bid price adjustments, while reducing disputes regarding data and risk, the former TRICARE contracts contained. However, with this sharing of risk and the MTF’s role of managing of the entire spectrum of health care for their enrolled population, the contractor will bill the MTFs for private sector claims provided to MTF enrollees on a monthly basis. As a result, revised financing provides funding allocated for purchased care costs, returning certain functions under the control of the MTF (appointing, UM, RSAs, HCIL, HEAR). Therefore, savings are available to the MTF if they manage their enrolled population effectively through providing as much direct care in the MTF as possible and recapturing those who would otherwise utilize private sector care. Thus, under revised financing, management decisions have a direct and immediate effect on the MTF’s budget. Besides having performance guarantees, the contractor also has award incentives for subjective measures including beneficiary satisfaction, regional director satisfaction, provider satisfaction, and MTF commander satisfaction (Tinling, 2003).
T-Nex has a much stronger focus on contingency planning than its predecessor. The contractor, regional director, and the MTF commander ensure the most efficient mix of health care. An important change is the requirement for a documented contingency plan at the MTF level for wartime deployments, operations other than war (OOTW), and training. The process for resource sharing and backfills by the contractor were not practical prior to T-Nex. The resource sharing agreement (RSA) development process was more than 30 days and they were not intended for contingency backfill. This caused an average time from request until a person was hired of 170 days. As a result of these unacceptable results, a contingency RSA (C-RSA) process was developed. This process encouraged MTFs to perform “gap analyses,” which involved anticipated or expected contingency impact of staff availability. This encouraged MTFs to submit “pre-positioned” C-RSAs, causing a sharp decrease in RSA processing time from 30 days to 5 days. This avoided heavy network costs. Through monitoring C-RSA workload, TMA can evaluate C-RSAs for currency and consider termination or conversion to the local support contract. There will be future requirements for the MCSCs. Besides the requirement for the contractor to develop and implement contingency plans for deployments and training, the documented program must be provided to the regional director’s office within a specified time period and be updated annually. Additionally, the contractor is required to participate in two MTF contingency exercises annually, as well as regionally-coordinated table-top exercises. Thus, the contractor must be able to implement the contingency program within 48 hours of being notified by the regional director. These contingency requirements are the greatest changes to support combat medicine that TRICARE has established since its inception (DoD Health Services, 2003).
Conclusion
Garrison
and combat medicine have primarily evolved independently of each other. Since its inception, TRICARE has strived to
improve military medicine and to establish a link between combat medicine and
managed care. However, in practice, the
established link between combat medicine and managed care may not be as strong
as the initial concept. Challenges
within the PROFIS system, geographic separation, and collective training
continue to affect readiness. Further
development of TRICARE is needed to strengthen its link with garrison and
combat medicine. The implementation of
T-Nex is an important first step towards achieving this goal.
References
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Clinton, J. J. (2001, July 1). The military health system. Overview statement submitted to the Personnel Subcommittee, Committee on Armed Services, U.S. House
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