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All Aboard for TRICARE!
As Delivered by Dr. Stephen C. Joseph, assistant secretary of defense for health affairs, The 1995 TRICARE Conference, Reston, Va., Monday, January 09, 1995

As this conference gets under way let's remember that we are well-embarked on the most fundamental change in military medicine since the advent of CHAMPUS three decades ago!

This year, 1995, is a very important year to all of us. It is the big year for TRICARE and for the Military Health Services System -- the year for concrete readiness improvements, the year for completing close to 8,000 comprehensive clinical evaluations of our Persian Gulf war veterans, the year for implementing your regional health care delivery plans, the year for having managed care support contracts in every stage of the procurement process, the year for expanding our technological capabilities to better meet our twin missions of readiness and health care delivery.

This year is when the rubber hits the road. Together we have charted our course so that we have a clear vision of our goals, and I am confident we have the ability to travel that road and to achieve those goals.

This week you are here to discuss TRICARE. Clearly that name is growing to encompass the entire Military Health Services System and its two missions. Most tend to think of TRICARE in terms of our everyday responsibility to care for patients, operating from fixed facilities, having our capability supplemented by managed care support contractors. But TRICARE is more than that. It includes important aspects of our readiness mission as well.

This change offers us the ability to retain military medicine. With the tremendous reshuffling of world politics, the national security objectives of our country have changed. The scope and size of the armed forces have changed and will continue to change. And there is considerable pressure in each re-examination of the Military Health Services System to retain only that which is necessary to deploy in support of contingency operations.

We do need change in military medicine, but like the reduction of the armed forces themselves we must exercise caution so that the changes do not leave a hollow military medical system. We need to right-size the Military Health Services System. We need to look at our end strength with the eyes of a personnel chief who is counting more nurses than war-fighters. We need to weigh carefully our facilities in terms of readiness support, population served and cost effectiveness. We need to be totally committed in our efforts to operate a health care system jointly and to take the bold and objective actions needed to bring about a seamless right-sized Military Health Services System.

TRICARE, in and of itself, does not reduce the size of the Military Health Services System, but it does bring unprecedented joint service operations. Such cooperation among the military services affords the surgeons general and me the ability to better manage all military health care resources for all scenarios, including everyday health care delivery.

TRICARE does drive the consolidation and consequent strengthening of many programs, to include graduate medical education. TRICARE will improve access to managed care for our patients by ensuring all care provided is necessary and in the appropriate setting. The supplemental support brought by the managed care support contractors will further improve access for patients as well as expand the availability of specialty capabilities in many locations.

The lead agents have a tremendous responsibility to mesh the many segments of TRICARE into a well-run regional program. The extraordinary efforts demonstrated thus far have served to reinforce my early impression of the talent and professionalism within military medicine.

A clear example of this talent and professionalism applied in support of both the readiness mission and the everyday health care delivery mission is the comprehensive clinical evaluation program for our Persian Gulf war veterans. The program itself, the depth and character of the examinations, the care and treatment, the application of what has been learned to the next deployments and the dedication of everyone involved in this massive program are outstanding. And it could not have been accomplished without the system of military medical treatment facilities, medical centers and dedicated military health care professionals.

As lead agents and hospital commanders your readiness missions will take you beyond the health care delivery system. You have the challenging responsibility to know the missions of the forces you and the medical facilities in your region support. You should know where the "alert" units are and which units will be tapped to go to what corners of the earth, how many days or hours each unit has before it must be at readiness level one and what medical units and personnel will be taken from the everyday operation of military hospitals to support the deploying forces.

With this information, and it changes all the time, you must be prepared to get those deploying personnel ready to go physically and mentally, to backfill your facilities, to alert patients to a shift in care locations or schedules and to receive, orient and employ activated reserve component personnel should they be called to duty. As these readiness missions of the armed forces are under way the lead agents, as leaders of health care within the region, must be alert to how best to help coordinate military health care resources within the region, working with the military services and surgeons general to retain patient access to high quality and cost-effective health care. At the same time they must be sensitive to and work with the families who now are without a sponsor for some period of time and must be prepared to care for the families of reserve component personnel who become eligible with activation of their sponsors.

In addition to actual deployment missions, as lead agents and military treatment facility commanders you must support efforts to ensure that the military medical personnel within your region are trained militarily and prepared to join the combat and combat support units with which they deploy. This often is among the most difficult of decisions. Military health care professionals want to practice medicine, yet time taken from that practice to hone their military skills will be critical if and when they are called to serve in a contingency operation. It is time and training necessary for them and for their patients.

Some lead agents may be wondering just how to tackle their support of this monumental requirement in addition to commanding a medical center and directing plans and operations for regional health care delivery. It will not be easy.

First, you must have staff within the lead agent office who understand and can work readiness issues with the military treatment facility and service readiness staffs side by side with everyday health care delivery decisions. You can do this immediately. All hospitals have an office responsible for plans, operations and training or some version of that. That office in the lead agent's medical center can expand their reach by coordinating with other similar shops in the military hospitals within the region. Working together they can generate the planning process to ensure a viable readiness posture in all regions, in medical units, in medical facilities and on all bases.

Second, each of the lead agents, personally, as well as hospital commanders and staff members, must get out whenever possible to speak with the line. This communication is vital to the success of our health care delivery, whether at home or in a deployed status. I want the lead agents to visit the units within your region -- especially those of the other services. Speak with the troops, hear what they have to say about health care, at home and deployed. We must recognize the importance of understanding what the men and women of our line units endure in their daily activities.

I have been trying to speak directly with as many of our colleagues as possible. I will not soon forget the awesome responsibilities of the independent duty corpsman on board the submarine or the austere, yet highly functional, capability set up in Zagreb [Croatia]. And I continue to be impressed with the system of following patients through the air evacuation system; it's called TRAC2ES [U.S. Transportation Command Regulating and Command and Control System] and was developed by the Transportation Command at Scott Air Force Base [Ill.].

Communication, and with it education, are critically important as we launch into full implementation of TRICARE. Each place I visit I seek out the commander in chief or the installation commander to talk about their experiences with military health care both for support of their missions and also in its delivery to their personnel and their families. So far every one of those commanders -- and I have visited EUCOM [European Command], PACOM [Pacific Command], CENTCOM [Central Command], SOCOM [Special Operations Command], ACOM [Atlantic Command] and TRANSCOM [Transportation Command] -- has expressed appreciation for the willingness and professionalism of the medical personnel in their commands.

I will never forget the seasoned Army general who told me that he tells all his young officers, "When the incoming arrives, the two people you will look for first are your forward observer and your medic."

A recent Air Force public affairs survey found that headquarters and base level officials were the most trusted source of information, while nonofficial media and institutions were the least trusted. The most believable information tools were commander's calls and policy letters; these two plus base papers, like the Bolling [Air Force Base, Washington, D.C.] Beam, were considered the most useful. And the topics of highest interest are personnel issues. That includes health care.

As community health care professionals, you must be concerned for the active duty individual, but also for his or her family and our retirees and their families. We have to be concerned about them personally to be certain they understand what is occurring within military medicine, that they know what they can expect in trying to obtain health care, who to go to for what types of health care. Education must be a routine and regular part of your schedules through commander's calls, unit fitness days, spouse club activity days, retiree days, health days. Whatever good ideas those smart young people on your staff come up with, try it!

We need to rapidly follow up on the recent announcements on cost-sharing for the TRICARE Prime option, the so-called uniform benefit, and get that information in accurate form to all of our beneficiaries. It is a good-news story for all categories of our patients who enroll in Prime. Of highest importance: Active duty families only pay nominal fees when using network civilian providers -- there are no other out-of-pocket costs; retirees, their families and survivors, when hospitalized, pay only the daily subsistence charge even when hospitalized in a network civilian hospital.

Yet already there is misinformation spreading among the beneficiary population, such as "TRICARE will require retirees to pay up front for their health care." As you know, only those retirees electing to enroll in TRICARE Prime will pay an enrollment fee. For the options of TRICARE Extra and TRICARE Standard, there is not an enrollment fee. We must waste no time in getting the correct and full information to line commanders, military community leaders and individual patients.

Having an educated patient population will hold your providers' feet to the fire. The patients will arrive at a set of expectations, and we have to meet those expectations. So we start with education of our line commanders and staff and expand that circle to reach all patient categories on a regular and continuing basis. We have got to demonstrate the value we bring to the armed forces and their families today while they serve and tomorrow when they retire.

The TRICARE introduction of a uniform utilization management policy for all care our beneficiaries receive brings consistency to when and where care occurs. This new policy also offers a sound basis for comparing utilization patterns throughout the system and against national norms. We all will use these comparisons at individual facilities, regionally and from a system management perspective. With this ability to view utilization across the entire system we will have concrete evidence of our competitiveness as an affordable system offering convenient access to high quality health care.

Lead agents developed their own utilization management plans for each region based on full implementation of the uniform policy agreed to by the surgeons general and myself. In some cases there will be a shared responsibility with contractor assistance, and in other cases either the military will do all military treatment facility utilization management directly or the contractor will do it all. Regardless of how it is conducted, it is essential that everyone join in this effort to improve our delivery of care to our patients.

Another measure we instituted several months ago, beginning with our active duty members, is a set of guidelines for access to care. These guidelines are indicators or values which we will use for regional report cards. They are yet another means to demonstrate that the care provided in the military system is of high quality and is patient-focused. Another benefit from having these guidelines is to do our own analysis of our performance. It is instructive to have such measures to show where we are in the scope of the entire delivery system. For our patients it is their assurance that their care is appropriate care and in keeping with quality standards.

These guidelines have acquired the caption "access standards" to our beneficiaries, and I think that the recognition is meaningful. The biggest problem military medicine faces in its delivery of everyday care is access. The problem continues today, but with your efforts, resolution is in view.

The reasons for access being the major obstacle to care are many: far more eligible patients than can be cared for, patient management by queue, limited specialty care at many locations and a set of incentives that rewards less-than-effective health care delivery. Among the components of TRICARE are the solutions to these obstacles and the means to enhance patient access to care. Your implementation of the TRICARE components is a giant step toward removing the obstacles.

Capitation budgeting is one of the most important TRICARE components. We adopted it from the Army's Gateway to Care, where it was successfully incorporated in that program's design and operations. Capitation budgeting is the component of TRICARE that will change our practice patterns by changing our incentives. It will spark decisions designed to ensure only necessary care is provided and that care will be received in the appropriate setting. Capitation budgeting affords the Defense Health Program managers a much improved ability to predict health care expenditures. All of these advantages lead to a highly competitive health care delivery system.

As I pointed out, the competitiveness of our system as regions and as individual military hospitals is essential for us to survive as the Military Health Services System. A decisive factor in determining our competitiveness will be patient satisfaction.

I know that the individual services have been conducting patient satisfaction surveys for some time. And for the past year we have included a question about satisfaction on our user surveys. However, as TRICARE takes hold across the country it makes good sense to measure the satisfaction of our patients in every area, using the same carefully constructed instrument. We have begun that process, and the first annual survey on patient satisfaction will be mailed to about 170,000 beneficiaries ... . Initial results should be in by this spring.

How our patients think about their health care, where they go to receive it and what they want to experience in a patient care setting are measures that help us improve the full spectrum of health care delivery. It is a vital responsibility of all leaders to think about the future and how to improve on what exists today. That thinking must be beyond the early set of tomorrows and on into the arena where one projects from history and draws upon the trends forming today. The surgeons general and I, as well as senior members of our staffs, have been actively involved with this responsibility. Thus far we have agreed to devote separate and defined time to this strategic planning; we have met as different groups on several occasions; and we have crafted a set of assumptions on which we will build a blueprint and a framework for the future of military medicine.

The assumptions encapsulate current thinking about the Military Health Services System and about how our world will look in 1998. I want to take a moment to share them with you.

First, the two missions of military medicine will remain as they are today, both vital and interwoven.

Second, military readiness is the cornerstone of the Military Health Services System, and joint service cooperation will permeate medical planning and operations.

Third, TRICARE enables the department to operate a flexible health care system, readily adaptable to the vastly changing operational missions of the armed forces.

Fourth, the Defense Medical Advisory Council and the TRICARE executive committee advise Health Affairs in all policy matters affecting health care, and the foundation of these advisory bodies is cooperation and collaboration among the services, the Joint Staff and Health Affairs.

Fifth, the regional lead agent concept is operational.

Sixth, Military Health Services System resources continue to right-size in relation to the armed forces.

Seventh, TRICARE has quantifiable goals and objectives which demonstrate the high quality of care, the widespread patient satisfaction, and the tough competitiveness of military medicine.

Eighth, the defense health budget continues its lower rate of growth when compared with the national rate, and budgeting will be regional.

Ninth, managed care support contracts will be comprehensive, consistent across regions and competitively awarded.

Tenth, Medicare reimbursement will be attained.

Eleventh, additional procurement, personnel and facility planning reforms will be achieved to allow lead agents more flexibility in obtaining resources, to increase the role and representation of women and minorities at all levels of the Military Health Services System and to modernize facility design.

Twelfth, graduate medical education programs and medical training will be triservice, integrated and somewhat smaller.

Finally, advanced technology will significantly influence the delivery of health care within the Military Health Services System for both its readiness missions and its everyday health care missions.

There are no significant revelations in this compilation, but then, none of us reads crystal balls, tarot cards or tea leaves. We do read history, and we read trends, and together we bring to the table a vast array of knowledge and experience that I am certain will guide our thinking about the future to a set of characteristics that will shape the Military Health Services System for the next 20 years.

In closing let me say that it is important that you know that time and thought are being dedicated to the next generation of TRICARE. But most important right now is this generation of TRICARE. Clearly, it is the course that is right for this time and this set of influences if military medicine is to continue a healthy existence. It is up to us to fulfill our responsibilities to get this generation of TRICARE up and running smoothly in all regions. There is no time to delay. As each of you arrive back at your home stations I want you to go to work immediately on those things that I mentioned this morning.

Rededicate yourselves to joint collaboration and cooperation in every way possible.

Establish firmly the lead agent's staff, to include readiness expertise.

Prepare for administering, on time, the most supportive managed care support contract for your region that you can develop and award.

Begin immediately to seek out and cause opportunities to market TRICARE in its readiness and health care delivery roles to all of our beneficiaries.

Continue to strive for quality performance and quality improvements in all that you do.

The seeds of TRICARE were planted a few years ago with the CHAMPUS Reform Initiative, and they have been nurtured and trimmed to become the budding program which is now ready to blossom. This is the year we begin to realize all the planning, calculating and development that you have poured into making TRICARE a reality. It will be a year of hard, satisfying work. Let's all climb aboard and get the job done! ...




Published for internal information use by the American Forces Information Service, a field activity of the Office of the Assistant to the Secretary of Defense (Public Affairs), Washington, D.C. Parenthetical entries are speaker/author notes; bracketed entries are editorial notes. This material is in the public domain and may be reprinted without permission