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TRICARE Moves Toward Population-Based Health Care

By Douglas J. Gillert
American Forces Press Service

SAN DIEGO, June 30, 1999 – Fresh from a preventive medicine residency at the University of California campus here, Navy Dr. (Capt.) Kathleen Fischer guides an effort to screen the 193,000 Southern California beneficiaries enrolled in TRICARE Prime, DoD's managed health plan. Her goal: Target care where it is needed and intervene in patients' health care when necessary.

For example, in an area where the population is mostly young soldiers in a rugged training environment, there might be a need for greater injury prevention and orthopedics. In a city with a lot of smog or in the high desert, there could be a need for more respiratory therapy. From Fort Irwin in the Southern California desert to Naval Amphibious Base Coronado on the Pacific Ocean coastline, Fischer oversees a plan to reduce preventive diseases and injuries throughout TRICARE Southern California.

By learning the health needs of a specific population, hospitals and clinics can tailor their services to those needs, said Fischer, head of clinical operations for the TRICARE region.

Fischer's residency was a virtual study of managed-care populations. "How do you take care of an enrolled population? The Navy, Army and Air Force have committed people to learning this," she said.

Population health involves clinical preventive services for healthy people and secondary and follow-up preventive care for people who already have diseases, she said. In the past, military medicine focused primarily on providing episodic care; in many cases, it still does. When people are sick -- or think they are -- they show up at the emergency room or sick call or make an appointment.

"Some people show early, when they don't need help. Some show up late, when a whole lot of damage has been done," Fischer said. "We want to manage those visits and integrate them into the way we do our business."

The idea is to get a bigger bang for the buck. Medics have resource constraints just like most everyone else in DoD. The money saved by preventing disease and managing care can then be spent on improving prevention and treatment programs, Fischer said.

TRICARE Southern California aligned its population health goals with DoD and Department of Veterans Affairs guidelines that focus on conditions that can affect population groups, such as lower back pain, hypertension, tobacco-related illnesses, asthma, diabetes and depression. To learn about population needs, military treatment facilities in the region rely on the Health Enrollment and Risk Survey that new TRICARE Prime enrollees must complete.

"At our [headquarters] level, we're trying to develop other tools, training aids and guidelines to help military treatment facilities determine who needs care and when," Fischer said. "There's a big payoff to targeting people. It may take some time, but when we can target, patients become more vested in their health care."

The toughest groups to reach are adolescents and post- adolescents, a population that includes many young service members and their families, she said. "They think they are healthy and will never be ill and don't have to take preventive measures."

Take tobacco use, for example. "Smoking doesn't cause much harm early on but in the long term it causes cancer and heart disease," she said. "We have to get young people thinking about those consequences before they occur."

It's more difficult to assess the health behaviors and needs of military beneficiaries not enrolled in TRICARE Prime, Fischer said. "If you don't know who's out there, it's hard to target," she said. But the region tries to reach everyone. For example, the managed care support contractor for the region, Foundation Health Federal Services Inc., routinely sends information to all beneficiaries in the region, not just Prime enrollees.

"Population health is here to stay," Fischer said. "It affects readiness by making sure service members are in shape. It also includes all other beneficiaries -- family members and retirees -- in our preventive health efforts."

Civilian health maintenance organizations have taken a population health perspective from the beginning, and Fischer sees it as complementary to TRICARE Prime. But while civilian HMO beneficiaries complain about their health plan's focus on money, Fischer said military people should rest assured that the Prime focus is on good medicine.

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