As they review the Defense Department's latest plan to raise Tricare fees and co-pays, particularly for working-age retirees and their families, key congressional panels are asking what beneficiaries can expect in return.
Faster appointments, more evening clinic hours, more physicians spending more time seeing patients, more base hospitals operating at full capacity were some answers given this week by military health-care leaders.
Perhaps the most important commitment came from Dr. Jonathan Woodson, assistant secretary of defense for health affairs, who said he, the new director of the Defense Health Agency Vice Admiral Raquel C. Bono and the surgeons general of Army, Navy and Air Force all recognize the need "to pivot to a full patient-centered, customer-focused delivery system."
The comment came in response to Rep. Joe Heck, R-Nev., an Army Reserve physician who said that while assigned to military treatment facilities "we did not have a taxing schedule of patient flow," while doctors in civilian hospitals "see many more patients in the same period of time."
Woodson seemed to give a less satisfactory response to Rep. Susan Davis, D-Calif., who asked what to tell beneficiaries who want to know what they stand to gain from having to bear a larger share of overall health costs.
Their share of total health costs would climb from 8 percent to 10.4 percent, Woodson said, modestly compared with 27 percent when Tricare was rolled out two decades ago. The catastrophic cap on total health expenditures by individuals and families would rise for the first time since 2001, Woodson said, yet remain low relative to other insurance plans.
"There's also a second-payer option put forward which lowers the fees for those who have other health insurance," Woodson said. "We've also set the fee structure so it incentivizes" use of military treatment facilities where users fees are "very low cost or no cost."
The Senate and House Armed Services Personnel subcommittees took different approaches in separate hearings as they moved closer to deciding how to reform to Tricare, the multi-option military health-insurance benefit.
The House subcommittee chaired by Heck pressed Woodson and Bono about proposed fee hikes while praising its intention to simplify three Tricare options down to only Tricare Select (currently called Prime) for managed care and Choice (Standard), the fee-for-service insurance plan.
Retirees younger than 65 would see the biggest pop in out-of-pocket costs. Their cost to enroll in managed care would climb about 25 percent in 2018. Working age retirees who prefer Choice also would have to pay to participate ($450 for individuals, $900 for families) or lose health coverage.
A first-ever enrollment fee for older retirees who use Tricare for Life to Medicare Part B would apply only to new TFL users, not current TFL beneficiaries. But most anyone filling prescriptions off base would see increasingly higher co-pays, including through mail order.
A promised improvement in health insurance for Reserve and National Guard members will not be ready until next year, Woodson said. Tricare needs more information on these members' current insurance choices before deciding on an option to replace or enhance the unpopular Tricare Reserve Select with some version of active duty Tricare Choice.
The big complaint with TRS is that families often have to switch doctors when members are called to active duty. To end that turbulence in continuity of care, Woodson said, several options are being studied.
One would be to pay reservists a Basic Allowance for Health Care when called to active duty so families could afford to keep civilian insurance coverage. Another might offer a version of Tricare Choice to Reserve and Guard members through civilian employer health plans.
"We need to really poll and assess the reserve community about what they are doing for insurance now, what the options are," Woodson said. "Because we don't have enough data to make the right answer now."
Ways to reform
A day earlier, the Senate subcommittee led by Sen. Lindsey Graham, R-S.C., heard first from a panel of industry healthcare experts on ways to reform Tricare, before it asks Woodson, Bono and the surgeons general to testify on current efforts to make Tricare more responsive and efficient.
Bernadette C. Loftus, executive-in-charge for The Mid-Atlantic Permanente Medical Group, described how critical it is for health plans to monitor closely patient access to care and the performance of every provider.
"The reliable achievement of better results starts with knowledge of current results," Loftus said. "We measure all aspects of our care at all levels," using metrics "that are evidence-based, nationally recognized and reasonably comparable across geographies and populations. This minimizes distracting arguments that 'My patients are so unique you can't hold me accountable for any particular outcome.' "
Permanente also had learned from decades of study that patients have a much higher standard on timely access to care than do doctors who weigh medical necessity. So to achieve higher patient satisfaction rates, she said, "we base our access standards solely on our members' expectations."
On fees and co-pays, Dr. A. Mark Fendrick, professor of internal medicine and health management policy at the University of Michigan, urged that Tricare be moved to a value-based insurance design now being used by hundreds of public and private employers. The idea is to replace a one-size-fits-all approach to setting fees and co-pays by charging less for services more valuable to patient health, and charging more for services of less value.
"Does it make sense," Fendrick said, "that my Tricare patients pay the same copayment to see a cardiologist after a heart attack as to see a dermatologist for mild acne?"
"It's just common sense," he added. "When barriers to high-value services are reduced and access to low-value services are discouraged, we attain more health for every dollar."
In closing the hearing, Graham called the current design of Tricare "antiquated" and told Woodson he wanted to see his team offer "reforms, not just premium increases. We're going to look at Tricare and turn it upside down and make it more transparent, more accountable."
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