Statement
of
David
H. Howes, MD
President and Chief Executive Officer
Martin's Point Health Care
on
behalf of the
Uniformed Services Family Health Plan
May 17, 2001
Introduction
Mr. Chairman and members of the Military Personnel Subcommittee, thank you for the opportunity to speak with you today regarding the Uniformed Services Family Health Plan (USFHP) and its role within the Department of Defense's Military Health System (MHS). I am Dr. David Howes, president and chief executive officer of Martin's Point Health Care, which serves patients in Maine and parts of New Hampshire. I am here today not only representing Martin's Point but also the organizations that sponsor the USFHP in six other regions of the country. These organizations are:
v Johns Hopkins Community Physicians, part of Johns Hopkins Health System, serving military beneficiaries in Maryland and parts of adjoining states;
v Fairview Hospital, part of the Cleveland Clinic Health System, in Cleveland, Ohio;
v CHRISTUS Health, serving military beneficiaries in southeastern Texas and western Louisiana;
v Brighton Marine Health Center, serving military beneficiaries in eastern Massachusetts, as well as Cape Cod and Rhode Island;
v PacMed Clinics, serving military beneficiaries in the Puget Sound area of Washington State; and
v Saint Vincent Catholic Medical Centers, serving parts of New York, including New York City, all of Long Island and New Jersey, and southern Connecticut.
I want to express the appreciation of the representatives of all seven of us for the opportunity to appear here today.
Description of USFHP
The USFHP sponsoring organizations have been a part of the MHS since 1981. This year we are celebrating our twentieth year of providing "care fulfilling the promise" to our beneficiaries. USFHP is a proud member of the TRICARE Program. Our status as a managed care program, moreover, has enabled us to develop features that distinguish us from our partner programs in the MHS. Among these advantages are:
v strong, continuous relationships between patients and their physicians, especially their primary care doctors;
v successful integration of care management into our care delivery systems; and
v our ability to focus on care delivery rather than insurance as our principal mission.
USFHP provides eligible members of the uniformed services community with a choice as to the type and character of their health care in a way that generates healthy competition within the MHS.
Not only are we successful because we are a managed care program, but we are skilled at administering managed care. We are proud to report that, according to surveys of our members, for the seventh straight year overall member satisfaction with the USFHP rated significantly higher than the national average for all commercial managed care plans.
USFHP is a fully at risk managed care program that receives payment from the Department of Defense (DoD) on a capitated basis. As a result, USFHP represents for DoD a fixed and predictable annual budget, which varies only by the number and demographics (e.g., age, sex) of our enrolled population, not our cost of providing services. USFHP currently serves 95,000 uniformed services beneficiaries in our seven locations, with a service area that encompasses all or a portion of fourteen states. I have included a map of our service areas as Exhibit A.
Today, as throughout our program's history, about a third of our beneficiaries are aged 65 and over. We have developed special expertise in addressing the health care needs of this segment of the beneficiary population, a group in which this Committee has a special interest. With the advent of TRICARE for Life, we have begun to work closely with the Office of Health Affairs and TRICARE Management Activity to share our experience in caring for this community.
History - Twenty Years of Service
A brief look at our history helps frame our presentation this morning. The USFHP program had its origins in 1981 when Congress, in Section 987 of Public Law 97-34, authorized the transfer of ten US Public Service hospitals and clinics to private not-for-profit health care entities. Congress required at the time that these facilities continue to be used for health care purposes. Later that year, Congress adopted an amendment to the FY 1982 Military Construction Authorization Act (PL 97-99, Section 911) that designated these former Public Health Service facilities as "treatment facilities of the uniformed services." As a result, uniformed services beneficiaries who were eligible to receive care at military treatment facilities, including those age 65 and over, were now entitled to care at what became known as the seven Uniformed Services Treatment Facilities (USTFs).
At the direction of this Subcommittee in 1989, DoD and the USTFs were asked to develop "a new managed-care delivery and reimbursement model" that could be used as a template for future DoD managed care initiatives. After extensive negotiations with DoD to design the new program, USFHP, which is what that managed care program has come to be called, began operations on October 1, 1993. Even though the program required periodic congressional reauthorization, enrollment in USFHP quickly grew to over 100,000.
Following the introduction of the TRICARE Program, the FY 1997 Defense Authorization Act made the USTFs, now described as TRICARE Designated Providers, a permanent part of the MHS. It also made permanent our managed care program by explicitly authorizing us to offer the TRICARE Prime option as an alternative within the MHS, including to beneficiaries aged 65 and older who live in our service areas. The FY 1997 Authorization Act provided the basis on which our relationship with DoD has gone forward in a constructive partnership that has worked very effectively to promote high quality and effective care for our beneficiaries.
In short, it has been an exciting twenty years for us, during which we have learned much about caring for uniformed services beneficiaries, lessons that I will discuss later in this testimony. And our program has evolved into a plan that has clearly been successful from the beneficiary point of view.
Model for Care
One measure of that success has been our ability to maintain a consistently high level of patient satisfaction. We have conducted Enrollee Satisfaction Surveys since 1994. For the 2001 Survey, which has just been completed, an independent market research firm contacted over three thousand USFHP enrollees by telephone. Eighty-two percent (82%) of those surveyed rated USFHP overall as 8 or higher on a ten-point scale on which 10 is the highest or best. In comparison only 56.7 percent of members in commercial managed care plans rated their plans at 8 or higher. When asked about the health care they received, 87.7 percent of the USFHP enrollees who used health care services in the past year rated overall health care at 8 or higher on a ten-point scale. Again, in comparison, commercial plans received a rating of 70.2 percent on a similar scale. These results are consistent with past years. I have included several charts showing the results from our most recent survey and they are attached as Exhibit B.
Through the USFHP Alliance, which is made up of the seven organizations that sponsor USFHP, we have been examining the factors that have contributed to the results shown in our ongoing surveys. We have already begun providing, and will continue to provide, to DoD the results of our analyses. We are sensitive to the daunting tasks that lie ahead for the TRICARE Management Activity, the Office of the Assistant Secretary for Health Affairs and the Lead Agents, particularly with the initiatives included in the FY 2001 National Defense Authorization Act.
We hope that we can be helpful to DoD as it thinks about how most effectively to address the health care needs of uniformed services beneficiaries resulting from these changes, given our extensive experience in providing health services and care management to the 65 and over population. We believe that many of the lessons that USFHP has learned may provide models for the rest of the MHS.
As we have engaged in our strategic assessment of USFHP, certain aspects of our program stand out as being, we believe, principal contributors to our success. We feel the key is our ability, as a partner in the MHS, to offer population-based health care at its best. In many ways, the USFHP can serve as a model for the delivery of care to an enrolled population of active duty dependents and retirees, whether younger than sixty-five or sixty-five and older. The results of our enrollee satisfaction surveys suggest that we can provide managed care in a way that retains a high degree of patient loyalty and satisfaction. We understand that our approach to care delivery is the objective of the MHS as a whole, as is reflected in the congressional directive contained in the report accompanying the FY 2001 Authorization Act.
Reasons for Success
I will describe those more discrete facets of the USFHP program that we believe have been prime contributors to its high rate of acceptance. These include the following:
1. Population-Based Care: USFHP is sponsored by integrated health management organizations that provide population based care. The overall management of the care of a population allows us to develop and implement innovative care delivery models that keep the patient foremost in our focus. The seven sponsoring organizations regularly share information on these models and continuously strive toward "best practices".
2. Provider Based Program: The USFHP is operated by local or regional not-for-profit health care systems that are provider based. They approach care from a provider, rather than a payer or insurer, perspective, and maintain a strong clinical focus throughout all of their activities.
3. Full Risk for Care: The seven sponsoring organizations of USFHP have accepted full risk for the care of their enrollees. We believe we are the only program within the MHS where full risk is taken for the care of uniformed services beneficiaries. This commitment requires each of the seven of us to develop and implement accurate measurements of outcomes, both clinical and financial, and continuously to monitor and improve the care of our enrollees. Being clinical enterprises, we have learned that clinical management is essential for quality and economy.
Being
fully at risk, we necessarily focus financial
and human resources on the health needs and
requirements of our enrollees in a structured
care environment. We actively coordinate among the seven
sponsoring organizations the communication of
information about each one's experiences
with different care management initiatives. In addition, our financial model, where
all of the TRICARE Prime benefits are paid on
a strict capitation basis, provides DoD with
fixed predictable costs, with no retroactive
adjustments, as well as access to data on a
controlled normative population.
4. Care Management and Disease Management: USFHP maintains a strong
emphasis on Care Management and Disease
Management programs with demonstrated clinical
outcomes. Our clinical focus and care delivery
model affords us the ability to manage
effectively the primary, specialty care and
inpatient care provided to our enrolled
population. We have been able to develop a number
of innovative programs to effect these
results. These include the following:
v The coumadin clinic and diabetic heart failure programs at Johns Hopkins Community Physicians
v The medical management model that utilizes hospitalists, risk stratification protocols and intensive outpatient disease management clinics and programs at CHRISTUS Health.
v A health risk assessment tool for the elder population that PacMed Clinics has developed and the support resources it makes available to the highest risk group.
At my organization, Martin's Point Health Care, we introduced the award-winning Patient's Personal Points, which provides customized, online health information for patients and allows them to securely submit questions to their doctors, schedule appointments, renew prescriptions and more. Martin's Point's pharmacy also installed a robotic pharmacy dispensing system to perform the time-consuming task of counting pills and filling and labeling vials. To ensure accuracy, a pharmacist oversees the robot's work. This robot is helping to fill accurately up to 100 prescriptions an hour and freeing up time for the pharmacist to spend with patients.
5.
Primary Care Manager: At the center of
USFHP's care management model is the primary
care manager (PCM), who coordinates the care
of those individuals who have selected him or
her as their PCM. PCM by Name has been fully in effect
throughout the USFHP program for many years. The results of our 2001 survey showed
that 88.7% of those participating in the
survey identify with a primary care manager.
6. Customer Focus: For USFHP enrollees and all patients of these
health systems, we have a strong
customer-friendly focus and place great
emphasis on convenient and timely access to
care. USFHP is dedicated to facilitating that access. We are one of
a series of options available to our
beneficiary population (especially now with
the planned extension of TRICARE to the
Medicare eligible population) and thus must
compete for our enrollees. Thus, as an
enrolled program, we have learned the
following:
v We must compete every day in the market place for the loyalty of our enrollees and attention of potential enrollees;
v We need to maintain a strong emphasis on responsiveness to patient concerns, needs and demands;
v We must be committed to a member services function that addresses those concerns, needs and demands in a timely manner;
v Telephones must be answered and appointments must be available and timely; and
v Physicians and support staff must be attentive and caring, and the quality of care must be both the best and recognized as such.
The systems and techniques we have developed to attain and maintain these objectives may be of relevance to the MHS at large. We would be happy to share with this Subcommittee and with representatives of the Department more detailed information about how our program works and how we believe we have been able to retain the support of our beneficiary population.
USFHP Experience and TRICARE for Life
With the upcoming start of the new TRICARE for Life benefit for beneficiaries 65 and older, USFHP can play a unique role in assisting the Department with the special issues and needs of these individuals. For the twenty years of our program we have had the privilege of taking care of these individuals. Since 1993, we have cared for them in the managed care setting that I described above, in which we assume the full responsibility and risk for all their health care needs. As a physician I can tell this Subcommittee that these individuals come with complicated and special needs. We have learned much from our work with them.
As the DoD prepares to launch TRICARE for Life, and issues the next round of requests for proposals for the managed care support contracts, we have experience, dating back to 1993, that we can share and that others may use to assist in their endeavors on behalf of this population. We believe that our experience will be useful for both the military treatment facilities (MTFs) and the managed care support contractors (MCSCs).
Our experience demonstrates what we know intuitively, that the health care requirements of this population are many times higher than for patients under age 65. But the data we have gathered since the inception of USFHP provides an important statistical basis from which to project the utilization and likely cost of care for these beneficiaries. For example, during last year USFHP enrollees 65 and older needed 1,580 inpatient hospital days per 1000, which was six times the need for the under 65 enrollees (263 days per thousand). We have seen similar patterns for other aspects of health care including prescriptions and primary care visits. I note for the Subcommittee that we are pleased that DoD has begun to use the monthly data that we report under our contracts as it begins its efforts to prepare for the implementation of the TRICARE for Life benefit.
Beyond the statistics, though, we have come to understand in very discrete ways how the increased usage of medical care by these beneficiaries produces an increase in other operational needs for our programs. Examples include: increased time from our member services personnel; special consideration in parking and access to our facilities; and considerable time and attention from our outpatient pharmacy personnel because of their need for multiple drugs and the complications associated with taking these medicines.
Recommendations Concerning TRICARE for Life
Based on our experience caring for the 65 and over population, we believe we are in a position to make some preliminary recommendations to this Subcommittee and to DoD as TRICARE for Life is implemented:
1. Need for More Time and Resources: MTFs and the MCSCs must make allowances for the additional time and resources that they will need to devote to the care of this population.
2. Value of the Primary Care Manager: DoD, the MTFs and the MCSCs need to recognize the significance our older military attach to their primary care manager. In addition, it would be a mistake to short-change the infrastructure that supports the primary care manager. Although there will be two principal sources for the payment of care for these individuals, the Health Care Financing Administration (HCFA) through Medicare Part A and Part B funds, and DoD, serious thought needs to be given to structuring a program that encourages TRICARE for Life beneficiaries to elect to receive care through an organized delivery system that has the primary care manager as the focal point.
3. Importance of the TRICARE Prime Option: Following from the preceding recommendations, we respectfully suggest that managed care models be vigorously promoted as the best alternative for TRICARE for Life beneficiaries. We believe that a structured care environment similar to that within USFHP works effectively for these individuals. We have shown that we can manage well in this situation and devote the resources necessary to take care of the special needs of these enrollees.
4. Incentives for Enrollment: DoD should be encouraged to develop incentives to enroll these individuals in managed care models, where the costs of such incentives could be covered from the projected savings to be realized from managing care within such a structured environment. Our recommendation requires looking at the cost of care for this population as a total government responsibility, not differentially as a DoD and a HCFA budget matter. Thus, a cooperative relationship between the two agencies is necessary to maximize the benefits for both the government and this population of beneficiaries. Without a structured care environment similar to USFHP, we envision considerably higher costs for both HCFA and DoD.
Recent Accomplishments & Developments
In addition to commenting on the lessons learned from caring for military beneficiaries through a managed care program, I would like to summarize for the Subcommittee some of the recent accomplishments of USFHP.
1. Continuous Open Enrollment
In response to comments from our enrollees we have improved access to USFHP. We worked with this Committee and the Senate Armed Services Committee to make USFHP enrollment more convenient for eligible uniformed services retirees and their families. Based on Congressional action, DoD implemented an open enrollment demonstration that has allowed retirees and their dependents to enroll at any time during the year, rather than during an annual open enrollment month. The demonstration was implemented for USFHP in three locations: Brighton Marine Health Center in Boston, PacMed Clinics in Seattle, and Saint Vincent Catholic Medical Centers in New York.
This demonstration has already proven successful. Each of these three service areas has experienced a steady increase in enrollment. Based on a recent Congressionally mandated study of the demonstration by the RAND Corporation, DoD is now moving to expand continuous open enrollment to all seven USFHP locations and to make this a permanent program feature.
2. TRICARE Prime Remote
In addition, last year Congress, with support from DoD, authorized USFHP to participate in the TRICARE Prime Remote (TPR) program. This program is designed to better serve active duty uniformed services personnel stationed in areas that DoD considers remote - more than 50 miles from the nearest medical treatment facility.
At the request of DoD, Saint Vincent Catholic Medical Centers of New York has already begun participating in TPR on Long Island. Prior to Saint Vincent's participation, the Coast Guard and other active duty personnel stationed on the island had to drive more than an hour for access to care. USFHP is in active negotiations with DoD to expand TPR coverage to other service areas during 2001.
3. Expanded Delivery Networks
In addition to these two national initiatives, the USFHP sponsoring organizations have been expanding their delivery networks in their respective service areas to increase beneficiary access to dedicated health professionals and service locations. Within the past few years:
v In New York, a merger with two other long-established Catholic health care systems allowed Sisters of Charity Medical Center (the original sponsor of the Staten Island-based USFHP program) to add more health care providers to its service area. That merger, which created the Saint Vincent Catholic Medical Centers of New York, has resulted in more convenient access to military health care for families and retirees living in the boroughs of Manhattan, Queens and Brooklyn.
v Brighton Marine Health Center, based in Boston, has expanded its health care delivery network in Rhode Island and on Cape Cod in Massachusetts to better serve retirees and active duty families who previously had limited access to military health care options.
v Martin's Point Health Care, based in Portland, Maine, has extended its primary care network to include seven new sites in Maine and two additional sites in New Hampshire, allowing beneficiaries in more rural areas increased local access to care.
v In Ohio, another merger created the Fairview Hospital-Cleveland Clinic Health System with over 300 primary care physicians and 1,000 specialists to serve USFHP members in the Cleveland area. Now enrollees in East Cleveland have expanded and convenient access to USFHP health care.
v Working closely with DoD, CHRISTUS Health, whose USFHP is based in Houston, Texas, has added to its network the CHRISTUS St. Catherine Health and Wellness Center, on the west side of Houston, and is expanding its primary care network within its current service area. In addition it is expanding the USFHP service area to cover more uniformed services beneficiaries in Texas and Louisiana.
v Johns Hopkins Community Physicians, serving USFHP members in Maryland and parts of Pennsylvania, Virginia and West Virginia, merged two primary care physician groups to offer patients more convenient access to Johns Hopkins primary care in the community. The Johns Hopkins USFHP now has 19 primary care practices throughout Maryland, with 115 providers specializing in internal medicine, family practice and pediatrics. In addition, Johns Hopkins at White Marsh, a comprehensive new health center north of Baltimore, is a remarkable example of the success of primary care consolidation. The center offers Johns Hopkins USFHP members access to a dozen family practice, internal medicine and pediatrics practitioners, along with medical and surgical specialties, in one easily accessible suburban location.
v PacMed Clinics in Seattle has expanded its specialty physician and hospital network north into Snohomish County. PacMed took these steps in order to provide more convenient access and increased availability of services for military seniors who are joining USFHP because they were losing Medicare HMO coverage because those carriers pulled out of the Medicare risk business.
4. Relationships with Stakeholders
As my testimony emphasizes, the USFHP Alliance and the individual sponsoring organizations continue to work to strengthen our knowledge of the needs of our beneficiaries. We continue to strive to be sure not only that we understand the changes taking place in the MHS but that we can actively help the Congress and DoD in facilitating those changes through sharing our experience, insights and data.
The USFHP Alliance works with the policy leaders who are dedicated to achieving the highest level of quality and access within the MHS and to advocating for legislation that benefits our enrollees and all the others who receive care through the MHS. We are grateful for our productive relationship with DoD in general, with TMA specifically, and with the Lead Agents in Regions One (where four of our sponsoring organizations are located), Five, Six and Eleven. Lead Agents such as General Harold Timboe in Region One have been strong supporters of our program, and we are grateful for the cooperation we have received throughout the leadership of the MHS. We were very pleased that recently Admiral James Sears accepted a distinguished service award from us in conjunction with his retirement from TMA.
We also work closely and, we believe, effectively with the Military Coalition and the National Military and Veterans Alliance. We hold regular meetings on matters of mutual importance, the most recent one being just last week, where USFHP representatives from around the country can talk directly and informally with leaders of these organizations to obtain important information as to how our program is perceived among retirees and their dependents.
We are especially grateful to the Congressmen and Senators who represent our beneficiaries in our service areas for their continuous strong support and their interest in how we serve the health care needs of their constituents. The continuation and expansion of the USFHP program is a direct result of their efforts and of the efforts of this Committee and its counterpart in the Senate.
Conclusion
In closing, I want to restate that, measured at least by the high level of enrollee satisfaction, USFHP has been a very successful program within the MHS. We believe that there are many features of USFHP that have contributed to its success. We also believe that many of these features likely are transferable to the MHS at large as DoD continues to look at more effective ways to provide high quality care, to manage that care effectively, and to improve the delivery of hard-earned benefits to the 65 and over population. We would be very pleased to continue our work with DoD and with the Congress to provide our data and our insights on care for the uniformed services beneficiaries.
We very much appreciate the opportunity to tell you about our program today. We hope that this hearing will be one more step in our ongoing and productive association with the Military Health System. We hope that we can in a way repay you for your support by making ourselves readily available to assist you and DoD in whatever way we can as the exciting new initiatives contained in the FY 2001 National Defense Authorization Act are implemented
2120 Rayburn House Office Building
Washington, D.C. 20515
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