STATEMENT OF:
Major General Lee Rodgers
Commander, Wilford Hall Medical Center, and
Lead Agent, DoD Health Services Region
May 17, 2001
Mr. Chairman, Mr. Meehan and members of the committee, thank you for this opportunity to represent the Air Force Medical Service as a lead agent and facility commander. I am the Commander of the 59th Medical Wing, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas. I also serve as the lead agent for TRICARE Southwest, DoD Health Services Region 6. This is a four-state region consisting of Texas (excluding the far west El Paso area), Oklahoma, Arkansas, and Louisiana (excluding the New Orleans area).
We serve and support approximately 1 million beneficiaries in this region. A recent review of the HMO industry in Texas would suggest that TRICARE Prime in Region 6 is among the very largest HMOs in the state and the region. Beneficiaries in Region 6 are supported by a network of 17 military treatment facilities and over 23,000 civilian providers and facilities.
Our managed care support contractor (MCSC) and partner for this region is Health Net Federal Services (formerly Foundation Health Federal Services). They started operations in Region 6 as the managed care support contractor in October 1995. The current managed care support contract in my region was developed in 1993. The contract was awarded in 1995 with a six-month implementation period and five option years, at a total cost of $1.8 billion. In October of last year, we entered our first of two extensions of the contract.
The MCSC is responsible for administration of enrollment functions, beneficiary support, benefits education and counseling, marketing, claims processing, development and management of the contracted network of providers, and coordination of managed care activities with the military treatment facilities. This involves shared risk between the contractor and the government. As it developed over the past five years, our contractor support has matured and we have sufficient network coverage over the region. In those areas where we have limited network coverage, the network is consistent with the general distribution of civilian medical services and providers in those community areas.
We work closely with the MCSC and military treatment facility (MTF) commanders to ensure that quality, cost, and access standards are met in each Region 6 community. Today, we find our patient and network provider surveys support high levels of patient satisfaction, growing provider support for the referral and claims payment process, and partnership and integration with our contractor.
A lesson we've learned over the past five years is that the HMO industry is a moving target. In 1995, Region 6 military medical facilities consisted of two major medical centers, 11 hospitals, and four ambulatory clinics. Today, we have two major medical centers, only four hospitals, and now 11 ambulatory clinics. This has resulted in significant challenges to make appropriate changes to contract coverage to ensure support for the same size beneficiary market with a shifting mix of contracted and military medical facilities.
These dynamics have pointed us to the issue of developing appropriate skill sets among our officer corps and managers to effectively respond to these changing market forces. We have developed arrangements for education with industry, reoriented graduate management education, and developed new business and health care delivery practices. The business practices include market analysis, facility optimization through resource sharing and partnerships, and an array of business skill sets such as cost-benefit and make-buy analyses. In addition, we have looked at clinical practice changes including population health processes and greater use of demand, condition, and case management principles.
Having a managed care support contract in common between the military departments has definitely improved the frequency and quality of our communication, development of like nomenclature and terminology, and the ability to share information. Between the contractors themselves, I am seeing improved continuity of care and am heartened by the developing portability for our beneficiaries as they move across regions. Our comprehensive approach to managing care for our populations is a noteworthy improvement over what had been known as Standard CHAMPUS. Integration with the contracted network begins within the MTF as referrals are processed through the TRICARE Service Center with the support of trained service representatives, healthcare finders and case managers. As patients are referred outside the MTF, they encounter referral sources that are already accustomed to dealing with military patients through affiliation in the network, and the patient benefits directly by not having unnecessary concerns regarding access, quality and billing.
Moreover, we now have established similar support structures and arrangements in non-MTF-served communities. About one fourth of our beneficiaries in Region 6 fit into this category. Those people now have the same access to and support from TRICARE Service Centers and support staff, and are directly enrolled to civilian primary care managers in the contracted networks. In contrast to pre-TRICARE days, they now enjoy the same level of HMO-type support as people living in MTF-served communities. TRICARE Prime is now a recognized health care plan in this industry!
Mr. Chairman, we've made many improvements to TRICARE since its inception, but you also invited me to address areas in which we need improvement. You have heard, or will hear, some of these same things from my colleague in Region 11. From my perspective, however, one of the fundamental issues in working managed care within the military health services system is that we are attempting to take an entitlement program and squeeze it into a risk-based model. This has resulted in ill-defined performance expectations on the part of patients, conflicting incentives for MTF commanders, and a dynamic benefit structure, which makes for significant management challenges, both for the contractors and MTF commanders.
Within the military, healthcare has been and remains a vital benefit issue. As the dynamic benefit structure has evolved, problems associated with efficient benefit changes have arisen. These changes have resulted in slower implementation than other health plans with higher costs because the contract change mechanism is protracted and not easily tailored. As a lead agent, I don't hold command authority to make resource allocation decisions (manpower, facilities, or money) to directly impact the provision of health services. This results in essentially being required to optimize rather than maximize health care delivery systems. Unfortunately, having complete power over resource decisions would still require time for the culture and mindset of both staff and patients to accommodate the new approach.
Another important area that I would address as a challenge is effective knowledge management. Our information management structure is only barely uniform across the services and even less so between contractors. Only a few are actually held in common between the services.
As I look forward, I can foresee a number of opportunities that I believe the MHS is prepared to accept with the continued support of the Congress. Your far-reaching, bold initiatives to honor "the promise" to our retired members presents perhaps the greatest healthcare delivery challenge to our political and military leadership. I'm proud to say that we are jointly working to realize this goal. Building such a network poses an opportunity to correctly quantify Military Health System capacity, accurately coordinate network capability, and appropriately report resource requirements to avoid becoming individually overwhelmed or collectively bankrupt. Good people will have disparate views and may emphasize one method over another to achieve the same goal. I would advocate that we first turn to our MTFs, where we have significant investments, and develop broad-based, full service clinical models and then build a national network of healthcare using contractor support systems.
For example, within Wilford Hall Medical Center, there has been considerable investment of talent and resources to maintain its tradition of excellent medicine and care for our patients. Our Joint Commission on Accreditation of Healthcare Organizations review this past December rated Wilford Hall Medical Center very highly, and recognized our advances in developing an Integrated Clinical Data Base, which has pushed us forward in automating our patient documentation. Other technology advances in digitalized radiography, laboratory robotics and miniaturized deployable packages enable our people to work smarter and in many instances provide capability that did not exist even a few years ago. In addition to our technological advances, we've also taken steps to optimize our services to our beneficiary population: 36,000 basic trainees, the active duty population at Lackland AFB, the retired military population in San Antonio and their family members.
However, as with any large hospital in the United States, our optimization efforts are challenged by a significant shortage of nurses. It is paramount that we act together to address this challenge by making nursing in the military more attractive - by supporting nursing education and nursing practice that provides improved opportunities for nurses as part of the total patient care team.
In closing, I very much appreciate having had this opportunity to share with you some of my thoughts and concerns. I stress that as we look back over the past decade and the changes in military health services, our beneficiaries have been greatly served by the development and maturation of TRICARE. In their current development and with the changes on the horizon, it will be TRICARE that represents the enabling force to support military medicine in the future.
2120 Rayburn House Office Building
Washington, D.C. 20515
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