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Viewpoint
November 9, 2017

Transforming the Military Health System

Author Affiliations
  • 1Office of the Secretary of Defense, US Department of Defense, Washington, DC
  • 2Defense Health Agency, US Department of Defense, Falls Church, Virginia
  • 3Defense Health Agency, Strategy Management, US Department of Defense, Falls Church, Virginia
JAMA. Published online November 9, 2017. doi:10.1001/jama.2017.16718

The Military Health System (MHS) is one of the largest health systems in the United States, delivering health services to 9.4 million eligible patients in nearly 700 military hospitals and clinics around the world as well as through the TRICARE health plan.1 The TRICARE health plan provides care to all members of the Uniformed Forces,2 their families, and retirees, rendering TRICARE the fourth largest health plan in the United States. However, military health services are currently managed by 4 separate entities: Army, Navy, Air Force, and the Defense Health Agency (DHA), creating opportunities for variation and inefficiency. The MHS falls under the Department of Defense and is distinct from the Veterans Health Administration, which provides care to the majority of veterans and to veterans ineligible for TRICARE.3

The National Defense Authorization Act for Fiscal Year 20174 directs changes to existing management structures, enabling the MHS to collectively transform into an integrated system of readiness and health. The law provides a set of interdependent and nested initiatives to optimize delivery of the Quadruple Aim of improved readiness, better health, better care, and lower cost.

With so many provisions in the law related to reform, it is important to maintain sight of the larger strategic imperative. In its entirety, the law drives several overarching health care goals: to ensure trained and ready military medical personnel, to deliver an improved health care experience to beneficiaries, and to perform both functions as one efficient enterprise. This Viewpoint describes the strategic logic of a transformation that Sen John McCain (R, Arizona) stated was the “Most sweeping overhaul of the [MHS] in a generation.”5

Transforming the Military Health System

Centralized administration of military hospitals and clinics (ie, military medical treatment facilities [MTFs]) under the authority of the new law affords the MHS an opportunity to focus on readiness, provide a common, high-quality experience for patients, and eliminate redundancies. Today, the Army, Navy, Air Force, and DHA deliver health services independently with varying degrees of integration. Working as a single integrated enterprise, the MHS intends to focus on value expected and defined by the beneficiaries, improve the experience of each patient, and modernize the TRICARE health plan. The Department of Defense plans to transform the MHS through 5 lines of effort.

First, a clear, measurable definition of the medical readiness for which the health system is responsible for delivering is necessary. The MHS requires a common vernacular to determine whether the system meets the medical requirements of the military’s joint operational plans.6 This begins by specifying the types of combat casualty care disciplines (eg, emergency medicine, trauma surgery, critical care), calculating the number of personnel needed to fill operational medical force requirements, and then determining the appropriate means to acquire and sustain these capabilities.

A major effort is under way to define the knowledge, skills, and abilities (KSAs) required by military medical personnel for deployment to a combat zone or in support of humanitarian crises. The military surgical community developed its expeditionary KSAs first; follow-on efforts to develop KSAs for other clinical disciplines are ongoing. KSAs are linked to procedure codes, which provide the MHS with a powerful tool to correlate the relationship between the workload of health care personnel and their military medical readiness while informing decisions for training and skills maintenance.

Second, with clinical readiness more clearly defined, the MHS plans to optimize MTFs as training platforms for the ready medical force. This includes determining which MTFs will be designated as medical centers and primary training platforms for critical wartime specialties with level I or II trauma capability, serving as the foundation of military graduate medical education. At MTFs that provide such readiness training, the law expands care to veterans and civilians to increase KSAs. Other MTFs will be designated as hospitals or ambulatory care centers based on readiness need as well as the availability of local civilian care. Concurrently, the Department of Defense will review graduate medical education programs to ensure appropriate alignment with operational readiness requirements.

The new law provides opportunities for partnerships with civilian academic medical centers and trauma teaching hospitals to provide greater exposure to patients with complex, critical injuries. High-performance military-civilian integrated markets should improve access, care, outcomes, and experience for patients while simultaneously improving military medical skills. Given the imperative of sustaining a trained and ready combat casualty care team, the DHA will oversee the Joint Trauma System and develop a Joint Trauma Education and Training Directorate, both focused on standardizing care, translating research, and creating clinical practice guidelines applicable to both combat injuries and domestic mass casualty care.

Third, plans for centralization of health care administration will focus on standardization of health care delivery and readiness support. At present, each service branch and DHA administer MTFs with relative independence under the guidance of governance councils, creating a loosely integrated direct care system with degrees of duplication and variation. Under the new law, the DHA becomes responsible for the administration of all MTFs with respect to budgetary matters, information technology, health care administration and management, administrative policy and procedure, as well as other matters determined by the Secretary of Defense. The service branches, supported by the DHA, will ensure the readiness of the military medical force based on future mission requirements. These changes could drive functional and clinical integration to create savings through found efficiencies across the enterprise. To build accountability, common performance standards for MTF leaders will be developed for readiness, quality, access, outcomes, and safety.

Fourth, the Department of Defense plans to improve the patient experience so that each MTF is the first choice for beneficiaries where available and appropriate. A standardized system for scheduling appointments should enable timely access to care, while access to urgent care and expanded primary care services will be better aligned to civilian health care practices. For instance, wait times in pharmacies will be displayed, unifying focus on optimizing wait times for any service and identifying drivers for additional efficiencies. Expanding telehealth can bring asynchronous care to patients where they live when they need it.

The integrated MHS plans to focus on measurement of health outcomes, quality of care, and safety. Enterprise core quality metrics will be adopted to ensure that performance is assessed relative to national measures and benchmarks, eliminating undesired variability and improving quality through evidence-based best practices. Advisory committees of military personnel, patients, and family members plan to co-create the future integrated system of readiness and health alongside the MHS, adding insights that improve the experience of care from the patients’ perspectives.

Fifth, the new law directs the DHA to modernize the TRICARE health plan. Two comprehensive options will be offered: a managed care plan (TRICARE Prime) and a preferred provider network (TRICARE Select). A strategy for value in development rewards quality, safety, experience, and outcomes rather than volume and intensity through value-based pilots and demonstration projects that target savings and value creation through patient-defined and clinical outcomes.

The new law catalyzes integration, creating a common experience for patients and driving improvement across the system.7 The DHA will go a step further than most health systems are able, integrating care purchased from the civilian market and that which the military provides to create a ready medical force. The transformation of the MHS plans to create this new model that could elevate military health services and inform national health care standards.

Summary

Maintaining readiness and medical skills is the primary mission of the MHS and will always take highest priority. Moreover, the MHS has important professional and statutory obligations to active duty personnel, their families, and military retirees to receive the highest-quality care and achieve the best health outcomes possible, in the most efficient way. The National Defense Authorization Act for Fiscal Year 2017 is a welcome prescription for transformation. The provisions of the law work together, ensuring that a trained, ready health team fully supports military personnel and the military service branches, improve the patient experience, and enable the MHS to act as one enterprise.

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Article Information

Corresponding Author: Bryce J. Slinger, MPH, Defense Health Headquarters, 7700 Arlington Blvd, Falls Church, VA 22042 (Bryce.J.Slinger.civ@mail.mil).

Published Online: November 9, 2017. doi:10.1001/jama.2017.16718

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

References
1.
Defense Health Agency.  Evaluation of the TRICARE Program Fiscal Year 2017 Report to Congress. Washington, DC: US Dept of Defense; 2017. https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Health-Care-Program-Evaluation/Annual-Evaluation-of-the-TRICARE-Program.
3.
Health benefits. US Department of Veterans Affairs website. https://www.va.gov/HEALTHBENEFITS/apply/veterans.asp. Accessed November 7, 2017.
4.
National Defense Authorization Act for Fiscal Year 2017, Pub L 114-328, Title VII, December 23, 2016.
5.
McCain  J. Remarks by Senate Armed Services Committee Chairman John McCain on the National Defense Authorization Act for FY17. Washington, DC: Brookings Institution; May 26, 2016. https://www.mccain.senate.gov/public/index.cfm/2016/5/remarks-by-sasc-chairman-john-mccain-on-the-national-defense-authorization-act-for-fy17.
6.
Report of the Military Compensation and Retirement Modernization Commission: Final Report. Washington, DC: US Military Compensation and Retirement Modernization Commission; January 29, 2015. https://www.ngaus.org/sites/default/files/MCRMC%202015_0.pdf.
7.
Berwick  DM, Nolan  TW, Whittington  J.  The triple aim: care, health, and cost.  Health Aff (Millwood). 2008;27(3):759-769.PubMedGoogle ScholarCrossref
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