By SARAH PEACHEY
Editor’s note: Due to the lengthy responses from the testifying parties, the discussion of the MCRMC proposals has been split into two articles: This one focusing solely on the TRICARE changes, and another, focusing on the remaining recommendations. You can also view a breakdown of the original MCRMC proposals from Jan. 29 here. You can find the complete individual testimonies here.
WASHINGTON — Top military and Family organizations met with the Senate Armed Forces Committee today on Capitol Hill to discuss the Military Compensation and Retirement Modernization Commission’s proposals to dismantle the TRICARE military health care system. The Military Officer’s Association of America, The National Military Family Association and the Fleet Reserve Association, all leaders in issues important to service members and their Families, offered mixed evaluations of the Commission’s suggestions, offering what they supported and what they felt needed more work. Across the military community, the reception has also been varied.
Current TRICARE issues
The current TRICARE system was placed on the chopping block in favor of a commercial-type plan known as TRICARE Choice for a number of reasons, as laid out by the NMFA:
• Access challenges: TRICARE’s referral and authorization process is difficult to navigate and often leads to treatment delays. A limited provider network poses challenges to Families seeking care due to provider shortages and a lack of certain specialties, including behavioral health care. There are also a number of inadequate access standards within the Military Treatment Facilities, making it difficult to make appointments.
• Coverage issues: TRICARE is slow to cover emerging technologies and treatment protocols, even those that are commonly reimbursed by commercial plans. TRICARE’s pediatric coverage is also problematic, authorizing care only when it is medically or psychologically necessary based on reliable evidence. It leads to a lack of coverage for treatments that are widely accepted and practiced in other health care systems.
• Lack of choice: This is one of the most profound issues with the current TRICARE system. The uniform benefit means that military Families cannot choose their coverage to meet their anticipated level of care as it is the same for everyone. For example, those who use and support chiropractic care cannot receive coverage. Lack of choice also arises in the current Reserve Component of TRICARE during mobilization and demobilization. Switching to TRICARE when a service member is activated creates a disruption in care, while maintaining employer-sponsored care leads to additional out-of-pocket expenses.
• Customer service: TRICARE is slow to adopt customer service innovations from the private sector such as the Nurse Advice Line. TRICARE’s contracting process leads to customer service problems during transitions between regional contractors, which occurred in April 2013 when military Families experienced referral and customer service issues during the West Region transition to a new contractor. TRICARE beneficiary communications are inadequate, especially with coverage changes. Many coverage changes were implemented without notifying the beneficiaries, causing confusion and some out-of-pocket expenses.
“The Department of Defense has been well aware of these TRICARE problems, in some instances for years, but has failed to take corrective action,” NMFA said. “We agree with the Commissioners who have testified before Congress that TRICARE — both the benefit and the system to deliver the benefit — is unsustainable as currently structured. Specifically, TRICARE’s beneficiary satisfaction and fiscal sustainability have both declined.”
The NMFA supports the concept of moving military Families to high quality commercial health plans, but felt more information and analysis were needed before the organization could fully endorse the Commissions health care proposal.
How TRICARE Choice can help
Both the NMFA and the FRA believe that TRICARE Choice, the Commission’s proposed health care plan, offers increased benefits for service members, Families, retirees and survivors in a number of ways:
• Enhanced access to care: Beneficiaries can find a wider range of Primary Care Managers and specialists within a network, easing the referral process. This style of health care would also streamline the transition of care during a PCS, assuming Families select a national coverage plan. Barriers to Urgent Care facilities would be eliminated, offering Families a choice between the emergency room and urgent care without concern for increased fees. Beneficiaries that want to continue their care at an MTF for familiarity and comfort would still maintain that choice.
• Better coverage policies: Commercial health care plans would reduce problems currently found in TRICARE, such as questionable pediatric policies and a lack of coverage for emerging technologies and treatments.
• Greater choice: TRICARE Choice allows military Families to tailor their coverage to best meet their needs, even offering coverage for previously unavailable services like chiropractic, vision and acupuncture. Beneficiaries would be able to choose their own providers to find what they like. National Guard and Reserve members would also have more options. They could retain their employer coverage, but receive the Basic Allowance for Health Care when activated to cover their premiums.
• Minimal active duty Family out-of-pocket costs (in principle): The NMFA is not yet convinced that active duty Families are insulated from increased medical expenses, but the principle of minimal out-of-pocket costs with the proposed BAHC gives Families a way to cover their health care costs.
NMFA concerns regarding TRICARE Choice proposals
“Our Association believes the Commission’s TRICARE Choice health care proposal has the potential to provide military Families with a more robust and valuable health care benefit than they have today. However, while we are open to the idea of transitioning military Families to commercial health plans, the MCRMC report raises questions and concerns that must be addressed before we can fully support the Commission’s health care proposal,” the NMFA said.
The NMFA concerns include:
• TRICARE Choice’s impact on MTFs/military medical readiness is unclear: So far, there is no analysis of the proposed plan on MTF caseload. “It’s been our experience that many military medical providers believe they must maintain the ability to force military Families into the military treatment facilities in order to maintain needed skills and patient loads. The proposed Joint Readiness Command, charged with attracting a mix of medical cases into MTFs to support combat care training and medical readiness may not be enough,” the NMFA said. It is still unknown what services and medical specialties would be available at MTFs.
• TRICARE Choice does not address current access and quality issues within the MTFs: The MCRMC report highlights where a beneficiary is unsatisfied, but does nothing to address how those problems would be rectified under the TRICARE Choice system. It leaves service members to question, if the problems are not fixed, why change anything?
• Potential for significant out-of-pocket expenses for active duty Families: A concern for many military Families is how they would handle the potential for higher health care costs, since current out-of-pocket costs are either non-existent or minimal. While TRICARE Choice offers a catastrophic cap, it is unspecified and details are sparse. The BAHC is also concerning to the NMFA as it is calculated to cover the premium cost share of the health plan selected in the prior year by the median active duty Family. “The level should be set based on the costs of plans available for (the Family’s) location in the current year and not on what Families chose in the prior year,” the NMFA said. The BAHC also leaves larger Families vulnerable to higher out-of-pocket costs since the BAHC would not vary based on Family size.
• Potential for significant out-of-pocket expenses for Non-Medicare Eligible Retirees: Retirees would not receive BAHC and instead be fully responsible for their premiums and cost shares under TRICARE Choice. The NMFA believes that those costs could become too high and diminish the retirement benefit. And again, the catastrophic cap is unspecified. The FRA is concerned about shifting costs to retirees under 65. “The Association believes that this shift devalues 20 or more years of arduous military service that earned the retiree an offset in health care premiums during retirement,” they said.
• No mention of Wounded Warrior and medically retired service members: “This omission must be addressed before we can fully assess TRICARE Choice,” the NMFA said. Currently, non-Medicare eligible retired service members receive the same TRICARE benefit as all other non-Medicare eligible retirees. The NMFA believes the minimal costs must be maintained. There is also no mention of the current expenses the severely wounded face.
• Implementation details must be rectified: Military Families who frequently move will require high quality national health plans, combined with an “unprecedented” level of beneficiary communication and education, the NMFA said. Financial planning is just as critical to ensure that Families have a plan for the BAHC, the FRA said, since housing costs are predictable, but health care costs are not. MOAA echoed the need for regular education on health care plans and benefits as well as finances, but fears education may not be enough.
“We view the TRICARE Choice proposal as a first step in a needed process toward change,” the NMFA said. “The statute authorizing TRICARE Choice must set clear baseline standards that ensure Families have access to high quality plans that meet their unique needs at the best possible cost.”
The FRA is still on the fence, saying, “At this time, the FRA does not support or oppose (the health care recommendation), but believes that such vast and dramatic change to the health care benefit requires additional review.”
No need to dismantle the current system
MOAA was the only organization that was against the incorporation of a commercial health care system, believing that the benefit of TRICARE should be sustained by fixing the current problems. “Several of the health care recommendations represent nothing short of a seismic change and have not been modeled and studied within the complex and dynamic realities of the military health care system,” MOAA said. These realities include frequent Permanent Change of Station moves, service-related issues, behavioral health issues, a high level of readiness and more.
MOAA believes that the current cost of TRICARE shouldn’t be a concern based on the percentage costs. “Health care costs comprise 23 percent of the nation’s budget, 22 percent of the average state budget, 16 percent of household discretionary spending and are 16 percent of the U.S. gross domestic product. A 10 percent share of the Department of Defense’s budget is not too bad of a deal,” MOAA said.
While MOAA recognized the current issues with TRICARE, they do not feel a commercial plan is necessary, but that many of its faults can be improved with Congressional leadership. “Problems like rising costs, barriers to access and lack of customer service in certain areas can be addressed in a systematic manner without resorting to its elimination. The development of a new set of TRICARE contracts, set to start in 2017, is about to commence bidding. Now would be an opportune time to institute innovative ideas from the industry,” MOAA said.
Problems with commercial plans
MOAA believes that the commercial plans vary premiums, co-pays, plan features and the determination of medical necessity based on location and plan design. It only allows Families to plan as far as their next set of PCS orders. Here are some of their concerns:
• Certain programs, like the Applied Behavior Analysis, frequently sought by military Families with autistic dependents, “is only offered by 20 plans in a handful of states,” according to MOAA.
•The Commission proposes that the TRICARE pharmacy program remain unchanged, but most commercial plans include different levels of pharmacy coverage. The TRICARE pharmacy program is unusable if other coverage exists. MOAA believes this could entrap Families between higher costs for civilian coverage or bureaucratic problems if using the TRICARE pharmacy program.
• Commercial plans are more beneficial for National Guard and Reserve members and their Families since they are not subject to frequent relocation and often prefer to keep their employer coverage.
• TRICARE Choice is not a favorable plan for military Families. In a survey of over 7,000 respondents (active duty, active duty Family members, retirees, military spouses and survivors of all services), four out of five prefer TRICARE to a commercial system and nine out of ten do not feel confident that the Office of Personnel Management would be able to understand and accommodate the unique needs of military Families.
“TRICARE has come to a unique moment in its history, and is presented with an opportunity for a thoughtful re-design of the program,” MOAA said. “This should be done with the goals of ensuring that the TRICARE benefit remains robust and medical readiness is strengthened while keeping beneficiary care and access in the forefront.”