Health Care Happenings

This past Wednesday I had the opportunity to sit in and observe the Senate Armed Services Personnel Subcommittee’s hearing to consider the Defense Health Program (DHP) and the Administration’s proposed FY-2011 Defense budget. The Subcommittee was chaired by Senator Jim Webb (D) Virginia and the ranking minority member Senator Lindsey Graham (R) South Carolina. Testifying for the Defense Health Program was acting OSD/ Health Affairs, Dr. Charles Rice MD, RADM Chris Hunter for the TRICARE Management Activity, each of the service Surgeons Generals, and the Medical Officer of the Marine Corps.

Senator Webb opened the meeting expressing tremendous support for military medicine and noted that “..we have been at this war now for 9 years and we are now in unchartered territory”. This was in reference to the challenges our troops face with multiple deployments, rotational cycles and generalized stress on the force. He continues to maintain his focus on the deployed forces and in this respect he expressed great concern on the reported increased use of precription drugs by both active and the deployed forces. An alarming statistic he quoted was 1 in 6 of our active forces are on psychiatric type drugs such as anti-depressents, sleep aids and pain killers. Understanding this problem is imperative.

Echoing this concern, we also heard testimony from Senator Ben Cardin (D) Maryland. Noting that this is an extremely sensitive issue, and this may be a reflection of how the troops are dealing with deployment. He noted that in 2005 the use of prescription drugs was about 1% and in 2007 the use of prescription drugs of this nature was up to 5%. He expressed concerns with respect to the proper medical monitoring of the effects of these drugs especially during the first 6 weeks of prescribing. He also stated that DOD must drill into this further to gain understanding and develop policy. Also, there is a need to understand this in relation to the increase in suicides.

Bottom line is that Congress is highly concerned and has charged the Defense Health leaders to provide the very best data on the issue of psychiatric prescriptive drug use and to provide clarity of the magnitude. You can bet on a required report out on this!

Even though the DHP is fully funded for this year (2011) in the budget, concerns were noted that the cost of the program continues to go up and is putting strain on the total defense budget. Senator Graham was interested to know if the department was doing everything it could to control costs and asked if they were employing all the strategies they could. He explicitly stated that before any notion of a premium increase would be entertained he wanted to ensure the department was aggressively pursuing system efficiency measures.

The department’s testimony noted that it is under mounting financial pressure. The DHP has more than doubled since 2001 – from $19 billion to $50.7 billion in 2010. The majority of DoD health spending supports healthcare benefits for military retirees and their dependents. The department projects that up to 65% of DoD healthcare spending will be going toward retirees in FY 2011, this is up 45% from FY 2001. As civilian employers’ health costs are shifted to their military retiree employees, TRICARE is seen as a better, less costly option and they are likely to drop their employer’s insurance. These costs are expected to grow from 6 % of the Department’s total budget in FY 2001 to more than 10% by 2015. Since 2008 the number of enrollee’s has increased by 370,000.

The Department discussed the many initiatives and ways that they are addressing costs. Some of these include identifying and understanding variations in clinical practices across geographic areas and the many efforts they are undertaking in the area of patient safety and quality. In addition, when the electronic health record becomes fully utilized, this will provide a great deal of efficiency and medical management. In addition initiatives to encourage patient utilization of appropriate venues of care with a focus of decreasing inappropriate emergency room usage.

Also of the many issues touched on, lastley Senator Webb questioned the current disability evaluation (DES) pilot program which is underway. Noting that there remain system challenges he suggests a concept of a joint VA/DoD disability board. Something needs to happen to improve these two systems which at times are antiquated and adversial!
Well said.

Some say today is a “monumental day” – the day the President signed the National Health Care Reform bill into law.

It certainly looks like it when you read all the things the President and the Congress says the law will do, or in some cases, what it doesn’t do.

The way I see it, there are still a lot of unknowns and what ifs.

It’s one thing to see a law pass; it’s quite another thing to implement that law. There will likely be many more bumps along the way before the law is completely rolled out.

          You can be sure of one thing though, MOAA’s staff and passionate members like yourself will be watching the horizon like a hawk, monitoring all the moving parts associated with the health care reform law—doing our part to protect health care benefits for all military, retirees, their survivors and family members.

            Now, if we can only get Congress to permanently fix the 21 percent Medicare/TRICARE payment cuts—NOW THAT WOULD REALLY BE MONUMENTAL!

                                    So, what do you say?

I read a story yesterday that was inspiring and full of hope. Something we don’t hear enough of these days, in my opinion when talking about wounds of war.

The story is of a young Navy Corpsman injured in November 2004, during Operation Phantom Fury, the well known insurgency operations in Fallujah, Iraq. While responding to Marine casualties during a fire fight, his humvee was hit by a homicide car bomber.

Derek McGinnis lost his left leg.

His right foot was severely fractured.

He had shrapnel throughout his body.

And, if that weren’t enough, he suffered from massive traumatic brain injury (TBI) and nearly lost all sight in his right eye.

What’s so inspiring was how Derek rose above the excruciating pain, hopelessness, mental and physical hardships. His new mission in the aftermath of tragedy was living. He spent the next three years fulfilling another mission, a mission to recover.

I’m sure you will be as inspired as I was when you read his story, “Don’t Quit! A Story of Optimism for Wounded Warriors.”.

Derek also went on to write a book, “Exit Wounds: A Survival Guide to Pain Management for Returning Veterans and Their Families,” to help others cope with their pain. In fact, he’s spending his days in a Veterans Affairs office in Modesto, CA working with returning wounded warriors.

This month is National Brain Injury Awareness Month. I thought this article provides a little insight into the challenges faced by military medicine in caring for warriors with TBI, a signature wound of this war. The article is also a great tribute to the strength, resiliency and sacrifices of warriors, just like Derek who fight every day to keep us safe and free.

I was privileged to testify last week before the Senate and House Veterans Affairs Committees on MOAA’s 2010 priorities for veterans, including women veterans.

The opportunity to highlight women veterans’ issues is particularly meaningful since this is National Women’s History Month.

Women are joining the ranks of the military as never before. As of September 30, 2008, 14 percent of the members of the armed forces were women—1.7 million veterans in the U.S. were women.

Women are also accessing Department of Veterans Affairs (VA) medical and veterans’ benefits at higher rates than their male counterparts. Yet, women veterans are 3-4 times more likely to be homeless—health being a contributing factor.

VA has done some creative workarounds in their medical centers to meet the increased demand of care for women veterans, but more must be done to remove current barriers to care.

As a VA user of over 6 years it’s frustrating to be farmed out to numerous clinics in VA medical facilities or to be sent to civilian providers to get my health care. I end up managing my own care because it appears as though no one is in charge.

MOAA commends VA Secretary Shinseki for his leadership and progress in transforming VA into a veterans-centric agency.

But, there’s more to be done to help women veterans and the VA in general. MOAA looks forward to continuing our efforts to advocate on behalf of women veterans.

I hope you will join us this month and reach out to a female member in the military or veteran and thank them for their service and sacrifice.

If you are a woman in the military or a woman veteran who would like to share with us your experiences in using VA health care or applying for benefits we’d love to hear from you.

MOAA salutes all women who are serving or have served. We thank you for making possible the success of future generations.

There has been quite a bit of discussion, research studies, and of course proposed legislative language with respect to reforming health-care in this country. In this regard, I thought this recent Commission report deserved a closer look as TRICARE reimbursement rates are tied to Medicare’s. As required by the Congress, each March the Medicare Payment Advisory Commission (commonly referred to as MedPAC, and is non-partisan independent agency), reviews and makes recommendations for Medicare payment systems. These are the fee for service systems (FFS) and the Medicare Advantage (MA) program. This report is widely anticipated as its principal purpose is to make recommendations for annual rate increases and updates under Medicare’s various FFS payment systems.

The goal of Medicare payment policy is to get good value for the program’s expenditures, which means maintaining beneficiaries’ access to high-quality services while encouraging efficient use of resources. This is good, in that as a taxpayer, anything less would not serve either those that rely on this system, or those of us who finance this system through our taxes.

The report gives great consideration to the current national environment for context in setting its payment policy. The report makes very clear that the Medicare program and other U.S. health care payers are on an “un-sustainable financial path”. For most of the post-World War II period, health care costs have risen faster than the economy. The Centers for Medicare Services (CMS) reports that health cares total share of the economy rose from 7% in 1970 to an estimated 17% in 2009. This high rate of growth is projected to continue, absent meaningful financing and delivery reforms. Hence, the drive for some degree and level of health care reform. This is at least a start.

A number of factors are responsible for the sustained high rates of growth in health care costs for public and private programs. The Congressional Budget Office (CBO) cites advances in medical technology, national wealth, and the consumption-increasing effects of insurance as major contributors to historic and projected growth. Other factors include changes in demographics and disease burden, rising personal incomes, and increases in prices charged by providers.

Rising spending places an increased burden on those who fund it. For example, higher premiums for health care benefits have resulted in increased costs for employees (which are starting to surpass any increase in their wages), and for Medicare beneficaries a growing share of their income must be used to pay Medicare premiums and cost sharing, and higher taxes.

Most importantly, numerous studies have shown that much of the increase in health care spending is not explained by improvements in health status, clinical outcomes, or quality of life. These findings, combined with the projected increases in health spending, represent the core challenges for policy makers. That is: how to increase quality, improve the efficiency of the delivery system, and find the resources to finance care.

To begin to address these issues, the Commission has recommended a number of changes, such as rewarding providers for improving quality and holding providers accountable for the quality of care beneficiaries recieve and the resources expended to provide it. Many of these recommended changes aim to improve the quality of care and health outcomes by creating incentives for providers to work together to coordinate care, to decrease fragmation in the system and promote true patient centered care models.
Some selected findings:

• Hospital Inpatient and Outpatient Services. In aggregate, most indicators of payment adequacy are positive, but profit margins on Medicare patients remain negative for most of the 3500 hospitals participating in the Medicare payment systems. In other words, most hospitals have to balance their payor mix to achieve an overall positive rate of retern.
• Physician Services. Most indicators of payment adequacy for physician services are positive and stable, suggesting that most beneficiaries can obtain physician care on a timely basis. A 2008 survey found that most physicians (74%) accepted all or most new Medicare patients in their practice and more than 95% had participation agreements which require them to accept Medicare’s fee schedule.

Overall though, the Commission remains concerned about the access issue and the direction in which it might be heading. There are reiterations of recommendations to increase payments for selected primary care services and there are plans for future work on those issues in particurlar.

One issue that will certainly remain in the spotlight is that spending due to health cost growth, if it remains on its present trajectory, will surpass growth in GDP in a matter of a few years. This is a dialogue in which we all will need to participate in.