Health Care Happenings

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.

Recently, I had the opportunity to attend the annual Military Health System (MHS) Conference held here in Washington DC. This occurred only a few days before the “Blizzard of 2010″, and as I have reflected on what I saw and heard there, I wanted to offer some observations from that excellent and informative conference.

As I listened to some of the plenary speakers, which were principally the service Surgeon Generals, senior Health Affairs officials, and guests such as the Chairman of the Joint Chiefs of Staff and other healthcare industry notables, I was struck with the sheer vastness, mission complexitiy, and the actual impact that the MHS is charged with performing. For contextual purposes, it is worthy to note a few statistics of this system which is composed of over 9.5 million beneficiaries.
Consider that in one week the following occurs:

• There are 21,800 hospital admissions and 1.6 million outpatient visits
• There are 25,800 behavorial health outpatient visits
• 2.48 million prescriptions filled
• and 2,380 babies are birthed

Not to mention that simultaneously the deployed medical staff support our wounded servicemembers in theatre resulting in a 54% return to duty within 72 hours and the lowest disease and nonbattle injury rates ever reported. This, along with a battlefield survival rate that now stands at 97% which is the highest in history. I could not imagine any other “health system” responsible for and able to, achieve so much. How does it remain focused to achieve these complex objectives which seem to be at odds with each other?

We learned that in order to get an arm around all of the vast array of needs in the military medical community and to remain on target, TRICARE and the MHS have adopted the concept of the “Quadruple Aim”. This is an adaptation to a frequently discussed phrase in the healthcare community known as the “Triple Aim”. It is an idea that refers to the three integral factors that determine the overall quality of healthcare: population health, positive patient experience, and per capita cost. The MHS has taken this paradigm and added a necessary fourth determinant - readiness. Thus, to remain “on target” it is imperative that the MHS achieve objectives within these four foundational goals.

During the course of the Conference we had ample opportunities to hear how these goals were being achieved. For instance, it is well known that readiness has steadily grown in the total force for four consecutive quarters. There was initially a great deal of concern beginning in 2007, with an increase in mental health diagnoses. The MHS responded with a 20% surge in mental health providers, the establishment of behavioral health locator lines and tele-health initiatives also added capacity.

The MHS is making significant progress in the preventative health realm. The Enrollee Preventive Health Quality Index which tracks population health shows that MHS health outcomes have been on a steady rise since 2007. Notable areas where the military is ahead of target are in colo-rectal and breast cancer screenings, as well as a reduction in smoking.

There were perspectives offered on the many medical advances that have made a difference both on the battlefield and off. Since 2001, there has been remarkable progress in prosthetics, implants, hand and limb transplantation, skin therapies and in many other areas of regenerative medicine. Other advancements have been made in bandages to stop bleeding, drugs to treat or prevent chronic pain, robotic support for tele-surgery, cranial reconstructions, and the detection and treatment of traumatic stress and traumatic brain injuries. The majority of these advances have improved the lives of service men and women and ultimately can be translated to all Americans.

After attending this for a week, I came away gratified that the MHS, with all of its moving parts, people and missions, can continue to evolve and meet the healthcare needs of the active force, their families, and retirees - day in and day out. No easy feat.

TRICARE has just issued its new handbook for TRICARE Standard and Extra beneficiaries.

The 68-page handbook includes information on accessing routine, urgent and emergency care, as well as TRICARE’s prior authorization and referral requirements. Also provided are sections on what’s covered by TRICARE Standard’s health and pharmacy benefits, and how to coordinate TRICARE with other health insurance (OHI). Information on claims, appeals, grievances, reporting fraud and abuse and much more can also be found in this new TRICARE Standard handbook.

TRICARE STandard and Extra are available to family members of active duty service members, retired service members and their families and others including those who purchase TRICARE Reserve Select. With TRICARE Standard, beneficiaries manage their own healthcare and have the freedom to seek care from any TRICARE-authorized provider. TRICARE Extra provides discounted cost-shares for seeking care from network providers.

The “TRICARE Standard Handbook: Your Guide to Using TRICARE Standard and TRICARE Extra” is available in a convenient e-Version at: http://www.tricare.mil/standardhandbook

Did you know TRICARE covers the following nutritional therapy for medically necessary nutrition used as the primary source of nutrition?

• Enteral nutritional therapy,
• Parenteral nutritional therapy,
• Oral nutritional therapy,
• Medically necessary vitamins and minerals added to the nutritional solution,
• Intraperitoneal nutrition (IPN) therapy for individuals suffering from malnutrition as a result of end stage renal disease, and
• Ketogenic diet if it is part of a medically necessary admission for epilepsy.

For further information, go to the TRICARE Policy Manual 6010.54-M Chapter 8, Section 7.1.

TRICARE beneficiaries can now receive the following three vaccines with NO out-of-pocket copay at your local retail network pharmacy:

• H1N1 flu vaccine
• Seasonal flu vaccine
• Pneumococcal vaccine

In order to receive the vaccine you’ll want to call your local TRICARE retail network pharmacy to ensure it :

• participates in the vaccine program,
• has the vaccine in stock, and
• has a certified pharmacist on duty to administer the vaccine before you leave your home.

Click to locate a participating retail network pharmacy or call 877-363-1303.

Having recently retired from active duty one of the biggest adjustments I faced (and pleasantly), was the choices that existed for my healthcare.  Retiring from my active duty career in the military offered a lot of choices that were not available while I was serving in uniform. 

While on active duty we were required to use TRICARE Prime or Prime Remote.  Retiree’s such as myself, who are not eligible for Medicare can and may be eligible to continue on in Prime or choose TRICARE Standard or Extra.  Each of these programs has advantages pertaining to cost, location and convenience.  But the great thing is you get to decide what is best for you!

If space is available, continuing care in a military treatment facility (MTF) with a primary care manager through TRICARE Prime requires re-enrolling and paying an annual fee of $230 for an individual and $460 for a family.  Retirees who choose to enroll in TRICARE Prime at an MTF, in my case NNMC Bethesda, will recieve care based upon the same access-to-care standards as all other Prime beneficiaries.  I choose this because of location convienence and continuity with my provider.

Retirees who move to a location that is not near an MTF, or where Prime is not offered, may find TRICARE Standard or Extra to be the best options.  TRICARE Standard is a flexible, affordable plan that gives beneficiaries and their eligible family members a greater choice of providers, no enrollment fees, waiver of cost shares for most preventive healthcare services and the same low catastrophic cap as TRICARE Prime.

TRICARE Extra offers even lower out of pocket expense if beneficiaries use network providers.   Although there is no enrollment fee for TRICARE Standard and Extra, a deductible of $150 for individuals and $300 for a family must be met before cost-sharing begins.  Under TRICARE Standard and Extra, most beneficiaries retain the same access to pharmacy benefits through a local MTF or the TRICARE Mail Order Pharmacy, as well as the option to use the TRICARE retail pharmacy network.

A couple of other things to keep in mind are that as a retiree you may also be eligible for certain medical and pharmacy benefits from the Department of Veterans Affairs in addition to your TRICARE benefit.  Also, you may want to start serious consideration of your healthcare choices well ahead of your actual transition as it will ensure a smooth transition post-retirement.  Believe me there is a lot to think about as you may find out in your Transition Assistance Program (TAP).