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i 

95–314 2015

[H.A.S.C. No. 114–39] 

THE DEPARTMENT OF DEFENSE VIEWS 

ON THE MILITARY COMPENSATION 

AND RETIREMENT MODERNIZATION 

COMMISSION’S RECOMMENDATIONS 

FOR MILITARY HEALTH CARE REFORM 

HEARING 

BEFORE THE

SUBCOMMITTEE ON MILITARY PERSONNEL 

OF THE

COMMITTEE ON ARMED SERVICES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

HEARING HELD 

JUNE 11, 2015 
(II) 

SUBCOMMITTEE ON MILITARY PERSONNEL 

JOSEPH J. HECK, Nevada, Chairman 

WALTER B. JONES, North Carolina 

JOHN KLINE, Minnesota 

MIKE COFFMAN, Colorado 

THOMAS MACARTHUR, New Jersey, Vice 

Chair 

ELISE M. STEFANIK, New York 

PAUL COOK, California 

STEPHEN KNIGHT, California 

SUSAN A. DAVIS, California 

ROBERT A. BRADY, Pennsylvania 

NIKI TSONGAS, Massachusetts 

JACKIE SPEIER, California 

TIMOTHY J. WALZ, Minnesota 

BETO O’ROURKE, Texas 

JEANETTE JAMES, Professional Staff Member 

CRAIG GREENE, Professional Staff Member 

COLIN BOSSE, Clerk 
(III) 

C O N T E N T S 

Page 

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS 

Davis, Hon. Susan A., a Representative from California, Ranking Member, 

Subcommittee on Military Personnel ................................................................. 2 

Heck, Hon. Joseph J., a Representative from Nevada, Chairman, Subcommittee on Military Personnel ........................................................................ 1 

WITNESSES 

Ediger, Lt Gen Mark A., USAF, Surgeon General, United States Air Force ..... 6 

Faison, RADM C. Forrest, III, MC, USN, Deputy Surgeon General, United 

States Navy .......................................................................................................... 7 

Horoho, LTG Patricia D., USA, Surgeon General, United States Army ............. 5 

Woodson, Dr. Jonathan, Assistant Secretary of Defense for Health Affairs, 

Department of Defense ........................................................................................ 3 

APPENDIX 

PREPARED STATEMENTS: 

Heck, Hon. Joseph J. ........................................................................................ 29 

Woodson, Dr. Jonathan, joint with Surgeons General of the Military 

Departments .................................................................................................. 30 

DOCUMENTS SUBMITTED FOR THE RECORD: 

Statement of the National Association of Chain Drug Stores ...................... 53 

WITNESS RESPONSES TO QUESTIONS ASKED DURING THE HEARING: 

[There were no Questions submitted during the hearing.] 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING: 

Mr. Jones ........................................................................................................... 65 

Mr. Walz ............................................................................................................ 66 

(1) 

THE DEPARTMENT OF DEFENSE VIEWS ON THE 

MILITARY COMPENSATION AND RETIREMENT 

MODERNIZATION COMMISSION’S RECOMMENDATIONS 

FOR MILITARY HEALTH CARE REFORM 

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, 

SUBCOMMITTEE ON MILITARY PERSONNEL, 

Washington, DC, Thursday, June 11, 2015. 

The subcommittee met, pursuant to call, at 3:00 p.m., in room 

2212, Rayburn House Office Building, Hon. Joseph J. Heck (chairman of the subcommittee) presiding. 

OPENING STATEMENT OF HON. JOSEPH J. HECK, A REPRESENTATIVE FROM NEVADA, CHAIRMAN, SUBCOMMITTEE ON 

MILITARY PERSONNEL 

Dr. HECK. Good afternoon. 

I want to welcome everyone to this hearing to discuss the Department’s views on the Military Compensation and Retirement 

Modernization Commission’s recommendations for reforming the 

military healthcare system. 

I apologize for our tardiness. We understand there will be another vote coming up somewhere between 3:30 and 4:00. So we will 

try to get through as much as practically possible. 

We ask the witnesses to bring their statements down to 3 minutes so that we can get to questions. And then, once the vote is 

called, we will determine whether or not we need to come back. It 

is only one vote. So it should take no more than walking time there 

and back if we need to continue. 

As we studied the Commission’s recommendations over the past 

5 months, we considered the views of our current and retired service members through the organizations that represent them. 

We heard mixed reviews about TRICARE and the military health 

system. However, the consistent viewpoint is that TRICARE can 

and should be improved. We take their concerns seriously and will 

consider all views before undertaking any changes to the military 

healthcare system. 

That being said, I do believe that we can all agree that the work 

conducted by the Commission identified weaknesses in the current 

system that give us an opportunity to focus our efforts as we discuss reforming the Military Health System. 

It is our duty, as the Military Personnel Subcommittee, to get to 

the root cause of the issues and help determine the best course of 

action to fix them. Today is the first hearing where we will receive 

specific testimony from the Department of Defense [DOD] on their 
2 

reaction to the Commission’s recommendations to improve health 

benefits for our service members and their families. 

I am interested in hearing from our distinguished panel if they 

agree or disagree with the Commission’s recommendations or if 

they have alternative suggestions for addressing the perceived 

shortfalls identified by the Commission. 

In addition, I am interested in hearing the Surgeons General’s 

views on how the recommendations would specifically affect the future of the military treatment facilities and the direct care system. 

As I said before, guiding consideration for our work is to ensure 

that we can continue to recruit and retain the best and brightest 

in order to maintain the viability of the All-Volunteer Force and 

ensuring that we do not break faith with our service members, retirees, and their family members. 

[The prepared statement of Dr. Heck can be found in the Appendix on page 29.] 

Dr. HECK. I would like to take this opportunity to ask unanimous 

consent to enter a statement from the National Association of 

Chain Drug Stores into the record. 

Without objection, so ordered. 

[The information referred to can be found in the Appendix on 

page 53.] 

Dr. HECK. And before I introduce the panel, let me offer the 

ranking member, the distinguished woman from California, Congresswoman Davis, an opportunity to make her opening remarks. 

STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE 

FROM CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON 

MILITARY PERSONNEL 

Mrs. DAVIS. Thank you very much. Thank you, Mr. Chairman. 

And welcome to all of you, all of our witnesses, particularly those 

who I have known from San Diego. 

And it is great to see you here, Admiral Faison. 

This topic, as we all know, is very important. It is very important 

to the committee. It is very important to the men and women and 

their families who serve our country. So as we move forward toward reforming TRICARE, we have to really hold on to this, I 

think, and really explore it well. 

We have a responsibility to ensure that we provide a cost-effective world-class healthcare system for our military. And while we 

have had several hearings and briefings on the Commission’s recommendations, this is really the first time that we have had to 

hear from the Department of Defense with their thoughts on the 

healthcare piece. 

And, more importantly, this is an opportunity to begin discussing 

the best way to improve TRICARE and military readiness. The Department obviously has to balance medical readiness with the rising cost of health care while at the very same time improving access, improving choice, and quality care for beneficiaries. We know 

that this is no easy task. 

I look forward to hearing from the witnesses on how they propose 

that we move forward. 

Thank you, Mr. Chairman. 

Dr. HECK. Thank you, Mrs. Davis. 
3 

We are joined by a distinguished panel representing the offices 

of the Secretary of Defense in the military departments. We will 

give each witness the opportunity to present his or her testimony 

and each member an opportunity to question the witness. 

Again, we would ask the witnesses to keep their spoken testimony down to 3 minutes. Your entire written testimony will be 

made part of the hearing record. 

Now let me welcome our panel: 

Dr. Jonathan Woodson, Assistant Secretary of Defense for Health 

Affairs and my former senior rater. 

Lieutenant General Patricia D. Horoho, Surgeon General of the 

United States Army. 

And I understand this is probably the last time that you will be 

appearing before our subcommittee. 

General HOROHO. I hope so. 

Dr. HECK. I want to say thank you for your lifetime of service 

and looking out for the men and women in uniform and for your 

passion and leadership on championing the Performance Triad. 

General HOROHO. Thank you very much. 

Dr. HECK. Lieutenant General Mark A. Ediger, Surgeon General 

of the United States Air Force, newly appointed. 

Congratulations and welcome. 

And Rear Admiral C. Forrest Faison III, Deputy Surgeon General of the United States Navy. 

Welcome, sir. 

With that, I turn the floor over to you, Secretary Woodson. 

STATEMENT OF DR. JONATHAN WOODSON, ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, DEPARTMENT 

OF DEFENSE 

Dr. WOODSON. Thank you very much. Chairman Heck, Ranking 

Member Davis, members of the committee, thank you for the opportunity to appear before you today. 

The Military Compensation and Retirement Modernization Commission has performed a valuable service to the Department and 

the Nation. We agree with their overarching findings regarding 

challenges facing military medicine. We concur with many recommendations and have already moved to implementation. 

In fact, some members of this committee may recall that, when 

I testified in this room in February of last year, I talked about the 

need to ensure an agile, relevant, and forward-leaning Military 

Health System [MHS]. I stated that, to meet our mission in these 

changing times, I had outlined for the MHS six strategic lines of 

effort. 

These include modernize the Military Health System management with an enterprise focus, the successful establishment of the 

Defense Health Agency and the development of enhanced multiservice market represent signature initiatives; two, define and deliver the medical capabilities needed in the 21st century; three, invest and expand the strategic partnerships; four, assess and refine 

the balance and needs of our medical force; five, modernize 

TRICARE health program; and, six, define the MHS’s requirements 

in terms of global health engagement. 
4 

These strategic lines of effort will help us deliver on our overarching quadruple aim of readiness, improving the health of the 

population we serve, improving the experience of care in our system, and responsibly managing our costs. Our written testimony 

provides a more comprehensive summary of our positions on the 

Commission’s recommendations. 

For my remarks today, I would like to focus on all of the strategic efforts underway to make the Military Health System stronger, better, and more relevant for the future. 

Here is what we have been working on to address the readiness 

requirements, ensure quality, and serve as effective stewards of the 

resources you have provided us: 

Over the last 2 years, we have undertaken a comprehensive review of our medical infrastructure and resources and presented a 

modernization plan that proposes to place our most skilled professionals in the military communities where they are likely to keep 

those skills sharpest. 

We have reformed governance and established the Defense 

Health Agency and have provided a collaborative and affordable 

way for the Department to leverage economies of scale for those 

functions that are common among the service medical departments. 

And, third, our system is implementing recommendations that 

emerged from the Secretary’s review of the Military Health System 

and culminated in the Secretary’s action plan of 1 October 2014. 

We are making it easier for access to care in our system. We are 

focusing on key measures of quality and safety and participating 

in national quality improvement initiatives, such as the Partnership for Patients. And we are making our performance data more 

transparent for our beneficiaries and the public to see. 

Similar to achieving historical survival rates on the battlefield, 

our leadership team will be relentless in our efforts to be a national 

leader in quality and safety in all that we do. 

And, finally, we are reforming our health benefit. TRICARE is an 

exceptional health benefit tailored to meet the unique needs of 

military families. Elements of TRICARE can be improved and must 

be improved, and that work is underway. 

We have released an RFP [request for proposal] to recompete the 

national TRICARE contracts, and we have included provisions that 

reward innovation and simplify administration of the contracts. 

In summary, the Military Health System is a unique and indispensable instrument of national security. Our mission is supported 

by some of the most respected medical professionals in the world 

and attracts an extraordinary pool of young medical professionals 

who understand how compelling and vital this system is to others. 

We are fortunate to be entrusted with serving as stewards of this 

system, and we take this seriously. So I am grateful for this opportunity to be here today and to answer your questions. 

[The joint prepared statement of Dr. Woodson and the Surgeons 

General can be found in the Appendix on page 30.] 

Dr. HECK. Thank you. 

General Horoho. 
5 

STATEMENT OF LTG PATRICIA D. HOROHO, USA, SURGEON 

GENERAL, UNITED STATES ARMY 

General HOROHO. Chairman Heck, Ranking Member Davis, and 

distinguished members of this subcommittee, thank you for this opportunity to provide the Army and Army Medicine’s perspective on 

the healthcare forum recommendations. 

After 13 years of war, the Army remains globally engaged. Any 

changes to the compensation and benefits must not only honor 

their sacrifices, but preserve the long-term viability of an All-Volunteer Force. The Army supports the underlying objectives of the 

Commission’s health-related recommendations. However, we do 

have concerns regarding certain elements that threaten readiness 

and our medical skills. 

It is critical to understand that our direct healthcare system connects with the battlefield and exists to provide health readiness to 

our soldiers and their families. This is what separates us from the 

civilian healthcare system. Our hospitals are our readiness training 

platforms which produce a ready medical force and a medically 

ready force. It is a system that performed so well over the last 13 

years of war. 

We concur that a comprehensive list of essential medical capabilities, or EMCs, should drive our training and resourcing. However, those EMCs must address the whole spectrum of health rather than focusing solely on combat trauma and surgical capabilities. 

For instance, less than one out of every five service members 

evacuated from Iraq and Afghanistan were injured in battle. During Operation United Assistance, the major threats to our soldiers 

were endemic infectious diseases. The Army already utilizes joint 

structures and mechanisms to identify, monitor, and report on 

medical readiness. We are working to integrate EMCs into these 

processes; therefore, the Army does not support establishing a fourstar readiness command. 

The Army supports the Commission’s objectives of affordable 

health care and increased choice for our beneficiaries. However, the 

Commission’s recommendation to establish TRICARE Choice would 

negatively impact our readiness of our entire healthcare team and 

present financial challenges to both Active Duty families and retirees. 

Currently, non-Active-Duty beneficiaries comprise 67 percent of 

our total beneficiary population, 83 percent of our inpatient care, 

and 79 percent of our high-acuity inpatient workload. These patients are vital to the sustainment of our 148 graduate medical and 

health professional education programs. The loss of these beneficiaries from our direct system would pose tremendous risk to our 

training programs and negatively impact our medical force’s readiness posture. 

The Army sees financial risk to soldiers and to families and injured in the Commission’s recommendation to offset TRICARE 

Choice costs through a basic allowance for health care. Year-to-year 

healthcare expenses are unpredictable, and many areas of our 

country are medically underserved. 

In conclusion, the Army needs a medically ready force. When the 

gate on the Stryker opens, commanders need to know that it will 

be full of soldiers that are ready to deploy. And the Army needs 
6 

a ready medical force. When the wounded soldiers hear the rotor 

blades of a medevac [medical evacuation] helicopter, they need to 

continue to have confidence that our providers are trained and 

ready. Any radical departure presents significant risk to a system 

that has produced record levels of both combat casualty survival 

and readiness. 

I would like to thank the Congress for your continued support. 

Army Medicine team is proudly serving to heal and honored to 

serve. 

Dr. HECK. Thank you. 

General Ediger. 

STATEMENT OF LT GEN MARK A. EDIGER, USAF, SURGEON 

GENERAL, UNITED STATES AIR FORCE 

General EDIGER. Chairman Heck, Ranking Member Davis, and 

distinguished members of the subcommittee, thank you for inviting 

us to appear before you today. 

The Air Force is truly grateful for the hard work of the Military 

Compensation and Retirement Modernization Commission. Many 

parts of the Commission’s recommendations will enhance and facilitate programs that serve our airmen, their families, and our veterans. 

Today I will speak to impacts in two areas of primary importance 

for the Air Force based upon our analysis of the Commission’s recommendations. I will begin with the impacts on the readiness of 

our medical force. 

We appreciate the Commission’s focus on the linkage between 

care provided in our hospitals and the readiness of our medical 

force. We found their proposal to identify and quantify readinessrelated essential medical capabilities helpful to focus efforts on the 

capture of specialty care for our hospitals. That concept builds upon 

the Readiness Skills Verification Program we have utilized in the 

Air Force for over 15 years to set clinical standards for the readiness of our medical force. 

However, we do not see the need for a joint readiness command, 

as existing processes jointly utilized by the services enable us to 

measure and assess the readiness of our force. 

We have significant concern about the impact the Commission’s 

health plan recommendations would have on the readiness of our 

force. We believe the proposal would shift family member and retiree care significantly to the private sector and thereby move care 

essential to our readiness out of our medical facilities. 

We also believe the proposal to place our medical facilities into 

competition with the private sector would drive up administrative 

costs and significantly detract from the focus on the operational 

mission in our medical facilities. 

The second area of primary concern centers on our support to Active Duty families. We believe resilient families with excellent 

health service support greatly enhance the resilience of all of our 

airmen. We support changes in the President’s budget to improve 

TRICARE while enhancing our readiness. 

Additionally, significant progress in the strategic line of efforts 

referenced by Dr. Woodson has occurred, and we are a progressive 

system of health and readiness as a result. 
7 

We are concerned that the Commission’s proposed change to the 

health plan would increase stress on airmen and families by requiring them to navigate a complex insurance marketplace on a recurring basis. We are concerned that the Commission’s proposal 

would shift family care significantly into the private sector, thereby 

creating a hole in the safety net commanders depend upon for Active Duty families under stress. 

Proper balance in the mix of our medical force is important to 

maintaining a ready medical force while providing safe and highquality health services. The National Defense Authorization Act of 

2010 permanently prohibited the services from converting non-military essential Active Duty medical positions to civilian positions. 

Relief from this prohibition would enable the Air Force to judiciously increase the proportion of civilians in its force mix. 

I thank the committee for your continued support for Air Force 

medicine and the opportunity to answer your questions today. 

Dr. HECK. Thank you. 

Admiral Faison. 

STATEMENT OF RADM C. FORREST FAISON III, MC, USN, 

DEPUTY SURGEON GENERAL, UNITED STATES NAVY 

Admiral FAISON. Chairman Heck, Ranking Member Davis, distinguished members of the subcommittee, thank you for the opportunity to appear before you today. 

The Navy appreciates your leadership in establishing the Commission and commends the Commission for their thorough and 

independent assessments. We remain guided by our Navy Medicine’s strategic priorities of readiness, value, and jointness. 

We note that the Commission recognized the importance of these 

imperatives and many of their overarching objectives are largely 

aligned with our strategic priorities. 

Following the release of the Commission’s final report in January, Navy Medicine participated in the DOD-led rapid and comprehensive review of the healthcare recommendations. While there 

is general support for the underlying objectives of the recommendations, I will briefly highlight some of our perspectives and concerns 

regarding them. 

In relation to medical readiness, we do support establishing common and service-specific essential medical capabilities, or EMCs, as 

they could be an effective means to monitor readiness and guide 

resourcing decisions. 

We note, however, that EMCs must be developed for more than 

just surgical trauma skills. Military medicine supports a wide 

range of operations, including treating disease and non-battle injuries during military operations as well as providing humanitarian 

assistance and disaster relief when called upon in crisis. 

While there is general agreement to the Commission’s objective 

to provide an affordable health benefit with additional choice, we 

must recognize that our medical centers, hospitals, and clinics are 

our most important readiness training platforms for our military 

medical personnel and critical to sustaining vital skills and clinical 

competencies of them. The availability of case mix, volume, complexity, and diversity is vital to having a trained and ready medical 

force. 
8 

In this regard, care of our beneficiaries is inextricably linked to 

our readiness mission. Patient enrollment is fundamental to our 

approach to maintaining the health of our patients. The Military 

Health System is working hard to recapture workload into our direct care system and leveraging initiatives like our Patient Centered Medical Home program to improve access and care. 

Navy Medicine is leading forward in these areas as they continue 

to show progress. We believe that the Commission’s approach to 

offer greater choice through the use of commercial insurance plans 

presents risk by reducing patient volume and case mix in our system and positioning MTFs [military treatment facilities] at a significant disadvantage in attracting patients when competing 

against commercial insurance plans. 

The careful assessment of the recommendations for exceptional 

family members requires additional time. We agree with the objective of expanding services to help family members with specific 

needs, but more work is needed to identify which specific services 

among the many State Medicare waiver programs most meet their 

needs. 

Regarding the DOD and VA [Department of Veterans Affairs] 

recommendations, we support the goals of the Commission, but we 

believe that the current joint executive committee has sufficient authorities to realize the outcomes desired by the Commission. 

Throughout Navy Medicine, we work closely with the VA in assessing opportunities to collaborate and cost effectively share services to meet the needs of service members and our veterans, and 

we have several unique collaborations, sharing agreements, and 

partnerships already in existence that benefit both Department 

beneficiaries. 

We are working with the Assistant Secretary of Defense for 

Health Affairs, the Defense Health Agency, as well as our sister 

services to incorporate many of these opportunities in the MHS. 

Some changes can be accomplished within existing policy, while 

others may require legislative changes for which we would appreciate the Commission’s and the committee’s support. 

In summary, we recognize we need to recognize what sets us 

apart from civilian medicine, that we are a truly rapidly deployable, fully integrated medical system. This capability allows us to 

support combat casualty care with unprecedented battlefield survival rates, to meet global health threats as we recently did in deploying labs and personnel to Liberia in response to the global 

Ebola crisis, and to our hospital ships, Comfort and Mercy, deployed today and underway supporting missions around the world. 

We must also understand that our readiness mission is directly 

linked to the training and skill sustainment our personnel do every 

day in our hospitals, in our clinics, in our labs, and in our classrooms. We cannot expose our direct care system to risk that could 

negatively impact our readiness posture. Thank you very much. 

Dr. HECK. Thank you all for your testimony. 

We will now begin a 5-minute round of questioning from each 

member. I will defer my questions to the end and recognize the 

junior member of the subcommittee, the gentlelady from New York, 

Ms. Stefanik, for 5 minutes. 

Ms. STEFANIK. Thank you, Mr. Chair. 
9 

And thank you to all of our witnesses here today. 

I wanted to focus and address my question to General Horoho. 

I represent New York’s 21st District, which is home to Fort Drum, 

and part of the 10th Mountain Division is based at Fort Drum. 

Later this summer I plan on hosting a listening session with various service members and their families to hear their feedback on 

the Commission’s reports and healthcare plans going forward. 

And Fort Drum is unique, as you know. There is no hospital on 

post and we have a very strong partnership with civilian hospitals 

like Samaritan and River Hospital. I think you visited Fort Drum 

recently to assess—— 

General HOROHO. Yes, ma’am. 

Ms. STEFANIK [continuing]. That partnership. 

Could you talk about whether there will be an impact for Active 

Duty service members because of that unique relationship, because 

there is no on-post hospital. 

General HOROHO. Thank you, ma’am. 

If I understand the question correctly, are you asking whether or 

not there would be an impact if we move towards the Commission’s 

recommendation on Fort Drum? 

Ms. STEFANIK. Correct. 

General HOROHO. Okay. I do believe there will. And the reason 

why I say that is that right now many of the readiness skill sets 

even though we have a unique capability there with the clinic and 

then we have a strong partnership with the civilian facilities, we 

still rely on a large family member and retiree population getting 

their care at Fort Drum proper. 

That allows us to enhance our readiness skills of our medics as 

well as our clinicians, our orthopaedic surgeons, and the entire 

healthcare team. If that population goes out to one of the 11 different plans that are out there, then we become competition with 

the healthcare plans and it is an unpredictable population that we 

would be able to treat. 

Ms. STEFANIK. Great. Thank you very much. 

And then I just wanted to ask broadly: Can each of you talk 

about the kind of listening sessions that DOD has done to understand the concerns directly from the service members. I know this 

is a large question. Just broadly, if you can answer that. 

Dr. WOODSON. Sure. Let me start, and I will let the Surgeons 

General follow on. 

Just, you know, briefly, coming out of the MHS review, we conducted town halls. Of course, we routinely, in fact, use survey techniques to find out what is going on. 

And for the sake of brevity, I would just say that the Evaluation 

of the TRICARE Program: Access, Cost, and Quality, the 2015 report to Congress, contains a lot of good information about what we 

do to survey our population to adjust the program and understand 

where we are at and where the improvements are needed. And I 

would just recommend that to you. 

General EDIGER. Yes. In addition to what Dr. Woodson referenced from the MHS review, which was very valuable and helpful, 

each of our medical group commanders has a panel in which they 

conduct regular listening sessions of people who consume their 

health services in the local community. 
10 

We have a process by which the findings and the trends from 

those sessions are fed up and centrally analyzed for trends, and we 

found that to be a very helpful process. 

In addition, each of our medical groups uses social media to solicit input and feedback from the people that consume their health 

services, and we also use social media centrally for that purpose. 

Ms. STEFANIK. Great. Thank you very much. 

Did you want to add? 

Admiral FAISON. Yes, ma’am. 

Same in the Navy. We conduct regular town hall meetings. We 

have an expectation that all of our COs [commanding officers] will 

regularly attend the healthcare consumer councils at each of our 

bases. And whenever we travel, we make a point of meeting with 

every line commander to solicit their input. We also are very active 

on social media to get feedback in. 

General HOROHO. If we are going to go all the way, I will do the 

same thing, then, because we are very similar in our approaches. 

The other is are virtual town halls that actually are conducted 

from the Chief of Staff of the Army on down to get the feedback 

from our beneficiaries and being able to hear their voices and the 

concerns. 

We have also had high-reliability summits to be able to educate 

our Active Duty professionals in the healthcare business. And then 

we take that back to the commands and then they share information with the beneficiaries as well. 

Ms. STEFANIK. Great. Thank you very much. 

I yield back. 

Dr. HECK. Thank you. 

Mrs. Davis. 

Mrs. DAVIS. Thank you, Mr. Chairman. 

And I appreciate, again, all of you being here. 

I am not sure if my questions are related. Probably are. 

But, first, you did talk a little bit about the loss to the beneficiary because, if—in the Commission’s recommendations, we had 

a different system, and training of medical personnel was critical 

to that. 

So I wanted to ask about that, but also about the fact that the 

Commission determined that EMCs, the essential medical capabilities, are not clearly defined and they suggested that the DOD had 

not established the clinical proficiency standards for military medical personnel in facilities based on widely accepted metrics. 

So, you know, you may not agree with that assessment, but I 

wanted to know how you see that assessment and what you would 

propose. And if you can attach it to training, that would be great, 

but maybe that is a totally different question. So—— 

Dr. WOODSON. Yeah. Maybe I can start and, again, the Surgeons 

General can add on. 

From a context point of view, one of the things we have to understand is that medicine really has evolved. So four decades ago a doc 

[doctor] may have been a doc and a nurse may have been a nurse 

and today, with sub-specialization, the idea of what the competency 

is and how to maintain that competency is radically different. 

And so the issue, really, that we got to, again, as part of the 

modernization study and some of the self-analysis we were doing 
11 

is identifying what the specifics of the skill set should be by specialty and military occupational skill set. And this is a really big 

work, but important work to do so. 

We self-identified, prior to the Commission, that we needed to 

focus on this issue of better defining readiness, competency, and 

being able to measure that. I think the Surgeons General have 

done a great job, and the Air Force, I think, has a great matrix 

that they use. And the other services have their metrics as well. 

General HOROHO. Thank you, ma’am. 

We have looked at this over the last 3 years—this has been a culture shift across Army Medicine—and really looked at our hospitals 

as being our readiness training platforms because that is where we 

house our graduate medical education programs and our health 

professional education programs. 

So we rely on a constant beneficiary population that gives us the 

complexity and the case mix. We evaluated where we had our Active Duty, that there was a mismatch a couple of years ago where 

our green-suiters were. They were in more of the smaller areas, 

and then we had contract personnel and civilians more in the medical centers. 

Those medical centers are where we need that complex capability 

and readiness skill set training. So we have started migrating and 

shifting where our Active Duty population is. 

We have also looked at it from not just combat casualty care, but 

actually the readiness skill sets that are needed for every single 

one of our service members that are part of the medical team. And 

so I will give a good example. We looked at substitutability. 

So we may have rheumatologists that we need for our day-to-day 

healthcare beneficiaries, but for deployability, we are identifying 

what are the wartime skill sets that are needed for that specialty 

so that they can be substituted for a surgeon on the battlefield. 

And so we are now down to that level of detail of really looking at 

it. 

And, in addition to that, we now have standards in place where 

I can assess the readiness of my military treatment facilities, I can 

assess the individuals. And now we have just rolled out, with all 

three services using it together, a surgical tool that allows us to 

look at every one of our operating rooms, the number of cases that 

are needed, the complexity, and then being able to look at that in 

addition to assessing our surgeons. 

Mrs. DAVIS. Thank you. 

I think I will go ahead and have the Surgeons respond. 

And I think part of my question around this, too, and the whole 

issue I know Admiral Faison will and I talked about this a lot in 

San Diego because, you know, there is this concern—and it is partly why the Commission addressed this—in the mix in terms of the 

patient population and the ability of medical professionals to have 

access to be able to help those and treat those who are coming from 

a more diverse and a larger population. 

And so I guess I am just trying to get at that as well in terms 

of whether the mix that you have is adequate to do that, since we 

also are looking at the general public to help with that. We know 

that military medicine is not going to be able to support that always and—— 
12 

General EDIGER. Yes. An important point is that, when we talk 

about essential medical capabilities and clinical currency, we are 

talking about that within the context of readiness, the clinical 

skills that are needed in a deployed environment, which don’t always exactly match up with our day-to-day practices at home station. 

And so, in the Air Force, we have had a process that, by specialty, we actually define case volume and mix and skills that actually translate into the deployed environment, and then we keep 

records and we track the extent to which we are able to meet those 

requirements and keep clinicians ready. 

In some cases—you are right—our population doesn’t really have 

the demand in certain procedures that would support our readiness 

requirements. And so, in the Air Force, we have used strategic 

partnerships in some cases—and the other services have as well— 

to send selected clinicians to other places under training agreements to make sure they are current in those types of skills. 

I think what we have all decided to do together is to actually incorporate these standards for clinical readiness into the measurement of the preparation and readiness of our forces and present 

that jointly the same way our combatant partners in the line 

present the readiness of their forces. 

Mrs. DAVIS. Thank you. 

I know my time is up. Thank you, Mr. Chairman, for those additional minutes. Thank you. We will get it later. 

Mr. JONES. Mr. Chairman, thank you very much. 

And, Dr. Woodson, I read your letter on May 19th, and I would 

like to make reference to that. 

First, I would like to share with you and the panel an email from 

a marine’s wife down at Camp Lejeune, which is in my district, and 

I will start with this from her email. ‘‘2 weeks ago, on April 13 of 

2015, he attempted suicide. He has severe PTSD [post traumatic 

stress disorder], a TBI [traumatic brain injury] because of an IED 

[improvised explosive device] explosion, and has severe physical ailments associated with the blast. He was placed on a ventilator for 

about 12 hours as a precautionary while the pills he had overdosed 

on worked their way through his body while he was sedated and 

unresponsive.’’ 

The reason I wanted to bring that forward is because many of 

us, not all, but in Congress, including Senator Vitter, have been 

very supportive of an option that we would hope that the Department of Defense would give to the medical doctors in all services, 

should the doctor decide that maybe hyperbaric oxygen treatment 

[HBOT] might be a way to treat PTSD and TBI. 

I asked in the letter I wrote you that you respond and not Admiral Wagner. We had written Admiral Wagner and asked that the 

hyperbaric oxygen treatment—that Admiral Mullins himself go to 

Camp Lejeune, remain there and be put in the Intrepid Spirit Concussion Recovery Center at Camp Lejeune. Obviously, his response 

back was not very encouraging. So let me go to this paragraph. 

‘‘How much money was expended by DOD on medication in 2014 

to treat PTSD and TBI for Active Duty military? As we note, certain medications have been implicated in the suicidal epidemic in 

our veterans. Are you aware that Dr. Harch published a statistical 
13 

significant reduction in suicidal ideation in the HBOT-treated veterans and this was accomplished in veterans with the combined diagnosis of TBI and PTSD? Do you have any DOD studies showing 

the same with any other therapy?’’ 

I don’t expect you to answer that today, but I am looking forward 

to your answer. 

What is so ironic to marines down at Camp Lejeune is that, in 

this Intrepid Center, they can be treated with yoga and acupuncture, but they can’t be treated with hyperbaric oxygen. 

To many of us in both parties, House and Senate, we just don’t 

understand why and how that the Department of Defense in their 

studies say that they do not see where hyperbaric oxygen treatment would be a positive. 

And, yet, Dr. Harch, who is a foremost expert at LSU [Louisiana 

State University] on this treatment, has even offered—and I have 

written to Secretary Mabus—that he will take 12 marines from 

Camp Lejeune at no charge to DOD and LSU will absorb it to treat 

them for 8 weeks. And I hope that you will take the time to read 

carefully what we are asking you. 

As you know, Senators Vitter and Landrieu asked on Inspector 

Jones’ investigation as to how the Department of Defense—the different studies have studied hyperbaric oxygen and why they do not 

think this would be helpful to those with PTSD and TBI. 

So I hope that you will answer this letter. Again, it was May the 

19th. And I want to give you, as I would anybody, 6 to 7 weeks 

to respond back. 

But when you read—I have never heard of any, any, soldier or 

marine or anyone that had the treatment of hyperbaric oxygen that 

committed suicide. Yet, when they are medicated, we are averaging 

maybe 20 or 21 a day committing suicide. 

I don’t understand, sir, why this treatment will do no damage— 

if it doesn’t do any good, it doesn’t do any damage. I guarantee you 

it will do more good than yoga or acupuncture. 

Will you promise me today and this committee that you will respond back to this letter that we have written here? 

Dr. WOODSON. Absolutely. 

Mr. JONES. Thank you, Mr. Chairman. 

Dr. HECK. Mr. MacArthur. 

Mr. MACARTHUR. I pass. 

Dr. HECK. Okay. So we had a briefing from the current 

TRICARE administrative service organizations [ASOs] on how they 

viewed the Commission’s recommendations. Obviously, they all 

have a non-military health insurance option that they also provide, 

and they stated that they felt that there would be opportunity for 

them to address some of the shortfalls or deficiencies identified by 

the Commission if they were just allowed to utilize some of the best 

practices that they have on their non-military side on the military 

side. This is moving away from fee-for-service to value-based care. 

So, Dr. Woodson, I know we have had this discussion a little bit 

offline. You know, as the TRICARE 2017 contracts, RFP, is out, 

what would be the pathway to be able to, one, provide the authorities necessary to allow some of what is being done on the civilian 

side to come into the military side as far as managing health care? 
14 

And how would that happen if the TRICARE 2017 contracts are 

let prior to those changes being made? Would it be a mod? Is there 

a benefit to just extending current contracts till we figure this out? 

What do you believe is the best way forward? 

Dr. WOODSON. So thank you very much for that question. And 

we fully endorse moving toward utilizing value-based care in the 

management of both the TRICARE contracts and our patients to 

their betterment. 

As we move to 2017, again, we have approached it in a more disciplined way. And, in fact, we are looking for the authority to use 

value-based care. 

Now, as it relates to the flexibility, remember, there is a common 

misperception about the contracts that they are kind of 5-year 

locked-in entities. They are not. In fact, they are 1 year with yearly 

options. And we modify contracts all the time. 

Continuing the extension of current contracts is costly and, in 

fact, it just maintains sort of antiquated systems. And so, as we 

move more to trying to use utilization management tools, big data 

to better define and manage our populations, it is very important 

that we modernize the contracts. But we can incorporate all those 

things and fully anticipate incorporating all of those issues into the 

2017. 

And, lastly, we have already moved out in terms of value-based 

care. We have a demonstration project right now in Maryland in 

which we have a pay-for-performance model. 

And, lastly, we are working very closely with Medicare on their 

work group, but to define particularly those outcome parameters 

that are important in making sure you have success with valuebased care. 

Dr. HECK. Great. That is very encouraging. 

I look forward to continuing to work with you to make sure that 

DOD has all the authority it needs to be able to capitalize on some 

of these proven strategies that are currently forbidden or prohibited from being utilized in the military healthcare system. 

One of the other areas that was brought up is, of course, the importance of patient data and data analytics. And, you know, it 

seemed like there was a disconnect in being able to have all the 

data to adequately manage a patient’s care when the prescription 

part of TRICARE is not part of any one of the ASO’s service lines. 

And it was brought forward that perhaps and, as I understand 

it, prior to my arrival here, it was Congress that said, ‘‘Go ahead 

and go out and get us a separate PBM [pharmacy benefit manager].’’ 

But the idea of bringing prescription service back within the ASO 

contracts, thoughts on that? 

Dr. WOODSON. Well, I think it is very important, I guess, to address the central point of making sure there is single point of accountability for the coordination of all of the benefits and care, and 

that is one of the issues that concerns me about the Commission 

recommendation. 

So if you look at what would have to happen, we would have to 

disestablish the DHP [Defense Health Program], disestablish TRICARE. We would have to have OPM [Office of Personnel Management] establish this choice network with navigators because it 
15 

would be very important. They would have 250 programs which the 

service members and beneficiaries would have to negotiate. 

We would have to expand the MERHCF [Medicare-Eligible Retiree Health Care Fund] fund to cover the healthcare and pharmacy programs for non-Medicare-eligible retirees. Funds from the 

services’ MILPERS [Military Personnel] would have to be transferred to the employees’ health benefit fund managed by OPM for 

Active Duty family members, Reserve Component and family members. 

For gray-area retirees that is non-Medicare, funds should also be 

transferred from MERHCF to the employee health benefits fund 

managed by OPM. We would have to establish a new trust fund 

which would be managed by DOD to finance existing pharmacy 

and dental programs for Active Duty family members and Reserve 

Components. 

MTFs would be funded through a revolving fund and using reimbursements that they receive for care. And the services’ O&M [Operations and Maintenance] accounts would be at risk for shortfalls, 

and we estimate that would be about $2.4 billion a year. And we 

would have to establish a catastrophic fund for Active Duty family 

members. 

Now, the key here, though—and then DOD would still be responsible for pharmacy, dental, vision, the basic allowance for healthcare, the networks for Active Duty service members, the networks 

for overseas Active Duty service members, which there is no mention of how we would handle that in the Commission report, ECHO 

[Extended Care Health Option]. 

And so the important issue here is that, if you take it from the 

point of view of the beneficiary—and let’s just say, for example, we 

take an Active Duty family with an exceptional family member, a 

child with autism, let’s say. 

They are going to have to deal with these private insurers for the 

health care and then they are going to have to deal with us for 

other things. And if they have cost overruns, then they are going 

to have to try and get into this catastrophic fund. 

That is a lot of touchpoints. And then, if you add to that the 

highly mobile population we have, I think that there is substantial 

risk when you don’t have a single point of accountability for the entire health benefit, substantial education for retirees, substantial 

education for beneficiaries. 

So I think there are some risks, and I think there are easier approaches to reforming TRICARE to make it exceptional. And I 

think that is where we would love to work with Congress. 

Dr. HECK. Great. 

We will go for a continued round until we get called for votes. 

Mrs. Davis. 

Mrs. DAVIS. Thank you, Mr. Chairman. 

And perhaps, Dr. Woodson, I can pick up on that. And I hope the 

others will join in, too. 

One of the things that we heard with the Commission was I 

think they were a little displeased, actually, when they heard that 

there was a kind of protectionism coming through, that surely our 

military families might not be able to navigate on multiple systems 
16 

like this. And I think you all said as well that, you know, it is 

harder to navigate a more complex system. 

So I wonder if you could respond to that a little bit because I understand exactly what you are saying, how important it would be 

to have a point of accountability. But at the same time there was 

a sense that somehow we couldn’t provide the support system to 

enable families to be able to utilize that to the best of—you know, 

to serve their needs. 

And if you can expand on having more options for families, more 

choices, as they talked about, that seems to be a good thing, and 

maybe we shouldn’t get caught up in whether or not they can navigate it. 

So help me out with this a little bit because I don’t think that 

is really the reason to not do this, of course, but—— 

Dr. WOODSON. I am sure the Surgeons General will have—that 

is a great question, and the Surgeons General will certainly want 

to say something about this. 

But let me just say this, that when I go out and talk to folks and 

when I look at surveys, choice is not about wanting to navigate 

through 250 health plans. 

Choice, as expressed to me, is ensuring that I have a robust 

health benefit that will take care of my health needs when I want 

it, and then the real choice is about being able to see the provider 

that I want when and where I want them. 

And so if you look at PB [President’s budget] 2016 and 2015 proposal, it was about giving more choice to the family member so that 

they wouldn’t have the hassle of authorizations and referrals and 

they could choose when and where they wanted to see, you know, 

the doc or the provider. That is, I think, the choice that they want, 

not necessarily a lot of programs. 

By the way, when you boil it down and you go into the commercial market, you really find three types of programs. Right? You 

find health maintenance organizations, which is similar to our 

Prime. You find fee-for-service programs of two types. One is preferred provider and one is, again, more open fee-for-service. We 

have those, basically. 

So they are not going to have really different choices in terms of 

types of plans. They are just going to have to navigate through 

more insurance programs and not have a single point of accountability. 

Admiral FAISON. Ma’am. 

General HOROHO. Yeah. Go ahead. And we will go backward. 

Admiral FAISON. I will address the most difficult case for the 

Navy. Thirty-five percent of the Navy is deployed in any given day, 

and 75 percent of our sailors were born after 1986. They are very 

young. 

And so the typical sailor is married with two children. So they 

are stationed, let’s say, in San Diego. The ship is out at sea. Right 

now, if that family member has a problem with their health care, 

they call the CO [commanding officer] of the hospital. It is one 

point of contact. 

So I want to distinguish between navigate versus advocate. And 

so, if there is an issue, they call one person. If we allow them the 

choice, they are navigating several hundred health plans, as a CO 
17 

of a hospital, having just been one, I have no leverage over those 

plans. So how do I advocate for that mom and her children? 

And if one of those children is a special needs, she is dealing 

with the health plan for part of her healthcare needs, she is dealing with DOD for the special needs part, she is dealing with DOD 

somewhere else for pharmacy. It is overwhelming while you are 

trying to balance two kids as a single parent and your grandparents are back in Texas, as an example. 

So we are worried that we are adding to the plate of our service 

members to get a benefit where right now they have got kind of 

a single point of contact to pick up the phone and help them. 

Mrs. DAVIS. And, of course, we know a lot of those are ombudsman as well—— 

Admiral FAISON. Yes, ma’am. Absolutely. 

Mrs. DAVIS [continuing]. That single point of contact. And it is 

wonderful in San Diego. 

Sir. 

General EDIGER. I would agree with that completely. It is not 

that we think the families are incapable of navigating. We just see 

the complexity of it as another source of stress for families that we 

know are already under stress by virtue of the service and the 

OPSTEMPO [operations tempo] that they are a part of. 

I think the other thing that would be challenging in that venue 

is that, if we have families who have a variety of different health 

plans that they have chosen on the marketplace, those plans come 

at different prices. They will have different ranges of benefits. 

And so we have a remarkable system between all three services 

of employing the medical home concept in the way we provide primary care. And so with that comes timely prevention in a coordinated team-based approach to care. 

That becomes more difficult to apply if you are dealing with a patient population that has got a variety of different types of health 

coverage. 

And so we think we can do a better job of providing continuous 

support to their health and performance over the time of their service to the Nation if they are getting their care continuously in our 

MTFs. 

General HOROHO. And, ma’am, in addition to that—because we 

are pretty similar in all of our responses—I think the importance 

of the care coordination can’t be understated, especially when service members are deployed. 

And when we looked at the area with behavior health, one of the 

things that we realized is we had to be very unique in the way that 

we supported families or children that had stressors due to the deployment. So we took our behavior health and we are able to 

embed them into the school-based programs. 

When they are out into the civilian sector, those types of unique 

options are not going to be available to respond to really timely 

needs. 

And I think the other piece of it is, as we realize when health 

care is changing or opportunities to be able to be much more responsive in the area of health, that allows us to employ all of our 

capabilities together using tele-capabilities to really reach our patients where they need their care. 
18 

Mrs. DAVIS. Yeah. Thank you. 

Thank you, Mr. Chairman. 

Dr. HECK. Mr. MacArthur. 

Mr. MACARTHUR. Thank you, Mr. Chairman. 

I am sorry I missed your opening remarks. I would have been 

very interested in hearing them. But a lot of the discussion on this 

part of the Commission’s recommendations has been around the 

quality of health care to our military families, and rightfully so. 

And that is why the four of you are here with that focus. 

But some of the Commission’s focus was on the financing of 

health care, and that has given rise, I think, to a lot of the recommendations. 

And as I think about that, the financing of it, the creation of a 

structure, and they have gone down the private route, and I think 

there are other views that fixes to TRICARE would be a better approach to that, I worry about the next iteration. 

So we make fixes now and then the broader marketplace continues to evolve and new programs allow the non-military healthcare world to make changes and get efficiencies and TRICARE is 

stuck in whatever new model we create. And so my question has 

to do with how we create a self-evolving TRICARE. 

Let me explain what I mean with that. Something that doesn’t 

require an act of Congress every time we want the program to be 

able to keep pace with what is going on in the marketplace. And 

I think this concept is essential, and this is why I have been somewhat supportive of the private market idea, although I think there 

is problems with it. 

And so I am now back in my thinking to what do we do to 

TRICARE so it can evolve. Without you coming and getting 435 

members, you know, half plus 1, to agree to that, I would be interested in your insights on that. 

Dr. WOODSON. So let me start again, and the Surgeons General 

can follow on. 

That is an excellent question. That really is the heart. So one of 

the things I think we all need to consciously understand is that 

TRICARE is not an insurance program. It is a defined Federal benefit program in which it is guided by laws and statutes and the 

like. And that was probably very appropriate two decades ago. 

What we need to, again, I think partner on is giving the flexibility to the administrators of the program to evolve the program 

in real time to take advantage of what’s occurring in medicine. 

So I was very thankful to Congress when last year they gave me 

the ability to look at evolving medical technologies and implement 

them without coming to Congress right away, and that was just 

new. That is new. But it is that kind of thinking. 

You know, I had this discussion with some folks, and it had to 

do with something we wanted to do with TRICARE. And the lawyers at the time were telling me, ‘‘No. You can’t do that. No. You 

can’t do that.’’ And they were well meaning—don’t get me wrong— 

about this. 

But I said to them, you know, ‘‘Someone once said that the law 

should be stable, but never static. But medicine is neither stable 

nor static. And so we have to understand that and build in the 

flexibility.’’ 
19 

Now, you, as Congress, in your rightful authorities and position, 

should have oversight. And so what we owe to you is a mechanism 

for bringing to you what we have done and being accountable for 

what we have done, but we need to have the flexibility to modify 

and approve the program to make it, again, the exceptional program that the beneficiaries deserve. 

Mr. MACARTHUR. If any of you know, how many lives are covered 

by TRICARE today? 

Dr. WOODSON. 9.5 million. 

Mr. MACARTHUR. I mean, that is bigger than many, many health 

insurers. That is a lot of lives. One would think that we should be 

able to create a form of TRICARE that is competitive with anything—— 

Dr. WOODSON. You bet. 

Mr. MACARTHUR [continuing]. That the private market can offer 

and that can evolve just like the private markets evolve. 

And I would encourage a continued dialogue because I think 

there is the potential for that that could possibly overcome some 

of these hurdles that—and, as I said, I started as—we have had 

these discussions—I started as an advocate for change, but sometimes the—you know, sometimes the cure can be worse than the 

illness. And so I think maybe we need to explore this more. 

I yield back. Thank you. 

Dr. HECK. Thank you. 

And I want to go back. Dr. Woodson, thanks for, you know, pointing out all the things that the Commission would require you to 

do to set up this new program. 

And as we move towards the idea of value-based care and having 

that single point of accountability and contact for a patient in a 

medical home, it goes back to the previous question that I had, 

which is: Is there, you know, benefit in looking at—do we bring 

pharmacy benefits back in-house to the TRICARE ASOs, the nurse 

advice lines, which right now don’t go to the ASOs, so you have 

somebody calling for nurse line advice that is unrelated to the actual healthcare provider they are going to wind up seeing? 

So I think, as my colleague said, as we evolve and try to maximize the benefits of what has happened on the outside of the military healthcare system, again, we need to come up with how do we 

give you the authority to be as flexible and agile as you need to 

be. Right? 

And to the Surgeons General, a topic we haven’t discussed yet: 

Your opinions on the idea of a unified medical command. What do 

you think are pros versus cons, in 3 minutes 58 seconds? 

General HOROHO. Let me go quick. 

The Commission actually recommended a joint readiness—— 

Dr. HECK. We have taken that one off the table. 

General HOROHO. You have taken that off. Okay. 

Dr. HECK. We are just taking about specifically—kind of like a 

TRANSCOM [Transportation Command] for medicine. 

General HOROHO. You know, I think right now we have spent so 

much time and energy and we are starting to see some progress in 

the 10 shared services. 
20 

I think we need to allow that to continue to progress. We have 

really worked with standardizing our capabilities and looking 

where we need to be more interoperable. 

And so I think there is some goodness in cost savings and, also, 

just standards that will be common across the board to decrease 

unwarranted variance. 

So I support the direction of refinement of where we have been 

going with the Defense Health Agency and then common business 

processes across the board. 

General EDINGER. Yes, sir. I agree. 

I think, if you look at what has happened over the past 3 years, 

there have been substantive change in the Military Health System. 

We have worked together jointly under a new governance process. 

We have stood up the 10 shared services with the Defense 

Health Agency to gain efficiencies and effectiveness in what we do 

in common. We train our enlisted out of a joint platform. We have 

a medical school where our physicians train together. And we have 

a lot of our hospitals now, more than ever, that are jointly staffed. 

So I think what you are seeing is a significant evolution in the 

way we work together jointly in our home station medical support. 

Admiral FAISON. Sir, I would agree with that. 

You know, we have been doing this for a long time. All our IT 

[information technology] systems are architected jointly so that, no 

matter where you go and what facility you are in, your healthcare 

record is available. 

We deploy our staffs together. You know, when I was deployed 

in theater running a combat hospital, I was commander of a joint 

task force. I had Army and subordinate Air Force units working for 

me. We worked together side by side. 

In San Diego, when I was in garrison, all the wounded warrior 

care physical medicine rehabilitation was provided by Army physicians. We trained Air Force pediatricians. 

We have been doing this. And now we have evolved to these 

shared services. I would recommend we give these an opportunity 

to mature and then step back and say, ‘‘What problem are we solving?’’ 

Dr. HECK. And, General Edinger, thanks for putting out a plug 

for Uniformed Services University, one of the finest medical schools 

in the country and no better military medicine school in the world. 

I was on faculty there for 4 years. 

Mrs. Davis. 

Mrs. DAVIS. Thank you, Mr. Chairman. 

I might just ask if you are seeing any outstanding cultural issues 

in that integration as you move forward with jointness. 

Admiral FAISON. Ma’am, I will address that. 

I had the privilege of visiting San Antonio for our combined enlisted training program that we run for all our ‘‘A’’ school corpsmen, our medics, our technicians, and they all get their training together now. And although we preserve our service cultures, we 

teach our corpsmen how to salute and the different signal flags and 

things like that. 

What really impressed me the most was, when I looked down 

into the courtyard, I saw Army, Navy, and Air Force young, junior 

enlisted folks working together, making friendships and bonds that 
21 

were going to carry them throughout their careers. I have not seen 

service cultures, you know, we have the banter that goes back and 

forth where I am trying to learn how to say ‘‘Hooyah’’ and at the 

same time how to teach my Army colleagues how to say ‘‘Ooh Rah.’’ 

But when push comes to shove, when we are at the bedside, we are 

taking care of the patient as one team. I haven’t seen cultural 

issues. 

General HOROHO. If I could just give an example, when the issue 

came up with the capabilities that needed to deploy in support of 

the Ebola mission, it was all three services coming together and 

saying, ‘‘Let’s look at how do we do this jointly.’’ 

We looked across our facilities, as Surgeons General, and identified the capabilities that were needed. It was a tri-service effort. 

We went down to San Antonio. It was all services coming together, 

developing the training plan. 

And then they were ready to support that mission. That is a 

whole different way in which we have approached those types of 

missions. 

General EDINGER. I agree. 

We have learned that culture is important because we are part 

of a mission. And so, when we deploy our medical folks out to work 

within our missions, they need to be able to work within the culture of our service. 

But at the same time we have learned that culture should not 

and does not get in the way of the way we take care of our patients. And so I think we have learned how to strike that balance 

appropriately. 

Mrs. DAVIS. Thank you. 

Dr. HECK. Mr. MacArthur. 

Mr. MACARTHUR. I would like to continue that discussion that I 

suggested a few moments ago, and it is how can we give you more 

flexibility today. 

In broad strokes, are there two or three things that we could do 

now structurally that would give you the flexibility not to propose 

programs that we then approve, but give you the freedom to explore, to act, to try things without an act of Congress, you know, 

those broad changes? Are there things we could do today that 

would allow you to change the current program? 

Dr. WOODSON. So thank you again for what I think is an extraordinarily important question. 

So in the spirit of, again, medicine isn’t stable, we need to develop legislation that gives authority, I think, to the Assistant Secretary of Defense to define a process for evaluation involving medical technologies for inclusion in the program and then include 

them, even if it requires subsequent follow-up evaluation of their 

efficacy at some point in time in the future. 

And that ought to be broad. I think that is really very important 

because, again, medicine isn’t stable. New ways of treatment evolve 

every day. And the way the language reads now, it is pretty rigid 

about the requirements for evidence, and that sort of stalls us a little bit. 

I think there are some other things that we need to deal with 

to synchronize our efforts. One of the things that the Surgeons 

General and my office have come together on is looking at new 
22 

models in which we can manage markets, optimize the use of the 

military treatment facilities, and optimize the use of the purchase 

care market. 

And so there are going to be some new, I think, authorities that 

we’ll need to allow patients to flow from the market to the MTFs 

to ensure we have the proper case mix, this to include new ways 

of attracting Medicare-eligible or -aged patients, whether or not we 

actually define and establish a sort of Medicare Advantage within 

the MTFs. 

We need to be given broader authorities, I think, that relate to 

taking care of veterans. I think, in fact, there is even an opportunity for us to take care of DOD civilians. And, in fact, you know, 

we have a lot of dual-eligible folks who, in fact, work for the Federal Government and they have TRICARE benefits. Well, why not 

allow them to use the TRICARE benefits within the MTFs? 

See, I think this would lead to proper utilization of the MTFs, 

proper market management, meet the case mix-skill mix issue and 

actually allow us to deliver extraordinary service to the beneficiary 

population. 

So those are some of the things. There are other things that we 

could talk about, but off the top of my head, that would be some 

of the things we would look forward to. 

Mr. MACARTHUR. Let me explore one other. And I am happy to 

have any of you answer. 

In the private sector, you have a constant dynamic interaction 

between the provider of health care and the financier of health 

care. It is largely how the private sector healthcare system has 

evolved, that tension between high quality of care and affordability. 

And everyone hates it, but it works well. You don’t have that. 

As you observed earlier, TRICARE is not insurance. We are the 

financier of health care on behalf of the American taxpayer, and 

you don’t have that same daily dynamic interchange. 

Can you achieve what I am talking about, what we have been 

talking about—can you achieve that without this two-party negotiation going on a day-to-day basis? 

General HOROHO. I will take that one and share it down the 

road. 

Each of us have to be fiscally solvent to be able to manage and 

run our healthcare facilities. And so we have very well-defined 

business plans. We have incentives where we incentivize our providers and clinicians for patient satisfaction for their care experience, for health outcomes, and then we also incentivize them for 

readiness. 

So we have moved as we improve readiness. That is something 

that they get incentivized and financial rewards for that and moving even more so in a complicated system of looking at how do we 

really move towards outcomes and functional health. 

So this movement from health care to a system for health is a 

huge culture change that your financial system has to be able to 

drive it and support it. 

General EDINGER. Yes. I think really the answer to the question 

you pose is really the value-based approach to providing health 

care. And I think to do that we have got to define and consider and 

measure and manage the performance and value in all of its as-
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pects. And so that is quality, that is safety, that is patient experience, but it is also cost and efficiency. 

The performance management system that we built in the direct 

care system and the action plans that followed up the MHS review 

last summer are really focused on all the aspects of value, including cost and per-member per-month cost, those kind of things. We 

are now managing to that as a metric. So I think really the answer 

is value-based approach to providing care. 

Admiral FAISON. And, sir, also adding into that flexibility, flexibility, as we had talked about earlier, and agility. Health care is 

dramatically changing and it is impacting the military because, as 

I shared earlier, 75 percent of our uniformed force were born after 

1986. 

How they make their healthcare decisions and what influences 

those decisions is fundamentally different than what influences us, 

as Baby Boomers. And so they pursue convenience and the experience of care and increasingly technology, having the agility to pursue value-based options. 

Using those things without requiring them to come to a hospital 

for their care is fundamental to our success and really an operational imperative. So the things that you could do to help to give 

us that agility is where success is going to lie. 

Mr. MACARTHUR. Thank you, Mr. Chairman. I appreciate your 

indulgence. I was making up for lost time earlier. 

Dr. HECK. I appreciate your very informed questions. 

So I agree with Secretary Woodson’s comments about trying to 

attract more consumers of health care into our MTFs to provide a 

better training platform for our military healthcare providers to be 

better ready. 

And I think that was really one of the places where the Commission missed the mark. Certainly, when they presented to us, they 

seemed to be focused on the idea of the MTFs being training platforms solely for combat casualty care, not realizing, as you well 

pointed out, General Horoho, that the vast majority of folks we 

treat are not traumatic injuries. 

So the question is: If you get the authorities and the flexibility 

and the marketing campaign is successful to bring more lives into 

the MTFs, is there capacity within the MTFs to be able to absorb 

a higher patient volume, whether it is the may we go to a Medicare 

Advantage-type TFL [TRICARE for Life] product or we go out and 

try to allow DOD civilians to participate and receive care at the 

MTFs? Are you going to be able to absorb that increased patient 

volume? And will the cost associated with caring for those new patients keep your business plan in the black? 

Dr. WOODSON. So let me start again. I think the Surgeons General really need to weigh in on this. 

So, first of all, within the MTFs, we have fixed cost. So if we take 

care of one patient, the cost of care for that patient is extraordinarily high. If we take care of more patients, of course, the costs 

go down. And there are some built-in costs of readiness, which is 

the issue we are talking about in terms of maintaining skill and 

the graduate medical education program. 

So the bottom line for me is that there is capacity. I think what 

we have been working on is retooling how we are thinking and how 
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we are managing to make the system clearly more efficient and to 

make us a preferred provider. And I will stop there and let the 

Surgeons General talk. 

General HOROHO. And, sir, just in two areas with that, it would 

be very helpful to be able to have a diverse population that we 

could care for, but it is going to have to be tied to our readiness: 

What is the complex cases that we need to really to support our 

training programs and increase our medical readiness of our providers and the support staff? 

With that, though, it is going to require a commercial financial 

system and a business intelligence system because both of those 

are capabilities that we don’t have right now and we would need 

to be able do that so that we could bill for certain services. 

General EDINGER. So the care that is needed to help enhance and 

support our readiness is specialty and inpatient care. And in Air 

Force hospitals, yes, sir, we do have capacity. 

I think, as we potentially gain the ability to more effectively capture care, that is the kind of care we would want to capture. And 

so I think we would need to go about it in a way using the business 

intelligence systems where we were capturing the kind of care that 

is most relevant to our readiness. 

And that is the kind of care where we have capacity. Our hospitals are fully enrolled and growing. Our primary care workforce 

is really not what we need so much on the readiness side as it is 

to pull in specialty and inpatient care. 

Admiral FAISON. Sir, I would agree with the other panel members. We not only see unit costs go down as you see more patients, 

but there is an inherent efficiency in the staff so that you see more 

patients much more efficiently and you get better outcomes. 

And so long-term costs are down because you are getting better 

outcomes and keeping people healthy. Short-term costs are down 

because you are not using as many things to take care of them in 

the short term. So I think there are inherent efficiencies to that. 

We have capacity to do that. But, as General Edinger and General Horoho said, we have to be selective. So we don’t want to recapture all of one thing. We only need to look at what exactly do 

we need for our mission and then go after those. 

Business intelligence is critical for that, and we don’t have that 

right now. And so I think that will be an important tool that we 

will need in our toolkit to go after those things. 

Dr. HECK. Perfect timing. 

Well, I want to thank all of you, one, for staying with us even 

though we started late, and for your answers to the questions here 

today. Obviously, we look forward to continuing to work with all of 

you to make TRICARE the premier healthcare provider in the Nation. 

I want to again hail Lieutenant General Edinger to our group. 

And farewell to General Horoho. It has been a pleasure working 

with you, and I am sure we will be talking to you soon. 

This hearing is adjourned. 

[Whereupon, at 4:16 p.m., the subcommittee was adjourned.] 
A P P E N D I X 

JUNE 11, 2015 

PREPARED STATEMENTS SUBMITTED FOR THE RECORD 

JUNE 11, 2015 

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DOCUMENTS SUBMITTED FOR THE RECORD 

JUNE 11, 2015 

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QUESTIONS SUBMITTED BY MEMBERS POST HEARING 

JUNE 11, 2015 

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QUESTIONS SUBMITTED BY MR. JONES 

Mr. JONES. In response to a congressional inquiry addressed to you, the Army reported that, in May 2014, General Horoho’s office approved a business case analysis 

(BCA) submitted by HDRL to take all HIV testing services ‘‘in-house.’’ In the 

months following this decision key assumptions of the BCA have proven to be incorrect. Current facilities have proven to be inadequate, test equipment, supplies and 

Army resources unavailable. These significant lapses led to the Army’s delay in pursuing this for up to 3 years. It’s also seems that the Army’s effort to do this would 

result in sole sourcing with a company that has been heavily fined by the Justice 

Department, for bribing foreign government officials in order to obtain government 

business, in violation of the Foreign Corrupt Practices Act. (That company is BioRad.) Bottom line, fundamental assumptions of the BCA have proven to be incorrect 

and the decision to take testing ‘‘in-house’’ needs to be reviewed as the evidence appears to indicate increased costs. Just as troubling the inferior performance of the 

proposed equipment, HDRL’s track record on shipment and turn around and the inevitable uncertainties and inefficiencies associated with transition are cause for serious concern. 

Secretary Woodson, General Horoho; are you reviewing this decision and if not, 

why not; and will you provide the committee with a copy of the original BCA, along 

with analysis addressing those areas mentioned above and any other areas where 

the BCA’s assumptions have proven to be incorrect, as well as, provide details of 

the estimated costs associated with those changes. Thank you 

Dr. WOODSON. The basic requirements of HDRL’s BCA, which support the change 

in the Army’s acquisition strategy for HIV testing, have not been significantly altered. Delays to date have been due to ensuring compliance with applicable policies 

and regulatory guidance, adherence to current contractual requirements, and addressing solicitation protests by the current contractor. The Army’s current acquisition strategy is resourced, and is proceeding according to schedule barring any additional solicitation protests. HDRL’s final costs within the BCA are currently under 

revision due to several procurement actions that are still out for bid. The Government’s final cost for 4th Generation HIV testing is projected to be lower than the 

current contracted cost per test, which is based on a sole-source procurement to the 

incumbent contractor. All Army Procurements are done in accordance with the Federal Acquisition Regulations (FAR) and the Defense Federal Acquisition Regulation 

Supplement (DFARS). This includes ensuring that contract awardees are not currently suspended, debarred or otherwise ineligible from receiving any Government 

contracts. 

HDRL is fully accredited by the College of American Pathologists (CAP), and has 

served as the DOD/HA HIV reference lab since 1987. HDRL performs all OCONUS 

HIV testing (60K HIV screen tests/year), 6K HIV viral loads/year of USA/USN infected personnel for confirmatory testing and clinical monitoring, and 1.2K HIV resistance genotypes/year for all DOD HIV infected Soldiers and beneficiaries. Under 

the current contract all CONUS HIV testing that screens POSITIVE must be 

shipped to HDRL for supplemental, confirmatory testing. 

Under HDRL’s BCA, greater efficiencies would be achieved with the Army’s HIV 

testing algorithm through performance of both screening and confirmatory testing 

at a single location. This would facilitate a quicker turnaround time for the Government for confirmed results as HDRL would not have to wait for a contractor to ship 

samples that screen positive to HDRL for confirmation. There are no known systemic issues with quality or performance of either Bio-Rad or Abbott’s 4th Generation HIV testing method. A review of the Safety and Effectiveness data submitted 

to the US Food and Drug Administration by Bio-Rad and Abbott for their 4th Generation HIV test methods demonstrates comparable analytic performance for both 

manufacturers that meets or exceeds the FDA’s sensitivity (>99%) and specificity requirements (>99%) for HIV assays. 

Currently, there are four open procurements actions. As the BCA contains contractor bid and proposal information, commercial vendor sensitive information, and 

source selection information related to these ongoing procurement actions, the release of the full BCA prior to final award would violate the Procurement Integrity 
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Act (PL 111–350, Section 2102 and FAR 3.104). Final award of the open actions is 

anticipated in mid-August 2015, and the BCA will be releasable at that time. 

QUESTIONS SUBMITTED BY MR. WALZ 

Mr. WALZ. Dr. Woodson, do you agree with the MCRMC Conclusion that ‘‘As evidenced by the similarity in benefits authorized under the HCBS and ECHO programs, as well as the directive to use state and local services before accessing 

ECHO, the Congress intended ECHO as an alternative to unavailable waiver benefits. Yet ECHO benefits, as currently implemented, are not robust enough to replace 

state waiver programs when those programs are inaccessible to Service members 

and their EFMs. With the exception of home health care services and ABA therapy 

services, the ECHO program is not highly utilized. This is due to a lack of needed 

services.’’? 

Dr. WOODSON. The ECHO program, as currently implemented, offers a robust 

range of integrated services and supplies beyond those offered by the basic 

TRICARE health benefit program. These services and supplies include, but are not 

limited to, assistive services (e.g., from a qualified interpreter or translator), durable 

equipment (including adaptation and maintenance equipment), expanded in-home 

medical services (through ECHO Home Health Care (EHHC), rehabilitative services, respite care, training to use special education and assistive technology devices, 

limited transportation services to and from institutions or facilities, etc. The ECHO 

program was not designed to serve as a full replacement to state waiver programs, 

and as a result, there are significant differences between benefits authorized under 

the HCBS and ECHO programs. To assist DHA in better aligning ECHO services 

with HCBS, DHA has initiated an analysis of HCBS waivers and eligibility criteria, 

and is in the process of designing a beneficiary survey to identify current gaps in 

ECHO services and to evaluate which HCBS services should be added to the ECHO 

program to better support our military families. 

Mr. WALZ. Dr. Woodson, do you agree with the MCRMC’s recommendation that 

‘‘Services covered through ECHO should be increased to more closely align with 

state Medicaid waiver programs, to include allowing for consumer-directed care.’’? 

If so, what is the implementation plan and timeline? If not, what alternative would 

you propose? 

Dr. WOODSON. DHA is currently developing a beneficiary survey to identify current gaps in ECHO services and to evaluate which state Medicaid waiver services 

should be added to the ECHO program to better support our military families. Consumer-directed care (which is legally limited to respite and attendant care) is one 

avenue of service delivery that will be considered after the survey has been completed and the needs have been identified. To better understand how consumer-directed care might be effectively implemented under the ECHO program, DHA has 

met with the MCRMC research group to review the process for, and the impact of, 

the implementation of consumer-directed care in several states. Additional research 

in this area will occur over the next 4–6 weeks. 

Mr. WALZ. Dr. Woodson, how can DOD in the immediate term, address the underlying objectives of increasing access, choice and value in military health care, specifically for families and children under TRICARE? Do the steps require legislation 

or does DOD already have the authority? 

Dr. WOODSON. The Military Health System (MHS) is addressing access, choice 

and value in military health care through initiatives in primary and specialty care. 

The Patient Centered Medical Home (PCMH) model of primary care is our foundation for enhancing access, improving health and increasing quality. Currently, over 

310 of our primary care clinics are recognized by the National Committee for Quality Assurance (NCQA) as meeting the highest PCMH standards. The PCMH model 

of evidence-based care supports the patient’s continuous relationship with his or her 

primary care manager (PCM) and healthcare team, who coordinates and integrates 

the patient’s care needs. PCMH also enhances access to care by offering alternatives 

to face-to-face medical appointments including walk-in clinics for common acute conditions, a Nurse Advice Line available 24 hours a day and secure messaging, which 

allows patients to email their PCM and healthcare team. To further improve access 

to care, the MHS has embedded specialty providers for commonly occurring medical 

issues directly in the PCMHs; these providers include behavioral health specialists, 

clinical pharmacists and physical therapist. PCMH is supported by two new access 

initiatives to ensure patient medical needs are addressed in a timely manner. 

First, MHS is implementing policies, which identify standard processes for patients calling for appointments to ensure patients’ needs are resolved on the first 

phone call. The MHS also is implementing Simplified Appointing Guidance, which 
67 

will better match primary care appointment supply by patient demand, especially 

for appointments available within 24-hours. Simplified Appointing guidance also 

identifies processes to appoint patients based on their preference for when they 

want to be seen rather than on the acuity of their medical condition. Simplified Appointing is based on best practices recognized by the Institute of Medicine. By leveraging the success of the Tri-Service PCMH program, the MHS is now developing 

standard processes and goal to improve access to specialty care in the direct care 

system. Finally, to expedite our patients’ access to specialty care in the direct care 

system or in the TRICARE network, the MHS is now developing a streamlined specialty appointing process. DOD has the authority to accomplish required actions and 

steps do not require legislation. 

Mr. WALZ. Dr. Woodson, one of the key recommendations in the MHS Review that 

was completed last summer stated ‘‘The Department will expand its collaboration 

with external health care organizations to improve as a learning organization’’. It 

is my understanding that senior leadership within the Defense Health Agency will 

be meeting with pediatric stakeholders, including the TRICARE for Kids Coalition, 

which includes, among others, the American Academy of Pediatrics and the Children’s Hospital Association on the 24th of June. Using that meeting as an example, 

can you explain how you intend to take their input as it relates to pediatrics to improve ‘‘as a learning organization’’? I would appreciate an out brief after the meeting, helping the committee understand what their recommendations are, and how 

you plan to incorporate their suggestions into ensuring we are providing excellent 

medical care for our military connected children. 

Dr. WOODSON. The June 24, 2015, meeting did occur and we had great attendance 

with representation from about 10 different groups, to include the American Academy of Pediatrics, National Military Family Association, and the National Association for Children’s Behavioral Health. Attendees were provided information on: (1) 

compound drugs, and informed that TRICARE is dedicated to getting safe, effective, 

and appropriate compound drugs to all beneficiaries, to include our pediatric population. (2) Pediatric Program Updates (e.g. changes planned for the Extended Care 

Health Option (ECHO) program (e.g. respite care and adult diapers for incontinence, 

breastfeeding supplies and services), and (3) TRICARE’s benefits regarding mental 

health care for children. 

We are committed to hosting two meetings a year with the group and will work 

to address their recommendations as they arise. We trust this will ensure we continue to provide excellent medical care to our military children. 

Mr. WALZ. Dr. Woodson, similarly, when it comes to children, we hear that Medicaid and CHIP are the gold standard, in terms of the comprehensive coverage and 

the attention to pediatric health and development. What can you learn or adopt 

from those programs that will enhance and protect children’s health coverage, particularly in order to create a program that responds to and develops in alignment 

with best practices and technology and treatment options as they are emerging and 

developing, so that the DHA is not always playing catch up in the children’s health 

care arena. Do the steps require legislation or does DOD already have the authority? 

Dr. WOODSON. Medicare and CHIP are not designed as specific uniform standards 

but rather are health insurance plans underwritten by the states for children in 

families with income up to 200 percent of the federal poverty level ($48,500 per year 

for a family of four). Eligible children and teens can receive regular check-ups, immunizations, doctor and dentist visits, vision care, hospital care, mental health services and medications. These services are different in each state with different requirements of income and necessity. All the medical services in Medicaid and CHIP 

are available and some more robust within the TRICARE entitlement programs. 

The alignment with emerging best practices, technology and treatment options require evaluation of the cost and legislative authority (Well Child Care defined up 

to age 5). With the statutory permission received from Section 704 from NDAA 

2015, the DHA has been able to begin to design an enhanced approach to adopt and 

review emerging and developing technologies. This will continue to be strengthened 

through use of the governance system to review, evaluate and recommend benefit 

changes to address evolving beneficiary needs. 

Mr. WALZ. Dr. Woodson, has the DOD calculated any comprehensive comparison 

of benefits and costs, including cost-shares and catastrophic caps, between the recommended TRICARE Choice plans and the current TRICARE plans? This is a big 

concern for families with special healthcare needs, active duty and retired. Does 

DOD have a plan to ensure that it can provide benefits (comparable to private plans 

and MA/CHIP as they relate to pediatrics) without increased or variable cost shares 

and catastrophic caps? 
68 

Dr. WOODSON. The current TRICARE Prime and TRICARE Prime Remote plans 

for Active Duty family members involve very minimal out of pocket costs (primarily 

for prescriptions which would be unaffected by the Commission’s recommendation). 

Our analysis indicates that while the proposed Basic Allowance for Health Care 

(BAHC) equals or exceeds the average out-of-pocket costs, the financial risk for active duty family members varies considerably by eligibility status, family size, choice 

of plan selected, and health status (including for families with special health care 

needs). According to the Commission’s report, nearly 1 in 6 Service member families 

will be negatively impacted financially. 50,000–100,000 families will experience unreimbursed out-of-pocket expenses of more than $1,000 above the BAHC, disproportionately affecting those paid the least. In addition, unlike housing expenses covered 

by BAH, health care expenses are unpredictable and highly variable. Without controls to ensure BAHC is saved for health care-related costs (deductibles, co-insurance, premium cost-shares, etc.), it is highly likely that some members will face significant financial hardships without the resources to meet them. As for non-Medicare eligible retirees, the Department estimates that in the steady state (20% of premiums) the average retiree family of three will experience an increase of $3,600 (FY 

2014 dollars) in out-of-pocket expenses, significantly more than current out-of-pocket 

and much more than Department proposals that have been rejected in the past. The 

Department’s proposals for PB 2016 allowed active duty family members to continue 

with an MTF managed option with the same low out-of-pocket costs as today. In 

addition, the proposal for retiree health care was estimated to increase the out-ofpocket cost for a family of 3 by less than $300 per year. 

Mr. WALZ. How does DHA intend to monitor the ECHO plan to ensure it maintains this alignment with state Medicaid waiver programs as technology and best 

practices change in the future? 

Dr. WOODSON. DHA already has expertise in the area of medical benefit policy 

development, which includes a well-established process for continually monitoring 

reliable evidence for evolving medical benefits and technology. DHA will establish 

a similar process to continually monitor future changes to state Medicaid waiver 

programs and to assess whether ECHO policy or benefit revisions are indicated. 

Mr. WALZ. A recent study by DOD stated ‘‘Overall, 37% of military families with 

a special needs child reported they had heard of the TRICARE ECHO program.’’ 

Why is reaching these families difficult and what are you doing to improve your outreach to these families? 

Dr. WOODSON. DHA currently utilizes a wide range of contemporary communication techniques to inform beneficiaries and providers about all aspects of the 

TRICARE program. However, this study suggests a need for additional emphasis on 

the TRICARE ECHO program to ensure that military families are fully informed 

of the process for participating in the ECHO program so that a family member with 

special needs can receive integrated services and supplies beyond those offered by 

the basic TRICARE health benefit program. DHA will explore options for providing 

focused ECHO messages under the current and future TRICARE contracts. These 

outreach efforts will include military families, primary care managers and other providers in the Military Treatment Facilities (MTFs), and network providers participating in TRICARE Managed Care Support Contracts. Additionally, DHA will reach 

out to the Services to ensure that Exceptional Family Member Program (EFMP) 

program coordinators are familiar with the ECHO program and can advise military 

families accordingly. 

Mr. WALZ. The same report noted ‘‘72% of military families whose child was enrolled in TRICARE ECHO were satisfied or very satisfied with the program’’. What 

is the trend in satisfaction since the ECHO program was created? Is this a high 

number or a low number? Do you think the MCRMC recommendation would improve satisfaction with the ECHO program? 

Dr. WOODSON. DHA regularly conducts various inpatient and outpatient beneficiary satisfaction surveys; however, ECHO program satisfaction is not routinely 

tracked by the agency. Therefore, DHA is unable to provide information on ECHO 

program satisfaction trends, nor can DHA state with certainty whether 72% represents a high number or a low number. However, Gallup researchers conduct annual surveys on a wide range of health care satisfaction metrics, including overall 

patient satisfaction with their health care coverage. Based on survey results from 

2001 through 2012, between 63% and 72% of patients who were surveyed rated 

their overall satisfaction with their health care coverage as ‘‘excellent’’ or ‘‘good’’ (the 

other rating options were ‘‘fair’’ and ‘‘poor’’). Although these surveys are not limited 

to patients with special needs, as an indicator of overall program satisfaction, it 

would appear that a 72% ECHO program satisfaction rating is consistent with the 

upper range of overall patient satisfaction with their health care coverage. DHA is 

committed to quality improvement and is currently developing a beneficiary survey 
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to identify gaps in ECHO services. The results of this survey will be used to evaluate which HCBS services from the MCRMC recommendation should be added to the 

ECHO program to better support our military families. This identification of coverage gaps and the subsequent implementation of necessary policy and program 

changes to better align the ECHO program with the MCRMC recommendation 

should lead to improved beneficiary satisfaction. 

Mr. WALZ. What actions is DOD taking or contemplating to increase access to specialty care—which the MCRMC identified as a big challenge for families? Do the 

steps require legislation or does DOD already have the authority? 

Dr. WOODSON. The Military Health System (MHS) is improving access to specialty 

care in both our direct care system and in our TRICARE network. The MHS Review 

of Access, Quality and Safety recommended leveraging the success of the Tri-Service 

Patient Centered Medical Home (PCMH) program to develop standard processes and 

goals to improve access to specialty care in the direct care system. Recapturing specialty care to the direct care system supports our goals of maintaining a ready military medical force, which is able to respond quickly and effectively in support of National Strategy. Our direct care PCMHs using evidence-based clinical practice guidelines (CPGs) to deliver more comprehensive, coordinated care in primary care without having to refer the patient to specialty care, which frees up specialty care access. In addition, the MHS has embedded specialty providers in PCMHs for commonly occurring medical issues directly so patients can be seen quickly without a 

referral; these providers include behavioral health specialists, clinical pharmacists 

and physical therapists. Our telehealth program also is expanding the reach of direct care specialists by providing tele-consultations to remote PCMHs, which do not 

have in-house specialty care capabilities. 

To achieve the goal of improving access to specialty care and in support of our 

integrated delivery system, the MHS has developed a new Tri-Service Specialty 

Care Advisory Board. Our direct care specialties are increasing the number of available appointments as well as maximizing the availability of operating rooms and 

other support services. If specialty care is not available in the direct care system, 

patients will be referred to high quality specialty care in our TRICARE network. 

Our specialty care access standard is for patients to be seen for an appointment 

within 28 days and care in most specialties is available well within this access 

standard in both the direct care system and in the TRICARE network. Some specialties are in short supply nation-wide; however, the MHS ensures patients needing 

care are seen as quickly as possible. Finally, to expedite our patients’ access to specialty care and in response to patient feedback, the MHS is now developing a 

streamlined specialty appointing process so patients know when and where they will 

be seen more quickly. DOD has the authority to accomplish required actions and 

steps do not require legislation. 

Mr. WALZ. Children’s behavioral health care seemed to be a particularly difficult 

area, due to the unavailability of outpatient providers, the obsolete model of residential treatment that TRICARE imposes, and the lack of some intermediate service 

levels. How is DOD addressing this shortfall? Do the steps require legislation or 

does DOD already have the authority? 

Dr. WOODSON. Many of the challenges TRICARE faces regarding behavioral 

health care for children parallel the nationwide problem of appropriate care for this 

population, to include the shortage of outpatient providers, child psychiatrists and 

psychologists; access to residential treatment and partial hospital programs for substance use disorders; and appropriate services in between the two levels of care. 

TRICARE has several efforts underway to improve behavioral health care for our 

beneficiaries. In 2014, TRICARE regulations were finalized to add TRICARE-Certified Mental Health Counselors as authorized independent providers of mental 

health care. Also in 2014, the Department sought legislative relief to remove statutory quantitative limits on inpatient psychiatric and residential treatment center 

care for children in the TRICARE program. As a result, the National Defense Authorization Act for Fiscal Year 2015, Section 703 ‘‘Elimination of inpatient day limits and other limits in provision of mental health services’’ amended section 1079 

of Title 10 United States Code to remove these quantitative limits, and we are currently revising our TRICARE program manuals to implement these changes. Additionally, the Defense Health Agency is in the process of drafting proposed regulatory 

changes to ensure our mental health benefit has parity with the benefits for medical/surgical procedures, is consistent with current industry standards of care, and 

facilitates access to qualified institutional and professional providers of mental 

health services. We anticipate that a proposed rule outlining these changes will be 

published in the Federal Register in the near future, and we will encourage stakeholders to provide feedback during the public comment period. 
70 

In addition to medical services, non-medical services continue to be available to 

all TRICARE eligible beneficiaries. Non-clinical counseling programs and resources 

are sponsored by the Services (such as the Army’s Strong Bonds program and the 

Navy’s Project Focus) and by Deputy Assistant Secretary of Defense for Military 

Community and Family Policy (such as Military Family Life Consultants, Military 

OneSource Programs, and the Joint Family Support Assistance Program). These adjunct programs, in addition to Military Health System behavioral health care, help 

ensure that children and families have access to a broad range of psychological services. 

Mr. WALZ. If DOD does not agree with the MCRMC recommendations, what are 

some of the elements of private health plan design and administration that can be 

adopted to address the concerns so compellingly set forth in the MCRMC report? 

Do the steps require legislation or does DOD already have the authority? 

Dr. WOODSON. The Department believes that adopting the proposal set forth in 

the 2016 President’s Budget has many of the elements of most private health plans. 

That proposal would replace the two TRICARE plans (PRIME, Standard/Extra) with 

a simplified Preferred Provider Organization (PPO) plan. In 2014, 58% of beneficiaries covered by employer-sponsored insurance were enrolled in a PPO. In a 

PPO, beneficiaries have the choice to choose their providers. There are no requirements for referrals and authorizations, which is a source of many access-related 

complaints associated with TRICARE. Also, co-pays will differ to steer patients to 

the lower cost providers. In the PB 2016 proposal, co-pays were lowest for military 

treatment facilities (where patients are needed for our active duty providers), low 

for network providers (where the Department has lower costs) and highest for outof-network care. Furthermore, copays are zero for preventive services, lowest for primary care, higher for specialty care and highest for emergency room visits. 

While the PB 2106 proposal does require legislation, we are looking at options to 

address other aspects of the MCRMC report that will not require legislation, including implementing value based purchasing. The Department is reviewing those options now. 

Mr. WALZ. The 2013 NDAA, Sec 735 directed ‘‘The Secretary of Defense shall conduct a study on the health care and related support provided by the Secretary to 

dependent children.’’ The report was to include the (1) the findings of the study; (2) 

a plan to improve and continuously monitor the access of dependent children to 

quality health care; and (3) any recommendations for legislation that the Secretary 

considers necessary to maintain the highest quality of health care for dependent 

children. The findings of the study were published almost a year ago, in July 2014, 

but we still don’t have a plan or recommendations for legislation. When do you anticipate providing this information? 

Dr. WOODSON. Defense Health Agency began a Pediatric Integrated Project Team 

(IPT) in March to address the gaps and areas of consideration in the 2013 NDAA, 

Sec 735. This team is addressing each of the areas in the nine original elements 

in a multidisciplinary collaborative group from direct care, purchased care and other 

Department of Defense Agencies. The group is reviewing advocacy group responses 

to the 2013 NDAA Sec 735 for additional input and recommendations. The report 

from this group is anticipated to be reported to DHA governance in December 2015. 

Mr. WALZ. General Horoho, one of the reasons the commission recommended 

changing the Military Health Care system is because military families and retirees 

told them they wanted choices. If your members do want more choice, is the Commission’s recommendation what the members of your organization want? Do they 

believe choice will improve medical care? What are your concerns with the recommended change? Are there ways to improve the TRICARE program instead? If 

so how? 

General HOROHO. The Army supports the Commission’s objectives to increase 

choice for beneficiaries; however, we believe the DOD proposals in the 2016 President’s Budget will achieve these goals without jeopardizing the ability to maintain 

a ready and deployable medical force and a medically deployable force. We are concerned that the Commission’s proposal to establish a Federal Employee Health Benefit type program for beneficiaries risks loss of beneficiaries from the direct care system that provide the volume and complexity to sustain the skills of our military 

healthcare providers. The PB16 proposal offer Active Duty Family Members and Retirees the choice of using Military Treatment Facilities or network providers and 

incentivizes use of the direct care system. This creates choice as recommended by 

the Commission while preserving the case load required to sustain skills for our 

military providers. Additionally, Army Medicine must maintain the ability to provide critical healthcare services not available to our beneficiary population in the 

civilian market, for example, School-based Behavioral Health Care. Many of the 

Commission’s goals are currently being achieved through initiatives such as patient- 
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centered medical home, nurse advice line, shared services, Defense Health Agency, 

and MHS governance. In order to improve the TRICARE program, the Army recommends expanding authorities to increase patient populations and therefore the 

case mix to keep military providers ready to deploy; seeking cost effective solutions 

to improve healthcare coverage of Reserve Component Families impacted during activation of Reserve Component Soldiers; and exploring strategies to transition from 

a fee-based health plan to a value-based health plan that incentivizes preventive 

care, improves health outcomes, and encourages healthy behaviors. 

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