Nation, their families and those who earned a retirement benefit due to their career of service. I believe any framework for reform needs to begin with an assessment of whats working and not working, what the environmental conditions are likely to look like in the future including the go to work the capabilities and needs and what approach will likely insure success in the future. For my nearly 20 years of Privileged Service at the side of d. O. D. And now v. A. I believe there are four fundamental questions worthy of explosions. First, does dodd have the most effective efficient Management Structure and tools to deliver on the needs . And is the investment in the direct care system being optimized . Theres a great deal of experience inherent in the footprint and the personnel required to establish the foot print. Theres great efficiency to be gained when sizing a system, hen making make vs. Buy decisions and croort cooperating appropriately and leasing when the leasing is broached. I believe the analytics tools need to be maximized especially age. Is day and there has been much written on this topic. It would seep that seem that theres an opportunity to achieve savings just as has been done in the evolution in which the medical community now supports the war fighter in theater. While not easy, streamlining the number of players and consolidating functions will make the organizations more agile and fiscally efficient. Second, does the benefit available to the population make sense and is it priced properly . The individual that testified just before me spoke eloquently of one component park that ought to be considered. The tricare benefit has evolved greatly in the last 20 years. Having said that one challenge that remain as constant is what to do with the pricing structure which was previously addressed. I believe part of that needs to include indexing. One of the challenges with programs in are developed is that we fail to index them and i hink a simple index would be worthy of consideration. Third, is access to care easy . And what is the optimal approach to providing the direct care system with the needed elasticity to insure that access to quality providers is available than to meet the needs that the direct system cannot meet itself. My understanding is an electronic authorization system that allows work flow to efficiently and effectively move between the direct system and the providers still does not exist. I would say that needs to be remedied. And it needs be grounded in processs that effective and efficient that include supporting how to make sure that appointments work effectively and accurately. Lastly, the networks built by those that support the dodd as contractors need to be supported to meet the neetsdz of those in the community. One size does not fit all. Those networks should be priced at market rate. And fourth are we promoting health and efficiently supporting those whos unmanaged decisions are bad for the individual and presenting an avoidable expense. It starts with effectively supporting the patient. If done right, it also results in cost avoidance. So the two go hand in hand. Segmenting the population and focusing in on those who benefit most from assistance in the management of their conditions is just smart. And annually reviewing the analysis of the populations health is critical to doing this right. Developing and deploig an integrated approach to disease management for that specific provide of conditions is also critical. Something that we tried in tricare when i was doing it. And we failed to focus in on the right spaces where opportunity exists. You want the treatment to be coordinate and well managed regardless of where the care is delivered whether its in the direct system or in the community there should then be the development of a treatment plan for the individual patient and the modification of the design of the Tricare Program to provide incentives and disincentives with compliance with that treatment plan. Lastly the models that appropriately reward providers for quality outcomes and reduce and overall spend need to be adopt as theyre the key partner in o delivering care, i would suggest doing pilots to continue to test this but then deploig it effectively and quickly is important. Senator giilibrand i would like to draw your attention to one propotype that i was part of one one of the next panels participants. The first lady in that conway who is a special educator, we had the privilege then captain faison and myself now the Navy Surgeon General ho prototype how to put a special Needs Service together to serve the families at camp pendleton. And i believe, sir, that they worked extremely effectively. Theres some clues from a while ago and there are clues from a current pilot that could be rolled up and made vainl as you map the final policy. I want to thank you for the invitation to appear before you today. It was an honor and a privilege for my colleagues and i and our nonprofit owners to be of service to the beneficiaries of the milliontary Health System at the sight of the ladies and gentlemen who wear the cloth of the nation that is work we will not return to because we have the awesome privilege of leaning forward in the sight of the v. A. In the current furnace and thats where we stayed focus. I hope that my testimony has been helpful to you as you contemplate the future as you continue to refine the military Healthcare System and i look forward to answering any uestions you might have. The military medical community is a dedicated force trying to provide beneficiaries as a high quality benefit and maintain their ready nbc the battlefield. This Community Works within the milliontary Health System it often fails to encourages these outcomes. I commend the congress for addressing these challenges. I make three primary points which ill summarize briefly. First, tricare reform is not mply raising beneficiary ealthcare. It should be about replaying a system of fiveyear, winner take all largely fee for Service Contracts with a modernized system that provides that improves the equal of the benefit for our families and retirees while saving the taxpayer money. Second, tricare reform has increased focus to the Healthcare System in particular on how to maintain the capable built during the wars. As the commission reported Research Reveals a long hist referee the medical community needing to refocus these capabilities after concentrating on peacetime in beneficiary healthcare. G. A. O. Was reporting that since most military Treatment Facilities provide healthcare to active duty personnel and beneficiaries and do not receive patient patients they cannot maintain combat skills by working in these facilities. Although there are a lot of improvements made during the war, military physicians are still reporting. Today the service that the physician was referring to has less than 300 special lists. They are specialists. This is largely because the allocations are based on traditional peacetime needs refocusing wartime needs could repopulation it with a Critical Mass of trauma specialist and drive further advances in battle time care. This brings me to my third point. Tricare reform san opportunity to reform the entire military Healthcare System. It is a set of Missions Delivery systems benefits and benn funding streams. It involves layers and fails unification on the key outcomes of readiness and cost control. A prime example of these problems is the Military Hospital network. It includes over 50 incare patient hospitals and 300 inpatient clinics. The purpose is to provide the clinical skill paint innocence for the medical force. But the daytoday workload at these hospitals are focused on beneficiary healthcare. I show in my written statement how different it is from the deployed and patient workload. This puts Military Hospital commanders in an almost impossible situation and it creates a climate of confusion within the m. H. S. And affects everything. These Military Hospitals are expensive and key driver of healthcare costs within the dodd. D. O. D. It is driven by a lack of transparency and funding. Line Service Leadership and the secretary defense in congress cannot identify how much is and on ben fish area care ready beneficiary care and readiness. I offered challenges and i would be happy to elaborate on them. I would like to commend you for taking on these issues and for including me in this conversation. Thank you all. Ill lead this off and i want to thank my colleagues for attending. Im going to make a general statement and see if you agree wit. The battlefield medical care provided in the last 14 years has produced outcomes historic in terms of warfare. Does anybody disagree with that . The answer is you all agree . Nod your head. So lets make sure we dont break the one thing that is working. Now, mr. Whitley, you said that Military Hospitals are skewed toward basically family care and not Battlefield Medicine readiness. Well, how do you explain that in light of my first statement . So its a very sensitive issue. And i want to be very careful in how i describe it. You said that the survivalal tes have reached survival rates have reached great heights and thats a great testament. What i would caution is using all of that as a measure of success of the clinical currency of the medical force prior to deployment particularly at the start of the wars in 2001, 2002 and three. That measure of the overall survival rate was contributed by many rates. We organized the war differently. We moved patiently differently and we had some of the best men and women that we could have ever possibly had that measure is the cumulative effect of all those things. What were asking here when we talk about the medical hospitals, we have to go down to more specific measures. They get at the question of heres my concern if youre a uniformed doctor or nurse, you can be deployed, Tricare Network physicians are not going to be deployed. What i want to make sure is in trying to fix a system that i think is very much in need of repair that we dont destroy the one thing that seems to work very well. I want to look at your reform measures but i want to do anything that dwow in the Military Hospitals enhances the Battlefield Medicine. If we need that footprint even though it isnt the most efficient beas these doctors will go to the battlefield themselves and theyre going to practice in an environment where they can be shot at. So lets not miss that boat. Doctors, when you look at tricare for families for the Retirement Community and family members and active duty members, how antiquated would you say it is . From an a to f rating . Well, thats a difficult question. I would say thats why i ask it. I would say that i have seen aspects or observed from the outside aspects that what grade would you give it overall . On an antiquated basis . I would give it a b. So were starting a b. I would say bplus actually. I would say bplus actually. Dr. Mcintyre . I would say somewhere in rms of a bminus in terms of keeping where we need to be. Dr. Whitley . Ill be the odd man out. Ill give it a c. Whats the 30second answer to get us to a . I think that the military Health System needs to do a better job of measuring its actual performance and trying to compare itself to internal and external benchmarks and to work continuously to improve that care. Doctor . I would pay provider mrs for providing the service that makes military providers and make it more easy for those members to do that. Mr. Mcintyre . I would insure that providers getting paid for their performance and their quality. Number two, i would make the patient in part responsible for their care from an incentive and disinsenity perspective. Third, i would index the benefit so that it keeps pace with inflation. And fourth, i would focus on the question of alignment of the providers that are in the direct care system with the providers that are downtown. Nals terms of requirements but also what their focus is as a patient. Dr. Whitley . I would focus with respect to the tricare contracts. Increasing greater competition, having annual contracters with multiple winners per location. I would focus on making those riskbearing and increasing the flexibility to the contractor to manage care. Could you provide in a three or fourpage report to the committee how you go from c to a and b plus to a . Be specific. Brand. Gilli our country has a shortage of Mental Health providers. What do you see as the solutions to this problem and mr. Mcintyre specifically how does triwest insure that mental care providers has the experience they need . And does tricare require this type of experience . So ill start. We no longer do the work in tricare. Which is why were here because thatnt have a conflict in regard. It was mapped closed to a military installation but also those in the garden reserve. What we currently do is relevant to that topic and that is were doing exactly the same thing. And were looking at the zip codes as to where people live. Were looking at what the direct care system actually has in the way of footprint which is applicable to the d. O. D. And were going back to train the Mental Health providers and the primary care providers which is how do you recognize where threat is . How do you be relevant and where do you turn people to if theyre in distress . Others . I would say that if we were serious about changing our conversation, we would see a serious investment in infra structure for Mental Health and send providers and patients to do those evidencebased services. What infra structures would you make . The problem is na most medical services are not producing a lot of health for the money you spend. As long as you continue to allow a fee for Service Payment system, theyll go to those services that produce lots of revenue and theyll never been measured on the health produced. I think if we again, go get this point and say ill m im going to pay a lot of money but insists that it goes to services and providers whether it be Mental Health, op yoid abuse or other things that are away from the standard orthopedic surgery. You have enough money there. It just takes the courage to make the shift that would be going upstream against some interests they may not want that to happen. I would add that integrating Mental Healthcare into primary care is actually important. I dont mean that mental hale care is pro vied solely by primary hale physician but breaking down the barriers and sharing information about atients with bhavel behavioral hale issues are important. Theyre not aware of those issues. We cannot bring to bear all of the power of the entire multispecialty power that we have in front of us to the kir of those Mental Health patients. I have nothing to add to that another major concern is the care for Service Members special needs dependence which i mentioned in my opening. Military families move frequently. And that means to Different Service provision. From the private sector experience how you do ensure ha the continuity of needs continue whenever they move . How does triwest handle provisions of this service . I think thats a fundamental question. And the thing that captain faison and myself learn at the time through the lens of the marine corps is you need to come to understand what the needs are and you need to Pay Attention to them and meet them while theyre in your midst. And then you need to prepare and plan for their change geographically. So that if they move from place to place youre thinking about them not only moving forward but to see them on the other side. The same thing applies to those that are injured and those who have Mental Health needs. As they move within the system and the military and as they also move between the military and the v. A. Last thing id sigh if i can go back to a second to the Mental Health piece that you raised previously. Very few providers are trained in evidence based therapies. And we have a network of 25,000 Mental Health providers now built across 28 states. And were in the process of looking at that issue market by market. Were doing a test in phoenix. Actually this weekend were doing something today with the private community as well as those who served in the federal space. The bottom line is, it is possible to go through and do that training. Are in xpertise of it the d. O. D. Spaces and the military. We need to narrow in on the populations that need services. How many there are. What types of e. B. T. s you need and to make the investments to actually insure that theyre trained. Were going to be testing that in the chairmans hometown of phoenix, arizona starting this weekend. And with that, senator mccain . Dr. Whitley, i am very interested in your recommendations. M. T. F. Management layers should be reduced. Are you talking about one service . I think there are many options to do that. One thoopings others have talked about is consolidating the Military Hospitalization and the existing Defense Health agency. Another would be another single service. I think there are many options the way you should get there, senator. Would you do me a favor and send that to me in writing . Be very happy, sir. You also say that they should be managed. Does that mean you contract out to a manage group . I think thatss an option on the table and used in appropriate situations, senator. Does that mean like in a ilot sflam program . Would you recommend a pilot