To provide the committee further assistance. Thank you very much. At after new chairman mccain, chairman graham, Ranking Member killer brand and members of the personnel subcommittee. It is a privilege to appear before you today at this initial hearing on Defense Health care reform and i hope my participation in todays hearing will be of assistance to you in the Defense Department as you seek to ensure the military Health System is strength in and is able to provide optimal support to those who wear the cloth of this nation, their families and those who are in the retirement benefit due to their careers service. I believe im a framework for reform is to begin with an assessment of what is working and not working. But the environmental conditions are like me to look like in the future, including the go to work capabilities and needs than what approach will likely ensure success in the future. For my nearly 20 years a Privilege Service at the site of dod and now va, this worm and up until questions exploration. First, does dod have the optimal footprint and most effective and efficient Management Structure and tools and system to deliver underneath. And is the investment in the direct care system be enough demise . Theres a great deal of expense in the physical footprint, the equipment that has to be purchased and kept current and personnel required to effectively staff the footprint. Not easy streamlining the number of players and consolidating functions will also make the organization more agile and fiscally efficient. Secondly, the benefit available to the population makes sense and is priced properly. The individual could testifies before me spoke eloquently of one component part that ought to be considered. As we all know the tricare benefit has evolved greatly in the last 20 years. Having said that, when challenge that remains constant is what to do with the pricing structure which was previously addressed to. I believe part of that needs to including taxing and one of the challenges of programs that are developed is that we fail to index them. A simple actuarially based and automatic triggered index would be worthy of consideration. Third, access to care easy . What is the optimal approach to providing direct care system with needed elasticity to ensure access to quality providers is available to meet the needs the direct system cannot meet its self. My understanding is electronic authorization system that allows workflow to efficiently and effectively move between the direct system and the tricare contractors and providers still does not exist. I would say that needs to be remedied. It needs to be grounded in processes that are effected and efficient to include supporting how to make sure they work effectively and accurately. Leslie i would say the networks built by those that support the dods contractors need to be constructed to match the need that exists for care in the community, one size does not fit all. In order to optimize the dod budget those networks should be priced at market rate. Fourth, i we optimally promoting health and effectively and efficiently supporting those whose unmanaged Health Individuals are bad for the individual and avoiding the preventable expense for the taxpayer . Promoting Health Starts with effectively supporting the patient which my colleagues have addressed previously. If done right, it also results in cost avoidance so the two go handinhand with a segment thating the population and focusing in on those who benefit most from assistants in management of their conditions is just smart. Annually reviewing the analysis of the populations health is critical to doing this right. Developing and deploying an integrated approach to disease management for that specific profile of conditions is also critical, something we tried in tricare when i was doing and we failed to focus in on the right spaces where opportunity exists. You want the treatment to be coordinated and wellmanaged regardless of where the care is delivered whether it is in the direct system or in the community. There should then be development of a customized treatment plan for the individual patient and the modification of the design of the Tricare Program to provide a series of incentives and disincentives for compliance with that treatment plan. Lastly, a provider payment models that appropriately reward provided for equality outcomes and reduce overall spending need to be adopted as they are the key partner in delivering care. I would suggest doing pilots to continue to test this by deploying it effectively and quickly is important. I would like to draw senator gillibrands attention, one of the next panels participants, that is that the site of the first lady of the marine corps, a special educator, we had the privilege, the navy surgeon general, 2 prototype how to put a special Needs Program together to serve the families at Camp Pendleton and i believe that worked extremely effectively so there are clues from awhile ago and probably clues from current pilots that could be rolled up and made available as you the final policy bleaching closing i want to thank you for the invitation to appear before you today. Was an honor and privilege for my colleagues and i and our nonprofit owners to be of service to the beneficiaries of the military Health System at the site of ladies and gentlemen who wear the cloth of the nation. That is work we will not return to because we have the awesome privilege now of leaning forward in the current furnace and that is where we will stay focused until our job is done. My testimony has totally been helpful to you as you contemplate the way ahead as it relates to continuing to refine the military Health System and the important tricare benefit. I look forward to answering any questions you might have, thank you. Members of the committee is a privilege to participate in this panel. These, should not be interpreted as reflecting it is a dedicated force trying to provide beneficiarys, highquality benefit and maintain readiness to find lifesaving care on the battlefield. His Community Work within a military Health System that fails to encourage these outcomes and at times hinders their ability to succeed. I commend congress for addressing challenges. Imac three primary points in my written testimony which i will summarize briefly. Tricare reform is not just raising beneficiary cost shares. And fix the program that is out of step with current trends, not simply raising costs of retirees to save money, it is about replacing a system of five year winnertakeall largely passed through largely fee for Service Contract with modernized system that provides, improve quality of the benefit for entire families and retirees and taxpayer money. Second tricare reform is an opportunity to bring increased focus on readiness to the missouri Health System in particular how to retain the capability built during a wars with the Compensation Commission reported, quote, Research Reveals long history of medical mccrery British Military community and refocusing its capabilities after concentrating during peacetime and Beneficiary Health care. Before the wars iraq and afghanistan, since most military Treatment Facilities provide health care to activeduty personnel and beneficiaries, military medical personnel cannot maintain combat trauma skills in peacetime working these facilities. There are a lot of improvements made during the war, military physicians are still reporting, quote, to date the service the physician was referring to it has less than a dozen specialists and the same number of trauma surgeons on active duty. That service has the same number of radiation oncologist and three times the number of pediatric psychiatrist in the force. This is largely because medical specialty allocations, beneficiaries refocusing on wartime needs to populate the institutions for the Critical Mass of hospital and trauma specialists and drive further advances in battlefield care during peacetime. This focus on beneficiary care mission brings me to my third point. Tricare reform is an opportunity to reform the entire military Health System. The complex and tweeting set of missions, delivery systems, benefits and funding streams involved duplicative management layers and fails to incentivize unity of effort on the key systemwide outcomes of readiness, highquality benefit, and cost control. A prime example of this, the Military Hospital network. And Outpatient Clinics, the purpose of having that dod run Hospital System with clinical skill maintenance platforms for the operationally required medical force. A to d. A. Workload and operations of these hospitals exclusively focused on Beneficiary Health care. As an example i show in my written statement out given the inpatient workload is from the deployed in patient work load. This puts Military Hospital commanders in an impossible situation. It creates a climate of confusion that affects everyone from staffing decisions to major investment decisionmaking it the Military Hospitals are key driver of excess costs of Health Care Costs. Many of these incentive challenges are driven by a lack of transparency and funding. The service leadership, secretary of defense and congress would not identify what was spent on beneficiary care and readiness, reducing the effectiveness of resource allocation decisionmaking an reducing accountability. I offer suggestions on reform options for each of these challenges in my written testimony and i will elaborate on them in the question and answer period. I would like to close by commending you for taking on these important complex issues and including me in this conversation. I will lead this off and members ask questions and i thank my colleagues for attending. 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, not your head. Lets make sure we dont break the one thing that is working. John whitley said Military Hospitals are skewed toward family care and not Battlefield Medicine readiness. How do you explain in light of my first statement . Is a very sensitive issue. You, said the survival rates on the battlefield have reached unprecedented heights and that is true and that is a great testament to everybody involved in that situation. What i would caution is using that as major clinical readiness, prior to deployment at the start of the wars in 2002, and 2003. The overall survival rate is contributed by many things. We organize the battlefield differently, moved patients differently, and the providing medical care downrange. That measure is the cumulative effect of all those things. What we are asking here when we talk about Military Hospitals, readiness of the medical force, we have to get down to more specific measures that get at the question of if you are in uniform, doctor or nurse, you could be deployed, Tricare Network physicians are not going to be deployed. I want to make sure in trying to fix a system in need of repair that we dont destroy the one thing that works very well. I will look at your reform measures and make short what we do in the Military Hospital systems enhance Battlefield Medicine. If you need that footprint even though it might that be the most efficient way to deliver health care, these doctors and nurses will do something no one else will do, go to the battlefield themselves and practice in an environment where they can be shot at. Lets not miss that boat. Mark fendrick, Forrest Faison, when you look at tricare for families, activeduty members, how antiquated would you say it is . Difficult question. I have seen aspects that i think what grade would you give the overall . On an antiquated basis and give it a b. So we are starting with a d. I say it be plus actually. David mcintyre . I would say bein terms of keeping up with where we need to be. I will be the odd man out and give the a c at best. What is the 30second answer cost to get us to a . Military Health System needs to do a better job measuring its actual performance and trying to compare its self to internal and external benchmarks and work continuously to improve that care. I would pay providers more for providing services that make military members healthier. Theres strong evidence based to back that up and make it easy for members to do that. I would ensure that providers getting paid for their performance, and make the patient impart responsible for their care from an incentive and disincentive perspective. Third i would index the benefits so that it properly keeps pace with inflation and forth, i would focus on the question of alignment of providers in the direct care system with providers that are down down. In terms of requirements but also in terms of what their focus is. I would focus with respect to the tricare contracts i would focus on increasing greater competition, having annual contract with multiple i would focus on contract being risk bearing and increase its ability to the contractor to manage the care. Could you provide in a three or four page report to the committee how you go see to a and c plus to a . Be specific. Thank you all for being here. Our country has a shortage of Mental Health providers resulting in many patients receiving Mental Health care from their primary provider. What do you see as the solution to this problem . How do you ensure Mental Health providers in the network had experienced unique needs at with Service Members including military children and last does tricare require this type of experience . We no longer do the work in tricare which is partly why i am here because i dont have a conflict in that regard. It was mapped to the needs of the population, both those that are close to a military installation but also those observed in the garden research. What we currently do is relevant to that topic and that is we are doing exactly the same thing and were looking at the sid code where people live and what the direct care system has in the way of footprint which i believe is applicable to the dod and we are going back to something we did at the start of the wars and that is to train the Mental Health providers and primary care providers in how do you recognize where a threat is for your patient from a Mental Health perspective . How do you be relevant and where do you turn people to in distress . If we are changing from how much we spend to how much we spend we would see a serious investment in infrastructure, to do evidence based services. What infrastructure changes would you make . The problem is most medical services that are most profitable would have a lot of help for the money is spent and as long as you continue to allow feeforservice Payment System they will go to the services that produced lots of revenue that have never been measured, points made by folks to the right and the left of me. If we again get to this point and say i will pay a lot of money for a military healthcare, but insist that it goes to services and providers for things that are actually needed whether it be Mental Health, bogey at abuse or other things that are away from the standard cardiology and orthopedic surgery and other things that are needed but tend to be overused in the system. You have enough money dare, it discouraged to make the shifts that are going upstream end you may not want that to happen. I would add that integrating Mental Health care into primary care is important. I dont mean Mental Health care is provided solely by primary care physicians that breaking down the barriers and sharing information about patients with Behavioral Health problems there are great privacy concerns about Behavioral Health but when primarycare physicians and others not treating the same patients are not aware of those issues we cannot bring to bear all of the power of the multi specialty power we have in front of us to the care of Mental Health patients. I have nothing to add. Major concern is the care of Service Members special needs dependence, military families moved frequently and that means moving to Different Levels of service provisions, we have private sector experience, how do we ensure continuity of care for special needs are met when secret Service Members may be moved and how does tricare handle provisions of the Specialized Service . I think that is a fundamental question and the thing thats Forrest Faison and myself learned at the time through the lens of the marine corps was you need to understand what the needs are and Pay Attention to them and