1. Your Military Health System
CAPT Edward (Ed) Simmer
Deputy Chief & Chief Clinical Officer, TRICARE Health Plan
Defense Health Agency
August 13, 2019

2. A Week in the Life of TRICARE
19,021
Inpatient Admissions
2.38 M
Prescriptions (~$107M)
13,444
1.73 M
1.98 M
Outpatient Visits
174,721
Behavioral Health Visits
0.85 M
108,693
1.83 M
2,081
Births
55,706
Emergency Room Visits
2,230
108,669
3.8 M
Claims Processed
Sources:
TRICARE 2019 Annual Report
Kaiser Permanente 2017 Annual Report, 2015 VA patient volume, data.va.gov
Data definitions may vary across organizations
$287 M
Last revised: 02 Apr 2018

3. TRICARE Compared to Largest Plans by Membership*
* Fahad Saleem, Insider Monkey, 10 Largest Health Insurance Companies by Membership (May 10, 2017), available at
** Director, Defense Health Agency (DHA) Memo dated Nov. 3, 2016, “Estimate of Beneficiaries Eligible for Health Care in Fiscal Year 2017
*** Available at 3

4. TRICARE A Simplistic Definition Today
Military Healthcare System (MHS)
TRICARE Program
Operational Medicine
TRICARE Contractors
MTF

5. Military Health System Consolidation
1 OCT 2018
1 OCT 2019
1 OCT 2020
1 OCT 2021
Previously transferred
Transferring within phase
7% Facilities
13% MIL/CIV FTEs
12% Enrollees
17% Dispositions
52% Facilities
54% MIL/CIV FTEs
57% Enrollees
55% Dispositions
81% Facilities
93% MIL/CIV FTEs
89% Enrollees
88% Dispositions
100% MHS Enterprise
Full Authority to Standardize Policies for all MTFs
Health Plan, Pharmacy & Quadruple Aim Performance Plan (QPP) Functional Capabilities
Facilities, MEDLOG & Acquisition Functional Capabilities
All other Functional Capabilities

6. Military Health System Reforms Our Goals
What Stays the Same
Support to the Mission
Patient-Centered Care
What’s Changing
Standardized Appointing & Referrals across System
“Market” Orientation
Reporting Relationships

7. Market Orientation Resources closest to health care delivery
Local medical leaders with real authority
to effectively move money and people to responsibly coordinate patient-centered care
Data-driven

8. NCR Medical Directorate
Reporting Relationships – Old
Army
Operational
Units
Navy
MEDCOM
Marine
Air Force
MAJCOMs
CNO
CMC
BUMED
CJCS
Secretary of Defense
Sec Army
Sec Navy
Sec
CSAF
CSA
USD(P&R)
ASD(HA)
Defense Health Agency
USUHS
Combat Support Agency
Responsibilities
Policy & Oversight
Army SG
Navy SG
Air Force SG
NCR Medical Directorate
MTFs

9. Military Health System – Before FY 2019 Reporting Relationships – New
Secretary of Defense
CJCS
Sec Army
Sec Navy
Sec
Air Force
USD(P&R)
ASD(HA)
CSA
CNO
CMC
CSAF
USUHS
Defense Health Agency
Policy & Oversight
Army SG
Navy SG
Air Force SG
Combat Support Agency
Responsibilities
Air Force
MAJCOMs
Markets
MTFs
Army
Operational
Units
Navy
Operational
Units
Marine
Operational
Units
Air Force
Operational
Units

10. NDAA 2017, Section 702 TRICARE Implications
One of three functional areas identified for enterprise-level transition
Common Medical Benefit Across Direct & Purchased Care
Referral Management Improvements
Streamlined Case Management

11. Recent TRICARE Enhancements: Mental Healthcare
Goals
Align TRICARE’s mental health and substance use disorder (SUD) benefit with the principles of mental health parity
Expand covered MH and SUD treatment under TRICARE
Streamline requirements for institutional providers
Develop TRICARE reimbursement and cost- sharing methodologies
Final rule published in Federal Register in September 2016, TRICARE manual changes published in June 217
Results
400%
Increase in intensive outpatient
78%
Decrease in partial hospitalization
Helping families and children receive care in the least restrictive environment

12. TRICARE Changes in 2019: Introducing TRICARE Open Season
Starting in 2019 you’ll need to use open season to change plans (Prime and Select)
If you like your plan, you don’t need to do anything
Changes outside of Open Season with a Qualifying Life Event
For more information, go to TRICARE.mil/openseason
Military Changes
Activating, Deactivating, Moving. Injured on Active Duty, Separating from Active Duty, or Retiring
Family Changes
Getting Married, Getting Divorced, Having a Baby or Adopting, Moving, Children Going to College, Children Becoming Adults, Gaining/Losing Other Health Insurance, Becoming Medicare Eligible, or Death in Family

13. TRICARE Changes in 2019: Introducing FEDVIP Open Season
Federal Employee Dental and Vision Insurance Program (FEDVIP)
New access to FEDVIP dental and vision plans!
Dental is available for retirees.
Vision is available for most eligible TRICARE beneficiaries, including TRICARE for Life (TFL)
Newly eligible or those who have experienced a Qualifying Life Event (QLE) can enroll in FEDVIP now
For all others, next opportunity to enroll will be during the Federal Benefits Open Season which begins the second Monday in November
To check eligibility and explore/compare plans go to Benefeds.com

14. TRICARE Costs and Fees 2019
Go to for easy reference to all beneficiary out- of—pocket costs

16. What comes next? T-5: The next generation of TRICARE contracts
Enhanced Readiness
Beneficiary Centric
Focus on high value care
Move toward Industry Standards

17. TRICARE A Simplistic Definition Today
Military Healthcare System (MHS)
TRICARE Program
Operational Medicine
TRICARE Contractors
MTF

18. TRICARE A Simplistic Definition in T-5
Military Healthcare System (MHS) Mu
TRICARE Program
Markets
Operational Medicine
Multiple high
Value contractors
MTFs

19. Core Attributes of A New TRICARE Contract Fundamental Reorientation
Market-oriented Model (not East and West bolt-on solutions)
Tailored networks to each market
Consideration of national centers of excellence for select procedures (e.g., organ transplants, complex surgery)
Value as driver – networks and reimbursements driven by outcomes and performance, not discounts off of Medicare allowable charges
Use / offer integrated delivery networks within geographic communities; explicit partnerships with vendor proposed outcome measures
Heighten value of ability to accurately move health data to and from MHS GENESIS in a timely manner
Data Exchange Investments – ensure integrated system is properly structured to accommodate expanded data exchange requirements
Agile – rapid-cycle approach to innovation and aggressive use of demonstration authority for the purpose of evaluating healthcare delivery options

20. Outcomes & Experience of Care
Enterprise Approach
Outcomes & Experience of Care
Safety & Quality
Improve
Improve
processing time between appointment referrals and appointment scheduling
critical patient safety measures
Unintended Retained Foreign Objects, Wrong Site Surgery, Hospital Infections
Increase
patients satisfied with getting care when they need it
Transparency of performance at MHS and MTF levels
Readiness
Efficiencies
Reduce
the proportion of Service members that are non-deployable due to preventable medical reasons
Streamline
overhead staffing through the consolidation of headquarters functions
Strengthen
Standardize
the capability of the deployable medical force
business, clinical and administrative policies and processes
FY18 Savings Reprogrammed
Bolster
Cybersecurity
medical networks and Cyber standards
Eliminate
duplicative IT Systems

21. Rosita, Julia, and some guy who crashed the party

22. TRICARE.mil is The Source of TRICARE Info

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