Last week’s much-anticipated report on modernizing the military compensation system included major changes to the Defense Department’s health care delivery system, including the wholesale replacement of the current TRICARE system.

But in congressional testimony Tuesday, members of the Military Compensation and Retirement Modernization Commission implored lawmakers to keep in mind that a “modernized” system would require big changes from not just one, but two of the government’s largest bureaucracies, and called for a single panel that could craft and enforce policy decisions for both DoD and the Department of Veterans Affairs.

In their published report and in Tuesday’s testimony before the Senate Armed Services, panelists pointed to major opportunities for collaboration between the services currently provided by the separate health care systems in DoD and VA. Yes, that’s been a governmentwide objective for ages, but the panel identified major seams that are ripe to be closed during the current reform effort: a shared drug formulary, much more use of shared services and better synchronization of a broad range of disparate policies.

All of the above would require more authority for the Joint Executive Committee (JEC), a working group that already convenes regular meetings to talk about harmonizing DoD and VA’s operations, but is toothless to actually enforce its decisions.

“This really lies at the heart of making sure that two departments of government work together seamlessly,” said Stephen Buyer, a former Indiana Congressman who served on the commission. “As a soldier, sailor, airman or marine transitions from active status and into VA, they really shouldn’t feel it.”

But as of today, they feel it acutely in a myriad of ways, said retired Gen. Peter Chiarelli, another commissioner.

“When I was vice chief of staff of the Army, I had no idea that there were two different drug formularies between DoD and VA,” he said. “I really believed that every soldier who had post- traumatic stress or traumatic brain injury could take their off-label DoD prescription to their new VA doctor, and he would automatically refill it. That is not the case. DoD has a very expansive drug formulary that includes just about everything the FDA has approved, and when an individual finally gets on the right drug at the right dosage, in too many cases, they find themselves in a situation where they go over to the VA for their antipsychotics or antidepressants or pain medications and the doctor says, ‘I’m sorry, I can’t fill that prescription.’ If there is one single thing we could do today to fix the suicide problem we have today, it would be to make sure that once a kid finally gets on the right drug at the right dosage, he can get it anywhere in the system, instead of being told ‘That’s not in our formulary.'”

Separate and unequal

In the modernized system the commission envisions in its report, experts working for the Joint Executive Committee would be in charge of those kinds of technical details: developing a “blended” formulary that both departments would use, and coordinating the sharing of electronic health data.

Buyer said the existing joint committee regularly makes detailed recommendations along those lines.

But it lacks any authority to compel anyone within VA or DoD to actually execute the policies it suggests.

“It doesn’t have any power now, so it just creates a lot of paper. We’d like you to give it statutory power to implement the recommendations,” Buyer said. “This wasn’t in our recommendations, but I also suspect that the secretary of VA would also like to have parity on the JEC.”

Buyer argued there is no such parity today: VA’s representative to the committee is the department’s deputy secretary, and DoD’s delegate to the joint decision making body — the department’s undersecretary for personnel — is one rung lower in the government’s pecking order, and consequently, is less likely to be able to turn the committee’s decisions into departmentwide priorities.

“It’s not the same,” he said. “If Congress raised it so that both departments’ deputy secretaries were at the table and had the power to implement their decisions, that’s a big difference.”

In addition to better integrating drug formularies and mandating more expeditious changes on health IT integration, the commission thinks the two departments have a chance to make better decisions about where and when to build new medical facilities so that they can leverage each other’s clinics and hospitals in various parts of the country where one or another of them might have capability gaps.

“Whether it’s building new VA or military hospitals in close proximity to each other or building super clinics for both departments,” more centralized guidance would help, Buyer said. “We need some resource sharing. Never again should we have a situation where we all struggle to get the timelines together for building a VA hospital and an Army hospital. That shouldn’t ever happen again. We did find a lot of resource sharing initiatives as we went around the country, but they were based on local agreements, and they were personality-driven. But there were a lot of things that worked and a lot of lessons learned in that crucible, and the JEC could help to centralize a lot of those decisions instead of leaving it up to local cooperation.”

Current system is broken

Former Sen. Bob Kerrey, another commission member, said the objective of tighter integration between DoD and VA is all well and good — he, and the rest of the panel voted in favor of the idea, just like the other 14 recommendations the compensation commission delivered last Thursday.

But speaking for himself, Kerrey said he’d be happier if Congress took a much more radical step and did away with the bifurcated DoD-VA health care system once and for all.

“I think this collaboration idea is not going to work,” he said. “I don’t think you’re going to get where you want to go unless you consider actually combining those two systems together, and because of the military’s requirements for medical readiness, it’s going to be DoD that’s going to be in charge of it. I remember talking with this with [former Hawaiian Sen.] Danny Inouye, because both of us had transferred from the DoD system and into VA. It’s nice to talk about collaboration, but unless and until you combine the two systems, it’s going to be very difficult to get the kind of changes that you want.”

In its final report, the panel told Congress that it should eliminate the current TRICARE health insurance system for military members, retirees and their families and replace it with a new private insurance marketplace that closely resembles the system the government already has in place for civilian federal employees.

While that recommendation is expected to save several billion dollars per year and also increase beneficiaries’ access to care, it also introduces a few new complications.

For instance, DoD and VA’s own efforts to transform their medical records into interoperable data that flows seamlessly between the two departments have turned out to be much harder than either department imagined. But the data exchange will become even more challenging as both departments send more of their patients to private sector doctors. With Congress’ blessing, VA has already begun a large-scale effort to let veterans seek private-sector care in the wake of a series of public scandals, and the commission’s recommendations are explicitly designed to give DoD beneficiaries more access to nongovernmental providers.

“A lot of care is going to be provided in the private sector,” Buyer said. “We have to have data standards that are bi-directional. So the setting of national standards for how the country will communicate medical information is going to be incredibly important. Congress needs to take leadership in setting those national standards.”

Expanded reach of military hospitals

Chiarelli cautioned that creating a new private health insurance market for DoD beneficiaries also has the potential to take patients away from the military’s own hospitals, if the transition is not managed thoughtfully.

That’s something DoD desperately wants to avoid, since it sees those clinical settings as vital training environments for military clinicians who will one day have to deploy to a distant battlefield and provide care for troops in combat situations.

But the commission also pointed to an already-existing mismatch between the kinds of medical cases clinical staff encounter in military treatment facilities today and the kinds of injuries they’re likely to run into in combat zones.

To remedy that, the report recommended that military hospitals start taking in veteran and even civilian patients, as long as their cases help the military preserve what the commission calls “essential medical capabilities.”

“I think our military treatment facilities are in a death spiral right now,” Chiarelli said. “They just don’t have enough of the cases they need to keep their doctors up to standard. This is a way that we can bring our MTFs the cases that contribute to battlefield medicine. That’s what makes our system so different from any other medical system. We need well-trained doctors who can not only treat patients in hospitals, but also be able to deploy wherever we send them and provide that same level of treatment on day one of a conflict. This will allow us to attract the kinds of cases and skills that were absolutely crucial to our survival of wounds rate during the last 14 years of war. It will do that on the day one of the next conflict, and if we don’t do it, we’re going to have a very, very hard time providing that level of care in the future.”

RELATED STORIES:

Panel recommending changes to military health care, benefits

Cost doesn’t factor heavily in military compensation panel recommendations

VA referrals to private doctors on rise

Copyright © 2024 Federal News Network. All rights reserved. This website is not intended for users located within the European Economic Area.