A decade after its creation, DHA thinks it has building blocks in place for an integrated military health system

After a decade of constant change, DHA's new director says it's time to focus on delivering a truly integrated military health system.

The Defense Health Agency has been in an almost constant state of change since it first reached initial operating capability 10 years ago. Over that time, what started as a fairly limited mission to offer shared services to military medical organizations has grown to encompass almost every aspect of the Military Health System — from management of DoD’s electronic health record and its TRICARE health plans to medical logistics and the day-to-day operation of every military treatment facility in the world.

But Lt. Gen. Telita Crosland, who became DHA’s director in January, sees her tenure as marking the end of what’s ended up being a very long transition period. From here on out, she said, the focus needs to be on execution.

“The last piece was moving the military treatment facilities, medical research and development and public health — that all happened in the last three to five years,” she said during an extended interview for Federal News Network’s 2024 Open Season Exchange.

“My predecessors and the department leadership were very focused on getting that done — moving the dollars, moving the resources,” Crosland said. “It means I as the director can now give clarity on what the mission set is, now that DHA has all of that under it. That was a big part of what our new strategy was meant to do. Now that we’re here, what are we going to do with all of this responsibility?”

Planning for future military health care needs

That strategic plan, published in late August, outlines how DHA plans to evolve military health care in the coming years — with a major focus on “stabilizing” the system and establishing more integration between the more than 700 hospitals and clinics DHA now operates around the world and the billions of dollars it spends each year to purchase private sector care via its TRICARE networks.

The overall objective, Crosland said, is to be able to visualize the military treatment facilities (MTFs) and the TRICARE networks together as a single, coherent system.

“We need to consciously make decisions on where that care is delivered and how best to organize that care, whether it’s inside of a military treatment facility or in the network, and how to pay for that care,” Crosland said. “In some cases, the best care for this system is inside a military troop treatment facility. In some cases, the best availability for that care is in the network. And talking at the managed care support contract level — which we do regularly — it’s a conscious decision on how much care we try to keep inside of our system versus how much care we purchase.”

But those “direct care” versus “purchased care” decisions are going to vary a lot based on factors like geography and the different types of populations DHA serves. Health care issues and availability vary widely between, say, Washington, D.C., and the Indo-Pacific region. And within those geographic areas, there are varying considerations for how to deliver care to active duty service members, retirees, family members and in some cases federal civilian employees.

To try to better manage those variables, in October, Crosland reorganized DHA into nine geographic Defense Health Networks, each led by a general or flag officer. The new networks replace 23 markets that previously reported to the DHA director — a number she said was unmanageable at the headquarters level.

“That allows us to do a couple of things more effectively. It allows me as director to see the system — it was very difficult to see and know what’s going on across that much of a span of reporting,” she said. “It also allows me to interface with the military services we directly support a little more efficiently, and certainly more effectively. Those flag officers and general officers also wear uniforms, so that’s an interface that allows me a little more ability to communicate at the right level to get the entire system moving in the same direction. It really didn’t get rid of anything. It rearranged things in a more cogent way for me to lead. And for the military treatment facilities in the field, they now have a much cleaner route to come to us and amplify what their challenges are.”

Focused on avoiding DoD health care crisis scenarios

Crosland said that lack of DHA senior leadership’s ability to “see” the overall system was a significant contributor to the health care access crisis DoD civilian employees in Japan faced a year ago.

In that instance, faced with a shortage of clinicians, a market leader decided to implement a more restrictive policy that made it almost impossible for civilians to get care, and even in some cases prescription refills at the MTFs where they’d typically been seen. Technically, DoD civilians had always been treated at MTFs on a space available or “Space-A” basis, but the space for civilians evaporated rapidly late last year because of the policy change.

Officials in Washington didn’t understand the implications of that decision until the Pentagon’s top personnel official held town hall sessions in Japan last December and heard directly from packed audiences of civilians who said they’d abruptly lost any meaningful access to health care.

“We pushed a policy that effectively made them getting access more complicated and more difficult,” Crosland said. “Since then, we’ve gone back and sat down with those military treatment facilities and worked through the challenges they’re having in meeting their demands. We’ve unencumbered them to support the Space-A population on the the same footing they’d previously supported them. We said, ‘We really do have some capacity, let’s maximize our capacity for all beneficiaries.’”

Crosland said the new network structure should be fully stood up and staffed by the end of fiscal 2024.

“We will have those staffs in place so that those networks are fully able to support the MTFs and interface with the managed care support contractors. By then, our headquarters will be organized so that information can flow down and come up and we can make good decisions across the entire direct system. That’s what I mean when I talk about stabilization,” she said. “The agency has gone from moving things over to actually running those things. That includes medical research, good governance, public health — being able to support mission sets like Red Hill or getting COVID vaccines out to the MTFs. We need to run the system in a consistent way such that we’re accountable for our job. That’s what stabilization is for me.”

Addressing Defense health care staffing demands

The new strategy also has implications for how DHA thinks about wartime medicine. The military health system has always thought in terms of being able to produce both a “medically ready” force of rank-and-file service members and a “ready medical force” of uniformed doctors and nurses who can care for battlefield casualties.

That’s not changing, but it’s more complicated now: Previously, the military services were responsible both for recruiting and training their medical personnel and for running the MTFs they worked in. Under the new structure, DHA runs the hospitals and clinics, but it has no direct control over how many uniformed clinicians will be recruited and billeted to staff them each year. That’s still up to the Army, Navy and Air Force, which reluctantly relinquished control of those facilities during the congressionally-mandated transition.

In recent weeks, Crosland said, DHA and senior medical leaders from each of the services established a new venue to sit down regularly and iron out those complications.

“Step one is to make sure everybody understands DHA runs the military treatment facilities on behalf of the military departments and DoD. We don’t run these facilities just for DHA, we run them as as part of the Military Health System,” she said. “We all sat around a table, and I took the locations that are our priority for our business plan to keep the system stable and upright. I and my team sat down with the Army, Navy and Air Force, and they showed us what they’re already putting against that mission set. And then we literally said, ‘OK, what else can you do to help with some of our shortfalls in these locations?’ We’ll take that forward to the senior leaders in the department in another forum in a couple of weeks, show them what we came up with, and then offer an opportunity to get more feedback and find out whether we need to go back and try harder.”

To discover more insights and advice shared during the 2024 Open Season Exchange, visit the event page.

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