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Services want more control over medical funds

The service surgeons general are picking at some old wounds in a battle that, if won, could lead to more money to upgrade on-base medical facilities and, over time, might allow more patients to be seen by military doctors rather than being sent off base.

The problem, however, is that they already lost this battle.

The increased control they seek over military medical budgets was taken from them years ago as the Pentagon strengthened its defense health program, and after the number of military beneficiaries being seen by private-sector health providers exceeded the number receiving so-called direct care at military hospitals and clinics.

Today, of the entire universe of people receiving military health care — active, reserve and retired service members and their families — only about 20 percent get care directly from military doctors. Eighty percent use the Tricare network of off-base providers.

Testifying April 29 before the House Armed Services military personnel panel, the Army, Navy and Air Force surgeons general complained that the Defense Department has too much power over health care policy and resources.

“I am concerned the role of the services is diminished,” said Army Surgeon General Lt. Gen. Eric Schoomaker, who said the health affairs section of the Defense Department and the Tricare Management Agency “have begun assuming more control of operational activities at some risk to their strategic role.”

“I am concerned that this trend will obscure and minimize service-specific challenges in achieving desired clinical and programmatic outcomes and threaten the viability of the direct care system,” Schoomaker said.

He wasn’t alone.

Vice Adm. Adam Robinson, the Navy surgeon general, said he is “increasingly concerned that the lines between policy and execution have become blurred.”

Robinson said that with tighter budgets, “the services must play a more active and influential role. It is difficult for the services to have the responsibility to execute a policy, and to be held accountable for said execution, without the ability to affect or influence the process.”

Lt. Gen. James Roudebush, the Air Force surgeon general, said the Defense Department health office should concentrate on policy and strategic issues and the Tricare agency should concentrate on holding down costs and working with the services to coordinate care.

Direct care from the services “needs to be robust and the centerpiece” of military health care, Roudebush said.

In theory, giving the services more control over regional health care budgets could lead to more money being spent on direct care and less on off-base care, although that is not guaranteed and the surgeons general did not say exactly what they would do.

Following up

Rep. Vic Snyder, D-Ark., said following up is a bit difficult because this is essentially an argument about organizational structure, and the effect on patients is not readily apparent.

There is some sympathy for the services in Congress, partly because the Obama administration and lawmakers have agreed to spend money to build new military hospitals as a way to both stimulate the economy through the creation of construction jobs and improve the quality of life of military families.

This would be a way for the services to begin treating more people who had been turned away from aging military facilities over the past decade as money, staffing and space have become scarce.

Another factor in congressional interest is the unusual structure of the Defense Department health affairs organization that gives it responsibility for both making and carrying out policy, which also raises questions for lawmakers.

Rep. Susan Davis, D-Calif., who chairs the personnel panel, said this dual-purpose structure “has no corollary in other defense agencies or activities.”

“We do not know if that is a good-different, a bad-different or just different,” she said.

Defense and Tricare officials said complaints from the services are nothing new, and provided lawmakers with a list of accomplishments resulting from defense-level control of health policy.

Arm Maj. Gen. Elder Granger, deputy director of the Tricare Management Agency, said these include creating standardized disease management programs for asthma, congestive heart failure and diabetes that have helped more than 50,000 beneficiaries and trimmed $30 million in costs; reducing pharmacy costs by encouraging contractors to shift prescriptions for expensive drugs to mail order instead of retail; and cutting premiums for reservists using the Tricare Reserve Select program by 29 percent.

Granger did not mention that the reserve premium reductions came after military associations complained to Congress, and a Government Accountability Office report confirmed that reservists were being overcharged.