TRICARE Overseas PacificYear in Review,

Today’s Challenges, Tomorrow’s Solutions

Director, TAO-Pacific

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TMA Announcement/Direction

Request For Proposal & New Overseas contract is off limits and will NOT be discussed. Any questions should be directed to POC below:

Mr. Thomas L. GriffinContracting Officer

TRICARE Management ActivityPh: 303.676.3823 FAX: 303.676.3987

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Military Health System (MHS) Mission

Our team provides optimal Health Services in support of our nation’s military mission — anytime, anywhere.

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MHS Mission

Patient Care, Sustain Skillsand Training

Promote & Protect Health of the Force

Deploy toSupport the Combatant

Commanders

to and

In Peace & War

Manage Beneficiary Care

Deploy A Healthy Force

Manage Beneficiary Care

Deploy A Healthy Force

Deploy Medical Force

Manage Beneficiary Care

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MHS Vision• The provider of premier care for our warriors and

their families • An integrated team ready to go in harm’s way to

meet our nation’s challenges at home or abroad

• A leader in health education, training, research, and technology

• A bridge to peace through humanitarian support

• A nationally recognized leader in prevention and health promotion

• Our nation’s workplace of choice

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TRICARE Facts and Figures

9.2 million TRICARE Eligible Beneficiaries• 5.0 million TRICARE Prime Enrollees • 2.2 million Non-enrolled Users • 1.6 million TRICARE For Life • 167,000 TRICARE Plus • 96,000 US Family Health Plan • 75,000 Age 65 & older (not TRICARE For Life) • 57,000 TRICARE Reserve Select

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TRICARE Facts and Figures

MHS Direct Care Facilities• 63 Military Hospitals • 413 Medical Clinics • 413 Dental Clinics

133,500 MHS Personnel• 89,400 Military • 44,100 Civilian

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$42.2 billion FY07 Budget(Unified Medical Program)

• $23.7 billion Defense Health Program • $11.2 billion Medicare Eligible Retiree

Accrual Fund • $6.9 billion Medical Military Personnel• $0.4 billion Medical Military Construction

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A Week in The Life of the MHS

18,500 Inpatient Admissions• 4,800 Direct Care • 13,700 Purchased Care Outpatient Workload (Direct care only)• 664,000 Professional Outpatient Encounters

2,240 Births• 980 Direct Care • 1,260 Purchased Care

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A Week in The Life of the MHS

2.3 million Prescriptions• 1.2 million Retail Pharmacies • 940,000 Direct Care • 175,000 Mail Order

3.7 million Claims Processed

$809 million Weekly Bill – Purchased care

Year In Review

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Wounded Warrior Program• Most significant Military Health Issue• Walter Reed and Disability System Issues• DOD and Congressional Support • VA Partnerships• TMA and Service Initiatives

“More than just medical care at the bedside, but the comprehensive levels of coordination, communication, and caring for America’s heroes”

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The Dole-Shalala Commission Recommendations (10/2007) :

1. Modernize and improve the disability and compensation systems

2. Aggressively prevent and treat post traumatic stress disorder (PTSD) and traumatic brain injury (TBI)

3. Significantly strengthen support for families 4. Create comprehensive recovery plans to provide the right care

and support at the right time in the right place 5. Rapidly transfer patient information between DoD and the VA 6. Strongly support Walter Reed by recruiting and retaining first-

rate professionals through 2011

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PTDS, MH, Wounded Warrior

• On-line tools for AD and family (PTDS/MH)– http://www.afterdeployment.org/– http://www.MilitaryOneSource.com– http://www.mentalhealthscreening.org/– http://www.tricare.mil– http://www.militarymentalhealth.org

• Wounded Warriors – Service Links– http://www.aw2.army.mil – http://www.npc.navy.mil/commandsupport/safeharbor – http://www.afwounded.warrior@randolph.af.mil – http://www.m4l.usmc.mil

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Sesameworkshop.Orghttp://archive.sesameworkshop.org/tlc/index.php

This bilingual (English and Spanish) multimedia outreach program is designed to support military families with children between the ages of two and five who are experiencing deployment, multiple deployments, or a parent's return home changed due to a combat-related injury.To order your FREE kit, visit Military OneSource.Download the materials: • • Magazine for Parents and Caregivers (PDF) • • Children's Poster (PDF) • • Facilitator Guide (PDF) • • Supplement to the Facilitator Guide (PDF) Download the videos: • • Deployments (WMV) • • Deployments (For Grown Ups) (WMV) • • Homecomings (WMV) • • Homecomings (For Grown Ups) (WMV) • • Changes (WMV) • • Changes (For Grown Ups) (WMV) Download the music: • • Proud (MP3) • • Change (MP3) • • Change - Raul Midon (MP3) • • We Can Do It (MP3)

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Seamless transition of health services from MHS and the VA - critical elements:

• A full understanding of medical care capabilities within both agencies by all medical providers involved,

• Clear communications of the transition plan between providers in each agency and with the patient and patient's family,

• Timely transfer of all pertinent medical records before or at the time of transfer of the patient, and

• Ongoing communication after the transfer of the patient between the medical providers in each agency and with the patient and patient's family.

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Centers Dedicated to Wounded Warrior Care

• Walter Reed Army Medical Center Amputee Care Center and Gait Laboratory

• National Naval Medical Center’s Traumatic Stress and Brain Injury Program

• Center for the Intrepid - state-of-the-art rehabilitation facility and Brooke Army Medical Center Burn Center at Ft. Sam Houston

• Naval Medical Center San Diego Comprehensive Combat Casualty Care Center

• The multi-site DoD/VA Defense and Veterans Brain Injury Center for patient care, education, and clinical research

• Warrior Transition Units – later brief

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Overseas Contract

• Off limits for conference discussion

• See Section C in RFP for Identification of Contract Requirements

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ADSM Travel Benefit• Expanded TGRO benefit to MTF countries• Implemented on April 14, 2008• Covers urgent and emergent care throughout

Overseas Countries -(Deployments / Exercises / TDY / Leave)– Guarantee of Payment– Referral and Medical Advice– Right of First Refusal

• ADFM benefit (emergent care) October 2

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ADSM Claims Processing - WPS

• Pacific ADSM not referred under supplemental health care program can now file claim through WPS

• Previously, ADSM had difficulties getting reimbursement from Units or MTFs

• Does not substitute for Supplemental Health Care Program

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Shipboard Referral for Care

• Seventh Fleet message – Aug 1, 2008– Clarifies program, roles and responsibilities

• 7th Fleet SG / TAO-P Medical Director will discuss in more detail in later session

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TAO-P Satellite Offices

• Philippines support >12K retirees/families– More detail in later session

• Korea – Senior leadership request/support– Deputy Director TMA working with Leadership– Update from Korea in later session

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Retiree Dental Program

• Startup in Overseas Locations 10/1/2008• Monthly Premium:

– Single: $37 2-Person: $71 Family: $118• For more information, see TRDP.Org

• Retirees continue to get Space-A care• Provides insurance for HN referrals

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TRICARE Cost and Workload

Does Not Include Supplemental Health Care Claims

Totals for FY07 Institutional and Non-Institutional Care as of 10/8/08

Admissions Paid Visits PaidKorea 626 $2,598,698 6,138 $1,253,982Japan 454 $1,308,379 11,119 $577,618Guam 33 $57,717 7,473 $2,003,125Philippines 2866 $10,905,584 157,941 $23,433,129

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FY07 Admits Cost and WorkloadKorea Admits Paid

373 120 $265,589 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES371 42 $180,932 CESAREAN SECTION W/O CC391 37 $22,441 NORMAL NEWBORN275 20 $51,028 MALIGNANT BREAST DISORDERS W/O CC469 20 $81,532 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS369 18 $50,001 MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS404 18 $23,556 LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC082 17 $59,064 RESPIRATORY NEOPLASMS

Japan Admits Paid373 164 $526,740 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES469 29 $79,782 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS391 15 $13,124 NORMAL NEWBORN183 9 $27,488 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W/O CC379 8 $26,781 THREATENED ABORTION

Guam Admits Paid391 3 $3,506 NORMAL NEWBORN630 3 $4,267 NEONATE, BW >2499G, W/O SIGNIF OR PROC, W OTHER PROB373 2 $9,174 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES

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FY07 Visit cost and workloadVisits Paid Korea5002 $1,107,717 Facility outpatient charges *

478 $47,920 General Practice281 $37,431 Speech Pathologist/Speech Therapist

0 $25,870 Pharmacy237 $16,309 Clinic or other group practice

Japan6488 $340,812 Facility outpatient charges *1242 $108,048 Medical Supply Co1177 $44,904 General Practice

0 $31,745 Pharmacy433 $14,260 Obstetrics/Gynecology

Guam91 $427,893 Radiology

0 $331,551 Pharmacy1532 $283,474 General Practice2237 $274,720 Facility outpatient charges *

171 $216,580 Medical Supply Co

* ambulatory surgery, hospital services

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TPMRC Medical Evacuation ’08

Total TPMRC Transports 3262 Commercial Air 2480 Routine 3059 Rail 427 Priority 123 MILAIR 355 Urgent 46

Primary Specialty Orthopedics 578Psychiatry 313Neurosurgery 231General Surgery 170OB 162

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TPMRC Medical Evacuation ’08

Medical Evacs Origination MTF Medical Evacs Destination MTFNH OKINAWA 714 TRIPLER 1269IWAKUNI 611 NH YOKOSUKA 769SASEBO 394 NH OKINAWA 505NH YOKOSUKA 394 NH SAN DIEGO 229MISAWA 311NH GUAM 268YOKOTA 230121 GENERAL HOSPITAL 172ANDERSON 102DIEGO GARCIA 31OSAN 25

Today’s challengesTomorrow’s Solutions

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Upfront Payment HN Care

Challenge: Financial burden on patients/ Impact on HN provider relationships

Solutions:• Supplemental Health Care Program• Relief Societies – no cost loan• MOU HN support for delayed payment• TSC support for claims filing – later brief• See Section C

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Supplemental Health Care

• 32 C.F.R. § 199.16   Supplemental Health Care Program for active duty members – (a.3) This section applies to all health care services

covered by the CHAMPUS. For purposes of this section, health care services ordered by a military treatment facility (MTF) provider for an MTF patient (who is not an active duty member) for whom the MTF provider maintains responsibility are also covered by the supplemental care program and subject to the requirements of this section.

• MTFs should work with Service Resource Management to clarify Service positions

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Supplemental Health CareThe SHCP exists under authority of 10 USC 1074(c) and

32 CFR 199.16(a)(3). The use of the SHCP for pay for care referred by MTF providers is governed by Assistant Secretary of Defense (Health Affairs) (ASD(HA)) Policy Memorandum 96-005, “Policy on Use of Supplemental Care Funds by the Military Departments” (October 18, 1995).

That policy states, in pertinent part:“Circumstances where supplemental funds may be used to

reimburse for care rendered by non-governmental health care providers to non-active duty patients are limited to those where a medical treatment facility (MTF) provider orders the needed health care services from civilian sources for a patient, and the MTF provider maintains full clinical responsibility for the episode of care. This means that the patient is not disengaged from the MTF that is providing the care.”

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Network Providers

Challenge: MOU providers are not network providers / Acceptance of our Patients

Solutions:• Clear Communication and Understanding• Roles and Responsibilities for MTFs, HN

Providers and Beneficiaries• Timely and Accurate payment is Key• See Section C

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Understanding HN Care

Challenges: Patients don’t know what to expect when referred to HN providers

Solutions:– Guide to understand differences between US

and Japan/Korea/Guam/Remote health care systems

– Pregnancy and Delivery Guides – Videos and Books– Sensitivity to HN provider’s profession/culture

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Emergency Care in Japan

Have your local address availableOff Base dial 119; On Base dial 911

Do not hang up until directed to do so

Helpful phrases: Emergency. Help Kyuu-kan desuI don't speak Japanese Nihongo WakarimasenDo you speak English? Eigo WakarimasukaI need an ambulance Kyuu-kyuu sha O negai shimasu

-- Preauthorization is not required for emergency care-- If you are treated in a host nation hospital, contact the TRICARE Service Center or your unit as soon as possible. Visits by MTF staff or relocation to an MTF may be possible.

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Emergency Care in Korea

Have your local address availableOff Base dial 911; On Base dial 911

Do not hang up until directed to do so

Helpful phrases:

Emergency. Help. Eung Geup! Do Ah Joo Sae Yo!I don't speak Korean. Han Gook Mar Mot Hae Yo.Do you speak English? Young Uh Ha Sae Yo?I need an ambulance. Am Bue Lan Ce Boo Juh Hoo Sae Yo!

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Command Sponsored Prime

Challenges: Non-command sponsored ADFM not eligible for Prime.

Solutions:– Seek command sponsorship – Personnel issue– If Services allow, use supplemental health care for

referrals– Relief Societies for no cost loan

ADFM non Prime Responsibilities:– $1000 catastrophic cap / 20% copayment /

$150 Individual or $300 family deductible

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DoD Civilian / Contractor Care

Challenges: HN provider expect MTFs to pay for all “American” care / Issues with civilians and contractors affect TRICARE

Solutions:– Educate HN providers and de-link TRICARE– Clear understanding – patient “on own”– Identify participating HN providers for

insurance carrier (Next slides)– Not in Section C

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Blue Cross/Blue Shield HospitalsSeoul, Korea

Seoul Adventist Hospital

General Hospital

29-1 Hwi Kyung-Dong Seoul, South Korea

Soon Chun Hyang University Hospital

General Hospital

657 Hannam Dong Seoul, South Korea

Seoul Wooridul Spine Hospital

Orthopedic/Spine Treatment

47-4 Chungdam-Dong Gangnam-Gu Seoul, South Korea

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BC/BS Providers (22 in Seoul)

Chai, Soo Eung, Urology Samsung Medical Center #50 Ilwon-Dong

Chu, In Sook, Pediatrics

Samho Apt.Annex Room 201, Seocho-Ku

Kim, Young Joe, Orthopedics Samsung Cheil Hospital

Lee, Eil-Soo, Dermatology

Samsung Medical Center #50 Ilwon-Dong

Lee, Je Ho, Obstetrics & Gynecology Samsung Medical Center #50 Ilwon-Dong

Linton, John, Family Practice Severance Hospital, Intl Clinic

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Find a Provider – Blue Cross / Blue Shield (Seoul, Korea)- similar in Japan25 providers matched your search criteria. To arrange service with a provider, or if you did not find a suitable provider, please contact the Overseas Service Center 1-800-699-4337 or call collect at 1-804-673-1678.

Civilian or contractor – patient responsibility! Clearly communicate! No confusion for MOU providers.

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Infrastructure Changes

Challenges: Planning for force structure changes (Guam/Japan), Normalization (Korea), Deployments (All)

Solutions:• Work with Services to ensure right size of

MTF for capabilities and capacities • See Section C• Use business planning tools (later brief)• Later briefings of Footprint changes

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Drive Times to HN Providers

Challenges: Long drive times to HN providers for emergencies

Solutions:• USFK or USFJ medivac system (Heli)• MOU or contract with local host nation

medivac system – Dr. Heli• Travel times are relative – compare with

Medivac to Hawaii or CONUS

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Host Nation Providers

Challenge: Cultural Differences, Quality of Care, Acceptance of referrals

Solutions:• Educate Beneficiaries

– What to expect when referred• Visit Providers, Survey patients• Pay bills, See Section C• Later briefings to cover

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HN Relationship Building

• Don’t just focus on CEOs, middle managers (Admissions, Billing) may be just as important

• Tea is ok, but sake/soju/scotch may be better• Invite to base, MTF, golf course• Understand the culture and traditions

– Small gifts, coins, letters of appreciation• Respect – they don’t need our business

Good Relationships are Key for Success – MTFs will need to foster even under new contract

Other Health Care Challenges

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U.S Health Care

• Despite spending over $2 trillion a year on health care - 18% of the U.S. GDP and twice as much as any other nation

– United States ranks only 45th in life expectancy and 37th in a World Health Organization study on the performance of national health systems. 1,2

1 CIA: The World Factbook, June 19, 2007.

2 "Health Systems Performance Assessment," World Health Organization

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U.S. Health Care

• In 1960, health care accounted for $1 of every $20 spent in the US economy

• In 2008, it is $1 of every $6• Congressional Budget Office estimates it

could be $1 of every $4 by 2025

How Does DOD Health Spending Compare?

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Growth in the Unified Medical Budget(Excluding GWOT)

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07

FY2000 Unified Medical Program Price Inflation Volume/Intensity/Cost Share Creep, etc.

New Users <65 Explicit Benefit Changes to <65 Explicit Benefit Changes to 65+, i.e. TFL

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Value of Managing Defense Health Spending

$-

$10

$20

$30

$40

$50

$60

$70

FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15

AnnualTotal

DefenseHealth

Expenditures($B)

CumulativeAmount = $84B If DoD Health Budget

grows at recent trend rates, it will reach $64 B, or 12% of DoD topline in 2015

If DoD Health Budget managed to 8% of DoD topline, budget will reach $44 B in 2015

2006 DoD Health Budget = 8% of total DoD Budget Projections are for 12% by FY 2015

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Federal spending will more than double, driven by Medicare, Medicaid and Social Security

Medicare

Medicaid

Social Security

Defense

Other

Net Interest

45-Year Historical Level of Tax Revenue

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

1975 1985 1995 2005 2015 2025 2035 2045

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Source: Calculations based on Congressional Budget Office (CBO) Data.

Total Federal Spending and Tax Revenue as a Percentage of GDP

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MHS Predictions

• Defense budget increases will slow• Shift of healthcare resources from DOD to

Veterans Affairs• Continued Shift of Health Care Resources from

MTFs to Civilian Sector• Transparency will increase for cost and quality of

medical care – Performance• Senior DoD leadership will Challenge MHS to

become more efficient and effective

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Fixing our Health Care System • The public needs to be educated about the differences

between wants, needs, affordability, and sustainability at both the individual and aggregate level

Ideally, health care reform proposals will:• Align Incentives for providers and consumers to make

prudent decisions about the use of medical services,• Foster Transparency with respect to the value and

costs of care, and• Ensure Accountability from insurers and providers to

meet standards for appropriate use and quality• Ultimately, we need to address four key dimensions:

access, cost, quality, and personal responsibility

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Key Leadership Attributes Needed for These Challenging Times

Courage

Integrity

Creativity

Partnership

Stewardship

Questions?Discussion