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Too many beneficiaries of the military direct-care health system still can’t get timely appointments, or reach doctors after hours, or establish a close family-doctor relationship with a single military physician or group.

For these reasons and more , Army Maj. Gen. (Dr.) Elder Granger, deputy director of TRICARE and a principal advisor within the Department of Defense on health policy and performance, gave the military health system an overall grade of “C plus or B minus” in an interview with Military Update.

In the first half of our 45-minute phone interview, Granger reviewed steps being taken to improve health care and customer satisfaction. In the final half, pressed to explain the overall grade he give the system, Granger expressed frustration over the hurdles many beneficiaries still must clear, particularly to use military treatment facilities versus TRICARE’s expanding network of civilian providers. In fiscal 2008, the number of civilian providers accepting TRICARE patients grew by 115,000 to reach 1.1 million nationwide.

Users of military hospital and clinics, he said, too often face telephone busy signals in trying to make appointments. He wants more consistency in administrative support, from how phones are answered to how appointments are booked, from how providers are reached after hours to how health readiness is tracked and preventive care services are offered.

“How do you get to your primary care provider after hours? That’s a challenge we continue to work,” Granger said. “That’s why I’m being honest about this C+ or B-.”

There is uneven support online in the system, and improvements needed with electronic records, Granger said. He wants more emphasis too on disease prevention and measuring performance among health providers

How does a patient reach a military physician after hours?

“Well, it varies,” Granger explained. “Some places will say ‘Go to the emergency room.’ Some will say, ‘Call this number.’ Some will say ‘Call the hospital and get the administrative officer of the day.’ It’s not a consistent process. Yet our policy says we must take care of you 7-24-365. That’s why I’m being a little hard on us because we’ve got to get that under control.”

Every year more beneficiaries migrate from base hospitals and clinics to networks of civilian physicians under contract to TRICARE. The migration is seen in enrollments figures for TRICARE Prime, the managed care option. Since October 2003, the number of enrollees with civilian doctors has doubled, from 600,000 to 1.2 million while enrollees in military direct care have fallen by roughly 300,000 to stand below 3 million.

Patient workloads show a sharper drop. The number of inpatients in military hospitals in 2008 was 30,000 below the 2003 total, even as the beneficiary population grew, yet the number of military beneficiaries with stays in civilian hospitals rose by 80,000.

Walk-in visits to military facilities in 2008 were a million down from the 30 million reported in 2003. Meanwhile, military patient visits to civilian contract doctor climbed from 24 million in ’03 to nearly 40 million in ’08.

Various reasons are cited for the shift: base closures; downsizing (“right-sizing”) of Air Force facilities; wartime deployments of medical staff; overall growth in number of beneficiaries; a priority for wounded warrior care in military facilities. Granger suggested that more light also must be shed on how beneficiaries judge the performance of their health care system.

“If you look at the [Department of Veterans Affairs], they are very transparent about their quality. We have to be more transparent about our quality and outcomes,” he said.

As deputy director of the TRICARE Management Activity in Falls Church, Va., Granger, 55, leads a staff of 1800 in planning, budgeting and executing an $18 billion-a-year defense health program. He is responsible for ensuring access to quality healthcare for 9.2 million beneficiaries.

Granger said his boss, Dr. S. Ward Casscells, assistant secretary of defense for health affairs, also has been pushing for greater transparency. President Bush has too, signing an August 2006 executive order promoting quality and efficiency in federal health care programs through greater use of information technology and greater transparency on care quality and price.

Every year the Department of Defense conducts a Health Care Survey of DoD Beneficiaries, asking more than 200,000 users to report on the quality of their experience in the military health system. The results haven’t received much public attention but Granger’s staff noted the website where they are posted:

They show the military system falls below most “benchmarks” of beneficiary satisfaction from surveys of healthcare users across America. As expected the satisfaction gap is wider for military direct care than for users of TRICARE’s civilian networks. For example, the nationwide benchmark is 77 percent satisfaction with getting care quickly. For military beneficiaries who see military doctors, the comparable figure for quick care is 61 percent. It is 74 percent for military patients using TRICARE civilian doctors.

Likewise, the nationwide benchmark is 90 percent satisfaction with how well doctors communicate. For military beneficiaries who see military docs, satisfaction with communication is 83 percent. Patients of TRICARE civilian docs give an average score 89 percent, near to the benchmark.

The steady shift of patients away from military direct care is worrisome, Granger said, “because the backbone of our medical readiness is what we do within our military health care system and [by] sending our providers and nurses to the civilian sector to get training. That is…our go-to-war, support-the-war fighter readiness piece. So yes, I’m concerned.”

To comment, e-mail, write to Military Update, P.O. Box 231111, Centreville, VA, 20120-1111 or visit:


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