What are you doing in terms of broad strokes, to get more out of the DoD health care budget? How do items like electronic health records and better procurement policies look to help you control costs and improve service?

In my response to one of your earlier questions, I spoke of the comprehensive programs that MHS provides to ensure the health and fitness of our service members and their families. While this has proven to be an effective system for delivering health care at the home front and on the battlefield, we are implementing a number of initiatives to improve the health of our patients while enhancing their health care experience and supporting military readiness – all at the best possible cost. This is what we call the MHS Quadruple Aim.

The Quadruple Aim seeks to align care within the MHS to enhance the health of our population by reducing generators of illness through the encouragement of healthy behaviors; ensure the medical care experience is patient- and family-centered, compassionate, convenient, equitable, safe, and only of the highest quality; achieve maximum force readiness at all times; and manage per capita health costs by focusing on quality, eliminating waste, reducing variation and redundancies, and viewing health costs through the consideration of total cost of care over time, and not simply on the cost of individual health care activity. Like other health care providers, we have seen health care costs growing for a number of reasons. The number of beneficiaries has increased by nearly a million in just this decade; benefits have been expanded; existing users are consuming more of those services; and the rise in health care costs has been consistent with the inflation rate seen in the civilian health care sector.

That said, we have a number of goals designed to address not only the fourth quadrant in our Quadruple Aim – to manage costs effectively – but also to create a more efficient MHS. We’ll be looking to re-engineer our TRICARE contracts; introduce more aggressive market-based pricing initiatives; redirect our pharmacy to lower-cost venues; and create the patient-centered medical home – a concept which would redesign the delivery of health care in the MHS by focusing health care on the needs and experiences of the individual patient. This will include easy access to a quality physician, with proactive appointments for chronic and preventive care. The patient-centered medical home is structured around three primary elements of patient satisfaction in primary care. First, there must be appropriate access, convenience, and choice. Service members should not feel like a number. Second, there must be effective communication between the patient and the physician in a respectful environment. They should feel the physician is fully engaged in their immediate issues and concerns. And third, there must be continuity and quality – patients should expect the same experience regardless of where care is received. This concept has been endorsed by the Patient Centered Primary Care Collaborative as, “… consistently associated with better outcomes, reduced mortality, fewer preventable hospital admissions for patients with chronic diseases, lower utilization improved patient compliance with recommended care, and lower medical spending.”

How does the DoD health care funding base look in the next few decades, particularly in terms of the TRICARE budget? Is Congress stepping up to keep this funded at levels consistent with the needs of the force?

It is presently impossible to determine how TRICARE and the Military Health System will be funded by Congress in the future. Today, however, TRICARE is implementing several programs and initiatives to improve beneficiaries’ overall health while cutting costs through improved efficiency. A major effort is under way to increase the use of TRICARE’s Pharmacy Home Delivery option, which allows patients to receive their prescription medications through the mail at a substantial savings to both the patient and the government. Federal pricing in the retail pharmacy network alone is projected to recoup over $1 billion this year. And the modified Outpatient Prospective Payment system has already saved us many more millions.

What future trends and technologies do you see emerging in the defense health areas in the next few years? In particular, what developments in the area of combat medicine does your office see coming in the future, and how do you see them improving the survival and recovery rates of soldiers wounded in battle?

Each year, we devote more than $1 billion in research funding to programs in information technology and medical training, military infectious diseases, combat casualty care, military operational medicine, clinical and rehabilitation medicine, radiobiology, as well as congressional special interest items including breast and prostate cancer. There are more than 40 DoD biomedical laboratories and research centers located across the globe, each seeking new ways to treat wounds sustained in combat, fight infectious disease, and contribute to the overall health and readiness of our service members and others.

As for our present conflicts, survival rates for Operation Iraqi Freedom and Operation Enduring Freedom have been the highest in U.S. military history, due in large part to innovations and training techniques that have made an immediate difference on the battlefield. As an example, a 2005 study conducted by the U.S. Army Institute of Surgical Research led to the development of a standard combat application tourniquet for use by service members in the field. All service members are required to be versed in its use. The No. 1 cause of death for members of the military in combat is blood loss. Due to this innovation, wounds that might have caused death in the past are being properly clamped to prevent blood loss, leading to higher chances of survivability.

Now, we certainly still have a long way to go. Our focus for 2011 will be to find new ways to tackle post-traumatic stress disorder and traumatic brain injury; enhance prosthetic research; conduct more research into the treatment of burns and burn healing techniques with an emphasis in reducing scars to the extent possible; improve vision and eye care research through our new Vision Center of Excellence; and improve hearing through the new Hearing Center of Excellence.

With the recent passage of national heath care how do you see the health systems of DoD fitting into the new health care dynamic developing in America over the next decade? What does DoD have to offer to this evolution in the way of processes, technologies, and experience?

TRICARE already meets, with one exception, the provisions of the Patient Protection and Affordable Care Act that went into effect in September. There are no annual dollar limits, lifetime maximums, “high user” cancellations, or denial of coverage for pre-existing conditions for the more than 9.6 million active-duty military, retiree, and family members using TRICARE. Beneficiaries currently enjoy access to a wide variety of preventive care services and screenings without co-pays or cost shares. There are bills pending in the U.S. Senate and U.S. House of Representatives that would extend dependent medical coverage up to age 26. [The National Defense Authorization Act of 2011 did, in fact, extend TRICARE coverage to children of service members to age 26.]

The Military Health System is also a leader in electronic health record [EHR] development. Medical personnel in all fixed and deployed military treatment facilities around the world already use centralized EHRs. The EHR allows health care personnel to access complete, accurate health data to make informed patient care decisions – at the point of care – anytime, anywhere in the world. This is the first system to allow for the central storage of [a] standardized EHR data set that is available for worldwide sharing of patient information. We are also actively exploring the basis for our next-generation EHR, and are also focused on working more closely with the VA on electronic health records overall.

It is a sad reality that wartime tends to accelerate progress in areas like emergency medicine and long-term health care for the warfighters. How do you see such developments trickling down to the civilian health care industry in the next decade, and can you give us some examples that already are there today?

It is certainly true that the exigencies of the battlefield and its injuries drive medical innovations, which almost always filter their way into civilian medicine, becoming a benefit for all. From the first instance of mass inoculations for a fighting force, to the discovery of bacteria, military medicine has been at the forefront of tremendous advancements, which we take for granted today. Fortunately, it doesn’t always take a war for the Department of Defense to spearhead medical achievements. Just last year, U.S. Army researchers in Thailand conducted a trial of a new HIV/AIDS vaccine, which had a success rate of 31 percent. While this doesn’t appear to be a significant percentage, this result has been much more successful than previous efforts, and represents real hope for millions who suffer from this dreaded disease. Each of our armed services conducts and sponsors medical research and development activities which benefit civilians as well as soldiers. We are feeding back our experiences with the Institute for Surgical Research, and also through our collaborations in critical care training at sites such as the R Adams Cowley Shock Trauma Center in Baltimore, Md., and the University of Cincinnati.

This article first appeared in the Year in Defense Annual 2010 Review Edition.