Originally Broadcast Saturday, April 21, 2007

Washington, D.C.

Welcome to The Business of Government Hour, a conversation about management with a government executive who is changing the way government does business. The Business of Government Hour is produced by The IBM Center for The Business of Government, which was created in 1998 to encourage discussion and research into new approaches to improving government effectiveness.

You can find out more about the Center by visiting us on the web at businessofgovernment.org.

And now, The Business of Government Hour.

Mr. Morales: Good morning. I'm Albert Morales, your host, and managing partner of The IBM Center for The Business of Government.

From frontline combat support hospitals to its TRICARE program, the military health system provides health care services to its troops and their families on multiple fronts. Today, military medicine is saving hundreds of lives that previously would have been lost on the battlefield. Better training and medical readiness of service personnel have contributed to this success.

A critical component in sustaining the medical readiness of U.S. service personnel is DoD's TRICARE program. With us this morning to discuss the TRICARE program is our special guest, Major General Elder Granger, Deputy Director, TRICARE Management Activity, within the Department of Defense.

Good morning, General.

MG Granger: Good morning, and thank you.

Mr. Morales: And joining us in our conversation is Russ Sanford, partner in IBM's DoD consulting practice.

Good morning, Russ.

Mr. Sanford: Good morning.

Mr. Morales: General, to provide proper context around the subject of military medicine, could you give us a general sense of the purpose, mission, and scale of the Department of Defense's Health Affairs, and specifically, the military health system?

MG Granger: I'll tell you, the military health system, first of all, its mission is to provide world-class health care anywhere anytime, to more than 9.2 million beneficiaries scattered throughout the globe and around the world. And what we really want to do is making sure that we're training a medical force, deployed with our military allied force, we're making sure we're protecting that force that we deploy with. And third thing we're doing, we're putting in preventative health care, and managing the health of our military communities. That's what I see our overall mission when you start looking at the military health care system. And how does TRICARE fit in that big piece? I'd call it the three legs of what we do.

We have a direct care system, we have a purchase care system, and also we have part of the system where we do other things; i.e., with the other contractors, whether it be with pharmacy or with our managed care support contractors, but that's what we call our military health care system.

Mr. Morales: General, you've given us a brief overview of TRICARE. Can you give us some more specifics in terms of how it's organized, how does it operate, the size of the budget, and finally, how many full-time employees work within your specific organization?

MG Granger: I would say, if you look at TRICARE Management Activity, it was first established in February 1998. And as I stated, it's designed to be that military managed care arm, and it consists of approximately 9.2 million beneficiaries. And we have a staff of approximately 1,500 that include DoD civilians, contractors as well as military forces. And if you look at the budget, it equates to roughly around about $11 billion, and that budget is designed to take care of our managed care support contractors, and that includes our pharmacy contract, a TRICARE for life contract, and other small contracts, to include a designated provider program.

Mr. Sanford: General, you've told us of TRICARE, you know, given us an idea of the size and the scope of TRICARE. But can you give the listeners an idea of the specific responsibilities, and the duties that you hold as the Deputy Director of the TRICARE Management Activity?

MG Granger: Absolutely. In my duty, I'm not only the Deputy Director, I'm the Chief Operating Officer for TRICARE. And in that responsibility, I advise the Assistant Secretary of Defense for Health Affairs, Dr. William Winkenwerder, who as the director of TRICARE Management Activity on Health Policies, is making sure we're executing the TRICARE program in an appropriate manner, we're holding the contractors responsible and accountable. And also we're doing something that's unique, too -- we're working with the contractors, as our true partners, as we manage the benefit around our beneficiaries. So at the end of the day, you've got the TRICARE leadership, myself, and including our staff, as well as the services -- I cannot leave out that important point -- as part of managing this $11 billion and growing managed care support, part of the TRICARE program.

Mr. Sanford: Given your responsibilities and duties that you've got, as you said, you know, Deputy Director as well as the COO, what do you view as the top three challenges that you're faced with, and how do you address those challenges?

MG Granger: If I had to look at it this way, I would use what I call the five Ps. I call the first P people. We've got to make sure we've got the right systems in place. And when I'm talking about people, I'm talking about our beneficiaries, to make sure we're putting in prevention, number one. Number two, we're managing those acute conditions, medical conditions; number 3, we're managing those chronic conditions. That's the first P. And the last thing about that first P, we've got to make sure that our staff are trained to manage this huge responsibility and contract activity.

The second P is what I call processes. Do we have the right business processes in place to make sure we're minimizing the risks for our taxpayers with these contractors? And we're trying to seek -- and we take some of the best practices in term of processes from the private sector and managing this process or these contracts. The third P I call is prevention. Prevention can be looked at in several different ways, not only disease prevention, but what are we doing to prevent some of the problems we had years ago with TRICARE in terms of issues with claims not being paid timely?

We have a very robust claim process in place; they process over 14 million claims a year, with a 99.9 percent pay-on-time in less than 30 days in accuracy. That's the second thing. The fourth P I call is are we truly being productive. Productivity in my opinion means you're talking about effectiveness plus efficiency. Are we taking the dollars that we've been entrusted with, are we being effective, are we putting in processes that would be proficient. And last but not least, are we taking those ideals and inculcating them throughout our entire military health care system. The last P, I call it price. We're entrusted with what is a large amount of money when you start talking about $11 billion.

Are we being truly cost effective with those $11 billion, are we serving the American public and our government, but at the same time, we're not taking a dollar saying look, we're going to neglect the health care, those we serve our beneficiaries by not doing the right thing based on dollars. At the end of the day, we don't want to never sacrifice the care we need to take care of those we serve, based on the dollar. We've got to be cost effective as a health care system.

Mr. Morales: That's a very broad mission, and I like the way you sort of organized it in ways that make sense. Before this show, we had an opportunity to chat a little bit about your career, starting in Arkansas, working your way through Colorado, Germany, and back now to Washington. Can you describe for our listeners your career path? How did you get started in the Army and in medicine?

MG Granger: Well, first of all, I started off in high school working on a program that was called the Neighborhood Youth Program. That was a fellow program started back in latter '60s and early '70s. I had an opportunity to work in a National Guard armory in my hometown, West Memphis, Arkansas. And while working there, there was one officer by the name of Chief Long. He took an interest in me -- I was attending high school with his daughter -- and he asked me would I consider joining the National Guard.

And you know, during the early '70s, we were still in Vietnam, and I said, look, I love what they do here in the National Guard, I want to be a part of this unit, but he had to convince my parents. So he convinced my parents, and I joined the National Guard on the delayed entry program. I joined in my senior year. I was delayed until I finished high school, and after high school, I went to basic training at Fort Polk in Louisiana. And I always wanted to be in something in medical, so I qualified based on my military tests, which you take at that time to become a medic.

So I served the National Guard for about 2-1/2 years, and when I started college January of 1973, I was walking through freshman orientation. I saw a table over there, and as a freshman, they say get in each line as you go through these different lines. I saw the ROTC table. There was three people at that table. So I said, I want go to this table to try to get ahead of the crowd. I saw military guys there. So what I did, I walked up there, they are smiling, I'm smiling, too. They said, "well, why are you here?" I said well, I was told to go to the next table where there's an empty line or short line. They said, "What do you know about ROTC?" Reserve Officer Training Corps, at that time. I said I have no idea. I said, I'm in the National Guard.

And they said, "oh, you're in the National Guard," and they said, well, you can sign up for ROTC, if you had good grades or decent grades out of high school, then you can become -- get a scholarship and become part of ROTC. So I applied for the following school year and I got accepted for an ROTC scholarship, did well in college, got accepted to Medical School, University of Arkansas.

And at that time, we had the Army Health Professional Scholarship program, and I got accepted for that program, and the rest of that is history. I went to Fitzsimmons after completing medical school at the University of Arkansas, and I trained there in internal medicine, sub-specialized in hematology-oncology, which is blood disease and cancer. After that, I decided to stay in the military, because my obligation when I completed ROTC plus medical school was a total of eight-year obligation, and with my National Guard time, by the time I finished my obligation, had a total of 14-plus years here.

Mr. Morales: That's fantastic. You've obviously had some great experiences. I'm curious: how has your experience both as a medial doctor and as a field commander prepared you for your current leadership role, and shaped the management approach and leadership style that you bring to your role now?

MG Granger: I want to say that I practiced medicine practically full-time up to about almost 17 years, 18 years of my military career. And I always wanted to be in a position to make a difference in how the system operates in terms of access, quality, you know, all those things we talked about in terms of health care, how it can be more efficient to take beneficiaries. So I was encouraged around about 1992, when I was a brand-new Lieutenant Colonel, the only way you can improve the system, you've got to get in and take on some leadership roles.

So I took my first job as a Deputy Commander of a hospital at Fort Huachuca in Arizona. Very small hospital, total mission support to men and women of the signal and military intelligence branch out there at Fort Huachuca, and I sort of got the bug. In that small place, worked with a great team, was able to do a lot to improve health care for that community.

And after I left there, I got an opportunity to go back and be with what I call being with the line, as a division surgeon at Fort Carson. And each step along the way, working with what we do day-to-day in our military treatment facilities, working with the line, and what we do to take care of troops and troop health care, our battalion aid station.

I saw a need that I could make a difference. And as I moved up the system, meeting commanders, going to the Army War College, with my line colleagues and commanding Landstuhl on a critical time of my military career -- USS Cole happened -- and I saw a need to continue to stay on that track. And after 9/11, when I left Landstuhl, General Peake, the Army Surgeon General asked me to come work for him, and I started working 9/11.

So I think those jobs: Landstuhl, coming back to Washington, being in Washington, going back to Europe serving as a regional medical commander and a TRICARE lead agent for all the services in Europe, has really prepared me in such a way to really focus on this job. And last but not least, my experience as a senior medical commander with the 18 Airborne Corps out of Fort Bragg and the commander of the 44th Medcom, being the senior medical commander and surgeon in Iraq really sort of culminated in preparing me for this job as the Deputy Director, and Chief Operating Officer and senior adviser to Dr. Winkenwerder on the TRICARE program.

Mr. Morales: It's just a wonderful set of experiences.

How has the level of operational tempo impacted TRICARE's ability to manage and provide health care services to servicemembers?

We will ask Major General Elder Granger, Deputy Director, TRICARE Management Activity, to share with us when the conversation of our management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Major General Elder Granger, Deputy Director, TRICARE Management Activity.

Also joining us in our conversation is Russ Sanford, partner in IBM's DoD consulting practice.

General, could you elaborate on the different benefit packages and plan eligibility provided under the TRICARE program? And in what ways does the TRICARE program differ from its predecessor program, called CHAMPUS?

MG Granger: Well, first of all, let me go through the programs. We have what is called TRICARE Prime. This is where you enroll to a primary care provider, and you can select from a menu of providers at our military treatment facilities, or in some cases in our TRICARE management activity network, our managed care support providers.

In this program, we have approximately 5.2 out of 9 million beneficiaries enrolled in this program. That's the first program. The second program is what we call TRICARE Extra, whereby there is a network that's been established by our managed care support contractors. And if you go to those providers that's in that network, you get a discount in terms of your care or your cost sharing or co-pay that you have to provide.

The other program is what we call TRICARE for Life. This program was established for our TRICARE beneficiaries over the age of 65 as a combined program with the Center for Medicare and Medicaid, whereby, once you become age 65, or prior to becoming age 65, you enroll in Medicare Part B, and Medicare pays 80 percent, TRICARE pays 20 percent of those coverage that is covered by TRICARE -- or both by TRICARE and Medicare from that standpoint.

The third program is what we call TRICARE Plus. And TRICARE Plus is where, if you're over the age of 65, you can enroll in the MTF based on space available. The Military Treatment Facilities, the MTF, will say that look, we have space for X number for those over the age of 65, and they can stay with the Military Treatment Facility beyond the age of 65.

We have approximately 169 individuals enrolled in our TRICARE Plus program. For our TRICARE for Life program, it's about 1.6 million beneficiaries. The other program is what we call the U.S. Family Health Plan. It's approximately close to 100,000, and that is located along the East Coast and was designed to be a replacement for our old Public Health Service hospitals. We do have one located down in the Texas area. But that program consists of -- once you're in that program, it's a capitated program in terms of cost; you're not allowed to participate in any other programs. You cannot go to a Military Treatment Facility -- you know, emergency we'll see you. But everything's provided by this program. It enrolls active duty, active duty family members, retired members and their families, as well those over the age of 65.

We also have approximately 34,000 enrolled in our TRICARE Reserve Select program, which has been going on since we started the Operation Enduring Freedom/Operation Iraqi Freedom.

And the last is about 2.2 million beneficiaries in what we call TRICARE Standard. And this is just they go out and it's almost like fee for service. And they have a co-pay pay, and they have a deductible, and there's a maximum amount we pay in terms of catastrophic cap. And that catastrophic cap is $3,000 for those individuals.

But those are the major programs. There are a few other programs. We have the Active Duty dental program, which is about 1.7 million beneficiaries; we have the Active Family Member program, which is about 1.8. And there's something unique, the third program is a TRICARE retiree dental program. It is 100 percent covered by the retirees enrolled in this program on a premium base. This is strictly now to the United States, but we just put in a proposal to expand this program over the next year to overseas. But those are our major programs.

Mr. Morales: General, you talked about Operation Iraqi Freedom, and earlier, we talked about 9/11. Certainly given the Global War of Terrorism, I'm curious, how has the level of operational tempo impacted TRICARE's ability to manage and maintain health care services to its members? And has it created challenges around funding, staffing or technology?

MG Granger: Let me just talk about that. Well, first of all, that's the whole idea years ago when we established -- went from having 12 or 13 TRICARE regions down to three. We had to have a buffer whereby if we could not take care of you in our Military Treatment Facility, called the Direct Care System, there is a robust, what we call TRICARE Network, and that consists of right now over 200,000 providers, something like 50,000 hospitals. And you look at it from our TRICARE pharmacy program, over 55,000 pharmacies throughout the country; that program has the flexibility to expand, if we can't take care of them in our Military Treatment Facilities, it can expand and serve as that catcher's mitt -- a coordinated, integrated health care system for the TRICARE management activity.

So from an operational standpoint, our managed care support contractors and partners have been in step with us and they've given us that expansion capability. From a budgetary standpoint, have there been some budgetary challenges? Absolutely yes, but from that standpoint, Congress and our senior leadership have been very supportive in getting us the resources we need to not only support the ongoing operation, but in addition, making sure we have what we need to support our men and women on the battlefield from the point of injury, whether it be using electronic health care record, handheld devices, using the latest technology in terms of blood products, et cetera, all the way to our first Level-4 as we call the Level-5, Landstuhl, all the way back to the Walter Reed, Bethesda and Brook Army Medical Centers and Wilford Hall and Balboas and other major medical centers throughout our country.

So to summarize this, we have the managed care support contractor to assist the direct care system, and 70 percent right now of the health care we provide is in the private sector in terms of our managed care support contractors. We have internally the electronic health care record to get data to flow from point of the injuries using technology all the way back to integrating and sending information electronically to the VA using bidirectional health information exchange. And then with the managed care support contractors; if we send you out in the private sector, we have that integrated system. So from an operational standpoint, we've had a coordinated system to integrate what we doing. There's always room for improvements. That's what we're working on today.

Mr. Sanford: General, a moment ago you spoke of the challenges you're faced because of the budget. With the health cost rising within your organization, it doubled in the last five years from approximately $19 billion in fiscal year 2001 to about $38 billion in fiscal year 2006.

Can you tell us a little bit about some of the initiatives that you've got underway to contain some of the costs associated with the delivery of the health care, such as savings in pharmaceutical expenditures, the TRICARE Pharmacy Formulary, new contracting strategies you're having for the TRICARE next generation of contracts, and then given those budget constraints, can you talk to us a little bit about just how do you ensure that the access of care, the quality of care, is going to be maintained for those beneficiaries that you're serving?

MG Granger: First of all, let me go back to those five Ps I spoke about earlier. In terms of making sure that we have what we need to take of this population, how we're going to manage this population -- I talked about people and what we have in the people, we're talking about disease management, managing diseases, whether it be diabetes, congestive heart failure, asthma -- we've got a very nice demo going up in the northwest part or mid-part of the United States looking at obesity, tobacco use, decreasing the use of alcohol to a more or less a mild or moderate level. That's one way of managing our conditions.

And we're basing this on evidence-based medicine, preventive type of activities. We're looking at the Healthy Population 2010 in terms of making sure you're getting your mammograms, pap smears -- if you need a colonoscopy, to try to detect early colon cancer polyps. These are some of the preventive things we're putting in place. This is all based on standard of care, evidence-based medicine, high quality. That's one thing we're doing.

The second thing is that we look at our claims process, the second P of the process. We're looking at are we processing claims timely? And if so, as we use the electronic claims process, can we get more bang for our buck by processing the claim electronically? It's cheaper than using paper. That's another issue. We're making sure that all of our contracts are performance-based with positive incentives if you perform well, as well as negative incentives if you don't perform well.

This is all associated with quality. No question about it. Do we have access standards in, in terms of acute appointments within 24 hours, routine appointments within 7 to 30 days? We have all those access standards in place. And we're making sure that not only are we following them, but our beneficiaries are educated in those access standards. So if I had to look at it, we're looking at providing good quality care. And we have quality metrics, annual report to Congress to validate that -- access. And access is based on, we survey our beneficiaries, we asking them the question: are you getting timely access, were you happy with your providers, were you happy with the staff inside of the clinic, whether it be in our Military Treatment Facilities or one of our private contracts, in terms of their clinics? We're looking at all those things.

And what does this all mean in terms of budget. If you look at health care cost in this country, we spend about $2.1 trillion on health care. And what are we doing to tackle it? From a military health care standpoint, we're putting all those things in place, improving quality, decreased costs based on evidence-based medicines.

So if I had to summarize all this, disease management, having better-performing contracts that are performance-based, having the right performance metrics in the contracts, and also surveying our customers, listening to our customers. And the current thinking right now is it's got to be patient-centered, patient-focused care. If we do the entire cycle from the time you're about to have a chronic disease or develop one, we start managing during the entire process.

Now, what does that mean in budget? Like most things, when health care started going up in the private sector, with 70 percent of our health care being in the private sector, the budgetary amount's got to flow with that, too. If we just validate to our leadership that this is what we need in order to manage this population, they've yet to let us down.

Mr. Sanford: You've brought up a very interesting point. You said as the costs continue to rise, you've been able to go back and ask for additional monies to support that. But over the last 13 years, the TRICARE program has continued to enhance its benefits at a time when the private sector is shifting more of the costs of providing the medical care to its employee base.

How has the effect of greater benefits for DoD beneficiaries, coupled with the reduced benefits in the private sector, led to an increase in military retirees to elect to drop their private coverage and switch back into the TRICARE programs? How are you managing, what strategies are you taking now to contain that or keep it in check? And then how are you coping or planning for the obvious increase in workload efforts associated with the programs and the facilities that provide that care?

MG Granger: Well, let me answer this way. Last year, there was an attempt by the military health care system to answer a need on how do we sustain this great benefit. Because if you look over time, we've brought on TRICARE, Remote TRICARE, Prime Remote, we've brought on the TRICARE Reserve Select program, we've brought on TRICARE for Life program. We brought on a number of programs that's the right thing to do. At the same time, we've got to make sure we're getting the budget to flow, or increasing budget to follow all those programs.

If you look at our overall budget, the military health care system, we call it the Defense Health program budget, has basically the cost-sharing, that's been provided on a TRICARE program, a TRICARE Prime, has remained the same since the 1995-96 time frame. At that point, the premiums we collected represented 24 to 28 percent of our overall cost of the program. That adjustment has not been made at all since then.

Now, there was a taskforce looking at our entire military health care system, and saying are organized properly in terms of the leadership, are we being more efficient and effective? And also one of the things they're looking at, are we being properly set up for success from a budgetary standpoint?

So before I can further answer that question, we got to wait on what the taskforce is going to come out with recommendation. But at the end of the day, we're getting the resources we need to go forward, whether it be in supplemental in terms of the budget, to go forward. So we're hoping the taskforce will give us a lot of recommendations, not just whether or not how much we need sustain this great benefit, but other things we need to look at, too.

Mr. Sanford: General, servicemembers post-deployment now, especially in these areas of conflict, are returning with a lot of different conditions, to include the Post Traumatic Stress Syndrome and other mental health issues. Could you talk to us a little bit about what's going on in regards to TRICARE efforts to provide the proper care for those afflicted, what type of treatment options are being afforded to these individuals, and what strategies are being developed to support them both in and outside of the TRICARE facilities? And then what's being done to look to recognize and manage the treatment? And are these benefits being afforded to the National Guard individual returning?

MG Granger: Well, first of all, I can say this: all benefits are being afforded to all our men and women in our uniformed services whether deployed or non-deployed. But let me just talk about what has transpired over the last few years. We developed a very robust and aggressive three-department survey form prior to you going. I went through it myself personally, a post-deployment health assessment or survey form, and a re-deployment second survey form, as we call it, at about anywhere from 90 to 180 days.

So just to summarize it I went through a form at assessment prior to deploying to Iraq, when I returned from Iraq, and a third one about say 90 to 180 days upon returning.

And what this is designed to do is identify what are some of the issues that you had prior to your going , what other issues developed upon return, and what are some what we call delayed or latent issues -- whether it be mental or adjustment back to society within say 90 to 180 days. And we have a very aggressive mental health program, not only while you're on active duty, but also in partnership with the Veterans Health Association Administration to also try to get that captured.

If you look at the current operation compared to World War I, World War II, when you were injured and we got you to a field hospital or what we call a MASH hospital or battalion aid station, by the time we got you back to the United States, that was normally about two to three weeks -- you got on a ship, you were stabilized, and on your way back, you had time to sort of readjust. You can be injured right now in Iraq or Afghanistan, or anywhere in the world where we have our men and women deployed, and you can be back on U.S. soil within 48 to 72 hours without going through this entire process.

So part of this, we got to make sure that all along the way, we're doing some type of assessment, which we are, of our men and women from a mental perspective, trying to do early detection and treatment, traumatic brain injury. And if we cannot take care of it in our system, then we have a very robust network in our managed care support contractors who assist us, as well as a transition from our system, the Department of Defense, over to the VA making sure that there's a smooth handoff. And we're working those issues every day right now.

This whole process of mental health, Post Traumatic Stress Disorder, traumatic brain is going to take a continued coordinated effort, research and all the things we talk about as we go in the future.

Mr. Morales: General, along the same lines, life after sustaining a serious injury can be fraught with many difficulties for our servicemembers, especially with the loss of a limb, eyesight or some life-changing injury. Can you elaborate on the efforts and initiatives being pursued to facilitate servicemembers from deployment back to employment and integration into the workforce?

MG Granger: Absolutely. We have a program, we call it the Computer Application Assistance Program, better known as CAP, and it uses some computer technology. And part of that program is that if you have say an injury whereby you're blind, we now have computer technology using things like Braille; if you lost hearing, you can still use your eyesight, or if you lost a limb, you got prosthetic devices that can teach you how to do all kinds of typing and additional things. That's part of the overall program going from deployment to employment, as we call it. We've been working with the Veterans Administration, the Department of Labor. We had a conference last August here in D.C., we had all those agencies coming together saying what can we do to go from deployment, get them stabilized to get them to employment.

There's a huge effort out there among the American corporations, the veteran agencies and others to employ the men and women of our uniformed services who are not allowed to stay on active duty due to their inability to do their current military job, but they can't be reclassified on to another job. So that program is up and running.

The key about that program, we need to make sure that program gets more publicized, and we get more exposed, expose the men and women about the program as well their leadership. I would highly recommend sometime in the future that, just like we have in this talk show, that we allow you to interview the individual runs that program, Ms. Dana Coins, that's a very effective program. It's been highly used by a few, but yet there's room for a lot more use of the program.

Mr. Morales: That's fantastic.

What are some of the innovative ways TRICARE delivers health care services and sustains the health of our armed forces and their families?

We will ask Major General Elder Granger, Deputy Director, TRICARE Management Activity, to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Major General Elder Granger, Deputy Director, TRICARE Management Activity.

Also joining us in our conversation is Russ Sanford, partner in IBM's DoD consulting practice.

General, we talked about the diverse and expansive system of hospitals and clinics that TRICARE manages. Given this diversity, what are the biggest technological challenges to managing a health information technology network of this size and diversity, and are there any industry best practices and solutions that could solve some of these challenges?

MG Granger: Well, first of all, the biggest challenge is trying to get all this clinical and administrative information into one electronic system, and that system we have right now is called AHLTA -- it's our electronic health care record. And the key components that take in the day-to-day health care encounters that takes place on military treatment facilities and integrating the same clinical information we have at a managed care support contract into one electronic record. We're in the process of integrating information from our Military Treatment Facilities as well as what we see in our managed care support contract, those clinical encounters out there into our system, that's one of the biggest challenges.

And as we go forward, we're looking at technology on how we can basically take a consultation, whether it be a consult that consists of radiology consult, lab information or physician consult, and sending in information electronically into our electronic health care record. That's one challenge. The second challenge is how do you take the information in our electronic health care record and put it in such a way that it is usable information that the clinician can truly look at their profiles of their population, manage their population in terms of disease management, preventative services, as well as sort of forecast out what the patient will need in the future.

So as I say, as we go forward, our biggest challenge is in having an integrated electronic health care record that not only integrates what takes place in our Military Treatment Facilities, our managed care support contracts, in term of those providers, and last but not least, another important third arm, I'll call it, is that information flowing either from the VA to us or to the VA from us, the back and forth flow of information.

And I think right now with our electronic health care record, which is about 119,000 encounters daily covering about 11 countries around the globe, and with the number of providers using the system, this is going to be a big challenge as we go forward. How do we take all those information on our clinical data repository and truly make it useful information? And I think this is the model in my opinion, based on the President's Executive Order to have an electronic health record by 2014. I truly believe that the military health care system and our electronic health care record, and working with the other fellow agencies in the nation, can truly have an ideal electronic health care record, so we can manage not only our DoD population but also set some benchmark for the private sector, how they can manage overall population in terms of having electronic health care records for our entire nation.

Mr. Morales: So really your plan is to use this health record all the way from enlistment all the way through to the final days?

MG Granger: Absolutely. You bet.

Mr. Sanford: General, we understand that the TRICARE has enhanced its beneficiary online capabilities. Could you tell us a little bit about the TRICARE online Web portal? What services does it provide to the beneficiary population, and how do the capabilities that exist within it compare to those that are offered to the civilian counterparts?

MG Granger: Well, first of all, TRICARE online has been up and running for the last two or three years. You can make appointments in a Military Treatment Facility, you as a beneficiary can go in online where we're offering it in some of our Military Treatment Facilities, not all our Military Treatment Facilities. You can get information about your health, if you want to go in and look at and just do some searching on, good helpful information.

We also have the ability, as part of TRICARE online, you can go in and do some basic learning, we call it Military Health System Learn, in terms of your health information, protective information -- we call it HIPAA. You can go in and do that type of training. In addition to that, providers can go in from the comfort of their homes wherever they maybe located, and go into TRICARE online and check their lab results on their patients, do prescriptions, review radiology information, all through this TRICARE online portal.

Our biggest challenge is trying to get better use of the system; more education to our military leaders and providers about the use of this great system, TRICARE online. Some additional or future enhancement having basically like a -- your health information, you as a beneficiary being allowed to look at certain health information, whether it be your lab, some of your X-rays, trying to do refills online, these are all the things that we're going to have coming in the future as part of our TRICARE online.

We have a portion of our providers, whether it be our managed care support contract providers or our own providers, can go in and look at basic education material or questions about what are some of the things TRICARE offers in terms of benefits. So as we go forward, TRICARE online is really going to be the portal into how our beneficiaries as well as providers continue to use that for patient information, in terms of information therapy, making appointments online, looking at lab, X-ray, pharmacy information, as well as being able to do those ordering or refill medication as we go forward.

Mr. Sanford: General Granger, the DoDs TRICARE encounter data application received a 2006 Government Computer News Agency award for outstanding use of information technology in government. Given such an achievement, what other technological forces are shaping the way you partner with managed care support contractors, and the scope of the network services they provide for the TRICARE management activity? And what new or innovative medical and information technology do you see coming online that are going to most aid your staff in performing their duties?

MG Granger: You're talking about the -- we call it the TEDs -- the TRICARE Encounter Data. That information validates are you eligible for care? If so, what are you eligible for in terms of the different program for this TRICARE Prime, TRICARE for Life, or some of our other programs? That has allowed us to validate your eligibility information, which leads to an improved and faster means of processing your claims, number one; and number two, as we go forward, we're looking at other systems -- we have a very robust pharmacy data transaction system, whereby if you get a prescription anywhere within our system, whether it be the purchase care system or in our Military Treatment Facilities, we can see exactly where you got that prescription. It's designed to decrease medication errors and prevent you from getting a drug-to-drug interaction or getting a prescription you probably received some other place that you should not have for a second or third time.

That particular system just won a national award, our Pharmacy Data Transaction system. The other system that you look at is we process a lot of claims, and having technology that's processing 3.5 million claims per day or over 14 million claims per week, and getting that kind of accuracy of 99 percent being processed in 21 days or 30 days or less, it is that kind of technology that's designed to make our -- not only our system more efficient, but also how we interact with our managed care support contractors. We have another system called PACER, whereby we can look at the number of patients that's on chronic medication -- whether it be on five chronic meds, ten chronic meds or fifteen chronic meds, and manage that population of disease -- we use the terminology "Polypharmacy,"and sometime they might not need to be on all these meds, so that's another technology we're using.

You can look at what's happening at the NTF, what's happening in the purchased care system. So those are just some of the technologies as we go forward. And last but not least is, I mentioned our electronic health care record, how do we take the information of the electronic health care record and put that into usable information? We have partnered with Microsoft out in Seattle, Washington on the concept we call CRADA.

We give them data that has been de-identified in our electronic health care record to determine your identification; we give them the clinical data into a server. They take that clinical information, and with the input of our providers, they put it in an usable fashion, and then this becomes a tool whereby you can manage your population. That's the next innovative tool we're going with -- using data like this, not only in our direct care system, but as we go forward trying to -- as we get information from the purchased care system, clinical information, also add that information.

I think that's the next innovative technique we've got coming forward. Truly managing our population base on improving quality, decreasing cost, prevention and evidence-based medicine, as well as good outcomes.

Mr. Morales: General, earlier, you talked a little bit about some of the changing doctrine in battlefield health care from World War II to present day. Would you elaborate on some of the other key aspects of battlefield health care? What are some of the key lessons being learned in Iraq? And what is your perspective on the transformational nature of battlefield health care on the military health system?

MG Granger: One of the key components is not only good medical and surgical technique, but our robust Aeromedical Evacuation system. With having in the air an intensive care unit whereby the men and women of our Air Force and other Services are in air taking care of wounded warriors from the time they are injured, getting to our combat support hospitals or our field hospitals or theater hospitals, and then getting seamless hand-off to the Aeromedical Evacuation system operated by the U.S. Air Force, and while they are in air, they're still getting care. And then when they land, they land at a place like Landstuhl, they're continuing to hand that care off..

So not only being watched for preventing blood clots and giving the right prophylactic medication, whether it be a blood thinner to prevent them from getting a blood clot, or getting the right blood products on the battlefield, or having the right surgical procedures that are closing the wound, covering the wound with a special-type dressing, and then when you get to the next level of care, washing the wound out again and then doing definitive closure at the wound when they get to their final place like Walter Reed, Wilford Hall or Brooke Army Medical Center, Balboa.

Those are some of the things we're learning. We have a technique called -- we call it wound vacuum, where you basically -- you're doing certain things to the wound to maintain in a dry state -- and all those things. Those are technologies being used more and more in the battlefield medicine. And a key component with all of this is how well our medics and corpsmen are trained at the point of the injury. We have medics that are world-class. They've been trained to do not only from the basic level of first aid up to advanced, whether it be the Navy corpsmen out there with the Marines or the Army, we call them 68 Whiskies -- used to call them 91 Whiskies -- unbelievably trained on how to handle a lot of trauma right there on the first line of injury. That has made an unbelievable difference.

So if you take the entire system, from the medic to that individual corpsmen, to getting a first level of care, whether it be a forward surgical team -- or as we say in the Air Force, EMEDS, Expeditionary Medical System, to our field hospitals, our combat support hospitals, care being taken place all along those levels of care, and documenting the care: those are the things we're working on. And making sure those documents flow electronically so when you get to the next level of care, either you have the information with you or the information's already been transmitted prior to you getting to your next level of care, and making sure you're only getting the right antibiotics, blood products, the right things being done to the wound, being managed throughout the air as well as to your next level, getting to final definitive care.

Those are advancements that we're seeing right now in military medicine on the battlefield. You know about the world-class amputation care that we're providing right now -- amputee care, burn care, this is second to none. We've not seen this level of expertise since the Vietnam era. And that level of expertise is being developed going on every day in military medicine. We have been able to capture a lot of these great lessons and share it with our civilian counterparts.

There is another piece that we don't hear a lot about; it's called effects-based medicine. How do we go out when we do combat operation and show the people of Iraq and Afghanistan that we're now here to provide humanitarian assistance? That's the effect-based medicine, or prior to going in doing some goodwill as we try to locate the enemy or the insurgents, that's effect-based medicine. That's a part of medicine that we're learning how to apply it as we continue to persecute this war.

Mr. Morales: General, given the complexities of your organization and the changing national security threats, what are the plans to ensure that the U.S. Armed Forces are provided with the best world-class operational medicine capabilities while delivering the comprehensive TRICARE benefits to your beneficiaries?

MG Granger: What are the plans? Number one is that we make sure that our providers, whether it be doctors, nurses, medics, corpsmen, are receiving world-class training, either in the military or through our Uniformed Service University, which I'm yet to talk about, and I'll be glad to discuss that -- or in our civilian process.

So we're making sure that we're staying up-to-date in the latest -- whether it be research -- U.S. Army Medical Research Materiel Command up at Fort Detrick, the Uniformed Services University, in conjuncture with a lot of things we do with the private sector -- whether being sending our providers out there into the private sector to maintain these skills. All those things come into play when it comes down to maintaining a very effective military force that can go anywhere anytime to support America's sons and daughters.

Mr. Morales: That's great.

What does the future hold for DoDs TRICARE program? We'll ask Major General Elder Granger, Deputy Director, TRICARE Management Activity, to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Major General Elder Granger, Deputy Director, TRICARE Management Activity.

Also joining us in our conversation is Russ Sanford, partner in IBM's DoD consulting practice.

General, to what extent does the changing nature of the population, its age, its size, present different challenges for managing health care and your mission?

MG Granger: First of all, our population age and change just like what we see in the civilian population. But I think the beauty about our population is it's so like in a closed system. And in our population, we have the opportunity to start managing different processes or preventing different diseases or processes, actually go through the entire life cycle of health care or life in general with our military beneficiaries.

So if you look at it, the challenge being making sure we treat the condition. If it's going to be chronic, we manage it; we try to prevent the complications. And we do it in such a way that the patient has a role in terms of patient-centered care; educating our patients to also serve as a partnership with us to help us do the right thing, to take care of them and giving them more onus and responsibility in terms of managing their care. And we're headed in that direction with patient-centered care. We call it infotherapy, information therapy, giving a patient information, allowing them to make healthy choices.

Mr. Sanford: General Granger, would you discuss the goals, objectives, and the strategies that the DoD plans to deploy to increase the efficiencies in health care delivery and management over the next year and beyond? What are the plans to ensure that our forces are medically deployable, that you're able to sustain the TRICARE benefit throughout -- good resource management? What efforts are being made to revamp the MHS infrastructure for the most efficient use of your resources?

MG Granger: Well, first of all, the last two to four years, we worked aggressively on a military health care system strategic plan. And that strategic plan follows the balanced scorecard approach. And we have laid out those things we want to do in terms of quality issues, looking at infrastructure of our facilities, looking at doing more smarter contracting or buying of resources, putting systems into place to truly manage that, having a human capital strategy. How do we truly develop not only our military in having the right skills we need, but also our civilians, too? How do we make sure as we go forward we're developing and producing those right skills? And that's part of our overall military health care system strategy as we go forward.

We have some short-term goals as well as some long-term goals in terms of how we do that. One of the short-term goals I talked about earlier was from a quality standpoint, putting in a good disease management program, looking at how can we do more consolidation of our facilities -- in the National Capital region, in San Antonio, doing joint staffing and co-location of facilities, having a joint training campus down in San Antonio. That's part of our infrastructure alignment strategy as we go forward. Doing centralized buying and management of our information technology systems. I've spoken about the electronic health care record. We're looking at other processes.

And also when we go forward, we're going to co-locate our headquarters. The Surgeon General's along with the TRICARE Management Activity -- getting better efficiencies by being co-located. Those are just some of the strategies we're looking at as we go forward for the future.

There's one other piece that I've yet to talk about is what are we doing to make sure as we -- you go from the United States, the continental United States -- and you have a truly managed care system in place? What are we doing overseas? Well, the next thing we're doing overseas for the next two years is making sure that as you go from the continental United States to overseas, the managed care program, the TRICARE program, looks identical, that we have a network overseas that is being managed identically like it is stateside so that when you go overseas, you have the same look and feel, with a few minor modifications, of our TRICARE program. And our beneficiaries can see the same process overseas. And that's being developed for the future.

We're putting more emphasis on, as I stated earlier, getting truly performance-based type contracts, and we're looking at civilian models and best practices. Those are things we're going to do as we go forward, as we try to truly continue to integrate this big Department of Defense military health care system. And the final challenge, like most things, is making sure we got the right financial structure to sustain this great benefit.

Mr. Sanford: We've talked a lot about what's being done right now for the warfighter, the warriors that are over there right now, and the beneficiary population, but what about the staff that's back here working to support the infrastructure? With everything that's been going on with the war effort, with all the deployed forces, with the increased surge, has it impacted your ability to retain the individuals needed stateside back here to help support the program? And then what are you doing to do additional recruitment efforts to make sure that you maintain that workforce?

MG Granger: We have a very aggressive recruitment program, not only among all our three services, we're also in the process looking at how can we centralize that process, making sure that as a military health care system, we have almost an identical look and feel in terms of recruitment, recruiting the right skill mix, retention -- improving the incentive pay for the mixture that we need in terms of doctors and nurses and other experts in our military health care system, and really using our Uniformed Services University. That's a great resource for producing America's sons and daughters in terms of future physicians, graduate nursing program at the University, research and development.

So we're looking at very aggressively, as part of that human capital strategy, what do we need for the day-to-day war support, what do we need for the day-to-day military treatment facility in terms of staff, and what do we need also if we start projecting out in the future. So are there some challenges? Absolutely yes. And that's where we need not only our recruiters engaged, but we also too ought to become recruiters ourselves, those of us in the military health care system.

Now, how do we maintain the morale of the staff? It's very important that we continue to emphasize to our staff they're doing a superb job. They're supporting a mission, whether it be a peacetime mission, a wartime mission, or whether it's going out on a managed care support contract, the purchase care piece, that what they do in my opinion is a higher calling. And I can't think of a more honorable profession or service to do that in than the Department of Defense, and we have to recognize them for that.

Mr. Morales: General, along those same lines, you've just had a fantastic career in the military and in medicine and in public service. So I'm curious, what advice could you give to someone who's perhaps thinking about a career in public service, maybe is standing on the long line looking at that short line over there? What advice can you give that individual?

MG Granger: I would say that first of all, our nation was founded on volunteers, and I can't think of a more higher calling than to volunteer to serve our nation, whether it be in peacetime, in the military, or the Department of Defense civilian, because at the end of the day, we all have to look back on our life and say to ourselves, "What did I contribute?" I call it The Dash of Life.

If you look at our great leaders like George Washington or Abraham Lincoln, just to mention a few, if you ask the average individual that's walking the street what is the birthday of George Washington, they probably can't tell you the year, nor can they probably tell you the day that George Washington died or Abraham Lincoln. But what they can tell you, what they did for our nation when they was on this earth. You want to be able to look back on life and say that during the time I was on this earth, I was born this day, I died this day. That dash, I did make a difference. I gave back something in terms of touching the lives of not only a few but maybe many, but also serving my nation and serving my country, because at the end of the day, that's what life is all about.

We all ought to go through life and leave life with the thought that I did give something back to public service; I gave something back to the life of somebody else. So if they're on the fence thinking about whether or not they want to become a public servant, I'm here to convince them. I can't think of a higher calling than serving our nation.

Mr. Morales: That's fantastic. Thank you.

Unfortunately, we have reached the end of our time. I want to thank you for fitting us into your busy schedule. But more importantly, Russ and I would like to thank you for your dedicated service to our country in the armed forces and as a physician.

MG Granger: Thank you. And if you want to know more about TRICARE, I highly recommend you go to our website at tricare.mil.

Mr. Morales: This has been The Business of Government Hour, featuring a conversation with Major General Elder Granger, Deputy Director, TRICARE Management Activity at the U.S. Department of Defense.

As you enjoy the rest of your day, please take time to remember the men and women of our armed and civil services abroad who can't hear this morning's show on how we're improving their government, but who deserve our unconditional respect and support.

For The Business of Government Hour, I'm Albert Morales. Thank you for listening.

This has been The Business of Government Hour.

Be sure to join us every Saturday at 9:00 a.m., and visit us on the web at businessofgovernment.org. There, you can learn more about our programs and get a transcript of today's conversation.

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