The Impact of Mammography Screening Guideline Changes in a Universally Insured Population.

Background: The U.S. Preventive Services Task Force (USPSTF) modified breast cancer screening guidelines in November 2009. The impact has been studied among privately and Medicare insured populations, but not among universally insured women. Materials and Methods: This study compared the proportion of TRICARE beneficiaries aged 40-64 receiving mammograms from fiscal years 2006 to 2015 using an interrupted time series analysis to determine the impact of the 2009 USPSTF guideline changes. Stratified analyses evaluated differences by age (ages 40-49, 50-64), race, care setting, beneficiary type, and military status. Results: The proportion of women receiving mammograms increased from October 2005 through September 2009. A small, but significant decrease of 65-66 fewer women screened per 10,000 occurred in the first quarter of 2010 (October 1 to December 31) following the screening guideline update publication. The proportion screened then remained unchanged through 2015. Comparative analysis revealed no differences in impact between age groups, blacks and whites, or military dependents and active-duty/retirees. Conclusions: This study determined that the USPSTF guideline updates had a small, but immediate and lasting impact that was not different across age groups, beneficiary type, or race. No racial disparities in the proportion screened or in the impact of the guideline change were noted in our universally insured population.

Factors Associated With the Acceptance of New TRICARE and Medicare Patients by Health Care Providers.

We use data from the 2012-2015 TRICARE Standard Survey to examine factors that affect civilian health care providers' acceptance of patients covered by the U.S. Department of Defense's TRICARE insurance program and Medicare. We find that 74% of physicians report that they accept new TRICARE patients compared with 83% accepting new Medicare patients; in contrast, only 36% of mental health providers report that they accept new Medicare and/or TRICARE patients. Among the most common reasons provided by both physicians and mental health providers for not accepting either insurance type are insufficient reimbursement or their specialty not being covered; lack of awareness of TRICARE is also frequently cited, particularly among mental health providers. These findings suggest that successful strategies to increase provider acceptance of TRICARE and Medicare may include improving reimbursement rates and specialty coverage and increasing provider awareness of TRICARE through outreach programs.

Use of low-value pediatric services in the Military Health System.

BACKGROUND: Low-value care (LVC) is understudied in pediatric populations and in the Military Health System (MHS). This cross-sectional study applies previously developed measures of pediatric LVC diagnostic tests, procedures, and treatments to children receiving care within the direct and purchased care environments of the MHS. METHODS: We queried the MHS Data Repository (MDR) to identify children (n = 1,111,534) who received one or more of 20 previously described types of LVC in fiscal year 2015. We calculated the proportion of eligible children and all children who received the service at least once during fiscal year 2015. Among children eligible for each measure, we used logistic regressions to calculate the adjusted odds ratios (AOR) for receiving LVC at least once during fiscal year 2015 in direct versus purchased care. RESULTS: All 20 measures of pediatric LVC were found in the MDR. Of the 1,111,534 eligible children identified, 15.41% received at least one LVC service, and the two most common procedures were cough and cold medications in children under 6 years and acid blockers for infants with uncomplicated gastroesophageal reflux. Eighteen of the 20 measures of pediatric LVC were eligible for comparison across care environments: 6 were significantly more likely to be delivered in direct care and 10 were significantly more likely to be delivered in purchased care. The greatest differences between direct and purchased care were seen in respiratory syncytial virus testing in children with bronchiolitis (AOR = 21.01, 95% CI = 12.23-36.10) and blood tests in children with simple febrile seizure (AOR = 24.44, 95% CI = 5.49-108.82). A notably greater difference of inappropriate antibiotic prescribing was seen in purchased versus direct care. CONCLUSIONS: Significant differences existed between provision of LVC services in direct and purchased care, unlike previous studies showing little difference between publicly and privately insured children. In fiscal year 2015, 1 in 7 children received one of 20 types of LVC. These proportions are higher than prior estimates from privately and publicly insured children, suggesting the particular need to focus on decreasing wasteful care in the MHS. Collectively, these studies demonstrate the high prevalence of LVC in children and the necessity of reducing potentially harmful care in this vulnerable population.

Racial Differences in Extremity Soft Tissue Sarcoma Treatment in a Universally Insured Population.

BACKGROUND: In prior reports from population-based databases, black patients with extremity soft tissue sarcoma (ESTS) have lower reported rates of limb-sparing surgery and adjuvant treatment. The objective of this study was to compare the multimodality treatment of ESTS between black and white patients within a universally insured and equal-access health care system. METHODS: Claims data from TRICARE, the US Department of Defense insurance plan that provides health care coverage for 9 million active-duty personnel, retirees, and dependents, were queried for patients younger than 65 y with ESTS who underwent limb-sparing surgery or amputation between 2006 and 2014 and identified as black or white race. Multivariable logistic regression analysis was used to evaluate the impact of race on the utilization of surgery, chemotherapy, and radiation. RESULTS: Of the 719 patients included for analysis, 605 patients (84%) were white and 114 (16%) were black. Compared with whites, blacks had the same likelihood of receiving limb-sparing surgery (odds ratio [OR], 0.861; 95% confidence interval [95% CI], 0.284-2.611; P = 0.79), neoadjuvant radiation (OR, 1.177; 95% CI, 0.204-1.319; P = 0.34), and neoadjuvant (OR, 0.852; 95% CI, 0.554-1.311; P = 0.47) and adjuvant (OR, 1.211; 95% CI, 0.911-1.611; P = 0.19) chemotherapy; blacks more likely to receive adjuvant radiation (OR, 1.917; 95% CI, 1.162-3.162; P = 0.011). CONCLUSIONS: In a universally insured population, racial differences in the rates of limb-sparing surgery for ESTS are significantly mitigated compared with prior reports. Biologic or disease factors that could not be accounted for in this study may contribute to the increased use of adjuvant radiation among black patients.

Variation in expenditure for common, high cost surgical procedures in a working age population: implications for reimbursement reform.

BACKGROUND: In the move toward value-based care, bundled payments are believed to reduce waste and improve coordination. Some commercial insurers have addressed this through the use of bundled payment, the provision of one fee for all care associated with a given index procedure. This system was pioneered by Medicare, using a population generally over 65 years of age, and despite its adoption by mainstream insurers, little is known of bundled payments' ability to reduce variation or cost in a working-age population. This study uses a universally-insured, nationally-representative population of adults aged 18-65 to examine the effect of bundled payments for five high-cost surgical procedures which are known to vary widely in Medicare reimbursement: hip replacement, knee replacement, coronary artery bypass grafting (CABG), lumbar spinal fusion, and colectomy. METHODS: Five procedures conducted on adults aged 18-65 were identified from the TRICARE database from 2011 to 2014. A 90-day period from index procedure was used to determine episodes of associated post-acute care. Data was sorted by Zip code into hospital referral regions (HRR). Payments were determined from TRICARE reimbursement records, they were subsequently price standardized and adjusted for patient and surgical characteristics. Variation was assessed by stratifying the HRR into quintiles by spending for each index procedure. RESULTS: After adjusting for case mix, significant inter-quintile variation was observed for all procedures, with knee replacement showing the greatest variation in both index surgery (107%) and total cost of care (75%). Readmission was a driver of variation for colectomy and CABG, with absolute cost variation of $17,257 and $13,289 respectively. Other post-acute care spending was low overall (≤$1606, for CABG). CONCLUSIONS: This study demonstrates significant regional variation in total spending for these procedures, but much lower spending for post-acute care than previously demonstrated by similar procedures in Medicare. Targeting post-acute care spending, a common approach taken by providers in bundled payment arrangements with Medicare, may be less fruitful in working aged populations.

TRICARE For Children: Between Medicaid And Marketplace Plans For Comprehensiveness And Cost Sharing.

TRICARE provides health care benefits to nearly two million children of active duty, retired, National Guard, and reserve service members. Child health advocates and congressional reports have raised questions regarding the adequacy of these benefits, compared with other sources of children's health insurance. To help address these questions, we compared TRICARE benefits with benefits from Medicaid and Marketplace plans because they represent alternative sources of coverage for many of the families enrolled in TRICARE. Overall, we found that TRICARE benefits fell in the middle-between Medicaid plans' more comprehensive benefits with no cost sharing and Marketplace plans' more restrictive benefits with higher cost sharing.

Families With TRICARE Report Lower Health Care Quality And Access Compared To Other Insured And Uninsured Families.

Children in military families, who receive health insurance through the TRICARE program, face barriers to care such as frequent relocations, unique behavioral health needs, increased complex health care needs, and lack of accessible specialty care. How TRICARE-insured families perceive health care access and quality for their children compared to their civilian peers' perceptions remains unknown. Using data from the Medical Expenditure Panel Survey, we found that TRICARE-insured families were less likely to report accessible or responsive care compared to civilian peers, whether commercially or publicly insured or uninsured. Military families whose children had complex health or behavioral health care needs reported worse health care access and quality than similar nonmilitary families. Addressing these gaps may require military leaders to examine barriers to achieving acceptable health care access across military treatment facilities and off-base nonmilitary specialty providers, particularly for children with complex health or behavioral health needs.

Provider Acceptance And Beneficiary Access Under TRICARE's PPO Health Plan.

TRICARE provides health benefits to more than nine million beneficiaries (active duty and retired military members and their families). Complaints about access to civilian providers in TRICARE's preferred provider organization (PPO) plan led Congress to mandate surveys of beneficiaries and providers to identify the extent of the problem and the reasons for it. The beneficiary survey asked about beneficiaries' perceived access to care, and the provider survey asked about providers' acceptance of TRICARE patients. TRICARE's civilian PPO plans are required to maintain provider networks wherever TRICARE's health maintenance organization option (known as Prime) is offered. For the years 2012-15, we describe beneficiary access and utilization and provider participation in TRICARE's PPO plans in Prime and non-Prime markets. We also compare individual market rankings for access and acceptance. In both market types, most providers reported participating in TRICARE's PPO network, and most PPO users reported using network providers. In areas where Prime is not offered, PPO users reported slightly better access, and providers were more likely to accept new PPO patients. Areas with low access and acceptance, or where multiple access measures indicate problems, may be fruitful for in-depth investigation.

A Military Health System For The Twenty-First Century.

The Military Health System is one of the largest integrated health care systems in the United States. It is composed of a "direct care" system of military treatment facilities managed in a federated manner by the Army, Navy, Air Force, and Defense Health Agency and a "purchased care" component that consists of a network of health care providers managed through TRICARE. The system is undergoing significant reform and transformation. In 2017 Congress directed the Department of Defense (DoD) to consolidate all DoD military treatment facilities of the Army, Navy, and Air Force under the Defense Health Agency, while at the same time DoD civilian leaders put additional pressure on the system to accelerate reform efforts across the enterprise. Similar to other health systems, the Military Health System is under pressure to achieve greater efficiencies and reduce costs. This article portrays the drivers for consolidation of the three medical departments-those of the Army, Navy, and Air Force-under one agency and reflects on the impacts of this transformation in light of the DoD's unique mission.

Delay in initiation of DMARD or anti-inflammatory therapy in patients newly diagnosed with rheumatoid arthritis: An analysis of United States Military Health System TRICARE beneficiaries.

OBJECTIVE: To investigate factors associated with delay in initiation of initial disease-modifying antirheumatic drug (DMARD) in patients newly diagnosed with rheumatoid arthritis (RA). METHODS: We performed a retrospective cohort descriptive study using administrative data from the US military's TRICARE program (2007-2012). We identified incident RA cases using billing codes and initial DMARD receipt using prescription fill date. We quantified the time between RA presentation and initial DMARD receipt, evaluated temporal changes in delay over the study period, and investigated predictors of treatment delay (> 90 days) using logistic regression. RESULTS: We identified 16,680 patients with incident RA that were prescribed DMARDs and mean age was 47.2 (SD 13.5) years. The mean time from initial RA presentation to first DMARD prescription receipt was 125.3days (SD 175.4). Over one-third (35.6%) of incident RA patients initiated DMARD > 90days after presentation. There was less treatment delay in later years of the study (mean days to DMARD of 144.7days in 2007; 109.7days in 2012). Patients prescribed opioids had mean time to DMARD of 212.8days (SD 207.4) compared to mean of 77.3days (SD 132.3) for those who did not use opioids (p < 0.0001). Patients prescribed opioids between RA presentation and initial DMARD receipt were more likely to have delay in initial DMARD (OR 4.07, 95% CI: 3.78-4.37). CONCLUSION: In this large US nationwide study, delays in initial DMARD receipt for incident RA were common but time to treatment improved in recent years. While further analysis using clinical data is warranted, these findings suggest that limiting opioid use in patients newly presenting with RA may decrease delay in initiating DMARDs.

Effect of an equal-access military health system on racial disparities in colorectal cancer screening.

BACKGROUND: Racial disparities in colorectal cancer (CRC) screening are frequently attributed to variations in insurance status. The objective of this study was to ascertain whether universal insurance would lead to more equitable utilization of CRC screening for black patients in comparison with white patients. METHODS: Claims data from TRICARE (insurance coverage for active, reserve, and retired members of the US Armed Services and their dependents) for 2007-2010 were queried for adults aged 50 years in 2007, and they were followed forward in time for 4 years (ages, 50-53 years) to identify their first lower endoscopy and/or fecal occult blood test (FOBT). Variations in CRC screening were compared with descriptive statistics and multivariate logistic regression. RESULTS: Among the 24,944 patients studied, 69.2% were white, 20.3% were black, 4.9% were Asian, and 5.6% were other. Overall, 54.0% received any screening: 83.7% received endoscopy, and 16.3% received FOBT alone. Compared with whites, black patients had higher screening rates (56.5%) and had 20% higher risk-adjusted odds of being screened (95% confidence interval [CI], 1.11-1.29). Asian patients had a likelihood of screening similar to that of white patients (odds ratio [OR], 1.06; 95% CI, 0.92-1.23). Females (OR, 1.20; 95% CI, 1.10-1.33), active-duty personnel (OR, 1.15; 95% CI, 1.06-1.25), and officers (OR, 1.28; 95% CI, 1.18-1.37) were also more likely to be screened. CONCLUSION: Within an equal-access, universal health care system, black patients had higher rates of CRC screening in comparison with prior reports and even in comparison with white patients within the population. These findings highlight the need to understand and develop meaningful approaches for promoting more equitable access to preventative care. Moreover, equal-access, universal health insurance for both the military and civilian populations can be presumed to improve access for underserved minorities.

Future Health and Economic Impact of Comprehensive Tobacco Control in DoD: A Microsimulation Approach.

Background: Tobacco use is a major concern to the Military Health System of the Department of Defense (DoD). The 2011 DoD Health Related Behavior Survey reported that 24.5% of active duty personnel are current smokers, which is higher than the national estimate of 20.6% for the civilian population. Overall, it is estimated that tobacco use costs the DoD $1.6 billion a year through related medical care, increased hospitalization, and lost days of work, among others. Methods: This study evaluated future health outcomes of Tricare Prime beneficiaries aged 18-64 yr (N = 3.2 million, including active duty and retired military members and their dependents) and the potential economic impact of initiatives that DoD may take to further its effort to transform the military into a tobacco-free environment. Our analysis simulated the future smoking status, risk of developing 25 smoking-related diseases, and associated medical costs for each individual using a Markov Chain Monte Carlo microsimulation model. Data sources included Tricare administrative data, national data such as Centers for Disease Control and Prevention mortality data and National Cancer Institute's cancer registry data, as well as relative risks of diseases obtained from a literature review. Findings: We found that the prevalence of active smoking among the Tricare Prime population will decrease from about 24% in 2015 to 18% in 2020 under a status quo scenario. However, if a comprehensive tobacco control initiative that includes a 5% price increase, a tighter clean air policy, and an intensified media campaign were to be implemented between 2016 and 2020, the prevalence of smoking could further decrease to 16%. The near 2 percentage points reduction in smoking prevalence represents an additional 81,240 quitters and translates to a total lifetime medical cost savings (in 2016 present value) of $968 million, with 39% ($382 million) attributable to Tricare savings. Discussion: A comprehensive tobacco control policy within the DoD could significantly decrease the prevalence and lifetime medical cost of tobacco use. If the smoking prevalence among Prime beneficiaries could reach the Healthy People 2020 goal of 12%, through additional measures, the lifetime savings could mount to $2.08 billion. To achieve future savings, DoD needs to pay close attention to program design and implementation issues of any additional tobacco control initiatives.