September1,2016DearMembersoftheDepartmentofDefenseMilitaryFamilyReadinessCouncil(MFRC):TheTRICAREforKidsCoalitionisastakeholdergroupofchildren’shealthcareadvocacyandprofessionalorganizations,disabilityadvocacygroups,militaryandveterans’serviceorganizationsandmilitaryfamiliescommittedtoensuringthattheDepartmentofDefensemeetstheuniqueneedsofchildrenofmilitaryfamilies.TheCoalitiongreatlyappreciatestheMFRC’sinterestinthehealthcareandsupportsprovidedtothe2.4millionpediatricbeneficiariesintheMilitaryHealthSystem.ThatinterestwasobviousintheCouncil’srequestthattheDefenseHealthAgency(DHA)brieftheMFRCon“TRICAREforKids(TFK)ReporttoCongress:UpdatefromtheOfficeoftheAssistantSecretaryofDefenseforHealthAffairs”1atitsJune2016meeting.“TRICAREforKids”isthepopularnameforlegislationpassedasSec735ofthe2013NationalDefenseAuthorizationAct(NDAA),whichorderedtheSecretaryofDefensetostudythehealthcareandrelatedservicesforchildrenofmembersoftheArmedForces,andisusedasacolloquialismfortheeffortssurroundingthatlegislationandimplementation.Then-UndersecretaryforPersonnelandReadiness,theHonorableJessicaL.Wright,submittedtheSection735pediatric(TricareforKids)reporttotheCongressionalDefenseCommitteesinJulyof2014.TheDoDreportincluded31significantfindingsrelatedtothenineCongressionally-directedelementsinSection735.TheTRICAREforKidsCoalitionrespondedtothisreportinSeptemberof20142.Whileagreeingwiththe31findings,thecoalitionwasalsotroubledbynumerousdiscrepanciesandomissionsinthereport.Twoexamplesincludeitsfailure“tosetforthaplantoimproveandcontinuallymonitorpediatriccare”andtomake“recommendationsforlegislationthattheSecretaryconsidersnecessarytomaintainthehighestqualityofhealthcarefordependentchildren,”bothrequirementsofSec735ofthe2013NDAA.AddressingthesefindingsandrespondingfullytoCongressionaldirectionareabsolutelynecessarytoensuringthattheDepartmentismeetingtheneedsofmilitarychildrenandtheirfamilies.Unfortunately,theJune2016MFRCbriefingprovidedbyDHAofficialsfailedtoaddressDoD’s31findingsorstakeholders’previouslysubmittedquestionstoDHAregardingstatusofthosefindingsinJune2015(bothattached).TheMFRCbriefbyDHAprovidedlittlemorethanageneralupdate.Whilesomeoftheinformationwasinteresting,thebriefwasn’tspecifictotheDoDreportandleftMFRCmemberswithmorequestionsthananswers,andadvocateswithsignificantconcerns.Besidesthefailuretoaddressthe31specificDoDfindings,wehadsignificantconcernsbecauseoffactuallyincorrectstatementswithrespecttointeractionwiththeMilitaryCompensationandRetirement

1FederalRegistryNotice:https://www.gpo.gov/fdsys/pkg/FR-2016-05-18/pdf/2016-11736.pdf2TRICAREForKidsStakeholdersCoalitionSummaryandAnalysis:https://www.childrenshospitals.org/issues-and-advocacy/tricare/tricare-for-kids-stakeholders-coalition-summary-and-analysis

ModernizationCommission(MCRMC)findingsregardingtheExtendedCareHealthOption(ECHO)program,thepurposeofECHO,andakeyelementoftheECHOprogram,intheDHAbriefing.Becausetheywerestatedasfactversusopinion,andbecausethemisstatementswillleadtofurtherdelayandpotentiallyinappropriateimplementationoftheTricareforKidsfindings,wewouldhopethattheCouncilwillcontinueitsengagementandleadershiponTricareforKids,looktoDoDtocorrecttherecord,andconsiderreceivingrelevanttestimonyfromstakeholdersandexperts.WewouldspecificallyrecommendtheprofessionalstafffromtheMCRMC,chargedwiththeCommission’sresearch,analysisandrecommendationsregardingthecriticalneedsoffamilieswithexceptionalmembers(EFMPs)whorelyonECHOservices.Similarly,egregiousenoughtowarrantcommentandconcernbystakeholderswasthepointmadeinthebriefingaboutDHAmanagementoftherespitecarebenefit,referencingconcernsthatitwouldbeusedasababysittingservice,astatementwhichsuggestsbothanunacceptablelevelofignoranceoffamilies’needsandunduesuspicionofmotivesdirectedatourmostvulnerablemilitaryfamilies.Thesekindsofcommentsandmisconceptionsarethetypethatadvocatesworktirelesslytocorrectamongthegeneralpublic,butitisespeciallyconcerningwhensuchremarksareprovidedbytheagencychargedwithreformingtheseprogramsandservingthesefamilies.OurconcernswithlackofprogressaddressingthespecificfindingsandthedelaysinimprovingpediatriccarearemirroredinboththeHouseandSenateArmedServicesCommittees(HASCandSASC)sincetheReportwasfiledin2014.Lastyear,regardingDoD’sreporttoCongress,theSASCstated,

“Thereportdeeplyconcernsthecommitteebecausedatagapsanddeficienciesinthisareafailtosubstantiatetheconclusionthatthemilitaryhealthsystemmeetsthehealthcareneedsofchildren,especiallythosechildrenwithspecialneeds.”

Additionalstatutorylanguagecanbefoundthroughoutthisyear’sNDAAindicatingcontinuingdissatisfactionwithDoD’sfollow-upregardingthistopic3.EverydaythatDoDisnotmovingforwardoncorrectingandimprovingtheissueshighlightedinDoD’sreport,aswellasourTRICAREforKidsCoalitionresponsetothatreport,isadaythatmilitaryfamiliesarenotaccessingneededsupportsandservices.TheMFRC’scontinuedengagementandleadershipinrequestingupdatesandmonitoringprogressiscrucialtoensuringaccountabilitywithCongressionaldirectivesandDHA’sownstatedgoalsofmeetingtheuniqueneedsofchildren.Tothatend,theTRICAREforKidsCoalitionrequeststheMilitaryFamilyReadinessCouncilincludeasoneofits2016recommendationstoSecretaryofDefenseCarterastatementthatacknowledgestheimportanceofpediatriccareformilitarychildrenandthenecessityofupdatingtheCouncilandstakeholdersonactionstakentodateandplannedtospecificallyaddressthe31findingsoftheTFK/Section735reportandrelatedquestions.TheTFKCoalitionappreciatesandapplaudsthediligenceoftheMFRCregardingTRICAREforKidsmattersasDoDworkstowardfillingthegaps,addressingareasforimprovement,andimprovinghealthcaresupportsandservicesformilitarychildrenandtheirfamilies,especiallythosewithspecialneeds.Sincerely,Kara Tollett Oakley KaraTollettOakleyChair

3Sec580,GAOReportonEFMP(page233)andSec762,ReportonPlantoImprovePediatricServices(page452)athttps://www.gpo.gov/fdsys/pkg/BILLS-114s2943pcs/pdf/BILLS-114s2943pcs.pdf

SignificantFindingsinReporttoCongressional

DefenseCommittees:

StudyonHealthCareandRelatedSupportforChildrenofMembersoftheArmedForces

OfficeoftheSecretaryofDefenseJuly2014

Element1:AcomprehensivereviewofthepoliciesoftheSecretaryandtheTRICAREprogramwithrespecttoprovidingpediatriccare.

1. ReviewprocessesforevaluatingemergingtechnologyinuseinthegeneralcommunitybutnotsupportedbythehierarchyofevidencerequiredfortheTRICAREpurchasedcareprogram.

2. ReviewregulatoryprovisionsforTRICAREprogramcost-sharingofcarethatappearstohavegainedacceptanceinthelargermedicalcommunitybutdoesnotmeettheTRICARE-specificdefinitionapplicabletothepurchasedcarecomponent.

3. Analyzeuseofhealthcarebenefitsbychildrenages6to21yearstoassessifdevelopmental-andage-appropriatecareisbeingdeliveredascomparedtoAAP-recommendedperiodicityschedulesandguidelines,the2010PatientProtectionandAffordableCareAct,orMedicaid’sEarlyandPeriodicScreening,DiagnosisandTreatmentbenefit.

4. Determinetheextentofuseofspecialmetabolicformulasbychildrenwithcomplexmetabolicordigestivediseasetomaintainessentialnutritionandmedicalfood.

5. Assessthebenefitofnutritionalcounselingandmanagementwhenprovidedbynutritionistsand/orregistereddieticiansasauthorizedprovidersforchildrenwithcomplexmedicalandmetabolicmedicalconditions.

6. DetermineifthecurrentbenefitofhabilitativecareauthorizedunderECHOonlyforADFMspromotesage-appropriateanddevelopmentalsupportforchildrenalongwithskillattainmentandsustainmentthatisdistinctfromrehabilitativecare,andwhetherlegislativechangestoremovethecurrentstatutoryexclusionofhabilitativecarefromtheBasicprogramwouldbeappropriate.

7. UsageofcompoundedmedicationforpediatricbeneficiariesandreviewtheimpactoftheDHAdecisiononcoverageforcompoundedmedicationsincompliancewithPublicLaw113-54,DrugQualityandSecurityAct,oncetheFDAprovidesdirectiononimplementationofthenewlaw.

8. Reimbursementpoliciesandtheirflexibilityforsafeandeffectivecareofthepediatricbeneficiaryaspediatrichealthdeliverymodelschange.

Element2:Anassessmentofaccesstopediatrichealthcarebydependentchildreninappropriatesettings.

9. Futureassessmentsshouldfocusonmorefinelytunedaccessmetrics,includingwaittimesandreferrals,reasonsforhigherratesofnon-networkERuse,andavailabilityofproviders.Evaluatecurrentlyavailablemetricsanddatasourcestoassessiftheyeffectivelyaddressadequacyofaccessforpediatricbeneficiaries.

10. SpecificanalysesofthepediatricpopulationintheannualEvaluationofTRICAREPrograms:Access,CostandQualitywouldprovideacomprehensivereviewofadultandpediatricERutilizationratesintheMHS.

11. Strategiesareneededtoaccuratelydifferentiatebetweenutilizationoffreestandingversushospital-basedERutilizationandcostdifferences,whichcouldinformassessmentofaccessofservices.

12. PotentialrecaptureofpediatricERvisitsthroughreviewofdiagnosesandacuityofvisitswouldinformaccessofservices.

13. Studyofregionalcontractorrequiredreportstoevaluatetheneedforcontractmodificationstohavedataavailableforfinelytunedaccessmetrics,includingwaittimesandreferrals,reasonsforhigherratesofnon-networkERuse,andavailabilityofproviders.

14. EvaluatetheneedforcontractmodificationstodevelopNARsthatwouldreflectavailabilityofprovidersonamonthlybasis.

Element3:Anassessmentofaccesstospecialtycarebydependentchildren,includingcareforchildrenwithspecialhealthcareneeds.

15. Potentialmethodsforcodingthatwillmoreeasilyidentifypediatricspecialtyorsubspecialtyproviders,orallowfordual(adultandpediatric)coding.

16. Furtherdefinediagnosisforhigh-utilizationspecialtyprovidersandaccessstandardsbetweenreferralsandappointments.

17. CollectingdataonpediatricaccessandproviderspecialtyintheannualMHSTRICAREsurveycouldbeausefultoolfortrackingpediatricaccessandsatisfaction,includinguseofspecificquestionsonCAHPStoassessfamilysatisfactionspecifictopediatriccare.

18. DeterminethecomponentsofaconsistentNARfordirectandpurchasedcarecomponentthatidentifiesforreferralsandconsultationstheparticipatingpediatricsubspecialtyproviders.

19. RegionalcontractrequirementsforNARstoincludenetworkadequacyasmeasuredbyutilizationofpediatricsubspecialtyproviders.

20. ConsidertheinclusionofthepediatricpopulationintheannualEvaluationofTRICAREPrograms:Access,CostandQualityreporttoprovideacomprehensivereviewofadultandpediatriccareintheMHS.

Element4:AcomprehensivereviewandanalysisofreimbursementundertheTRICAREprogramforpediatriccare.

21. Periodicallyreviewreimbursementpoliciesinordertocollaborateoninnovativeprocessesneededtocontinuetomeettheuniquehealthcareneedsofchildrenashealthcaredeliverymodelschange.

Element5:AnassessmentoftheadequacyoftheECHOPrograminmeetingtheneedsofdependentchildrenwithextraordinaryhealthcareneeds.

22. ReviewdataregardingEFMPfamilymemberseligibleforECHOenrollment,currentECHO-enrolledbeneficiarieswhocontinuetobeeligibleforservices,andcurrentECHO-enrolledbeneficiarieswhoduetochangesinconditionarenolongereligibleforECHOservices.CollaboratewiththeMHSBeneficiaryEducationandSupportDivision,theMilitaryDepartments,TROs,theOfficeofSpecialNeeds,andcontractorpartnerstoprovideinformationtoalleligiblefamiliesandtrackECHOenrollmentandutilization.

23. DevelopsatisfactionoroutcomemeasurementsforallECHOprogramswithregardtoimpactonbeneficiariesandfamilyreadiness.

Element6:Anassessmentoftheadequacyofcaremanagementfordependentchildrenwithspecialhealthcareneeds.

24. DoDcollaborativereviewtoestablishaformalfamily-focusedprocesstoevaluatetheadequacyofcareandcasemanagementinmeetingcomplexindividualhealthneedsandpromotingqualitycost-effectiveoutcomes.

25. Developaformalcollaborativeprocessinandbetweendirectandpurchasedcaretodefineandreviewoutcomesforappropriatecare/casemanagementofpediatricbeneficiariesandtheirfamilies.

26. Developoutcome/efficacymetricsfortheimpactofcasemanagementindirectandpurchasedcareforbeneficiarieswithsignificantmedical/behavioralhealthissues.

27. FuturelongitudinalstudyontheimpactofPCMHonpediatricbeneficiariesintheMTFsetting.

Element7:AnassessmentofthesupportprovidedthroughotherDepartmentofDefenseormilitarydepartmentprogramsandpoliciesthatsupportthephysicalandbehavioralhealthofdependentchildren,includingchildrenwithspecialhealthcareneeds.

28. Developacommoncoreofprograms/benefitsthatsupportfamiliesavailableatallinstallationswithcriteriaforevaluatingeffectivenessofprogramsandoutcomes.

29. Evaluateaprocessfora“one-stop-shoppingsystem”tosupportfamiliesinevaluatingthemultitudeofservicesavailableintheMilitaryDepartments,DoD,andcommunitytomeettheirneeds.

Element8:MechanismsforlinkingdependentchildrenwithspecialhealthcareneedswithStateandlocalcommunityresources,includingchildren’shospitalsandprovidersofpediatricspecialtycare.

30. Futurestudytodevelopandtestconsistentprocessesofcommunicationandcollaborationbetweennonclinicalandclinicalsupportforthefamily’snetworkofneeds.

Element9:Strategiestomitigatetheimpactoffrequentrelocationsrelatedtomilitaryserviceonthecontinuityofhealthcareservicesfordependentchildren,includingchildrenwithspecialhealthandbehavioralhealthcareneeds.

31. FormalizedcollaborationofEFMPMilitaryDepartmentmedicalandregionalcontractorsindeterminationofavailabilityofmedicalresourcesincomplexmedicalcasepriortorelocation.

From:TRICAREForKidsCoalitionTo:DefenseHealthAgencyPediatricIntegratedProjectTeamQuestionsforSubmissiontothePIPTfortheJune24,2015meetingwithstakeholdersA.TheTricareforKidsCoalitionidentifiedthefollowinglistofopportunitiestoimprovecareandcareexperiencesformilitaryconnectedchildrenpursuanttotheDoDPediatricReporttoCongressreleasedinJuly2014.

1. ForeachofthefollowingissuesidentifiedintheSection735Reportandrecommendationsmadebystakeholders:WhatistheDoD/DHApositiononthetopic/recommendation?WhatisthestatusandsummaryofactivitysincetheReportpublicationdate?Pleasedescribeaplanforimplementation?Whatifany,additionalauthorityisneeded?

• AligningTricarewithpreventivebenefitsavailablethroughthePatientProtectionandAffordableCare

Act(ACA),BrightFuturesandMedicaid’sEarlyandPeriodScreening,DiagnosticandTreatment(EPSDT).• AligningmedicalnecessitydefinitionforpurchasedcaresectorwithAAPrecommendationandbroader

definitionallowedinthedirectcaresystemtoensureaconsistentbenefitandcare.• Creatingapediatricphysicianadvisorygroupwithinternalandexternalpractitionersthatmeetsona

regularbasistoprovidepediatricspecificperspectiveonpolicyandpractices.• EstablishinganAdvisoryPanelonCommunitySupportforMilitaryFamilieswithSpecialNeedsas

requiredbylaw.• AmendingtheinpatientonlylistTRICAREadoptedfromMedicareforpediatrics.• AddressingreimbursementareascitedintheReportandstakeholdercommentsthroughoutthe

process.Wouldyoudiscusstheneedforandworkwithapediatricpaymentadvisorygrouptoaddress?• Adjustingdefinitionsandprovidercategoriesasnecessarytocovermedicalnutritionforchildrenwith

complexnutritionalneeds.• ImplementinginternalECHOreformsandincreaseflexibilityofECHObenefittoensurethatitalignswith

theCentersforMedicare&MedicaidServices(CMS)standardsforcommunitybasedsupportsandprovidesimprovedaccessandcontinuityofcaretofamilies.

• Ensuringthatcompoundedmedicationcoverageandregulationallowspediatricneedstobemet.• Conveningdatastakeholdersadvisorygrouptoassistwithmetrics,appropriatecomparisons,etc.for

pediatricsincludingcomplexcareandcarecoordinationandmanagement.• Immediatelyadoptingmentalandbehavioralhealthstandardsmorecommonplaceinpediatriccare

systemssuchaswraparoundcare,intensiveoutpatientprograms,familycenteredcare,communitybasedcareanduniformaccesstospecialtycare.

• Removingartificialbarrierstoresidentialtreatmentcentercertifications.• ParticularlywithregardstoEFMPfamilies,compilingrecommendationsfromthemanyrecentreports

andstudiesandcreationofachecklistofactionitemsandissueareastoaddress.Canyouassurethisstakeholdercommunitythatthiswillbedoneincollaborationwithinternalandexternalstakeholders?

2. ForeachofthefollowingdeepdiveissuesidentifiedintheSection735Reportandrecommendations

madebystakeholders:

WhatstepshasDHA/DoDtakensincetheReportpublicationdatetobegintoaddress:

• Thelackofdata,inefficiencyofcollectionandanalysisandinabilitytomeaningfullyutilizedata.

• EnsuringthatqualifiedEFMPbeneficiarieshaveaccesstoMedicaidwaiverservices.• Streamliningtheprocessforpediatric-specificcoverageandreimbursementissuesthatarechild/patient

centered.• ImplementingcodingchangesthatmoreaccuratelyreflectpediatriccaresuchasAPR-DRGs.• AllowingTRICAREtoformulatepoliciesandcoveragewithbestpracticesidentifiedandrecommended

byotherfederalagencieswithsubstantiveoversight;forexample,insteadofconductingitsownanalysesregardingsubstanceabusetreatmentandmentalandbehavioralhealthonwhichtodesignpolicies,utilizeSAMSHAstudiesandreports.

B.Inthe2015NDAADHAwasgivenflexibilitytocoveremergingtechnology.

3.HowandwhendoesDHAplantoimplementthisflexibilityforpediatrichealthcare?