Review and Assessment of Current MHS SUD Services

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1 Review and Assessment of Current MHS SUD Services CAPT Robert DeMartino, MC, USPHS, Behavioral Medicine Division Office of the Chief Medical Officer TRICARE Management Activity

2 Overview The Military Health System (MHS) Introduction Characteristics of the population we serve TRICARE benefit Additional support available from the DoD The Committee s Charge National Defense Authorization Act for Fiscal Year 2010 Issues for review 2

3 The Military Health System and the TRICARE Benefit

4 TRICARE - Who We Are 9.4 million beneficiaries 5 million TRICARE Prime enrollees Remainder TRICARE Standard/Extra TRICARE for Life TRICARE Plus TRICARE Reserve Select Military Treatment Facilities (MTFs) 63 Hospitals & Medical Centers 414 Health Clinics Network providers 347,673 individual providers TRICARE dental coverage 1.7 million Active Duty (AD) 1.8 million AD family 1.4 million retirees 4

5 Complete, Unified & Integrated Health System Military Treatment Facilities (MTF) Direct Care System Run by the services Surgeons General Includes hospitals, clinics and pharmacy Civilian Health Care Facilities Purchased Care System Networks of civilian providers administered by the Managed Care Support Contractors (MCSC) Overseen by TRICARE Management Activity 5

6 A Week in the Life of TRICARE 19,600 inpatient admissions 5,000 direct care 14,600 purchased care 1.8 million outpatient visits 642,000 direct care 1.17 million purchased care 103,400 dental visits Direct care only 2.22 million prescriptions 948,000 direct care 1.12 million retail pharmacies 150,000 mail order 2,100 births 1,000 direct care 1,100 purchased care 3.5 million claims processed 6

7 TRICARE Management Activity Mission Manage the TRICARE health plan Develop medical and dental care program initiatives to support the direct care system Procure and manage health care contracts Execute $47.4 billion Military Health System Unified Program (including the Medicare Eligible Retiree Health Care Fund (MERHCF) normal cost contribution) (FY 2010) $21.6 billion is TRICARE s purchased care costs (FY 2010) $14.3 billion Defense Health Program $7.3 billion MERHCF Manage the civilian health benefits program for Uniformed Services beneficiaries Implement legislated changes and other updates to TRICARE Provide oversight of purchased care contracts and claims processing activities 7

8 Three Managed Care Support Contractors in the US North: Health Net South: Humana West: Tri-west Healthcare Alliance Regional Contractors Work With TRICARE Regional Offices (Tros) Under TMA Guidance Regional Contractor Responsibilities Include: Establishment of provider networks Operation of TRICARE Service Centers Administrative support TRICARE The Military Health System 8

9 The Population We Serve While most of our population is relatively healthy, a number of complex conditions are faced by military mental health providers Active duty combat veterans Increased risk for PTSD, depression or anxiety PTSD prevalence as high as 19% (more than five firefights) Hoge et al, NEJM, 2004 Deployment can result in stress for the entire family A significant proportion of TRICARE mental health users are spouses of active duty members or retirees with adult children serving in active duty status and therefore may benefit from family focused supports Meredith et al, RAND,

10 Health Related Behavior Survey

11 Health Related Behavior Survey

12 The Population We serve DoD policies provide broad guidance to the services Service specific guidance is tailored to unique service mission, but aligned with DoD policies DoD Directives exclusively establishes policy, assigns responsibilities, and delegates authority to DoD components DoD Instructions establish or implement policy, may contain overarching procedures DoD Manuals implement or supplement a Directive or policy instruction DoD Directive-Type Memos ONLY for time-sensitive action that affects current DoD issuance (time prevents publication guidance) Service Level Policy or Instructions Must minimally comply with DoD level policy Can increase a standard, detail procedures, or address an issue not covered in DoD Policies 12

13 TRICARE SUD Benefit TRICARE coverage is outlined in Code of Federal Regulations (CFR) 32, Treatment of substance use disorders. Emergency and inpatient hospital care for complications of alcohol and drug abuse or dependency and detoxification are covered as for any other medical condition. Specific coverage for the treatment of substance use disorders includes detoxification, rehabilitation, and outpatient care provided in authorized substance use disorder rehabilitation facilities. Residential Inpatient or partial - 21 Days + 7 Days Detox Outpatient Care Up to 60 Visits Per Benefit Period Family Therapy Up to 15 Visits Per Benefit Period 13

14 Examples of Non-Medical Psychosocial Support In the DoD Military One Source Offers counseling free of charge to active duty, reserve, and national guard service members and their families and do not do not report to military commanders Military Family Life Consultants Licensed mental health professionals who provide confidential counseling outside of the health care system with no documentation in the medical record. The goal is to reduce barriers to treatment. DCoE Outreach Center 24/7 behavioral health support on the range of psychological health (PH) and traumatic brain injury (TBI) issues 14

15 That Guy Additional Support Offered by the DoD Outside of the Military Health System Targets binge drinking among service members Red Ribbon Campaign Present a visible commitment to a safe, healthy and drug-free lifestyle Military Pathways DoD teamed up with the nonprofit organization, Screening for Mental Health, to launch Military Pathways (formerly the mental health selfassessment program ). The free and anonymous self-assessments are available online over the phone. Goals: Reduce stigma; raise awareness, refer to DoD or VA services 15

16 The IOM Committees Charge

17 Scope of IOM Study The adequacy and appropriateness of protocols for the diagnosis, treatment, and management of substance use disorders (SUDs) in members of the armed forces DoD evaluated the adequacy and availability of protocols by: Reviewing all DoD and Service level policies related to the diagnosis, treatment and management of SUDs Reviewing policies and procedures to determine their comprehensiveness with respect to the dx, tx and mgt. of SUDs Determining if DoD utilizes evidence-based, clinically accepted methods for providing care related to the diagnosis, treatment and management of SUDs 17

18 Scope of IOM Study The adequacy of the availability of and access to care for substance use disorders in the military medical treatment facilities and under the TRICARE program DoD examined adequacy of the availability of and access to care by: Evaluating the range of SUD services offered both in the direct care system and through TRICARE network providers and the extent to which those services can be obtained Reviewing access standards that included a clarification of access standards outlined in HA Policy Emergency Urgent (within 24 hours) Routine (within one week) Soliciting qualitative assessments from MTFs as to their ability to meet the SUD needs of their population 18

19 Scope of IOM Study The adequacy and appropriateness of current credentials and other requirements for physician and non-physician healthcare professionals treating members of the armed forces with substance use disorders DoD determined the adequacy and appropriateness of current credentialing methods by confirming that: DoD requires facility accreditation through the Joint Commission or Accreditation Association for Ambulatory Health Clinics (AAAHC) to validate credentialing functions DoD guidance outlines standards for non-licensed healthcare providers to be certified to provide care in DoD facilities Specified rehabilitation centered knowledge and skills that include education, training and experience A supervised one-year internship Functional assessment of their performance 19

20 Scope of IOM Study The advisable ratio of physician and non-physician care providers for substance use disorder to members of the armed forces with such disorders DoD examined models related to staffing for health care personnel and confirmed that: DoD delegates this responsibility to the Services DoD supports the Services models through feedback and the collaborative development of the Psychological Health Risk- Adjusted Model for Staffing (PHRAMS) 20

21 Scope of IOM Study The adequacy of the prevention, diagnosis, treatment, and management of substance use disorders programs for dependents of members of the armed forces, whether such dependents suffer from their own substance use disorder or because of the substance use disorder of a member of the armed forces DoD determined the adequacy of the prevention, diagnosis, treatment and management of SUDs programs for family member s by: Evaluating the range of SUD services offered both in the direct care system and through TRICARE network providers and the extent to which those services can be obtained Reviewing a broad range of community initiatives and continuum of care process to determine how efficiently it is provided to family members Evaluating how psychosocial support programs, self-assessment tools and population focused prevention education and training act to improve the access to medical treatment for SUDs 21

22 Questions?

Licensed Mental Health Counselors and the Military Health System

Licensed Mental Health Counselors and the Military Health System LT Rick Schobitz, Ph.D., USPHS Deputy Director, Behavioral Medicine Division Office of the Chief Medical Officer TRICARE Management Activity