Streamlining Managed Care Processes for Clinics in the Bavarian Region

Military Medicine, Aug 2008 by Warthen, Lawanda D

The effects of the Global War on Terrorism have been felt throughout the world, and it has had a particularly profound effect on medical services that have been traditionally provided by the military. The Military Healthcare System (MHSS) is a broad and highly organized structure that in war and peacetime has been able to provide complete preventive treatment, and care. It is also one of America's largest healthcare systems, which in 2000 was cited as "offering benefits to about 8.3 million people at an annual cost exceeding $15 billion (Shi & Sing, p. 200). Medical treatment facilities (MTFs) were once the heart of the military healthcare delivery system, providing about 75% of all care for beneficiaries. This is no longer true because of base closings in Europe and the downsizing of military hospital facilities.

While military hospitals like Wuerzburg Medical Center have closed, downsized or been redesigned as ambulatory care centers, the number of personnel relying on the military to provide healthcare has remained constant. Now beneficiaries and military healthcare facilities in Europe have to rely more on local and host nation providers for specialized healthcare needs. This major change has affected the processes that impact quality, cost, access to care, and keeping accurate and up-to-date records. "Economic impacts have forced [the military] ... to reevaluate the way it conducts the service of delivering quality healthcare that is both compassionate and cost efficient" (Schwartz & Pogge, 2000, p. 189).

Getting the Word Out

An additional issue is that MTFs have been traditionally staffed to provide care for nearly all medical conditions. When one facility couldn't provide a service, the patient could be referred to anther military treatment center that had the specialization. However, because of budgetary constraints resulting from TRICARE Next Generation Contract, ALTHA, and the Global War on Terrorism, MTFs have had to reduce specializations and rely more on local medical care. Thus, while the military facility once gave beneficiaries the comfort of accessing comprehensive treatment, they now function more as referring agencies, and beneficiaries can no longer depend on the military facility to be their sole provider.

United States Healthcare System

The U.S. healthcare system is both fragmented and experiencing rapid changes from ongoing concerns about cost, access, and quality. Over the past several years, it has faced the many challenges of the Global War on Terrorism, downsizing, and right sizing in concert with the rest of the DoD, plus trying to control escalating costs associated with the entire healthcare industry. Classical and contemporary social and organization systems theorists concur that when the whole is affected by changes, so are its parts.

Healthcare is organic to military organizations (active, reserve, and national guard) within the DoD and is apportioned to the various branches of the service according to numbers and concentrations of beneficiaries. It must be ready to travel with the troops and deliver healthcare to them and their families. These resources are found in MTFs, clinics, dispensaries, and medical aid organizations which are part of military units.

Just as systems thinking focuses on interactions among the interdependent parts or components of a complex organization, TRICARE is not simply healthcare coverage; it is a healthcare delivery system that provides varying levels of benefits depending on where a beneficiary lives. TRICARE, like civilian healthcare in America, is a patchwork of subsystems loosely connected to provide medical care rather than health care. Therefore, a military healthcare network is needed that can meet the needs of all beneficiaries.

The Problem

As the military increased the use of host nation services, significant delays occurred in medical bill processing and maintaining up-to-date patient medical records. Of the eight outlying clinics around Wuerzburg that assisted beneficiaries with appointments with local providers, several had difficulties with both processing bills and referring patients. One way the problem was addressed was to seek ways to improve healthcare delivery and, at the same time, increase the efficiency of data processing to provide the most up-to-date medical records possible. This was accomplished in four steps. The first was to provide the right atmosphere. A waiting area and consulting rooms were created to provide privacy for the patient and the Beneficiary Counseling Assistance Coordinator (BCAC) in military medical facilities. The next step was wise allocation of human resources. This was done by ensuring that each office was staffed with the right mix of personnel based on workload and beneficiaries' needs for service- including a backup cadre of military to assist when a BCAC is not available. The third step was education. Host nation providers were trained to process administrative paperwork for routine payment by ensuring that all staff understood the TRICARE billing process and how it worked through Wisconsin Physicians Systems, the TRICARE processing center. The final step was access. Host nation facilities were allowed to upload information into the military database system, which entered it directly onto beneficiaries' medical records. All information would then be documented and complete for optimum continuity of care and immediate availability without another step in the process.