For the U.S. Defense Department, providing healthcare to military personnel and their families abroad has become a grass-roots effort.
Faced with dramatic reductions in its medical infrastructure abroad, the department in 1995 began assembling a network of civilian providers to treat the 460,000 American military members and dependents in Europe, Latin America and the Pacific.
It has been an intensive, hands-on undertaking for the Defense Department. Of the $4 billion it spends on healthcare worldwide each year, only $50 million is earmarked for reimbursing host-nation, nonmilitary medical providers overseas.
But despite cultural and geographic barriers, the department's Tricare Overseas managed-care and indemnity plan in Europe has grown to include 1,800 civilian and military providers and institutions in Germany, Greece, Italy, the Netherlands, Portugal, Spain, Switzerland, Turkey and the United Kingdom. Tricare Overseas also has contracts with 100 civilian providers serving the military's Latin American and Pacific regions.
The U.S. military enlisted the help of civilian providers to augment its shrinking healthcare ranks overseas.
Since the end of the Cold War, more than 40 U.S. military clinics and 18 hospitals have closed in Europe, says Maj. Brian Hurley, senior health policy analyst for Tricare Overseas. That leaves nine U.S. military hospitals and 45 clinics in Europe, anchored by Landstul Regional Medical Center near Ramstein Air Base in Germany.
In response, the Pentagon contracts aggressively with primary-care physicians and specialists in host European, Latin American and Pacific nations.
"We really are changing the way we look at healthcare overseas," Hurley says. "We always relied on host-nation doctors, but now we recognize they are an integral part of the system and we need to draw them closer to us."
Enrollment in Tricare Overseas, which comprises Tricare Europe, Tricare Latin America and Tricare Pacific, began in 1996 and has grown steadily since then.
In Europe, 223,000 military personnel and their dependents are enrolled in Tricare Prime, an HMO. Another 30,000 active-duty members and their dependents receive care under Tricare Standard, a fee-for-service plan.
In the Pacific region, Tricare Overseas has 142,000 HMO enrollees and 41,000 fee-for-service enrollees. In Latin America, it has 10,000 HMO enrollees and 9,000 fee-for-service enrollees.
The Defense Department launched its U.S. Tricare program in 1993 in response to a similar crisis involving military hospital and clinic closures. To better coordinate care between military and civilian healthcare providers, the department solicited bids from managed-care companies to enroll military dependents and retirees covered by the Civilian Health and Medical Program of the Uniformed Services, or CHAMPUS.
In the U.S., the military can contract with commercial insurers and provider networks to complement its own healthcare services. Overseas, however, it's largely on its own. Finding competent doctors who follow the parameters of the health plan is essential to Tricare's strength.
"Overseas, it's just as much a quality-of-life issue as it is a healthcare issue," Hurley says. "Because there is not a social network in place (for those U.S. military personnel abroad), there is a tendency for people to go to hospitals or clinics more frequently."
Assembling extended provider networks tests the military's resourcefulness, cultural sensitivity, language skills and ability to overcome geographic barriers. Just assuring that quality and level of care among foreign providers authorized to treat U.S. military personnel are acceptable is a mountainous task.
"You can look around the U.S. and have a sense of a minimal level of medical training and measure from a quality and cost perspective," Hurley says. "When you go (abroad), what you get and how you get it is a lot different. It's a whole different ballgame."
To adjust, Tricare Overseas offers bilingual patient liaisons and translation services for medical documentation. Enrollees abroad are aided further by a nurse-on-call system for each nation. The system connects enrollees with a nurse in the U.S. who directs them to the proper health services in their host country. Access Health, a healthcare information service based in Sacramento, Calif., administers the service.
In tandem with network development for Tricare, the Defense Department also plans to offer joint continuing education for military medical personnel and host-nation providers to better integrate networks. Already joint education and training are taking place in Vicenza, Italy, Hurley says. Likewise, in Misawa, Japan, military and civilian providers are meeting to better integrate their services, he says.
To further expand its network of providers, the Defense Department is in discussions with the U.S. State Department to allow military service people and their families to access providers available to State Department employees, Hurley says. The State Department has no formal provider network in place, he says, but its contacts abroad could serve as a guidepost for establishing additional ties with high-quality providers. The departments expect to conclude their talks within the next two months, he adds.
On its own, Tricare Overseas aims to expand its Latin American and Pacific provider networks and to establish networks in more remote areas where handfuls of military service people remain underserved. Targeted areas include parts of Africa, Asia and Eastern Europe.
In more remote areas, finding competent doctors is an even bigger challenge.
"We're working on developing civilian networks in cities and Third World countries that aren't as well-developed," says Sue Christensen, a spokeswoman for Tricare Europe. "We have a harder time finding qualified physicians. It's not an easy task. We rely heavily on people in those areas to give us guidance and advice."
Santiago is a reporter at Crain's Cleveland Business, a sister publication of MODERN HEALTHCARE.