This article by Karen Jowers originally appeared on Military Times, the nation's largest independent newsroom dedicated to covering the military and veteran community.

Shifting more military patients to local civilian hospitals could result in “significant harm” to these patients, according to a new study funded by the Defense Department.

That was the conclusion of researchers after comparing the quality and safety of patient care at military treatment facilities with those at local civilian hospitals — facility by facility. Researchers found that on average, military patients received better outcomes in MTFs, compared to military patients who were treated in local civilian hospitals.

It’s the first time researchers have conducted a deep dive to compare the quality of care in MTFs and local civilian hospitals, said Tracey Perez Koehlmoos, professor of preventive medicine and biostatistics at the Uniformed Services University of the Health Sciences, and principal investigator in the research.

And it could put a hurdle in the path of ongoing reform efforts within the Military Health System, which have included moving an unknown number of patients to the civilian purchased care system under Tricare.

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The research “is really a good news story that highlights the high quality of care available in our military treatment facilities,” said Koehlmoos, who is director of the USUHS Center for Health Services Research.

“Military treatment facilities as a whole remain among the best performing hospitals for patient safety in the U.S.,” said Koehlmoos. The study also highlights an area where the Defense Health Agency might work to “incentivize a higher quality of care through the Tricare benefit,” she said, which would benefit all patients in the local community, not just Tricare beneficiaries.

Reducing access to military treatment facilities by as little as 10 percent of the current population could result in “significantly worse” surgical mortality rates, medical mortality rates and patient safety, the study found.

The study, titled, “In Defense of Direct Care: Limiting Access to Military Hospitals Could Worsen Quality and Safety,” was published Oct. 4 in the journal Health Services Research.

Researchers from Yale and Harvard also worked on the analysis.

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The researchers were tasked to examine how reforms within the Military Health System are likely to affect the quality of care in the system. They examined current data for MTFs and civilian hospitals in the local areas that treated Tricare patients; and also national civilian adult inpatient claims. They included only patients ages 18 to 64 years old.

Then they conducted simulations on what the quality indicators might look like under various proposed scenarios of reducing access to military treatment facilities.

“It’s gratifying to see that MTFs compare favorably with civilian hospitals when it comes to patient outcomes,” said Eileen Huck, government relations senior deputy director for the National Military Family Association. “However, the report raises concerns about what will be the impact on beneficiaries as more of them are shifted to the purchased care system.”

The researchers compared data from 502,252 admissions of adult military beneficiaries at 37 military treatment facilities (326,076 admissions) and surrounding civilian hospitals (179,176 admissions under the Tricare purchased care system). They used Military Health System data from fiscal years 2016 to 2018 to compare patients’ outcomes in MTFs with those of military Tricare patients treated in local civilian hospitals.

The researchers also compared MTF patients’ outcomes with the broader national civilian adult inpatient admissions, using calendar 2017 hospital data, which fell into that military inpatient data period.

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The researchers conducted simulations for patient outcomes in hypothetical scenarios where defense officials reduced access for patients by 10 percent, 20 percent, or 50 percent nationwide. In the 10-percent scenario, researchers estimated 170,000 to 190,000 beneficiaries age 18 to 64 could be moved out of MTFs to the civilian hospitals.

They also simulated the outcome if MTF access were restricted to active-duty only, with no retirees, reservists or dependents. In this most extreme scenario, researchers estimated it would be up to 1.9 million adult beneficiaries ages 18 to 64 who would be affected.

Researchers also simulated the outcome if the worst-performing MTFs were removed. The study doesn’t name those MTFs, but the information could be provided internally only to DoD, if requested, Koehlmoos said.

“This research highlights a risk we’ve been concerned about, that when beneficiaries are moved out of MTFs, they may not have access to quality care,” said Karen Ruedisueli, director of health affairs for the Military Officers Association of America. The point that MOAA has been trying to make, she said, is that “access to care is not the same as access to quality care.

“If military families and retirees must be moved out of MTFs in order to improve the focus on readiness, it must only be done in areas where we know beneficiaries can still access quality care in the civilian community.”

The research “underscores that this is very complicated, and it’s not something that’s going to be done quickly,” she said.

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Among the findings:

• In region-specific comparisons, in 30 out of 37 regions, beneficiaries experienced better patient safety at MTFs, compared to local civilian hospitals. The study doesn’t specify those regions.
  
  
• MTFs on average had better outcomes in four out of 11 inpatient-quality indicators, and in five out of nine patient safety indicators, compared to local civilian hospitals. Most of the other indicators were about the same. “This really highlights the quality of care in the military treatment facilities,” Koehlmoos said. One example was the heart failure mortality rate. In local civilian hospitals, the rate was 32.3 deaths per 1,000 admissions, compared to 27 per 1,000 in MTFs.
  
  
• In the broader comparison to hospitals nationwide, the study found MTFs had “significantly better” condition-specific rates in eight out of 11 inpatient quality metrics; and in seven out of nine patient-safety indicators. Again, most of the other indicators were about the same. The civilian hospital data analyzed came from the Nationwide Readmissions Database, which includes hospitalizations for patients in the 28 participating states, regardless of age or insurance. Those records account for more than 18 million annual hospitalizations, 60 percent of U.S. population and 58 percent of all U.S. hospital admissions, the researchers noted.
  
  
• The simulations estimated that reducing access to MTFs by as little as 10 percent of the nationwide beneficiary population “could result in significantly worse surgical mortality, such as 0.7 percent increase in [coronary artery bypass graft] mortality.” It could result in an increase of medical mortality, such as a 1.3 percent increase in heart failure mortality.
  
  
• The simulations showed that limiting access to active duty military only could increase adverse patient safety events for the rest of the beneficiary population by 23 percent. For example, researchers projected that post-operative respiratory failure rates could increase by 13.6 percent.

The researchers measured metrics for inpatient quality and inpatient safety, using the quality metrics endorsed by the U.S. Agency for Healthcare Research and Quality.

In 2016, Congress enacted major reforms to the military health care system, including organizational changes. DoD notified Congress in 2020 of plans for realignment of MTFs, and to shift toward active-duty-only access at certain MTFs, which has already been happening.

Defense officials also have been planning to cut the number of medical billets, “to increase the number of operational billets needed for lethality,” according to DoD documents. In August, a DoD report to Congress noted they’ve racheted down the numbers they had planned to cut.

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This study didn’t examine the issue of numbers of providers.

The researchers excluded beneficiaries age 65 and older because they receive health insurance through Medicare. They also excluded children because of insufficient numbers of cases.

Previous research has shown that the quality of care was the same or better in MTFs compared to civilian hospitals, regardless of whether the volume of cases is high, medium or low. “This work seconds that original work, that things are either the same or better in direct care,” Koehlmoos said.

“People often make it a rainy day when they talk about the Military Health System, but we’re really a model for the nation on how to deliver equitable, affordable health care to your population,” Koehlmoos said. “For those of us who have been studying this, there are so many great lessons that can be taken from the military health system and shared with the rest of America.”

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