specialty is internal medicine, Hunter came to TMA in May 2009 after two years in command of Navy Medicine West and the Naval Medical Center San Diego. From 2004-06, she was chief of staff, Bureau of Medicine and Surgery. Hunt- er served two years as Pacific Fleet surgeon and then headed Naval Hospital Bremerton, Wash. Hunter also is board-certified in hematology and oncology. Her undergraduate and medical degrees are from Boston University. n In an in- terview with Contributing Editor Tom Philpott, Hunter discusses two big challenges — improv- ing access to care and controlling costs — which she maintains are not in conflict. She says TRI- CARE has four responsibilities: medical readi- ness; population health through quality care and by encouraging healthy behaviors; ensuring a good care experience for patients by emphasiz- ing compassion, convenience, and safety; and managing health care costs. n The following in- terview has been edited for length and clarity.
Could you characterize challenges of access to care today, particularly in military facilities? Is it correct patients enrolled in TRICARE Prime often have better access than those in the direct-care system?
Yes, that’s still true. Access is getting what you need at the moment you need it, whether it’s information, an appointment, or a referral. We have worked hard to expand opportunities for all of these. Our standards are that urgent things should be seen today; routine problems within a week; and specialty care, if not for emergent
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conditions, within four weeks. Those targets ... are being met. But when you ask enrollees how satisfied they are with getting timely care, [those with] a network provider generally say they’re more satisfied. Both are improving, however. We have invested a lot of ef- fort in medical-home-style practices to improve access in the direct-care system [at military facilities].
What does medical-home-style practice mean?
It’s team-based primary care. A few years ago, we [used the] Primary Care
Manager by Name initiative. With interruptions for deployments and permanent change-of-station [moves], that couldn’t completely be fulfilled. Some beneficiaries didn’t feel they had a close relationship with their team. The medical home model tries to
improve health outcomes by strength- ening the patient-provider relation- ship. We’ve adopted it for the direct-care system. We organize around teams, each anchored with at least one civilian. Generally, there are two providers on a team — physician and physician assistant or nurse prac- titioner. One is a civilian, so if [team members] deploy or transfer, there’s continuity. All the services are adopt- ing a version of this. … The focus is on total care of the enrolled population, being accessible by phone and, within the next year, more often by secure e- mail. We’ll be judging success using a continuity-of-care metric — the per- cent of time a patient sees his or her primary care manager. Each service has a phased rollout. A total rollout period of three years is realistic.
What happens to direct-care access when these doctors and nurses deploy?
The whole design of TRICARE is to complement the direct-care system with contracted providers when mili- tary providers need to go forward. The direct-care system has done an amaz- ing job in Iraq and Afghanistan, and it continued to be able to provide access through the Haiti [earthquake] mis- sion. They’ve done so by adding ad- ditional resources in-house, [thereby] streamlining referral capability. Even with 1,500 medical providers in Haiti, at the peak of that terrible crisis, we were able to meet commitments. Each day TRICARE regional direc-
tors are in contact with the medical fa- cilities most affected by deployments, looking at their day-to-day needs.
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