Q&A: Major General Elder Granger

Health Care Provider
Delivering World-Class Health Care to 9.2 Million Beneficiaries



Major General Elder Granger
Deputy Director
TRICARE Management Activity

Major General Elder Granger is the deputy director and program executive officer of the TRICARE Management Activity, Office of the Assistant Secretary of Defense (Health Affairs), Washington, D.C. Granger serves as the principal advisor to the assistant secretary of defense (Health Affairs) on DoD health plan policy and oversight of the health plan performance. He is responsible for the operation and overall performance of the DoD’s managed health care program for members of the uniformed services, their families, retirees and other eligible beneficiaries. He directs a staff of 185 and an annual Defense Health Program budget of $11 billion with oversight including the effective provision of high-quality, accessible health care for 9.2 million beneficiaries worldwide.

Granger began his career with the Army Medical Department in 1971 as a combat medic with the United States Army National Guard. He earned his Bachelor of Science degree from Arkansas State University in 1976. A distinguished military graduate, he was initially commissioned as a quartermaster officer through the Reserve Officer Training Corps. Upon graduation from the University of Arkansas School of Medicine in 1980, he was awarded the Henry Kaiser Medical Fellowship for Medical Excellence and Leadership. Granger completed a residency in internal medicine in 1983 at Fitzsimons Army Medical Center and a fellowship in hematology-oncology in 1986. Military schooling includes the Army Medical Department Officer Basic and Advanced Courses, the Combat Casualty Care Course, the U.S. Army Command and General Staff College, and the Army War College. Granger’s previous assignments include Commander, 44th Medical Command, XVIII Airborne Corps surgeon and director of health services, Fort Bragg, N.C.; commander, Task Force 44th Medical Command and surgeon for the Multinational Corps Iraq; commander U.S. Army Europe Regional Medical Command and command surgeon for U.S. Army Europe and Seventh Army; commander, Landstuhl Regional Medical Center; acting assistant surgeon general for force protection, Office of the Surgeon General, Department of the Army, Falls Church, Va.; commander Ireland Army Community Hospital, Fort Knox, Ky; deputy commander for clinical services, U.S. Army Medical Department Activity, Fort Huachuca, Ariz.; division surgeon, 4th Infantry Division, Fort Carson, Colo.; chief, Department of Medicine/chief, Hematology Service, 2nd General Hospital, Landstuhl, Germany; and staff hematologist/oncologist, Fitzsimons Army Medical Center, Aurora, Colo.

Granger is the recipient of numerous awards, decorations and honors including the Defense Superior Service Medal, the Bronze Star, the Legion of Merit with four oak leaf clusters, the Ehrenkreuz der Bundeswehr Silber by the German Army, the Meritorious Service Medal with four oak leaf clusters, the Order of the Military Medical Merit, and the Expert Field Medical Badge. He is board certified by the American Board of Internal Medicine and the Board of Hematology and Oncology. Additionally, the Army surgeon general has bestowed upon him the “A” proficiency designator for health care professionals. His professional affiliations include Fellow of the American College of Physicians, member of the National Medical Association, the Interagency Institute for Federal Health Care Executives, member of American College of Physician Executive and the American Society of Clinical Oncology.

Interviewed by MMT Editor Jeff McKaughan

Q: Good morning, General Granger. I would like to start by asking you for a general overview of TRICARE as we start 2007. What is the strategy to financially support the growing number of beneficiaries in your care?

A: Thank you for your question. In the last year, many publications have run articles on the topic of financing TRICARE coverage for our 9.2 million beneficiaries. TRICARE Management Activity projects the health care usage of military beneficiaries and works closely with other activities in the department and with key committees in Congress to reach agreement on the financial requirement necessary to provide these services in our direct care—military treatment facility—system or through our TRICARE contractors.

As you know, over the past several years we have seen an increasing number of beneficiaries who have dropped their other health insurance and become more reliant on their military health benefit. In order to meet this increased demand, we have focused many of our internal management efforts on reducing the cost of providing these services and reducing administrative costs. Over the past few years, we have changed the large managed care support contracts, pushed to get the best possible pricing for our pharmaceuticals and worked with the Department of Veterans Affairs to share services where possible. All of these efforts are designed to lower costs.

Q: The long-term care needs of those returning from combat with injuries and disabilities were needs that would not have been forecasted into the budget five years ago. Is your budget keeping pace with the needs of the servicemembers?

A: First, let me say that the brave American military medics in Iraq and Afghanistan are rewriting the history books on combat medicine, and all of us could not be prouder of their accomplishments and bravery. As wounded heroes return to our medical centers, such as Walter Reed and National Naval Medical Center here in the national capital area, we are providing the most modern and effective care possible to treat these men and women.

We receive a great deal of the funds for their care via the global war on terrorism supplemental funding that the administration requests and is appropriated by Congress. We have worked closely with the DoD Comptroller staff, Office of Management and Budget and Congress to make sure that we have the right amount of resources to meet these needs.

Q: Is it just a fact of life that beneficiaries are going to have to contribute more for their health care?

A: As you know, we have not increased the out-of-pocket costs for our beneficiaries since TRICARE was initiated more than 10 years ago. In fact, we have reduced these costs for our active duty family members and reduced the catastrophic cap amount that retiree families pay.

While all other health plans have increased such costs as premiums, deductibles and co-payments, we have not done that. As more beneficiaries drop their other health insurance and return to use their TRICARE benefit, the costs of our program have risen dramatically over the past five years. Last year, the department proposed in concert with the fiscal year 2007 president’s budget a series of cost increases designed to place the benefit on a sound financial footing for the long term. While Congress did not act on this proposal, it did direct a Task Force on the Future of Military Health Care, which will look at the government and beneficiary sharing structure. The military health system leadership is looking forward to working closely with the task force and hope that their recommendations will help us achieve a cost structure that will sustain the benefit.

Q: Do you see any trends that lead you to believe that TRICARE will look to use commercial health services? For example, the use of more private health care providers instead of military clinicians.

A: Over the past decade, we have relied more on private sector care for a number of reasons. For one thing, closures or downsizing of some military facilities under the Base Realignment and Closure [BRAC] process have reduced the footprint of the military medical system. We’ll see more of that in the coming years, with about 20 inpatient facilities slated for conversion to clinics. Along with the BRAC changes, we have needed to rely on our private sector partners more when military medical staff members are deployed in support of the global war on terrorism. Despite this, it is important to note that a key purchased care objective is to optimize care in military facilities. We continue to work closely with each military medical service to ensure we are producing the right requirement in purchased care endeavors. As we speak today, requirements are being developed for a new generation of TRICARE contracts. For the most part, we have not seen specific trends that are going to greatly alter our current model—and I expect that we will always need to partner effectively with private sector providers to deliver the TRICARE benefit. If we were to greatly expand our reliance on private sector health care providers over military clinicians, we would not be able to achieve other important goals of the military health system.

Q: What is TRICARE’s role in pre-deployment health care and preparation?

A: The Department of Defense performs pre-deployment health assessments to ensure that only medically fit military personnel deploy in support of contingency operations. The assessment confirms and documents a servicemember’s health readiness status and identifies any need for additional clinical evaluation prior to deploying.

The department provides pre-deployment health assessments within 60 days of deployment, and they are placed in the servicemember’s medical record and in the central electronic database of the Defense Medical Surveillance System. Registered health care providers may access electronic copies of the DD Form 2795 [predeployment health assessment form] via TRICARE Online.

Another critical part of readiness for National Guard and Reserve members is dental readiness. The department continues to administer the TRICARE Dental Program [TDP] for members of the National Guard and Reserve and their families. The TDP is the DoD’s voluntary dental insurance program for these groups and provides its members with a nationwide network of participating dentists, world-wide comprehensive coverage and competitive monthly premiums.

In addition to offering members excellent dental benefits at affordable rates, the TDP is a contributor to dental readiness. The TDP provides National Guard and Reserve members with the best avenue to help maintain dental readiness for worldwide deployment, as required by the DoD. Our network of participating dentists can provide the dental examination and will complete the necessary DoD form at no cost to the enrolled member. If dental treatment is required, our network dentists can provide the services necessary to ensure the member meets his/her dental readiness requirement.

Q: This question deals with the opposite end of the deployment— the return home. Post-traumatic stress is well-documented. How active is TRICARE in trying to find treatment options and strategies to recognize the symptoms before they become deeper and longer-lasting issues?

A: Safeguarding the health and safety of our servicemembers is the Defense Department’s highest priority. Servicemembers who are exposed to violence or the possibility of death or serious injury are at increased risk for post-traumatic stress disorder [PTSD]. The DoD stands ready to care for any servicemember who develops mental health problems, including PTSD.

Servicemembers returning from Operation Enduring Freedom and Operation Iraqi Freedom receive education on PTSD prior to redeployment and are screened [using the Post Deployment Health Assessment form] for symptoms of mental health problems and exposure to events that may increase their risk for PTSD. If mental health issues are present during redeployment, referral to appropriate care and follow-up is made.

The screening form becomes a part of a servicemember’s medical record in case problems arise in the future. If a servicemember develops problems after returning home, care is available through the military health system for active duty or retired servicemembers [plus de-activated reservists for 180 days] and through the Veterans Health Administration for those veterans who have separated from the military [provides at least two years’ coverage for all those who served in an Operation Enduring Freedom and Operation Iraqi Freedom combat zone].

Within TRICARE, we offer the following four resources:

First is the he PTSD WebPortal is funded for fiscal year 2007 and fulfills requirements in the National Defense Authorization Act of 2006 and 2007. This project will result in access to on-line assessment and learning modules intended to help participants make sense of what they are feeling and explore self-initiated help for behavioral health problems, including symptoms of post-traumatic stress. The intent of the self-help site is to attract and serve persons who have not yet sought medical care, though it is expected that the resources offered at the site will be extremely useful to those persons who are already in treatment. Specially developed and commercial products will be available through one site.

Second, TRICARE is funding a study of the RESPECT-MIL program [REengineering Systems of Primary Care Treatment in the MILitary, a primary care managed treatment protocol for PTSD and depression offered through the Army] to determine the success of the program in identifying those with depression and PTSD and referring them successfully into a treatment program. In addition, the study will seek explanations when care managers do not generate a referral following a positive screening. This process allows us to document efforts to ensure that referrals to mental health care are completed and will help us gain further insight into the outcomes of individuals who have a positive screening but do not pursue treatment and care management.

Third, through the Behavioral Health Access Workgroup, TRICARE is currently reviewing access of its beneficiaries to various forms of outpatient, residential and rehabilitation mental health and substance use disorder facilities. Ensuring access to such facilities and the expertise of the professionals within is one means of providing early, timely assessment and intervention services to those who require them.

And fourth, The Healthy Lifestyles initiative to reduce alcohol use, tobacco use and obesity encourages active duty servicemembers to seek assistance for self-identified problems and be more aware of symptoms and behaviors that may be interfering with their work and home lives. Such awareness is critical if active duty servicemembers are to identify the presence and seriousness of PTSD symptoms in themselves and to seek understanding and help for those symptoms.

Q: And what about outside of TRICARE?

A: Outside of TRICARE, we work with agencies throughout the Defense Department on the following programs.

The Mental Health Self-Assessment Program [MHSAP] at www.militarymentalhealth.org/welcome.asp is a voluntary, anonymous mental health and alcohol screening and referral program offered to families and servicemembers affected by deployment or mobilization. It is offered online 24/7, as well as through in-person events. The MHSAP is funded by the DoD Office of Health Affairs.

Each individual who requires a Post-Deployment Health Assessment [PDHA], such as those returning from deployment, is scheduled for a face-to-face health assessment with a trained health care provider [e.g., physician, physician assistant, nurse practitioner, advanced practice nurse, independent duty corpsman]. The assessment occurs as close to the return date as possible but not earlier than 30 days before the expected return date and not later than 30 days after returning home or to the processing station. The purposes of this screening are to review each servicemember’s current health, mental health or psychosocial issues commonly associated with deployments, special medications taken during the deployment, and possible deployment-related occupational/environmental exposures, and to discuss deployment-related health concerns. Servicemember responses that suggest illness or other health concerns require use of supplemental assessment tools or referrals for medical consultation. The provider will document concerns and referral needs and discuss resources available to help resolve any post-deployment issues.

The Post-Deployment Health Re-Assessment [PDHRA] is designed to identify and address health concerns, with specific emphasis on mental health, that have emerged over time after the PDHA screening. The PDHRA provides a second health assessment during the three- to six-month period after return from deployment, ideally at the three- to four-month mark. The reassessment is scheduled for completion before the end of 180 days after return so that Reserve Component members have the option of treatment using their TRICARE health benefit. After servicemembers have completed the form, a health care provider discusses with the servicemember any health concerns they have indicated on the form and makes referrals to appropriate health care or community-based services if further evaluation or treatment is needed.

Military treatment facility Behavioral Health Clinic walk-ins are available for self-referral by active duty service members, with no primary care provider referral required.

The Army is rolling out an ambitious program at 15 bases in the United States and abroad. The RESPECT-MIL program builds on science-based evidence in which the identification and successful entry into treatment by active duty servicemembers with depression is greatly improved when screening for depression occurs at the time of a primary care visit. The current program offers a primary care managed treatment protocol for PTSD and depression.

The Military OneSource [www.militaryonesource.com] program offers 24/7 information and resources, as well as referrals to in-person counseling. When there is a need, a consultant can refer a servicemember or eligible family member to a licensed professional counselor in the local community for six sessions per issue at no cost to the military or family member. The face-to-face counseling benefit addresses short-term concerns and is limited to six sessions per issue. It is not designed to address such long-term issues as child and spouse abuse, suicidal ideation and mental illness. People in need of long-term treatment are referred to a military treatment facility or TRICARE for services. The fact that clients use Military OneSource for six sessions does not affect their ability to access mental health treatment under TRICARE.

Fleet and family support centers/Marine Corps community service centers/health and wellness centers on bases [and other similar services] provide stress and anger-management classes, mental health assessment, individual and group counseling, family counseling and other related services. These all provide opportunities for active duty service members to uncover stress-related symptoms, speak with mental health professionals about those symptoms, and seek and receive guidance on means to obtain help.

Q: Prescription costs are a huge concern for an aging population— actually an issue for everyone. With the buying power of TRICARE, what are you doing to make the best pharmaceuticals available to your beneficiaries but at the lowest possible price?

A: The department’s Pharmacy and Therapeutics Committee is responsible for reviewing classes of pharmaceuticals and does comprehensive evaluations of each drug in each of the classes to identify those that are most clinically and cost effective. The results of those evaluations determine where the drug is placed on the Uniform Formulary, which in turn determines the beneficiary copayment. Through the use of tiered co-payments, based on Uniform Formulary placement, the DoD pharmacy benefit is structured to encourage our beneficiaries to utilize the least expensive venues: the military treatment facility pharmacies and the TRICARE Mail Order Pharmacy [TMOP]. By utilizing one of these two venues, beneficiaries 1) ensure they incur the lowest cost to themselves and to the government and 2) receive the best pharmaceuticals available. In March 2006, TRICARE launched a successful, comprehensive education campaign to familiarize beneficiaries with the advantages of using TMOP. The campaign resulted in significant savings to beneficiaries while maintaining access to the medications they require. Our beneficiaries are also saving themselves money by asking their doctors to write a prescription for a generically available drug to treat their conditions.

Q: With Wal-Mart experimenting with a $4 generic prescription plan, can TRICARE do better?

A: Beneficiary co-payments for generics through the DoD Pharmacy benefit have always been and remain less than the generic plans offered by numerous retail pharmacy chains. The DoD’s pharmacy benefit offers generics at military treatment facilities at $0, and is $3 at TMOP for up to a 90-day supply [that equates to $1/month as compared to Wal-Mart’s $4/month] and $3 at the TRICARE retail network pharmacies for up to a 30-day supply [compared to $4 at Wal-Mart]. In addition, active duty members have $0 co-payments at any pharmacy points of service.

Q: Electronic health records offer so many potential benefits. What are some of the technological hurdles to getting EHRs secure enough to use broadly and will there be an impact on your IT infrastructure to accommodate and accept EHRs fully?

A: In December 2006, the department completed the worldwide deployment of AHLTA, the military’s electronic health record, which began in January 2004. With the rollout of AHLTA now complete, AHLTA programmers continue to make updates to improve system performance and functionality.

AHLTA is one of the most comprehensive technology deployments ever undertaken by a health system. Its principle purpose is to improve care for military beneficiaries. It is patient-centric, which means we designed it with the safety and welfare of patients in mind. Patient information is gathered from our military treatment facilities around the world into a single, secure, complete, legible and durable record. We designed AHLTA to be scalable, so we could extend its use to the battlefield. In addition, a theater version is now being used to document care to our service members in Iraq, Kuwait and Afghanistan. The continuity of medical care for our wounded service members from the battlefield to home and sometimes to the Veterans Health Administration is greatly facilitated by the ability to transfer health care information to each successive point of care. AHLTA makes this possible.

One of the greatest challenges was and continues to be network and system security. Maintaining the privacy and security of our information systems, and the patient health information they contain, is a high priority and one of our greatest concerns.
In addition to safeguarding our patients’ health information, we have the added responsibility of ensuring that our systems and networks do not compromise the integrity of DoD’s overarching IT systems and security framework. Our systems, databases, interfaces and facilities must comply with DoD’s overall Defense in Depth strategy. To this end, our information assurance program has three major components: physical security, electronic security and personnel security.

Although DoD uses extensive procedures to encrypt information and keep it private, as well as role-based rules to grant appropriate user access, technological solutions alone cannot guarantee information safety. We continuously assess the vulnerabilities of our systems and collaborate with other federal agencies and commercial partners to identify new threats and develop and apply appropriate countermeasures. We will continue to explore new technical and procedural solutions to augment our three aspects of defense and strike the balance of safeguarding beneficiary health information without compromising the benefits of global access by our worldwide health care delivery team

Regarding the impact on information technology infrastructure to accommodate and accept electronic health records fully, we must have the ability to securely send, receive and share health information both within the military health system and externally with other health systems such as the Veterans Health Administration. We secure and transfer information through computers, databases, servers, communication networks and security firewalls, all of which make up the information technology infrastructure. Within the military health system we have gained a wealth of experience in developing and implementing common and unique infrastructure solutions, which provide the foundation for information exchange. We continue to partner with industry to look for innovative ways to address the technical challenges involved with transmitting and storing digitized files and managing the sheer size of the health records in our Clinical Data Repository.

Q: TRICARE manages almost 900 hospitals and clinics. What are the biggest technological challenges to managing a health information technology network of this number and diversity in size? Are there any silver bullets that you are hoping for from industry that can solve some of these challenges?

A: The three toughest technical challenges for developing and managing a health information technology network of this size and complexity are scalability, system availability and component integration.

The goal of AHLTA is to provide seamless visibility of health information across our entire continuum of medical care, giving our providers access to critical health information whenever and wherever care is provided. To meet this goal, we made scalability an absolute requirement of its design. AHLTA needed to capture care provided in diverse environments, from first response on the battlefield, to combat support hospitals in low or no communications environments, to large medical centers supported by large communication networks within the United States. The department even tailored AHLTA to run on a combination of hand-held devices and stand-alone laptops while in the field, and as part of a large integrated global network when used in our fixed medical facilities. Scalability is one challenge we have overcome, which sets us apart from other large-scale EHR systems.

Regarding availability, the heart of AHLTA is the clinical data repository [CDR] where we store the data for each comprehensive, life-long, computer-based patient record. AHLTA and the CDR must be available 24/7. We designed the system with built-in redundancy and rapid-recovery mechanisms to ensure against data loss. In addition, we made the network infrastructure robust enough to support thousands of concurrent users and millions of rapid transactions going back and forth between the point of user entry and the CDR.

We constructed AHLTA as an integrated system of commercial off-the-shelf technologies. We incorporated the dynamic interoperability of best-of-breed COTS systems and prepared the components to function as one integrated whole. This was and continues to be a challenge as we look to add enhancements and additional capabilities as AHLTA continues to evolve.

We keep pace with technology advancement by leveraging our industry partnerships to continuously upgrade our capabilities. We do not seek silver-bullet solutions from industry. Instead, we join with our commercial partners in a two-way collaborative effort. Our goal is to bring the best and appropriate technologies to our patients. We do this by working with our industry partners to research, test and incorporate innovative, best-of-breed commercial products that meet our needs.

Our partners also incorporate into their commercial releases our adaptations or enhancements. In other words, we work with companies to fully meet our needs by enhancing their core commercial products. As a result, our expertise, lessons learned and investment are available to the nation, because we have pushed the advancement of products available commercially, in effect, accelerating industry.

Q: What technological forces are shaping the way you partner with managed care support contractors and the scope of network services they provide for TRICARE Management Activity?

A: When I think of networks and technological challenges the first things that come to mind are the positive impacts that will come with the full implementation of standardized electronic transactions under the Health Insurance Portability and Accountability Act [HIPAA] and standardized National Provider Identifiers. There has been a huge increase in use of electronic media in recent years. For example, filing electronic medical claims or using electronic funds transfers are now quite common and no longer present the challenges they once did. Today’s technological challenges are now reaching into patient care and quality care arenas. The Department of Defense electronic medical record [AHLTA] and the visibility it affords providers of a complete and integrated patient record is extremely important to quality. Additionally, the recent presidential executive order to promote quality and efficient health care in health care programs administered or sponsored by the federal government provides us with the additional challenge to integrate and standardize data exchanges between federal and private sector partners. This vision and emphasis will certainly impact our focus for the next decade.

Q: How much impact do you have on the focus and direction of research and development efforts towards pharmaceuticals, medical devices, medical IT systems, etc? Do you have any R&D funds that you directly control?

A: Research and development is done at commands such as Walter Reed Army Institute of Research. Many military treatment facilities also participate in clinical research protocols, some in conjunction with the National Cancer Institute, but TRICARE is not involved in those activities except to the extent that we sometimes assist beneficiaries who are looking for research protocols that are eligible for TRICARE reimbursement.

Using the fiscal year 2007 military health system information management/information technology budget as a reference point, approximately 9.5 percent of the centrally funded IT budget supports research, development, testing and evaluation efforts. These funds are used for basic and applied research, fabrication of technology-demonstration devices and development and testing of prototypes and full-scale preproduction hardware.

Additionally, TRICARE Management Activity collaborates with such military research agencies as the U.S. Army Telemedicine and Advanced Technology Research Center [TATRC] to develop and test cutting-edge technical solutions that may benefit the military health system. For example, TATRC led the development of the Battlefield Medical Information System-Tactical, a point-of-care hand-held solution designed to support deployed medical personnel. The BMIS-T provides diagnostic support, records patient clinical encounters and transmits those records to the military health system Clinical Data Repository.

Q: With an organization as large as yours, there are obviously going to be times of dispute between the organization and individual patients. What systems do you have in place to make sure no one falls through the cracks and is provided every opportunity to receive care they deserve and that TRICARE wants to provide?

A: Even with an eligible population of 9.2 million worldwide, we have systems and processes in place to avoid a situation that would cause anyone to fall through the cracks. First and foremost, beneficiaries, guardians and providers know that we rely on the Defense Enrollment Eligibility Reporting System [DEERS] for eligibility determinations. Once beneficiary information is properly recorded in DEERS, individuals have access to authorized and needed care. Beneficiaries who disagree with certain benefits decisions made by TRICARE Management Activity or by a TRICARE contractor have the right to appeal that decision.

The multi-level appeals process varies depending on whether the denial of benefits involves a medical-necessity determination, a factual determination or a dual-eligible determination. TRICARE notifies beneficiaries of the appeals process they should follow at the same time they receive a written decision denying benefits. All initial determination and appeal denials explain how, where and by what date to file the next level of appeal.

Finally, our managed care support contractors along with their network of providers are all poised to assist in even the most difficult circumstances. Customer service protocols, which in turn drive customer satisfaction, are a key element to award fee payments to the contractor. It certainly is not in the best interest of anyone involved to have eligible beneficiaries not get the care they need or not to receive payment for the care they receive.

Q: Finally, sir, is there anything else you would like to add about TRICARE and its people?

A: TRICARE Management Activity comprises people from many areas of expertise working hard toward the same goal of patient satisfaction. Everything we do comes down to this one goal. For example, if we actively manage a patient’s chronic disease, his quality of life will improve, his outcome will improve and he will be a more satisfied patient. I look at everything I do through the patient-satisfaction lens.

As a leader, working at TRICARE is extremely fulfilling, because I work with people who are dedicated to improving the quality of life for beneficiaries. My staff members are smart and responsive, and they all want to do the right thing for beneficiaries. I’m the kind of leader who likes to visit with staff members and find out what keeps them up at night. My job is to minimize the crazy-makers that hold back innovation in the workplace.

So far, I’ve had just over a year in this job, and my staff and I have contributed toward greater patient satisfaction through innovations in patient safety and better management of disease. Over the last year, many of our benefit improvements have helped the most vulnerable members of our patient population, and that is a source of great pride to the staff at TRICARE.

Finally, I’ve been a doctor at war, and I’m an unabashed patriot. TRICARE is one of many programs that supports readiness. When you are fighting a war, the health and welfare of your troops is your number one priority. On the battlefield, I was proud to care for America’s sons and daughters, and at TRICARE, I am proud to care for the entire uniformed services family. ♦

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