Ninety-three percent of expectant mothers who are eligible for military health care get their maternity care in military clinics and hospitals.

At first glance, it’s a statistic civilian obstetricians would envy. But 93 percent is not a strong measure of performance. It flows from a legal requirement and is no more praiseworthy than a tyrant’s reelection with 100 percent of the vote.

Over the years, patients have been forced to use the military health care system—including for maternity care. Those in TRICARE Prime, the military’s managed care plan, have no choice but to use the military system. To seek civilian maternity care, TRICARE Standard users living within 40 miles of a military hospital or clinic must obtain a statement from the facility that military care is not available.

Without the so-called non-availability statement (NAS), Standard patients aren’t covered for certain procedures performed by civilian providers including, historically, their maternity care. The idea is to provide sufficient patient loads for military obstetricians and staff to be busy and well-trained. It also is intended to ensure cost-effective care to save defense dollars.

The cost, over the years, has been patient satisfaction.

Because the military hasn’t needed to compete for expectant mothers, maternity care scores lower than most kinds of care on patient satisfaction surveys. Women are unhappy with continuity of care, availability of doctor appointments, restrictions on use of ultrasound, and pain management options. Military obstetric care clinics don’t stack up well against civilian facilities for providing creature comforts like child care services during doctor visits or close-in parking— particularly for women in their third trimester.
All of these challenges are expected to ease under a new family centered care initiative for expectant mothers unveiled a few months ago. Dr. William Winkenwerder, assistant secretary of Defense for Health Affairs, promised a turnaround in maternity care and delivery of “a world-class standardized” benefit.

It better be more than a promise by Dec. 28, when the NAS requirement for expectant mothers ends. Congress elected to kill it after years of patient complaints and lobbying against the NAS by MOAA and other service associations.

The question for military obstetricians will be whether they can keep enough patients. Active duty dependents dissatisfied with maternity care could decide to disenroll from TRICARE Prime. That’s possible under an exception to law that Congress has declined to rescind. It makes active duty family members, when seeking maternity care, exempt from Standard cost shares.

That cost break for patients, on top of military obstetric clinics losing discretionary power to capture Standard patients, is forcing military obstetric care to become more competitive, says Dr. David Tornberg, deputy assistant secretary for Clinic and Program Policy. Defense health officials and the surgeons general of the Army, Navy, and Air Force began a year ago to develop a strategy to upgrade and standardize maternity care. The resulting family centered care concept means shifting focus from what’s convenient for physicians and hospitals to what’s important to patients, Tornberg says.

It emphasizes patient empowerment. Clinics will help women develop birth plans. Appointment scheduling will improve. Ultrasound will become more available, maybe routine in the second trimester, Tornberg says. Obstetric clinics will add parking. Care will improve with a team concept of providers. The services also will look at building additional obstetric clinics.

“What we wanted to establish was… uniformed expectations across our health system,” explains Tornberg.

Improvements will require more spending to upgrade facilities and staff. Precisely how much, Tornberg couldn’t say. The trend will be up for all services, but by how much will vary.

If military obstetric care still isn’t good enough, TRICARE Prime beneficiaries could decide to disenroll and use their Standard benefit, joining the 7 percent of expectant moms using Standard coverage. Defense and service health leaders will monitor patient satisfaction as well as the number of deliveries at military facilities versus under the Standard insurance benefit, says Tornberg.

“We don’t want people leaving our plan,” says Tornberg. “We want to be able to nurture our beneficiaries.” 

Tom Philpott is a freelance writer and syndicated news columnist. His column, "Military Update," appears in 48 daily newspapers throughout the United States and overseas.