Reports & Projects

Reports & Projects

Defense Health Horizons (DHH) is organized to produce quick turnaround (generally 90 - 120 days) reports requiring limited resource investment. It provides policymakers with several potential courses of action and the likely consequences of each. DHH leverages USUHS resources, including faculty and students, internal MHS subject matter experts, and engages a robust steering committee comprised of health leaders from across the MHS, federal and civilian healthcare.

The DHH approach involves the following steps:

1) Identification of an issue or relevance to the MHS by a leader within the MHS

2) DHH receipt of a request to examine the issue

3) Review by DHH staff and steering committee

4) Identification and engagement of SMEs to consult on the project

5) Research and documentation of the issue and potential courses of action

6) Review by the DHH steering committee

7) Finalization of the report and dissemination to MHS leadership


Completed Reports & Projects

Coding Guidelines for Graduate Medical Education

September 17, 2015


On April 1, 2015, the military health system (MHS) implemented new coding guidelines addressing resident and medical student supervision and documentation of medical care to support coding and billing.




Although the policy was ostensibly adopted to align MHS practices with those of civilian teaching institutions, discussions with civilian experts in graduate medical education (GME) and 3rd party billing determined that the MHS’ proposed approach was far more restrictive than that followed by civilian programs and the Veterans Healthcare Administration. In addition, civilian and military medical education experts we interviewed expressed concern that the MHS’ proposed policy could adversely affect undergraduate and graduate medical education (potentially leading to accreditation problems), hinder supervising physician productivity, impede throughput and therefore limit access to care and could ultimate compromise readiness. In light of these unintended consequences, DHH recommended that the new policy be rescinded or substantially revised to mitigate its most serious adverse effects. The MHS committee has adopted a more reasonable approach to medical record documentation.


Photo: 3958586 by Marcy Sanchez. Posted on The appearance of U.S. Department of Defense (DoD) visual information does not imply or constitute DoD endorsement.

MHS GME Oversight and Organization

July 5, 2018

In January 2018 Vice Admiral Raquel Bono, Director of the Defense Health Agency (DHA), requested DHH investigate the pros and cons for different models of the Military Health System (MHS) Graduate Medical Education (GME) program. DHH engaged external subject matter experts (SMEs) and MHS GME leaders.



DHH analyzed strategies which DHA and the services might consider to meet elements of the 2017 National Defense Authorization Act (NDAA). The final report detailed potential courses of action (COAs) pertaining to strengthening oversight and coordination of GME in the MHS.


Photo: 3387226 by Michelle Gigante. Posted on The appearance of U.S. Department of Defense (DoD) visual information does not imply or constitute DoD endorsement.

Improving the Health and Readiness of Military Women

April 26, 2018

Assuring TRICARE Coverage of Preventive Health Services for Women

June 5, 2018


Women are 14% of the active duty (AD) force and most are of child-bearing age. The unique health needs of women, make women’s health a readiness issue. It is impacted by availability and accessibility of services designed to meet these unique needs. To address this topic, DHH engaged two SMEs, Col Cathy Witkop, MD, MPH and Dr. Elizabeth Kostas-Polston, to lead an effort to identify options for improving access to preventive health services for active duty service women, including access to various methods for contraception. 


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(Clockwise from top left) Photo: 3116773 by Cynthia McIntyre. Photo: 1624701 by Sgt. Richard Blumenstein. Photo: 545044 by Sgt. John Herrick. Photo: 2909039 by Cpl. Clarence Wimberly. Posted on The appearance of U.S. Department of Defense (DoD) visual information does not imply or constitute DoD endorsement.


In addition to analyzing treatment of servicewomen, the team also worked with faculty from George Washington University to compare provisions for women’s health services in the Affordable Care Act that are based on guidelines promulgated by the American College of Obstetrics and Gynecology (ACOG) guidelines with current TRICARE coverage.





Two reports were generated, both of which offer potential courses of action to improve access to appropriate women’s health services for female Service members as well as TRICARE beneficiaries.


Photo: 3840489 by Petty Officer 3rd Class Juan Sua. Posted on The appearance of U.S. Department of Defense (DoD) visual information does not imply or constitute DoD endorsement.

Out of the Crucible: How the US Military Transformed Combat Casualty Care in Iraq and Afghanistan



Out of the Crucible a book that was conceived by Defense Health Horizons and published by the Army’s Borden Institute, tells the story of one of the most remarkable achievements in the history of American Medicine.  During OEF and OIF, the military health system completely transformed its approach to combat casualty care, from the point of injury to on the battlefield to forward aid stations to surgery in theater, and from Critical Care Air Transport (CCAT) to Role 4 and 5 military hospitals in the US, followed by comprehensive rehabilitation and recovery. In the process, it achieved the highest survival rate from battlefield wounds in the history of warfare.




Written by many of the uniformed and civilian innovators who brought these changes about, this 44-chapter book describes the foundations of the MHS that made this progress possible, 27 advances that contributed to the dramatic improvement in survival and recovery, and future challenges the MHS much address to adapt and respond to the next conflict. Interspersed throughout the book are personal stories of wounded warriors and the MHS providers who treated them. Written to appeal to lay readers, Out of the Crucible is part of the Textbooks of Military Medicine series published and maintained by the US Army’s Borden Institute. Service members can obtain a copy of the book from the Borden Institute and civilians can order it from the U.S. Government Publishing Office (GPO). EBooks compatible with different readers such as Kindle or iPad can be downloaded for free from the GPO’s website:

Policy Options to Address the Use of Specialty Drugs

November 14, 2017


Specialty drugs are used for patients undergoing intensive therapies for uncommon or rare diseases. Most are administered by intravenous infusion. Not only are they more expensive than standard pharmaceuticals; their cost is rising at a far higher rate. 


The expense of a specialty drug can vary dramatically depending on where it is administered. When a drug is dispensed to patients from an MTF pharmacy under the pharmacy benefit, the DoD enjoys federal pricing. However, some specialty drugs, such as chemotherapy for cancer and treatments for rheumatoid arthritis, are usually administered within a doctor’s office, infusion center or hospital inpatient setting.  These drugs, which can be extremely expensive, are currently reimbursed under the purchased care medical benefit which is not subject to federal pricing.




To approach this issue, DHH engaged Tom McGinnis, Former Chief, Pharmaceutical Operations Directorate, Office of the Assistant Secretary of Defense (HA/TMA). He reviewed the methods used to charge for administration of specialty drugs with specific focus on the differences between two methods of reimbursement – “white bagging” and “brown bagging;” costs of the drugs and administration methods; and various options for decreasing costs while ensuring that patients have continued access to needed drugs. The report identified substantial potential savings if reimbursement strategies are modified.


Photo: 2647816 by Senior Airman Justyn Freeman. Posted on The appearance of U.S. Department of Defense (DoD) visual information does not imply or constitute DoD endorsement.

The Role of Graduate Medical Education in the MHS

July 22, 2016


In June 2016 Defense Health Horizons examined the role of Graduate Medical Education (GME) in the Military Health System, as it relates to shaping the future military medical workforce to assure that the MHS can meet its readiness requirements and the other components of the quadruple aim. Prepared at the request of (then) Assistant Secretary of Defense for Health Affairs, Dr. Jonathan Woodson, the report provides a high-level analysis of strategic objectives and poses potential directions to enhance the oversight and impact of military GME. The report addresses several important questions of relevance to military medicine:



  1. How to best allocate GME resources to balance differing medical needs of combat operations and garrison care;
  2. Should the focus of military MTF residencies be on combat requirements? Can civilian residencies meet our garrison care needs? Are there specialties for which the MHS does not match adequate patient volumes & clinical experience of civilian programs?
  3. What are opportunities to improve sharing of training slots and resources across the MHS?
  4. Is the MHS most efficiently rationalizing training effort across services? If not how do we begin to do so?
  5. ACGME Clinical Learning Environment Reviews (CLER) now are voluntary but would the MHS be ready if that changed?
  6. How do CLER precepts align with the MHS High Reliability Organization (HRO) strategy? Are current GME programs implementing CLER? If not, what actions can be taken now to meet future needs?

To answer these questions, DHH reviewed existing data from MHS GME programs, reviewed MHS GME policies, conducted interviews with MHS and civilian GME leaders and key stakeholders, and analyzed the literature. DHH recommendations focused on responses to the questions posed by Dr. Woodson and included the following summary of findings: “Although readiness is the MHS primary mission, it is not the only one. GME is also vital to meet the other 3 components of the quadruple aim (better health, better care, lower costs). Properly managed and resourced, military GME can accelerate the transformation of the MHS into a High Reliability Organization. This white paper identified numerous opportunities to strengthen GME in the MHS so it is more integrated, coordinated across services, efficient, and produces physicians that approach practice with a team and systems-oriented focus. This is the best way to ensure that the MHS physicians of the future meet the needs of deployed warfighters, service members and their families and military retirees in the most accessible, safe and efficient way possible.”


Photo: 4030916 by Staff Sgt. Kevin Iinuma. Posted on The appearance of U.S. Department of Defense (DoD) visual information does not imply or constitute DoD endorsement.


Telehealth in the MHS: Impact, Obstacles and Opportunities

December 13, 2016


The Military Health System (MHS) has historically adopted telehealth in deployment settings more frequently than in CONUS. The practice of telehealth is appealing to both providers and patients for various reasons including: the convenience of after-hours care, the use of commonly utilized electronic devices, no requisite for transportation and the elimination of facility costs associated with brick and mortar buildings.




DHH engaged Dr. Ronald Porapotich to review the MHS’s past telehealth accomplishments, current telehealth programs, opportunities to expand the delivery of telehealth services and the barriers to using telehealth. The DHH report details proposed courses of action to address the future of telehealth in the MHS and identifies benefits of expanding telehealth in CONUS that include increased access to healthcare, improved quality of care, better health outcomes, reduced per capita costs and enhanced readiness.


Photo: 494260 by Capt. Cory Gerould. Posted on The appearance of U.S. Department of Defense (DoD) visual information does not imply or constitute DoD endorsement.

Works in Progress

Measuring Productivity of the MHS

Currently the MHS uses Relative Value Units (RVUs) to assess productivity of clinicians. RVUs are based essentially on the fee for service system that reimburses TRICARE providers in the civilian sector. DHH is exploring the issues related to the use of RVUs as a measure of clinical productivity, and propose options for measurements that account for the range of activities that clinicians are involved in, including training, education, research, administration, support to bases, and most importantly, readiness, which are not quantifiable using RVUs.

Decision Aid Computer App for Military Women’s Health

A decision aid tool that allows military women to review their reproductive health status and document questions about their health and options for interventions such as menstrual suppression prior to deployment would aid in ensuring that active duty servicewomen are able to access the preventive health services they need, and prevent health problems that may affect their readiness. DHH is working with a team that designed and tested a similar computer-based app for civilian women to use. The decision aid will be integrated into other efforts through DHA once it is piloted within the MHS.

Health Affairs Thematic Issue on Military Health System Research

Despite its critical role assuring the health of the men and women who protect our nation, the military health system is poorly understood by the civilian health sector and by the policymakers charged with overseeing civilian health programs. Military and civilian systems face similar challenges regarding effective use of personnel, efficient organization of services, managing readiness and surge capacity, and promoting population health. The military health system also faces particular challenges that warrant additional attention, such as balancing direct provision of care with purchased care, and meeting the health and social needs of young families. By subjecting analysis of the military health system to peer review, and placing a spotlight on issues facing the military health system, Health Affairs will help set the course for innovation and improvement in the MHS well into the future.

Human Performance and Strategy

In the midst of NDAA-driven changes to the MHS, readiness, operational mission support, and health services must be appropriately balanced to realize the value of the MHS to the operational missions of the Services they support. DHH is developing a report defining the strategic framework for improving the health and performance of highly trained, specialized operational communities. This report will help inform the MHS on the future role of Military Treatment Facilities and other MHS organizations in supporting traditional and evolving missions through operational outreach and mission-relevant connection.

Outcome Metrics for a Health System / Vital Signs

Metrics that are intended to measure the performance and outcomes of a health system are not always optimized to provide the information that is desirable about system performance. In 2015, the Institute of Medicine (IOM – now the National Academy of Medicine (NAM)), issued a consensus report that proposed a streamlined set of 15 standardized measures, with recommendations for their application at every level of a health system and across sectors in the system. Through the engagement of internal and external SMEs, DHH is examining the applicability of the NAM’s Vital Signs to the MHS and will lay out potential courses of action for implementing system outcome metrics for the military healthcare system.