pacity, and price. CMS is also conducting disease management demonstration projects that focus on Medicare FFS beneficiaries with congestive heart failure, diabetes, and coronary heart disease. These demonstrations involve innovative care management approaches, expanded coverage for prescription drugs, and the assumption of financial risk by providers (Centers for Medicare and Medicaid Services, 2002c). In addition, CMS has awarded 15 grants for coordinated care demonstration projects focused on Medicare fee-for-service beneficiaries with complex chronic conditions, and these, too, involve care delivery innovations and alternative payment models (Department of Health and Human Services, 2001).

In 1997, DOD initiated a Centers of Excellence program to select, on the basis of a rigorous evaluation process, a limited number of providers to deliver highly specialized services in selected clinical areas (TRICARE, 2002). This program is not yet operational, but a great deal of work has been done to identify the selected clinical areas and the criteria for selection. The selected areas are bone marrow and solid organ transplants, burn care, cardiac care, complex general surgery, cranial and spinal procedures, gynecologic oncology, head and neck oncology, neonatal and prenatal medicine, and total joint replacement. The criteria for selection emphasize the ability to measure various aspects of quality, adjust for severity, measure outcomes, and report externally on clinical processes and outcomes.

In 1998, DOD began reporting some information on quality and access to beneficiaries (Department of Defense, 2001). The Military Treatment Facility Report Card includes information on waiting times for major services; patient satisfaction; and summary scores from JCAHO accreditation surveys applicable to credentialing, provider/staff competence, infection control, and nursing care.

Although beyond the immediate scope of the present study, it should be noted that the federal government has pursued a purchaser approach in carrying out its responsibilities under the Federal Employees Health Benefits Program. For health plans participating in this program, federal employees can access CAHPS and HEDIS data and summary results from NCQA accreditation surveys (Office of Personnel Management, 2002).

CARE DELIVERY

VHA and IHS have comprehensive care delivery programs. For the most part, the federal government owns and operates the health care facilities and employs the workforce necessary to provide comprehensive services to beneficiaries in these programs. The DOD TRICARE program also has a large delivery system component—just over half of health care services are provided through DOD’s treatment facilities (located mainly on military bases), with the remainder being delivered through private-



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