By Anne M. Burton

Much of what we know about the public provision of health care in the U.S. comes from studies of Medicare, and to a lesser extent, Medicaid. Both of these programs, however, only cover specific populations: the elderly and disabled in the case of Medicare, and low-income families for Medicaid. Less well known is a third government healthcare program: the Military Health System. This program provides direct access to health care for military servicemembers, veterans, and their families, as well as providing reimbursement for care offered by private providers. To learn more about the Military Health System and a Notice of Funding Opportunity they just released, I spoke with Richard Shoge, Branch Chief of the Military Health System Research Program at the Defense Health Agency.

Anne: What is the Military Health System?

Richard: The Military Health System (MHS) is a global, comprehensive healthcare system that supports the U.S. military’s readiness mission. It provides healthcare to approximately 9.6 million beneficiaries, including active-duty service members, retirees, and their families. MHS integrates direct care services provided at military hospitals and clinics known as Military Treatment Facilities (MTFs) with private care from civilian providers through TRICARE benefits. Additionally, MHS supports medical research, education, and public health initiatives to advance military and national health objectives. The Military Health System plays a critical role in supporting the health and readiness of our armed forces and their families. Despite this vital mission, the MHS has often mirrored challenges seen across the broader U.S. healthcare system, including fragmented care, inconsistent innovation adoption, and lagging research-to-practice transitions.

Anne: What is the Defense Health Agency?

Richard: The Defense Health Agency (DHA) is a joint, integrated Combat Support Agency within the Department of Defense (DoD) that manages, executes, and oversees healthcare delivery in the Military Health System (MHS). The DHA enables the Army, Navy, and Air Force’s medical services to provide a medically ready force and a ready medical force for support to the Geographic Military Commands and military missions.  DHA operates in both peace and war, providing care to a global workforce through 45 hospitals (32 in the continental United States), 572 military ambulatory and occupational facilities (481 in the United States), and 115 dental clinics (88 in the United States).  Healthcare is provided by two systems: direct care (care provided in military clinics and hospitals) and private care (care provided in the private sector health system and paid for by TRICARE). The Unified Medical budget for FY23 was $55.8 billion which is approximately 7.2% of the overall DoD budget.  This includes the DoD Health plan, TRICARE, which is $18.5 billion of the budget.

Anne: Tell me more about the Military Health System Research Program and why it awards funding.

Richard: The Military Health System Research Program (MHSRP) was established in response to the National Defense Authorization Act of 2017.  The law required the establishment and implementation of best healthcare practices, reduction of variation in healthcare quality, and improvement of outcomes, therefore, the program executes a Notice of Funding Opportunity (NOFO) to identify and award research that provides insights into how care is delivered and can be improved.  All funded research must have an impact on cost, quality, outcome, or variation, illuminating ways in which leadership decision-making and policies can improve care. We also fund evaluation of policies that examines the impact on cost, quality, and outcome.

Anne: Tell me more about the DoD healthcare data that you have. Who is included in the data?

Richard: DoD healthcare data encompasses information on active-duty service members, National Guard and Reserve members, retirees, and their eligible family members. It includes the electronic health records for all enrolled beneficiaries enrolled in the MHS for the past 12 years, including cost data. Additionally, there are nearly 42 additional research databases that contain additional information on Active-Duty Service Members (ADSM).

Anne: Does the DoD healthcare data cover public and private-sector care?

Richard: Yes, the data include both direct care provided at MTFs and purchased care delivered through private-sector providers participating in TRICARE networks, we are also second payer to Medicare for our retiree population. This comprehensive coverage ensures universal access to care within the MHS.

Anne: What kinds of variables are included in the DoD Healthcare Data?

Richard: The DoD healthcare data capture a wide range of variables, including:

– Claims and billing data

– Diagnoses and treatment codes

– Pharmacy data, including prescription medications

– Laboratory and diagnostic test results

– Demographic information (age, gender, rank, etc.)

– Healthcare utilization patterns

– Expenditure data and cost analysis

Data dictionaries for the majority of datasets are available for review.

Anne: Are external researchers able to access the DoD Healthcare Data?

Richard: External researchers can access certain portions of DoD healthcare data through approved processes. The Military Health System Data Repository (MDR) and other platforms provide de-identified data for research purposes. Researchers must have either a grant award, Cooperative Research and Development Agreement (CRADA), or contract with the DoD.  All research must undergo Institutional Review Board (IRB) approval and complete a Data Sharing Agreement (DSA) application.

Anne: How can researchers learn more about DHA’s Notice of Funding Opportunity (NOFO)?

Richard: The Notice of Funding Opportunity was issued at the end of January- Early February 2025 on Grants.gov.  All inquiries regarding the program can be sent to dha.ncr.j-9.mbx.hsr@health.mil.

Anne: What type of research is supported?

Richard: The DHA’s NOFO supports innovative research to enhance medical readiness and healthcare delivery for service members and beneficiaries. Key focus areas include:

– Cost

– Quality

– Outcomes

– Variation

– Policy Impact

– Health Readiness

Anne: What are the eligibility requirements?

Richard: Eligible applicants from academic institutions, nonprofit organizations, and other federal government organizations outside of DoD may apply.  Federally Funded Research and Development Centers (FFRDCs) are not eligible to directly receive awards under this NOFO.  However, teaming arrangements between FFRDCs and eligible organizations are allowed if permitted under the sponsoring agreement between the federal government and the specific FFRDC. For government agencies within the US: local, state, and non-DoD federal government agencies are eligible to the extent that proposals do not overlap with their fully funded internal programs. Such agencies are required to explain how their proposals do not overlap with their internal programs.  We highly recommend partnerships between academia and military research groups, as this ensures that the research is understood within the context of the MHS.

Anne: When is the deadline to apply?

Richard: The NOFO typically provides a 60- to 90-day window for receipt of a Letter of Intent (LOI). Specific details are outlined in the NOFO document, and applicants are encouraged to review the guidelines thoroughly to ensure compliance with all requirements.  Applications with the January-February 2025 announcement will be funded in FY2026 subject to availability of funds.

Anne: Is there anything else you would like to share about the MHS?

Richard: If you have a burning question that can’t be answered with the data you have, we invite you to seek the answer within the MHS.  Our extensive data sources provide an opportunity to ask questions not possible with Medicare and Medicaid data.  We invite researchers to make a meaningful and lasting impact in support of our Active-Duty population by responding to the research call and becoming experts on our extensive and complex data universe.

Anne: Thank you for taking the time to tell us about the Military Health System and the Notice of Funding Opportunity. I hope ASHEcon members will take this opportunity to work on this type of research and advance knowledge on military healthcare and U.S. healthcare more broadly as there are many important insights to be learned from these data.