What Are the New Findings?

In 2018, mental health disorders accounted for the largest proportions of the morbidity and health care burdens that affected the pediatric and younger adult beneficiary age groups. Among adults aged 45–64 years, musculoskeletal diseases accounted for the most morbidity and health care burdens, and among adults aged 65 years or older, cardiovascular diseases accounted for the most.

What Is the Impact on Readiness and Force Health Protection?

Mental health disorders among military family member dependents may affect service members' readiness and their focus on the mission by contributing to stress or by affecting the mental health status of the service member. It is important to connect families to social support services to improve military family readiness, which can impact the overall readiness of the force.

Background

Individuals who are eligible for care through the Military Health System (MHS) ("beneficiaries") include active component service members and their eligible family members, activated National Guard and Reserve service members and their eligible family members, and retirees and their eligible family members. In 2018, there were approximately 9.51 million beneficiaries eligible for health care in the MHS: 1.38 million active duty and activated reserve component service members, 1.68 million active duty family members, 190,000 Guard/Reserve members, 780,000 Guard/Reserve family members, and 5.49 million retirees and their family members.¹ Some beneficiaries of MHS care do not enroll in the health care plans provided by the MHS (e.g., they use insurance through their own employment), and some of those who are enrolled do not seek care through the MHS.

MHS beneficiaries may receive care from resources provided directly by the Uniformed Services (i.e., military medical treatment facilities [MTFs]) or from civilian health care resources (i.e., outsourced [purchased] care) that supplement direct military medical care.¹ In 2018, approximately 6.5 million non-service member beneficiaries utilized inpatient or outpatient services provided by the MHS (data source: the Defense Medical Surveillance System [DMSS]). In the population of non-service member MHS care recipients in 2018, there were more females (57.1%) than males (42.9%) and more infants, children, and adolescents (those younger than 20 years old: n=1.66 million; 25.4%) and more seniors (those aged 65 years or older: n=2.07 million; 31.6%) than younger (aged 20–44 years: n=1.29 million; 19.7%) or older (aged 45–64 years: n=1.52 million; 23.3%) adults.

Since 1998, the MSMR has published annual summaries of the numbers and rates of hospitalizations and outpatient medical encounters to assess the health care burdens of 16 categories of illnesses and injuries among active component military members. Beginning in 2001, the MSMR complemented those summaries with annual reports on the combined health care burden of both inpatient and outpatient care for 25 categories of health care. Since then, the MSMR's annual burden issue has contained a report on hospital care, ambulatory care, and the overall burden of care each for active component service members. In 2014, for the first time and using similar methodology, the MSMR published a report that quantified the health care burden for illnesses and injuries among non-service members in 2013.² The current report represents an update and provides a summary of care provided to non-service members in the MHS during calendar year 2018. Health care burden estimates are stratified by direct versus outsourced care and across 4 age groups of health care recipients.

Methods

The surveillance period was 1 Jan. through 31 Dec. 2018. The surveillance population included all non-service member beneficiaries of the MHS who had at least 1 hospitalization or outpatient medical encounter during 2018 either through a military medical facility/provider or a civilian facility/provider (if paid for by the MHS). For this analysis, all inpatient and outpatient medical encounters were summarized according to the primary (first-listed) diagnoses documented on administrative records of the encounters if the diagnoses were reported with International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes that indicate the natures of illnesses or injuries (i.e., ICD-10 codes A00–T88). Nearly all records of encounters with first-listed diagnoses that were Z-codes (care other than for a current illness or injury—e.g., general medical examinations, after care, vaccinations) or V-, W-, X-, or Y-codes (indicators of the external causes but not the natures of injuries) were excluded from the analysis; however, encounters with primary diagnoses of Z37 ("outcome of delivery, single liveborn") were retained.

For summary purposes, all illness- and injury-specific diagnoses (as defined by the ICD-10) were grouped into 142 burden of disease-related conditions and 25 major categories based on a modified version of the classification system developed for the Global Burden of Disease Study.³ The methodology for summarizing absolute and relative morbidity burdens is described on page 2 of this issue of the MSMR.

The new electronic health record for the MHS, MHS GENESIS, was implemented at several military treatment facilities during 2017. Medical data from sites that are using MHS GENESIS are not available in the DMSS. These sites include Naval Hospital Oak Harbor, Naval Hospital Bremerton, Air Force Medical Services Fairchild, and Madigan Army Medical Center. Therefore, medical encounter data for individuals seeking care at any of these facilities during 2018 were not included in this analysis.

Results

In 2018, a total of 6,537,135 non-service member beneficiaries of the MHS had 86,788,454 medical encounters (Table). Thus, on average, each individual who accessed care from the MHS had 13.³medical encounters over the course of the year. The top 3 morbidity-related categories, which accounted for a little more than one-third (34.3%) of all medical encounters, were signs, symptoms, and ill-defined conditions (12.0%); musculoskeletal diseases (12.0%); and injury/poisoning (10.3%) (Figures 1a, 1b). The illness/injury categories that affected the most beneficiaries who received any care were signs, symptoms, and ill-defined conditions (45.8%); injury/poisoning (34.1%); and sense organ diseases (29.6%).

Cardiovascular diseases accounted for more hospital bed days (n=1,103,494) than any other illness/injury category and 16.6% of all hospital bed days overall (Figures 1a, 1b). An additional 38.2% of all bed days were attributable to injury/poisoning (15.2%), mental health disorders (9.8%), infectious/parasitic diseases (6.6%), and digestive diseases (6.6%).

Of note, among all beneficiaries, maternal conditions (including pregnancy complications and delivery) accounted for relatively more hospital bed days (n=331,973; 5.0%) than individuals affected (n=163,349; 2.5%) (Figure 1a).

Click to closeDirect CareDirect care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.”Direct Care vs. Outsourced Care

In 2018, among non-service member beneficiaries, most medical encounters (90.6%) were in non-military medical facilities (outsourced care) (Table). Of all beneficiaries with any illness or injury-related encounters during the year, many more received exclusively outsourced care (n=4,728,130; 72.3%) than either military medical (direct) care only (n=708,585; 10.8%) or both outsourced and direct care (n=1,100,420; 16.8%). By far, most inpatient care (92.9% of all bed days) was received in non-military facilities (outsourced).

The proportions of medical encounters by morbidity-related categories were broadly similar for direct and outsourced care (Figures 2a, 2b, 3a, 3b). However, encounters for injury/poisoning and respiratory infections were relatively more common in direct (13.5% and 8.1%, respectively) compared to outsourced (9.9% and 3.5%, respectively) care. Musculoskeletal diseases, cardiovascular diseases, neurologic conditions, and malignant neoplasms were relatively more common in outsourced (12.3%, 9.5%, 4.8%, and 3.3%, respectively) compared to direct (9.5%, 5.3%, 2.0%, and 1.5%, respectively) care.

Maternal conditions accounted for 21.3% of all direct care bed days but only 3.8% of all outsourced care bed days (Figures 2a, 2b, 3a, 3b). However, cardiovascular diseases, mental health disorders, and musculoskeletal diseases accounted for relatively more of all outsourced than direct care bed days (% of outsourced vs. % of direct care bed days: cardiovascular, 17.0% vs. 11.9%; mental health, 10.3% vs. 4.3%; musculoskeletal, 6.4% vs. 4.4%).

Pediatric beneficiaries (Aged 0–17 Years)

In 2018, pediatric beneficiaries accounted for 13.9% of all medical encounters, 23.0% of all individuals affected, and 7.5% of all hospital bed days (Table). On average, each affected individual had 8.0 medical encounters during the year.

Mental health disorders accounted for slightly more than one-third (34.1%; n=4,108,901) of all medical encounters and 60.2% of all hospital bed days (n=298,975) among pediatric beneficiaries (Figures 4a, 4b). On average, each pediatric beneficiary who was affected by a mental health disorder had 14.7 mental health disorder-related encounters during the year. More than two-thirds (67.9%) of all medical encounters for mental health disorders among pediatric beneficiaries were for autistic disorders (34.6%), followed by developmental speech/language disorders (22.1%), and attention deficit disorders (11.1%) (Figures 4c, 4d). On average, there were 48.3 autism-related encounters per individual affected with an autistic disorder and 12.2 encounters for developmental speech/language disorder per individual affected with those specific disorders (data not shown). Despite the high numbers of encounters associated with these 3 categories of mental health disorders, 44.7% of mental health disorder-related bed days were attributable to mood disorders, and 37.4% of mood-related bed days were attributable to "major depressive disorder, recurrent severe without psychotic features" (data not shown).

Among pediatric beneficiaries overall, "conditions arising during the perinatal period" (i.e., perinatal conditions) accounted for the second most hospital bed days (n=38,034; 7.7%) (Figures 4a, 4b). Of note, among pediatric beneficiaries with at least 1 illness or injury-related diagnosis, those with malignant neoplasms had the second highest number of related encounters per affected individual (12.6). The highest numbers of malignant neoplasm-related encounters were attributable to leukemias, "all other malignant neoplasms," and brain neoplasms, while the highest numbers of bed days were attributable to leukemias, brain neoplasms, and "all other malignant neoplasms" (data not shown).

Finally, respiratory infections (including upper and lower respiratory infections and otitis media) accounted for relatively more medical encounters and bed days among pediatric beneficiaries (12.2% and 4.3%, respectively) when compared to any older age group of beneficiaries (with the exception of beneficiaries aged 65 years or older among whom respiratory infections accounted for 4.9% of total bed days) (Figures 4b, 5b, 6b, and 7b).

Beneficiaries (Aged 18–44 Years)

In 2018, non-service member beneficiaries aged 18–44 years accounted for 13.6% of all medical encounters, 22.1% of all individuals affected, and 11.2% of hospital bed days (Table). On average, each individual affected with an illness or injury (any cause) had 8.2 medical encounters during the year.

Among beneficiaries aged 18–44 years, the morbidity-related category that accounted for the most medical encounters was mental health disorders (n=2,151,074; 18.2% of all encounters) (Figures 5a, 5b). Among these adult beneficiaries, mental health disorders accounted for 22.0% of all bed days, and, on average, each adult affected by a mental health disorder had 6.6 mental health disorder-related encounters during the year. Mood disorders (33.4%), anxiety disorders (28.2%), and adjustment disorders (16.7%) accounted for nearly four-fifths (78.3%) of all mental health disorder-related medical encounters among beneficiaries aged 18–44 years (data not shown).

Among adults aged 18–44 years, maternal conditions accounted for more than two-fifths (44.6%) of all bed days and, on average, 6.1 medical encounters per affected individual (Figures 5a, 5b). Normal deliveries accounted for 11.1% of maternal condition-related medical encounters (data not shown). Adults aged 18–44 years accounted for nearly all (99.2%) maternal condition-related bed days among beneficiaries not in military service. Although adults aged 18–44 years had the lowest percentage of total medical encounters (13.6%), if morbidity burdens associated with maternal conditions were excluded from the overall analysis, this age group would account for even lower percentages of total medical encounters (12.5%) and the lowest percentage of total hospital bed days (6.2%) when compared to any other age group (data not shown).

Among beneficiaries aged 18–44 years with at least 1 illness or injury-related diagnosis, those with malignant neoplasms had the second most (along with maternal conditions) category-specific encounters per affected individual (6.1). Of all malignant neoplasms, breast cancer accounted for the most malignant neoplasm-related encounters (27.8% of the total) (data not shown).

Beneficiaries (Aged 45–64 Years)

In 2018, non-service member beneficiaries aged 45–64 years accounted for 21.1% of all medical encounters, 23.3% of all individuals affected, and 13.9% of hospital bed days (Table). On average, each affected individual had 12.0 medical encounters during the year.

Of all morbidity-related categories, musculoskeletal diseases accounted for the most medical encounters (n=2,766,188; 15.1%) among older adult beneficiaries (Figures 6a, 6b). In addition, in this age group, back problems accounted for 44.9% of all musculoskeletal disease-related encounters (data not shown). Cardiovascular diseases accounted for more hospital bed days (15.9% of the total) than any other category of illnesses or injuries, and cerebrovascular disease and ischemic heart disease accounted for 33.3% and 18.9%, respectively, of all cardiovascular disease-related bed days (data not shown). Digestive diseases accounted for a larger percentage (9.6%) of total hospital bed days among beneficiaries in this age group when compared to those in the other age groups.

The most medical encounters per affected individual were associated with malignant neoplasms (6.5), mental health disorders (6.0), musculoskeletal diseases (5.0), maternal conditions (4.9), neurologic conditions (4.4), injury/poisoning (4.3), and respiratory diseases (4.2) (Figures 6a, 6b). Malignant neoplasms (8.3%) accounted for a larger proportion of total bed days among beneficiaries aged 45–64 years than the other age groups of beneficiaries. Breast cancer accounted for nearly one-fourth (23.9%) of all malignant neoplasm-related encounters among older adult beneficiaries (data not shown).

Beneficiaries (Aged 65 Years or Older)

In 2018, non-service member beneficiaries aged 65 years or older accounted for slightly more than half (51.4%) of all medical encounters, nearly one-third (31.6%) of all individuals affected, and slightly more than two-thirds (67.5%) of hospital bed days (Table 1). On average, each affected individual had 21.6 medical encounters during the year.

Of all morbidity-related categories, cardiovascular diseases accounted for the most medical encounters (n=6,297,744; 14.1%) and bed days (n=938,343; 21.0%) (Figures 7a, 7b). Essential hypertension (26.6%), ischemic heart disease (14.5%), and cerebrovascular disease (9.7%) accounted for slightly more than half (50.8%) of all cardiovascular disease-related medical encounters, and cerebrovascular disease accounted for over one-quarter (29.1%) of all cardiovascular disease-related bed days (data not shown).

Among the oldest age group of beneficiaries, the most medical encounters per affected individual were associated with musculoskeletal diseases (6.5), malignant neoplasms (5.8), respiratory diseases (5.6), diseases of the genitourinary system (5.3), cardiovascular diseases (5.1), and mental health disorders (5.0). In this age group, back problems accounted for more than one-third (36.2%) of all musculoskeletal disease-related encounters. Together, melanomas and other skin cancers (19.9%); prostate cancer (14.4%); breast cancer (12.3%); and trachea, bronchus, and lung cancers (10.7%) accounted for more than half (57.4%) of all malignant neoplasm-related encounters (data not shown). Chronic obstructive pulmonary disease accounted for more than two-fifths of all medical encounters (42.3%) and approximately three-eighths of all bed days (37.1%) attributable to respiratory diseases (data not shown).

Infectious and parasitic diseases (7.7%) accounted for a larger proportion of total bed days among the oldest age group compared to the other age groups of beneficiaries (Figures 7a, 7b). In contrast, mental health disorders accounted for smaller percentages of medical encounters (2.5%) and bed days (2.5%) among the oldest age group compared to the younger age groups.

Editorial Comment

This report describes the sixth estimate of overall morbidity burdens among nonservice member beneficiaries of the MHS. The report notes that a large majority of the health care services for current illness and injury (excluding encounters with diagnoses identified by Z-codes) that are provided through the MHS to non-service member beneficiaries are delivered in non-military medical facilities (i.e., outsourced [purchased] care). The report also documents that there are pronounced differences in the types of morbidity and the natures of the care provided for evaluation and treatment across age groups of beneficiaries. Of particular note, individuals aged 65 years or older account for slightly more than half of all medical encounters (51.4%) and a majority (67.5%) of all hospital bed days delivered to beneficiaries not currently in military service.

In 2018, mental health disorders accounted for the largest proportions of the morbidity and health care burdens that affected the pediatric (aged 0–17 years) and younger adult (aged 18–44 years) beneficiary age groups. Among pediatric beneficiaries, 67.9% of medical encounters for mental health disorders were attributable to autistic disorders, developmental speech/language disorders, or attention deficit disorders. Of particular note, children affected by autistic disorders had, on average, 48.3 autism-related encounters each during the 1-year surveillance period.

Although mental health disorders also accounted for more medical encounters among young adult (18–44 years) beneficiaries than any other major category of illnesses or injuries, the proportion of all encounters attributable to mental health disorders was markedly less among young adult (18.2%) than pediatric (34.1%) beneficiaries. Also, as expected, the mental health disorders that accounted for the largest health care burdens among younger adults (18–44 years)—mood, anxiety, and adjustment disorders—differed from those that most affected the pediatric age group.

It is not surprising that the highest numbers and proportions of hospital bed days among adults aged 18–44 years were for maternal conditions because this age group encompasses nearly all women of childbearing age. Among older adults (aged 45–64 years), musculoskeletal diseases were the greatest contributors to morbidity and health care burdens, and among adults aged 65 years or older, cardiovascular diseases were the greatest contributors to morbidity and health care burdens.

Of musculoskeletal diseases, back problems were a major source of health care burden; of cardiovascular diseases, cerebrovascular disease, ischemic heart disease, and essential hypertension accounted for the largest health care burdens. These findings are not surprising and reflect the inevitable effects of aging on the health and health care needs of the older segment of the MHS beneficiary population. However, many of the health conditions associated with the largest morbidity and health care burdens among beneficiaries in older age groups are also associated with unhealthy lifestyles (e.g., unhealthy diet, inadequate exercise, or tobacco use). As such, to varying extents, the most costly health conditions may be preventable and their disabling or life-threatening long-term consequences may be avoidable. Illnesses and injuries that disproportionately contribute to morbidity and health care burdens in various age groups of MHS beneficiaries should be targeted for early detection and treatment by comprehensive prevention and research programs.

References

1. Department of Defense. Evaluation of the TRICARE Program: Access, Cost, and Quality: Fiscal Year 2017 Report to Congress. https://www.health.mil/Reference-Center/Reports/2019/05/10/Evaluation-of-the-TRICARE-Program-Fiscal-Year-2018-Report-to-Congress. Accessed 22 May 2019.
2. Armed Forces Health Surveillance Center. Absolute and relative morbidity burdens attributable to various illnesses and injuries, non-service member beneficiaries of the Military Health System, 2013. MSMR. 2014;21(4):23–30.
3. Murray CJ and Lopez AD, eds. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard University Press; 1996:120–122.