Defense Health Care
Health Care Benefit for Women Comparable to Other Plans Gao ID: GAO-02-602 May 1, 2002Half of all beneficiaries in the Department of Defense's (DOD) Tricare health care program are women. With a health care system historically oriented towards men, DOD has had to work to ensure that its women beneficiaries receive the full range of medical services they are entitled to, including obstetrical and gynecological care and diagnostic services such as Pap smears and mammograms. TRICARE-covered benefits are in line with American College of Obstetricians and Gynecologists guidelines and are comparable to women's health benefits offered by two of the largest health plans under the Federal Employees Health Benefits Program (FEHBP). DOD also requires some beneficiaries to share in the cost of their health care. Both DOD's and FEHBP's copayments, which are the same for men and women, vary depending on the plan option and the providers selected. Women beneficiaries report being satisfied with the health care benefits they receive under TRICARE. Some women beneficiaries, however, have expressed concerns about obtaining services when they are stationed overseas or in remote areas. Some active duty women are also concerned that command personnel may not understand women's health care needs.
GAO-02-602, Defense Health Care: Health Care Benefit for Women Comparable to Other Plans
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United States General Accounting Office:
GAO:
Report to Congressional Committees:
May 2002:
Defense Health Care:
Health Care Benefit for Women Comparable to Other Plans:
GAO-02-602:
Contents:
Letter:
Results in Brief:
Background:
DOD's Health Care Benefit for Women is Comparable to Other Plans:
Most Women Beneficiaries Are Satisfied With DOD's Health Care Benefit,
but Some Concerns Exist:
Concluding Observations:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: DOD Policies And Initiatives To Improve Women's Health
Care:
DOD-wide Policies and Initiatives:
Specific Initiatives by Each Branch of Service:
Appendix III: Comments from the Department of Defense:
Appendix IV: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Staff Acknowledgments:
Tables:
Table 1: Comparison of TRICARE Pap Smear and Mammogram Standards With
ACOG Guidelines and Other Plan Standards:
Table 2: Women Beneficiaries' Responses to Measures of Satisfaction
Compared to Men's:
Figure:
Figure 1: Men and Women Active Duty and Nonactive Duty Beneficiaries
by Branch of the Military, as of April 1, 2002:
Abbreviations:
ACOG: American College of Obstetricians and Gynecologists:
CHPPM: Center for Health Promotion and Preventive Medicine:
DACOWITS: Defense Advisory Committee on Women in the Services:
DES: diethylstilbestrol:
DOD: Department of Defense:
FEHBP: Federal Employees Health Benefits Program:
HMO: health maintenance organization:
MTF: military treatment facility:
NDAA: National Defense Authorization Act:
NMFA: National Military Family Association:
PCM: primary care manager:
REACH: Recruit Education to Achieve Health:
SHARP: Sexual Health and Responsibility Program:
TMA: TRICARE Management Activity:
TPR: TRICARE Prime Remote:
[End of section]
United States General Accounting Office:
Washington, D.C. 20548:
May 1, 2002:
Congressional Committees:
About half of all beneficiaries who are eligible to use TRICARE, the
Department of Defense's (DOD) health care program, are women”either
active duty personnel, family members, or retirees. With a health care
system historically oriented towards men, DOD has been challenged to
ensure that its women beneficiaries receive the full range of services
including primary, specialty, preventive, and reproductive care. The
National Defense Authorization Act (NDAA) for fiscal year 2002
directed that we study the adequacy and quality of the health care
provided to women by DOD. As agreed with the committees of
jurisdiction, we will describe (1) the health care benefit targeted to
women covered under the TRICARE program and how this benefit compares
to national clinical guidelines and other health plans' offerings and
(2) women beneficiaries' satisfaction with and concerns about DOD's
health care benefit.
To conduct our work, we reviewed relevant policies and procedures and
interviewed officials from DOD's Health Affairs' Office of Clinical
and Program Policy; DOD's TRICARE Management Activity (TMA); and the
Surgeons General Offices for the Air Force, Army, and Navy. We also
interviewed officials from the American College of Obstetricians and
Gynecologists (ACOG)[Footnote 1] and reviewed two of the largest
health care plans under the Federal Employees Health Benefits Program
(FEHBP)[Footnote 2] to compare the covered benefits with TRICARE's. To
determine beneficiaries' perceptions on women's health care services
in TRICARE, we relied on our past work on DOD health care, and we
reviewed the latest available data from two DOD surveys: a DOD-wide
health care survey on beneficiary satisfaction and a survey targeted
at inpatient care during childbirth at selected military treatment
facilities (MTF). In addition, we held interviews with the Defense
Advisory Committee on Women in the Services (DACOWITS), a group that
advises the Secretary of Defense on issues concerning active duty
women, and the National Military Family Association (NMFA), an
advocacy group that obtains beneficiary views on issues concerning
military families. However, we did not independently validate this
information or determine the prevalence of beneficiary concerns. It
should also be noted that while our review focuses on health care for
women beneficiaries, a number of our findings pertain to men as well,
which we note where appropriate. Our work was conducted from November
2001 through April 2002 in accordance with generally accepted
government auditing standards. (For more on our scope and methodology,
see appendix I.)
Results in Brief:
TRICARE offers a full range of health care services for women
beneficiaries, including obstetrical and gynecological care and
diagnostic services such as Papanicolaou (Pap) smears and mammograms.
The TRICARE benefits package is uniform across all three branches of
the military and for all beneficiary types”active duty personnel,
family members, and retirees. The TRICARE covered benefits are in line
with ACOG guidelines and are comparable to women's health benefits
offered by two of the largest health plans under FEHBP. In addition,
DOD”like the FEHBP plans we reviewed”requires some beneficiaries to
share in the cost of their health care. Both DOD's and FEHBP's
copayments, which are the same for men and women, vary depending on
the plan option and providers selected.[Footnote 3]
DOD's women beneficiaries, overall, report being satisfied with the
health care benefit they receive under TRICARE. For example, the
average rating from women for the health care they received was 7.8 on
a scale where 10 represents the best health care possible”the same
rating as given by men. Some of DOD's women beneficiaries, however,
have expressed concerns about obtaining the services available to
them. Generally, these concerns stem from where the beneficiary is
located”especially those stationed overseas or in remote areas”and
beneficiaries' expectations about the providers, sources of care, and
supplies available to them. For example, in overseas locations, DOD
beneficiaries may face medical practice, language, and cultural
differences with host nation care that can make them reluctant to seek
care. DOD officials told us that for active duty women, concerns also
stem from the attitudes and the climate established by the command
personnel who may not understand women's health care needs. DOD
officials also told us that some commanders may be reluctant to allow
active duty members”both men and women”time away from their duty
stations to obtain health care services. In commenting on a draft of our
report, DOD agreed with our findings.
DOD's medical mission includes maintaining the health of 1.7 million
active duty personnel[Footnote 4] and providing health care to them
during military operations. About 12 percent of the Navy's active duty
personnel,[Footnote 5] about 16 percent of the Army's active duty
personnel, and about 19 percent of the Air Force's active duty
personnel are women. DOD also offers health care to women who are
family members of active duty personnel, retirees, family members of
retirees, and survivors of active duty and retired active duty members
(see figure 1).
Figure 1: Men and Women Active Duty and Nonactive Duty Beneficiaries
by Branch of the Military, as of April 1, 2002:
[Refer to PDF for image: vertical bar graph]
The graph depicts the number of beneficiaries for the Navy[A], Army,
and Air Force in the following categories:
Active duty women;
Active duty men;
Nonactive duty women[B];
Nonactive duty men[B].
[A] The number of Navy beneficiaries includes beneficiaries in the
Marine Corps.
[B] Nonactive duty beneficiaries include family members of active duty
personnel, retirees, family members of retirees, and survivors of
active duty and retired active duty members.
Source: DOD.
[End of figure]
DOD beneficiaries are provided benefits through one of three health
plans: TRICARE Prime (an HMO option), TRICARE Extra (a preferred
provider option), and TRICARE Standard (a fee-for-service option).
Active duty members are required to enroll in TRICARE Prime, but
family members and retirees under age 65 can choose among any of the
three plans. DOD also provides benefits to military beneficiaries who
are Medicare-eligible.[Footnote 6] Beneficiary copayments vary
depending on the TRICARE option. Active duty personnel and their
family members who are enrolled in TRICARE Prime do not have
copayments.
Under TRICARE, health care is provided in MTFs worldwide and by
civilian providers. Priority for care at MTFs varies depending on the
beneficiary type”active duty, family member, or retiree”and the
TRICARE option. Active duty members have the highest priority for care
at MTFs, followed by other beneficiaries enrolled in TRICARE Prime.
[Footnote 7] Beneficiaries who are eligible for military health care,
but not enrolled in TRICARE Prime, may receive care at MTFs on a space-
available basis. Active duty members are required to use MTF care, if
available. Family members and retirees may obtain care at either
military or civilian facilities, depending on the TRICARE plan they
choose.
Policy regarding health care for all DOD beneficiaries is developed by
the Office of the Assistant Secretary of Defense for Health Affairs
(Health Affairs) TMA oversees the operation of the TRICARE Program.
Health Affairs and TMA coordinate with the Air Force, Army, and Navy
to implement TRICARE, but the Surgeon General of each branch of the
military has authority over its own MTFs. TMA also oversees the
TRICARE contracts with the civilian providers.
DOD and the three branches of the military have implemented policies
and initiatives specifically aimed at improving the delivery of health
services for women. (See app. II for details.) For example, a 1998 DOD
policy states that women enrolled in TRICARE Prime shall have the
option to choose a primary care manager (PCM)[Footnote 8] who has
advanced training in women's health issues.[Footnote 9] Additionally,
MTFs have begun providing "family-centered" obstetrical care by
involving the family in the continuum of care from prenatal through
postpartum. Other efforts have been aimed at educating line commanders
and beneficiaries about the importance of women's health care services
to readiness.
DOD's Health Care Benefit for Women is Comparable to Other Plans:
DOD offers a full range of health care services for women
beneficiaries through the TRICARE benefit. In general, TRICARE-covered
benefits for women reflect national clinical guidelines developed by
ACOG and are comparable to widely used FEHBP health plans. DOD”like
the FEHBP plans we reviewed”requires some beneficiaries to share in
the cost of their health care. These copayments, which are the same
for men and women, vary depending on the plan option and providers
selected.
DOD Health Care Services for Women:
In addition to the range of health care services offered to all DOD
beneficiaries, TRICARE provides health care services targeted
specifically to women. The benefit is uniform across all three
branches of the military, and generally for all beneficiary types,
including active duty members, family members, and retirees. These
services include the following primary, specialty, preventive, and
reproductive care.
* Comprehensive obstetrical and gynecological care, including care
related to pregnancy and family planning, and screening for
gynecological cancers:
- prenatal, maternity, and postpartum care, including HIV and
Hepatitis B screening for pregnant women, and genetic testing when
medically indicated to determine if an unborn child has genetic
defects,[Footnote 10] and;
- family planning, including contraceptives, diagnosis and treatment
of infertility, and sterilization;
* pelvic exams and Pap smears;
* breast examinations and mammography;
* breast reconstructive surgery for mastectomy patients and other
breast surgery;[Footnote 11]
* hormone replacement therapy and counseling regarding the benefits
and risks of hormone replacement therapy for menopausal women; and;
* bone density studies to diagnose and monitor osteoporosis,
osteopenia, and for those at high-risk of bone disease.
TRICARE Health Benefits for Women Are In Line With National Guidelines
and Other Health Plans:
The TRICARE benefit is consistent with the guidelines for women's
health issued by ACOG for primary, specialty, preventive, and
reproductive care. TRICARE benefits are also comparable to the range
of benefits for women offered under two FEHBP health plans”-BlueCross
and BlueShield Service Benefit Plans (BlueCross BlueShield), a fee-for-
service and preferred provider plan with the largest number of
participants in FEHBP; and Kaiser Foundation Health Plan of the Mid-
Atlantic States, Inc. (Kaiser), one of the FEHBP's largest HMO plans.
Specifically, BlueCross BlueShield and Kaiser also offer the full
range of women's health care services covered by TRICARE as listed
above, including obstetrical and gynecological care, maternity care,
family planning, mammography, reconstructive breast surgery, hormone
therapy, and bone density studies. For example, TRICARE coverage for
Pap smears and mammograms is in line with the FEHBP plans that we
reviewed as well as with ACOG guidelines that call for screenings
based on age and risk (See table 1.)
Table 1: Comparison of TRICARE Pap Smear and Mammogram Standards With
ACOG Guidelines and Other Plan Standards:
Pap smear:
ACOG: Preventive care includes a routine Pap smear annually when
sexually active or at age 18. For patients age 19 and above, physician
and patient discretion is recommended after three consecutive normal
tests, if low risk[A];
TRICARE: Preventive care includes a routine Pap smear annually at age
18 (or younger, if sexually active) until three normal tests. After
three normal tests, then test frequency is a physician and patient
decision, but not less than every three years;
FEHBP HMO (Kaiser): Preventive care includes a routine Pap smear.
Regarding test frequency, members are advised to consult with
physician to determine what is appropriate;
FEHBP Fee-for-service (BlueCross BlueShield): Preventive care includes
a routine Pap smear annually for women of any age.
Mammogram:
ACOG: Preventive care includes a routine mammogram for women as
follows:
* Age 19 to 39: periodic assessment, if high risk[B];
* Age 40 to 49: 1 test every 1 to 2 years;
* Age 50 to 64: yearly;
* Age 65 and above: periodic assessment.
TRICARE: Preventive care includes a routine mammogram for women as
follows:
* Age 40 and below: 1 baseline test;
* Age 41 to 50: 1 test every 2 years;
* Age 50 and above: yearly;
FEHBP HMO (Kaiser): Preventive care includes a routine mammogram for
women as follows:
* Age 35 to 39: 1 baseline test;
* Age 40 to 64: 1 test every calendar year;
* Age 65 and above: 1 test every 2 consecutive calendar years;
FEHBP Fee-for-service (BlueCross BlueShield): Preventive care includes
a routine mammogram for women as follows:
* Age 35 to 39: 1 baseline test
* Age 40 to 64: 1 test annually
* Age 65 and above: 1 test every 2 consecutive calendar years.
[A] ACOG recommends more frequent Pap tests when one or more high risk
factors is present, for example, women who have had multiple sexual
partners and women with a history of sexually transmitted diseases.
[B] For mammograms, high risk is defined as women who have had breast
cancer or have a first-degree relative (that is, mother, sister, or
daughter) or multiple other relatives who have a history of
premenopausal breast, or breast and ovarian, cancer.
Sources: ACOG guidelines effective in 2002, DOD TRICARE benefit for
2002, Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
for 2002, and BlueCross BlueShield Service Benefit Plans for 2002.
[End of table]
Benefits not provided under TRICARE are also comparable to the
benefits not covered under the FEHBP plans we reviewed. For example,
TRICARE does not cover:
* over-the-counter contraceptives or over-the-counter pregnancy tests,
* artificial insemination including in vitro fertilization,
* routine genetic testing to determine paternity or child's gender,
* surgery to reverse sterilization, and,
* abortion, except when the life of the mother is endangered.[Footnote
12]
BlueCross BlueShield and Kaiser generally do not cover these services
either, although there are limited exceptions. For example, Kaiser
covers artificial insemination and in vitro fertilization in certain
cases.[Footnote 13] While in vitro fertilization services are not
covered under the TRICARE benefit, DOD officials told us that these
services are offered with a required patient copayment at five MTFs:
Keesler Air Force Base, Biloxi, Mississippi; Naval Medical Center, San
Diego, California; Walter Reed Army Medical Center, Washington, D.C.;
Wilford Hall Medical Center, San Antonio, Texas; and Wright-Patterson
Air Force Base, Dayton, Ohio.[Footnote 14]
In addition, the TRICARE benefit requires some beneficiaries to share
in the cost of their health care”a characteristic also found in the
FEHBP plans we reviewed. However, the various plan options make direct
comparisons difficult. TRICARE Prime enrollees who are active duty
members or their family members have no copayments, while Kaiser
requires its beneficiaries to pay a $10 copayment for routine
screenings. TRICARE Extra and Standard beneficiaries and BlueCross
BlueShield beneficiaries share in the cost of care, with the
copayments varying depending on the plan option and the type of
provider chosen by the beneficiary.
Most Women Beneficiaries Are Satisfied With DOD's Health Care Benefit,
but Some Concerns Exist:
Overall, women beneficiaries report being satisfied with the TRICARE
health care benefit, but some have concerns about the type of care
they receive. Generally, these concerns stem from where beneficiaries
are located and their expectations about the types of providers,
sources of care, and supplies that should be available. For active
duty women, the attitudes of the command personnel can also influence
women beneficiaries' satisfaction.
DOD Survey Data Indicate Women Are Generally Satisfied With Health
Care Services:
According to DOD survey data from 2000, women beneficiaries report
being generally satisfied with the TRICARE health benefit and their
access to health care services.[Footnote 15] Results of this survey
indicate that women are as satisfied as men with their DOD health plan
on four measures pertaining to their experiences with their providers
and accessing care. For example, the average rating from women for the
health care they received in the last 12 months from all providers was
7.8 on a scale where 10 represents the best health care possible”the
same rating as given by men. In addition, 85 percent of women and 87
percent of men reported that they were usually or always satisfied
with how well providers communicated. (See table 2.)
Table 2: Women Beneficiaries' Responses to Measures of Satisfaction
Compared to Men's:
Measure: Average rating of all health care in the last 12 months from
all doctors and other health providers (on a scale where 10 represents
the best health care possible);
Women: 7.8;
Men: 7.8.
Measure: Average rating of all experiences with health care plan (on a
scale where 10 represents the best health plan possible);
Women: 7.3;
Men: 7.1.
Measure: Percent who reported that getting needed care was not a
problem;
Women: 68;
Men: 67.
Measure: Percent who reported that they were usually or always
satisfied with how well doctors and other health care providers
communicated;
Women: 85;
Men: 87.
Source: DOD's Health Care Survey of DOD Beneficiaries for year 2000.
[End of table]
Some Women Beneficiaries Have Concerns About the Available Care:
While most of DOD's women beneficiaries are satisfied with the care
they receive, some have expressed concerns about their health care.
These concerns generally stem from the beneficiary's location”
overseas, in remote areas, or in deployed settings”and expectations
about the type and source of care available. For active duty women,
concerns also stem from the attitudes and the climate established by
the command personnel who may not understand women's health care needs.
Some Concerns Are About Care in Overseas, Remote, and Deployed
Settings:
Military beneficiaries”both men and women”stationed in overseas or
remote locations provide a significant challenge for DOD's health
system.[Footnote 16] In locations overseas, DOD supplements its MTF
care with civilian host nation care, where medical practice, language,
and culture can differ significantly from U.S. civilian care. For
example, health care in Japan and Italy is characterized by more
inpatient admissions and longer hospital stays than in the U.S.
system. In many countries, nurses and administrative staff do not
speak English, and the English fluency of doctors varies, making it
difficult for patients to discuss their medical problems with host
nation personnel. In addition, patients expressed concerns that
medical terms might not be translated accurately. Cultural differences
have similarly affected beneficiary perceptions of care. For example,
in some areas of Europe and the Pacific, doctors are unaccustomed to
American patients who may take a more active role in their health care
and ask questions about their diagnosis or treatment strategies,
procedures, and expected outcomes. As a result, these patients can
become frustrated with the more reserved attitude of host nation
doctors. Other cultural differences can create a gap in care. For
example, in Japan and Korea, patients' families, not nursing staff,
typically provide sheets, towels, and toiletries and assist patients
during hospitalizations. In 2000, we reported[Footnote 17] that
differences such as these have caused frustrations for some
beneficiaries”both men and women”and in some cases have resulted in
their delaying care until they can travel to an MTF.
Remote locations-”both in the United States and overseas-”also present
a challenge to DOD in providing care to all of its beneficiaries. In
2000, we reported[Footnote 18] that, according to DOD, there are some
deficiencies in provider availability in rural areas of TRICARE
regions in the United States.[Footnote 19] In remote areas,
beneficiaries can have difficulty finding providers, especially for
certain types of specialty care, and often have to follow the accepted
community access standards, which may require traveling a long
distance to obtain care. For example, in some parts of South Dakota, a
2-hour drive is considered routine, and in Alaska, all patients are
transported to the lower 48 states for certain types of care. In
remote locations overseas, many of DOD's beneficiaries rely on the
State Department to provide or help arrange their medical care through
a list of local providers who meet U.S. medical standards.[Footnote 20]
In deployed settings, such as in the field or on a ship, active duty
members may be limited in the choice of health care services and
supplies available since DOD tailors the medical capability to the
setting and the size of the unit deployed. For women, this constraint
has raised concerns about privacy. In 1999, we reported that women
deployed to Bosnia described the base camp clinics as very small and
lacking interior walls and doors to shield individuals being examined.
[Footnote 21] These deployed women also had concerns that their
medical problems would not be kept confidential by staff at the
clinics and that word of their visit would be known around the camp.
Deployed women also raised concerns about the availability of
supplies, such as feminine hygiene products and birth control pills,
in the field or on ships. Due to limited storage space, women may not
be able to obtain their preferred brand, but most women were able to
obtain adequate supplies. At the end of 2001, DOD officials and
representatives from beneficiary groups told us that these concerns
remain among deployed women.
Some Concerns About Care Stem From Beneficiary Preferences:
According to DOD officials, some women beneficiaries were dissatisfied
with the care they received or were reluctant to seek available care
because of certain expectations about the type of provider they should
see and the setting in which they should receive their care. Several
DOD officials told us that some women expressed dissatisfaction or
reluctance to seek care from a provider who they perceive to be
inexperienced or insensitive to women's issues or who is male. These
officials also told us that some women prefer or expect to see a
doctor who specializes in obstetrical and gynecological care for their
gynecological examinations. This preference or expectation is
generally the result of their believing that specialists are better
qualified than generalists, such as internists or family practice
doctors. According to DOD officials, while obstetrical and
gynecological specialists are needed for some procedures, generalists,
physician assistants, or nurse practitioners can provide routine care
and perform preventive tests. According to beneficiary representatives
from DACOWITS and NMFA, women also expressed dissatisfaction with the
lack of continuity of care because they did not see the same provider
from visit to visit. Finally, DOD officials also said that active duty
women noted that they were reluctant to seek care from a provider who
is a peer or junior in rank, or is someone with whom they socialize.
This can be a particular problem in some deployed settings where the
number of medical staff is limited.
DOD officials also reported that women have preferences for where they
receive their maternity care. According to DOD officials, some women
prefer to have their babies delivered in civilian hospitals instead of
MTFs. Additionally, results from a DOD survey on inpatient care during
childbirth at selected MTFs show that some women reported problems
with obstetrical care received at MTFs.[Footnote 22] According to
survey results from 2000, 26 percent of women beneficiaries reported
dissatisfaction with obstetrical care at the MTF, compared to the
civilian hospital average of 22 percent. These women reported that
their dissatisfaction related to coordination of care, physical
comfort, respect for patient preferences, emotional support,
involvement of family and friends, and information and education. (See
appendix II for recent legislation and initiatives by the military
branches to address these concerns.)
Commanders and Beneficiaries May Lack Understanding About Women's
Health Care Needs:
DOD officials told us that reports from the field have indicated that
some line commanders, including officers and senior enlisted
personnel, may not understand the importance of women's health care.
These officials also said in some cases, women beneficiaries also
lacked an understanding of their health care needs. Specifically, DOD
officials said that some commanders and beneficiaries lack knowledge
about women's health issues, the health care services available to
women through DOD, when this care should be accessed, and the need for
such care. For example, some women beneficiaries do not understand the
importance of physical exams and preventive screenings such as Pap
smears and mammograms. This can be especially problematic for women”
both active duty and family members”who are young and away from their
families or other sources of support who might provide health care
guidance and teach them the importance of primary and preventive care.
[Footnote 23]
In some cases, beneficiaries and commanders have not been adequately
trained about the importance of women's basic health care and its
effect on readiness. For example, according to DOD officials, neither
the Army nor the Air Force has a program to train line commanders
about women's health care, although the Navy has some efforts to train
its leaders about these issues. DOD officials said that, lacking this
understanding, some commanders may be reluctant to allow active duty
members”both men and women”time away from their duty station to obtain
health care services”especially if the commander perceives that their
time away will negatively affect the primary mission. For active duty
women, explaining their specific ailment to their commanding officer
(usually male) or appearing like they need special treatment may make
them reluctant to seek the care they need.
Concluding Observations:
DOD offers a full range of health care services for women
beneficiaries through the TRICARE benefit. In general, TRICARE-covered
benefits for women reflect national clinical guidelines developed by
ACOG and are comparable to widely used FEHBP health plans. In
addition, the TRICARE benefit requires some beneficiaries to share in
the cost of their health care”a characteristic also found in the FEHBP
plans we reviewed. These copayments vary depending on the plan option
and providers selected.
Overall, DOD data indicate that women beneficiaries are satisfied with
the TRICARE health care benefit, but some have concerns about the care
available to them. Generally, these concerns stem from where the
beneficiary is located”overseas, in remote areas, or in deployed
settings”and beneficiaries' expectations about the type and source of
care that should be available. Concerns can also stem from the
attitudes and the climate established by the command personnel. We did
not, however, determine the prevalence of any of these concerns.
Additionally, we note that some concerns are relevant only to women,
but others pertain to men as well.
Agency Comments:
We provided DOD a draft of our report for its review. In its comments,
DOD agreed with our findings, noting that our portrayal of DOD's
health care benefit for women was accurate. DOD also provided
technical comments, which we incorporated where appropriate. (DOD's
comments appear in appendix III)
We are sending copies of this report to the Secretary of Defense,
appropriate congressional committees, and other interested parties. We
will also make copies available to others upon request. If you or your
staff have questions about this report, please contact me at (202) 512-
7101. Other contacts and staff acknowledgments are listed in appendix
IV.
Signed by:
Marjorie Kanof:
Director, Health Care”Clinical and Military Health Care Issues:
List of Committees:
The Honorable Carl Levin:
Chairman:
The Honorable John Warner:
Ranking Minority Member:
Committee on Armed Services:
United States Senate:
The Honorable Bob Stump:
Chairman:
The Honorable Ike Skelton:
Ranking Minority Member:
Committee on Armed Services:
House of Representatives:
The Honorable Daniel Inouye:
Chairman:
The Honorable Ted Stevens:
Ranking Minority Member:
Subcommittee on Defense:
Committee on Appropriations:
United States Senate:
The Honorable Jerry Lewis:
Chairman:
The Honorable John Murtha:
Ranking Minority Member:
Subcommittee on Defense:
Committee on Appropriations:
House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
Our review focused on issues related to health care provided by the
Department of Defense (DOD) that are specific to women, including
preventive and reproductive care. To address the key questions, we
analyzed pertinent documents (including policies, procedures, and
survey results) and interviewed officials from:
* DOD's Health Affairs' Office of Clinical and Program Policy,
* DOD's TRICARE Management Activity (TMA),
* the Surgeons General Offices for the Air Force, Army, and Navy, and,
* the American College of Obstetricians and Gynecologists (ACOG).
We reviewed selected health care plans under the Federal Employees
Health Benefits Program (FEHBP) to compare the covered benefits with
those provided by TRICARE. We selected BlueCross and BlueShield
Service Benefit Plans, a fee-for-service and preferred provider plan
with the largest number of participants in FEHBP, and Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc., one of the
FEHBP's largest health maintenance organization (HMO) plans. In
addition, we reviewed completed studies addressing military health
care, including those we conducted and those conducted by DOD. We also
conducted a site visit to Walter Reed Army Medical Center to review
the in vitro fertilization services offered at this military treatment
facility (MTF).
To further address these questions, we agreed with the committees of
jurisdiction to conduct a high-level review to obtain DOD
beneficiaries' perceptions on women's health care services and
identify potential concerns about women's health care in DOD. To do
this, we interviewed DOD headquarters officials and relied on two DOD
surveys: a DOD-wide health care survey on beneficiary satisfaction and
a survey targeted at inpatient care during childbirth at selected
MTFs. Both of these surveys are from 2000”the most recent data
available. We also conducted interviews with:
* the Defense Advisory Committee on Women in the Services (DACOWITS),
a group that advises the Secretary of Defense on issues concerning
active duty women, including health care, and,
* the National Military Family Association (NMFA), an advocacy group
that obtains beneficiary views on issues concerning military families,
including health care.
To supplement these interviews, we relied on our past work on DOD
health care.
We did not independently validate the information we received from
DOD, DACOWITS, or NMFA, nor did we determine the prevalence of
beneficiary concerns. Additionally, while our review focused on health
care for women beneficiaries, some of our findings pertained to men as
well, which we have noted in our report where appropriate. Our work
was conducted from November 2001 through April 2002 in accordance with
generally accepted government auditing standards.
[End of section]
Appendix II: DOD Policies And Initiatives To Improve Women's Health
Care:
Over the past decade, DOD has taken a number of steps to improve its
women's health care services in response to several factors, such as
legislation and beneficiary concerns. Notably, in 1990, DOD added
women's health as a responsibility of its Office of Clinical and
Program Policy to formulate DOD-wide policy related to women's health
issues and to coordinate women's health care activities initiated by
the three branches of the military.[Footnote 24] In addition, DOD has
established several DOD-wide policies to clarify TRICARE's benefits
for women. DOD has also implemented specific initiatives that affect
health care provided to women beneficiaries, including maternity care
and breast cancer care. Similarly, the three branches of the military
have developed initiatives targeted to meet the specific needs of
women patients. Many of these efforts aim to better educate leaders
and beneficiaries about the importance of women's health care services
to readiness.
DOD-wide Policies and Initiatives:
Since 1992, DOD has refined and enhanced some of its policies and
implemented several initiatives related to women's health care. Many
of these efforts were undertaken to respond to findings in the medical
community and concerns by the Congress, DACOWITS, and beneficiaries.
Key efforts are listed below.
* In 1992, in response to DACOWITS concerns, DOD issued a policy
regarding obstetrical care, stating that epidural analgesia would be
an option to women for normal vaginal deliveries. According to DOD
officials, this policy was based on the medical community's findings
that epidural analgesia was the most effective method to control pain
during labor and delivery, and allowed for an alert, participating
mother.
* In the early 1990s, DOD began to develop and implement the Breast
Cancer Initiative to improve early diagnosis, education, and
prevention of breast cancer for women beneficiaries. Funds were
allocated through the surgeons general of each branch of the military
to the local level for beneficiary access to breast cancer screening,
diagnosis, and treatment; training of primary care managers; and
education programs.
* In 1993, also in response to DACOWITS concerns, DOD established a
policy to clarify its standards for (1) access to and timely
notification of the results of Pap smears and mammograms and (2) the
availability of obstetrical and gynecological appointments for active
duty women.
* In 1994, the National Defense Authorization Act (NDAA) authorized
DOD to establish a Defense Women's Health Research Center at a
selected medical treatment center to coordinate research conducted
under DOD, the Department of Health and Human Services, and other
federal agencies on women's health issues that are related to military
service. The center researches women's health care issues such as the
effect on women of exposure to toxins and other environmental hazards;
combat stress and trauma; and mental health, including post-traumatic
stress disorder and depression.
* In 1995, DOD issued a policy refining the clinical preventive
services benefit for all TRICARE Prime enrollees based on the
collective expertise of military preventive medicine and to be more
consistent with nationally recognized standards for preventive
services. These preventive services include the following screenings
specific to women: breast cancer (physical exam and mammography);
cancer of female reproductive organs (physical exam and Pap smear);
Hepatitis B for pregnant women; and counseling about breast self-
examination for cancer surveillance.
* In 1998, DOD refined its policy on assigning primary care managers
(PCM) to beneficiaries enrolled in TRICARE Prime. PCMs coordinate
enrollees' care and refer them to the appropriate specialists, if
needed. This policy states that women enrolled in TRICARE Prime shall
have the option to choose a PCM who has advanced training in women's
health issues.[Footnote 25]
* In 2002, NDAA included a provision that will make it easier for
TRICARE Standard beneficiaries to obtain civilian maternity care
without prior approval from the MTF. DOD is required to implement this
provision on the earlier date of either of the following: the date
that a new TRICARE Standard contract takes effect or December 28, 2003.
Specific Initiatives by Each Branch of Service:
In addition to these DOD-wide efforts, the branches of the military
have implemented a number of women's health care initiatives”some of
which have been developed by one branch of the service and then
adopted by the others. Some of these initiatives aim to improve health
care for women, while others focus on providing education to leaders
and women beneficiaries to emphasize the importance of women's health
to DOD's readiness mission. Other education initiatives focus on the
importance of family planning and maternity wellness.
Over the past several years, the Army, Navy, and Air Force have each
implemented initiatives aimed at improving health care for their women
beneficiaries. For example, in November 2001, all Army MTFs began
using liquid-based cytology to read Papanicolaou (Pap) smears which is
a faster test than the standard Pap test. According to Army officials,
the use of liquid-based cytology will address the readiness concerns
identified during the Gulf War. Specifically, women who had received
Pap smears in their predeployment screening and were found to have
abnormal test results after being deployed were usually returned to
Europe or the United States for additional testing or treatment. With
the faster test, the Army expects to avoid the cost of returning
soldiers from a deployment and the need to back fill these
deployments. Both the Navy and the Air Force are also using the liquid-
based cytology Pap test in some locations.
The Navy's Perinatal Advisory Board (formerly, the Birth Product Line)
has been working to keep deliveries "in house" by improving the birth
experience at MTFs. Since its inception in 1997, the board has been
assessing patient satisfaction and health care concerns at MTFs
worldwide, including why some women choose MTFs and why others choose
civilian facilities to deliver their babies. Every Navy MTF worldwide
is in the process of implementing "family-centered care" to better
coordinate care within the facility and to involve the family in the
continuum of care from prenatal through postpartum. The Army and the
Air Force have also begun to focus on obstetrical care at their MTFs.
The Air Force also has several other initiatives related to improving
women's health care. For example, in 2000, the Air Force began pilot
testing "Project Athena" at Aviano Air Force Base in Italy, to provide
specialty care in areas”such as obstetrics and gynecology”where it
does not have sufficient patient populations to permanently assign
several specialists. While Aviano's workload was sufficient to support
one obstetrical and gynecological doctor, it was not enough to support
two, although more than one was needed at times. To meet these needs,
the Air Force assigned one obstetrical and gynecological specialist
full-time, and rotates other specialists to the MTF on temporary
assignments”usually 90 days. In addition to providing patients access
to specialized care, these rotations have given specialists enough
work to keep their skills current. The Air Force has expanded this
initiative of rotating obstetrical and gynecological doctors to
another location”Misawa Air Force Base in Japan.
Some of the military branches' health care initiatives for women were
developed by one branch and then adopted by the others. For example,
the Army and the Air Force have developed deployment readiness guides
for active duty women and their leaders. The need for such guides was
demonstrated in 1999, when we reported[Footnote 26] that 51 percent of
women deployed to Bosnia stated that they had not received any
information on women-specific health care and hygiene practices in the
field prior to deployment. The Army's Female Soldier Readiness Guide”
which covers areas such as field needs, health care preventive
measures in the barracks, and pregnancy”suggests strategies for
leaders and soldiers to ensure female readiness. The Air Force's
Female Airman Readiness Guide is based on the Army's readiness guide
and, like the Army guide, aims to enable military leaders to
effectively manage women in the Air Force by addressing topics such as
hygiene in the field and pregnancy counseling.
Each military branch is also developing systems for tracking women's
routine gynecological exams, including Pap smears. Currently, the Air
Force reviews the health needs of active duty women and men annually
during a preventive health appointment and makes recommendations for
further care based on their medical history. For example, during this
annual visit, active duty women are told when they are due for their
next gynecological exam. In addition, the Army is working on an Army-
wide initiative to track active duty women's Pap smears so they can
notify them of their annual exams, thereby helping to ensure they
receive needed care. This initiative is in the planning stages and has
not been implemented, although in the meantime some individual
installations have tracking processes in place. Similarly, the Navy
has no Navy-wide mechanism for tracking annual exams for women,
although there is some tracking of Pap smears at the MTF level.
Many of the Army's, Navy's, and Air Force's education initiatives aim
to educate leaders and beneficiaries about health care services for
women, including family planning and pregnancy wellness. According to
Army officials, unplanned pregnancies can disrupt work and training
situations. Army officials told us various studies show that more than
half of births to active duty women in the Army are from unplanned
pregnancies. In response, the Army has developed several initiatives
to provide beneficiaries with the knowledge to make informed decisions
about having children and taking appropriate care measures while
pregnant.
* The Center for Health Promotion and Preventive Medicine (CHPPM) is
developing a Personal Responsibility Program, including an Army-
specific curriculum for soldiers. Its purpose is to provide soldiers
with better skills for reducing unplanned pregnancies, including
education on reproduction and contraception as well as meshing family
planning with career and financial planning. Following pilot testing,
this program may be implemented Army-wide.
* The Army's Office of the Deputy Chief of Staff for Personnel
convened a multidisciplinary work group that is looking at many
aspects of parenthood and its effects on readiness, including
unplanned pregnancy and physical training for women after birth. Its
intent is to develop a comprehensive reference manual for military
leaders to use in managing the myriad issues connected to parenthood.
* CHPPM, with the assistance of a contractor, is developing a
certification program for physical training during pregnancy and
postpartum. The intent of this program is twofold: to provide Army
certification in pregnancy fitness and to provide a safe, standardized
program for pregnant and postpartum soldiers. Most women may exercise
safely throughout pregnancy within ACOG guidelines and under the
advice of their health care provider. Exercise during pregnancy helps
prevent unwanted body fat gain and promotes a faster return to
physical readiness levels. According to Army officials, one Army study
suggested that active duty women who participated in a pregnancy
wellness program were more likely to pass the postpartum height/weight
requirements than those who did not participate in a structured
physical fitness program. In addition, they told us that other studies
showed that the caesarian section rate was lower among fitness program
participants than the national average, and there were no increases in
adverse outcomes to either the pregnant soldiers or their fetuses or
infants. They also said that preliminary Army data from the initial
pilot program indicate that there is a beneficial effect on labor and
that military readiness is promoted following a regular special
exercise program.
The Navy and Air Force have also developed initiatives on family
planning and pregnancy wellness. For example, the Navy's Environmental
Health Center developed a program called the Sexual Health and
Responsibility Program (SHARP) to provide sexual health and
responsibility training Navy-wide to both leaders and active duty
members through the Internet and CD-ROMs. In addition, the Navy's
CHOICES program provides sailors with education on sexually
transmitted diseases, pregnancy, relationship building, and sexual
responsibility. The goal of the program is to assist sailors in making
better choices, which will reduce the number of unplanned pregnancies.
CHOICES is available at selected commands, including in San Diego
where the Deployment Program Manager of the Fleet Family Services
Center has indicated that male and female sailors at Naval Station San
Diego, including all shipboard personnel, are required to attend this
program. The Navy's recruit training also includes a component on
conception and contraception. Specifically, in the seventh week of
basic training both females and males attend a program called Recruit
Education to Achieve Health (REACH) that includes training on sexual
responsibility, family planning, and emergency contraception. The Air
Force supports the use of doulas-”specially trained women to help
other women, particularly first-time mothers, during pregnancy and
childbirth”-as long as this does not interfere with providing care. A
national society of doulas has offered their services free of charge
to women beneficiaries. According to Air Force officials, this service
could be particularly beneficial to women whose husbands have been
deployed.
The branches of the military have provided education on women's health
through targeted web sites or a CD-ROM. For example, a Navy website
provides information about dysuria, family planning, and emergency
contraception. It also provides information on the breast care centers
at the National Naval Medical Center in Bethesda and the Naval Medical
Centers at San Diego and Portsmouth. The Navy also developed the
Operational Obstetrics and Gynecology CD-ROM to serve as a self-
contained resource on obstetrical and gynecological care for health
care providers of all levels from corpsman through physician providers
who are deployed and ashore, stationed away from an MTF or other
hospital. According to Navy officials, the fact that it does not
require Internet access is crucial during deployment. The CD-ROM is a
refresher on the full range of women's health care from Pap smears,
family planning, gynecological emergencies, and obstetrical care
through menopause. It also includes DOD-wide medical instructions
pertinent to all three military branches and copies of the female
readiness guides for the Army and Air Force. The CD-ROM has been
distributed to the Air Force, Army, Coast Guard, and various
international military medical forces.
[End of section]
Appendix III: Comments from the Department of Defense:
The Assistant Secretary Of Defense:
Health Affairs:
Washington, D.C. 20301-1200:
April 25, 2002:
Marjorie Kanof, M.D.
Director, Clinical and Military Health Issues:
U.S. General Accounting Office:
Washington, DC 20548:
Dear Dr. Kanof:
This is the Department of Defense (DoD) response to the GAO draft
report GAO-02-602, "Defense Health Care: Health Care Benefit for Women
Comparable to Other Plans," dated April 12, 2002 (GAO Code 290137).
Overall, DoD finds that the report is an accurate and positive
portrayal of the health care benefit for women. In addition, the GAO
appropriately identifies the limitations in the report with respect to
the reliance on historical reports and inability to validate some of
the findings reported by DoD, the Defense Advisory Committee for Women
in the Service, or the National Military Family Association.
The Department appreciates the opportunity to comment on the draft
report. Please feel free to address any questions to my project
officers on this matter, Ms. Patricia Collins, Senior Health Policy
Analyst, Operations, (functional) at (703) 681-3900 or Mr. Gunther J.
Zimmerman (GAO/IG Liaison) at (703) 681-7889.
Sincerely,
Signed by:
E. P. Wyatt, for:
William Winkenwerder, Jr., MD:
[End of section]
Appendix IV: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Kristi A. Peterson (202) 512-7951:
Linda L. Siegel (202) 512-7150:
Staff Acknowledgments:
Contributors to this report were Ann Calvaresi-Barr, Cynthia D.
Forbes, Janice S. Raynor, Mary W. Reich, and Karen Sloan.
[End of section]
Footnotes:
[1] AGOG is a national organization that develops guidelines for
clinical practice for women's health care services.
[2] The FEHBP, administered by the Office of Personnel Management, is
the largest employer-sponsored group health insurance program in the
world. FEHBP offers fee-for-service plans with preferred provider
organizations, health maintenance organization (HMO) plans, and plans
offering a point-of-service product.
[3] Active duty personnel and their family members who are enrolled in
TRICARE Prime”DOD's HMO option”do not have copayments.
[4] Includes members of the Coast Guard, the Commissioned Corps of the
National Oceanic and Atmospheric Administration and of the Public
Health Service. It also includes National Guard members who are
eligible for care in the military health system when they are in
active duty status.
[5] The calculation of the percent of women active duty personnel in
the Navy includes active duty personnel in the Marine Corps.
[6] Medicare is a federally financed health insurance program that
covers health care expenses of the elderly, some people with
disabilities, and people with end-stage kidney disease. Military
retirees aged 65 or older are eligible for Medicare on the same basis
as civilian retirees. In 2001, military retirees enrolled in Medicare
part B (which covers physician care, other outpatient services, and
selected home health services) became eligible for TRICARE coverage”
commonly called TRICARE for Life. As a result, TRICARE is now a
secondary payer for these retirees' Medicare-covered services”paying
most of the required cost sharing. Retirees can also obtain services
at MTFs, but when they do this, DOD does not receive payments from
Medicare for those services it provides them.
[7] Beneficiaries enrolled in TRICARE Plus”a new MTF primary care
enrollment program offered at selected MTFs”also receive primary care
appointments with the same access standards as TRICARE Prime enrollees.
[8] A PCM coordinates enrollees' care and refers them to the
appropriate specialists, if needed.
[9] According to DOD officials, the availability of PCMs with advanced
training in women's health care may be limited.
[10] TRICARE covers genetic testing if the mother is aged 35 or older
or had rubella during the first 3 months of pregnancy, or has a family
history of genetic defects.
[11] TRICARE covers cosmetic, reconstructive, and plastic surgery for
breasts in the following cases: (1) correction of a congenital
anomaly, (2) restoration of body form (including revision of scars)
following an accidental injury, (3) revision of disfiguring and
extensive scars resulting from neoplastic surgery, and (4)
reconstructive breast surgery following a medically necessary
mastectomy performed for the treatment of carcinoma, severe
fibrocystic disease, other nonmalignant tumors, or traumatic injuries.
[12] See 10 U.S.C. § 1093. This statute places the following
restrictions on abortions: (a) funds available to DOD may not be used
to perform abortions except where the life of the mother would be
endangered if the fetus were carried to term and (b) no medical
treatment facility or other facility of DOD may be used to perform an
abortion except where the life of the mother would be endangered if
the fetus were carried to term or in a case in which the pregnancy is
the result of an act of rape or incest.
[13] Kaiser Mid-Atlantic offers in vitro fertilization if (1) the
patient and her spouse have a history of infertility of at least 2
years duration as a result of endometriosis, exposure in utero to
diethylstilbestrol (commonly known as DES), blockage of, or surgical
removal of, one or both fallopian tubes, lateral or bilateral
salpingectomy, or abnormal male factors, including oligospermia,
contributing to the infertility and (2) the patient has been unable to
become pregnant through a less costly infertility treatment for which
coverage is available under this plan and (3) the patient's oocytes
are fertilized with her spouse's sperm.
[14] According to officials at Walter Reed, beneficiaries at their MTF
are required to pay a copayment of about $3,500 to $5,000 for in vitro
fertilization services, while in the civilian sector, the cost would
be about $8,000 to $10,000. The cost of this service may vary at other
MTFs.
[15] The Health Care Survey of DOD Beneficiaries is a recurring survey
that asks a sample of eligible beneficiaries to comment on their
health, the availability of health services, and their level of
satisfaction with health services.
[16] According to DOD data, over 200,000 active duty members and over
190,000 active duty family members live overseas; and over 160,000
active duty members and over 360,000 active duty family members live
in remote areas. DOD defines a "remote" area as one in which an active
duty member lives and works more than 50 miles, or about an hour
drive, from an MTF.
[17] U.S. General Accounting Office, Defense Health Care: Resources,
Patient Access, and Challenges in Europe and the Pacific, [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-172] (Washington, D.C.: Aug.
31, 2000).
[18] U.S. General Accounting Office, Military Health Care: TRICARE's
Civilian Provider Networks, [hyperlink,
http://www.gao.gov/products/GAO/HEHS-00-64R] (Washington, D.C.: Mar.
13, 2000).
[19] To address provider availability deficiencies, in October 1999
DOD implemented TRICARE Prime Remote (TPR) for active duty members
stationed in the U.S. who live and work more than 50 miles from an
MTF. Eligible active duty members are required to enroll in TPR. TPR
enrollees have access to (1) a PCM to manage their health care,
authorize specialty care referrals, and file claims, and (2) health
care finders”contract staff accessed by toll-free numbers”to help
identify primary and specialty care providers and process referrals.
DOD plans to expand the program to include family members by September
2002. In the meantime, copayments are waived for family members
eligible for TPR.
[20] [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-172].
[21] U.S. General Accounting Office, Gender Issues: Medical Support
for Female Soldiers Deployed to Bosnia, [hyperlink,
http://www.gao.gov/products/GAO/NSIAD-99-58] (Washington, D.C.: Mar.
10, 1999).
[22] In 2000, DOD conducted a survey to determine beneficiary
satisfaction with inpatient care during childbirth at 20 MTFs.
[23] The Air Force and the Navy require annual physical exams for all
active duty members”men and women. The Army requires annual exams for
active duty women, and periodic exams for active duty men, as
appropriate (average is every 5 years for men).
[24] The Office of Clinical and Program Policy has several program
directors assigned to handle different issues. Currently, women's
issues are assigned to one program director who is also responsible
for mental health issues.
[25] According to DOD officials, the availability of PCMs with
advanced training in women's health care may be limited.
[26] [hyperlink, http://www.gao.gov/products/GAO/NSIAD-99-58].
[End of section]
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