Defense Health Care
Oversight of the TRICARE Civilian Provider Network Should Be Improved Gao ID: GAO-03-928 July 31, 2003Testifying before Congress in 2002, military beneficiary groups described problems accessing care from TRICARE's civilian medical providers. Providers also testified on their dissatisfaction with the TRICARE program, specifying low reimbursement rates and administrative burdens. The Bob Stump National Defense Authorization Act of 2003 required GAO to review the oversight of the TRICARE network of civilian providers. Specifically, GAO describes how the Department of Defense (DOD) oversees the adequacy of the civilian provider network, evaluates DOD's oversight of the civilian provider network, and describes the factors that have been reported to contribute to network inadequacy. GAO analyzed TRICARE Prime--the managed care component of TRICARE. To describe and evaluate DOD's oversight, GAO reviewed and analyzed information from reports on network adequacy and interviewed DOD and contractor officials in 5 of 11 TRICARE regions.
For the 8.7 million TRICARE beneficiaries, DOD relies on the civilian provider network to supplement health care delivered by its military treatment facilities. To ensure the adequacy of the civilian provider network, DOD has standards for the number and mix of providers, both primary care and specialists, necessary to satisfy TRICARE Prime beneficiaries' needs. In addition, DOD has standards for appointment wait, office wait, and travel times to ensure that TRICARE Prime beneficiaries have timely access to care. DOD has delegated oversight of the civilian provider network to the local level through regional TRICARE lead agents. DOD's ability to effectively oversee the TRICARE civilian provider network is hindered in several ways. First, the measurement used to determine if there is a sufficient number and mix of providers in a geographic area does not always account for the total number of beneficiaries who may seek care or the availability of providers. This may result in an underestimation of the number of providers needed in an area. Second, incomplete contractor reporting on access to care makes it difficult for DOD to assess compliance with these standards. Finally, DOD does not systematically collect and analyze beneficiary complaints, which might assist in identifying inadequacies in the civilian provider network. However, DOD has tools, such as surveys of network providers and automated reporting systems which, while not designed specifically for monitoring the civilian provider network, could, if modified, improve DOD's ability to oversee the network. DOD and its contractors have reported that a lack of providers in certain geographic locations, low reimbursement rates, and administrative requirements contribute to potential civilian provider network inadequacy. DOD and contractors have reported long-standing provider shortages in some geographic areas. In areas where DOD determines that access to care is severely impaired, DOD has the authority to increase reimbursement rates. Since 2002, DOD has used its reimbursement authority to increase rates in Alaska and Idaho in an attempt to entice more providers to join the network. DOD officials told us that the contractors have achieved some success in recruiting additional providers by using this authority. Additionally, civilian providers have expressed concerns that TRICARE's reimbursement rates are generally too low and administrative requirements too cumbersome. However, while reimbursement rates and administrative requirements may have created provider dissatisfaction, it is not clear how much this has affected civilian provider network adequacy except in limited geographic locations, because the information contractors provide to DOD is not sufficient to measure network adequacy.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-03-928, Defense Health Care: Oversight of the TRICARE Civilian Provider Network Should Be Improved
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Report to Congressional Committees:
United States General Accounting Office:
GAO:
July 2003:
Defense Health Care:
Oversight of the TRICARE Civilian Provider Network Should Be Improved:
TRICARE Civilian Provider Network:
GAO-03-928:
GAO Highlights:
Highlights of GAO-03-928, a report to congressional committees
Why GAO Did This Study:
Testifying before Congress in 2002, military beneficiary groups
described problems accessing care from TRICARE‘s civilian medical
providers. Providers also testified on their dissatisfaction with the
TRICARE program, specifying low reimbursement rates and administrative
burdens.
The Bob Stump National Defense Authorization Act of 2003 required GAO
to review the oversight of the TRICARE network of civilian providers.
Specifically, GAO describes how the Department of Defense (DOD)
oversees the adequacy of the civilian provider network, evaluates DOD‘s oversight of the civilian provider network, and describes the factors that have been reported to contribute to network inadequacy.
GAO analyzed TRICARE Prime”the managed care component of TRICARE. To
describe and evaluate DOD‘s oversight, GAO reviewed and analyzed
information from reports on network adequacy and interviewed DOD and
contractor officials in 5 of 11 TRICARE regions.
What GAO Found:
For the 8.7 million TRICARE beneficiaries, DOD relies on the civilian
provider network to supplement health care delivered by its military
treatment facilities. To ensure the adequacy of the civilian provider
network, DOD has standards for the number and mix of providers, both
primary care and specialists, necessary to satisfy TRICARE Prime
beneficiaries‘ needs. In addition, DOD has standards for appointment
wait, office wait, and travel times to ensure that TRICARE Prime
beneficiaries have timely access to care. DOD has delegated oversight
of the civilian provider network to the local level through regional
TRICARE lead agents.
DOD‘s ability to effectively oversee the TRICARE civilian provider
network is hindered in several ways. First, the measurement used to
determine if there is a sufficient number and mix of providers in a
geographic area does not always account for the total number of
beneficiaries who may seek care or the availability of providers. This
may result in an underestimation of the number of providers needed in
an area. Second, incomplete contractor reporting on access to care
makes it difficult for DOD to assess compliance with these standards.
Finally, DOD does not systematically collect and analyze beneficiary
complaints, which might assist in identifying inadequacies in the
civilian provider network. However, DOD has tools, such as surveys of
network providers and automated reporting systems which, while not
designed specifically for monitoring the civilian provider network,
could, if modified, improve DOD‘s ability to oversee the network.
DOD and its contractors have reported that a lack of providers in
certain geographic locations, low reimbursement rates, and
administrative requirements contribute to potential civilian provider
network inadequacy. DOD and contractors have reported long-standing
provider shortages in some geographic areas. In areas where DOD
determines that access to care is severely impaired, DOD has the
authority to increase reimbursement rates. Since 2002, DOD has used
its reimbursement authority to increase rates in Alaska and Idaho in
an attempt to entice more providers to join the network. DOD officials
told us that the contractors have achieved some success in recruiting
additional providers by using this authority. Additionally, civilian
providers have expressed concerns that TRICARE‘s reimbursement rates
are generally too low and administrative requirements too cumbersome.
However, while reimbursement rates and administrative requirements may
have created provider dissatisfaction, it is not clear how much this
has affected civilian provider network adequacy except in limited
geographic locations, because the information contractors provide to
DOD is not sufficient to measure network adequacy.
What GAO Recommends:
GAO recommends that DOD improve its oversight of the civilian provider
network by ensuring sufficient information is reported and by
exploring options for evaluating beneficiary complaints and improving
provider survey data. DOD concurred with the recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-03-928.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Marjorie Kanof at
(202) 512-7101.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
DOD Has Standards for Network Adequacy and Requires Contractors'
Compliance:
DOD's Oversight of the Civilian Provider Network Has Weaknesses, But
Additional Tools May Help:
DOD and Contractors Report Three Factors That May Contribute to
Civilian Provider Network Inadequacy:
New Contracts May Address Some Network Concerns, But May Create Others:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comparison of Current and Future TRICARE Regions:
Appendix III: Comments from the Department of Defense:
Appendix IV: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Acknowledgments:
Figures:
Figure 1: Areas of the United States with a TRICARE Network of Civilian
Providers:
Figure 2: Current TRICARE Regions:
Figure 3: Future TRICARE Regions After TNEX Implementation:
Abbreviations:
ATC: Access To Care Project:
DOD: Department of Defense:
EWRAS: Enterprise Wide Referral and Authorization System:
HCSDB: Health Care Survey of DOD Beneficiaries:
JCAHO: Joint Commission on Accreditation of Healthcare Organizations:
MOAA: Military Officers Association of America:
MTF: military treatment facility:
NCQA: National Committee for Quality Assurance:
PCM: primary care manager:
TMA: TRICARE Management Activity:
United States General Accounting Office:
Washington, DC 20548:
July 31, 2003:
The Honorable John Warner
Chairman
The Honorable Carl Levin
Ranking Minority Member
Committee on Armed Services
United States Senate:
The Honorable Duncan L. Hunter
Chairman
The Honorable Ike Skelton
Ranking Minority Member
Committee on Armed Services
House of Representatives:
The primary mission of TRICARE, the Department of Defense's (DOD)
health care system, is to provide care for eligible active duty
personnel, retirees, and dependents. These beneficiaries, currently
numbering more than 8.7 million, can receive their care through
military hospitals and clinics called military treatment facilities
(MTFs) or through TRICARE's civilian provider network. The civilian
provider network is developed by managed care support contractors and
is designed to complement the availability of care offered by
MTFs.[Footnote 1]
DOD faces new challenges in ensuring that the TRICARE civilian provider
network can provide adequate access to care that complements the
capabilities of MTFs. In 2003, DOD intends to award new contracts for
the delivery of care in the civilian provider network because the
current contracts will expire. As a result, the providers who choose to
participate in the network may change, while those who remain will
operate under new policies and procedures. During this transition, DOD
is still responsible for ensuring that the civilian provider network
provides adequate access to care, even if beneficiaries must change
providers.
TRICARE also faces beneficiary and provider dissatisfaction with the
existing civilian provider network. During April 2002 testimony before
the Subcommittee on Personnel of the House Armed Services Committee,
beneficiary groups described problems with access to care from
TRICARE's civilian providers. Also, providers testified about their
dissatisfaction with the TRICARE program, specifying low reimbursement
rates and administrative burdens.
In response to these concerns, the Bob Stump National Defense
Authorization Act of 2003 required that we review DOD's oversight of
the adequacy of the TRICARE civilian provider network.[Footnote 2] As
agreed with the committees of jurisdiction we focused on DOD's
oversight and did not assess the adequacy of the network. Also, we
analyzed TRICARE Prime, the managed care component of the TRICARE
health delivery system. Specifically, we agreed to (1) describe how DOD
oversees the adequacy of the civilian provider network, (2) evaluate
DOD's oversight of the adequacy of the civilian provider network, (3)
describe the factors that have been reported to contribute to network
inadequacy, and (4) describe how the new contracts might affect network
adequacy. We testified before the Subcommittee on Total Force of the
House Committee on Armed Services on March 27, 2003, about our findings
at that time.[Footnote 3]
To describe and evaluate DOD's oversight of the TRICARE civilian
provider network, we reviewed and analyzed information from five
network adequacy reports submitted between June and October of 2002. We
reviewed at least one report from each of the contractors who develop
and maintain the network of providers to augment the care provided by
MTFs. We also interviewed DOD regional officials, known as lead agents,
and MTF officials from 5 of 11 TRICARE regions. In addition, we
interviewed officials from each of the four contractors. As part of our
assessment of DOD's oversight, we reviewed surveys of beneficiaries and
providers, as well as DOD data collection initiatives that could be
used by DOD to oversee its civilian provider network. We did not
validate the data in the surveys or collection initiatives. We also
interviewed officials at TRICARE Management Activity (TMA) in Falls
Church, Va., the office with responsibility for ensuring that DOD
health policy is implemented, and officials at TMA-West, the office
that carries out contracting functions, including monitoring the
civilian contracts and writing the requests for proposals for the
future contracts. To describe factors that may contribute to network
inadequacy, we interviewed DOD, contractor, and professional health
association officials. In addition, we met with groups representing
TRICARE beneficiaries to discuss their concerns. Finally, we reviewed
DOD's request for proposals for the new health care contracts and
interviewed DOD and contractor officials to determine how the new
contracts might affect network adequacy. Appendix I contains more
details about our scope and methodology. We conducted our work from
June 2002 through July 2003 in accordance with generally accepted
government auditing standards.
Results in Brief:
To oversee the adequacy of the civilian provider network, DOD has
standards that are designed to ensure that the network has a sufficient
number and mix of providers, both primary care and specialists, to
satisfy TRICARE Prime beneficiaries' needs. In addition, DOD has
standards for appointment wait, office wait, and travel times that are
designed to ensure that TRICARE Prime beneficiaries have adequate
access to care. DOD has delegated oversight of the civilian provider
network to lead agents, who are responsible for ensuring that these
standards have been met.
DOD's ability to effectively oversee the TRICARE civilian provider
network is hindered in several ways. First, the measurement used to
determine if there is a sufficient number of providers for the
beneficiaries in an area does not always account for the actual number
of beneficiaries who may seek care or the availability of providers. In
some cases, this may result in an underestimation of the number of
providers needed in an area. Second, incomplete contractor reporting on
access to care makes it difficult for DOD to assess compliance with
these standards. Finally, DOD does not systematically collect and
analyze beneficiary complaints, which might assist in identifying
inadequacies in the TRICARE civilian provider network. However, DOD has
surveys of TRICARE beneficiaries and network providers and automated
reporting systems on appointments and referrals that, while not
designed specifically for monitoring the civilian provider network,
could provide information and potentially improve DOD's ability to
oversee the civilian provider network.
DOD and its contractors have reported three factors that may contribute
to potential civilian provider network inadequacy: lack of providers in
certain geographic locations, low reimbursement rates, and
administrative requirements. DOD and contractors have reported long-
standing provider shortages in some geographic areas because providers
in certain areas may refuse to join any network. In areas where DOD
determines that access to care is severely impaired, DOD has the
authority to increase reimbursement rates. Since 2002, DOD has used
this authority to increase reimbursement rates in Alaska and Idaho in
an attempt to remedy such provider shortages. DOD told us that the
contractors have achieved some success in recruiting additional
providers by using this authority. Additionally, civilian providers
have expressed concerns about TRICARE's reimbursement rates being too
low and administrative requirements being too cumbersome. However,
while reimbursement rates and administrative requirements may have
created dissatisfaction among providers, it is not clear that these
factors have resulted in insufficient numbers of providers in the
civilian network because the information contractors provide to DOD is
not sufficient to measure network adequacy.
The new contracts, which DOD expects to award during the summer of
2003, may result in improved civilian provider network participation by
addressing some network providers' concerns about administrative
requirements. For example, the new contracts may simplify requirements
for provider credentialing and referrals, two administrative procedures
providers have complained about. However, according to contractors, the
new contracts may also create requirements that could discourage
provider participation, such as the new requirement that all network
claims submitted by civilian providers be filed electronically.
Currently, only about 25 percent of such claims are submitted
electronically.
We are recommending that the Secretary of Defense direct the Assistant
Secretary of Defense for Health Affairs to improve DOD's oversight of
the civilian provider network by ensuring sufficient information is
reported to assess network adequacy and by exploring options for
evaluating beneficiary complaints and improving provider survey data.
In commenting on a draft of this report, DOD concurred with the
report's recommendations.
Background:
TRICARE has three options for its eligible beneficiaries:
* TRICARE Prime, a program in which beneficiaries enroll and receive
care in a managed network similar to a health maintenance organization;
* TRICARE Extra, a program in which beneficiaries receive care from a
network of preferred providers; and:
* TRICARE Standard, a fee-for-service program that requires no network
use.
The programs vary according to the amount beneficiaries must contribute
toward the cost of their care and according to the choices
beneficiaries have in selecting providers. In TRICARE Prime,[Footnote
4] the program in which active duty personnel generally must
participate, the beneficiaries must select a primary care manager
(PCM)[Footnote 5] who either provides care or authorizes referrals to
specialists. Most beneficiaries who enroll in TRICARE Prime select
their PCMs from MTFs, while other enrollees select their PCMs from the
civilian provider network. Regardless of their status--military or
civilian--PCMs may refer Prime beneficiaries to providers in either
MTFs or TRICARE's civilian provider network.[Footnote 6]
Both TRICARE Extra and TRICARE Standard require copayments, but
beneficiaries do not enroll with or have their care managed by PCMs.
Beneficiaries choosing TRICARE Extra use the same civilian provider
network available to those in TRICARE Prime, and beneficiaries choosing
TRICARE Standard are not required to use providers in any network.
TRICARE Extra and Standard beneficiaries may receive care at an MTF
when space is available.
The Office of the Assistant Secretary of Defense for Health Affairs
(Health Affairs) establishes TRICARE policy and has overall
responsibility for the program. TMA, under Health Affairs, is
responsible for awarding and monitoring the TRICARE contracts. DOD has
delegated oversight of the civilian provider network to regional
TRICARE lead agents. The lead agent for each region coordinates the
services provided by MTFs and civilian network providers. The lead
agents respond to direction from Health Affairs, but report directly to
their respective Surgeons General. In overseeing the network, lead
agents have staff assigned to MTFs to provide the local interaction
with contractor representatives and respond to beneficiary complaints
as needed and report back to the lead agent.
Currently, DOD employs four civilian health care companies or
contractors that are responsible for developing and maintaining the
civilian provider network that complements the care delivered by MTFs.
The contractors recruit civilian providers into a network of PCMs and
specialists who provide care to beneficiaries enrolled in TRICARE
Prime. Contractors are required to establish and maintain the network
of civilian providers in the following locations: all catchment
areas,[Footnote 7] base realignment and closure sites,[Footnote 8]
other contract-specified areas, and noncatchment areas where a
contractor deems it cost effective. These locations are called prime
service areas. In the remaining areas, a network is not required. (See
fig. 1.):
Figure 1: Areas of the United States with a TRICARE Network of Civilian
Providers:
[See PDF for image]
Note: Shaded areas represent zip codes in which there was a TRICARE
network of civilian providers as of May 2003.
[End of figure]
This network of civilian providers also serves as the network of
preferred providers for beneficiaries who use TRICARE Extra. In 2002,
contractors reported that the civilian provider network included about
37,000 PCMs and 134,000 specialists.
The contractors are also responsible for ensuring adequate access to
health care, referring and authorizing beneficiaries for health care,
educating providers and beneficiaries about TRICARE benefits, ensuring
that providers are credentialed, and processing claims. In their
network agreements with civilian providers, contractors establish
reimbursement rates and certain requirements for submitting claims.
Reimbursement rates cannot be greater than Medicare rates unless DOD
authorizes a higher rate.
DOD's four contractors manage the delivery of care to beneficiaries in
11 TRICARE regions. DOD is currently analyzing proposals to award new
civilian health care contracts, and when they are awarded in 2003, DOD
will reorganize the 11 regions into 3--North, South, and West--with a
single contract for each region. Contractors will be responsible for
developing a new civilian provider network that will become operational
in April 2004. Under these new contracts DOD will continue to emphasize
maximizing the role of MTFs in providing care. See appendix II for maps
depicting the current and future regions.
DOD Has Standards for Network Adequacy and Requires Contractors'
Compliance:
DOD has standards intended to ensure that its civilian provider network
enhances and supports the capabilities of the MTFs in providing care to
millions of TRICARE Prime beneficiaries. DOD requires that contractors
have a sufficient number and mix of providers, both primary care and
specialists, to satisfy the needs of beneficiaries enrolled in the
Prime option. Specifically, it is the responsibility of the contractors
to ensure that each prime service area in the network has at least one
full-time equivalent PCM for every 2,000 TRICARE Prime enrollees and
one full-time equivalent provider (both PCMs and specialists) for every
1,200 TRICARE Prime enrollees.[Footnote 9]
In addition, DOD has access-to-care standards that are designed to
ensure that Prime beneficiaries receive timely care from
providers.[Footnote 10] Under these standards:
* appointment wait times shall not exceed 24 hours for urgent care, 1
week for routine care, or 4 weeks for well-patient and specialty care;
* office wait times shall not exceed 30 minutes for nonemergency care;
and:
* travel times shall not exceed 30 minutes for routine care and 1 hour
for specialty care.[Footnote 11]
Lead agents are responsible for ensuring that the civilian provider
network meets these standards so that all TRICARE Prime beneficiaries
in their region have adequate access to health care. To do so, lead
agents told us they use network adequacy reports that contractors
provide each quarter as the primary tool to oversee the network.
According to DOD's operations manual, these reports are to contain
information on the status of the network, such as the number and type
of specialists; data on adherence to the access standards; a list of
civilian and military primary care managers; and the number of their
enrollees. The reports may also contain information on steps
contractors have taken to address any network inadequacies.
However, because the reporting requirements do not specify a standard
process for collecting information on network adequacy, contractors
vary in how they obtain this information. For example, lead agents told
us that one contractor conducts visits of providers' offices to review
appointment wait times, while another contractor uses an automated
appointment tracking system to collect this information.
Lead agents told us they also rely on beneficiary complaints to oversee
the adequacy of the civilian provider network. Beneficiaries may
complain directly to DOD, the contractor, lead agent, or MTF. DOD
officials said that when they receive a beneficiary complaint, they
direct the complaint to either the contractor, lead agent, or MTF,
depending on the subject of the complaint.
In addition to these tools, lead agents periodically monitor contractor
compliance by reviewing performance related to specific contract
requirements, including requirements related to network adequacy. Lead
agents also told us they periodically schedule reviews of special
issues related to network adequacy, such as conducting telephone
surveys of providers to determine whether they are accepting TRICARE
Prime patients. In addition, lead agents stated they meet regularly
with MTF and contractor representatives to discuss network adequacy.
If lead agents determine that the network is inadequate, the lead
agents or TMA may issue enforcement actions to encourage contractors to
address deficiencies in their region. However, lead agents told us that
few enforcement actions have been issued. During our review, three
enforcement actions related to network adequacy were open for the five
regions we visited.[Footnote 12] Lead agents said they prefer to
address deficiencies informally rather than take formal actions,
particularly in areas where they do not believe the contractor can
correct the deficiency because of local market conditions. For example,
rather than taking a formal enforcement action, one lead agent worked
with the contractor to arrange for a specialist from one area to travel
to another area periodically.
DOD's Oversight of the Civilian Provider Network Has Weaknesses, But
Additional Tools May Help:
DOD's ability to effectively oversee the TRICARE civilian provider
network is hindered by (1) flaws in its required provider-to-
beneficiary ratios, (2) incomplete reporting on beneficiaries' access
to providers, and (3) the absence of a systematic assessment of
complaints. Although DOD has required the network to meet established
ratios of providers to beneficiaries, the ratios may underestimate the
number of providers needed in an area. Similarly, although DOD has
certain requirements governing Prime beneficiary access to available
providers, the information reported to DOD on this access is often
incomplete--making it difficult to assess compliance with the
requirements. Finally, when beneficiaries complain about availability
or access in the network, these complaints can be directed to different
DOD entities, with no guarantee that the complaints will be compiled
and analyzed in the aggregate to identify possible trends or patterns
and correct network problems. However, DOD has existing surveys and
automated reporting systems that, while not designed specifically for
monitoring the civilian provider network, could provide valuable
information and potentially improve DOD's ability to oversee the
civilian provider network.
Provider-to-Beneficiary Ratios May Not Account for Actual Number of
Beneficiaries or Availability of Providers:
The provider-to-beneficiary ratios contractors report to DOD for a
prime service area do not always accurately reflect the potential
health care workload for that area or the provider capability to
deliver the care. In some cases, the provider-to-beneficiary ratios
underestimate the number of providers, particularly specialists, needed
in an area. This underestimation occurs because in calculating the
ratios, some contractors do not include the total number of Prime
enrollees within the area. Instead, in some areas contractors base
their ratio calculations on the total number of beneficiaries enrolled
with civilian PCMs and do not count beneficiaries enrolled with PCMs in
MTFs. The ratio is most likely to result in an underestimation of the
need for providers in areas in which the MTF is a clinic or small
hospital with a limited availability of specialists. For example, the
Air Force clinic at Grand Forks, N. Dak. has few specialists on staff
and must rely on the civilian provider network for a large proportion
of specialist care. In fiscal year 2002, 90 percent of its specialist
appointments were referred to the network. In contrast, a large MTF,
such as Wright Patterson Medical Center in Dayton, Ohio, has many
specialist providers on staff and referred only 2 percent of its
specialty appointments to the civilian provider network during fiscal
year 2002. Incorporating MTF provider capability and the total number
of Prime enrollees into the network assessment would give DOD a more
complete and accurate assessment of the adequacy of the network for a
geographical area.
Moreover, in reporting whether the network meets the established
ratios, contractors do not make the same assumptions about the level of
participation on the part of civilian network providers. Contractors
generally assume that between 10 to 20 percent of their providers'
practices are dedicated to TRICARE Prime beneficiaries. Therefore, if a
contractor assumes 20 percent of all providers' practices are dedicated
to TRICARE Prime rather than 10 percent, the contractor will need half
as many providers in the network in order to meet the prescribed ratio
standard. These assumptions may or may not be accurate, and the
assumptions have a significant effect on the number of providers
required in the network.
Information Reported on Access Standards Was Incomplete:
In the network adequacy reports we reviewed, the contractors did not
always report all the information required by DOD to assess compliance
with the access standards. Specifically, for the network adequacy
reports we reviewed from 5 of the 11 TRICARE regions, we found that
contractors reported less than half of the required information on
access standards for appointment wait, office wait, and travel times.
Some contractors reported more information than others, but none
reported all the required access information. Contractors said they had
difficulties in capturing and reporting information to demonstrate
compliance with the access standards. They stated that it was not
practical or feasible to document every appointment and office wait
time because some beneficiaries make their own appointments directly
and provider offices are spread throughout the geographic area.
Beneficiary Complaints Are Not Systematically Collected and Evaluated:
Most of the DOD lead agents we interviewed told us that because
information on access standards is not fully reported, they monitor
compliance with the access standards by reviewing beneficiary
complaints. Lead agents and contractors said such complaints may
include a beneficiary's inability to get an appointment, having to
drive long distances for care, or a provider not accepting new TRICARE
Prime patients. Because beneficiary complaints are received through
numerous venues, often handled informally on a case-by-case basis, and
not centrally evaluated, it is difficult for DOD to assess the extent
of any systemic access problems. Separately, TMA has a database of
complaints that includes some complaints about access to care. TMA has
received these complaints either directly, through DOD's beneficiary
survey, or from letters sent by beneficiaries to their congressional
representatives. However, the usefulness of the database is limited
because it does not capture complaints sent to MTFs, lead agents, or
contractors.
While contractor and lead agent officials told us they have received
few complaints about network access problems, this small number of
complaints could indicate either an overall satisfaction with care or a
general lack of knowledge about how or to whom to complain.
Additionally, a small number of complaints, particularly when spread
among many sources, limits DOD's ability to identify any specific
trends of systemic problems related to network adequacy within TRICARE.
The next generation of contracts, called TNEX, may result in a more
structured approach to collecting complaint information when
implemented in 2004. Under TNEX, the civilian provider network must be
accredited in each region by a nationally recognized accrediting
organization, such as the National Committee for Quality Assurance
(NCQA) or the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO). These organizations typically require
procedures for addressing beneficiary complaints. For example, NCQA
guidance requires procedures for registering, responding to, and
investigating complaints. It also requires documentation of actions
taken to address complaints. JCAHO guidance has similar requirements.
Such procedures could provide DOD with a basic structure that in turn
could lead to a more systematic means of collecting and evaluating
complaint data at the prime service area and regional levels.
Potential Network Oversight Tools:
DOD has some tools that, while not designed specifically for monitoring
the civilian provider network, could be useful for oversight. For
example, the Health Care Survey of DOD Beneficiaries (HCSDB) could be
used as a source of information for overseeing civilian provider
network adequacy at the national level.[Footnote 13] This quarterly
survey contains specific questions on all beneficiaries' experiences
related to access to care.[Footnote 14] For example, our analysis of
the 2000 HCSDB data for all Prime beneficiaries receiving care from
civilian providers indicates that over one-third of these beneficiaries
waited more than DOD's standard of 1 day for access to a provider for
an illness or an injury. However, the survey's sample design does not
generally allow for assessing the adequacy of the civilian provider
network in most prime service areas and the survey's response rate of
35 percent further limits its usefulness.[Footnote 15]
In addition to DOD's beneficiary survey, contractors conduct surveys of
providers that could assist in DOD's oversight of the civilian provider
network. These surveys are intended to assess providers' satisfaction
with contractors' performance and other TRICARE requirements. However,
these surveys have very low response rates, ranging from 4 to 19
percent, and in some cases they reflect unrepresentative samples of
providers. For example, one contractor surveyed only those providers
who participated in a contractor-sponsored seminar. Also, we found
considerable variation among the survey instruments, with some
assessing provider satisfaction more thoroughly than others. Despite
these weaknesses, if improved, the surveys could reveal concerns
providers may have about participating in the TRICARE network. This in
turn could help DOD address these concerns and mitigate problems that
might affect the adequacy of the network.
In addition to these existing surveys, DOD is piloting two initiatives
for collecting information on meeting access standards that could help
in the oversight of network adequacy. The first, the Enterprise Wide
Referral and Authorization System (EWRAS), which is currently being
tested in the Washington D.C. area, captures information on specialty
care appointments in MTFs and information on some specialty care
appointments in the civilian provider network. DOD officials said they
expect EWRAS to be fully implemented in Spring 2004. The second
initiative, the Access to Care (ATC) Project, gathers information on
appointments and specialty referrals at or originating from MTFs.
Specifically, it captures data on whether beneficiaries had a referral,
declined an appointment that was available, cancelled an appointment,
or left without being seen. It also records the average number of days
between when the appointment was made and when the beneficiary was
seen, as well as clinic cancellations and future appointments. This
information can help indicate the extent to which MTFs are meeting the
appointment wait-time access standards. Although the ATC Project is
currently being piloted at four MTFs, a similar system, if modified to
accommodate the requirements of the contractors for the civilian
provider network, could provide valuable information on appointment
wait time standards--information that is necessary for overseeing the
adequacy of the network.
DOD and Contractors Report Three Factors That May Contribute to
Civilian Provider Network Inadequacy:
DOD and its contractors have reported three factors that may contribute
to potential civilian provider network inadequacy: lack of providers in
certain geographic locations, low reimbursement rates, and
administrative requirements. First, DOD and contractors have reported
regional shortages for certain types of specialists in rural areas. For
example, they reported shortages for endocrinologists in the Upper
Peninsula of Michigan, dermatologists in New Mexico, and neurologists
and allergists in Mountain Home, Idaho. Additionally, in these
instances, TRICARE officials and contractors have reported difficulties
in recruiting providers into the TRICARE Prime network because in some
areas providers, notably specialists, will not join managed care
programs. For example, contractor network data indicate that there have
been long-standing specialist shortages in TRICARE in areas such as
Alaska or eastern New Mexico, where the lead agent stated that the
providers in those locations have repeatedly refused to join any
managed care network.
There are certain geographic locations in which DOD has confirmed
shortages of providers and has raised TRICARE's reimbursement rates as
a means of remedying such shortages. Although by statute DOD generally
cannot pay TRICARE network providers more than they would be paid under
the Medicare fee schedule,[Footnote 16] DOD may make payments of up to
115 percent of the Medicare fee to ensure the availability of an
adequate number of qualified healthcare providers.[Footnote 17] In
2000, DOD increased reimbursement rates in rural Alaska in an attempt
to entice more providers to join the network. Similarly, in 2002, DOD
increased reimbursement rates for the rest of Alaska, and in 2003, DOD
increased the rates for selected specialists in Idaho to address
documented network shortcomings. These three instances are the only
times DOD has used its authority to pay above the Medicare rate in
order to address local area provider shortages,[Footnote 18] and the
increases have had mixed success. In 2001, for instance, we found that
the 2000 rate increase in rural Alaska had not increased provider
participation.[Footnote 19] On the other hand, DOD officials told us
that with the 2002 increase in Alaska and the 2003 increase in Idaho,
contractors were experiencing some success in recruiting providers in
those areas. According to DOD officials, for example, six neurosurgeons
in Boise, Idaho agreed to join the network, eliminating the
neurosurgeon shortfall in that prime service area. In Alaska, DOD
officials reported that since the reimbursement rate increased,
providers for radiology, thoracic surgery, pediatrics, and other
specialties have stated they will participate in TRICARE.
The general levels of TRICARE's reimbursement rates are another factor
that DOD and contractor officials told us may contribute to civilian
provider network inadequacy. Specifically, according to contractor
officials, civilian network providers have expressed concerns about the
decline in Medicare fees in 2002 and the potential for further
reductions, which they have said will affect their participation in the
network. In addition, there have been reported instances in which
groups of providers have banded together and refused to accept TRICARE
Prime patients due to their concerns with low reimbursement rates. One
contractor identified low reimbursement rates as the most frequent
cause of provider dissatisfaction. In addition to provider complaints,
beneficiary advocacy groups, such as the Military Officers Association
of America (MOAA), have cited instances of providers refusing care to
beneficiaries because of low reimbursement rates. However, while
TRICARE's reimbursement rates may have created dissatisfaction among
providers, it is not clear how much this has affected civilian provider
network adequacy except in limited geographic locations, because the
information contractors provide to DOD is not sufficient to measure
network adequacy. Additionally, there are indications that
reimbursement rates have little influence on providers' decisions to
leave the TRICARE network. Data from one contractor indicated that out
of the 2,156 providers who left the network between June 2001 and May
2002, 900 providers cited reasons for leaving and only 10 percent of
these cited reimbursement rates as a reason for leaving the network.
Contractors report that providers have also expressed dissatisfaction
with some TRICARE administrative requirements, such as credentialing
and preauthorizations and referrals--but the effect of these
requirements on civilian provider network adequacy is also unclear. For
example, many providers have complained about TRICARE's credentialing
requirements. In TRICARE, a provider must get recredentialed every 2
years, compared to every 3 years for the private sector. Providers have
said that this places cumbersome administrative requirements on them.
Another widely reported concern about TRICARE administrative
requirements relates to preauthorization and referral requirements.
Civilian PCM providers are required to get preauthorizations from MTFs
before referring patients for care. While preauthorization is a
standard managed care practice, providers complain that obtaining
preauthorization adversely affects the quality of care provided to
beneficiaries because it takes too much time. In addition, civilian
PCMs have expressed concern that they cannot refer beneficiaries to the
specialist of their choice because of MTFs' "right of first refusal"
that gives an MTF discretion to care for the beneficiary or refer the
care to a civilian provider. Nevertheless, there are not direct data
confirming that administrative burdens translate into widespread
civilian provider network inadequacies. Further, when reviewing one
contractor's survey of providers who left the network, we found that
only 1 percent of providers responding cited administrative burdens as
a factor.
New Contracts May Address Some Network Concerns, But May Create Others:
DOD's new contracts for providing civilian health care, called TNEX,
may address some network concerns raised by providers and
beneficiaries, but may create other areas of concern. Because the new
contracts had not yet been finalized as of June 2003, the specific
mechanisms DOD and the contractors will use to ensure network adequacy
are not known. Under TNEX, DOD plans to retain the requirement that the
civilian provider network complement the clinical services provided by
MTFs; the access standards for appointment and office wait times, as
well as travel-time standards; and the periodic reporting on the
adequacy of the network. However, the requirement to use provider-to-
beneficiary ratios to measure network adequacy will be eliminated,
although such ratios may be used during the network accreditation
process.
Further, TNEX contains a provision intended to encourage contractors to
develop an adequate civilian provider network. This provision states
that at least 96 percent of contractor referrals shall be to a MTF or
network provider with an appointment available within the access
standards. Failure to achieve the 96 percent standard will affect
contractors financially.
TNEX may reduce the administrative burden related to provider
credentialing and patient referrals. Currently, civilian network
providers must follow TRICARE-specific requirements for credentialing.
In contrast, TNEX will allow network providers to be credentialed
through a nationally recognized accrediting organization. DOD officials
stated this approach is more in line with industry practices. Patient
referral procedures will also change under TNEX. Referral requirements
will be reduced, but the MTFs will still retain the right of first
refusal.
On the other hand, TNEX may be creating a new administrative concern
for contractors and providers by requiring that all network claims
submitted by civilian providers be filed electronically.[Footnote 20]
In fiscal year 2002, only 25 percent of processed claims were submitted
electronically.[Footnote 21] Contractors stated that such a requirement
could discourage providers from joining or staying in the network
because providers may not be willing to modify their systems to submit
electronic claims for a small volume of TRICARE beneficiaries. DOD
states that electronic filing will reduce claims-processing costs.
Conclusions:
DOD spends over $5 billion a year for health care delivered by the
network of civilian providers to complement care provided in the MTFs;
however, DOD has exercised limited oversight of the adequacy of the
civilian provider network. The information DOD relies on to assess the
network does not always accurately reflect the actual numbers of
beneficiaries or availability of providers. Further, the contractors do
not report comprehensive data on the network's compliance with DOD's
access standards, which are key benchmarks in assessing network
adequacy. This information will be important as DOD oversees the
transition to the new health care delivery contracts.
Incorporating data on the numbers and types of providers in the MTFs
and the total number of beneficiaries enrolled in TRICARE Prime would
give DOD a more accurate and comprehensive report of the potential
workload the civilian provider network faces in a prime service area
and the adequacy of the number of PCMs and specialists to deliver that
care. Similarly, more thorough reporting on beneficiaries' access to
care within the standard time frames and development of a more
systematic means of collecting and evaluating complaint data would help
DOD's oversight of the ability of the civilian provider network to
deliver timely care to beneficiaries. Further, with improvements in
response rates and provider representation, the civilian provider
satisfaction surveys could also be useful in identifying actions DOD
and the contractors could take to address provider concerns and ensure
network stability.
Recommendations for Executive Action:
To improve DOD's oversight of the civilian provider network, we
recommend that the Secretary of Defense direct the Assistant Secretary
of Defense for Health Affairs to:
* ensure that MTF capabilities and all enrolled Prime beneficiaries in
prime service areas are accounted for when assessing and documenting
the adequacy of the civilian provider network;
* ensure that the information reported on the required access standards
is sufficient and reliable;
* explore ways to ensure that beneficiary complaints are systematically
evaluated and used to oversee the civilian provider network; and:
* explore options for improving the civilian provider surveys so that
the results of the surveys could be useful to DOD and the contractors
in identifying civilian provider concerns and developing actions that
might mitigate concerns and help ensure the adequacy of the civilian
provider network.
Agency Comments and Our Evaluation:
DOD provided written comments on a draft of this report. (See app.
III.) DOD concurred with the report's recommendations.
In its written comments, DOD stressed that strong oversight of the
civilian provider network is necessary and should be continuously
monitored for improvements. DOD said that the implementation of TNEX
will address many of the points raised in our report. DOD said TNEX
will enhance the reporting of information about network adequacy as
well as provide powerful financial incentives for contractors to
optimize the direct care system, maximize the extent of civilian
provider networks, and achieve the highest level of beneficiary
satisfaction. However, since the TNEX contracts have not been finalized
as of July 2003, it is too early to assess whether the contracts will
result in improved oversight.
In its written comments DOD also said that the report title might
mislead some into concluding that we found the TRICARE network to be
inadequate. As we noted in the draft report, we did not assess the
adequacy of the civilian provider network but focused our work on DOD's
oversight of the network. We believe the title of the report reflects
that focus.
DOD also provided technical comments, which we incorporated into the
report as appropriate.
We are sending copies of this report to the Secretary of Defense,
appropriate congressional committees, and other interested parties.
Copies will also be made available to others upon request. In addition,
the report is available at no charge on the GAO Web site at http://
www.gao.gov. 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.
Marjorie E. Kanof
Director, Health Care--Clinical and Military Health Care Issues:
Signed by Marjorie E. Kanof:
[End of section]
Appendix I: Scope and Methodology:
To describe and evaluate DOD's oversight of the adequacy of the
civilian provider network, we reviewed and analyzed the information in
the quarterly network adequacy reports submitted by each contractor. We
identified the requirements for the content of these adequacy reports
based upon the general requirements in the TRICARE Operations Manual
and the additional requirements in contractors' Best and Final Offers.
We reviewed the contents of five of the contractors' quarterly network
adequacy reports, submitted between June 2002 and October 2002, and
compared them to the applicable reporting requirements. Each report was
evaluated for compliance regarding the provider-to-beneficiary ratios
and the access-to-care standards.
Because DOD has delegated the oversight of the network to the regional
lead agents, we discussed civilian provider network oversight with
officials in 5 of the 11 TRICARE regions--Northeast, Mid-Atlantic,
Heartland, Central, and Northwest. To discuss network management, we
interviewed officials from the four contractors--HealthNet, Humana,
Sierra, and TriWest--that are responsible for developing and
maintaining the provider network that augments care provided by DOD's
MTFs. Because concerns regarding network adequacy may also be
identified at the local level, we met with lead agent and contractor
officials at MTFs in each of the regions we visited. Finally, we
interviewed officials at TMA in Falls Church, Va., the office that is
responsible for ensuring that DOD health policy is implemented, and
officials at TMA-West in Aurora, Colo., the office that carries out
contracting functions, including monitoring the civilian contracts and
writing the request for proposals for the future contracts.
As part of our assessment of DOD's oversight, we also reviewed surveys
of beneficiaries and providers, as well as DOD data collection
initiatives as potential tools for overseeing DOD's civilian provider
network, but did not validate the data in the surveys or collection
initiatives. Using annual data from the 2000 HCSDB, we analyzed
beneficiaries' responses to access-to-care questions for those who were
enrolled in Prime and received most of their health care in the
civilian provider network. We examined the results of access-to-care
questions based on whether or not these beneficiaries were seen within
the TRICARE access-to-care standards. Because we included only Prime
beneficiaries who received care in the civilian provider network, our
analysis of access to care does not reflect the entire survey sample.
To examine the provider surveys as potential oversight tools, we
obtained and reviewed each contractor's 2001 provider survey and
assessed the survey's response rate, sample selection, and the
instrument itself. We also discussed DOD initiatives underway and being
tested with cognizant officials to assess their potential as oversight
tools.
To describe factors that may contribute to network inadequacy, we
interviewed and obtained documentation from DOD and contractor
officials regarding current network inadequacies, including their
location, duration, and the type of specialty needed. We also obtained
provider termination reports from three of the four
contractors,[Footnote 22] which described providers' reasons for
leaving the network. To further explore DOD's response to civilian
provider concerns regarding rates, we interviewed DOD officials on the
use of their authority to raise reimbursement rates. We also
interviewed officials from the American Medical Association, The
Military Coalition, the MOAA, the National Association for Uniformed
Services, and the National Veteran's Alliance to supplement data on the
possible causes of network inadequacy.
Finally, we reviewed DOD's request for proposals for the future
contracts and interviewed DOD and contractor officials to describe how
the new contracts might affect network adequacy.
We conducted our work from June 2002 through July 2003 in accordance
with generally accepted government auditing standards.
[End of section]
Appendix II: Comparison of Current and Future TRICARE Regions:
The shaded areas in figure 2 represent the 11 current TRICARE
geographic regions. The shaded areas in figure 3 represent the 3
planned TRICARE geographic regions under the TNEX contracts expected to
be awarded in 2003.
Figure 2: Current TRICARE Regions:
[See PDF for image]
[End of figure]
Figure 3: Future TRICARE Regions After TNEX Implementation:
[See PDF for image]
[End of figure]
[End of section]
Appendix III: Comments from the Department of Defense:
[See PDF for image]
[End of figure]
[End of section]
Appendix IV: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Kristi Peterson, (202) 512-7951 Allan Richardson, (404) 679-1863:
Acknowledgments:
In addition to those named above, contributors to this report were
Louise Duhamel, Marc Feuerberg, Krister Friday, Gay Hee Lee, John Oh,
and Marie Stetser.
FOOTNOTES
[1] MTFs supply most of the health care services TRICARE beneficiaries
receive. The military health system was funded at about $26.4 billion
for fiscal year 2003. Approximately 20 percent of this amount, $5.2
billion, was budgeted for the TRICARE civilian provider network.
[2] Pub. L. No. 107-314, § 712, 116 Stat. 2458, 2588 (2002). See also,
H.R. Rep. No. 107-436.
[3] U.S. General Accounting Office, Defense Health Care: Oversight of
the Adequacy of TRICARE's Civilian Provider Network Has Weaknesses,
GAO-03-592T (Washington, D.C.: Mar. 27, 2003).
[4] Out of more than 8.7 million eligible beneficiaries, nearly half
are enrolled in TRICARE Prime.
[5] A primary care manager is a provider or team of providers at an MTF
or a provider in the civilian network to whom a beneficiary is assigned
for primary care services when he or she enrolls in TRICARE Prime.
Enrolled beneficiaries agree to initially seek all nonemergency,
nonmental health care services from these providers.
[6] DOD's policy is to optimize the use of the MTF. Accordingly, when a
referral for specialty care is made by a civilian PCM, the MTF retains
the "right of first refusal" to accommodate the beneficiary within the
MTF or refer the beneficiary to the civilian provider network for the
needed medical care.
[7] Catchment areas are geographic areas determined by the Assistant
Secretary of Defense for Health Affairs that are defined by five-digit
zip codes, usually within an approximate 40-mile radius of MTFs with
inpatient care.
[8] Base realignment and closure sites are military installations that
have been closed or realigned as the result of decisions made by the
Commissions on Base Realignment and Closure.
[9] In addition, all four contractors generally follow the Graduate
Medical Education National Advisory Committee recommendation for
determining the specialty mix requirements for their network.
[10] DOD does not specify access standards for eligible beneficiaries
who do not enroll in TRICARE Prime. However, DOD requires that
contractors provide information and/or assist all beneficiaries--
regardless of which option they choose--in finding a participating
provider in their area.
[11] 32 C.F.R. § 199.17(p)(5)(i), (ii), (iv) and (v) (2002).
[12] All three enforcement actions were for lack of available providers
in certain geographical areas. For example, there were shortfalls of
orthopedic surgeons and neurosurgeons in Spokane, Washington.
[13] This survey was required by the National Defense Authorization Act
for Fiscal Year 1993, Pub. L. No. 102-484, § 724, 106 Stat. 2315, 2440
(1992).
[14] These questions ask how many days a beneficiary had to wait to see
a provider for regular or routine care and how long they had to wait to
receive treatment for an injury or illness, among other things. Also,
DOD recently added questions to the survey specifically aimed at
beneficiaries receiving care from civilian providers. These questions
ask how difficult it was to obtain care and locate a doctor, and
whether a civilian provider had left the network.
[15] Even though DOD samples 180,000 beneficiaries annually, the 35
percent response rate reduces the sample to about 63,000. As a result
the survey estimates may be biased if those who responded to the survey
are not representative of the entire surveyed population.
[16] 10 U.S.C. § 1079(h)(1) (2000).
[17] 10 U.S.C. § 1097b (2000).
[18] DOD officials told us that all requests received by Health Affairs
to increase rates have been approved. Additionally, there are two other
instances in which DOD increased its reimbursement rates above
Medicare's, but these increases did not address local area shortages.
In 1997, DOD increased national reimbursement rates for obstetrical
care. In April 2002, DOD adopted a policy that will authorize a 10
percent bonus payment to selected TRICARE providers working in
medically underserved areas as defined by the Health Resources and
Services Administration, consistent with Medicare payment policy. DOD
plans to implement the bonus payment in July 2003.
[19] U.S. General Accounting Office, Defense Health Care: Across-the-
Board Physician Rate Increase Would Be Costly and Unnecessary,
GAO-01-620 (Washington, D.C.: May 24, 2001).
[20] The Health Insurance Portability and Accountability Act of 1996
included provisions for the establishment of standards and requirements
for the electronic transmission of health information. Pub. L. No. 104-
191, § 262, 110 Stat. 1936, 2021. Effective October 16, 2003, Medicare
claims generally must be submitted electronically.
[21] This percentage does not include pharmacy claims or claims for
care provided to Medicare-eligible beneficiaries under TRICARE For
Life.
[22] One contractor does not collect data on provider terminations.
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