Defense Health Care
Access to Care for Beneficiaries Who Have Not Enrolled in TRICARE's Managed Care Option Gao ID: GAO-07-48 December 22, 2006The Department of Defense (DOD) provides health care through its TRICARE program. Under TRICARE, beneficiaries may obtain care through a managed care option that requires enrollment and the use of civilian provider networks, which are developed and managed by contractors. Beneficiaries who do not enroll may receive care through TRICARE Standard, a fee-for-service option, using nonnetwork civilian providers or through TRICARE Extra, a preferred provider organization option, using network civilian providers. Nonenrolled beneficiaries in some locations have reported difficulties finding civilian providers who will accept them as patients. The National Defense Authorization Act (NDAA) for fiscal year 2004 directed GAO to provide information on access to care for nonenrolled TRICARE beneficiaries. This report describes (1) how DOD and its contractors evaluate nonenrolled beneficiaries' access to care and the results of these evaluations; (2) impediments to civilian provider acceptance of nonenrolled beneficiaries, and how they are being addressed; and (3) how DOD has implemented the NDAA fiscal year 2004 requirements to take actions to ensure nonenrolled beneficiaries' access to care. To address these objectives, GAO examined DOD's survey results and DOD and contractor documents and interviewed DOD and contractor officials.
DOD and contractor officials use various methods to evaluate access to care, and according to these officials, their methods indicate that access is generally sufficient for nonenrolled beneficiaries. For example, in its 2005 survey of civilian providers DOD found that 14 percent of civilian providers surveyed in 20 states were not accepting new patients from any health plan. Of those accepting new patients, about 80 percent would accept nonenrolled TRICARE beneficiaries as new patients. DOD's contractors use various methods to monitor access to care. While these methods were not designed specifically to evaluate access for nonenrolled beneficiaries, they provide information that allows contractors to monitor the availability of both network and nonnetwork civilian providers for this population. According to contractor officials, their measures indicate that nonenrolled beneficiaries' access to care is sufficient overall. DOD, its contractors, and beneficiary and provider representatives cited various factors as impediments to network and nonnetwork civilian providers' acceptance of nonenrolled TRICARE beneficiaries and ways to address them. These impediments include concerns specific to TRICARE, including reimbursement rates and administrative issues, as well as issues not specific to TRICARE, such as providers without sufficient practice capacity for additional patients. DOD and its contractors have specific ways to address impediments related to reimbursement rates and administrative issues, but issues that are not specific to TRICARE are more difficult to resolve. For example, DOD has authority to increase reimbursement rates for network and nonnetwork civilian providers in areas where access to care has been impaired. Furthermore, other impediments not specific to TRICARE, such as provider practices at capacity and few providers in geographically remote locations, cannot be readily resolved and create access difficulties for all local residents, including TRICARE beneficiaries. Various DOD offices as well as DOD's contractors are already carrying out the responsibilities outlined by the NDAA for fiscal year 2004--such as educating civilian providers and recommending reimbursement rate adjustments--actions that help ensure nonenrolled beneficiaries' access. However, a senior official was not formally designated to have responsibility for these mandated actions. DOD commented on the report, stating that GAO's approach was insightful, but disagreeing with GAO's finding that a senior official was not formally designated to be responsible for taking actions to ensure TRICARE beneficiaries' access to care as outlined in the NDAA. DOD said that an existing directive designating a senior official to serve as program manager for TRICARE met this requirement. However, the directive does not specifically designate an official responsible for ensuring access as specified in the NDAA. Nor did DOD take other actions to designate that a senior official have such responsibilities.
GAO-07-48, Defense Health Care: Access to Care for Beneficiaries Who Have Not Enrolled in TRICARE's Managed Care Option
This is the accessible text file for GAO report number GAO-07-48
entitled 'Defense Health Care: Access to Care for Beneficiaries Who
Have Not Enrolled in TRICARE's Managed Care Option' which was released
on December 22, 2006.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to Congressional Committees:
United States Government Accountability Office:
GAO:
December 2006:
Defense Health Care:
Access to Care for Beneficiaries Who Have Not Enrolled in TRICARE's
Managed Care Option:
GAO-07-48:
GAO Highlights:
Highlights of GAO-07-48, a report to congressional committees
Why GAO Did This Study:
The Department of Defense (DOD) provides health care through its
TRICARE program. Under TRICARE, beneficiaries may obtain care through a
managed care option that requires enrollment and the use of civilian
provider networks, which are developed and managed by contractors.
Beneficiaries who do not enroll may receive care through TRICARE
Standard, a fee-for-service option, using nonnetwork civilian providers
or through TRICARE Extra, a preferred provider organization option,
using network civilian providers. Nonenrolled beneficiaries in some
locations have reported difficulties finding civilian providers who
will accept them as patients.
The National Defense Authorization Act (NDAA) for fiscal year 2004
directed GAO to provide information on access to care for nonenrolled
TRICARE beneficiaries. This report describes (1) how DOD and its
contractors evaluate nonenrolled beneficiaries‘ access to care and the
results of these evaluations; (2) impediments to civilian provider
acceptance of nonenrolled beneficiaries, and how they are being
addressed; and (3) how DOD has implemented the NDAA fiscal year 2004
requirements to take actions to ensure nonenrolled beneficiaries‘
access to care. To address these objectives, GAO examined DOD‘s survey
results and DOD and contractor documents and interviewed DOD and
contractor officials
What GAO Found:
DOD and contractor officials use various methods to evaluate access to
care, and according to these officials, their methods indicate that
access is generally sufficient for nonenrolled beneficiaries. For
example, in its 2005 survey of civilian providers DOD found that 14
percent of civilian providers surveyed in 20 states were not accepting
new patients from any health plan. Of those accepting new patients,
about 80 percent would accept nonenrolled TRICARE beneficiaries as new
patients. DOD‘s contractors use various methods to monitor access to
care. While these methods were not designed specifically to evaluate
access for nonenrolled beneficiaries, they provide information that
allows contractors to monitor the availability of both network and
nonnetwork civilian providers for this population. According to
contractor officials, their measures indicate that nonenrolled
beneficiaries‘ access to care is sufficient overall.
DOD, its contractors, and beneficiary and provider representatives
cited various factors as impediments to network and nonnetwork civilian
providers‘ acceptance of nonenrolled TRICARE beneficiaries and ways to
address them. These impediments include concerns specific to TRICARE,
including reimbursement rates and administrative issues, as well as
issues not specific to TRICARE, such as providers without sufficient
practice capacity for additional patients. DOD and its contractors have
specific ways to address impediments related to reimbursement rates and
administrative issues, but issues that are not specific to TRICARE are
more difficult to resolve. For example, DOD has authority to increase
reimbursement rates for network and nonnetwork civilian providers in
areas where access to care has been impaired. Furthermore, other
impediments not specific to TRICARE, such as provider practices at
capacity and few providers in geographically remote locations, cannot
be readily resolved and create access difficulties for all local
residents, including TRICARE beneficiaries.
Various DOD offices as well as DOD‘s contractors are already carrying
out the responsibilities outlined by the NDAA for fiscal year 2004”such
as educating civilian providers and recommending reimbursement rate
adjustments”actions that help ensure nonenrolled beneficiaries‘ access.
However, a senior official was not formally designated to have
responsibility for these mandated actions.
DOD commented on the report, stating that GAO‘s approach was
insightful, but disagreeing with GAO‘s finding that a senior official
was not formally designated to be responsible for taking actions to
ensure TRICARE beneficiaries‘ access to care as outlined in the NDAA.
DOD said that an existing directive designating a senior official to
serve as program manager for TRICARE met this requirement. However, the
directive does not specifically designate an official responsible for
ensuring access as specified in the NDAA. Nor did DOD take other
actions to designate that a senior official have such responsibilities.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-48].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Marcia Crosse at (202)
512-7119 or crossem@gao.gov.
[End of Section]
Contents:
Letter:
Results in Brief:
Background:
TMA and Its MCSCs Use Various Methods to Evaluate Access to Care That
Indicate Sufficient Access for Nonenrolled TRICARE Beneficiaries:
Various Factors Impede Providers' Acceptance of Nonenrolled TRICARE
Beneficiaries, and TMA and MCSCs Have Different Ways to Address Them:
NDAA Responsibilities for Nonenrolled TRICARE Beneficiaries' Access to
Care Are Being Carried Out by TMA and the MCSCs, but Were Not Formally
Designated to a Senior Official:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Methodology Used for TMA's Civilian Provider Survey:
Appendix III: Civilian Provider Survey Instrument:
Appendix IV: Categorized Responses to the Civilian Provider Survey's
Open-ended Question:
Appendix V: TRICARE Reimbursement Rates That Remain Higher than
Medicare Reimbursement Rates:
Appendix VI: Comments from the Department of Defense:
Appendix VII: GAO Contacts and Staff Acknowledgments:
Tables:
Table 1: Summary of the Three Main TRICARE Options:
Table 2: TMA's 2005 Civilian Provider Survey Results Showing Percent of
Surveyed Providers Accepting Nonenrolled TRICARE Beneficiaries (of
Those Accepting New Patients) by State:
Table 3: TMA's 2005 Civilian Provider Survey Results Showing Percent of
Surveyed Providers Accepting Nonenrolled TRICARE Beneficiaries (of
Those Accepting New Patients) by Hospital Service Area:
Table 4: Applications for Locality Waivers and Approval Results:
Table 5: Applications for Network Waivers and Approval Results:
Table 6: Responsibilities Outlined in the NDAA for Fiscal Year 2004 and
the Entities Covering Them:
Table 7: "What are the reasons Doctor X is Not Accepting New TRICARE
[Nonenrolled] Patients?"
Figures:
Figure 1: TRICARE Beneficiaries in Fiscal Year 2005:
Figure 2: Location of Prime Service Areas in Each TRICARE Region:
Figure 3: All Nonenrolled TRICARE Beneficiaries by Region:
Figure 4: Percent of Claims Paid for TRICARE Standard and Extra for
Each TRICARE Region for Fiscal Years 2001-2005:
Abbreviations:
ART: Assistance Reporting Tool:
ASD: Assistant Secretary of Defense:
CAHPS: Consumer Assessment of Healthcare Providers and Systems:
CPT: current procedural terminology:
DOD: Department of Defense:
HSA: hospital service area:
MCSC: managed care support contractor:
MTF: military treatment facility:
NDAA: National Defense Authorization Act:
OMB: Office of Management and Budget:
TFL: TRICARE for Life:
TMA: TRICARE Management Activity:
TRO: TRICARE regional office:
United States Government Accountability Office:
Washington, DC 20548:
December 22, 2006:
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 Department of Defense (DOD) offers health care to almost 10 million
beneficiaries, including active duty personnel, retirees, and their
dependents, through its regionally structured TRICARE program, which is
expected to cost about $37 billion in fiscal year 2006. Under TRICARE,
health care is available through the military services' system of
military hospitals and clinics, referred to as military treatment
facilities (MTFs) and through civilian providers. Although DOD and the
military services strive to maximize the use of MTFs, TRICARE
beneficiaries have received an increasing amount of care through
civilian providers. Between fiscal years 2000 and 2005, the percent of
inpatient care delivered to TRICARE beneficiaries by civilian providers
increased from about 50 percent to an estimated 75 percent. During the
same time frame, the percent of outpatient care delivered by civilian
providers increased from 39 percent to an estimated 65
percent.[Footnote 1]
TRICARE has three options for its beneficiaries:[Footnote 2] Prime,
Standard, or Extra. These options vary according to enrollment
requirements, the choices beneficiaries have in selecting civilian and
MTF providers, and the amount they must contribute towards the cost of
their care. Prime, a program in which beneficiaries receive care in a
managed care provider network similar to a health maintenance
organization, is the only option requiring enrollment and has the
lowest copayments. Beneficiaries who enroll in Prime usually obtain
health care from the MTF, but they may also obtain care from a network
civilian provider when MTF care is not available. Beneficiaries do not
need to enroll to receive care under Standard, a fee-for-service
option, or Extra, a preferred provider organization option. Under
Standard, nonenrolled beneficiaries can obtain health care from
civilian providers who do not belong to the TRICARE network but agree
to accept TRICARE beneficiaries as patients. Beneficiaries have the
highest copayments under Standard. Under Extra, nonenrolled
beneficiaries may obtain health care from network civilian providers.
Nonenrolled beneficiaries cannot be categorized as belonging to an
Extra or Standard group because each time they seek care, they can
choose to see either a network or nonnetwork civilian provider, and
this choice determines whether they receive coverage under Extra or
Standard. Under any option, TRICARE beneficiaries may receive care at
an MTF when space is available. Priority for MTF usage is given first
to active duty personnel and then to beneficiaries enrolled in Prime.
DOD's TRICARE Management Activity (TMA) uses managed care support
contractors (MCSC) to develop networks of civilian providers and
perform other customer service functions, such as claims processing,
and to ensure that all beneficiaries--including nonenrolled
beneficiaries--receive satisfactory service under TRICARE, such as
assistance with finding providers. Currently, there is one MCSC for
each of TRICARE's three regions--North, South, and West. For each
region, TMA has established a TRICARE Regional Office (TRO) and has
designated the TRO directors as the health plan managers for their
regions with responsibilities such as monitoring provider network
quality and adequacy, overseeing the MCSCs, and monitoring customer
satisfaction.
Since TRICARE began in 1995, nonenrolled TRICARE beneficiaries in some
locations have complained about difficulties finding nonnetwork
civilian providers who will accept them as patients. In addition,
TRICARE beneficiaries have cited concerns that TMA has focused more
attention on the Prime option, which allows TMA to manage
beneficiaries' care, and has given less attention to the options
available for nonenrolled TRICARE beneficiaries. In response to these
concerns, the National Defense Authorization Act (NDAA) for fiscal year
2004 directed DOD to monitor nonenrolled TRICARE beneficiaries' access
to care through a survey of civilian providers.[Footnote 3] In
addition, the NDAA required DOD to designate a senior official to take
actions to ensure access to care for nonenrolled TRICARE beneficiaries.
The NDAA for fiscal year 2004 also directed GAO to review the
processes, procedures, and analysis used by DOD to determine the
adequacy of the number of network and nonnetwork civilian providers and
the actions taken to ensure access to care for nonenrolled TRICARE
beneficiaries. Specifically, as discussed with the committees of
jurisdiction, this report describes (1) how TMA and its MCSCs evaluate
nonenrolled TRICARE beneficiaries' access to care and the results of
these evaluations; (2) the impediments to civilian provider acceptance
of nonenrolled TRICARE beneficiaries, and how they are being addressed;
and (3) how DOD has implemented the fiscal year 2004 NDAA requirements
to take actions to ensure nonenrolled TRICARE beneficiaries' access to
care.
To determine how TMA evaluates nonenrolled TRICARE beneficiaries'
access to care, we interviewed and obtained documentation from TMA
officials about the civilian provider survey, which included a random,
representative sample of civilian providers in selected geographic
locations and therefore included both network and nonnetwork civilian
providers. We also reviewed information from TMA's annual beneficiary
health care survey, which includes information on beneficiaries' access
to care. In addition, we met with TRO and MCSC officials for each of
the three regions, TMA officials, and representatives from each of the
services' Surgeons General to identify and evaluate the tools used for
monitoring access to care. To identify the impediments to network and
nonnetwork civilian providers' acceptance of nonenrolled TRICARE
beneficiaries and how these impediments are being addressed, we
obtained information from TMA, TRO, and MCSC officials. We also met
with representatives of TRICARE beneficiaries and the American Medical
Association to discuss their concerns about impediments to health care
access for nonenrolled TRICARE beneficiaries. In addition, we obtained
and analyzed data related to TMA's implementation of reimbursement rate
increases in specific locations for the purpose of improving access to
care. However, we did not evaluate the extent to which the rate
increases improved civilian providers' acceptance of TRICARE
beneficiaries as patients. To examine how DOD has implemented the
fiscal year 2004 NDAA requirements to take actions to ensure
nonenrolled TRICARE beneficiaries' access to care, we obtained
information from TMA, TRO, and MCSC officials. Through our review of
the relevant documentation and our discussions with TMA, TRO, and MCSC
officials, we determined that the data presented in this report were
sufficiently reliable for our purposes. We conducted our work from July
2005 through December 2006 in accordance with generally accepted
government auditing standards. Appendix I contains more details about
our scope and methodology, and appendix II contains more detail about
the scope and methodology of DOD's civilian provider survey.
Results in Brief:
TMA and its MCSCs use various methods to evaluate access to care, and
according to TMA and MCSC officials, the resulting measures indicate
that nonenrolled TRICARE beneficiaries' access to care is generally
sufficient and that access problems appear to be minimal. Among methods
used by TMA to evaluate access to care are its recently implemented
civilian provider survey and an annual beneficiary health care survey.
The survey of civilian providers, which includes network and nonnetwork
providers, is designed to measure access to care by identifying how
many civilian providers are willing to accept nonenrolled TRICARE
beneficiaries as new patients. The first round of this survey,
implemented in 2005, focused on 20 states and found that 14 percent of
civilian providers were not accepting new patients from any government
or commercial health plan. Of those accepting new patients, about 80
percent would accept nonenrolled TRICARE beneficiaries as new patients.
In addition, the results of each of TMA's annual beneficiary health
care surveys for 2003 through 2005 show that nonenrolled TRICARE
beneficiaries' satisfaction with access to care was similar to
satisfaction reported by participants in commercial health plans. TMA
and the TROs also receive anecdotal information through beneficiary
feedback, and, according to these officials, complaints about access to
care are infrequent. Each of the MCSCs also has its own methods of
monitoring access to care, including analyzing provider and beneficiary
locations as part of their responsibility for ensuring sufficient
network capacity for all TRICARE beneficiaries residing in locations
with civilian provider networks. While the MCSCs' methods were not
designed specifically to evaluate access for nonenrolled TRICARE
beneficiaries, they do provide helpful information that allows the
MCSCs to monitor the availability of both network and nonnetwork
civilian providers for this population. According to MCSC officials,
their measures indicate that nonenrolled TRICARE beneficiaries' access
to care is sufficient overall.
TMA, MCSCs, and beneficiary and provider representatives cited various
factors as impediments to network and nonnetwork civilian providers'
acceptance of nonenrolled TRICARE beneficiaries and different ways to
address them. These impediments include concerns that are specific to
the TRICARE program, including reimbursement rates and administrative
issues, as well as issues that are not specific to TRICARE, such as
providers not having sufficient capacity in their practices for
additional patients and provider shortages in geographically remote
areas. TMA and the MCSCs have specific ways to respond to impediments
related to TRICARE reimbursement rates and administrative issues, while
the others are more difficult to address. For example, TMA has the
authority to increase reimbursement rates for network and nonnetwork
civilian providers in locations where TMA determines that access to
care is impaired. Using this authority, TMA has increased reimbursement
rates for specific services for network and nonnetwork civilian
providers in 15 locations, including two waivers covering the state of
Alaska. To respond to network and nonnetwork civilian providers'
concerns about administrative issues, such as problems with claims
processing, MCSCs are working to educate providers on TRICARE
requirements. However, while MCSCs and TMA believe that efforts to
increase reimbursement rates and assist providers with administrative
issues have improved access to care, the actual extent to which these
efforts have improved access is unclear. Nonetheless, other impediments
that are not specific to TRICARE are more difficult for TMA and MCSCs
to resolve. For example, some network and nonnetwork civilian providers
do not accept nonenrolled TRICARE beneficiaries as new patients because
their practices are already at capacity. In addition, there are few
practicing civilian providers, either network or nonnetwork, in some
geographically remote areas, impairing access for all local residents,
including TRICARE beneficiaries. Recently TMA has adopted two bonus
payment systems similar to those used by Medicare for locations with
provider shortages.
Various TMA offices, including the TROs, and the MCSCs are carrying out
the responsibilities outlined by the NDAA for fiscal year 2004--such as
educating civilian providers and recommending reimbursement rate
adjustments--actions that help ensure nonenrolled beneficiaries' access
to care. For example, in some locations, the TROs have recommended
adjustments to reimbursement rates when access to care was impaired.
Other activities, such as educating nonnetwork civilian providers, are
shared by the TROs, other TMA offices, and the MCSCs. However, a senior
official was not formally designated to have responsibility for these
actions as required in this mandate.
DOD said our approach used to address issues in this report was
thoughtful and insightful, but DOD disagreed with our finding that a
senior official was not formally designated to take actions to ensure
adequate access to care for nonenrolled TRICARE beneficiaries,
including ensuring adequate participation by nonnetwork providers, as
outlined by the NDAA for fiscal year 2004. DOD stated that the agency
has an existing directive that designates a senior official to serve as
program manager for TRICARE, which meets the NDAA mandate for
nonenrolled beneficiaries. However, we do not agree that DOD has
adequately addressed the mandate. First, during our audit work we found
that no specific actions had been taken to designate a senior official.
Second, while the responsibilities of the TMA Director and the TROs
under the directive generally encompass provision of care to
nonenrolled beneficiaries, the directive does not task any one official
with identifying the specific actions necessary to ensure adequate
provider participation in each market area, as the law required.
Background:
In fiscal year 2005, almost 10 million beneficiaries were eligible to
receive health care under TRICARE, DOD's regionally structured health
care program. Under TRICARE, beneficiaries have choices among three
different benefit options and may obtain care from either MTFs or
civilian providers. The NDAA for fiscal year 2004 directed DOD to
conduct a survey to monitor access to care for beneficiaries who chose
not to use TRICARE's managed care option and to appoint a senior
official to take actions to ensure that these beneficiaries have
adequate access to care.
Composition of TRICARE's Beneficiary Population:
TRICARE beneficiaries fall into various categories, including active
duty personnel and their dependents and retirees and their dependents.
Retirees and certain dependents and survivors who are entitled to
Medicare Part A and enrolled in Part B, and who are generally age 65
and older,[Footnote 4] are eligible to obtain care under a separate
program called TRICARE for Life (TFL).[Footnote 5] As shown in figure
1, active duty personnel and their dependents represent 42 percent of
the beneficiary population. Retirees and their dependents who are not
entitled to Medicare (generally under age 65) comprised 44 percent of
the TRICARE beneficiary population while retirees and dependents over
65 represented 14 percent of the beneficiary population.
Figure 1: TRICARE Beneficiaries in Fiscal Year 2005:
[See PDF for image]
Source: GAO analysis of DOD data.
[A] TRICARE beneficiaries under 65 years of age who are eligible for
Medicare Part A on the basis of disability or end stage renal disease
are eligible for TRICARE for Life if they enroll in Medicare Part B.
[B] National Guard and reservists who have been activated are included
as active duty personnel and their family members are included as
dependents.
[End of figure]
Network and Nonnetwork Civilian Providers Under TRICARE:
TRICARE beneficiaries can choose to obtain health care through MTFs or
through civilian providers, which includes providers who belong to the
TRICARE provider network as well as nonnetwork providers who agree to
accept TRICARE beneficiaries as patients. Individual civilian providers
must be licensed by their state, accredited by a national organization,
if one exists, and meet other standards of the medical community to be
authorized to provide care under TRICARE. Individual TRICARE-authorized
civilian providers can include attending physicians, certified nurse-
practitioners, clinical nurse specialists, dentists, clinical
psychologists, physician assistants, podiatrists, and optometrists,
among others. There are two types of authorized civilian providers--
network and nonnetwork providers. Network civilian providers are
TRICARE-authorized providers who enter a contractual agreement with the
regional MCSC to provide health care to TRICARE beneficiaries. By law,
TRICARE maximum allowable reimbursement rates must generally mirror
Medicare rates, but network providers may agree to accept lower
reimbursements as a condition of network membership. In some cases,
they agree to accept negotiated reimbursement rates, which are usually
discounts off of the TRICARE reimbursement rates, as payment in full
for medical care or services. Network civilian providers are reimbursed
at their negotiated rate regardless of whether they are providing care
to enrolled TRICARE beneficiaries under the Prime option or nonenrolled
TRICARE beneficiaries under the Extra option. Network civilian
providers file claim forms for TRICARE beneficiaries and follow other
contractually required processes, such as those for obtaining
referrals. However, network civilian providers are not obligated to
accept all TRICARE beneficiaries seeking care. For example, a network
civilian provider may decline to accept TRICARE beneficiaries as
patients because the provider's practice does not have sufficient
capacity or for other reasons.[Footnote 6]
Nonnetwork civilian providers are TRICARE-authorized providers who do
not have a contractual agreement with an MCSC to provide care to
TRICARE beneficiaries.[Footnote 7] Nonnetwork civilian providers may
accept TRICARE beneficiaries as patients on a case-by-case basis. These
providers may choose to accept the TRICARE reimbursement rate as
payment in full for their services on a case-by-case basis. This
practice is referred to as "participating" or accepting assignment on a
claim. Nonnetwork civilian providers also have the option of charging
up to 15 percent more than the TRICARE reimbursement rate for their
services on a case-by-case basis--a practice referred to as "non-
participating." However, when a nonnetwork civilian provider bills more
than the TRICARE reimbursement rate, TRICARE beneficiaries are
responsible for paying the extra amount billed in addition to their
required copayments. TROs and MCSCs told us that this authority is
infrequently used, in part, because when providers bill the additional
15 percent, they usually collect their total reimbursement from the
TRICARE beneficiaries, who may not always pay promptly.[Footnote 8]
When nonnetwork civilian providers "participate" on a claim and agree
to accept the TRICARE reimbursement amount as payment in full, the
MCSCs usually pay them directly, ensuring timely payment of the claim.
TRICARE's Benefit Options:
TRICARE provides its benefits through three main options for its non-
Medicare eligible beneficiary population that vary according to TRICARE
beneficiary enrollment requirements, the choices TRICARE beneficiaries
have in selecting civilian and MTF providers, and the amount TRICARE
beneficiaries must contribute towards the cost of their care. However,
while there are three main options, there are only two types of TRICARE
beneficiaries--enrolled and nonenrolled--and two types of civilian
providers--network and nonnetwork. (See table 1.) All beneficiaries may
also obtain care at MTFs although priority is given to active duty
beneficiaries and Prime enrollees.
Table 1: Summary of the Three Main TRICARE Options:
TRICARE option: Prime;
Type of option: Managed care;
Enrollment required: Yes;
Enrollment fee: Yes[C];
Civilian provider status[A]: Network;
Deductible: None;
Beneficiary copayment (outpatient care)[B]: $0-$12[D].
TRICARE option: Standard;
Type of option: Fee-for-service;
Enrollment required: No;
Enrollment fee: No;
Civilian provider status[A]: Nonnetwork;
Deductible: $50-$150 per individual; $100-$300 per family[F];
Beneficiary copayment (outpatient care)[B]: 20-25% of the TRICARE
reimbursement rate[E].
TRICARE option: Extra;
Type of option: Preferred provider organization;
Enrollment required: No;
Enrollment fee: No;
Civilian provider status[A]: Network;
Deductible: $50-$150 per individual; $100-$300 per family[F];
Beneficiary copayment (outpatient care)[B]: 15-20% of the TRICARE
reimbursement rate.
Source: GAO analysis of DOD data.
[A] Beneficiaries may also use MTF providers. Priority for MTF usage is
given to active duty personnel and beneficiaries enrolled in Prime.
[B] The lower range of copayments apply to active duty dependents while
higher copayments apply to retirees and their dependents. There is no
charge for outpatient care received at MTFs.
[C] There is no enrollment fee for active duty servicemembers and their
dependents. However, retirees and their dependents under 65 years must
pay an annual enrollment fee of $230 per individual or $460 per family.
[D] Inpatient care and other types of service require different levels
of copayment for retirees. Active duty family members who enroll in
Prime never incur a copayment.
[E] On a case-by-case basis, nonnetwork civilian providers may charge
up to 15 percent more than the TRICARE reimbursement rate. In these
instances, the TRICARE beneficiaries are also responsible for this
amount in addition to copayments.
[F] Dependents of lower-ranked enlisted personnel pay lower deductible
amounts. Dependents of higher-ranked military personnel, as well as
retirees and their dependents, pay the higher deductible amounts.
[End of table]
The three main options with their corresponding enrollment requirements
and provider categories are as follows:
* TRICARE Prime: This managed care option is the only TRICARE option
requiring enrollment. Active duty servicemembers are required to enroll
in this option while other TRICARE beneficiaries may choose to
enroll.[Footnote 9] Prime enrollees receive most of their care from
providers at MTFs, augmented by network civilian providers who have
agreed to meet specific access standards for appointment wait times
among other requirements.[Footnote 10] Prime enrollees have a primary
care manager who either provides care or authorizes referrals to
specialists. Beneficiaries can be assigned to a primary care manager at
the MTF or, if the MTF is at capacity or no MTF is available, Prime
enrollees may select a civilian primary care manager. Prime offers
lower out-of-pocket costs than the other TRICARE options. Active duty
personnel and their dependents do not pay enrollment fees, annual
deductibles, or copayments for care obtained from network civilian
providers. Retirees and their dependents who are not entitled to
Medicare pay an annual enrollment fee and small copayments for care
obtained from network civilian providers.
* TRICARE Standard: TRICARE beneficiaries who choose not to enroll in
Prime may obtain health care using this fee-for-service option, which
is designed to provide maximum flexibility in selecting providers.
Under Standard, nonenrolled TRICARE beneficiaries may obtain care from
TRICARE-authorized nonnetwork civilian providers of their choice.
TRICARE beneficiaries using this option do not need a referral for most
specialty care. Under Standard, all TRICARE beneficiaries must pay an
annual deductible and copayments, which vary among active duty
dependents and retirees and their dependents, and there is no annual
enrollment fee.[Footnote 11] In addition, nonnetwork providers are not
required to meet access standards, such as those for appointment wait
times.
* TRICARE Extra: Similar to a preferred-provider organization,
nonenrolled TRICARE beneficiaries may also obtain health care from a
TRICARE network civilian provider for lower copayments than they would
have under the Standard option--about 5 percent less. TRICARE
beneficiaries choosing to use Extra must pay towards the same annual
deductible as Standard and are responsible for copayments. Similar to
Standard, there is no annual enrollment fee. Additionally, network
civilian providers caring for nonenrolled TRICARE beneficiaries must
adhere to the same access standards for appointment wait times that
they use for enrolled TRICARE beneficiaries under Prime.
Among TRICARE beneficiaries who were not Medicare eligible in fiscal
year 2005, about 5.5 million or 65 percent of TRICARE's beneficiaries
were enrolled in Prime and thereby declared their intent to use their
TRICARE benefit. In contrast, TMA does not know whether nonenrolled
beneficiaries intend to use their TRICARE benefit. In fiscal year 2005,
claims data showed that about 1.2 million or 14 percent of nonenrolled
TRICARE beneficiaries obtained care with 66 percent of this care being
delivered through the Standard option and 34 percent delivered through
the Extra option. The remaining 1.8 million or 21 percent of
nonenrolled beneficiaries were eligible for TRICARE benefits but did
not use them during this time period.[Footnote 12] At any time, this
population of eligible nonusers could elect to use Standard or Extra,
and DOD would reimburse claims submitted for their health care after
annual deductibles are met.
TRICARE Contracts and Regional Structure:
TMA uses three MCSCs to provide civilian health care under the TRICARE
program. Each MCSC is responsible for the delivery of care to TRICARE
beneficiaries in one of three geographic regions--North, South, and
West. The MCSCs are contractually required to establish and maintain
networks of civilian providers in designated locations within these
regions that are referred to as Prime Service Areas. (See fig. 2 for
the location of Prime Service Areas in each of the three TRICARE
regions.) Prime Service Areas include all MTF enrollment
areas,[Footnote 13] Base Realignment and Closure sites,[Footnote 14]
and additional areas where either TMA or the MCSC deems networks to be
cost effective. As a result, each region may contain multiple Prime
Service Areas. In these areas, civilian provider networks are required
to be large enough to provide access for all TRICARE beneficiaries
regardless of enrollment status or Medicare-eligibility. TMA
contractually requires that MCSCs' civilian provider networks meet
specific access standards, such as travel times or wait times, for both
primary and specialty care. For example, TRICARE beneficiaries seeking
primary care should not have to drive more than 30 minutes to get to
their appointment locations. In addition to contractual requirements,
the MCSCs can add additional access standards that they strive to meet.
Figure 2: Location of Prime Service Areas in Each TRICARE Region:
[See PDF for image]
Source: GAO analysis of DOD data.
Note: Shaded areas represent counties in which there was a TRICARE
network of civilian providers available to serve both enrolled and
nonenrolled beneficiaries.
[End of figure]
MCSCs are also responsible for performing other customer service
functions, such as processing claims and helping TRICARE beneficiaries
locate providers. They also are required to operate TRICARE Service
Centers, which are frequently located within MTFs, to provide TRICARE
beneficiaries with information on the different TRICARE options,
information on benefit coverage, assistance with finding network and
nonnetwork civilian providers, determining eligibility status, and
other activities. MCSCs provide customer service to any TRICARE
beneficiary who requests assistance, regardless of their enrollment
status.
In each of the three regions, TMA uses a TRO to manage health care
delivery. TRO directors are considered the health plan managers for the
regions and are responsible for overseeing the MCSCs, including
monitoring network quality and adequacy, monitoring customer
satisfaction outcomes, and coordinating appointment and referral
management policies. TRO directors and staff also provide customer
service to all TRICARE beneficiaries who request assistance regardless
of their enrollment status.
Although they vary in the size of the geographic area covered, each
TRICARE region has approximately the same number of TRICARE
beneficiaries. However, the number of nonenrolled TRICARE beneficiaries
varies by region as does their access to network providers under the
Extra option depending on their proximity to a Prime Service Area. (See
fig. 3 for the number and distribution of nonenrolled beneficiaries by
region.)
Figure 3: All Nonenrolled TRICARE Beneficiaries by Region:
[See PDF for image]
Source: GAO analysis of DOD data.
Note: Shaded areas represent counties where nonenrolled beneficiaries
resided.
[End of figure]
Throughout the three regions, about 16 percent of nonenrolled TRICARE
beneficiaries reside outside of Prime Service Areas. In the North
region, 23 percent of nonenrolled TRICARE beneficiaries live outside of
Prime Service Areas, and in the West Region, 21 percent of nonenrolled
TRICARE beneficiaries live outside of Prime Service areas. Because the
South Region has extensive Prime Service Areas, no TRICARE
beneficiaries live in locations without a civilian provider network.
Although most nonenrolled TRICARE beneficiaries nationwide live in a
Prime Service Area, making Extra a readily available option,
nonenrolled TRICARE beneficiaries have used Standard more frequently
than Extra for each fiscal year from 2001 through 2005. (See fig. 4.)
Figure 4: Percent of Claims Paid for TRICARE Standard and Extra for
Each TRICARE Region for Fiscal Years 2001-2005:
[See PDF for image]
Source: GAO analysis of TMA data.
Note: In 2004, TMA consolidated its 11 TRICARE regions into 3 TRICARE
regions. TMA officials reallocated the data from the 11 regions to
correspond to the current regional structure.
[End of figure]
Requirements in the NDAA for Fiscal Year 2004 Related to Nonenrolled
TRICARE Beneficiaries:
The NDAA for fiscal year 2004 directed DOD to monitor nonenrolled
TRICARE beneficiaries' access to care under the TRICARE Standard option
and to designate a senior official to take the actions necessary to
ensure access to care for nonenrolled TRICARE beneficiaries.[Footnote
15] Specifically, the NDAA required surveys to be done in 20 market
areas[Footnote 16] each fiscal year until all markets were surveyed to
determine how many civilian providers[Footnote 17] were accepting
nonenrolled TRICARE beneficiaries as new patients. Although the law
focused on Standard, TMA officials told us that since nonenrolled
TRICARE beneficiaries can receive care through both the Standard and
Extra options, they designed the survey to monitor access to care from
both network and nonnetwork providers.
When developing the survey's methodology, TMA defined market areas as
individual states and determined that all states could be surveyed
within a 3-year period. TMA implemented its survey in fiscal year 2005
for the first 20 states.[Footnote 18] The survey collected data from
the billing and insurance specialists of selected civilian providers,
both network and nonnetwork, to determine how many were accepting
nonenrolled TRICARE beneficiaries as new patients and to identify the
reasons providers cite for not accepting these TRICARE beneficiaries.
About 17 percent of the providers in the sample belonged to a TRICARE
network while the remaining 83 percent of providers in the sample were
nonnetwork providers. Because about 14 percent of all civilian
providers belong to the TRICARE network, TMA's sample of civilian
providers is fairly representative of the network and nonnetwork
civilian provider population serving all TRICARE beneficiaries,
including nonenrolled beneficiaries who can use the Standard and Extra
options. TMA's four-question survey focused on a given provider's
awareness of TRICARE, whether the provider was accepting nonenrolled
beneficiaries as new patients, and if not, the reasons why they were
not. (See app. II for a detailed discussion of the methodology used for
this survey and app. III for the complete survey instrument.)
The NDAA for fiscal year 2004 also required DOD to designate a senior
official to take actions necessary for achieving and maintaining the
participation of nonnetwork civilian providers in a number adequate to
ensure care for nonenrolled TRICARE beneficiaries in each market area.
According to this legislation, the senior official would have the
following responsibilities:
* educating nonnetwork civilian providers about TRICARE,
* encouraging nonnetwork civilian providers to accept nonenrolled
TRICARE beneficiaries as patients,
* ensuring that nonenrolled TRICARE beneficiaries have the information
necessary to locate nonnetwork civilian providers readily, and:
* recommending adjustments in reimbursement rates that the official
considers necessary to ensure adequate availability of nonnetwork
civilian providers for nonenrolled TRICARE beneficiaries.
TMA and Its MCSCs Use Various Methods to Evaluate Access to Care That
Indicate Sufficient Access for Nonenrolled TRICARE Beneficiaries:
TMA and its MCSCs use various methods for evaluating access to care,
and according to TMA and MCSC officials, the resulting measures
indicate that access to care is generally sufficient for nonenrolled
TRICARE beneficiaries. TMA is administering the civilian provider
survey required by the NDAA for fiscal year 2004, which is designed to
obtain information on network and nonnetwork civilian providers'
willingness to accept nonenrolled TRICARE beneficiaries as new
patients. TMA also obtains information about access to care through its
annual health care survey of all TRICARE beneficiaries and through the
anecdotal beneficiary feedback they receive from the TROs, which
monitor access in their respective regions. MCSCs also use a variety of
approaches to evaluate access to care, including inquiries from
beneficiaries, analyses of claims data, and monitoring of the capacity
of civilian provider networks.
TMA Uses Various Methods for Evaluating Access to Care:
TMA uses multiple methods of evaluating access to care for its
nonenrolled TRICARE beneficiaries, including the recently implemented
survey of civilian providers and its annual health care survey of
TRICARE beneficiaries. In addition, TMA monitors centrally received
beneficiary complaints and inquiries, and each TRO monitors access to
care in its respective region.
TMA's Survey of Civilian Providers:
In fiscal year 2005, TMA completed the first phase of its mandated
survey of civilian health care providers.[Footnote 19] (See app. II for
discussion of technical aspects of this survey's methodology.) Although
the survey was designed to determine the extent to which providers were
willing to accept nonenrolled TRICARE beneficiaries as new patients, it
is premature to interpret the results because this is the first of
three rounds of the survey, and TMA does not have an established
benchmark for determining the number of civilian providers that are
needed for nonenrolled beneficiaries. During this initial round, TMA
randomly selected a representative sample of over 40,000 providers in
20 states. TMA found that the majority of the providers surveyed were
accepting new patients, including nonenrolled TRICARE
beneficiaries.[Footnote 20] Specifically, only 14 percent of providers
reported that they were not accepting new patients, including TRICARE
patients, privately insured patients, or patients who were paying for
their own care. Of the remaining 86 percent accepting new patients, the
percent that would accept nonenrolled TRICARE beneficiaries as new
patients averaged 80 percent for all 20 states.[Footnote 21] (See table
2 for overall results by state.) An additional comparison of the
acceptance rate for two categories of providers--primary care
providers[Footnote 22] and specialists[Footnote 23]--in each of these
20 states revealed very little difference between the two
categories.[Footnote 24] Of those accepting new patients, 78 percent of
primary care providers and 81 percent of specialists would accept
nonenrolled TRICARE beneficiaries as new patients.[Footnote 25]
Table 2: TMA's 2005 Civilian Provider Survey Results Showing Percent of
Surveyed Providers Accepting Nonenrolled TRICARE Beneficiaries (of
Those Accepting New Patients) by State:
Surveyed states: South Dakota;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 93.
Surveyed states: Maine;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 92.
Surveyed states: Idaho;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 91.
Surveyed states: Kansas;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 90.
Surveyed states: Mississippi;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 89.
Surveyed states: Nebraska;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 89.
Surveyed states: Wyoming;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 88.
Surveyed states: Alaska;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 87.
Surveyed states: Wisconsin;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 87.
Surveyed states: Massachusetts;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 87.
Surveyed states: New Mexico; Percent of surveyed providers accepting
nonenrolled TRICARE beneficiaries (of those accepting new patients):
86.
Surveyed states: Indiana;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 84.
Surveyed states: South Carolina;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 84.
Surveyed states: Illinois;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 83.
Surveyed states: California;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 81.
Surveyed states: Washington;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 79.
Surveyed states: Delaware;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 78.
Surveyed states: Texas;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 76.
Surveyed states: New Jersey;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 70.
Surveyed states: New York;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 68.
Surveyed states: Total;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 80.
Source: GAO analysis of DOD data.
[End of table]
In addition to the statewide sample, TMA also sampled civilian
providers in several smaller geographic locations, defined as hospital
service areas (HSA),[Footnote 26] in order to respond to concerns about
access to care that were specific to certain locations. TMA selected 29
HSAs--12 that were randomly selected from within the 20 states
evaluated for fiscal year 2005 and 17 based on beneficiary concerns
about specific locations.[Footnote 27] As in the 20-state survey, TMA
found that most providers in the selected HSAs were accepting new
patients, including nonenrolled TRICARE beneficiaries. Specifically,
only 13 percent of surveyed providers reported that they were not
accepting new patients. Of the remaining 87 percent accepting new
patients, 81 percent were accepting nonenrolled TRICARE beneficiaries
as new patients. (See table 3.) An additional comparison of the
acceptance rates for primary care providers and specialists who were
accepting new patients revealed that 75 percent of the surveyed primary
care providers and 85 percent of the surveyed specialists would accept
nonenrolled TRICARE beneficiaries as new patients.[Footnote 28] A
further comparison of providers accepting nonenrolled TRICARE
beneficiaries as new patients between the HSAs selected based on
TRICARE beneficiaries' concerns and the HSAs randomly selected from the
20 surveyed states showed minimal difference in acceptance rates--80
percent and 83 percent, respectively.
Table 3: TMA's 2005 Civilian Provider Survey Results Showing Percent of
Surveyed Providers Accepting Nonenrolled TRICARE Beneficiaries (of
Those Accepting New Patients) by Hospital Service Area:
Hospital Service Areas[A]: Peoria, Illinois[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 96.
Hospital Service Areas[A]: Fort Wayne, Indiana[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 94.
Hospital Service Areas[A]: Battle Creek, Michigan[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 93.
Hospital Service Areas[A]: Watertown, New York;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 92.
Hospital Service Areas[A]: Santa Fe, New Mexico[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 90.
Hospital Service Areas[A]: Eau Claire, Wisconsin[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 90.
Hospital Service Areas[A]: Belleville, Illinois;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 87.
Hospital Service Areas[A]: Waukegan, Illinois;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 87.
Hospital Service Areas[A]: Evansville, Indiana;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 89.
Hospital Service Areas[A]: Charleston, South Carolina[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 87.
Hospital Service Areas[A]: Lafayette, Indiana[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 87.
Hospital Service Areas[A]: Syracuse, New York;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 86.
Hospital Service Areas[A]: Corpus Christi, Texas[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 84.
Hospital Service Areas[A]: Killeen, Texas;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 84.
Hospital Service Areas[A]: Spokane, Washington;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 84.
Hospital Service Areas[A]: San Diego, California;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 83.
Hospital Service Areas[A]: Tallahassee, Florida[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 83.
Hospital Service Areas[A]: Kalamazoo, Michigan[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 80.
Hospital Service Areas[A]: San Antonio, Texas;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 80.
Hospital Service Areas[A]: Boca Raton, Florida[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 79.
Hospital Service Areas[A]: Indianapolis, Indiana;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 79.
Hospital Service Areas[A]: Columbia, South Carolina;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 79.
Hospital Service Areas[A]: Sacramento, California[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 77.
Hospital Service Areas[A]: Olympia, Washington;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 72.
Hospital Service Areas[A]: Houston, Texas[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 68.
Hospital Service Areas[A]: Monterey, California[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 67.
Hospital Service Areas[A]: Arlington, Texas[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 62.
Hospital Service Areas[A]: Brooklyn, New York[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 60.
Hospital Service Areas[A]: Seattle, Washington[B];
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 60.
Hospital Service Areas[A]: Total;
Percent of surveyed providers accepting nonenrolled TRICARE
beneficiaries (of those accepting new patients): 81.
Source: GAO analysis of DOD data.
[A] Hospital Service Areas are collections of zip codes organized into
geographic regions in which Medicare TRICARE beneficiaries seek the
majority of their care from one hospital or a collection of hospitals.
Hospital Service Areas have nonoverlapping borders and contain all U.S.
zip codes without gaps in coverage.
[B] Locations requested by TRICARE beneficiary groups and TRICARE
Regional Offices for assessment of access to care. These locations were
not randomly selected.
[End of table]
In both the states and HSAs, civilian providers who indicated that they
were not accepting nonenrolled TRICARE beneficiaries as new patients
were asked to identify why they made this decision in their own words,
and were permitted to provide as many reasons as they wanted. More than
half of both network and nonnetwork respondents cited not having a
provider available or reimbursement issues as reasons. For providers
citing nonavailability as a reason, many explained that they were
either in the process of retiring or were too busy to accept any new
patients at this time. Providers citing reimbursement issues most often
stated an opinion that TRICARE's reimbursement rates were low and that
claims payment was slow. (See app. IV for TMA's summary of the
aggregate results by category.)
Although there is no benchmark with which to compare the results of the
initial civilian provider survey effort, TMA officials stated that
their analysis of the 2005 survey results did not indicate widespread
problems with nonenrolled TRICARE beneficiaries' access to care.
Nonetheless, TRO officials used the survey results to identify specific
cities in their regions where civilian providers' acceptance of
nonenrolled TRICARE beneficiaries and knowledge about TRICARE were low
in comparison to the other locations surveyed.[Footnote 29] To assist
in this effort, the Assistant Secretary of Defense (ASD) for Health
Affairs directed TMA's Communications and Customer Service Directorate
to work with the TROs and other TMA officials to develop a strategic
marketing plan for these locations.[Footnote 30] The cities selected by
the TROs are as follows:
* West region: Olympia, Washington (2,732 nonenrolled beneficiaries),
Monterey, California (1,180 nonenrolled beneficiaries), Seattle,
Washington ( 2,358 nonenrolled beneficiaries), and Anchorage, Alaska
(3,381 nonenrolled beneficiaries);
* North region: Brooklyn, New York (4,276 nonenrolled beneficiaries)
and Eau Claire, Wisconsin (902 nonenrolled beneficiaries); and:
* South region: Arlington, Texas (3,025 nonenrolled beneficiaries),
Houston, Texas (6,415 nonenrolled beneficiaries), and Boca Raton,
Florida (447 nonenrolled beneficiaries).
TMA officials and TRICARE beneficiaries have stated that additional
survey questions could have yielded useful information. For example,
the survey did not ask providers whether they are accepting new
Medicare patients--an important proxy because TRICARE reimbursement
rates are established using Medicare reimbursement rates, and a
comparison of the two programs could provide information on whether
providers are more concerned with the amount of reimbursement or other
issues.[Footnote 31] Furthermore, the survey did not ask providers how
much of their current practice consists of TRICARE beneficiaries, to
capture whether or not providers may already have TRICARE beneficiaries
in their practices. However, a provision in the NDAA for fiscal year
2006 instructs TMA to add the following questions to its civilian
provider survey:
1. What percentage of Dr. X's current patient population uses any form
of TRICARE?
2. Does Dr. X accept patients under the Medicare program?
3. Would Dr. X accept additional Medicare patients?[Footnote 32]
TMA's Beneficiary Health Care Survey:
In addition to its civilian provider survey that covered 20 states, TMA
gathers worldwide information on nonenrolled TRICARE beneficiaries'
access to care through its annual Health Care Survey of DOD
Beneficiaries, which covers all TRICARE beneficiaries and all TRICARE
options.[Footnote 33] According to survey results from 2003 through
2005, about 77 percent of nonenrolled TRICARE beneficiaries who
obtained care reported that "getting needed care" was not a problem for
them. Similarly, over 80 percent of these TRICARE beneficiaries
reported that they could "get care quickly." For the same time period,
TMA compared its survey results with the results of a civilian health
plan survey, the Consumer Assessment of Healthcare Providers and
Systems (CAHPS®),[Footnote 34] which asked participants the same
questions on access to care under their plans. From this comparative
analysis, TMA found that a similar percentage of civilian health plan
participants--about 80 percent--responded that "getting needed care"
was not a problem and that they could "get care quickly." TMA uses this
survey as a benchmark to compare TRICARE against civilian plans.
Beneficiary Feedback:
Anecdotal information about access to care is available through TMA's
centralized Beneficiary and Provider Services office, which collects
and monitors information on TRICARE beneficiaries' complaints and
general inquiries, including issues about access to care. TRICARE
beneficiaries may contact this office by telephone, e-mail, written
correspondence, or through their congressional representatives. TMA
officials broadly categorize each contact by issue and use this
information to monitor trends in the feedback they receive through
these contacts. A TMA official stated that if the number of contacts
they receive related to an issue rises, the appropriate program
officials--such as the TROs--are notified and encouraged to investigate
the issue. Furthermore, TMA maintains a record of TRICARE beneficiary
and provider contacts that have been addressed and those that remain
open and continue to require attention. Although the Beneficiary and
Provider Services office does not specifically track access-to-care
issues as a separate issue, one of the TMA officials responsible for
tracking the contacts told us that TRICARE beneficiary complaints and
inquiries relating to access issues have been minimal. Overall,
concerns and inquiries for the "contractor service complaint" category,
which could include access-to-care issues for both enrolled and
nonenrolled TRICARE beneficiaries, represented about 1 percent of about
6,900 total contacts about the MCSCs for 2005.
In addition, on a regional level, the TROs collect and monitor TRICARE
beneficiary feedback gathered from e-mails and phone calls, as well as
correspondence they receive from TRICARE beneficiary groups. However,
the TROs told us that detailed information on each of these contacts is
not routinely maintained. For example, one TRO told us that when a
TRICARE beneficiary contacts them for assistance in locating a
provider, they track the general reason for the call, but do not
document the specific concerns. TRO officials told us that they receive
only a small number of contacts from nonenrolled TRICARE beneficiaries
who are unable to obtain care from nonnetwork civilian
providers.[Footnote 35] For example, one TRO told us that they received
approximately 34 requests for assistance locating a provider in
calendar year 2005 from the over 600,000 nonenrolled TRICARE
beneficiaries in this region. TRO officials indicated that sometimes
these requests are due to TRICARE beneficiaries' inability to obtain
care from a specific provider at a specific time and are not
necessarily indicative of access problems because that provider may be
available at another time or other providers may be available. The TROs
told us that they also monitor nonenrolled TRICARE beneficiaries'
access to care retrospectively by evaluating claims data as a record of
health care usage. For example, the TROs use these data to identify how
many network and nonnetwork providers have accepted nonenrolled TRICARE
beneficiaries as patients and to evaluate the use of the different
TRICARE options.
Finally, the TROs and military services are in the process of
implementing a new method of monitoring TRICARE beneficiary feedback.
The Assistance Reporting Tool (ART) is a computer database that when
fully operational will be used to archive and manage TRICARE
beneficiary feedback on all aspects of health care. Currently each of
the three TROs, all Army MTFs, and a portion of Navy and Air Force MTFs
use this system as either their primary or one of several tools for
managing and archiving TRICARE beneficiary feedback.[Footnote 36]
Because ART is not mandatory for all MTFs, the TROs also rely on other
feedback mechanisms to capture the most complete record of TRICARE
beneficiary concerns and questions. These other mechanisms include e-
mails from TRICARE beneficiaries to MTFs and data requests that the
TROs periodically make to MTFs. In addition, while the MCSCs are not
required to use ART because it was introduced after TRICARE's current
health care delivery contracts were awarded, one of the MCSCs is
currently using it. In the next cycle of TRICARE contracts, TMA
officials told us that they plan to require that all MCSCs use this
system. TMA officials who have reviewed the preliminary information
captured by ART told us that the tool has obtained very little feedback
that would indicate nonenrolled TRICARE beneficiaries are having
problems with access to care.
MCSCs Have Approaches for Monitoring Access to Care Though They Are Not
Specific to Nonenrolled TRICARE Beneficiaries:
Each of the three MCSCs has developed its own methods for monitoring
whether TRICARE beneficiaries in its region have access to care both in
Prime Service Areas and in areas where provider networks do not exist.
According to the MCSCs, while their methods for evaluating access to
care were not designed to evaluate access specifically for nonenrolled
TRICARE beneficiaries, they do provide some information that they use
to monitor the availability of both network and nonnetwork civilian
providers for this population, which is one component of access to
care.
The MCSCs also monitor access to care through beneficiary inquiries.
Each maintains a data system to archive and tabulate anecdotal TRICARE
beneficiary feedback received through some or all of the following
methods: telephone, e-mail, congressional correspondence, or walk-in
visits to a TRICARE Service Center. The MCSCs organize TRICARE
beneficiary feedback into subject categories and then monitor changes
in the frequency of contacts in these categories to identify trends and
important issues. At our request, each of the MCSCs reviewed their most
recent TRICARE beneficiary complaint data and found very small numbers
of comments pertaining to health care access. The MCSCs told us this
was an indication that TRICARE beneficiaries--both enrolled and
nonenrolled--were not experiencing any widespread problems with access
to care. For example, one MCSC identified fewer than 40 complaints
related to access out of one million contacts with TRICARE
beneficiaries in a 1-month period. The second MCSC reported that for
the last two quarters of 2005 they received an average of 355 inquiries
and complaints each month about access to care. Officials from this
MCSC told us that while their TRICARE beneficiary feedback system could
not quantify the total number of inquiries received, these 355
inquiries represented a small percentage of all contacts. The third
MCSC reported that out of more than 250,000 phone calls and walk-in
visits to TRICARE Service Centers during the month of December 2005, 71
contacts, or less than 1 percent of the total contacts, were related to
access.
The MCSCs also determine how many civilian providers have accepted at
least one TRICARE beneficiary by analyzing claims data to examine the
extent to which both network and nonnetwork civilian providers are
accepting TRICARE beneficiaries as patients. Each MCSC has concluded
that more than half of all licensed civilian providers--both network
and nonnetwork--in their respective regions have accepted at least one
TRICARE beneficiary, regardless of enrollment status, as a patient in
the last year.[Footnote 37] According to MCSCs, access to care appears
to be generally sufficient because the percentage of all licensed
civilian providers in each region who have submitted at least one
TRICARE claim during the past year are as follows: 90 percent in the
South region, where TRICARE beneficiaries represent 3.7 percent of the
entire region's population; 56 percent in the West region, where
TRICARE beneficiaries represent 3.1 percent of the region's population;
and 52 percent in the North region, where all TRICARE beneficiaries
represent an estimated 2.1 percent of the region's population.[Footnote
38]
Each MCSC told us that one of the primary ways they ensure sufficient
access to care for both enrolled and nonenrolled TRICARE beneficiaries
is by monitoring whether their civilian provider networks have the
capacity to provide care to all beneficiaries in their Prime Service
Areas. Throughout the three regions, the majority of nonenrolled
TRICARE beneficiaries--84 percent--live within Prime Service Areas,
making the choice of using a civilian network provider through Extra a
readily available option for them. In the South region, all TRICARE
beneficiaries reside in Prime Services Areas. In this region, the MCSC
monitors access to care through geographic analyses of provider and
TRICARE beneficiary locations to determine whether its networks meet
the needs of both enrolled and nonenrolled TRICARE beneficiaries using
TRICARE's access standards. In another region, where not all TRICARE
beneficiaries live in Prime Service Areas, the MCSC will assist
nonenrolled TRICARE beneficiaries in finding nonnetwork civilian
providers on an as-needed basis. In the third region where the Prime
Service Areas also do not encompass all TRICARE beneficiaries, the MCSC
recruits and contracts with providers outside of Prime Service Areas
who are available and willing to deliver care to nonenrolled TRICARE
beneficiaries living there. Network providers who deliver care in
locations outside of Prime Service Areas currently account for 25
percent of this MCSCs' network providers.
Various Factors Impede Providers' Acceptance of Nonenrolled TRICARE
Beneficiaries, and TMA and MCSCs Have Different Ways to Address Them:
TMA, MCSCs, and provider representatives have cited various factors as
impediments to civilian providers' willingness to accept nonenrolled
TRICARE beneficiaries as patients, and TMA and its MCSCs have different
ways to address them. Some impediments are specific to TRICARE,
including concerns about reimbursement rates and administrative issues,
and TMA and its MCSCs have specific ways to address these issues. For
example, TMA has the authority to increase reimbursement rates in
certain circumstances, and both TMA and MCSCs conduct outreach efforts
targeted to assist civilian providers with administrative issues. Other
impediments--such as providers' practices being at maximum patient
capacity and provider shortages in certain locations--are not specific
to TRICARE and are therefore inherently more difficult for TMA and the
MCSCs to address.
Providers Cite Concerns about TRICARE's Reimbursement Rates as a Reason
for Denying Nonenrolled TRICARE Beneficiaries' Access to Care, but TMA
Has Authority to Adjust Rates When Needed:
Since TRICARE was implemented in 1995, some civilian providers--both
network and nonnetwork--have complained that TRICARE's reimbursement
rates tend to be lower than those of other health plans, and as a
result, some of these providers have been unwilling to accept
nonenrolled TRICARE beneficiaries as patients. According to the results
of the initial round of TMA's civilian provider survey, concern about
reimbursement amounts was one of the primary reasons that both network
and nonnetwork civilian providers cited for not accepting nonenrolled
TRICARE beneficiaries as new patients. In the 2005 civilian provider
survey, of those who gave reasons for not accepting nonenrolled TRICARE
beneficiaries as new patients, 20 percent of network providers and 25
percent of nonnetwork providers cited concerns about reimbursement
amounts. However, TMA has the authority to adjust reimbursement rates
in areas where it determines that reimbursement rate amounts have been
negatively impacting TRICARE beneficiaries' ability to obtain care.
Providers' Concerns about TRICARE Reimbursement Rates:
One of providers' main reasons for not accepting nonenrolled TRICARE
beneficiaries as patients is providers' concern about low reimbursement
amounts. TRICARE's reimbursement rates generally mirror reimbursement
rates paid by the Medicare program. Beginning in fiscal year
1991,[Footnote 39] in an effort to control escalating health care
costs, Congress instructed DOD to gradually lower its reimbursement
rates for individual civilian providers to mirror those paid by
Medicare[Footnote 40]--an adjustment that has saved hundreds of
millions of dollars since the conversion.[Footnote 41] As of January
2006, the transition to Medicare rates was nearly complete, and
reimbursement rates for only 48 services remain higher than Medicare
reimbursement rates. (See app. V for a list of these services.)
According to TMA and MCSC officials, civilian providers, including both
network and nonnetwork, generally seek to develop a practice that
includes patients with higher-paying private insurers to compensate for
the acceptance of patients with lower-paying health plans, including
Medicare, Medicaid, and TRICARE. However, according to TMA and MCSC
officials, TRICARE generally has little leverage to encourage network
and nonnetwork civilian provider acceptance of its patients because the
TRICARE population is small and transient. Further, in locations where
the demand for providers' services exceeds the supply--such as in
Alaska--providers can be selective about who they accept as patients.
TMA and MCSC officials have also cited providers' concerns that
TRICARE's pediatric and obstetric rates are lower than Medicaid rates
for these services. To investigate these concerns, TMA conducted a
comparative analysis that found TRICARE's reimbursement rates for
selected pediatric and obstetric procedures were generally higher than
Medicaid's rates in many states for March 2006. TMA compared the
TRICARE reimbursement rate for the service most commonly billed by
pediatricians--an office visit for an established patient--with
Medicaid rates for this service and found that in 41 of the 45 states
for which Medicaid data were available, the TRICARE reimbursement rate
exceeded Medicaid's rate for this service. In addition, TMA compared
its reimbursement rates for 14 commonly used maternity and delivery
services with Medicaid rates and found that in 35 of the 45 states for
which Medicaid data were available,[Footnote 42] TRICARE reimbursement
rates for these services exceeded the Medicaid payment rates.
TMA also analyzed reimbursement rates for pediatric immunizations based
on MCSCs' concerns that providers viewed these rates as too low.
However, when TMA compared TRICARE's reimbursement rates with the cost
of the vaccine for the 10 most frequently used pediatric vaccines and
for the hepatitis A vaccine, TMA's analysts concluded that the TRICARE
reimbursement rates were generally reasonable and not undervalued in
relation to what a provider might actually pay to obtain them. Only one
vaccine--the pediatric hepatitis A vaccine--appeared to be priced lower
than the reasonable cost of obtaining the vaccine. In this instance,
the TRICARE reimbursement rate was $22.64, while pediatricians were
paying between $27.41 and $30.37 for the vaccine. As a result of this
discrepancy, TMA used its general authority to deviate from Medicare
rates,[Footnote 43] and starting May 1, 2006, TMA instructed the MCSCs
to reimburse pediatric hepatitis A vaccines nationally at a new
reimbursement rate of $30.40.
TMA Has Authority to Use Waivers to Adjust Reimbursement Rates:
TMA has the authority to increase TRICARE reimbursement rates for
network and nonnetwork civilian providers to ensure that all
beneficiaries, including nonenrolled beneficiaries, have adequate
access to care. TMA's authorities include (1) waiving reimbursement
rate reductions for both network and nonnetwork providers that resulted
when TRICARE reimbursement rates were lowered to Medicare
levels,[Footnote 44] (2) issuing locality waivers that increase rates
for specific procedures in specific localities,[Footnote 45] and (3)
issuing network-based waivers that increase some network civilian
providers' reimbursements.[Footnote 46] Once implemented, waivers
remain in effect indefinitely until TMA officials determine they are no
longer needed. As of August 2006, TMA had approved 15 waivers in total-
-2 waiving reimbursement rates reductions that resulted when TRICARE
reimbursement rates were lowered to Medicare levels, 7 locality
waivers, and 6 network waivers.
TMA can use its authority to waive reimbursement rate reductions to
restore TRICARE reimbursement rates in specific localities to the
levels that existed before a reduction was made to align TRICARE rates
with Medicare rates. On two occasions, TMA has used this authority in
Alaska to encourage both network and nonnetwork civilian providers to
accept TRICARE beneficiaries as patients in an effort to ensure
adequate access to care. In 2000, TMA used this waiver authority to
uniformly increase reimbursement rates for network and nonnetwork
civilian providers in rural Alaska, and in 2002 TMA implemented this
same waiver for network and nonnetwork civilian providers in Anchorage.
The use of these waivers resulted in an average reimbursement rate
increase of 28 percent for all of Alaska. However, in 2001, we studied
the effect of the 2000 waiver on access to care in rural Alaska and
found that it did not increase TRICARE beneficiaries' access to
care.[Footnote 47]
Locality waivers may be used to increase rates for specific medical
services in specific areas where access to care has been severely
impaired. Reimbursement rate increases for this type of waiver can be
established in one of three ways: by adding a percentage factor to the
existing TRICARE reimbursement rate, by calculating a prevailing
charge,[Footnote 48] or by using another government reimbursement rate,
such as rates used by the Department of Veterans Affairs to purchase
health care from civilian providers. The resulting rate increase would
be applied to both network and nonnetwork civilian providers for the
medical services identified in the areas where access is severely
impaired. A total of nine applications for locality-based waivers have
been submitted to TMA between January 2003 and August 2006. (See table
4.) Of these, seven locality waivers have been approved by TMA and two
are still pending. Six of the approved locality waivers as well as one
pending application are for locations in Alaska. This includes one
approved waiver to adjust the reimbursement rates for obstetric
services to match Medicaid rates in Alaska and nine additional states
based on TMA's comparative analysis of reimbursement rates for 14
obstetrical procedures.
Table 4: Applications for Locality Waivers and Approval Results:
Date submitted: 1/23/03;
Affected location: Juneau, AK;
Affected services: All gynecological procedures or services delivered
by one provider;
Amount of increase requested: 600 percent[A];
Status: 3/26/ 03--Approved for nonroutine gynecological procedures or
services.
Date submitted: 8/2004;
Affected location: Fairbanks, AK;
Affected services: All inpatient internal medicine procedures or
services delivered by providers employed by Fairbanks Memorial
Hospital;
Amount of increase requested: Veterans Administration rates[B];
Status: 10/28/ 04--Approved.
Date submitted: 6/08/05;
Affected location: Anchorage, AK;
Affected services: All medical procedures or services delivered by
perinatologists;
Amount of increase requested: 40 percent;
Status: 11/ 21/05--Approved for perinatologists who are participating
providers[C].
Date submitted: 6/08/05;
Affected location: Fairbanks, AK;
Affected services: Four medical procedures or services delivered by two
plastic surgeons;
Amount of increase requested: 175-253 percent;
Status: 5/18/ 06--Approved to increase rates to the rate paid by the
Veterans Administration for professional services provided by plastic
surgeons in Alaska.
Date submitted: 3/03/05;
Affected location: Puerto Rico[D];
Affected services: All medical procedures or services delivered by
neurosurgeons;
Amount of increase requested: 40 percent;
Status: 10/26/ 05--Approved.
Date submitted: 10/19/05;
Affected location: Alaska, Arizona, Connecticut, Montana, Nevada,
Oregon, South Carolina, Washington, West Virginia, Wyoming.[E];
Affected services: 14 obstetrical procedures or services;
Amount of increase requested: Medicaid reimbursement amounts;
Status: 03/20/06--Approved.
Date submitted: 2/23/06;
Affected location: Fairbanks, AK;
Affected services: All anesthesia or pain management and treatment
services delivered by anesthesiologists;
Amount of increase requested: 200 percent;
Status: 6/02/06--Approved to increase rates by 252 percent[F].
Date submitted: 3/06/06;
Affected location: Puerto Rico[D];
Affected services: Five high-risk medical procedures or services
delivered by obstetricians; multiple medical procedures or services
delivered by orthopedists and urologists;
Amount of increase requested: Various: Between 160 percent and 460
percent for obstetricians; 300 percent for orthopedists; and 162
percent for urologists;
Status: Pending.
Date submitted: 7/2006;
Affected location: All of Alaska;
Affected services: All medical services or procedures;
Amount of increase requested: Veterans Administration rates[B];
Status: Pending.
Source: DOD.
[A] Request did not include a specific increase amount. The approved
waiver was for the lesser of billed charges or 600 percent of the
TRICARE reimbursement rate.
[B] TMA agreed to match the Department of Veterans Affairs
reimbursement rates for these procedures.
[C] Participating providers submit claims for reimbursement and are not
permitted to bill TRICARE beneficiaries an additional 15 percent above
the TRICARE reimbursement rate.
[D] The TROs are not responsible for managing TRICARE in Puerto Rico
because it operates under a different contract than used for the
threeTRICARE regions.
[E] When reviewing the need for this rate adjustment, TMA compared
TRICARE reimbursement rates with Medicaid rates in 45 states for which
data were available. The 10 states listed were identified as needing a
rate adjustment based on this analysis. Each year when the TRICARE
reimbursement rates are adjusted, TMA intends to similarly determine
where this adjustment is needed.
[F] Because the TRICARE reimbursement rate changed during the period
between the application and the approval of this waiver, TMA raised the
percentage of the increase.
[End of table]
Network waivers are used to increase reimbursement rates for network
providers up to 15 percent above the TRICARE reimbursement rate in an
effort to ensure an adequate number and mix of primary and specialty
care network civilian providers for a specific location. Between
January 2002 and August 2006, 10 applications for network waivers have
been submitted to TMA. Of these, 6 network waivers have been approved
by TMA and 4 have been denied. (See table 5.)
Table 5: Applications for Network Waivers and Approval Results:
Date submitted: 1/29/02;
Affected location: Fredricksburg, VA;
Affected services: 33 varied medical procedures or services,
encompassing various specialties;
Amount of increase requested: 28 percent[A];
Status: Denied--Application did not substantiate an access to care
problem.
Date submitted: 3/07/02;
Affected location: Great Falls, MT;
Affected services: All medical procedures or services delivered by a
specific clinic representing 32 specialties;
Amount of increase requested: 200 percent[A];
Status: Denied--Application did not directly request a network waiver
and increase could be handled under TRICARE Prime Remote[B].
Date submitted: 8/13/02;
Affected location: Idaho;
Affected services: All medical procedures and services;
Amount of increase requested: 15 percent;
Status: 1/15/03--Approved for nine specialties in the Mountain Home Air
Force Base Prime Service Area.
Date submitted: 12/20/02;
Affected location: Bozeman, MT;
Affected services: All obstetrical or gynecological medical procedures
or services;
Amount of increase requested: 15 percent;
Status: Denied-- Increase available under TRICARE Prime Remote[B].
Date submitted: 4/08/03;
Affected location: Cheyenne, WY;
Affected services: Three newborn inpatient medical procedures or
services;
Amount of increase requested: To match civilian insurers' rates;
Status: 7/16/03--Approved increase to 15 percent above TRICARE
reimbursement rates.
Date submitted: 2/03 and 3/03;
Affected location: Watertown, NY Norwich, CT;
Affected services: Deliveries provided by nurse midwives in NY and
emergency gynecological services in CT;
Amount of increase requested: Not specified;
Status: Denied-Incomplete application package submitted.
Date submitted: 9/26/03;
Affected location: Ft. Leonard Wood and Springfield, MO;
Affected services: All medical procedures and services delivered by
network providers;
Amount of increase requested: 15 percent;
Status: 12/24/03--Approved for 11 specialties in Ft. Leonard Wood Prime
Service Area Denied for Springfield.
Date submitted: 1/05/05;
Affected location: Delta Junction and Tok, AK;
Affected services: All primary care medical procedures and services;
Amount of increase requested: 15 percent;
Status: 3/30/05--Approved for nonmental health medical care services,
excluding laboratory services.
Date submitted: 6/10/05;
Affected location: Norfolk, VA;
Affected services: All medical procedures and services for three
specialties delivered by a group of pediatric specialists;
Amount of increase requested: 15 percent;
Status: 7/08/05--Approved.
Date submitted: 3/06/06;
Affected location: Rapid City, SD;
Affected services: All obstetrical or gynecological services delivered
by a group of specialists;
Amount of increase requested: Not specified;
Status: 5/16/2006--Approved a 15 percent increase for one group of
obstetricians and gynecologists.
Source: DOD.
[A] According to TMA, the waiver requesters did not understand that the
maximum network waiver is 15 percent over TRICARE reimbursement rates.
If the waiver had been granted it would have been limited to 115
percent of the TRICARE reimbursement rate.
[B] TRICARE Prime Remote is a specialized version of TRICARE Prime
available for active duty members when they are assigned to duty
stations in areas not served by the military health care system. Under
this program, civilian network providers can be reimbursed up to 15
percent above the TRICARE reimbursement rate. Family members who reside
with service members who are enrolled in TRICARE Prime Remote are
eligible to enroll in and receive care under TRICARE Prime Remote for
Active Duty Family Members.
[End of table]
Providers, TRICARE beneficiaries, MCSCs, as well as TRO directors may
apply for a reimbursement rate waiver by submitting written requests
supporting the need for reimbursement rate increases on the grounds
that access to health care services is impaired due to low
reimbursement rates. These requests must contain specific
justifications to support the claim that access problems are related to
reimbursement rates and must include information such as the number of
providers and TRICARE beneficiaries in a location, the availability of
MTF providers, geographic characteristics, and cost effectiveness of
granting the waiver. All waiver requests are submitted to the TRO
directors, who review the application and make a decision whether to
forward the request to the Director of TMA through TMA's contracting
officers, who are responsible for administering the MCSCs' contracts.
According to a TMA official, the contracting officers work with TMA
analysts to review the submitted requests and verify whether there is
an insufficient number of providers in the area and conduct a cost-
benefit analysis before making a recommendation to the Director of TMA
that the waiver be accepted or denied. Each analysis is tailored to the
specific concerns outlined in the waiver requests. According to this
official, TMA conducts these additional analyses to ensure that an
increase in reimbursement rates would actually alleviate access
problems and that access was not impaired due to such things as
administrative problems or providers' unhappiness with claims payment
timeliness or accuracy.
Once a waiver is granted, there is no mechanism that automatically
terminates it. According to a TMA official, there was an expectation
within TMA that the continued need for existing waivers would be
evaluated on an annual basis.[Footnote 49] However, waivers have been
reviewed on a periodic, ad hoc basis rather than on an annual basis as
expected. When TMA implemented new MCSC contracts in fiscal years 2004
and 2005, TMA and the MCSCs discussed existing waivers and mutually
agreed to extend all of them because they continued to believe that
these waivers were necessary to ensure access to care. However, without
a formal analysis of how these waivers have impacted access in the
areas in which they were implemented, the actual extent of their effect
is unclear.
Providers Cite Concerns About TRICARE's Administrative Issues as
Reasons for Not Accepting Nonenrolled TRICARE Beneficiaries, but MCSCs
Use Various Methods to Address These Concerns:
Since the inception of TRICARE, both network and nonnetwork civilian
providers have expressed concerns about administrative issues or
"hassles" associated with the program, which, when combined with low
reimbursement rates, make them less likely to accept nonenrolled
TRICARE beneficiaries as patients. TMA and MCSC officials stated that
because TRICARE beneficiaries usually represent only a small percentage
of a provider's practice, both network and nonnetwork civilian
providers may not be as knowledgeable about the program and its unique
administration requirements. Adding to the potential for confusion,
while some administrative requirements apply to all TRICARE
beneficiaries, the TRICARE program also has separate and distinct
administrative requirements for enrolled and nonenrolled TRICARE
beneficiaries. For example, network providers must meet specific time
frame and documentation requirements when referring enrolled TRICARE
beneficiaries for specialty care or when delivering specialty care to
enrolled TRICARE beneficiaries. However, referral standards usually do
not apply to nonenrolled TRICARE beneficiaries. Additionally, according
to the initial round of TMA's civilian provider survey, 15 percent of
network respondents and 7 percent of nonnetwork respondents who gave
explanations for why they were not accepting nonenrolled TRICARE
beneficiaries as new patients cited administrative inconveniences as a
reason. These administrative inconveniences included too much
paperwork, problems understanding the benefits and policies, and a
lengthy referral process.
MCSC and TMA officials also told us that providers' past experiences
with TRICARE administrative issues may have biased their opinion of the
program, while, in some cases, there have been improvements. For
example, according to MCSCs and TMA officials, some providers perceive
that previously identified claims processing problems persist and cite
problems with timeliness and claims payment decisions as reasons for
not accepting TRICARE patients. While claims processing problems
plagued the TRICARE program in its early years, we reported in 2003
that efforts had been made to improve claims processing efficiency, and
as a result, claims were being processed in a more timely manner,
though some inefficiencies remained.[Footnote 50] In addition, some TRO
officials and providers said that TRICARE claims payment decisions
sometimes are not always clear to providers and, as a result, they may
believe problems with claims processing exist. This is due in part to
the fact that TRICARE's claims processing outcomes may differ from
Medicare's--despite the programs' similarities in reimbursement rates-
-due to different benefit structures and different claims processing
tools that are used to prevent overpayment. Furthermore, because they
do not always understand the program, providers and TRICARE
beneficiaries may complain about adjudication decisions on claims that
have been processed correctly. Problems may also occur because
providers and TRICARE beneficiaries may make mistakes when filing their
claims.
In efforts to address problems related to administrative issues, MCSCs
conduct a variety of outreach efforts to educate nonnetwork civilian
providers on TRICARE requirements and assist with both actual and
perceived administrative concerns. For example, MCSCs provide on-line
tools and toll-free telephone support to mitigate administrative
issues. Also, one MCSC works with state medical associations to address
provider concerns and to ensure that information about TRICARE
requirements is included in medical association newsletters. Each of
the MCSCs has provider relations representatives located in areas
throughout the region outside of their central office. These provider
relations representatives schedule opportunities to meet with
nonnetwork civilian providers that include booths or speaking
engagements at health fairs, conferences, and other provider events
and, when necessary, work one-on-one with network and nonnetwork
civilian providers to provide instructions on ways to respond to
TRICARE's administrative requirements and to help eliminate the burden
of unnecessary paperwork. According to MCSCs, these efforts have been
helpful because they are not experiencing widespread problems with
TRICARE beneficiaries' access to care. However, similar to the use of
waivers, the actual extent to which these efforts have improved access
to care is unclear.
Though TMA and MCSCs Attempt to Address Impediments That Are Not
Specific to TRICARE, These Issues Cannot Always be Resolved:
TMA and MCSCs attempt to address impediments to network and nonnetwork
provider acceptance of nonenrolled TRICARE beneficiaries that are not
specific to the TRICARE program. However, TMA and MCSCs cannot always
resolve access problems related to these impediments. Some network and
nonnetwork civilian providers may be unwilling to accept TRICARE
beneficiaries as patients because their practices are already at
capacity. For example, the initial round of TMA's civilian provider
survey found that 14 percent of providers in the 20 states surveyed
were not available to accept any new patients, including TRICARE
patients, privately insured patients, or patients who were paying for
their own care. According to the MCSCs, access problems related to
practice capacity are more likely to occur in geographically remote
areas that have few providers than in more densely populated areas with
more providers. However, one MCSC stated that access problems related
to practice capacity can also occur in urban areas where the medical
needs of the population exceed the supply of specific specialties, such
as dermatology.
TRICARE beneficiaries' access to care is also impeded in areas where
there are insufficient numbers and types of civilian providers, both
network and nonnetwork, to cover the local demand for health care. In
these locations, the entire community is impacted by provider
shortages. Consequently, TRICARE beneficiaries, as well as all other
local residents, must sometimes travel long distances to obtain health
care. MCSC officials stated that each TRICARE region includes areas
with civilian provider shortages. For example, in TRICARE's North
Region, Watertown, New York, has an insufficient number of certain
specialty providers for its population, which includes TRICARE
beneficiaries stationed at a nearby military installation whose MTF is
too small to handle all of their health care needs. TRICARE's South
Region contains many rural areas with few providers, including multiple
locations in Oklahoma and Texas. Likewise, in TRICARE's West Region,
MCSC officials stated that there are provider shortages in various
locations, including Cheyenne, Wyoming, and Mountain Home, Idaho.
TMA and the MCSCs have limited means of responding to access-to-care
impediments in areas with network and nonnetwork civilian provider
shortages, although TMA has adopted two bonus payment systems that
mirror those used by Medicare for these areas.[Footnote 51] In June
2003, TMA began paying providers a 10 percent bonus payment for the
services rendered in Health Professional Shortage Areas, which the
Department of Health and Human Services has identified as having a
shortage of primary care, dental, or mental health providers.[Footnote
52] Also, in January 2005, TMA followed Medicare in initiating payment
of a 5 percent bonus for services rendered by primary care providers in
geographic areas designated by the Department of Health and Human
Services as Physician Scarcity Areas,[Footnote 53] a program that is
only operational through 2007.[Footnote 54] Providers who are eligible
for and wish to receive either of these bonus payments must include a
specific code on every claim they submit to obtain these additional
payments. According to a TMA official, TMA does not know the extent to
which these payments have been used and has not evaluated the
effectiveness of these bonus payments on access to care.
TMA and the MCSCs have attempted to overcome obstacles related to
practice capacity and provider shortages by using high-ranking military
personnel and field provider relation representatives to make personal
appeals to network and nonnetwork civilian providers. In August 2004,
the ASD for Health Affairs wrote a letter to providers appealing to
their patriotism and asking them to accept TRICARE beneficiaries as
patients. One MCSC official claimed that this letter has resulted in
additional providers accepting both enrolled and nonenrolled TRICARE
beneficiaries as patients. In addition, in certain areas where access
is problematic, MCSC provider relations representatives or TRO
officials personally call on providers to solicit their support of
military personnel through TRICARE.
NDAA Responsibilities for Nonenrolled TRICARE Beneficiaries' Access to
Care Are Being Carried Out by TMA and the MCSCs, but Were Not Formally
Designated to a Senior Official:
Various TMA offices, including the TROs, and the MCSCs are carrying out
the responsibilities that are outlined in the NDAA for fiscal year 2004
to take actions to ensure nonenrolled beneficiaries' access to care,
such as educating civilian providers and recommending reimbursement
rate adjustments--though these responsibilities were not formally
designated to a single, senior official. For example, TMA's
Communications and Customer Service Directorate has primary
responsibility for education and marketing activities for all civilian
providers--including nonnetwork providers--although the TROs and MCSCs
also share this responsibility. (See table 6.) This office oversees a
national contract for marketing and education materials with input from
the TROs and the MCSCs. As part of this responsibility, this office
designs and prepares marketing and education materials in conjunction
with its contractor. On a regional level, the TROs and MCSCs also have
responsibilities for educating both network and nonnetwork civilian
providers. As part of these efforts, each TRO works with its region's
MCSC to host town-hall meetings and to provide briefings for network
and nonnetwork civilian providers. In addition, the MCSCs contact,
support, educate, and market to both network and nonnetwork civilian
providers. For example, one MCSC distributes its monthly provider
newsletter or bulletin to nonnetwork civilian providers who submit 25
or more TRICARE claims in 1 year. MCSCs also provide educational
materials to civilian providers, including nonnetwork providers, and,
in some instances, schedule provider seminars for nonnetwork providers.
Table 6: Responsibilities Outlined in the NDAA for Fiscal Year 2004 and
the Entities Covering Them:
Responsibilities: Educate nonnetwork civilian providers about Standard;
Entities:
* TMA's Communications and Customer Services Directorate;
* TROs;
* MCSCs.
Responsibilities: Encourage nonnetwork civilian providers to accept
nonenrolled TRICARE beneficiaries as patients under Standard;
Entities:
* MCSCs[A].
Responsibilities: Ensure that nonenrolled TRICARE beneficiaries have
information necessary to locate nonnetwork providers readily;
Entities:
* TMA;
* TROs;
* MCSCs.
Responsibilities: Recommend adjustments in provider reimbursement rates
to ensure adequate availability of nonnetwork providers for nonenrolled
TRICARE beneficiaries;
Entities:
* TROs[B].
Source: GAO analysis of DOD information.
[A] MCSCs solicit nonnetwork providers to accept TRICARE beneficiaries
when nonenrolled TRICARE beneficiaries cannot locate providers in a
specific location.
[B] Although the TROs are responsible for preparing and submitting
justification for payment waivers, other interested parties, including
MCSCs, providers, and TRICARE beneficiaries can submit requests for
payment adjustments through the TROs.
[End of table]
Actions to encourage both network and nonnetwork civilian providers to
accept nonenrolled TRICARE beneficiaries as patients are currently
being addressed by the MCSCs. First, in areas with network civilian
providers, MCSCs are required by contract to ensure that the networks
are robust enough to provide health care to both enrolled and
nonenrolled TRICARE beneficiaries in that location. As a result, MCSCs
strive to ensure adequate numbers of network civilian providers who
could also provide care to nonenrolled TRICARE beneficiaries. In
addition, when nonenrolled TRICARE beneficiaries request assistance
with finding providers, MCSCs work to encourage civilian providers, who
could be either network or nonnetwork, to accept these TRICARE
beneficiaries as patients. In some instances when a provider cannot be
easily identified for a TRICARE beneficiary, MCSCs told us their
provider relations representatives, who are knowledgeable about
providers in their regions, will call on individual providers to
encourage them to accept these TRICARE beneficiaries as patients.
Nonetheless, as contractually required, MCSCs are focused on recruiting
civilian providers for their networks and do not proactively recruit
nonnetwork civilian providers to accept TRICARE beneficiaries as
patients. Efforts to obtain nonnetwork civilian providers for
nonenrolled TRICARE beneficiaries using the Standard option are
initiated on an as-needed basis.
Additionally, TMA, its TROs, and the MCSCs all have procedures and
tools in place aimed at ensuring that nonenrolled TRICARE beneficiaries
can readily locate both network and nonnetwork civilian providers. A
central TMA office maintains an online directory of both network and
nonnetwork civilian providers who have accepted TRICARE beneficiaries
as patients in the last 2 years. MCSCs' Web sites provide a link to
this TMA directory and also provide a directory of network civilian
providers in their regions. Also, the TROs provide services, including
assistance with locating civilian providers, to any TRICARE beneficiary
who contacts them. Among other services they provide, Beneficiary
Service Representatives at MCSC-operated TRICARE Service Centers assist
"walk-in" TRICARE beneficiaries--regardless of their enrollment status--
to locate providers. In addition, all MCSCs are contractually required
to have representatives available by phone 24 hours a day, 7 days a
week to assist with locating a network provider. One MCSC told us that
if a network provider is not available, the phone representatives will
help locate nonnetwork providers in the area.
Finally, the TROs currently are responsible for recommending
reimbursement rate adjustments--that have been initiated by their
offices, MCSCs, providers, and TRICARE beneficiaries--to increase
provider reimbursement rates in areas where access to care is impaired
for both enrolled and nonenrolled TRICARE beneficiaries. Since the TROs
were established in 2004, two of the three TROs have recommended such
increases to provider reimbursement rates in their regions.[Footnote
55]
Nonetheless, TMA has not formally designated a senior official to take
responsibilities for nonenrolled TRICARE beneficiaries and nonnetwork
civilian providers as outlined in the NDAA for fiscal year 2004.
According to TMA officials, this role was assumed by the ASD for Health
Affairs, who is responsible for overseeing DOD's health programs and
resources, because these responsibilities are included in the official
directive for this position.[Footnote 56] According to senior TMA
officials, the ASD for Health Affairs intended to delegate these
responsibilities to the TRO directors. However, while this intent was
communicated verbally, the delegation was never formalized in writing.
TRO officials told us that while they were aware of the ASD for Health
Affairs' intent, they never received official notification or
designation outlining these responsibilities and expectations. As a
result, at the time of our site visits, the TROs had not undertaken any
efforts beyond the level of assistance they were already providing to
nonenrolled TRICARE beneficiaries and nonnetwork civilian
providers.[Footnote 57] Nonetheless, during the time of our review,
each TRO was in the process of assigning responsibilities for
nonenrolled beneficiaries to a specific staff member in accordance with
the staffing plan TMA established for the TROs. Additionally, officials
at each of the TROs told us that they provide services and assistance
to all TRICARE beneficiaries regardless of enrollment status.
To more directly assign responsibilities for nonenrolled beneficiaries'
access to care to the TROs, the NDAA for fiscal year 2006 specifically
instructs the TROs to (1) identify nonnetwork providers who will accept
nonenrolled TRICARE beneficiaries as patients; (2) communicate with
nonenrolled TRICARE beneficiaries; (3) conduct outreach to nonnetwork
providers, encouraging their acceptance of TRICARE beneficiaries as
patients; and (4) publicize which nonnetwork providers in each region
accept nonenrolled TRICARE beneficiaries as patients.[Footnote 58] It
also requires that DOD submit annual reports to Congress on efforts to
implement these activities.
Agency Comments and Our Evaluation:
We received comments on a draft of this report from DOD (see app. VI).
In its comments DOD stated that it appreciated the collaborative,
insightful, and thorough approach that was taken with this important
issue. However, DOD disagreed with our finding that it had not formally
designated a senior official to ensure nonenrolled beneficiaries'
access to care, including adequate participation by nonnetwork
providers, as required by the NDAA for fiscal year 2004. DOD stated
that DOD directive 5136.12 assigned these duties to the TMA director
and the TROs by designating the TMA Director as the program manager for
TRICARE health and medical resources and other responsibilities. DOD
stated that this responsibility clearly encompasses provision of care
to nonenrolled beneficiaries and therefore meets the NDAA requirement.
We continue to believe that DOD has not adequately addressed the
requirement in the mandate. First, in multiple interviews and e-mail
exchanges during our audit work, senior DOD officials told us that no
specific actions had been taken to designate a senior official and
that, by default, the duties fell to the ASD for Health Affairs who is
responsible for overseeing DOD's health programs and resources.
Further, during our site visits, TRO officials told us they had never
been officially notified of their responsibilities and expectations for
nonenrolled beneficiaries and nonnetwork providers. As a result, at the
time of our site visits the TROs told us they had not undertaken any
efforts beyond the level of assistance they had already been providing
to nonenrolled beneficiaries and nonnetwork civilian providers. Second,
we do not agree with DOD that the terms of the pre-existing directive
satisfy the requirements of the mandate. Contrary to the requirement in
the law that one official be designated, the directive generally
assigns responsibilities to TMA, as well as to multiple TROs on a
geographic basis. While part of the TROs' responsibilities include
developing a plan for the delivery of healthcare within the geographic
region, the mandate contemplated a more global approach to addressing
provider participation, specifically requiring one senior official to
ensure provider participation in each market area.
DOD also provided technical comments that we incorporated where
appropriate.
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. In addition,
the report is available at no charge on the GAO Web site at [Hyperlink,
http://www.gao.gov]. If you or your staff have questions about this
report, please contact me at (202) 512-7119. Contact points for our
Office of:
Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made major contributions are listed
in appendix VII.
Signed by:
Marcia Crosse:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
The National Defense Authorization Act (NDAA) for fiscal year 2004
directed GAO to review the processes, procedures, and analysis used by
the Department of Defense (DOD) to determine the adequacy of the number
of network and nonnetwork civilian providers and the actions taken to
ensure access to care for nonenrolled TRICARE beneficiaries.
Specifically, this report describes (1) how TRICARE Management Activity
(TMA) and its managed care support contractors (MCSC) evaluate
nonenrolled TRICARE beneficiaries' access to care and the results of
these evaluations; (2) the impediments to civilian provider acceptance
of nonenrolled TRICARE beneficiaries, and how they are being addressed;
(3) how DOD has implemented the fiscal year 2004 NDAA requirements to
take actions to ensure nonenrolled TRICARE beneficiaries' access to
care.
TMA and MCSCs' Evaluation of Nonenrolled Beneficiaries' Access to Care
and the Status of Access:
To describe how TMA evaluates nonenrolled TRICARE beneficiaries' access
to care, we interviewed and obtained documentation from officials in
TMA's Health Program Analysis and Evaluation Directorate about its
civilian provider survey, called the Survey on Continued Viability of
TRICARE Standard. Although DOD was required to conduct a survey to
assess nonenrolled beneficiaries' access to care under the Standard
option, the survey was administered to both network and nonnetwork
civilian providers since nonenrolled beneficiaries can receive care
from these providers under both the Extra and Standard options. We
reviewed the survey methodology, including the methods for selecting
respondents, the survey's response rate,[Footnote 59] the designation
of TRICARE market areas, and the survey instrument itself. We also
reviewed TMA's methods for randomly sampling market areas and providers
and their administration of the survey instrument and found these
decisions methodologically sound and statistically valid. In addition,
we reviewed the survey results, including the published results and
analysis. While we did not independently validate the survey data, we
did assess the reliability of the data by reviewing survey
documentation and internal controls and by interviewing knowledgeable
agency officials and found that the data were sufficiently reliable for
our purposes. To obtain information on how the civilian provider survey
was developed, we interviewed officials at the Office of Management and
Budget (OMB) because the Paperwork Reduction Act required OMB approval
before it could administered. We also interviewed TRICARE beneficiary
group representatives who had recommended sites for inclusion in the
survey where nonenrolled TRICARE beneficiaries' access to health care
may be impaired. To identify how the civilian provider survey results
would be used to evaluate access to care, we met with officials of
TMA's Office of Health Plan Operations, the director of TMA's Standard
Programs Division, and officials from the three TRICARE Regional
Offices (TROs).
We also reviewed TMA's annual Health Care Survey of Defense
Beneficiaries and compared it with a survey conducted by the Department
of Health and Human Services' Consumer Assessment of Health Care
Providers and System of individuals who received health care through
civilian health insurers. These surveys include identical questions on
access-to-care issues that allowed for comparative analysis of the
opinions expressed by TRICARE beneficiaries and civilian health plan
users. Using data from the 2003-2005 surveys we analyzed nonenrolled
TRICARE beneficiaries' responses to access to care and compared them
with results from the Consumer Assessment of Health Care Providers and
Systems. We did not independently verify the data from each of these
surveys; however, we did assess the reliability of these data by
reviewing related documentation and interviewing knowledgeable agency
officials and found that they were sufficiently reliable for our
purposes.
To further identify and describe other methods TMA and MCSCs used to
evaluate care access for nonenrolled TRICARE beneficiaries, we met with
officials of TMA, the TROs, MCSCs, and each of the services' Office of
the Surgeon General to obtain information on the systems they use for
monitoring TRICARE beneficiary feedback and conducting other types of
analyses, such as monitoring health care claims. The TROs and military
services provided information on the Assistance Reporting Tool, a
system that is being developed to monitor and archive TRICARE
beneficiary feedback. The MCSCs also shared information about their
independent systems for maintaining TRICARE beneficiary feedback. TMA,
MCSC, and military service officials provided us with examples of
TRICARE beneficiary feedback reports and health care claims data for
nonenrolled TRICARE beneficiaries that TMA uses to evaluate access to
care for this population. We did not independently verify data from the
MCSCs' TRICARE beneficiary feedback systems and TMA's claims data
files; however, we did assess the reliability of these data by
interviewing knowledgeable officials and reviewing previous GAO work
using these data and found that they were sufficiently reliable for our
purposes. To identify how the MCSCs monitor access to care both in
Prime Service Areas and in areas where networks have not been
established, we obtained information about their techniques for network
development and for civilian provider recruitment.
Impediments to Provider Acceptance of Nonenrolled TRICARE Beneficiaries
and How They Are Being Addressed:
To identify and describe the impediments to providers' acceptance of
nonenrolled TRICARE beneficiaries, we obtained information from TMA
Health Plan Operations, TMA Health Program Analysis and Evaluation
Directorate, TRO, and MCSC officials on the possible reasons that
providers were unwilling to accept nonenrolled TRICARE beneficiaries as
patients. We also met with representatives of TRICARE beneficiary
groups and the American Medical Association to obtain anecdotal
information about impediments to health care access and to supplement
our data on possible access-to-care problems.
To identify and describe how impediments, such as TRICARE reimbursement
rates and administrative issues, are being addressed, we reviewed
TRICARE's reimbursement policies and authorities as well as provider
outreach strategies and marketing and education efforts of TMA and its
MCSCs. We also reviewed the procedures for issuing waivers used to
increase reimbursement rates in areas where TMA determines that access
to care is impaired, including the application, review, and decision
process. We then obtained information from TMA's Office of Medical
Benefit and Reimbursement Systems on all of the completed and pending
requests for reimbursement waivers. Finally, we interviewed MCSC and
TRO officials to identify the administrative issues that impact
provider acceptance of TRICARE beneficiaries and how they conduct
outreach efforts to alleviate problems and/or educate providers about
these issues. However, we did not assess the extent to which these
efforts improved civilian providers' acceptance of nonenrolled
beneficiaries as patients.
DOD Implementation of NDAA Fiscal Year 2004 Requirements for Oversight
of Nonenrolled Beneficiaries' Access to Care:
To examine how DOD has implemented the NDAA fiscal year 2004
requirements for oversight of nonenrolled TRICARE beneficiaries' access
to care, we reviewed pertinent sections of this legislation outlining
the tasks that DOD must perform to comply with the law. We interviewed
officials in TMA's office of Health Plan Operations, the director of
the TRICARE Standard Programs Division, and officials in each of the
TROs. To identify whether and how the oversight responsibilities
outlined in the NDAA were being managed, we obtained information from
TRO and MCSC officials for each of the three regions and TMA's
Communications and Customer Service Directorate to identify activities
in place to educate network and nonnetwork providers about TRICARE
Standard, to encourage network and nonnetwork providers to treat
nonenrolled TRICARE beneficiaries, and to ensure that nonenrolled
TRICARE beneficiaries have the information necessary to locate
providers readily.
We conducted our work from July 2005 through December 2006 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix II: Methodology Used for TMA's Civilian Provider Survey:
The National Defense Authorization Act (NDAA) for fiscal year 2004
required that the TRICARE Management Activity (TMA) conduct surveys in
TRICARE market areas within the United States to determine how many
health care providers are accepting new patients under TRICARE Standard
in each market area. The NDAA did not stipulate how TMA should define a
market area but specified that 20 market areas should be completed each
fiscal year until all market areas in the United States have been
surveyed. Although the mandate focused on Standard, TMA officials
designed the survey to monitor access to care from both network and
nonnetwork providers since nonenrolled TRICARE beneficiaries can
receive care through both the Standard and Extra options.
Before TMA could begin administering the civilian provider survey, it
required review and clearance from the Office of Management and Budget
(OMB) under the Paperwork Reduction Act.[Footnote 60] Subsequent to
this review, OMB approved a four-item questionnaire for the study
administered in fiscal year 2005.[Footnote 61] (See app. III for the
approved questionnaire.)
In designing the Survey on Continued Viability of TRICARE Standard (the
civilian provider survey), TMA defined the individual states and the
District of Columbia as 51 market areas--a definition that will allow
TMA to complete the survey of all markets within a 3-year period and to
develop estimates of access to health care at both the state and
national levels. However, in order to provide information on smaller
geographic areas where nonenrolled TRICARE beneficiaries may be having
problems finding either network or nonnetwork providers, TMA
supplemented the statewide samples by oversampling[Footnote 62] from
submarkets within each state called Hospital Service Areas (HSA). The
HSA geographic designation is derived from a Dartmouth University study
that groups zip codes into distinct sets based on the analysis of
patient travel patterns to the hospital or hospitals they use most
often. TMA endorsed the HSA submarket methodology because these areas
are nonoverlapping and encompass all of the United States. In addition,
nonenrolled TRICARE beneficiaries reside in almost all of the 3,436
HSAs. TMA's methodology asks for oversamples from HSAs in the 24 states
where 80 percent of nonenrolled TRICARE beneficiaries reside. When the
study is complete in fiscal year 2007, TMA will have survey data from 2
HSAs selected randomly from each of the 24 states where the majority of
nonenrolled TRICARE beneficiaries live, as well as information from
HSAs purposively selected because TRICARE beneficiaries or TROs were
concerned with access in these areas.
To select the market areas that would be surveyed in fiscal year 2005,
TMA randomly selected sites from the individual states and the District
of Columbia and randomly selected 12 submarket HSAs within the 20
market areas. In addition, in order to be able to respond to TRICARE
beneficiary concerns that access in some locations was impaired, TMA
selected 17 additional submarket HSAs that TRICARE beneficiaries had
identified as problem areas in terms of access to health care. Four of
these 17 sites were outside the 20 selected state-wide market areas
because TRICARE beneficiaries had raised concerns about access issues
in these locations.
TMA selected its sample for the civilian provider survey from the
American Medical Association Masterfile, a data set of U.S. providers
that includes data on all providers who have the necessary educational
and credentialing requirements. This Masterfile did not differentiate
between TRICARE's network and nonnetwork civilian providers. However,
TMA selected this file because it is widely recognized as one the best
commercially available lists of providers in the United States and
contains over 600,000 active providers along with their addresses,
phone numbers, and information on practice characteristics, such as
their specialty.[Footnote 63] Although the Masterfile is considered to
contain most providers, deficiencies in coverage and inaccuracies in
detail remain. Therefore, TMA attempted to update providers' addresses
and phone numbers and to ensure that providers were eligible for the
survey.
From this Masterfile, TMA expected to randomly sample about 1,000
providers from each market and submarket area--a sample size that would
achieve TMA's desired margin of error.[Footnote 64] However, in some
instances, a sample of 1,000 exceeded the number of providers in the
market or submarket area, in which case TMA attempted to contact all
providers in that area. Overall, TMA initially sampled about 41,000
providers, including both network and nonnetwork civilian providers.
After verifying phone numbers and eliminating ineligible
providers,[Footnote 65] TMA attempted to contact about 33,000 office-
based providers in the 20 states and 29 HSAs evaluated in fiscal year
2005. When analyzing provider responses, TMA weighted each response so
that the sampled providers represented the population from which they
were selected.
To administer the civilian provider survey TMA hired a contractor, who
conducted the fieldwork for this project. The contractor mailed a
combined cover letter and questionnaire to the billing managers for all
providers in their sample. If the provider did not respond to the
mailed questionnaire, TMA followed up with a second mailing 3 weeks
later and conducted a telephone interview within 30 days of the first
mailing for those who did not respond to the mailed survey.[Footnote
66] During the survey period, telephone interviewers called each
provider's office up to 10 times in an attempt to obtain a completed
survey.
Because the overall response rate to the survey was 55 percent, TMA
conducted an analysis of their findings to determine whether the
results were biased by a high percentage of providers not responding.
Although TMA officials told us that OMB's approval for the fiscal year
2005 survey did not specify a required response rate, OMB's public
guidance specifies that if response rates are lower than 80 percent,
agencies need to conduct a nonresponse analysis.[Footnote 67] Such an
analysis is used to verify that nonrespondents to the survey would not
answer differently from those who did respond and that the respondents
are representative of the target population, thus ensuring that the
data are statistically valid. When conducting this analysis, TMA
interviewed a sample of providers who did not respond to the original
survey and compared their responses and demographics with the original
survey respondents.[Footnote 68] TMA also compared nonrespondents'
demographics with those of the target population of health care
providers. The results of TMA's nonresponse analysis indicate that the
survey respondents are representative of the target population of
providers.
The nonresponse analysis provided additional useful information for
TMA. First, it did not show a difference in the rate that responding
and nonresponding network civilian providers were aware of the TRICARE
program. However, it did show a statistically significant difference in
the rate of awareness between responding and nonresponding nonnetwork
civilian providers. These results indicate that having a familiarity
with TRICARE increases a provider's incentive to respond to the survey.
In order to adjust for this bias, TMA could have calculated an
adjustment to the sampling weights--an adjustment that has not been
applied to the survey results. As a result, the unweighted survey
results tend to overstate civilian providers' awareness and acceptance
of TRICARE.[Footnote 69] Nonetheless, TMA's survey contractor noted
that the survey results are not problematic if the survey is used to
compare changes in awareness and acceptance from year to year. Further,
TMA's use of the unadjusted results of the initial survey phase as
indicators of areas in which to focus marketing and outreach efforts is
appropriate because TMA is using it to make relative comparisons of the
areas surveyed.
TMA's survey of civilian providers continues, and their analysts expect
to complete data collection for the nation over a 3-year period ending
in fiscal year 2007. Although TMA's efforts meet the mandate's
requirement of surveying 20 market areas each fiscal year until all
market areas were surveyed, collecting survey results over this period
may limit TMA's stated goal of deriving an overall national estimate
because the national estimate will combine data collected over several
years rather than during one relatively short time period, as well as
the likelihood different instruments will be used over time. For
example, four additional questions may be added to the fiscal year 2006
survey. TMA officials told us that the time lag could potentially
impact the results used to derive a national estimate, but that their
limited resources for this study prevent them from conducting a
nationwide survey under a shorter time frame.
[End of section]
Appendix III: Civilian Provider Survey Instrument:
The National Defense Authorization Act (NDAA) for fiscal year 2004
directed the Department of Defense (DOD) to monitor nonenrolled TRICARE
beneficiaries' access to care under the TRICARE Standard
option.[Footnote 70] Although the mandate focused on Standard,
nonenrolled TRICARE beneficiaries can receive care from both nonnetwork
civilian providers through the Standard option and from network
civilian providers through the Extra option. Beneficiaries can move
freely between these options depending on their choice of civilian
provider each time they receive care. Therefore, DOD's survey was
designed to monitor nonenrolled beneficiaries' access to care from both
network and nonnetwork providers. As each cycle of the survey is
completed, TMA will be able to project survey results to the sampled
market areas. When all cycles of the survey are complete, TMA will be
able to project the survey data at the national level.
Following is the actual survey instrument that was used to obtain
information from civilian providers. The staff administering this
survey were not aware of whether the civilian providers they contacted
were network or nonnetwork, and the same survey questions, which
specifically mentioned the Standard option, were asked of all
respondents. Nonetheless, if network civilian providers were to deliver
care to nonenrolled beneficiaries, the responding providers' staff
would likely understand that this care would be provided under the
Extra option. Therefore, for the purposes of the survey, the term
"Standard" referred to both the Standard and Extra option.
Office Of The Assistant Secretary Of Defense:
Health Affairs:
Tricare Management Activity:
Health Program Analysis And Evaluation Directorate:
[Unique Physician 1D Number]
ATTN: Billing Manager For [Insert Physician Name]
Street Address:
City, State, and Zip:
Dear Billing Manager,
Hello! In support of the thousands of U.S. military men and women who
are currently defending our communities at home and abroad, Congress is
interested in whether family members of active duty military, and
military retirees and their families, have sufficient access to the
health care they need. Much of their care is delivered at military
facilities; however, a substantial amount of health care is delivered
by private, civilian physicians. The Department of Defense (DoD) health
care benefits program is known as TRICARE, and we need your help in
answering the enclosed survey.
To determine the adequacy of private health care access, Congress has
directed DoD's TRICARE program to survey civilian providers across the
U.S. The TRICARE program has contracted Synovate to conduct this
survey. The physician named above was randomly selected to participate
in this very important effort.
Please answer the questions on the back of this letter and return it in
the provided postage paid envelope or fax the completed survey to 1-
800-585-9446 within five days of receipt. Please note that more than
one survey may have been sent to you. If you are responsible for more
than one physician, please complete each survey only for the physician
listed above. If you are not the appropriate person to answer these
questions, please pass this on to the person in your office who would
be able to.
Thank you in advance for your cooperation and help as we examine this
important issue that impacts our American service men and women. If you
have questions about this survey, please call Synovate between the
hours of 8 AM and 5 PM Eastern Time at 1-800-228-6764.
Thank you again.
Sincerely yours,
Signed by:
Michael R. Peterson, DVM, MPH, DrPH:
Director:
Office of the Assistant Secretary of Defense (Health Affairs)
TRICARE Management Activity/Health Program Analysis and Evaluatiore
Directorat:
Survey Questions On Reverse Side:
[Unique Physician ID Number]
[Bar Code]
OMB NO.: 0720-0031:
Expiration Date: 0513112005:
Are you the person in the office who is most familiar with billing and
insurance for Dr. X? If so, please answer the following questions. If
not, please give this to the person who is the most familiar with
billing and insurance for Dr. X:
Q1. Is Dr. X aware of the TRICARE health care program?
Yes:
No:
Don't Know:
Q2. As of today, is Dr. X accepting NEW TRICARE Standard patients?
* Yes, for all claims (Go to Q4):
* Yes, on a claim-by-claim basis only (Go to Q4):
* No (Go to Q3):
* Don't know (Go to Q4):
Q3. What are the reasons Dr. X is not accepting new TRICARE Standard
patients? Please list all the reasons. (If Additional Space Is Needed,
Please Include A Separate Sheet Of Paper.):
Q4. As of today, is Dr. X accepting ANY new patients?
* Yes:
* No:
* Don't Know:
Thank you for taking the time to complete this survey.
Please put this in the enclosed postage-paid envelope and return it to
the Survey Processing Center or fax the survey to Synovate at 1-800-
585-9446:
[End of section]
Appendix IV: Categorized Responses to the Civilian Provider Survey's
Open-ended Question:
Table 7: "What are the reasons Doctor X is Not Accepting New TRICARE
[Nonenrolled] Patients?"
Reason for not accepting new TRICARE patients: Doctor not available;
Percent of providers who cited this reason: Network (Extra) providers:
31;
Percent of providers who cited this reason: Nonnetwork (Standard)
providers: 29;
Percent of providers who cited this reason: All providers: 29.
Reason for not accepting new TRICARE patients: Reimbursement;
Percent of providers who cited this reason: Network (Extra) providers:
20;
Percent of providers who cited this reason: Nonnetwork (Standard)
providers: 25;
Percent of providers who cited this reason: All providers: 24.
Reason for not accepting new TRICARE patients: Other/miscellaneous;
Percent of providers who cited this reason: Network (Extra) providers:
12;
Percent of providers who cited this reason: Nonnetwork (Standard)
providers: 11;
Percent of providers who cited this reason: All providers: 12.
Reason for not accepting new TRICARE patients: Administrative
inconveniences;
Percent of providers who cited this reason: Network (Extra) providers):
15;
Percent of providers who cited this reason: Nonnetwork (Standard)
providers): 7;
Percent of providers who cited this reason: All providers: 8.
Reason for not accepting new TRICARE patients: Takes other forms of
TRICARE;
Percent of providers who cited this reason: Network (Extra) providers):
7;
Percent of providers who cited this reason: Nonnetwork (Standard)
providers): 8;
Percent of providers who cited this reason: All providers: 8.
Reason for not accepting new TRICARE patients: Specialty not covered;
Percent of providers who cited this reason: Network (Extra) providers):
6;
Percent of providers who cited this reason: Nonnetwork (Standard)
providers): 6;
Percent of providers who cited this reason: All providers: 6.
Reason for not accepting new TRICARE patients: Insurance/image
problems;
Percent of providers who cited this reason: Network (Extra) providers):
3;
Percent of providers who cited this reason: Nonnetwork (Standard)
providers): 6;
Percent of providers who cited this reason: All providers: 5.
Reason for not accepting new TRICARE patients: Not aware of TRICARE;
Percent of providers who cited this reason: Network (Extra) providers):
1;
Percent of providers who cited this reason: Nonnetwork (Standard)
providers): 3;
Percent of providers who cited this reason: All providers: 3.
Reason for not accepting new TRICARE patients: Only takes certain
insurance;
Percent of providers who cited this reason: Network (Extra) providers):
0;
Percent of providers who cited this reason: Nonnetwork (Standard)
providers): 3;
Percent of providers who cited this reason: All providers: 3.
Reason for not accepting new TRICARE patients: Customer service;
Percent of providers who cited this reason: Network (Extra) providers):
4;
Percent of providers who cited this reason: Nonnetwork (Standard)
providers): 2;
Percent of providers who cited this reason: All providers: 2.
Reason for not accepting new TRICARE patients: Application in process;
Percent of providers who cited this reason: Network (Extra) providers):
0;
Percent of providers who cited this reason: Nonnetwork (Standard)
providers): 1;
Percent of providers who cited this reason: All providers: 1.
Total percent;
Percent of providers who cited this reason: Network (Extra) providers):
99[A];
Percent of providers who cited this reason: Nonnetwork (Standard)
providers): 101[A];
Percent of providers who cited this reason: All providers: 101[A].
Total responses;
Percent of providers who cited this reason: Network (Extra) providers):
378;
Percent of providers who cited this reason: Nonnetwork (Standard)
providers): 3837;
Percent of providers who cited this reason: All providers: 4215.
Source: GAO analysis of DOD data.
[A] Total does not equal 100 percent due to rounding errors.
[End of table]
[End of section]
Appendix V: TRICARE Reimbursement Rates That Remain Higher than
Medicare Reimbursement Rates:
Table 8:
CPT code[A]: 20250;
Procedure or service performed: Biopsy, vertebral body, open; thoracic;
Ratio of TRICARE to Medicare reimbursement: 1.007.
CPT code[A]: 38240;
Procedure or service performed: Bone marrow or blood-derived peripheral
stem cell transplantation; allogenic;
Ratio of TRICARE to Medicare reimbursement: 2.980.
CPT code[A]: 38241;
Procedure or service performed: Bone marrow or blood-derived peripheral
stem cell transplantation; autologous;
Ratio of TRICARE to Medicare reimbursement: 2.954.
CPT code[A]: 52355;
Procedure or service performed: Cystourethroscopy, with ureteroscopy
and/or pyeloscopy; with resection of ureteral or renal pelvic tumor;
Ratio of TRICARE to Medicare reimbursement: 1.090.
CPT code[A]: 58600;
Procedure or service performed: Litigation or transaction of fallopian
tube(s), abdominal or vaginal approach, unilateral or bilateral;
Ratio of TRICARE to Medicare reimbursement: 1.084.
CPT code[A]: 58605;
Procedure or service performed: Litigation or transaction of fallopian
tube(s), abdominal or vaginal approach, postpartum, unlaterial or
bilateral, during same hospitalization (separate procedure);
Ratio of TRICARE to Medicare reimbursement: 1.024.
CPT code[A]: 58615;
Procedure or service performed: Occlusion of fallopian tube(s) by
device (eg. Band, clip, Galope ring) vaginal or suprapubic approach;
Ratio of TRICARE to Medicare reimbursement: 1.040.
CPT code[A]: 59012;
Procedure or service performed: Cordocentesis (intrauterine), any
method;
Ratio of TRICARE to Medicare reimbursement: 1.137.
CPT code[A]: 59020;
Procedure or service performed: Fetal contraction stress test;
Ratio of TRICARE to Medicare reimbursement: 1.427.
CPT code[A]: 59025;
Procedure or service performed: Fetal non-stress test;
Ratio of TRICARE to Medicare reimbursement: 1.184.
CPT code[A]: 59030;
Procedure or service performed: Fetal scalp blood sampling;
Ratio of TRICARE to Medicare reimbursement: 1.210.
CPT code[A]: 59050;
Procedure or service performed: Fetal monitoring during labor by
consulting physician (ie, non-attending physician) with written report;
supervision and interpretation;
Ratio of TRICARE to Medicare reimbursement: 1.324.
CPT code[A]: 59051;
Procedure or service performed: Fetal monitoring during labor by
consulting physician (ie, non-attending physician) with written report;
interpretation only;
Ratio of TRICARE to Medicare reimbursement: 1.219.
CPT code[A]: 59120;
Procedure or service performed: Surgical treatment of ectopic
pregnancy; tubal or ovarian, requiring salpingectomy and/or
oophorectomy, abdominal or vaginal approach;
Ratio of TRICARE to Medicare reimbursement: 1.016.
CPT code[A]: 59135;
Procedure or service performed: Surgical treatment of ectopic
pregnancy; interstitial, uterine pregnancy requiring total
hysterectomy;
Ratio of TRICARE to Medicare reimbursement: 1.017.
CPT code[A]: 59140;
Procedure or service performed: Surgical treatment of ectopic
pregnancy; cervical, with evacuation;
Ratio of TRICARE to Medicare reimbursement: 1.161.
CPT code[A]: 59320;
Procedure or service performed: Cerciage of cervix, during pregnancy;
vaginal;
Ratio of TRICARE to Medicare reimbursement: 1.122.
CPT code[A]: 59325;
Procedure or service performed: Cerciage of cervix, during pregnancy;
abdominal;
Ratio of TRICARE to Medicare reimbursement: 1.094.
CPT code[A]: 59350;
Procedure or service performed: Hysterorrhaphy of ruptured uterus;
Ratio of TRICARE to Medicare reimbursement: 1.205.
CPT code[A]: 59409;
Procedure or service performed: Vaginal delivery only (with or without
episiotomy and/or forceps);
Ratio of TRICARE to Medicare reimbursement: 1.184.
CPT code[A]: 59410;
Procedure or service performed: Vaginal delivery only (with or without
episiotomy and/or forceps); including postpartum car;
Ratio of TRICARE to Medicare reimbursement: 1.156.
CPT code[A]: 59412;
Procedure or service performed: External cephalic version, with or
without tocolysis;
Ratio of TRICARE to Medicare reimbursement: 1.139.
CPT code[A]: 59414;
Procedure or service performed: Delivery of placenta (separate
procedure);
Ratio of TRICARE to Medicare reimbursement: 1.190.
CPT code[A]: 59514;
Procedure or service performed: Cesarean delivery only;
Ratio of TRICARE to Medicare reimbursement: 1.175.
CPT code[A]: 59515;
Procedure or service performed: Cesarean delivery only; including
postpartum care;
Ratio of TRICARE to Medicare reimbursement: 1.126.
CPT code[A]: 59612;
Procedure or service performed: Vaginal delivery only, after previous
cesarean delivery (with or without episiotomy and/ or forceps);
Ratio of TRICARE to Medicare reimbursement: 1.118.
CPT code[A]: 59614;
Procedure or service performed: Vaginal delivery only, after previous
cesarean delivery (with or without episiotomy and/ or forceps);
including postpartum care;
Ratio of TRICARE to Medicare reimbursement: 1.104.
CPT code[A]: 59620;
Procedure or service performed: Cesarean delivery only, following
attempted vaginal delivery after previous cesarean delivery;
Ratio of TRICARE to Medicare reimbursement: 1.127.
CPT code[A]: 59622;
Procedure or service performed: Cesarean delivery only, following
attempted vaginal delivery after previous cesarean delivery; including
postpartum care;
Ratio of TRICARE to Medicare reimbursement: 1.078.
CPT code[A]: 59812;
Procedure or service performed: Treatment of incomplete abortion, any
trimester, completed surgically;
Ratio of TRICARE to Medicare reimbursement: 1.044.
CPT code[A]: 59840;
Procedure or service performed: Induced abortion, by dilation and
curettage;
Ratio of TRICARE to Medicare reimbursement: 1.217.
CPT code[A]: 59850;
Procedure or service performed: Induced abortion, by one or more intra-
amniotic injuctions (amniocentesis-injections), including hospital
admission and visits, delivery of fetus and secundines;
Ratio of TRICARE to Medicare reimbursement: 1.021.
CPT code[A]: 59851;
Procedure or service performed: Induced abortion, by one or more intra-
amniotic injuctions (amniocentesis-injections), including hospital
admission and visits, delivery of fetus and secundines; with dilation
and curettage and/or evacuation;
Ratio of TRICARE to Medicare reimbursement: 1.019.
CPT code[A]: 59855;
Procedure or service performed: Induced abortion, by one or more
vaginal suppositories (eg, prostaglandin) with or without cervical
dilation (eg, laminaria), including hospital admission and visits,
delivery of fetus and secudines;
Ratio of TRICARE to Medicare reimbursement: 1.015.
CPT code[A]: 59856;
Procedure or service performed: Induced abortion, by one or more
vaginal suppositories (eg, prostaglandin) with or without cervical
dilation (eg, laminaria), including hospital admission and visits,
delivery of fetus and secudines; with dilation and curettage and/or
evacuation;
Ratio of TRICARE to Medicare reimbursement: 1.046.
CPT code[A]: 59857;
Procedure or service performed: Induced abortion, by one or more
vaginal suppositories (eg, prostaglandin) with or without cervical
dilation (eg, laminaria), including hospital admission and visits,
delivery of fetus and secudines; with hysterotomy (failed medical
evacuation);
Ratio of TRICARE to Medicare reimbursement: 1.058.
CPT code[A]: 59866;
Procedure or service performed: Multifetal pregnancy reduction(s)
(MPR);
Ratio of TRICARE to Medicare reimbursement: 1.151.
CPT code[A]: 63091;
Procedure or service performed: Vertebral corpectomy (vertebral body
resection), partial or complete, transperitoneal or retroperitoneal
approach with decompression of spinal cord, cauda equine or nerve
root(s), lower thoracic, lumbar, or sacral; each additional segment
(List separately in addition to code for primary procedure);
Ratio of TRICARE to Medicare reimbursement: 1.003.
CPT code[A]: 67334;
Procedure or service performed: Strabismus surgery by posterior
fixation suture technique, with or without muscle recession (List
separately in addition to code for primary procedure);
Ratio of TRICARE to Medicare reimbursement: 1.025.
CPT code[A]: 92953;
Procedure or service performed: Temporary transcutaneous pacing;
Ratio of TRICARE to Medicare reimbursement: 2.965.
CPT code[A]: 93541;
Procedure or service performed: Injection procedure during cardiac
catheterization; for pulmonary angiography;
Ratio of TRICARE to Medicare reimbursement: 1.624.
CPT code[A]: 93542;
Procedure or service performed: Injection procedure during cardiac
catheterization; for selective right ventricular or right atrial
angiography (eg.internal mammary), whether native or used for bypass;
Ratio of TRICARE to Medicare reimbursement: 1.216.
CPT code[A]: 93543;
Procedure or service performed: Injection procedure during cardiac
catheterization; for selective left ventricular or left atrial
angiography;
Ratio of TRICARE to Medicare reimbursement: 1.558.
CPT code[A]: 93544;
Procedure or service performed: Injection procedure during cardiac
catheterization; for aortography;
Ratio of TRICARE to Medicare reimbursement: 1.979.
CPT code[A]: 93545;
Procedure or service performed: Injection procedure during cardiac
catheterization; for selective coronary angiography (injection of
radiopaque material may be by hand);
Ratio of TRICARE to Medicare reimbursement: 1.833.
CPT code[A]: 93616;
Procedure or service performed: Esophageal recording of atrial
electrogram with or without ventricular electrogram(s); with pacing;
Ratio of TRICARE to Medicare reimbursement: 1.198.
CPT code[A]: 93660;
Procedure or service performed: Evaluation of cardiovascular function
with tilt table evaluation, with continuous ECG monitoring and
intermittent blood pressure monitoring, with or without pharmacological
intervention;
Ratio of TRICARE to Medicare reimbursement: 1.320.
CPT code[A]: 94760;
Procedure or service performed: Noninvasive ear or pulse oximetry for
oxygen saturation; single determination;
Ratio of TRICARE to Medicare reimbursement: 1.901.
Source: GAO analysis of DOD data.
[A] Current Procedural Terminology (CPT) is a set of codes,
descriptions, and guidelines intended to describe procedures and
services performed by physicians and other health care providers.
[End of table]
[End of section]
Appendix VI: Comments from the Department of Defense:
The Assistant Secretary Of Defense:
Washington, D.C. 20301-1200:
Health Affairs:
Nov 14 2006:
Ms. Marcia Crosse:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Ms. Crosse:
This is the Department of Defense (DoD) response to the GAO draft
report, GAO-07-48, "Defense Health Care: Access to Care for
Beneficiaries Who Have Not Enrolled in TRICARE's Managed Care Option,"
dated October 16, 2006 (GAO Code 290398).
Thank you for the opportunity to review and comment on the draft
report. First, let me say that I appreciate the collaborative,
insightful, and thorough approach your team has taken with this
important issue.
Technical comments about the draft report are enclosed. There is one
discrepancy, however, that I am compelled to specifically address
because it indicates GAO misunderstands a fundamental delegation of
responsibility and accountability for management of the health program.
Several instances within the draft report state that DoD has not
formally designated a senior official with responsibility for non-
enrolled TRICARE beneficiaries and non-network civilian providers as
outlined in the National Defense Authorization Act for Fiscal Year 2004
(NDAA for FY04). This is incorrect. By directive (DoDD 5136.12), the
Secretary of Defense has formally designated the TMA Director to "serve
as the program manager for TRICARE health and medical resources,
supervising and administering TRICARE programs, funding, and other
resources within the DoD." The Directive further assigns to the TRICARE
Regional Offices the responsibility and accountability for "ensuring
the consistent implementation and management of MHS policies and the
uniform health benefit within their geographical area" and "development
and execution of an integrated plan for the delivery of health care
within the geographic region." The scope of this responsibility clearly
encompasses provision of care to non-enrolled beneficiaries, whether by
network or non-network civilian providers. Congress has recognized the
appropriateness of this assignment by requiring, in the NDAA for FY06,
an annual report of the TRICARE Regional Office's efforts to monitor,
oversee, and improve TRICARE Standard.
Again, thank you for the opportunity to provide these comments. My
points of contact for additional information are Mr. Michael O'Bar
(functional) at (703) 681-0039 and Mr. Gunther Zimmerman (audit
liaison) at (703) 681-3492.
Sincerely,
Signed by:
William Winkenwerder, Jr., MD:
Enclosure:
As stated:
[End of section]
Appendix VII: GAO Contacts and Staff Acknowledgments:
GAO Contact:
Marcia Crosse (202) 512-7119 or crossem@gao.gov:
Acknowledgments:
In addition to the contact named above, Bonnie Anderson, Assistant
Director, Kevin Dietz, Cathleen Hamann, Lois Shoemaker, Robert Suls,
and Suzanne Worth made key contributions to this report.
FOOTNOTES
[1] Fiscal year 2005 data are estimates by the TRICARE Management
Activity (TMA) because providers and TRICARE beneficiaries have up to a
year to file health care claims.
[2] TRICARE beneficiaries who are eligible for Medicare and enroll in
Part B are eligible to receive care under TRICARE for Life. Under this
program, TRICARE processes claims after they have been adjudicated by
Medicare.
[3] See Pub. L. No. 108-136, § 723, 117 Stat. 1392, 1532-34 (2003) and
S. Rep. No. 108-46, at 330 (2003).
[4] TRICARE beneficiaries under 65 years of age who are eligible for
Medicare Part A on the basis of disability or end stage renal disease
are eligible for TRICARE for Life if they enroll in Medicare Part B.
[5] TRICARE for Life is a program for Medicare-eligible beneficiaries
enrolled in Medicare Part B, which covers charges from licensed
practitioners, as well as clinical laboratory and diagnostic services,
surgical supplies and durable medical equipment, and ambulance
services. TRICARE for Life pays expenses remaining after Medicare has
paid its share of claims and also pays for certain skilled nursing and
inpatient hospitalization services that Medicare does not cover.
[6] For example, network providers may determine that only a set amount
of their practice--such as 10 or 20 percent--will be allocated to
TRICARE patients. When this percentage is met, providers may decline to
accept any new TRICARE patients.
[7] TRICARE beneficiaries who choose to receive medical care from
providers who are not TRICARE-authorized may be responsible for all
billed charges.
[8] Between fiscal years 2001 and 2005 the percent of nonnetwork
civilian providers who billed TRICARE beneficiaries an additional 15
percent over the TRICARE reimbursement rate on some of their claims
decreased from 10 percent to 6.3 percent. Similarly, the percent of
nonnetwork civilian providers who billed an additional 15 percent over
the TRICARE reimbursement rate on all of their claims decreased from
7.4 percent in fiscal year 2001 to 4.4 percent in fiscal year 2005.
[9] To use the TRICARE Prime option, eligible TRICARE beneficiaries
must reside in locations where TRICARE Prime is offered.
[10] Prime enrollees may also receive care from nonnetwork providers;
however, such care is subject to deductibles and copayments of 50
percent of the TRICARE reimbursement rate unless the enrollee has a
referral for the care from the Primary Care Manager.
[11] The annual deductible also varies from $50 to $150 per person or
from $100 to $300 per family. Dependents of lower-ranked active duty
enlisted personnel pay the lower deductible amounts. Dependents of high-
ranked personnel and retirees and their dependents pay the higher
deductible amounts.
[12] About 1.3 million additional beneficiaries were eligible for
TRICARE for Life in fiscal year 2005.
[13] MTF enrollment areas are geographic areas determined by the ASD
for Health Affairs that are defined by five-digit zip codes, usually
within an approximate 40-mile radius of MTFs with inpatient care. In
areas encompassing MTFs, the civilian provider networks are expected to
complement the clinical services provided in MTFs.
[14] Base Realignment and Closure sites are military installations that
have been closed or realigned as a result of decisions made by the
Commission on Base Realignment and Closure.
[15] See Pub. L. No. 108-136, § 723, 117 Stat. 1392, 1532-34 (2003) and
S. Rep. No. 108-46, at 330 (2003).
[16] Neither the NDAA nor any congressional reports accompanying the
legislation provided a definition for 'market areas.'
[17] The NDAA did not specify network or nonnetwork providers for the
survey, but both types of providers can accept nonenrolled TRICARE
beneficiaries as patients. Network providers see nonenrolled TRICARE
beneficiaries under TRICARE's Extra option.
[18] TMA obtained clearance to distribute its Survey of Continued
Viability of TRICARE Standard (the civilian provider survey) from the
Office of Management and Budget on May 16, 2005. This clearance is
required by the Paperwork Reduction Act. See 44 U.S.C. §§ 3507 and
3508.
[19] In accordance with the law, TMA plans to conduct a survey of
civilian health care providers using a 3-year phased approach,
surveying 20 states in each year for 2 years, and 10 states plus the
District of Columbia during the final year.
[20] In fiscal year 2004 TMA piloted this survey in 20 cities where
TRICARE beneficiary advocacy groups anecdotally identified problems
with access to care for nonenrolled TRICARE beneficiaries.
[21] This ranged from a low of 68 percent in New York to a high of 93
percent in South Dakota.
[22] The primary care provider category consists of providers whose
specialties include family or general practice, internal medicine,
obstetrics and gynecology, or pediatrics.
[23] The specialist category consists of all other medical specialties
not captured in the primary care category.
[24] TMA did not subdivide primary care and specialist providers into
network and nonnetwork categories.
[25] Indiana is the only state, among those surveyed, with a
statistically significant difference in acceptance rates between
primary care and specialist providers. However, both primary care and
specialist acceptance rates in Indiana are relatively high, with 89
percent of specialists and 78 percent of primary care providers
accepting new nonenrolled TRICARE beneficiaries.
[26] HSAs are collections of zip codes organized into over 3,000
geographic regions in which Medicare beneficiaries seek the majority of
their care from one hospital or a collection of hospitals. HSAs have
nonoverlapping borders and contain all U.S. zip codes without gaps in
coverage.
[27] Four of the HSAs selected by TRICARE beneficiaries--two in Florida
and two in Michigan--were located outside of the selected states.
[28] In one community, Arlington, Texas, the survey found a sizeable
difference in the rate of acceptance between primary care providers (47
percent) and specialists (73 percent).
[29] Eight of the locations were surveyed as HSAs in the 2005 civilian
provider survey. One additional location, Anchorage, Alaska, was
previously identified as an area with low civilian provider acceptance
of nonenrolled beneficiaries during TMA's pilot of the survey in 2004.
[30] TMA has not specified a timeline for this task.
[31] In Medicare Fee-for-Service Beneficiary Access to Physician
Services: Trends in Utilization of Services, 2000 to 2002, GAO-05-145R
(Washington, D.C; Jan. 12, 2005), we evaluated two indicators of
beneficiary access to Medicare physician services and found that
although Medicare physician fees had been reduced by 5.4 percent in
2002, the indicators we evaluated suggested an increase in access to
care.
[32] See Pub. L. No. 109-163, § 711, 119 Stat. 3136, 3343.
[33] The Health Care Survey of DOD Beneficiaries was implemented in
response to a requirement in the NDAA for fiscal year 1993 to annually
survey beneficiaries of DOD's health care programs about their ability
to access health care services and their satisfaction with the services
they received, among other things. See 10 U.S.C. § 1071, note. TMA
conducts this survey on a yearly basis using a representative sample of
all TRICARE beneficiaries worldwide.
[34] CAHPS is a registered trademark of the Department of Health and
Human Services' Agency for Healthcare Research and Quality. CAHPS
refers to a family of surveys that asks consumers and patients to
evaluate their health care using a standardized set of questions. The
Centers for Medicare & Medicaid Services conducts a CAHPS survey of
both the Medicare fee-for-service population and the Medicare Advantage
population. Throughout this report we refer to the fee-for-service
CAHPS® survey as the CAHPS survey.
[35] The TROs acknowledge that the majority of TRICARE beneficiaries
direct their concerns and inquiries to the MCSCs and not to the TRO.
[36] The office of the Army Surgeon General has mandated that all Army
MTFs use the ART.
[37] TRICARE beneficiaries did not seek care from all licensed civilian
providers because in some areas TRICARE serves a small percentage of
the general population.
[38] Our estimate excluded the census population of residents living in
small portions of Iowa, Missouri, and Tennessee that are part of the
North Region.
[39] Prior to the implementation of TRICARE, DOD provided civilian
health care to eligible beneficiaries under the Civilian Health and
Medical Program of the Uniformed Services to supplement health care
provided through MTFs.
[40] Congress specified that reductions were not to exceed 15 percent
in a given year. See Department of Defense Appropriations Act for
Fiscal Year 1991, Pub. L. No. 101-511, § 8012 104 Stat. 1856, 1877
(1990). This instruction was eventually codified at 10 U.S.C. §
1079(h).
[41] We previously evaluated the methodology used to transition to
Medicare level of payment and concluded this methodology complies with
statutory requirements and generally conformed with accepted actuarial
practice in Reimbursement Rates Appropriately Set; Other Problems
Concern Physicians, GAO/HEHS-98-80 (Washington, D.C.: Feb. 26, 1998).
[42] Two states do not have fee-for-service Medicaid programs. The
remaining three states and the District of Columbia did not provide
data on Medicaid reimbursements.
[43] See 10 U.S.C. § 1079(h)(1).
[44] 32 C.F.R. § 199.14(j)(1)(iv)(C).
[45] 32 C.F.R. § 199.14(j)(1)(iv)(D). According to a TMA official, TMA
usually defines a locality using one or more zip codes.
[46] 32 C.F.R. § 199.14(j)(1)(iv)(E).
[47] See Across-the-Board Physician Rate Increases Would be Costly and
Unnecessary, GAO-01-620 (Washington, D.C.: May 24, 2001).
[48] Prevailing charges are commonly used charges that fall within the
range of charges most frequently and widely used by providers in a
locality for a particular procedure or service.
[49] The regulation authorizing locality waivers based on severe
impairment of access states that those decisions are "subject to review
and determination or modification at any time — if circumstances change
so that adequate access to health care services would no longer be
severely impaired." See 32 C.F.R. § 199.14(j)(1)(iv)(D)(1). The
regulations for the other two waivers do not specifically address
review.
[50] See GAO, Defense Health Care: TRICARE Claims Processing Has
Improved but Inefficiencies Remain, GAO-04-69 (Washington, D.C.: Oct.
15, 2003).
[51] TMA has the authority to implement bonus payment programs for
physicians in areas determined to be medically underserved areas by the
Department of Health and Human Services for Medicare purposes. TMA is
required to make the bonus payments in the same amounts as authorized
for Medicare. See 32 C.F.R. § 199.14(j)(2).
[52] See 42 U.S.C. § 1395l(m). Health Professional Shortage Area
designations are based on shortages of primary medical care, dental, or
mental health providers and may be rural or urban areas, population
groups, or medical or other public facilities.
[53] Physician Scarcity Area designations are based on the calculation
of the ratios of active providers of primary and specialty care to
Medicare beneficiaries in every county in the United States. See 42
U.S.C. § 1395l(u).
[54] The Medicare bonus payment program for Physician Scarcity Areas
expires at that time.
[55] Prior to the establishment of the TROs, regional offices, referred
to as Lead Agents, were responsible for coordinating and submitting
waiver request packages.
[56] DOD Directive 5136.1, which describes the responsibilities,
functions, relationships, and authorities of the ASD for Health
Affairs, would include these responsibilities.
[57] Since the NDAA for 2006, which tasked the TROs with responsibility
for monitoring, oversight, and improvement of the Standard option
within their respective regions, all three TROs have undertaken a
number of new initiatives to meet these responsibilities.
[58] See Pub. L. No. 109-163, § 716, 119 Stat. 3136, 3345.
[59] The survey had a 55 percent response rate.
[60] The Paperwork Reduction Act requires that all federal agency
activities that involve collecting information from the public
involving 10 or more people be approved by OMB to ensure that
collection of this information will have a minimum burden on the
public. See 44 U.S.C. §§ 3507 and 3508.
[61] DOD's submission package to OMB included additional questions that
OMB did not approve for inclusion in the fiscal year 2005 survey
because they did not directly respond to the NDAA for fiscal year 2004.
The excluded questions that did not satisfy OMB's clearance criteria
included the percentage of a provider's current patient population that
uses any form of TRICARE, a provider's willingness to accept new
Medicare patients, and if a provider is not accepting new Medicare
patients, the reasons why.
[62] The purpose of oversampling is to increase the sample size of some
target subpopulation. In this case the target subpopulation is several
defined geographic locations within each state that were randomly
selected for analysis. Oversampling this subpopulation provides TMA
with reliable information about health care providers at the local
level to supplement what they learn about providers in each state as a
whole.
[63] The providers in the American Medical Association's Masterfile are
both medical doctors and doctors of osteopathy.
[64] TMA ultimately dropped the sample size for each market and
submarket area to about 800 providers in each location in order to
accommodate both randomly and judgmentally selected sites and remain
within its resourced and OMB-approved overall sample of about 40,000
physicians. According to TMA officials, the reduction in sample size
did not affect the sample outcomes and their ability to project
results.
[65] According to TMA officials, providers were ineligible for such
reasons as being employed by the military or the government.
[66] The questionnaire or phone interview was directed to an
administrative staff person in the provider's office.
[67] According to OMB officials, this is a common industry practice
when there is potential for concern about the reliability of survey
results due to a low response rate.
[68] For example, TMA compared provider specialty and network status
between the original respondents and the nonrespondents in bias
analysis.
[69] According to TMA officials, TMA expects to provide post-survey
weighting to account for differential response rates.
[70] See Pub. L. No. 108-136, § 723, 117 Stat. 1392, 1532-34 (2003) and
S. Rep. No. 108-46, at 330 (2003).
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site (www.gao.gov). Each weekday, GAO posts
newly released reports, testimony, and correspondence on its Web site.
To have GAO e-mail you a list of newly posted products every afternoon,
go to www.gao.gov and select "Subscribe to Updates."
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office 441 G Street NW, Room LM
Washington, D.C. 20548:
To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202)
512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 U.S.
Government Accountability Office, 441 G Street NW, Room 7125
Washington, D.C. 20548:
Public Affairs:
Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, D.C. 20548:
