Defense Health Care
Access to Civilian Providers under TRICARE Standard and Extra Gao ID: GAO-11-500 June 2, 2011The Department of Defense (DOD) provides health care through its TRICARE program, which is managed by the TRICARE Management Activity (TMA). TRICARE offers three basic options. Beneficiaries who choose TRICARE Prime, an option that uses civilian provider networks, must enroll. TRICARE beneficiaries who do not enroll in this option may obtain care from nonnetwork providers under TRICARE Standard or from network providers under TRICARE Extra. The National Defense Authorization Act for Fiscal Year 2008 directed GAO to evaluate various aspects of beneficiaries' access to care under the TRICARE Standard and Extra options. This report examines (1) impediments to TRICARE Standard and Extra beneficiaries' access to civilian health care and mental health care providers and TMA's actions to address the impediments; (2) TMA's efforts to monitor access to civilian providers for TRICARE Standard and Extra beneficiaries; (3) how TMA informs network and nonnetwork civilian providers about TRICARE Standard and Extra; and (4) how TMA informs TRICARE Standard and Extra beneficiaries about their options. To address these objectives, GAO reviewed and analyzed TMA and TRICARE contractor data and documents. GAO also interviewed TMA officials, including those in its regional offices, as well as its contractors.
Reimbursement rates and provider shortages have been cited as the main impediments that hinder TRICARE Standard and Extra beneficiaries' access to civilian health care and mental health care providers. Providers' concern about TRICARE's reimbursement rates--which are generally set at Medicare rates--has been a long-standing issue and has more recently been cited as the primary reason civilian providers will not accept TRICARE Standard and Extra beneficiaries as patients, according to TMA's surveys of civilian providers. TMA can increase reimbursement rates in certain instances, such as when it determines that access to care is being affected by the level of reimbursement. Shortages of certain provider specialties, such as mental health care providers, at the national and local levels may also impede access, but these shortages are not specific to the TRICARE program and also affect the general population. As a result, there are limitations as to what TMA can do to address them. TMA has primarily used feedback mechanisms, including surveys of beneficiaries and civilian providers, to gauge TRICARE Standard and Extra beneficiaries' access to civilian providers. More recently, in February 2010, in recognition that TRICARE has had no established measures for monitoring the availability of civilian network and nonnetwork providers for these beneficiaries, TMA directed the TRICARE Regional Offices to develop a model to help identify geographic areas where they may experience access problems. GAO's review of the initial models found their methodology to be reasonable. However, because the regional models were recently developed, it is too early to determine their effectiveness. TMA's contractors educate civilian providers about TRICARE program requirements, policies, and procedures. Contractors also conduct outreach to increase providers' awareness of the program, and while TMA's provider survey results indicate that civilian providers are generally aware of the program, this does not necessarily signify that providers have an accurate understanding of the TRICARE program and its options. Similarly, TMA's contractors educate beneficiaries on all of the TRICARE options and maintain directories of network providers to facilitate beneficiaries' access to care. When the new TRICARE contracts are implemented, TMA will also require its contractors to include information on nonnetwork providers in their provider directories. In commenting on a draft of this report, DOD concurred with GAO's overall findings.
GAO-11-500, Defense Health Care: Access to Civilian Providers under TRICARE Standard and Extra
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
June 2011:
Defense Health Care:
Access to Civilian Providers under TRICARE Standard and Extra:
GAO-11-500:
GAO Highlights:
Highlights of GAO-11-500, a report to congressional committees.
Why GAO Did This Study:
The Department of Defense (DOD) provides health care through its
TRICARE program, which is managed by the TRICARE Management Activity
(TMA). TRICARE offers three basic options. Beneficiaries who choose
TRICARE Prime, an option that uses civilian provider networks, must
enroll. TRICARE beneficiaries who do not enroll in this option may
obtain care from nonnetwork providers under TRICARE Standard or from
network providers under TRICARE Extra.
The National Defense Authorization Act for Fiscal Year 2008 directed
GAO to evaluate various aspects of beneficiaries‘ access to care under
the TRICARE Standard and Extra options. This report examines
(1) impediments to TRICARE Standard and Extra beneficiaries‘ access to
civilian health care and mental health care providers and TMA‘s
actions to address the impediments; (2) TMA‘s efforts to monitor
access to civilian providers for TRICARE Standard and Extra
beneficiaries; (3) how TMA informs network and nonnetwork civilian
providers about TRICARE Standard and Extra; and (4) how TMA informs
TRICARE Standard and Extra beneficiaries about their options. To
address these objectives, GAO reviewed and analyzed TMA and TRICARE
contractor data and documents. GAO also interviewed TMA officials,
including those in its regional offices, as well as its contractors.
What GAO Found:
Reimbursement rates and provider shortages have been cited as the main
impediments that hinder TRICARE Standard and Extra beneficiaries‘
access to civilian health care and mental health care providers.
Providers‘ concern about TRICARE‘s reimbursement rates”which are
generally set at Medicare rates”has been a long-standing issue and has
more recently been cited as the primary reason civilian providers will
not accept TRICARE Standard and Extra beneficiaries as patients,
according to TMA‘s surveys of civilian providers. TMA can increase
reimbursement rates in certain instances, such as when it determines
that access to care is being affected by the level of reimbursement.
Shortages of certain provider specialties, such as mental health care
providers, at the national and local levels may also impede access,
but these shortages are not specific to the TRICARE program and also
affect the general population. As a result, there are limitations as
to what TMA can do to address them.
TMA has primarily used feedback mechanisms, including surveys of
beneficiaries and civilian providers, to gauge TRICARE Standard and
Extra beneficiaries‘ access to civilian providers. More recently, in
February 2010, in recognition that TRICARE has had no established
measures for monitoring the availability of civilian network and
nonnetwork providers for these beneficiaries, TMA directed the TRICARE
Regional Offices to develop a model to help identify geographic areas
where they may experience access problems. GAO‘s review of the initial
models found their methodology to be reasonable. However, because the
regional models were recently developed, it is too early to determine
their effectiveness.
TMA‘s contractors educate civilian providers about TRICARE program
requirements, policies, and procedures. Contractors also conduct
outreach to increase providers‘ awareness of the program, and while TMA‘
s provider survey results indicate that civilian providers are
generally aware of the program, this does not necessarily signify that
providers have an accurate understanding of the TRICARE program and
its options.
Similarly, TMA‘s contractors educate beneficiaries on all of the
TRICARE options and maintain directories of network providers to
facilitate beneficiaries‘ access to care. When the new TRICARE
contracts are implemented, TMA will also require its contractors to
include information on nonnetwork providers in their provider
directories.
In commenting on a draft of this report, DOD concurred with GAO‘s
overall findings.
View [hyperlink, http://www.gao.gov/products/GAO-11-500] or key
components. For more information, contact Randall Williamson at (202)
512-7114 or williamsonr@gao.gov.
[End of section]
Contents:
Letter:
Background:
Reimbursement Rates and Provider Shortages Hinder Access to Civilian
Providers; TMA Can Increase Reimbursement Rates When Needed, but Has
Only Limited Means to Address Shortages:
Although TMA Has Typically Used Feedback Mechanisms to Gauge TRICARE
Standard and Extra Beneficiaries' Access to Civilian Providers, It Is
Developing a New Method for Monitoring Access:
TMA's Contractors Educate Civilian Providers about TRICARE and Surveys
Indicate That Providers Are Generally Aware of the Program:
TMA's Contractors Educate Beneficiaries on All TRICARE Options and
Provide Information on Network Providers; New Contracts Will Also
Require Information about Nonnetwork Providers:
Agency Comments:
Appendix I: TRICARE Reimbursement Rates That Remain Higher than
Medicare Reimbursement Rates:
Appendix II: TMA's Studies on TRICARE Reimbursement Rates:
Appendix III: TMA's Use of Waivers:
Appendix IV: Access-to-Care Concerns in Alaska:
Appendix V: Network Adequacy Reporting Requirement of Contractors
under the Second Generation of TRICARE Contracts:
Appendix VI: Comments from the Department of Defense:
Appendix VII: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Summary of TRICARE's Basic Options:
Table 2: TRICARE-eligible Beneficiaries and Claims Paid to Civilian
Providers for Fiscal Years 2006 through 2010:
Table 3: TRICARE Reimbursement Waivers in August 2006 and January 2011:
Table 4: TRICARE Reimbursement Rates That Remain Higher than Medicare
Reimbursement Rates for Nonmaternity Procedures and Services:
Table 5: TRICARE Reimbursement Rates That Remain Higher than Medicare
Reimbursement Rates for Maternity Procedures and Services:
Table 6: Applications for Locality Waivers and Approval Results:
Table 7: Applications for Network Waivers and Approval Results:
Figures:
Figure 1: Location of TRICARE Regions:
Figure 2: TRICARE Standard and Extra Beneficiaries' Claims Paid to
Network and Nonnetwork Civilian Providers for Fiscal Years 2006
Through 2010:
Abbreviations:
BRAC: Base Realignment and Closure:
CPT: current procedural terminology:
DOD: Department of Defense:
NDAA: National Defense Authorization Act:
PPACA: Patient Protection and Affordable Care Act:
TMA: TRICARE Management Activity:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
June 2, 2011:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Member:
Committee on Armed Services:
United States Senate:
The Honorable Howard P. "Buck" McKeon:
Chairman:
The Honorable Adam Smith:
Ranking Member:
Committee on Armed Services:
House of Representatives:
In fiscal year 2010, the Department of Defense (DOD) offered health
care to almost 9.7 million eligible beneficiaries through its TRICARE
program.[Footnote 1] Under TRICARE, beneficiaries may choose among
three basic options--TRICARE Prime (a managed care option), TRICARE
Extra (a preferred provider organization option), and TRICARE Standard
(a fee-for-service option).[Footnote 2] TRICARE is different from
other health care plans because not all of the options require
eligible beneficiaries to enroll to use their benefits. Beneficiaries
who choose TRICARE Prime are required to enroll in this option.
Beneficiaries who decide not to use TRICARE Prime may still obtain
health care through the TRICARE program by using either the TRICARE
Standard or Extra options, or they may choose not to use their TRICARE
benefits at all.[Footnote 3] Consequently, DOD does not have complete
information on which beneficiaries intend to use their benefits, and
it cannot accurately predict the health care demands of beneficiaries
who have not enrolled, including how to ensure adequate access to care.
Under TRICARE, beneficiaries can obtain care either from providers at
military hospitals and clinics, referred to as military treatment
facilities, or from civilian providers. DOD's TRICARE Management
Activity (TMA), which oversees the program, contracts with managed
care support contractors (contractors) to develop networks of civilian
providers and to perform other customer service functions, such as
processing claims and assisting beneficiaries with finding providers.
Contractors are required to establish adequate networks of civilian
providers to serve all TRICARE beneficiaries regardless of enrollment
status in geographic areas called Prime Service Areas.[Footnote 4]
Contractors use estimates of the number of TRICARE users, among other
factors, to develop provider networks and ensure adequate access to
care for beneficiaries. Although some network providers may be located
outside of Prime Service Areas, contractors are not required to
develop networks in these areas (which we refer to as non-Prime
Service Areas).
All beneficiaries may obtain care at military treatment facilities,
although priority is given to active duty personnel and then to
beneficiaries enrolled in TRICARE Prime. Beneficiaries who enroll in
TRICARE Prime can also obtain care from the civilian providers who
have joined the provider network established by the TRICARE
contractors--referred to as network providers.[Footnote 5]
Beneficiaries who do not enroll in TRICARE Prime may receive care
either from network providers, in which case they are considered to be
using TRICARE Extra, or from nonnetwork providers (those outside the
network), in which case they are considered to be using TRICARE
Standard. The choices that beneficiaries have in selecting TRICARE
options and providers vary depending on their location. Beneficiaries
living in Prime Service Areas can choose between TRICARE Prime,
TRICARE Standard, and TRICARE Extra. Beneficiaries living in non-Prime
Service Areas can choose between TRICARE Standard and TRICARE Extra.
According to a TMA official, about 19 percent of beneficiaries
eligible for TRICARE Standard and Extra resided in non-Prime Service
Areas in fiscal year 2010.
Since TRICARE's inception in 1995, beneficiaries using the TRICARE
Standard and Extra options have reported difficulties finding civilian
providers who will accept them as patients. In response to these
concerns, the National Defense Authorization Act (NDAA) for Fiscal
Year 2004 directed DOD to monitor access to care for TRICARE
beneficiaries who were not enrolled in TRICARE Prime through a
multiyear survey of civilian providers.[Footnote 6] According to TMA,
which administered the survey, results indicated that nationally,
about 81 percent of physicians who were accepting new patients would
accept TRICARE beneficiaries as patients, although the results varied
by state and by provider specialty. The act also directed us 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 DOD has taken to ensure access to care for
beneficiaries who were not enrolled in TRICARE Prime. In December
2006, we reported that TMA and its contractors used various methods to
monitor access to care, and these methods indicated that access was
generally sufficient for users of TRICARE Standard and Extra.[Footnote
7]
Nonetheless, beneficiaries using the TRICARE Standard and Extra
options have continued to express concerns about access to civilian
providers. To better understand the adequacy of access to care for
this population, the NDAA for Fiscal Year 2008 directed DOD to conduct
two surveys[Footnote 8]--another multiyear survey of civilian
providers as well as a multiyear survey of beneficiaries, which
includes nonenrolled beneficiaries who were eligible to use the
TRICARE Standard and TRICARE Extra options as well as TRICARE Reserve
Select--an option similar to TRICARE Standard and Extra that is
available to certain members of the Reserves and National Guard. The
NDAA for Fiscal Year 2008 directed us to review these surveys, and in
March 2010, we reported that the methodology for DOD's surveys of
civilian providers and nonenrolled beneficiaries was sound, and we
provided an analysis of the first year's results for each of the
surveys.[Footnote 9]
Furthermore, access to mental health care providers is of particular
concern for all TRICARE beneficiaries, including those who use TRICARE
Standard and Extra, because the exposure to combat and the stress of
deployment and redeployment have increased beneficiaries' demand for
mental health services. From fiscal year 2006 through 2010, TRICARE
Standard and Extra beneficiaries' visits to civilian mental health
care providers increased over 27 percent. A June 2007 report by DOD's
Task Force on Mental Health stated that TRICARE's provider networks
have been tasked with providing an increasing volume and proportion of
mental health services for families and retirees.[Footnote 10] In
assessing the oversight of the mental health network at one location,
the task force discovered that out of 100 network mental health
providers contacted from a list on the contractor's Web site, only 3
would accept new TRICARE patients.
The NDAA for Fiscal Year 2008 directed us to evaluate issues related
to TRICARE Standard and Extra beneficiaries' access to health care and
mental health care, including the identification of access impediments
and education and outreach efforts directed at civilian providers and
these beneficiaries. This report identifies and examines: (1) the
impediments to TRICARE Standard and Extra beneficiaries' access to
civilian health care and mental health care providers and TMA's
actions to address the impediments; (2) TMA's efforts to monitor
access to civilian providers for TRICARE Standard and Extra
beneficiaries; (3) how TMA informs network and nonnetwork civilian
providers about TRICARE Standard and Extra; and (4) how TMA informs
TRICARE Standard and Extra beneficiaries about their options and
facilitates their access to network and nonnetwork civilian providers.
To address these objectives, we met with officials in each of the
three TRICARE Regional Offices (North, South, and West) and with
officials for each of the three contractors to discuss access
impediments in their respective regions, how access to network and
nonnetwork providers is monitored, and their efforts to educate
civilian providers and TRICARE Standard and Extra beneficiaries. We
also interviewed TMA officials responsible for program operations,
medical benefits and reimbursement, contract performance evaluation,
contract management, data quality, communication and customer service,
and program analysis and evaluation. We also obtained documentation on
the contractors' performance in meeting network adequacy and education
related requirements. Lastly, we met with representatives of military
beneficiary organizations as well as two national provider
organizations to obtain their perspectives about access to civilian
providers for TRICARE Standard and Extra beneficiaries.
To identify and examine impediments to TRICARE Standard and Extra
beneficiaries' access to civilian health care and mental health care
providers and TMA's actions to address them, we obtained and reviewed
relevant reports and studies. Specifically, we reviewed TMA's reported
results from its multiyear survey of civilian providers, conducted
from 2005 through 2007, as well as the first 2 years of its subsequent
surveys of these providers during fiscal years 2008 and 2009. We
assessed the reliability of these data by speaking with knowledgeable
officials and reviewing related documentation, and we determined that
the survey results were sufficiently reliable for the purposes of this
report. We also reviewed a 2008 report prepared by CNA[Footnote 11] on
the current participation of civilian providers in the TRICARE
program. To examine how TMA addresses access impediments, we reviewed
TMA's reimbursement policies, studies that assessed TRICARE's
reimbursement rates, TMA's procedures for increasing reimbursement
rates, and TMA's procedures for offering bonus payments to physicians
in areas identified as having physician shortages. We obtained TMA's
reported data on adjustments to reimbursement rates that it issued
between January 2002 and January 2011. However, we did not assess the
appropriateness of TMA's decision to make these adjustments or the
extent to which these adjustments improved civilian providers'
acceptance of TRICARE beneficiaries as patients. Additionally, we
reviewed DOD's 2009 Report to Congress: Access to Mental Health
Services, and spoke with TMA and contractor officials about access to
mental health care and actions to improve access.
To identify and examine the mechanisms that TMA uses to monitor
TRICARE Standard and Extra beneficiaries' access to civilian
providers, we reviewed various efforts, including feedback mechanisms,
that TMA and its contractors use to solicit and gauge beneficiaries'
concerns, including difficulties with access to civilian providers.
These feedback mechanisms included TMA's surveys of civilian providers
and nonenrolled beneficiaries (TRICARE Standard, TRICARE Extra, and
TRICARE Reserve Select), as well as data collected on beneficiaries'
inquiries and complaints by TMA and its contractors during either
fiscal or calendar years 2008 through 2010. We spoke with TMA
officials and obtained information from its contractors about the
reliability of their data on beneficiaries' inquiries and determined
them to be sufficiently reliable for the purpose of our report, but we
did not independently verify these data. We also reviewed TMA's 2010
memorandum that directed the TRICARE Regional Offices to implement a
new approach for monitoring access to civilian providers under the
TRICARE Standard and Extra options, and we obtained and reviewed
information about each regional office's monitoring methodology.
To identify and examine how TMA informs network and nonnetwork
civilian providers and beneficiaries about TRICARE Standard and Extra
and how it facilitates access to civilian providers, we reviewed TMA's
requirements of its contractors as related to educating providers and
beneficiaries in each TRICARE region under the second generation of
TRICARE managed care support contracts (contracts).[Footnote 12] We
also reviewed each contractor's marketing and education plans to
identify their specific education efforts. Additionally, we obtained
and reviewed TRICARE provider and beneficiary educational materials to
gain an understanding of the information that TMA and the contractors
use to educate providers and beneficiaries. However, we did not assess
the quality and effectiveness of TMA's or the contractors' education
efforts and materials. Finally, we reviewed TMA's 2010 memorandum and
related documentation regarding TMA's effort to facilitate access to
care through provider directories for TRICARE Standard and Extra
beneficiaries.
We conducted this performance audit from July 2010 through June 2011
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives.
Background:
In fiscal year 2010, DOD offered health care to almost 9.7 million
eligible beneficiaries through its TRICARE program. TRICARE is
organized into three regions, and within these regions, beneficiaries
may obtain health care from either providers at military treatment
facilities or civilian providers.
TRICARE's Benefit Options:
TRICARE provides three basic options for its non-Medicare-eligible
beneficiary population. These options vary according to TRICARE
beneficiary enrollment requirements, the choices TRICARE beneficiaries
have in selecting civilian and military treatment facility providers
and the amount TRICARE beneficiaries must contribute towards the cost
of their care. (See table 1.)
Table 1: Summary of TRICARE's Basic Options:
TRICARE option: TRICARE Prime;
Description: Beneficiaries who choose to use this managed care option
must enroll. All active duty servicemembers are required to use
TRICARE Prime, but other TRICARE eligible (i.e., non-active duty)
beneficiaries may choose to use this option and must enroll to do so.
TRICARE Prime enrollees may pay an annual enrollment fee[A] and
receive most of their care from providers at military treatment
facilities, augmented by network providers who have agreed to meet
specific standards for appointment wait times among other
requirements. TRICARE Prime offers lower out-of-pocket costs than the
other TRICARE options.
TRICARE option: TRICARE Standard;
Description: TRICARE beneficiaries who choose not to enroll in TRICARE
Prime may obtain health care from nonnetwork providers. Under this
option, beneficiaries must pay an annual deductible and cost-shares,
which vary among active duty dependents and retirees and their
dependents. There is no annual enrollment fee.
TRICARE option: TRICARE Extra;
Description: Similar to TRICARE Standard, beneficiaries do not have to
enroll or pay an annual enrollment fee for TRICARE Extra. Under this
option, beneficiaries may obtain care from a TRICARE network civilian
provider for lower cost-shares (about 5 percentage points less) than
they would have if they saw nonnetwork providers under the TRICARE
Standard option.
Source: GAO summary of the Department of Defense's TRICARE
documentation.
Note: All beneficiaries may obtain care at military treatment
facilities although priority is given to any active-duty personnel and
then to TRICARE Prime enrollees.
[A] There is no annual enrollment fee for active duty servicemembers
and their dependents. However, retirees and their dependents under 65
years must pay an annual enrollment fee.
[End of table]
TRICARE also offers other options, including TRICARE Reserve Select, a
premium-based health plan that certain Reserve and National Guard
servicemembers may purchase. Under TRICARE Reserve Select,
beneficiaries may obtain health care from either nonnetwork or network
providers, similar to beneficiaries using TRICARE Standard or Extra,
respectively, and pay lower cost-shares for using network providers.
TRICARE Regional Structure and Contracts:
TRICARE is a regionally structured program that is organized into
three main regions--North, South, and West. (See figure 1 for the
location of the three regions.) TMA manages civilian health care in
each of these regions through contractors. As of March 2011, the
second generation of TRICARE contracts were in operation, and TMA was
in the process of awarding the third generation of contracts.
Figure 1: Location of TRICARE Regions:
[Refer to PDF for image: U.S. map]
The map depicts the geographical areas withing each of the following
regions:
TRICARE North Region;
TRICARE South Region;
TRICARE West Region.
Source: GAO analysis of TRICARE data.
[End of figure]
The contractors are required to establish and maintain adequate
networks of civilian providers within designated locations referred to
as 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. These civilian provider networks are also required to
meet specific access standards for TRICARE Prime beneficiaries--such
as for travel times or wait times.[Footnote 13] However the access
standards do not apply to beneficiaries using options other than
TRICARE Prime, such as TRICARE Standard or Extra. The contractors are
also responsible for helping TRICARE beneficiaries locate providers
and for informing and educating TRICARE beneficiaries and providers on
all aspects of the TRICARE program. In addition, they provide customer
service to any TRICARE beneficiary who requests assistance, regardless
of their enrollment status.
TMA has a TRICARE Regional Office in each region that helps to manage
health care delivery. These offices are responsible for overseeing the
contractors, including monitoring network quality and adequacy and
customer-satisfaction outcomes. Similar to the contractors' efforts,
these offices provide customer service to all TRICARE beneficiaries
who request assistance, regardless of their enrollment status.
TRICARE Network and Nonnetwork Civilian Providers:
Civilian providers must be TRICARE-authorized to be reimbursed for
care under the program.[Footnote 14] Such authorization requires a
provider to be licensed by their state, accredited by a national
organization, if one exists, and meet other standards of the medical
community. There are two types of authorized civilian providers--
network and nonnetwork providers, and both types of providers may
accept TRICARE beneficiaries as patients on a case-by-case basis,
regardless of enrollment status.
* Network providers are TRICARE-authorized providers who enter into a
contract with the regional contractor to provide care to TRICARE
beneficiaries and agree to accept TRICARE reimbursement rates as
payment in full.[Footnote 15] By law, TRICARE reimbursement rates for
civilian providers are generally limited to Medicare rates, but
network providers may agree to accept lower reimbursements as a
condition of network membership.[Footnote 16] Network providers are
not obligated to accept all TRICARE beneficiaries seeking care. For
example, network providers may decline to accept TRICARE beneficiaries
as patients because their practices do not have sufficient capacity or
for other reasons.[Footnote 17]
* Nonnetwork providers are TRICARE-authorized providers who have not
entered into a contractual agreement with a contractor to provide care
to TRICARE beneficiaries. Nonnetwork providers may accept the TRICARE
reimbursement rate as payment in full or they may charge up to 15
percent above the reimbursement amount. The beneficiary is responsible
for paying the extra amount billed in addition to the required cost-
shares.
Beneficiaries' Use of TRICARE:
Claims data from fiscal years 2006 through 2010 show that overall
TRICARE claims paid to civilian providers have increased by more than
50 percent, even though the eligible population increased by less than
6 percent.[Footnote 18] (See table 2.)
Table 2: TRICARE-eligible Beneficiaries and Claims Paid to Civilian
Providers for Fiscal Years 2006 through 2010:
Fiscal year: 2006;
TRICARE-eligible beneficiaries[A]: 9.19 million;
TRICARE claims paid to civilian providers: 19.29 million.
Fiscal year: 2007;
TRICARE-eligible beneficiaries[A]: 9.22 million;
TRICARE claims paid to civilian providers: 21.31 million.
Fiscal year: 2008;
TRICARE-eligible beneficiaries[A]: 9.39 million;
TRICARE claims paid to civilian providers: 24.02 million.
Fiscal year: 2009;
TRICARE-eligible beneficiaries[A]: 9.58 million;
TRICARE claims paid to civilian providers: 26.97 million.
Fiscal year: 2010;
TRICARE-eligible beneficiaries: 9.69 million;
TRICARE claims paid to civilian providers: 29.60[B] million.
Fiscal year: Total percentage change from fiscal year 2006 to 2010;
TRICARE-eligible beneficiaries[A]: 5.4 percent;
TRICARE claims paid to civilian providers: 53.4 percent.
Source: GAO analysis of TRICARE Management Activity (TMA) data.
Note: Claims were for services provided in an office or other setting
outside of an institution. Claims for services rendered at hospitals,
military treatment facilities, and other institutions were excluded.
TRICARE for Life claims were excluded as well as claims for medical
supplies and from chiropractors and pharmacies.
[A] Eligible beneficiaries include active duty personnel and their
dependents, medically eligible Reserve and National Guard personnel
and their dependents, and retirees and their dependents and survivors.
[B] Fiscal year 2010 data are incomplete as TMA allows claims to be
submitted up to 1 year after care was provided.
[End of table]
Between fiscal years 2006 through 2010, TRICARE Standard and Extra
beneficiaries' use of network providers--as measured by the number of
claims paid to network providers--has increased significantly, while
their use of nonnetwork providers--as measured by the number of claims
paid to nonnetwork providers--has slightly decreased. (See figure 2.)
Specifically, their use of network providers has increased more than
66 percent between fiscal years 2006 and 2010, compared to about a 10
percent decrease in the use of nonnetwork providers over the same time
period.
Figure 2: TRICARE Standard and Extra Beneficiaries' Claims Paid to
Network and Nonnetwork Civilian Providers for Fiscal Years 2006
Through 2010:
[Refer to PDF for image: multiple line graph]
Fiscal year: 2006;
Claims paid to network civilian providers: 3,055;
Claims paid to nonnetwork civilian providers: 3,374.
Fiscal year: 2007;
Claims paid to network civilian providers: 3,462;
Claims paid to nonnetwork civilian providers: 3,267.
Fiscal year: 2008;
Claims paid to network civilian providers: 4,025;
Claims paid to nonnetwork civilian providers: 3,235.
Fiscal year: 2009;
Claims paid to network civilian providers: 4,668;
Claims paid to nonnetwork civilian providers: 3,122.
Fiscal year: 2010a;
Claims paid to network civilian providers: 5,075;
Claims paid to nonnetwork civilian providers: 3,038.
Source: GAO analysis of TRICARE Management Activity (TMA) data.
Note: Claims analyzed were for services provided in an office or other
setting outside of an institution. Claims for services rendered at
hospitals, military treatment facilities, and other institutions were
excluded. TRICARE for Life claims were excluded as well as claims for
medical supplies and from chiropractors and pharmacies.
[A] Fiscal year 2010 data are incomplete as TMA allows claims to be
submitted up to 1 year after care was provided.
[End of figure]
Reimbursement Rates and Provider Shortages Hinder Access to Civilian
Providers; TMA Can Increase Reimbursement Rates When Needed, but Has
Only Limited Means to Address Shortages:
Reimbursement rates have been cited as the primary impediment that
hinders beneficiaries' access to civilian health care and mental
health care providers under TRICARE Standard and Extra. TMA can
increase reimbursement rates in certain circumstances when a need has
been demonstrated. Although national and local shortages of certain
types of providers have also been cited as an impediment to TRICARE
Standard and Extra beneficiaries' access to civilian providers, TMA is
limited in its ability to address this impediment as it affects the
general population and not just TRICARE beneficiaries. Additionally,
beneficiaries' access to mental health care is affected by provider
shortages and other issues and is of particular concern because the
stress of deployment and redeployment has increased the demand for
these services.
Reimbursement Rates Have Been Cited as the Primary Impediment to
Beneficiaries' Access to Civilian Providers under TRICARE Standard and
Extra, and TMA Can Adjust Them When a Need is Demonstrated:
Since TRICARE was implemented in 1995, some civilian providers--both
network and nonnetwork--have expressed concerns about TRICARE's
reimbursement rates. For example, in 2006, we reported that both
network and nonnetwork civilian providers said that TRICARE's
reimbursement rates tended to be lower than those of other health
plans, and as a result, some of these providers had been unwilling to
accept TRICARE Standard and Extra beneficiaries as patients.[Footnote
19] More recent studies by TMA and others have cited TRICARE's
reimbursement rates as the primary reason civilian providers may be
unwilling to accept these beneficiaries as patients, for example:
* TMA's first multiyear survey of civilian providers (2005 through
2007) showed that TRICARE's reimbursement rates were the primary
reason cited by providers for not accepting TRICARE Standard and Extra
beneficiaries as new patients.[Footnote 20]
* Similarly, results from the first 2 years (2008 and 2009) of TMA's
second multiyear provider survey showed that the responding providers
cited TRICARE's reimbursement rates as one of the primary reasons that
they would not accept new TRICARE patients even though they would
accept new Medicare patients.[Footnote 21]
* In a 2008 study on civilian providers' acceptance of TRICARE
Standard and Extra beneficiaries, CNA reported that the medical
society officials and physicians they interviewed cited low
reimbursement as the primary reason for limiting their acceptance of
TRICARE beneficiaries as patients.[Footnote 22] The providers who were
interviewed as part of this study noted that while they could accept
more TRICARE beneficiaries as patients, there are services for which
the reimbursement was so low that accepting more TRICARE beneficiaries
as patients hurt rather than helped them.
In addition to these studies, officials from each of the TRICARE
Regional Offices and two of the contractors, as well as a national
provider organization, told us that reimbursement rates were civilian
providers' primary concern about TRICARE.
Concerns about TRICARE's reimbursement rates--which generally mirror
the Medicare program's physician fee schedule[Footnote 23]--have
increased by the uncertainty surrounding the annual update to these
Medicare fees.[Footnote 24] All of the contractors expressed concerns
about the proposed decreases to Medicare rates and how that would
affect providers' acceptance of TRICARE patients. One contractor told
us that providers already were expressing concerns about the Medicare
rate decreases and that some providers said they would no longer
accept TRICARE beneficiaries as patients if the rates were reduced.
Furthermore, as of September 2010, this contractor noted that one
provider had stopped accepting TRICARE beneficiaries as patients
because of concerns about potential Medicare reimbursement reductions.
TMA has the authority to adjust TRICARE reimbursement rates under
certain conditions to increase beneficiaries' access to civilian
providers, and has done so in some instances. In response to various
concerns about providers' willingness to accept TRICARE patients, TMA
contracted with a consulting firm to conduct a number of studies about
TRICARE reimbursement rates, and some of these studies have resulted
in increases to reimbursement amounts for certain procedures. (See
appendix II for a summary of the studies.) For example, in response to
civilian obstetric providers' concerns about TRICARE reimbursement
rates, TMA conducted an analysis of historical TRICARE claims data and
made nationwide changes to its physician payment rates for obstetric
care in 2006.[Footnote 25] These changes included an additional
payment for ultrasounds for uncomplicated pregnancies that is likely
to result in overall higher payments for civilian physicians who
perform one or more ultrasounds during the course of pregnancy.
TMA also has the authority to adjust reimbursement rates through the
use of waivers in areas where it determines that the rates have had a
negative impact on TRICARE beneficiaries' access to civilian
providers. TMA can issue three types of reimbursement waivers,
depending on the type of adjustment that is needed:
* Locality waivers may be used to increase rates for specific medical
services in specific areas where access to civilian providers has been
severely impaired and are applicable to both network and nonnetwork
providers.[Footnote 26]
* Network waivers may be 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 in a specific location.
[Footnote 27]
* TMA can restore TRICARE reimbursement rates in specific localities
to the levels that existed before a reduction was made to align
TRICARE reimbursement rates with Medicare rates for both network and
nonnetwork providers.[Footnote 28]
Waivers can be requested by providers, beneficiaries, contractors,
military treatment facilities, or TRICARE Regional Office directors,
although all requests must be submitted through the TRICARE Regional
Office directors. Individuals may apply for waivers by submitting
written requests to the TRICARE Regional Offices. These requests must
contain specific justifications to support the claim that access
problems are related to low reimbursement rates and must include
information such as the number of providers and TRICARE-eligible
beneficiaries in a location, the availability of military treatment
facility providers, geographic characteristics, and the cost-
effectiveness of granting the waiver. Ultimately, the TRICARE Regional
Office director reviews and analyzes the requests. If the TRICARE
Regional Office director agrees with the request, they make a
recommendation to the Director of TMA that the waiver request be
approved. Each analysis is tailored to the specific concerns outlined
in the waiver requests. Once implemented, waivers remain in effect
indefinitely or until TMA officials determine they are no longer
needed.
As shown in table 3, the total number of waivers has increased from 15
to 24 since we last reported on TMA's use of waivers in 2006. (See
appendix III for more details about the waivers.) Additionally, 13 of
the 24 waivers are for locations in Alaska. (See appendix IV for more
information about access-to-care issues in Alaska.)
Table 3: TRICARE Reimbursement Waivers in August 2006 and January 2011:
Type of waiver: Locality waiver;
Number of waivers in place as of August 2006: 7;
Number of waivers in place as of January 2011: 16.
Type of waiver: Network waiver;
Number of waivers in place as of August 2006: 6;
Number of waivers in place as of January 2011: 8.
Type of waiver: Waiving reimbursement rate reductions[A];
Number of waivers in place as of August 2006: 2;
Number of waivers in place as of January 2011: 0.
Type of waiver: Total;
Number of waivers in place as of August 2006: 15;
Number of waivers in place as of January 2011: 24.
Source: GAO analysis of TRICARE Management Activity (TMA) data.
[A] TMA has authority to restore TRICARE reimbursement rates in
specific localities to the levels that existed before a reduction was
made to align TRICARE reimbursement rates with Medicare rates. The two
waivers that were in place in 2006 were for Alaska and were
discontinued when a demonstration project, implemented in 2007,
increased TRICARE's reimbursement rates so that on average, they
matched those of the Department of Veterans Affairs.
[End of table]
Other than assessing the effectiveness of a specific rate adjustment
in Alaska, TMA has not conducted analyses to determine if its rate
adjustments or the use of waivers have increased beneficiaries' access
to civilian providers. Nonetheless, officials told us that using the
waivers has proved to be successful by maintaining the stability of
the provider networks and by increasing the size of the networks in
some areas.
National and Local Shortages of Certain Provider Specialties Impede
Beneficiaries' Access to Civilian Providers, and TMA Is Limited in Its
Ability to Address Them:
Another main impediment to TRICARE beneficiaries' access to civilian
providers is a shortage of certain provider specialties, both at the
national and local levels. However, TMA is limited in its ability to
address provider shortages because this impediment affects the entire
health care delivery system and is not specific to the TRICARE program.
National and Local Shortages of Certain Provider Specialties Impede
Access:
Although the number of civilian providers accepting TRICARE has
increased over the years,[Footnote 29] access to civilian providers
remains a concern due to national and local shortages of certain
provider specialties. These shortages limit access for the general
population, including all TRICARE beneficiaries regardless of
enrollment status. Several organizations have reported on national
provider work-force shortages in primary care as well as in a number
of specialties.[Footnote 30] For example, the Association of American
Medical Colleges reported national shortages in provider specialties
such as anesthesiology, dermatology, and psychiatry. Additionally, the
contractors and regional office officials we met with told us that
they were particularly concerned about the national shortage of child
psychiatrists.
In addition to national shortages, TRICARE beneficiaries' access to
civilian providers also may be impeded in certain locations where
there are insufficient numbers and types of civilian providers to
cover the local demand for health care. According to the contractors,
each TRICARE region had areas with civilian provider shortages, for
example:
* In TRICARE's West region, a Prime Service Area in northern
California had provider shortages in 21 different provider
specialties, including allergists and obstetricians as well as
psychologists and psychiatrists. According to this region's
contractor, either there were no providers located in the area or the
providers located in the area were already contracted as TRICARE
network providers.
* In TRICARE's South region, the contractor identified locations in
Texas, Louisiana, and Florida in which there were limited numbers of
specialists and mental health providers. For example, according to
this contractor, Del Rio, Texas has no providers in several
specialties including dermatology, allergy, and psychiatry.
* Likewise, in TRICARE's North region, the contractor stated that
there are mountainous areas, such as parts of West Virginia, and
remote areas, such as western North Carolina, in which there are
provider shortages. Consequently, the general population, including
TRICARE beneficiaries, has to drive longer distances to obtain certain
types of specialty care.
TMA is Limited in How it Can Address Provider Shortages:
TMA has attempted to address civilian provider shortages, but because
these shortages are not specific to the TRICARE program, there are
limitations in what TMA can do. One step TMA has taken is the adoption
of a bonus payment system that mirrors the one used by Medicare for
certain provider shortage areas.[Footnote 31] Under Medicare,
providers who provide services to beneficiaries located in Health
Professional Shortage Areas--geographic areas that the Department of
Health and Human Services has identified as having shortages of
primary health, dental, or mental health care providers--receive 10
percent bonus payments.[Footnote 32] Beginning in June 2003, TMA began
offering providers a 10 percent bonus payment for services rendered in
these same locations. TMA estimated that from fiscal year 2007 through
the third quarter of fiscal year 2010, more than 20,000 individual
providers received these payments.
Currently, civilian providers must include a specific code on every
TRICARE claim they submit to obtain the additional payment. However,
TMA officials noted that some providers may not be receiving this
bonus because they do not include the specific code on their claims.
TMA officials noted the process will become easier once the third
generation of managed care support contracts is implemented. Once this
occurs, the contractors will rely on the Centers for Medicare &
Medicaid Services' public database of zip codes to determine a
provider's eligibility for these bonus payments instead of requiring
the provider to include a code on each claim. TMA officials estimated
that this change will result in an additional $150,000 in bonus
payments each year for TRICARE claims.
TRICARE Beneficiaries' Access to Mental Health Care Is Affected by
Provider Shortages and Other Issues:
Access to mental health care is a concern for all TRICARE
beneficiaries, and it has been affected by provider shortages and
other issues, including providers' lack of knowledge about combat
related issues, providers' concerns about reimbursement rates, and
providers' lack of awareness about TRICARE. A 2007 report by the
American Psychological Association noted that shortages of mental
health providers specifically trained in military issues and the
challenge associated with modifying the military culture so that
mental health services are less stigmatized are impediments to TRICARE
beneficiaries' access to mental health care.[Footnote 33] Furthermore,
the report discusses that even where mental health providers are
available, it can be difficult to find psychiatrists and other mental
health providers with specific familiarity of TRICARE beneficiaries'
mental health conditions such as post-traumatic stress disorder and
deployment issues. This can be frustrating for TRICARE beneficiaries
who seek mental health care only to discover that providers cannot
relate to their specific concerns.
Over the years, Congress has required DOD to report on TRICARE
beneficiaries' access to mental health care providers. Specifically,
the NDAA for Fiscal Year 2008 required DOD to report on the adequacy
of access to mental health services under the TRICARE program. In
2009, DOD reported that it believed access to mental health care
providers for TRICARE beneficiaries was adequate due to a dramatic
increase in both inpatient and outpatient mental health care provided
in 2008.[Footnote 34] DOD also cited increases in the numbers of
mental health providers from May 2007 to May 2009 in both the direct
care system of military treatment facilities (1,952) and in the
civilian provider network (10,220), while acknowledging that there may
still be some areas where access to mental health care providers is
inadequate. However, in the same report, DOD noted that TRICARE
Standard and Extra beneficiaries reported more problems finding
civilian mental health care providers than beneficiaries who use other
health care coverage, and that psychiatrists have the lowest
acceptance rates of new TRICARE Standard and Extra beneficiaries
compared with other providers.[Footnote 35]
In its 2009 Access to Mental Health Services report, DOD noted that
two reasons most cited by civilian mental health providers, including
psychiatrists, for not accepting new TRICARE patients were "not aware
of TRICARE" and "reimbursement." DOD also reported that TMA would
increase outreach to mental health providers in selected locations to
improve awareness of the program. In addition to the increased
outreach, DOD also reported two initiatives designed to enhance
beneficiaries' access to mental health care--the Telemental Health
Program and the TRICARE Assistance Program. The Telemental Health
Program[Footnote 36] connects TRICARE beneficiaries in one office to
civilian mental health providers in another medical office through an
audiovisual link. The TRICARE Assistance Program[Footnote 37] is a Web-
based program that enables certain beneficiaries to contact licensed
civilian counselors 24 hours a day for short-term, nonmedical issues.
[Footnote 38] Also, in recognition that mental health is an issue of
concern for its beneficiaries, each of the TRICARE Regional Offices
and contractors has established staff positions that focus
specifically on mental health issues, including access to care.
More recently, the NDAA for fiscal year 2010 required DOD to report on
the appropriate number of personnel to meet the mental health care
needs of servicemembers, retired members, and dependents and to
develop and implement a plan to significantly increase the number of
DOD military and civilian mental health personnel, among other
requirements.[Footnote 39] In response to this requirement, DOD
reported in February 2011 that it has identified criteria for the
military services to use in determining the appropriate number of
mental health personnel needed to meet the needs of their
beneficiaries.[Footnote 40] However, DOD also noted that the military
services are still testing and validating these criteria to determine
how effective they would be in gauging adequate mental health staffing
numbers. Therefore, although DOD reported increases in the number of
mental health providers employed at military treatment facilities or
contracted to join TRICARE's network of providers, it did not
specifically estimate the appropriate number of mental health care
providers needed. DOD also reported that initiatives are under way to
increase the number of mental health providers in military treatment
facilities, including increasing the number of Public Health Service
providers serving in military treatment facilities as well as
recruitment and retention incentives. These initiatives, if
successfully implemented, could reduce the demand for civilian mental
health providers in those locations.
Although TMA Has Typically Used Feedback Mechanisms to Gauge TRICARE
Standard and Extra Beneficiaries' Access to Civilian Providers, It Is
Developing a New Method for Monitoring Access:
TMA and its contractors have used various feedback mechanisms, such as
surveys, to gauge beneficiaries' access to care under TRICARE Standard
and Extra. More recently, TMA officials have taken steps to develop a
model to help identify geographic areas where beneficiaries that use
TRICARE Standard and Extra may experience access problems. However,
because this initiative is still evolving, it is too early to
determine its effectiveness.
TMA Has Primarily Relied on Feedback Mechanisms to Gauge
Beneficiaries' Access to Civilian Providers under TRICARE Standard and
Extra:
TMA has primarily relied on feedback to gauge beneficiaries' access to
civilian providers under TRICARE Standard and Extra, as historically,
access to care has only been routinely monitored for beneficiaries
enrolled in TRICARE Prime, the only option with access standards.
[Footnote 41] These feedback mechanisms have included surveys of
civilian health care (including mental health care) providers as well
as surveys of nonenrolled beneficiaries who are eligible to use the
TRICARE Standard and Extra options as well as TRICARE Reserve Select.
Additionally, TMA and its contractors use feedback from beneficiaries'
inquiries and complaints to help identify problems with access, among
other issues.
In fiscal year 2005, TMA implemented its first multiyear survey of
civilian providers (network and nonnetwork) as required by the NDAA
2004. TMA's survey was supposed to assess beneficiaries' access to
civilian providers under the TRICARE Standard and Extra options by
determining whether civilian providers would accept these
beneficiaries as new patients. In 2006, we reported on TMA's survey
methodology, among other issues, and reported that it was sound and
statistically valid. TMA's results for this first multiyear survey of
civilian providers, which was fielded through 2007, showed that about
8 of 10 physicians and behavioral health providers accepted TRICARE
beneficiaries as new patients, if they accepted any patients at all.
[Footnote 42] However, while these results appear favorable, as we
reported in 2006, there is no benchmark with which to compare them.
Subsequently, the NDAA 2008 required TMA to conduct two multiyear
surveys--one of civilian providers and one of nonenrolled
beneficiaries--to determine the adequacy of access to health care and
mental health care for these beneficiaries. In March 2010, we
reported[Footnote 43] that the methodology for both of TMA's surveys
was sound and generally addressed the methodological requirements
outlined in the law.[Footnote 44] TMA has completed the first 2 years
(2008 and 2009) of these surveys.
TMA and its contractors also use feedback collected from
beneficiaries' inquiries and complaints to identify and gauge
potential problem areas, including issues with access to care.
However, this type of feedback is not representative because not every
beneficiary who has a question or complaint will contact TMA or its
contractors. TMA uses its Assistance Reporting Tool to collect and
analyze information on the beneficiary inquiries that it receives,
including inquiries on access to care from beneficiaries who use
TRICARE Standard and Extra.[Footnote 45] During fiscal years 2008
through 2010, data from the Assistance Reporting Tool showed that only
about 5 percent of closed cases on all TRICARE-related beneficiary
inquiries and complaints were from TRICARE Standard and Extra
beneficiaries. Further, of the total inquiries and complaints received
from these beneficiaries, TMA reported that 313 cases were access-to-
care related (2 percent).
The contractors separately receive feedback from beneficiaries through
some or all of the following methods: (1) telephone, (2) e-mail, (3)
in-person at a TRICARE Service Center, or (4) in writing. Each
contractor collects and reports information on their beneficiary
feedback differently. In reviewing contractors' data on beneficiary
inquiries or complaints received, we found:
* During fiscal year 2009, TMA's contractor in the North region
reported receiving 11,176 (less than 1 percent) access-to-care
inquiries out of a total of more than 5 million inquiries. This
contractor does not categorize its inquiries by TRICARE option, but
does collect and categorize inquiries specific to access-to-care
concerns. In fiscal year 2010, the contractor received 3,642 access-to-
care inquiries (less than 1 percent) out of a total of more than 5
million inquiries.
* TMA's contractor in the South region reported that during calendar
year 2009, it received a total of 7,785 complaints. Of these, 175 (2
percent) were submitted by TRICARE Standard and Extra beneficiaries.
While access to care did not represent a top reason for their
complaints in 2009, this contractor reported that 15 of the complaints
received were related to beneficiary appointment and wait times. This
contractor also reported that it received a total of 7,927 complaints
in calendar year 2010. Of these, 134 (about 2 percent) were submitted
by TRICARE Standard and Extra beneficiaries, and only 14 of the 134
complaints were specific to beneficiary appointment and wait times.
* Finally, data submitted to us by TMA's contractor in the West region
showed that it received a total of 809 grievances from TRICARE
beneficiaries between January 2008 and December 2010. Of these,
TRICARE Standard and Extra beneficiaries submitted 83 inquiries (about
10 percent), and about 2 percent of the 83 inquiries were specific to
provider appointment wait times.
TMA Has Initiated Steps to Establish a Method for Routinely Monitoring
Access to Civilian Providers for TRICARE Standard and Extra
Beneficiaries:
TMA has recently initiated steps to establish an approach to routinely
monitor beneficiaries' access to both network and nonnetwork providers
under the TRICARE Standard and Extra options. (The new approach will
also apply to beneficiaries using the TRICARE Reserve Select option.)
In recognition that the military health system had no established
measures for determining the adequacy of network and nonnetwork
providers for these beneficiaries, in February 2010, TMA's Office of
Policy and Operations directed the TRICARE Regional Offices to develop
a model to identify geographic areas where they may experience access
problems as well as areas of provider shortages for the general
population. The model is intended to help the TRICARE Regional Offices
and their contractors identify geographic areas where additional
efforts to increase access to civilian providers may be warranted.
To implement this approach, TMA recommended that each regional office
adapt and standardize the model that had originally been developed by
its West regional office in 2008. This model applies a specific
provider-to-beneficiary ratio based on the Graduate Medical Education
National Advisory Committee's recommended standards for health care
services[Footnote 46] to different provider specialties to determine
whether there are sufficient numbers and types of providers for the
nonenrolled beneficiary population in certain locations. To identify
locations for analysis, West regional office officials used zip codes
to identify locations with populations of 500 or more nonenrolled
beneficiaries. According to officials in the West regional office,
they then identified the network and nonnetwork providers who
practiced and had previously accepted a TRICARE patient in these same
locations and applied a specific provider-to-beneficiary ratio against
each provider specialty included in the model for the locations
assessed. Each regional office has developed a model that generally
follows the same methodology and includes similar data as the West
regional office's model, although variations exist. For example, while
one regional office includes provider data that represents 15 provider
specialties, another regional office includes 40 provider specialties
in its model. Officials at one regional office told us they have plans
to update their model to reflect changes in the beneficiary
population, and an official at another regional office said that staff
were already in the process of updating their model, which may include
additional provider demographic factors.
TMA directed each TRICARE Regional Office to apply the model at least
semiannually beginning on May 1, 2010. According to officials in TMA's
South region, they plan to apply the model semi-annually as directed
while TMA's regional offices in the North and West apply the model as
needed. More specifically, since TMA's office in the North region
implemented the model, it has assessed 20 locations, and now applies
the model as needed in response to specific concerns. Meanwhile,
officials from TMA's office in the West region told us that they
initially applied the model to over 50 locations and that they now
apply the model as needed, such as in response to a specific inquiry
about access to care in a particular location. Officials in the North
regional office noted that their model's data are used in conjunction
with other indicators to assess if further analysis of civilian
provider availability is needed. Officials in the West region said
that they plan to reach out to providers in the community or use the
contractor to help recruit additional providers to the TRICARE network
if the model identifies an area that is short of their targeted number
of providers in a given specialty.
Based on our review of each regional office's initial approach, we
found this methodology to be reasonable. However, because the regional
models were recently developed, it is too early to determine their
effectiveness. And, while the regional offices provided us with
examples of their models, they did not provide documentation of how
they applied a provider-to-beneficiary ratio as criteria to determine
the adequacy of access in these locations or any documentation of
their results, although they told us that they did not identify any
access problems.
TMA's Contractors Educate Civilian Providers about TRICARE and Surveys
Indicate That Providers Are Generally Aware of the Program:
TMA's contractors educate civilian providers about TRICARE program
requirements, policies, and procedures. Contractors also conduct
outreach to increase providers' awareness of TRICARE, and TMA's
provider survey results indicate providers are generally aware of the
program. However, providers' awareness of TRICARE does not necessarily
signify that they have an accurate understanding of it.
TMA's Contractors Inform Network and Nonnetwork Providers about
TRICARE:
Under the second generation of TRICARE contracts, TMA's contractors
are required to conduct activities to help ensure that providers--both
network and nonnetwork--are aware of TRICARE program requirements,
policies, and procedures in their respective regions. To accomplish
this, the contractors are required to have active provider education
programs. In addition, each contractor must submit an annual marketing
and education plan to TMA's Communications and Customer Service office
that outlines its methods for educating providers based on contractual
requirements. All contractors include details in these plans about
their efforts to satisfy requirements to distribute regular bulletins
and newsletters as well as educate new network providers, such as
through orientation sessions or with a Welcome Tool Kit.[Footnote 47]
The contractors' marketing and education plans also identify provider
education efforts that vary across the regions. These efforts vary
because contractors have some flexibility in how they achieve outcomes
and because the contractors may include additional performance
standards in their contracts.[Footnote 48] Under the second generation
of TRICARE contracts, contractors have added performance standards
related to provider education. For example, one contractor must visit
high-volume network and nonnetwork providers in its region annually,
while another contractor must conduct annual seminars for the network
and nonnetwork providers in its Prime Service Areas.[Footnote 49] TMA
reported that each contractor had fulfilled its provider education
requirements as of December 2010.
All of the contractors also make TRICARE education resources available
to providers. Many of these resources are available on the
contractors' Web sites and include the TRICARE Provider Handbook
[Footnote 50] as well as quick reference charts that include
information on provider resources and TRICARE covered benefits and
services, among other topics. One contractor hosts electronic seminars
on its Web site that allow providers to learn about the TRICARE
program at their convenience. Another contractor has developed a
reference chart that details the Prime, Standard, and Extra benefit
options and has mailed it to both network and nonnetwork providers in
its region who have accepted TRICARE beneficiaries as patients.
In addition, all of the contractors have conducted outreach activities
to promote or increase providers' awareness of TRICARE. This has
included participating in provider events with local, state, or
national groups, including physician associations, medical societies,
military treatment facilities, and military associations. Contractors
told us that while at these events, they answer providers' questions
about the program, distribute TRICARE materials, and encourage
providers to join the regional TRICARE network. All of the contractors
have also participated in events specific to behavioral health care.
Contractors said that these events allow them the opportunity to
discuss behavioral health issues that may particularly affect military
servicemembers and their families, such as suicide and post-traumatic
stress disorder, with providers. The contractors also use social media
[Footnote 51] to highlight TRICARE information for providers,
including resources and program news and changes. For example, one
contractor used its Twitter account to provide a link to information
on how to become a network or TRICARE-authorized provider in its
region. Additionally, two of the TRICARE Regional Offices as well as
two contractors have specifically conducted outreach related to either
encouraging network and nonnetwork providers to accept TRICARE
beneficiaries as patients or thanking them for doing so. For example,
in January 2011, one contractor mailed letters to nonnetwork
providers, encouraging them to support TRICARE beneficiaries by
joining the network.
Results of TMA's Provider Surveys Indicate a General Awareness of
TRICARE, but May Not Necessarily Signify an Accurate Understanding of
the Program:
Although TMA's provider surveys indicate a general awareness of the
program, these results may not signify an accurate understanding of
TRICARE. Survey results from TMA's first multiyear survey (2005
through 2007) of civilian providers (network and nonnetwork) indicated
that 87 percent of providers on average were aware of TRICARE. TMA's
second multiyear survey of civilian providers (network and
nonnetwork),[Footnote 52] which has completed 2 years (2008 and 2009)
of its 4-year cycle, similarly asked whether providers were aware of
the TRICARE program. Although the results of this survey are not
generalizeable,[Footnote 53] TMA's results show that, of those
providers who responded, 87 percent on average were aware of the
program.[Footnote 54]
Although TMA's survey results indicate that providers were generally
aware of TRICARE, this does not necessarily mean that providers had an
accurate understanding of the program's options and its requirements.
For example, representatives of an association representing current
and former servicemembers told us that providers do not always
understand the differences between the TRICARE Standard and TRICARE
Prime options. Similarly, in a November 2008 report, CNA stated that
the providers they interviewed were often confused about the
differences between TRICARE Standard and TRICARE Prime.[Footnote 55]
One provider, a former president of a local medical society, said many
providers are under the misconception that TRICARE Standard is the
same as TRICARE Prime and that when providers have had bad experiences
with TRICARE Prime, which generally pays network providers less than
Medicare, they end up refusing to accept any TRICARE patients because
they "don't want to deal with" a health maintenance organization. This
lack of understanding is not always easy to remedy. According to the
contractors, because many providers have relatively low volumes of
TRICARE patients, it can be challenging to encourage them to take
advantage of the available TRICARE education resources or to remain
current on updates and changes to the program. In 2009, the average
percentage of Prime Service Areas civilian providers' and non-Prime
Service Areas civilian providers' TRICARE patient population (under
any option) was 5.14 percent and 3. 42 percent, respectively.
TMA's Contractors Educate Beneficiaries on All TRICARE Options and
Provide Information on Network Providers; New Contracts Will Also
Require Information about Nonnetwork Providers:
Under the second generation of TRICARE contracts, TMA's contractors
have beneficiary education programs that contain information on all of
the TRICARE options; contractors also maintain directories of network
providers. Under its third generation of contracts, TMA will also
require contractors to include information on nonnetwork providers in
their directories.
TMA's Contractors Educate Beneficiaries on all TRICARE Options:
Under the second generation of TRICARE contracts, TMA's contractors
have established beneficiary education programs that contain
information on all of the TRICARE options, including Standard and
Extra. To meet its beneficiary education requirements, each contractor
must submit an annual marketing and education plan to TMA's
Communications and Customer Service office that outlines the
contractor's methods for educating beneficiaries based on its
contractual requirements. For example, the contractor may include
details in its marketing and education plan about intentions to
distribute required beneficiary newsletters and handbooks, which
include information on TRICARE's options and covered services. These
plans also specify how the contractors are to provide required weekly
one-hour TRICARE briefings to audiences specified by the commanders of
their regional military treatment facilities. TMA reported that each
of the contractors had fulfilled its beneficiary education
requirements as of December 2010.
TMA has only one beneficiary education requirement targeted to TRICARE
Standard and Extra beneficiaries: contractors must provide these
beneficiaries with the annual TRICARE Standard Health Matters
newsletter. The 2010 TRICARE Standard Health Matters newsletter
included articles on topics such as waiving cost-sharing for certain
preventive services under TRICARE Standard and Extra. In 2010, the
contractors mailed this newsletter to approximately 1.1 million
TRICARE Standard and Extra households and made it available
electronically through e-mail and their Web sites.[Footnote 56]
Additionally, for the first time, in summer 2010 TMA developed a
second TRICARE Standard Health Matters newsletter for TRICARE Standard
and Extra beneficiaries in an electronic format as an additional
resource to fill any possible information gaps to beneficiaries. The
contractors then e-mailed the electronic newsletter to beneficiaries
and posted it to their Web sites.[Footnote 57] This electronic
newsletter included articles on topics such as how beneficiaries may
save money by using TRICARE Extra and how they can stay informed about
TRICARE. Two of the contractors told us that it is difficult to
communicate with TRICARE Standard and Extra beneficiaries because they
do not necessarily have ready access to the beneficiaries' residential
or e-mail addresses as these beneficiaries are not required to enroll.
This lack of information can make communicating with these
beneficiaries challenging, and as a result, TRICARE Standard and Extra
beneficiaries may not receive all the available information on their
TRICARE benefit. A TMA official noted that TMA is not considering
making the additional electronic newsletter a requirement of the third
generation of TRICARE contracts, although the contractors may use it
to communicate with beneficiaries.
All of the contractors also make additional TRICARE education
resources available to beneficiaries. Many of these resources are
available on their Web sites, and may include the TRICARE Standard
Handbook[Footnote 58] and brochures that explain the different TRICARE
options and costs to beneficiaries, among other topics. For example,
one contractor makes games available on its Web site, which enables
beneficiaries to interactively learn about the TRICARE program.
Another contractor posts its own monthly newsletter to its Web site,
through which beneficiaries receive information about TRICARE,
including its different options, and activities specific to its
region. Meanwhile, the third contractor has developed several
different fact sheets for beneficiaries that summarize key TRICARE
program elements in short, easy-to-read formats.
Each of the three contractors also conducts outreach to enhance
beneficiaries' awareness of TRICARE. For example, each of the
contractors has attended events hosted by organizations such as the
Military Officers Association of America, the Enlisted Association of
the National Guard of the United States, the National Military Family
Association, the Military Health System, and the Adjutants General
Association of the United States. Contractors stated that while at
these events they can share TRICARE information with attendees. One
contractor also noted that while at these events it addresses
beneficiaries' concerns and directs them to further resources.
Contractors also use social media to communicate with beneficiaries
and provide information on different TRICARE topics, including (1)
benefits, (2) resources, and (3) health campaigns. For instance, one
contractor used its Facebook page to clarify whether TRICARE Standard
beneficiaries needed primary care managers to coordinate their
referrals. Another contractor included information on Facebook about
how beneficiaries could access information about their TRICARE benefit.
Contractors Provide Directories of Network Providers to Facilitate
Access to Care; New Contracts Will Also Require Information on
Nonnetwork Providers:
To facilitate beneficiaries' access to care, TMA requires its
contractors to maintain directories of TRICARE-authorized network
providers. These directories are to include current information
(updated within 30 days) about each network provider, including
specialty, address, and telephone number. The contractors are required
to make their directories readily accessible to all beneficiaries, and
as a result, all of the contractors' Web sites have online provider
directories. Under the second generation of TRICARE contracts, TMA
does not require its contractors to provide similar information on
nonnetwork providers. However, beneficiaries may contact the TRICARE
Regional Offices or the contractors for assistance in locating a
network or nonnetwork provider. Two of the contractors said they
currently collect information on nonnetwork providers who have
accepted TRICARE beneficiaries and can use this information to assist
beneficiaries in locating a nonnetwork provider. Beneficiaries can
also use TMA's TRICARE Web site, which refers beneficiaries to the
American Medical Association's provider directory and the Yellow
Pages, to find a nonnetwork provider. However, these online resources
do not indicate whether a provider is TRICARE-authorized or has
accepted TRICARE patients in the past.
TMA recognized that its Web site asked beneficiaries to "start from
square one" to identify a TRICARE-authorized nonnetwork provider.
Although it is not a routine practice for insurance companies to
identify nonnetwork providers in their online directories, in February
2010, TMA's Deputy Chief of TRICARE Policy and Operations recommended
(through a memo) that TMA establish an online search tool on its Web
site to enable beneficiaries to identify both network and nonnetwork
providers no later than May 1, 2010. However, TMA noted that it did
not have sufficient data to develop this online search tool. Instead,
TMA officials decided that under the third generation of TRICARE
contracts, each contractor would be responsible for creating an online
provider directory for its region that would include information for
beneficiaries on TRICARE-authorized providers, both network and
nonnetwork.
Agency Comments:
We received comments on a draft of this report from DOD. (See appendix
VI.) DOD concurred with our overall findings and provided technical
comments, which we incorporated where appropriate.
We are sending copies of this report to the Secretary of Defense and
appropriate congressional committees. The report is also available at
no charge on GAO's Web site at http://www.gao.gov.
If you or your staff members have any questions about this report,
please contact me at (202) 512-7114 or williamsonr@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this report. Key contributors to this
report are listed in appendix VII.
Signed by:
Randall B. Williamson Director, Health Care:
[End of section]
Appendix I: TRICARE Reimbursement Rates That Remain Higher than
Medicare Reimbursement Rates:
Beginning in fiscal year 1991, in an effort to control escalating
costs, Congress instructed the Department of Defense (DOD) to
gradually lower its reimbursement rates for individual civilian
providers to mirror those paid by Medicare.[Footnote 59] Congress
specified that reductions were not to exceed 15 percent in a given
year. As of March 2011, there were seven nonmaternity procedures or
services for which reimbursement remains higher under TRICARE than
Medicare. (See table 4.)
Table 4: TRICARE Reimbursement Rates That Remain Higher than Medicare
Reimbursement Rates for Nonmaternity Procedures and Services:
CPT code[A]: 36591;
Procedure or service performed: Collection of blood specimen from a
completely implantable venous access device;
Ratio of TRICARE to Medicare reimbursement: 1.017.
CPT code[A]: 38240;
Procedure or service performed: Bone marrow or blood-derived
peripheral stem cell transplantation; allogenic;
Ratio of TRICARE to Medicare reimbursement: 1.152.
CPT code[A]: 38241;
Procedure or service performed: Bone marrow or blood-derived
peripheral stem cell transplantation; autologous;
Ratio of TRICARE to Medicare reimbursement: 1.155.
CPT code[A]: 86901;
Procedure or service performed: Blood typing; Rh (D);
Ratio of TRICARE to Medicare reimbursement: 1.810.
CPT code[A]: 92953;
Procedure or service performed: Temporary transcutaneous pacing;
Ratio of TRICARE to Medicare reimbursement: 1.210.
CPT code[A]: 99173;
Procedure or service performed: Screening test of visual acuity,
quantitative, bilateral;
Ratio of TRICARE to Medicare reimbursement: 3.466.
CPT code[A]: 99359;
Procedure or service performed: Prolonged evaluation and management
service before and/or after direct (face-to-face) patient care; each
additional 30 minutes;
Ratio of TRICARE to Medicare reimbursement: 1.076.
Source: TRICARE Management Activity and the American Medical
Association.
[A] Current procedural terminology 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]
Additionally, beginning in 1998, the TRICARE Management Activity (TMA)
established a policy that its reimbursement rates for some maternity
services and procedures must be set at the higher of the current
Medicare fee or the 1997 Medicare fee.[Footnote 60] As a result, the
TRICARE reimbursement rates for 36 maternity services and procedures
are higher than Medicare. (See table 5.)
Table 5: TRICARE Reimbursement Rates That Remain Higher than Medicare
Reimbursement Rates for Maternity Procedures and Services:
CPT code[A]: 58300;
Procedure or service performed: Insertion of intrauterine device;
Ratio of TRICARE to Medicare reimbursement: 1.038.
CPT code[A]: 58600;
Procedure or service performed: Ligation or transection of fallopian
tube(s), abdominal or vaginal approach, unilateral or bilateral;
Ratio of TRICARE to Medicare reimbursement: 1.070.
CPT code[A]: 58605;
Procedure or service performed: Ligation or transection of fallopian
tube(s), abdominal or vaginal approach, postpartum, unilateral or
bilateral, during same hospitalization (separate procedure);
Ratio of TRICARE to Medicare reimbursement: 1.015.
CPT code[A]: 58615;
Procedure or service performed: Occlusion of fallopian tube(s) by
device (e.g., band, clip, Falope ring) vaginal or suprapubic approach;
Ratio of TRICARE to Medicare reimbursement: 1.118.
CPT code[A]: 58970;
Procedure or service performed: Follicle puncture for oocyte
retrieval, any method;
Ratio of TRICARE to Medicare reimbursement: 1.004.
CPT code[A]: 59012;
Procedure or service performed: Cordocentesis (intrauterine), any
method;
Ratio of TRICARE to Medicare reimbursement: 1.200.
CPT code[A]: 59020;
Procedure or service performed: Fetal contraction stress test;
Ratio of TRICARE to Medicare reimbursement: 1.327.
CPT code[A]: 59025;
Procedure or service performed: Fetal non-stress test;
Ratio of TRICARE to Medicare reimbursement: 1.055.
CPT code[A]: 59030;
Procedure or service performed: Fetal scalp blood sampling;
Ratio of TRICARE to Medicare reimbursement: 1.487.
CPT code[A]: 59050;
Procedure or service performed: Fetal monitoring during labor by
consulting physician (e.g., non-attending physician) with written
report; supervision and interpretation;
Ratio of TRICARE to Medicare reimbursement: 1.400.
CPT code[A]: 59051;
Procedure or service performed: Fetal monitoring during labor by
consulting physician (e.g. non-attending physician) with written
report; interpretation only;
Ratio of TRICARE to Medicare reimbursement: 1.285.
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: 1.127.
CPT code[A]: 59140;
Procedure or service performed: Surgical treatment of ectopic
pregnancy; cervical, with evacuation;
Ratio of TRICARE to Medicare reimbursement: 1.093.
CPT code[A]: 59160;
Procedure or service performed: Curettage, postpartum;
Ratio of TRICARE to Medicare reimbursement: 1.136.
CPT code[A]: 59320;
Procedure or service performed: Cerclage of cervix, during pregnancy;
vaginal;
Ratio of TRICARE to Medicare reimbursement: 1.178.
CPT code[A]: 59325;
Procedure or service performed: Cerclage of cervix, during pregnancy;
abdominal;
Ratio of TRICARE to Medicare reimbursement: 1.296.
CPT code[A]: 59350;
Procedure or service performed: Hysterorrhaphy of ruptured uterus;
Ratio of TRICARE to Medicare reimbursement: 1.276.
CPT code[A]: 59409;
Procedure or service performed: Vaginal delivery only (with or without
episiotomy and/or forceps);
Ratio of TRICARE to Medicare reimbursement: 1.318.
CPT code[A]: 59410;
Procedure or service performed: Vaginal delivery only (with or without
episiotomy and/or forceps); including postpartum care;
Ratio of TRICARE to Medicare reimbursement: 1.135.
CPT code[A]: 59412;
Procedure or service performed: External cephalic version, with or
without tocolysis;
Ratio of TRICARE to Medicare reimbursement: 1.307.
CPT code[A]: 59414;
Procedure or service performed: Delivery of placenta (separate
procedure);
Ratio of TRICARE to Medicare reimbursement: 1.397.
CPT code[A]: 59514;
Procedure or service performed: Cesarean delivery only;
Ratio of TRICARE to Medicare reimbursement: 1.361.
CPT code[A]: 59515;
Procedure or service performed: Cesarean delivery only;
including postpartum care;
Ratio of TRICARE to Medicare reimbursement: 1.087.
CPT code[A]: 59525;
Procedure or service performed: Subtotal or total hysterectomy after
cesarean delivery;
Ratio of TRICARE to Medicare reimbursement: 1.032.
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: 1.239.
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: 1.093.
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: 1.373.
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: 1.098.
CPT code[A]: 59840;
Procedure or service performed: Induced abortion, by dilation and
curettage;
Ratio of TRICARE to Medicare reimbursement: 1.237.
CPT code[A]: 59850;
Procedure or service performed: Induced abortion, by one or more intra-
amniotic injections (amniocentesis-injections), including hospital
admission and visits, delivery of fetus and secundines;
Ratio of TRICARE to Medicare reimbursement: 1.160.
CPT code[A]: 59851;
Procedure or service performed: Induced abortion, by one or more intra-
amniotic injections (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: 1.042.
CPT code[A]: 59852;
Procedure or service performed: Induced abortion, by one or more intra-
amniotic injections (amniocentesis-injections), including hospital
admission and visits, delivery of fetus and secundines; with
hysterectomy (failed intra-amniotic injection);
Ratio of TRICARE to Medicare reimbursement: 1.125.
CPT code[A]: 59855;
Procedure or service performed: Induced abortion, by one or more
vaginal suppositories (e.g., prostaglandin) with or without cervical
dilation (e.g. laminaria), including hospital admission and visits,
delivery of fetus and secundines;
Ratio of TRICARE to Medicare reimbursement: 1.010.
CPT code[A]: 59856;
Procedure or service performed: Induced abortion, by one or more
vaginal suppositories (e.g., prostaglandin) with or without cervical
dilation (e.g. laminaria), including hospital admission and visits,
delivery of fetus and secundines; with dilation and curettage and/or
evacuation;
Ratio of TRICARE to Medicare reimbursement: 1.060.
CPT code[A]: 59857;
Procedure or service performed: Induced abortion, by one or more
vaginal suppositories (e.g., prostaglandin) with or without cervical
dilation (e.g. laminaria), including hospital admission and visits,
delivery of fetus and secundines; with hysterotomy (failed-medical
evacuation);
Ratio of TRICARE to Medicare reimbursement: 1.229.
CPT code[A]: 59866;
Procedure or service performed: Multifetal pregnancy reduction(s);
Ratio of TRICARE to Medicare reimbursement: 1.365.
Source: TRICARE Management Activity and the American Medical
Association.
[A] Current procedural terminology 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 II: TMA's Studies on TRICARE Reimbursement Rates:
TMA contracted with a health-policy research and consulting firm to
conduct a number of studies about specific TRICARE reimbursement
rates. Some of these studies resulted in changes to the TRICARE
reimbursement rates for certain procedures. A brief description of
these studies is provided below.
Studies of Reimbursement Rates for Specific Maternity/Delivery
Procedures, 2006 through 2011[Footnote 61]
Starting in 2006, TMA's consultant has conducted annual comparisons of
TRICARE's reimbursement rates for certain maternity/delivery
procedures with Medicaid[Footnote 62] reimbursement rates on a state-
by-state basis. Any reimbursement rates that were found to be below
the Medicaid level of payment have been increased.
* For 2006, TMA found that for at least one procedure, the Medicaid
rates in 12 states were higher than TRICARE reimbursement rates.
[Footnote 63]
* For 2007, TMA found that for at least one procedure, the Medicaid
rates in 11 states were higher than TRICARE reimbursement rates.
[Footnote 64]
* For 2008, TMA found that for at least one procedure, the Medicaid
rates in 18 states were higher than TRICARE reimbursement rates.
[Footnote 65]
* For 2009, TMA found that for at least one procedure, the Medicaid
rates in 19 states were higher than TRICARE reimbursement rates.
For 2010, TMA found that for at least one procedure, the Medicaid
rates in the same 19 states were higher than TRICARE reimbursement
rates.
* For 2011, TMA found that 3 of the 19 states from 2010 no longer met
the criteria of having at least one maternity/delivery procedure with
TRICARE reimbursement rates lower than Medicaid. As a result, for at
least one procedure, the Medicaid rates in 16 states were higher than
TRICARE reimbursement rates.
Comparison of Commercial, Medicaid, and TRICARE Reimbursement Rates
for Selected Medical Specialties, April 2009[Footnote 66]
TMA's consultant compared specific TRICARE reimbursement rates with
reimbursement rates from Medicaid and commercial insurers. For the
comparison with Medicaid rates, it identified commonly used procedures
for 13 medical specialties[Footnote 67] and compared TRICARE's
reimbursement rates for these procedures with Medicaid's fee-for-
service rates in 49 states.[Footnote 68] Overall, the median value of
the 2009 Medicaid rates in the 49 states was about 18 percent lower
than TRICARE's reimbursement rates. In 24 states, the TRICARE
reimbursement rates exceeded the state Medicaid program rates for the
13 medical specialties reviewed. Conversely, the study found that in 3
states--New Mexico, Arizona, and Wyoming--Medicaid rates, on average,
exceeded the TRICARE reimbursement rates for these 13 specialties. For
the comparison with commercial rates, TMA's consultant analyzed
reimbursement amounts for 12 medical specialties[Footnote 69] in 15
geographic market areas[Footnote 70] and found that commercial rates
were higher than TRICARE reimbursement rates for these 12 specialties
in almost all of the geographic market areas analyzed.
Review of TRICARE Reimbursement Rates for Pediatric Vaccines and
Immunizations, January 2009[Footnote 71]:
TMA's consultant studied TRICARE's reimbursement rates for selected
pediatric immunizations and vaccines to determine whether TRICARE's
reimbursement amounts were below the cost that pediatricians must pay
to acquire these vaccines.[Footnote 72] It analyzed 15 vaccines codes
(which often have more than one type of vaccine product associated
with them) and found that for each of the vaccine codes, TRICARE's
reimbursement rates exceeded the average acquisition cost paid by
pediatric providers for at least one of the vaccine products. Overall,
in 2007 TRICARE's reimbursement rates exceeded the average acquisition
cost for the 15 vaccine codes by 30 percent (when weighted by volume).
The study also noted that some pediatricians may pay more than the
average acquisition price, and some network pediatricians may receive
TRICARE reimbursement rates below the average acquisition cost if they
have agreed to reimbursement discounts as a condition of belonging to
the TRICARE provider network.[Footnote 73] The study also compared
TRICARE's reimbursement rates to those of Medicare and Medicaid. The
study noted that TRICARE uses the same vaccine prices and
administration prices as Medicare for vaccine codes for which Medicare
sets a price (which is mostly at 106 percent of the average sales
price of the vaccine as of 2005--determined by the Centers for
Medicare & Medicaid Services). For those vaccines for which Medicare
does not have a set price, TRICARE reimbursement rates are set at 95
percent of average wholesale price--which is essentially a "list
price" set by the manufacturer. When compared to Medicaid's rates,
TRICARE's reimbursement rate for the administration of a vaccine or
immunization was higher than Medicaid's in every state in 2008.
[Footnote 74]
Analysis of TRICARE Payment Rates for Maternity/Delivery Services,
Evaluation and Management Services, and Pediatric Immunizations, March
2006[Footnote 75]:
TMA's consultant compared TRICARE's reimbursement rates for 14
specific maternity/delivery services and a pediatrician office visit
[Footnote 76] with Medicaid[Footnote 77] and commercial payment rates.
[Footnote 78] It found the following:
* For these specific maternity/delivery services, TRICARE's
reimbursement rates were higher than Medicaid rates in 35 of the 45
states reviewed. Additionally, in 27 of the 35 states, the Medicaid
payment rate for deliveries was less than 90 percent of TRICARE's
reimbursement rates. TRICARE's reimbursement rates for deliveries were
less than the median commercial rates in all but one of the 50 markets
studied (they were equivalent in the remaining market). Overall, the
median commercial rates for deliveries were 24 percent higher than
TRICARE's reimbursement rates in 2005.
* For pediatric care, TRICARE's reimbursement rate for a mid-level
office visit for an established patient (the most commonly billed code
by pediatricians) was higher than the state Medicaid reimbursement
rate in 41 of the 45 states in 2005.[Footnote 79] However, the median
commercial reimbursement rates were 10 percent higher than TRICARE's
reimbursement rates in the 50 TRICARE markets examined.
* TRICARE's reimbursement for pediatric vaccines and injectable drugs
generally appeared to be reasonable when derived from Medicare
pricing, based on an analysis of private sector costs, average
wholesale prices, and average sales prices for top volume CPT codes.
However, TRICARE's reimbursement rate for the pediatric and adolescent
dose of the hepatitis A vaccine was found to be 22 percent lower than
estimated private sector costs to obtain the vaccine in 2005.
Specifically, the TRICARE reimbursement rate for this vaccine dose was
$22.64, while pediatricians were paying between $27.41 and $30.37 for
the vaccine. Based on the results of this study, TMA used its general
authority to deviate from Medicare rates (upon which TRICARE rates are
based),[Footnote 80] and starting May 1, 2006, TMA instructed the
contractors to reimburse pediatric hepatitis A vaccines nationally at
a new reimbursement rate of $30.40.
[End of section]
Appendix III: TMA's Use of Waivers:
TMA has the authority to increase TRICARE reimbursement rates for
network and nonnetwork civilian providers to ensure that all
beneficiaries, including TRICARE Standard and Extra beneficiaries,
have adequate access to civilian providers. TMA's authorities include:
(1) issuing locality waivers that increase rates for specific
procedures in specific localities,[Footnote 81] (2) issuing network
waivers that increase some network civilian providers'
reimbursements,[Footnote 82] and (3) restoring TRICARE reimbursement
rates in specific localities to the levels that existed before a
reduction was made to align TRICARE reimbursement rates with Medicare
rates for both network and nonnetwork providers.[Footnote 83]
Locality waivers may be used to increase rates for specific medical
services in specific areas where access to civilian providers has been
severely impaired. 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 impaired. A total of
17 applications for locality waivers have been submitted to TMA
between January 2002 and January 2011. TMA approved 16 of these
waivers. (See table 6.)
Table 6: Applications for Locality Waivers and Approval Results:
Date submitted: 1/23/03;
Affected location: Juneau, Alaska;
Affected services: All gynecological procedures or services delivered
by one provider;
Amount of increase requested: 600 percent[A];
Outcome: 3/26/03--Approved for nonroutine gynecological procedures or
services.
Date submitted: 8/01/04;
Affected location: Fairbanks, Alaska;
Affected services: All inpatient internal medicine procedures or
services delivered by providers employed by Fairbanks Memorial
Hospital;
Amount of increase requested: Veterans Affairs rates;
Outcome: 10/28/04--Approved.
Date submitted: 6/08/05;
Affected location: Anchorage, Alaska;
Affected services: All medical procedures or services delivered by
perinatologists;
Amount of increase requested: 40 percent;
Outcome: 11/21/05--Approved for perinatologists who are participating
providers[B]; 11/21/07--Decreased the rate to 35 percent as a result
of an increase in overall TRICARE reimbursement rates in Alaska.
Date submitted: 6/08/05;
Affected location: Fairbanks, Alaska;
Affected services: Four medical procedures or services delivered by
two plastic surgeons;
Amount of increase requested: Veterans Affairs rates;
Outcome: 5/18/06--Approved to increase rates to the rate paid by the
Veterans Affairs for professional services provided by plastic
surgeons in Alaska.
Date submitted: 3/03/05;
Affected location: Puerto Rico[C];
Affected services: All medical procedures or services delivered by
neurosurgeons;
Amount of increase requested: 40 percent;
Outcome: 10/26/05--Approved.
Date submitted: Annual study[D] (originally requested on 10/19/05);
Affected location: Multiple states[E];
Affected services: 14 obstetrical procedures or services;
Amount of increase requested: Medicaid reimbursement amounts;
Outcome: 3/01/10--Approved.
Date submitted: 2/23/06;
Affected location: Fairbanks, Alaska;
Affected services: All anesthesia or pain management and treatment
services delivered by anesthesiologists;
Amount of increase requested: 200 percent;
Outcome: 6/02/06--Approved to increase rates by 252 percent[F].
Date submitted: 7/17/06[G];
Affected location: Puerto Rico[C];
Affected services: Medical procedures or services delivered by
perinatologists, orthopedists, and pediatric urologists;
Amount of increase requested: Various: 310 percent for perinatologists;
300 percent for orthopedists; and 162 percent for pediatric urologists;
Outcome: Denied because the request did not meet the requirements for
a locality waiver.
Date submitted: 7/01/06[G];
Affected location: All of Alaska;
Affected services: All medical procedures or services;
Amount of increase requested: Veterans Affairs rates;
Outcome: 1/01/07--Approved.
Date submitted: 8/07/06[G];
Affected location: Fairbanks, Alaska;
Affected services: Three services delivered by a pulmonologist;
Amount of increase requested: Veterans Affairs rates;
Outcome: 12/13/06--Approved.
Date submitted: 5/24/07[G];
Affected location: Juneau, Alaska;
Affected services: All orthopedic and physical medicine rehabilitation
at Juneau Bone & Joint Center;
Amount of increase requested: 15 percent;
Outcome: 8/06/07--Approved.
Date submitted: 12/18/07[G];
Affected location: Key West, Florida;
Affected services: All psychiatric services in the code range of 90800
through 90899 delivered by two providers;
Amount of increase requested: 50 percent;
Outcome: 1/07/08--Approved for patients 18 and under within the 33040
zip code.
Date submitted: 4/16/08[G];
Affected location: Puerto Rico[C];
Affected services: All medically indicated bilateral breast reduction
surgeries delivered by surgeons;
Amount of increase requested: $2,600 (bilateral procedure);
Outcome: 6/19/08--Approved.
Date submitted: 8/22/08[G];
Affected location: Juneau, Alaska;
Affected services: Orthopedic and physical medicine/rehabilitation
services at Juneau Bone & Joint Center;
Amount of increase requested: 35 percent;
Outcome: 9/05/08--Approved.
Date submitted: 5/05/09[G];
Affected location: Anchorage/Palmer, Alaska;
Affected services: Neurosurgical services for three provider groups;
Amount of increase requested: 250 percent;
Outcome: 7/14/09--Approved.
Date submitted: 8/20/09[G];
Affected location: Anchorage area, Alaska;
Affected services: Pain management services for four provider groups
in and around the Anchorage area;
Amount of increase requested: 217 percent;
Outcome: 11/17/09--Approved.
Date submitted: 11/13/09[G];
Affected location: All of Alaska;
Affected services: Certain rheumatology, orthopedics, and
otolaryngology services;
Amount of increase requested: Various: 125 percent for rheumatologists;
between 150 and 175 percent for orthopedists; and 175 percent for
otolaryngologists;
Outcome: 12/30/09--Approved for certain rheumatology, orthopedics, and
otolaryngology services provided by the 14 practices which have signed
letters of intent to provide these services, as well as any other
practices which sign a letter of intent to provide these services.
Source: GAO analysis of TRICARE Management Activity (TMA) data.
[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] Participating providers submit claims for reimbursement and accept
the TRICARE reimbursement rate as payment in full.
[C] The TRICARE Regional Offices are not responsible for managing
TRICARE in Puerto Rico because it operates under a different contract
than what is used for the three TRICARE regions.
[D] When reviewing the need for this rate adjustment, TMA annually
compares TRICARE reimbursement rates with Medicaid rates in states for
which data are available. The 19 states listed were identified as
needing a rate adjustment based on this analysis. The first of these
waivers was approved in 2006 and included only 12 states. Each year
when the TRICARE reimbursement rates are adjusted, TMA intends to
similarly determine where this adjustment is needed.
[E] The states are Alabama, Arizona, Connecticut, Georgia,
Massachusetts, Montana, Nebraska, New Mexico, New York, North Dakota,
Oregon, Pennsylvania, South Carolina, South Dakota, Vermont, Virginia,
Washington, West Virginia, and Wyoming.
[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.
[G] According to TMA, these dates are the dates the waiver submission
was assigned or received by TMA to better reflect when TMA started to
take action on the request.
[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 in a specific location. Between
January 2002 and January 2011, 13 applications for network waivers
have been submitted to TMA. Of these, eight network waivers have been
approved by TMA and five have been denied. (See table 7.)
Table 7: Applications for Network Waivers and Approval Results:
Date submitted: 1/29/02;
Affected location: Fredericksburg, Virginia;
Affected services: 33 varied medical procedures or services,
encompassing various specialties;
Amount of increase requested: 28 percent[A];
Outcome: Denied--Application did not substantiate an access-to-care
problem.
Date submitted: 3/07/02;
Affected location: Great Falls, Montana;
Affected services: All medical procedures or services delivered by a
specific clinic representing 32 specialties;
Amount of increase requested: 200 percent[A];
Outcome: 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;
Outcome: 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, Montana;
Affected services: All obstetrical or gynecological medical procedures
or services;
Amount of increase requested: 15 percent;
Outcome: Denied--Increase available under TRICARE Prime Remote[B].
Date submitted: 4/08/03;
Affected location: Cheyenne, Wyoming;
Affected services: Three newborn inpatient medical procedures or
services;
Amount of increase requested: To match civilian insurers' rates;
Outcome: 7/16/03--Approved increase to 15 percent above TRICARE
reimbursement rates.
Date submitted: 2/03 and 3/03;
Affected location: Watertown, New York, Norwich, Connecticut;
Affected services: Deliveries provided by nurse midwives in New York
and emergency gynecological services in Connecticut;
Amount of increase requested: Not specified;
Outcome: Denied-Incomplete application package submitted.
Date submitted: 9/26/03;
Affected location: Ft. Leonard Wood and Springfield, Missouri;
Affected services: All medical procedures and services delivered by
network providers;
Amount of increase requested: 15 percent;
Outcome: 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, Alaska;
Affected services: All primary care medical procedures and services;
Amount of increase requested: 15 percent;
Outcome: 3/30/05--Approved for nonmental health medical care services,
excluding laboratory services.
Date submitted: 6/10/05;
Affected location: Norfolk, Virginia;
Affected services: All medical procedures and services for three
specialties delivered by a group of pediatric specialists;
Amount of increase requested: 15 percent;
Outcome: 7/08/05--Approved.
Date submitted: 3/06/06;
Affected location: Rapid City, South Dakota;
Affected services: All obstetrical or gynecological services delivered
by a group of specialists;
Amount of increase requested: Not specified;
Outcome: 5/16/2006--Approved a 15 percent increase for one group of
obstetricians and gynecologists.
Date submitted: 2/16/07[C];
Affected location: Ellsworth Air Force Base, South Dakota;
Affected services: Evaluation and management codes for orthopedic and
rheumatology services by the Black Hills Orthopedic and Spine Center;
Amount of increase requested: 15 percent;
Outcome: 7/13/07--Approved.
Date submitted: 2/26/07[C];
Affected location: Fort Bliss, Texas;
Affected services: Opthalmology services provided by Southwest Retina
Consultants;
Amount of increase requested: 15 percent;
Outcome: Denied because the documentation was not sufficient to
support and justify the waiver.
Date submitted: 1/04/10[C];
Affected location: Hawaii;
Affected services: Inpatient neonatal and pediatric services by
providers at Kapiolani Medical Specialists;
Amount of increase requested: 15 percent;
Outcome: 2/25/10--Approved.
Source: GAO analysis of TRICARE Management Activity (TMA) data.
[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 servicemembers who are enrolled in TRICARE Prime Remote
are eligible to enroll in and receive care under TRICARE Prime Remote
for Active Duty Family Members.
[C] According to TMA, these dates are the dates the waiver submission
was assigned or received by TMA to better reflect when TMA started to
take action on the request.
[End of table]
TMA can also use its authority 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
previously, 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. However, in
2007 TMA implemented a demonstration project in Alaska that increased
reimbursement rates to match those of the Department of Veterans
Affairs. As a result, the waivers implemented under this authority
were ended. As of January 2011, TMA did not have any waivers of
reimbursement rate reductions in place.
[End of section]
Appendix IV: Access-to-Care Concerns in Alaska:
Access to health care in Alaska is hindered by unique impediments due
to its geographically remote location and small population base, which
has resulted in some of the highest costs for providing services in
the country. To identify and examine the unique access concerns for
Alaska, we reviewed the Interagency Access to Health Care in Alaska
Task Force Report to Congress. We also spoke with TMA officials and a
representative of the Alaska State Medical Association to obtain their
views on the unique access challenges in this state.
Federal health programs[Footnote 84] are the leading payer of health
care services to Alaska citizens, constituting approximately 31
percent of total health care expenditures in the state in 2006.
[Footnote 85] In 2010, the Department of Health and Human Services
reported that about 14 percent of the population in Alaska had
received health care from either DOD's TRICARE program or from the
Veterans Health Administration.[Footnote 86] According to a 2009 study
by the Alaska Center for Rural Health, Alaska has a shortage of
providers that has been further impacted by its remoteness, harsh
climate, and scarce training resources.[Footnote 87] Workforce
shortages in urban areas range from a complete lack of certain
specialists in Fairbanks and other towns, to a relative shortage of
primary care providers and many specialists in Anchorage. Moreover,
rural areas have far more difficulty attracting qualified candidates
than more heavily populated areas, such as Anchorage or Fairbanks.
TRICARE officials have identified this overall shortage of providers
and providers' reluctance to accept TRICARE reimbursement rates as the
main impediments to TRICARE beneficiaries' access to civilian
providers in Alaska--regardless of which option they use.
Alaska is part of TRICARE's West region, and until recently, Alaska
was the only state for which TMA administered and managed TRICARE
directly as well as being the only state that did not have Prime
Service Areas with networks of civilian providers.[Footnote 88] In a
November 2010 Federal Register notice, DOD announced that the
responsibility for administering and managing TRICARE in Alaska would
transfer from TMA to the contractor for the West region.[Footnote 89]
Additionally, the notice required the contractor to develop networks
of civilian providers in two Prime Service Areas to be established
around the military treatment facilities located at Fort Wainwright
and Eielson Air Force Base, near Fairbanks, Alaska. This transition of
responsibility took place in January 2011, and TMA expects these Prime
Service Areas to be developed by July 2011. Additionally, the West
region contractor noted that it expects to receive authorization to
develop a third Prime Service Area around Elmendorf Air Force Base in
Anchorage in late summer 2011.
TMA has taken actions to address TRICARE beneficiaries' access to
civilian providers in Alaska by (1) increasing TRICARE's reimbursement
rates through the use of waivers and a demonstration project and (2)
participating in a federal task force on the delivery of health care
in Alaska. Specifically, in areas where access is impaired, TMA has
increased reimbursement rates to encourage civilian providers to
accept TRICARE beneficiaries through TMA's reimbursement waivers. Of
the 24 waivers in place as of January 2011, 13 are for locations in
Alaska.
In addition, TMA began a demonstration project in Alaska in February
2007--originally expected to end in December 2009--that raised
reimbursement rates for physicians and other noninstitutional
professional providers so that on average, they matched those of the
Department of Veterans Affairs. Specifically, TRICARE's 2007
reimbursement rates were increased approximately 35 percent.[Footnote
90] In July 2009, TMA conducted a preliminary assessment of the
demonstration project and found mixed results. Specifically, TMA's
analysis determined that three of seven measures of access to care
indicated that access had improved since the beginning of the project,
while the other four measures did not show an improvement in access.
[Footnote 91] Despite this inconclusive assessment, TMA officials in
the West region said that the demonstration project and the use of
waivers have increased access to care, as the number of providers
accepting TRICARE's reimbursement rates increased. According to these
officials, the number of providers that have accepted TRICARE's
reimbursement rate went from under 300 before the demonstration
project to almost 800, as of July 2010. Although DOD has recognized
that there have been mixed results on the effectiveness of the
demonstration project, it extended the demonstration project through
December 31, 2012.
Finally, in recognition that Alaska has unique health care challenges,
Congress established the Interagency Access to Care in Alaska Task
Force to review how federal agencies with responsibility for health
care services in Alaska are meeting the needs of Alaskans.[Footnote
92] The Task Force consisted of members from the following: DOD
(including TMA), the Department of Veterans Affairs and its Veterans
Health Administration, the Department of Health and Human Services and
its Centers for Medicare & Medicaid Services and Indian Health
Service, and the U.S. Coast Guard. In September 2010, the Task Force
issued its report recommending that, among other things, federal
agencies providing health care reimbursement in Alaska should support
current projects to develop a budget-neutral, uniform provider
reimbursement rate for similar services for Medicare, TRICARE, and the
Veterans Health Administration.[Footnote 93] According to TMA
officials, TMA is currently reviewing the Task Force's recommendations
to develop options within the framework of current law and
regulations. However, the full implementation of the recommendations
will be under the direction of the Secretary of Health and Human
Services.
[End of section]
Appendix V: Network Adequacy Reporting Requirement of Contractors
under the Second Generation of TRICARE Contracts:
Under the second generation of contracts, TMA's contractors have been
required to develop and maintain adequate networks of providers, which
are to meet the needs of all TRICARE beneficiaries within Prime
Service Areas.[Footnote 94] In doing so, each contractor uses a
different methodology for determining the number of providers needed.
Contractors are also required to develop their own systems to
continuously monitor and evaluate network adequacy and to submit
routine reports to TMA on the status of their provider networks in
accordance with contract requirements. Specifically, TMA requires its
contractors to submit monthly and quarterly reports on network
inadequacy and network adequacy, respectively, and to submit
corrective action plans for each instance of network inadequacy.
* The monthly report on network inadequacy must include information on
each instance in which a beneficiary enrolled in TRICARE Prime is
being referred to: (1) a provider outside of TMA's time or distance
standards[Footnote 95] or (2) a nonnetwork provider. According to TMA
officials, network inadequacies may occur because of provider
shortages; in such instances, contractors are not held accountable for
not meeting access standards. However, other network inadequacies,
particularly referrals to nonnetwork providers, may also be due to
other factors, such as network providers not accepting new patients or
beneficiaries' not wanting to wait for available appointments with
network providers who are unable to provide an appointment within
TMA's access standards. According to a TMA official, none of the
contractors have been cited for not meeting TMA's time and distance
standards or for referrals to nonnetwork providers under the second
generation of TRICARE contracts.
* Contractors' quarterly reports include: (1) the total number of
network providers by specialty, (2) the number of additions and
deletions to the network by specialty, and (3) actions to contract
with additional providers in areas lacking networks to meet access
standards, among other things.
[End of section]
Appendix VI: Comments from the Department of Defense:
The Assistant Secretary Of Defense:
Health Affairs:
1200 Defense Pentagon:
Washington, DC 20301-1200:
May 23 2011:
Mr. Randall B. Williamson:
Director:
Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Williamson:
This is the Department of Defense response to the Government
Accountability Office (GAO) draft report, Defense Health Care: Access
to Civilian Providers Under TRICARE Standard and Extra (GA0-11-500,
Code #290858).
Thank you for the opportunity to review and provide comments on the
subject draft report. We have carefully reviewed the draft report and
concur with the report as written. Technical comments are attached to
address portions of your report.
We sincerely thank the GAO for their thorough review and analysis of
issues regarding access to civilian providers under TRICARE Standard
and Extra.
My points of contact on this effort are Mr. Mark Ellis (Functional)
and Mr. Gunther Zimmerman (TRICARE Management Activity Audit Liaison).
Mr. Ellis may be reached at (703) 681-0039, and Mr. Zimmerman may be
reached at (703) 681-4365.
Sincerely,
Signed by:
Jonathan Woodson, M.D.
Attachment: As stated.
[End of section]
Appendix VII: GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Bonnie Anderson, Assistant
Director; Jennie F. Apter; Kaitlin Coffey; Jeff Mayhew; Lisa Motley;
C. Jenna Sondhelm; and Suzanne Worth made major contributions to this
report.
[End of section]
Related GAO Products:
Defense Health Care: 2008 Access to Care Surveys Indicate Some
Problems, but Beneficiary Satisfaction Is Similar to Other Health
Plans. [hyperlink, http://www.gao.gov/products/GAO-10-402].
Washington, D.C.: March 31, 2010.
TRICARE: Changes to Access Policies and Payment Rates for Services
Provided by Civilian Obstetricians. [hyperlink,
http://www.gao.gov/products/GAO-07-941R]. Washington, D.C.: July 31,
2007.
Defense Health Care: Access to Care for Beneficiaries Who Have Not
Enrolled in TRICARE's Managed Care Option. [hyperlink,
http://www.gao.gov/products/GAO-07-48]. Washington, D.C.: December 22,
2006.
Defense Health Care: Oversight of the TRICARE Civilian Provider
Network Should Be Improved. [hyperlink,
http://www.gao.gov/products/GAO-03-928]. Washington, D.C.: July 31,
2003.
Defense Health Care: Oversight of the Adequacy of TRICARE's Civilian
Provider Network Has Weaknesses. [hyperlink,
http://www.gao.gov/products/GAO-03-592T]. Washington, D.C.: March 27,
2003.
Defense Health Care: Across-the-Board Physician Rate Increase Would be
Costly and Unnecessary. [hyperlink,
http://www.gao.gov/products/GAO-01-620]. Washington, D.C.: May 24,
2001.
[End of section]
Footnotes:
[1] Eligible beneficiaries include active duty personnel and their
dependents, medically eligible Reserve and National Guard personnel
and their dependents, and retirees and their dependents and survivors.
[2] The TRICARE program also offers other options, including TRICARE
Reserve Select and TRICARE for Life. TRICARE Reserve Select is a
premium-based health plan that qualified Reserve and National Guard
members may purchase, with care options that are similar to those of
TRICARE Standard and Extra. TRICARE beneficiaries who are eligible for
Medicare and enroll in Part B are eligible to receive care under
TRICARE for Life.
[3] Eligible beneficiaries may choose not to use TRICARE if, for
example, they are covered by another health care plan.
[4] Prime Service Areas are geographic areas determined by the
Assistant Secretary of Defense for Health Affairs and are defined by a
set of 5-digit zip codes, usually within an approximate 40-mile radius
of a military inpatient treatment facility. The managed care support
contracts also require the contractors to develop civilian provider
networks at all Base Realignment and Closure (BRAC) sites, which are
military installations that have been closed or realigned as a result
of decisions made by the Commission on Base Realignment and Closure.
[5] A network provider is a provider who has a contractual
relationship with the TRICARE regional contractors to provide care at
a negotiated rate.
[6] See Pub. L. No. 108-136, § 723, 117 Stat. 1392, 1532-34 (2003) and
S. Rep. No. 108-46, at 330 (2003).
[7] GAO, Defense Health Care: Access to Care for Beneficiaries Who
Have Not Enrolled in TRICARE's Managed Care Option. [hyperlink,
http://www.gao.gov/products/GAO-07-48] (Washington, D.C.: Dec. 22,
2006).
[8] See Pub. L. No. 110-181, § 711(a), 122 Stat. 3, 190-91.
[9] GAO, Defense Health Care: 2008 Access to Care Surveys Indicate
Some Problems, but Beneficiary Satisfaction Is Similar to Other Health
Plans, [hyperlink, http://www.gao.gov/products/GAO-10-402]
(Washington, D.C.; Mar. 31, 2010).
[10] Department of Defense, Task Force on Mental Health, An Achievable
Vision: Report of the Department of Defense Task Force on Mental
Health (Falls Church, Va., June 2007).
[11] CNA is a nonprofit research organization that operates the Center
for Naval Analyses and the Institute for Public Research.
[12] The contracts included in our review are the second generation of
TRICARE contracts. The implementation period for these contracts was
set to end on March 31, 2010, with the third generation of contracts
to begin implementation on April 1, 2010. However, this timeline was
delayed due to bid protests on two of the three contracts.
[13] The TRICARE Prime option has five access-to-care standards that
address the following: (1) travel time, (2) appointment wait time, (3)
availability and accessibility of emergency services, (4) composition
of network specialists, and (5) office wait time. See 32 C.F.R. §
199.17(p)(5) (2010).
[14] TRICARE beneficiaries who choose to receive medical care from
providers who are not TRICARE-authorized are responsible for all
billed charges. Civilian providers consist of primary care physicians,
specialists, certified clinical social workers, certified psychiatric
nurse specialists, clinical psychologists, certified marriage and
family therapists, pastoral counselors, mental health counselors, and
psychiatrists.
[15] Network providers also undergo a formal credentialing process
through the contractor. Credentialing includes a review of the
provider's training, educational degrees, licensure, practice history,
etc.
[16] Beginning in fiscal year 1991, 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. Congress specified that reductions were not to
exceed 15 percent in a given year. See 10 U.S.C. §§ 1079(h), 1086(f).
[17] 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.
[18] Claims analyzed were for services provided in an office or other
setting outside of an institution. Claims for services rendered at
hospitals, military treatment facilities, and other institutions were
excluded. TRICARE for Life claims were excluded as well as claims for
medical supplies and from chiropractors and pharmacies.
[19] See [hyperlink, http://www.gao.gov/products/GAO-07-48].
[20] TMA's first multiyear survey of civilian providers had
approximately 18,000, 18,900, and 19,000 responses in 2005, 2006, and
2007 respectively, for an eligible physician response rate of about 50
percent each year.
[21] The first 2 years of TMA's second multiyear survey of civilian
providers had 19,309 responses in 2008 and 19,812 responses in 2009
for a 2-year adjusted response rate of 39 percent. TRICARE's
reimbursement rates, along with a lack of awareness of the TRICARE
program were tied for the most-cited reasons by providers who were
accepting new Medicare patients, but would not accept new TRICARE
patients over all regions surveyed.
[22] Levy, Robert A., and Gabay, Mary, Some Additional Findings
Related to the Acceptance by Civilian Providers of TRICARE Standard,
CNA Research Memorandum D0019101.A2/Final (November 2008). TMA tasked
CNA to examine the current participation of civilian providers in the
TRICARE program, focusing on potential reasons that may inhibit many
of these providers from accepting TRICARE Standard and Extra
beneficiaries as patients.
[23] Beginning in fiscal year 1991, 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. Congress specified that reductions were not to
exceed 15 percent in a given year. See 10 U.S.C. §§ 1079(h), 1086(f).
As of March 2011, the transition to Medicare rates was nearly
complete, and reimbursement rates for only 43 services remain higher
than Medicare reimbursement rates. (See appendix I for a list of these
services.)
[24] The Medicare physician fee schedule is updated annually by the
sustainable growth rate system, with the intent of limiting the total
growth in Medicare spending for physician services over time. Because
of rapid growth in Medicare spending for physician services, the
sustainable growth rate has called for fee reductions since 2002.
However, congressional action has temporarily averted such fee
reductions for 2003 through 2011. Although under current law,
Medicare's fees to physicians are scheduled to be reduced by about
29.5 percent in 2012, Congress has considered ways to repeal or
replace the sustainable growth rate system for a number of years. See
42 U.S.C. § 1395w-4(d).
[25] For more information on TMA's changes to its physician payment
rates for obstetric care, see GAO, TRICARE: Changes to Access Policies
and Payment Rates for Services Provided by Civilian Obstetricians,
[hyperlink, http://www.gao.gov/products/GAO-07-941R] (Washington,
D.C.: July 31, 2007).
[26] 32 C.F.R. § 199.14(j)(1)(iv)(D) (2010). According to a TMA
official, TMA usually defines a locality using one or more zip codes.
[27] 32 C.F.R. § 199.14(j)(1)(iv)(E) (2010).
[28] 32 C.F.R. § 199.14(j)(1)(iv)(C) (2010).
[29] According to TMA, from fiscal year 2006 to 2009, 44,000
additional civilian providers (network and nonnetwork) accepted
TRICARE (a more than 13 percent increase).
[30] See for example: Institute of Medicine, Hospital-Based Emergency
Care: At the Breaking Point, (Washington, D.C.: The National Academies
Press, 2006), and Center for Workforce Studies, Association of
American Medical Colleges, Recent Studies and Reports on Physician
Shortages in the U.S. (November 2010).
[31] 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 generally required to make the bonus payments in the same amounts
as authorized for Medicare. See 32 C.F.R. § 199.14(j)(2) (2010).
[32] See 42 U.S.C. § 1395l(m). Health Professional Shortage Areas
include both urban and rural areas. For example, Fulton County,
Georgia, (which could be considered an urban area) contains 90 Health
Professional Shortage Areas because it lacks primary and mental health
care providers. Likewise, the state of Alaska (which is predominantly
considered to be a rural area) contains 141 Health Professional
Shortage Areas that lack primary and mental health care providers.
[33] American Psychological Association, Presidential Task Force on
Military Deployment Services for Youth, Families and Service Members,
The Psychological Needs of U.S. Military Service Members and Their
Families: A Preliminary Report (Feb. 18, 2007).
[34] Department of Defense, Report to Congress: Access to Mental
Health Services (Sept. 9, 2009).
[35] According to the first 2 years of TMA's second round of provider
surveys, less than 46 percent of responding psychiatrists who were
accepting any new patients would accept new nonenrolled beneficiaries,
compared to almost 69 percent of responding primary care providers and
almost 72 percent of responding specialist providers.
[36] TMA's Telemental Health Program, which began on August 1, 2009,
uses medically supervised, secure audio-visual conferencing to link
beneficiaries in one location with mental health care providers in
another. These providers can evaluate, treat, and refer patients as
necessary by video.
[37] TMA's TRICARE Assistance Program, which began on August 1, 2009,
allows eligible beneficiaries to access licensed counselors for
nonmedical issues including stress management and deployment issues.
[38] These beneficiaries include active duty family members and those
using TRICARE Reserve Select.
[39] The law also required the Secretary of Defense to assess the
feasibility of establishing one or more military mental health
specialties for officers or enlisted servicemembers and required the
secretary of each military department to increase the authorized
number of active-duty mental health personnel by at least 25 percent.
See Pub. L. No. 111-84, § 714, 123 Stat. 2190, 2381-82 (2009).
[40] DOD, Mental Health Personnel Required to Meet Mental Health Care
Needs of Service Members, Retired Members, and Dependents; Report to
Congress (Feb. 1, 2011).
[41] Contractors have only been required to monitor access to care for
TRICARE Prime beneficiaries. To do this, contractors are to determine
the adequacy of civilian provider networks. Although TRICARE Prime is
the only option with required access-to-care standards, network
adequacy may also affect nonenrolled beneficiaries who use network
providers. (See appendix V for information on network adequacy
requirements which are used to gauge access to care.)
[42] TMA's reported results showed that on average, 92 percent of
civilian providers were accepting any new patients.
[43] See [hyperlink, http://www.gao.gov/products/GAO-10-402].
[44] The law also directed DOD to give high priority to locations
having high concentrations of Selected Reserve servicemembers, which
would likely result in surveying beneficiaries who may be under the
TRICARE Reserve Select option. However, TMA did not give a high
priority to locations with high concentrations of Selected Reserve
members. Instead, for both of its surveys, TMA randomly selected areas
to produce results that can be generalized to the populations from
which the survey samples were drawn. TMA plans to cover the entire
United States at the end of the 4-year survey period, which will
include any locations with higher concentrations of Selected Reserve
servicemembers.
[45] The Assistance Reporting Tool does not include information
reported to the contractors. Implemented in 2001, this tool is used by
customer service staff in TRICARE program offices, military treatment
facilities, and the uniformed services.
[46] The Graduate Medical Education National Advisory Committee
projected the need for and supply of physicians and other providers
and developed guidelines for the geographic distribution of physicians.
[47] Welcome Tool Kits are distributed to new providers who join the
contractor's developed network, and may include reference charts, the
TRICARE Provider Handbook, and a welcome letter.
[48] The second generation of managed care support contracts are
performance-based contracts. A performance-based contract includes
certain performance standards that those offerors submitting bids must
achieve if selected for the contract or they may be subject to certain
penalties. In their bids for the contract, offerors may also submit
additional performance standards for incorporation into the contract
where the request for proposal does not have a minimum standard. Under
these managed care support contracts, contractors have different
requirements related to provider education due to contractors'
submission of additional performance standards during the solicitation
period.
[49] While these examples are unique to these contractors' contracts,
all three contractors may offer these resources to the providers in
their regions.
[50] TMA developed the TRICARE Provider Handbook and updates it
annually to inform providers about basic and important information
about TRICARE and emphasize key operational aspects of the program and
program options. The handbook assists providers in coordinating care
for TRICARE beneficiaries, and contains information about specific
TRICARE programs, policies, and procedures. Any TRICARE program
changes and updates may be communicated periodically through the
TRICARE Provider News publications.
[51] Social media refers to services that enable individuals to
publicly create, share, and discuss information. These services
include Facebook and Twitter.
[52] TMA's second civilian provider survey (2008 and 2009) was fielded
as two versions. The first version was fielded to physicians,
including psychiatrists. The second version was fielded to
nonphysician mental health providers, including: (1) certified
marriage and family therapists, (2) mental health counselors, (3)
pastoral counselors, (4) certified psychiatric nurse specialists, (5)
clinical psychologists, and (6) certified clinical social workers.
[53] TMA's consultant conducted analyses of the responses to determine
whether they could be generalized to the populations surveyed and
found that their responses could not be generalized. As each survey
year's results are cumulative, the results may be generalizable at the
end of the 4-year survey period.
[54] The result reported above is from responses to the physician
survey.
[55] Levy, Robert A., and Gabay, Mary, Some Additional Findings
Related to the Acceptance by Civilian Providers of TRICARE Standard
(Nov. 2008, p. 4, 29-30).
[56] TMA's Communications and Customer Service annually provides the
contractors with a mail file that includes the residential addresses
of TRICARE Standard beneficiaries for the purpose of mailing the
annual newsletter. TRICARE Extra beneficiaries are included in this
list because they are the same as TRICARE Standard beneficiaries
except that they choose to obtain health care from network providers.
[57] Although TRICARE Standard and Extra beneficiaries are not
required to enroll, these beneficiaries can sign-up for e-mail alerts
that deliver the latest TRICARE information. According to a TMA
official, the contractors may also collect beneficiaries' e-mail
addresses and use these e-mail addresses to communicate with
beneficiaries.
[58] The TRICARE Standard Handbook has been developed to guide TRICARE
beneficiaries in using the Standard and Extra options. It explains the
different types of TRICARE providers and outlines services covered
under TRICARE Standard and Extra as well as costs and requirements.
[59] See 10 U.S.C. §§ 1079(h), 1086(f).
[60] According to a TMA official, this TRICARE policy was established
in 1998 because Medicare decreased the maternity rates by 10 percent
that year. The official also noted that TMA determined this 10 percent
decrease would jeopardize access and decided that the rates should not
fall below the 1997 levels.
[61] See the 2011 report at Kennell, D., Witsberger, C., Doukeris, C.,
Information on Maternity CMACs for 2011 (Task Order No. 3005-001),
Kennell and Associates, Inc. (Feb. 1, 2011). This report contains
summaries of all previous analyses beginning in 2006.
[62] Medicaid is the joint federal-state program that provides health
care coverage for certain low-income individuals.
[63] TMA's consultant reviewed data from 47 states (all except
Tennessee, Delaware, and Rhode Island). A state was identified as
having TRICARE reimbursement rates below Medicaid if the TRICARE
reimbursement rate in any locality was below the Medicaid rate for any
of 6 specific maternity/delivery current procedural terminology (CPT)
codes. For any state where at least 1 of these 6 TRICARE reimbursement
rates were below the Medicaid rate, the rates for 14 CPT codes (the 6
specific codes plus 8 others) were set at the greater of the TRICARE
reimbursement rate or the Medicaid rate.
[64] TMA's consultant reviewed data from the 12 states identified in
2006, as well as Idaho, Oklahoma, Virginia, North Carolina, Maryland,
Alabama, Vermont, Utah, Kentucky, New Hampshire, and Illinois.
[65] For the 2008, 2009, 2010, and 2011 studies, TMA's consultant
reviewed data from all states except Tennessee.
[66] Kennell, D., Brooks, A., Witsberger, C., Cottrell, L., Caney, K.,
Comparison of Commercial, Medicaid, and TRICARE Reimbursement Rates
for Physicians (Task Order 1005-009), Kennell and Associates, Inc.
(Apr. 22, 2009).
[67] In order to capture differences between different types of
physicians, TMA's consultant examined 13 specialties that provide the
vast majority of physician services to TRICARE beneficiaries. The 13
specialties were (1) general and family practice providers, (2)
pediatricians, (3) internists, (4) obstetricians/gynecologists, (5)
psychiatrists, (6) psychologists, (7) cardiologists, (8) orthopedic
surgeons, (9) radiologists, (10) general surgeons, (11)
gastroenterologists, (12) physical medicine specialists, and (13)
ophthalmologists.
[68] Tennessee was not included as it did not have a Medicaid fee-for-
service program.
[69] There was insufficient commercial data to analyze rates for
obstetricians.
[70] The geographic market areas were equally distributed among the
three TRICARE regions: two high-volume TRICARE markets and three
smaller markets in each region.
[71] Kennell, D., Brooks, A., Witsberger, C., TRICARE Reimbursement of
Pediatric Vaccines and Immunizations (Task Order No. 1005-005),
Kennell and Associates, Inc. (Jan. 14, 2009).
[72] At the time of the study, TRICARE reimbursed providers for
pediatric vaccines in two components: (1) a reimbursement for the
vaccine and (2) a separate amount (in many cases) for the
administration of the vaccine.
[73] Network providers may agree to accept lower reimbursements as a
condition of network participation.
[74] According to the study, TRICARE payments for pediatric vaccines
could not be compared to Medicaid payments because pediatric vaccines
were typically supplied free to pediatricians by states and/or the
Centers for Disease Control and Prevention's Vaccines for Children
program. The Vaccines for Children program provides free vaccines to
enrolled public and private providers for recommended immunizations
for children who are Medicaid-eligible, uninsured, on Medicaid,
American Indian/Alaska Native, or underinsured by having insurance
that does not cover routine immunizations. When a pediatrician
receives Vaccines for Children products free, he or she is usually
paid an administration fee by most Medicaid programs which generally
ranges between $3 and $10, with most states paying between $4 and $6.
TRICARE's 2008 reimbursement rate for this same service is $20.57.
[75] Kennell and Associates, Inc., Analysis of TRICARE Payment Rates
for Maternity/Delivery Services, Evaluation and Management Services,
and Pediatric Immunizations (Mar. 30, 2006).
[76] The study examined the 14 maternity/delivery CPT codes with the
highest number of TRICARE purchased care uses, as well as the most
frequently billed CPT code under TRICARE used by pediatricians--a mid-
level office visit for an established patient.
[77] The study examined the 2006 state Medicaid rates for 45 states.
According to the study, Tennessee and Delaware did not have fee-for-
service Medicaid programs at the time of the study, and Massachusetts,
Rhode Island, and Kansas' data were unavailable.
[78] The study examined the median commercial rates for September 2005
in the 50 areas with the highest number of TRICARE purchased care
deliveries in fiscal year 2005.
[79] Three of the four states in which the Medicaid rates exceeded
TRICARE's reimbursement rates for this service were states that also
had higher Medicaid rates for maternity/delivery services. The fourth
state had Medicaid rates that were roughly equal to TRICARE's
reimbursement rate for this service.
[80] See 10 U.S.C. §§ 1079(h)(1), 1086(f).
[81] 32 C.F.R. § 199.14(j)(1)(iv)(D) (2010). According to a TMA
official, TMA usually defines a locality using one or more zip codes.
[82] 32 C.F.R. § 199.14(j)(1)(iv)(E) (2010).
[83] 32 C.F.R. § 199.14(j)(1)(iv)(C) (2010).
[84] The federal responsibility for health care in Alaska includes,
but is not limited to, providing or funding health care to users of
the Indian Health Service, Medicare, Medicaid, TRICARE, and Veterans
Health Administration.
[85] See Sebelius, Kathleen, Secretary of Health and Human Services,
Report to Congress of the Interagency Access to Health Care in Alaska
Task Force (Sept. 17, 2010, p. 19).
[86] Alaska ranks first in the nation in the percent of population
receiving TRICARE or Veterans Health Administration paid services. The
national average is about 4 percent of the population. See Report to
Congress of the Interagency Access to Health Care in Alaska Task Force
(Sept. 17, 2010, p.19).
[87] Alaska Center for Rural Health, Alaska's AHEC Institute of Social
and Economic Research, 2009 Alaska Health Workforce Vacancy Study
(December 2009).
[88] TRICARE administration and management in each of the other 49
states was overseen by one of three regional contractors.
[89] See 75 Fed. Reg. 67,695 (Nov. 3, 2010).
[90] TMA calculated that, on average, the Department of Veterans
Affairs reimbursement rates were 35 percent higher than TRICARE's
rates in 2006, and 73 percent higher than Medicare's rates in Alaska.
The 13 reimbursement waivers in Alaska are in addition to the
demonstration project rate increases.
[91] The seven measures included: (1) the number of unique
beneficiaries who received civilian care; (2) the number of unique
civilian physicians who saw a TRICARE beneficiary; (3) the number of
services (visits and other services) received by TRICARE patients; (4)
the number of civilian emergency room visits; (5) the number of visits
and admissions by Alaska residents outside of Alaska (prior to 2007,
many beneficiaries had to be sent outside of Alaska for services
because physicians would not treat them in Alaska); (6) the number of
TRICARE waivers granted for active-duty servicemembers; and (7) survey
information on whether physicians are willing to accept TRICARE
Standard patients (this indicator of access is based on results of TMA
surveys). These seven measures were developed in discussions with TMA
and TRICARE Regional Office officials.
[92] See Patient Protection and Affordable Care Act, Pub. L. No. 111-
148, § 10501(b), 124 Stat. 119, 993-94 (2010) (adding section 5104 to
PPACA).
[93] See Report to Congress of the Interagency Access to Health Care
in Alaska Task Force (Sept. 17, 2010).
[94] TMA defines an "adequate network" as one that ensures that all
access standards are continuously maintained in all TRICARE Prime
Service Areas for the delivery of health care under TRICARE Prime and
Extra.
[95] Among others, these time and distance standards set allowable
travel and appointment wait times. Specifically, under normal
circumstances, travel time may not exceed 30 minutes from home to
primary care delivery site, or 1 hour from home for specialty care,
unless a longer time is necessary because of the absence of providers
(including providers not part of the network) in the area.
Additionally, the wait time for an appointment for well-patient visits
or specialty care referrals shall not exceed 4 weeks; for a routine
visit, the wait time for an appointment shall not exceed 1 week; and
for an urgent care visit the wait time for an appointment shall
generally not exceed 24 hours. Office waiting times in nonemergency
circumstances must not exceed 30 minutes, except when emergency care
is being provided to patients and disrupts the normal schedule. See 32
C.F.R. § 199.17(p)(5) (2010).
[End of section]
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