Defense Health Care

TRICARE, the Defense Department's (DOD) managed health care program, covers 8.1 million active-duty personnel, their dependents, and retirees at an annual cost of $15.6 billion. Today, DOD is not meeting its standards for scheduling beneficiary appointments, even for active-duty members. Even though contractors are meeting TRICARE claims processing timeliness standards, millions of claims are paid late, and claims processing continues to burden beneficiaries, civilian providers, and TRICARE contractors and managers. DOD's efforts under way to combat health care fraud have not yet been effective, and additional opportunities exist to save hundreds of millions of dollars. To cost-effectively meet beneficiaries' needs for prescription drugs, a top-to-bottom redesign of the pharmacy program and its contractors is needed.

GAO noted that: (1) DOD is not meeting its standards for scheduling beneficiary appointments, even for active-duty members; (2) also, even though contractors are meeting TRICARE claims processing timeliness standards, millions of claims are paid late, and claims processing continues to burden beneficiaries, civilian providers, and TRICARE contractors and managers; (3) additionally, although DOD has efforts under way to combat health care fraud, these efforts have not yet been effective, and additional opportunities exist to save hundreds of millions of dollars; (4) to cost-effectively meet beneficiaries' needs for prescription drugs, a top-to-bottom redesign of the pharmacy programs of DOD and its contractors is needed; (5) GAO has offered a number of recommendations regarding timely access to appointments and the pharmacy programs, which GAO believes, and DOD agrees, should help address these issues; and (6) whether these operational difficulties will continue depends largely on the extent to which TRICARE management increases its attention and actions to fully resolve these problems.