Defense Health Care:

Oversight of the TRICARE Civilian Provider Network Should Be Improved

GAO-03-928: Published: Jul 31, 2003. Publicly Released: Jul 31, 2003.

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Testifying before Congress in 2002, military beneficiary groups described problems accessing care from TRICARE's civilian medical providers. Providers also testified on their dissatisfaction with the TRICARE program, specifying low reimbursement rates and administrative burdens. The Bob Stump National Defense Authorization Act of 2003 required GAO to review the oversight of the TRICARE network of civilian providers. Specifically, GAO describes how the Department of Defense (DOD) oversees the adequacy of the civilian provider network, evaluates DOD's oversight of the civilian provider network, and describes the factors that have been reported to contribute to network inadequacy. GAO analyzed TRICARE Prime--the managed care component of TRICARE. To describe and evaluate DOD's oversight, GAO reviewed and analyzed information from reports on network adequacy and interviewed DOD and contractor officials in 5 of 11 TRICARE regions.

For the 8.7 million TRICARE beneficiaries, DOD relies on the civilian provider network to supplement health care delivered by its military treatment facilities. To ensure the adequacy of the civilian provider network, DOD has standards for the number and mix of providers, both primary care and specialists, necessary to satisfy TRICARE Prime beneficiaries' needs. In addition, DOD has standards for appointment wait, office wait, and travel times to ensure that TRICARE Prime beneficiaries have timely access to care. DOD has delegated oversight of the civilian provider network to the local level through regional TRICARE lead agents. DOD's ability to effectively oversee the TRICARE civilian provider network is hindered in several ways. First, the measurement used to determine if there is a sufficient number and mix of providers in a geographic area does not always account for the total number of beneficiaries who may seek care or the availability of providers. This may result in an underestimation of the number of providers needed in an area. Second, incomplete contractor reporting on access to care makes it difficult for DOD to assess compliance with these standards. Finally, DOD does not systematically collect and analyze beneficiary complaints, which might assist in identifying inadequacies in the civilian provider network. However, DOD has tools, such as surveys of network providers and automated reporting systems which, while not designed specifically for monitoring the civilian provider network, could, if modified, improve DOD's ability to oversee the network. DOD and its contractors have reported that a lack of providers in certain geographic locations, low reimbursement rates, and administrative requirements contribute to potential civilian provider network inadequacy. DOD and contractors have reported long-standing provider shortages in some geographic areas. In areas where DOD determines that access to care is severely impaired, DOD has the authority to increase reimbursement rates. Since 2002, DOD has used its reimbursement authority to increase rates in Alaska and Idaho in an attempt to entice more providers to join the network. DOD officials told us that the contractors have achieved some success in recruiting additional providers by using this authority. Additionally, civilian providers have expressed concerns that TRICARE's reimbursement rates are generally too low and administrative requirements too cumbersome. However, while reimbursement rates and administrative requirements may have created provider dissatisfaction, it is not clear how much this has affected civilian provider network adequacy except in limited geographic locations, because the information contractors provide to DOD is not sufficient to measure network adequacy.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In March 2004, DOD began implementing a Centralized Assessment of Customer Feedback System to collect beneficiary feedback to customer service staff, monitor and analyze data, and explore new trends with program managers and beneficiaries.

    Recommendation: To improve DOD's oversight of the civilian provider network, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to explore ways to ensure that beneficiary complaints are systematically evaluated and used to oversee the civilian provider network.

    Agency Affected: Department of Defense

  2. Status: Closed - Not Implemented

    Comments: Since GAO made this recommendation, the Department of Defense (DOD) implemented new TRICARE contracts. Under these contracts, DOD uses a new method for ensuring network adequacy. Specifically, contractors are now required to ensure that no less than 96 percent of contractor referrals within a service are are referred to an MTF or network provider with an appointment available with in the access standards. Contractors must also inform DOD within 24 hours of any instance of network inadequacy and must submit a corrective action plan with each notice of network inadequacy. Contractor fees are withheld when they fail to meet the standard.

    Recommendation: To improve DOD's oversight of the civilian provider network, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to ensure that the information reported on the required access standards is sufficient and reliable.

    Agency Affected: Department of Defense

  3. Status: Closed - Not Implemented

    Comments: Since GAO made this recommendation, the Department of Defense (DOD) implemented new TRICARE contracts. Under these contracts, DOD uses a new method for ensuring network adequacy. Specifically, contractors are now required to ensure that no less than 96 percent of contractor referrals within a service are referred to an MTF or network provider with an appointment available with in the access standards. Contractors must also inform DOD within 24 hours of any instance of network inadequacy and must submit a corrective action plan with each notice of network inadequacy. Contractor fees are withheld when they fail to meet the standard.

    Recommendation: To improve DOD's oversight of the civilian provider network, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to ensure that military treatment facility capabilities and all enrolled Prime beneficiaries in prime service areas are accounted for when assessing and documenting the adequacy of the civilian provider network.

    Agency Affected: Department of Defense

  4. Status: Closed - Implemented

    Comments: In addition to our recommendation, the National Defense Authorization Act for FY2004 directed DOD to conduct a survey of U.S. civilian providers annually until all market areas in the United States have been surveyed. In response, DOD contracted for the first survey of civilian providers in August 2004.

    Recommendation: To improve DOD's oversight of the civilian provider network, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to explore options for improving the civilian provider surveys so that the results of the surveys could be useful to DOD and the contractors in identifying civilian provider concerns and developing actions that might mitigate concerns and help ensure the adequacy of the civilian provider network.

    Agency Affected: Department of Defense

 

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