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entitled 'Defense Health Care: Oversight of the TRICARE Civilian 
Provider Network Should Be Improved' which was released on July 31, 
2003.

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Report to Congressional Committees:

United States General Accounting Office:

GAO:

July 2003:

Defense Health Care:

Oversight of the TRICARE Civilian Provider Network Should Be Improved:

TRICARE Civilian Provider Network:

GAO-03-928:

GAO Highlights:

Highlights of GAO-03-928, a report to congressional committees 

Why GAO Did This Study:

Testifying before Congress in 2002, military beneficiary groups 
described problems accessing care from TRICARE’s civilian medical 
providers. Providers also testified on their dissatisfaction with the 
TRICARE program, specifying low reimbursement rates and administrative 
burdens. 

The Bob Stump National Defense Authorization Act of 2003 required GAO 
to review the oversight of the TRICARE network of civilian providers. 
Specifically, GAO describes how the Department of Defense (DOD) 
oversees the adequacy of the civilian provider network, evaluates DOD’s oversight of the civilian provider network, and describes the factors that have been reported to contribute to network inadequacy.

GAO analyzed TRICARE Prime—the managed care component of TRICARE. To 
describe and evaluate DOD’s oversight, GAO reviewed and analyzed 
information from reports on network adequacy and interviewed DOD and 
contractor officials in 5 of 11 TRICARE regions. 

What GAO Found:

For the 8.7 million TRICARE beneficiaries, DOD relies on the civilian 
provider network to supplement health care delivered by its military 
treatment facilities. To ensure the adequacy of the civilian provider 
network, DOD has standards for the number and mix of providers, both 
primary care and specialists, necessary to satisfy TRICARE Prime 
beneficiaries’ needs. In addition, DOD has standards for appointment 
wait, office wait, and travel times to ensure that TRICARE Prime 
beneficiaries have timely access to care. DOD has delegated oversight 
of the civilian provider network to the local level through regional 
TRICARE lead agents. 

DOD’s ability to effectively oversee the TRICARE civilian provider 
network is hindered in several ways. First, the measurement used to 
determine if there is a sufficient number and mix of providers in a 
geographic area does not always account for the total number of 
beneficiaries who may seek care or the availability of providers. This 
may result in an underestimation of the number of providers needed in 
an area. Second, incomplete contractor reporting on access to care 
makes it difficult for DOD to assess compliance with these standards. 
Finally, DOD does not systematically collect and analyze beneficiary 
complaints, which might assist in identifying inadequacies in the 
civilian provider network. However, DOD has tools, such as surveys of 
network providers and automated reporting systems which, while not 
designed specifically for monitoring the civilian provider network, 
could, if modified, improve DOD’s ability to oversee the network.

DOD and its contractors have reported that a lack of providers in 
certain geographic locations, low reimbursement rates, and 
administrative requirements contribute to potential civilian provider 
network inadequacy. DOD and contractors have reported long-standing 
provider shortages in some geographic areas. In areas where DOD 
determines that access to care is severely impaired, DOD has the 
authority to increase reimbursement rates. Since 2002, DOD has used 
its reimbursement authority to increase rates in Alaska and Idaho in 
an attempt to entice more providers to join the network. DOD officials 
told us that the contractors have achieved some success in recruiting 
additional providers by using this authority. Additionally, civilian 
providers have expressed concerns that TRICARE’s reimbursement rates 
are generally too low and administrative requirements too cumbersome. 
However, while reimbursement rates and administrative requirements may 
have created provider dissatisfaction, it is not clear how much this 
has affected civilian provider network adequacy except in limited 
geographic locations, because the information contractors provide to 
DOD is not sufficient to measure network adequacy.

What GAO Recommends: 

GAO recommends that DOD improve its oversight of the civilian provider 
network by ensuring sufficient information is reported and by 
exploring options for evaluating beneficiary complaints and improving 
provider survey data. DOD concurred with the recommendations.

www.gao.gov/cgi-bin/getrpt?GAO-03-928.

To view the full product, including the scope and methodology, click 
on the link above. For more information, contact Marjorie Kanof at 
(202) 512-7101.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

DOD Has Standards for Network Adequacy and Requires Contractors' 
Compliance:

DOD's Oversight of the Civilian Provider Network Has Weaknesses, But 
Additional Tools May Help:

DOD and Contractors Report Three Factors That May Contribute to 
Civilian Provider Network Inadequacy:

New Contracts May Address Some Network Concerns, But May Create Others:

Conclusions:

Recommendations for Executive Action:

Agency Comments and Our Evaluation:

Appendix I: Scope and Methodology:

Appendix II: Comparison of Current and Future TRICARE Regions:

Appendix III: Comments from the Department of Defense:

Appendix IV: GAO Contacts and Staff Acknowledgments:

GAO Contacts:

Acknowledgments:

Figures:

Figure 1: Areas of the United States with a TRICARE Network of Civilian 
Providers:

Figure 2: Current TRICARE Regions:

Figure 3: Future TRICARE Regions After TNEX Implementation:

Abbreviations:

ATC: Access To Care Project:  

DOD: Department of Defense:  

EWRAS: Enterprise Wide Referral and Authorization System: 

HCSDB: Health Care Survey of DOD Beneficiaries: 

JCAHO: Joint Commission on Accreditation of Healthcare Organizations:  

MOAA: Military Officers Association of America:  

MTF: military treatment facility:  

NCQA: National Committee for Quality Assurance:  

PCM: primary care manager: 

TMA: TRICARE Management Activity:

United States General Accounting Office:

Washington, DC 20548:

July 31, 2003:

The Honorable John Warner
Chairman 
The Honorable Carl Levin 
Ranking Minority Member 
Committee on Armed Services 
United States Senate:

The Honorable Duncan L. Hunter 
Chairman 
The Honorable Ike Skelton 
Ranking Minority Member 
Committee on Armed Services 
House of Representatives:

The primary mission of TRICARE, the Department of Defense's (DOD) 
health care system, is to provide care for eligible active duty 
personnel, retirees, and dependents. These beneficiaries, currently 
numbering more than 8.7 million, can receive their care through 
military hospitals and clinics called military treatment facilities 
(MTFs) or through TRICARE's civilian provider network. The civilian 
provider network is developed by managed care support contractors and 
is designed to complement the availability of care offered by 
MTFs.[Footnote 1]

DOD faces new challenges in ensuring that the TRICARE civilian provider 
network can provide adequate access to care that complements the 
capabilities of MTFs. In 2003, DOD intends to award new contracts for 
the delivery of care in the civilian provider network because the 
current contracts will expire. As a result, the providers who choose to 
participate in the network may change, while those who remain will 
operate under new policies and procedures. During this transition, DOD 
is still responsible for ensuring that the civilian provider network 
provides adequate access to care, even if beneficiaries must change 
providers.

TRICARE also faces beneficiary and provider dissatisfaction with the 
existing civilian provider network. During April 2002 testimony before 
the Subcommittee on Personnel of the House Armed Services Committee, 
beneficiary groups described problems with access to care from 
TRICARE's civilian providers. Also, providers testified about their 
dissatisfaction with the TRICARE program, specifying low reimbursement 
rates and administrative burdens.

In response to these concerns, the Bob Stump National Defense 
Authorization Act of 2003 required that we review DOD's oversight of 
the adequacy of the TRICARE civilian provider network.[Footnote 2] As 
agreed with the committees of jurisdiction we focused on DOD's 
oversight and did not assess the adequacy of the network. Also, we 
analyzed TRICARE Prime, the managed care component of the TRICARE 
health delivery system. Specifically, we agreed to (1) describe how DOD 
oversees the adequacy of the civilian provider network, (2) evaluate 
DOD's oversight of the adequacy of the civilian provider network, (3) 
describe the factors that have been reported to contribute to network 
inadequacy, and (4) describe how the new contracts might affect network 
adequacy. We testified before the Subcommittee on Total Force of the 
House Committee on Armed Services on March 27, 2003, about our findings 
at that time.[Footnote 3]

To describe and evaluate DOD's oversight of the TRICARE civilian 
provider network, we reviewed and analyzed information from five 
network adequacy reports submitted between June and October of 2002. We 
reviewed at least one report from each of the contractors who develop 
and maintain the network of providers to augment the care provided by 
MTFs. We also interviewed DOD regional officials, known as lead agents, 
and MTF officials from 5 of 11 TRICARE regions. In addition, we 
interviewed officials from each of the four contractors. As part of our 
assessment of DOD's oversight, we reviewed surveys of beneficiaries and 
providers, as well as DOD data collection initiatives that could be 
used by DOD to oversee its civilian provider network. We did not 
validate the data in the surveys or collection initiatives. We also 
interviewed officials at TRICARE Management Activity (TMA) in Falls 
Church, Va., the office with responsibility for ensuring that DOD 
health policy is implemented, and officials at TMA-West, the office 
that carries out contracting functions, including monitoring the 
civilian contracts and writing the requests for proposals for the 
future contracts. To describe factors that may contribute to network 
inadequacy, we interviewed DOD, contractor, and professional health 
association officials. In addition, we met with groups representing 
TRICARE beneficiaries to discuss their concerns. Finally, we reviewed 
DOD's request for proposals for the new health care contracts and 
interviewed DOD and contractor officials to determine how the new 
contracts might affect network adequacy. Appendix I contains more 
details about our scope and methodology. We conducted our work from 
June 2002 through July 2003 in accordance with generally accepted 
government auditing standards.

Results in Brief:

To oversee the adequacy of the civilian provider network, DOD has 
standards that are designed to ensure that the network has a sufficient 
number and mix of providers, both primary care and specialists, to 
satisfy TRICARE Prime beneficiaries' needs. In addition, DOD has 
standards for appointment wait, office wait, and travel times that are 
designed to ensure that TRICARE Prime beneficiaries have adequate 
access to care. DOD has delegated oversight of the civilian provider 
network to lead agents, who are responsible for ensuring that these 
standards have been met.

DOD's ability to effectively oversee the TRICARE civilian provider 
network is hindered in several ways. First, the measurement used to 
determine if there is a sufficient number of providers for the 
beneficiaries in an area does not always account for the actual number 
of beneficiaries who may seek care or the availability of providers. In 
some cases, this may result in an underestimation of the number of 
providers needed in an area. Second, incomplete contractor reporting on 
access to care makes it difficult for DOD to assess compliance with 
these standards. Finally, DOD does not systematically collect and 
analyze beneficiary complaints, which might assist in identifying 
inadequacies in the TRICARE civilian provider network. However, DOD has 
surveys of TRICARE beneficiaries and network providers and automated 
reporting systems on appointments and referrals that, while not 
designed specifically for monitoring the civilian provider network, 
could provide information and potentially improve DOD's ability to 
oversee the civilian provider network.

DOD and its contractors have reported three factors that may contribute 
to potential civilian provider network inadequacy: lack of providers in 
certain geographic locations, low reimbursement rates, and 
administrative requirements. DOD and contractors have reported long-
standing provider shortages in some geographic areas because providers 
in certain areas may refuse to join any network. In areas where DOD 
determines that access to care is severely impaired, DOD has the 
authority to increase reimbursement rates. Since 2002, DOD has used 
this authority to increase reimbursement rates in Alaska and Idaho in 
an attempt to remedy such provider shortages. DOD told us that the 
contractors have achieved some success in recruiting additional 
providers by using this authority. Additionally, civilian providers 
have expressed concerns about TRICARE's reimbursement rates being too 
low and administrative requirements being too cumbersome. However, 
while reimbursement rates and administrative requirements may have 
created dissatisfaction among providers, it is not clear that these 
factors have resulted in insufficient numbers of providers in the 
civilian network because the information contractors provide to DOD is 
not sufficient to measure network adequacy.

The new contracts, which DOD expects to award during the summer of 
2003, may result in improved civilian provider network participation by 
addressing some network providers' concerns about administrative 
requirements. For example, the new contracts may simplify requirements 
for provider credentialing and referrals, two administrative procedures 
providers have complained about. However, according to contractors, the 
new contracts may also create requirements that could discourage 
provider participation, such as the new requirement that all network 
claims submitted by civilian providers be filed electronically. 
Currently, only about 25 percent of such claims are submitted 
electronically.

We are recommending that the Secretary of Defense direct the Assistant 
Secretary of Defense for Health Affairs to improve DOD's oversight of 
the civilian provider network by ensuring sufficient information is 
reported to assess network adequacy and by exploring options for 
evaluating beneficiary complaints and improving provider survey data. 
In commenting on a draft of this report, DOD concurred with the 
report's recommendations.

Background:

TRICARE has three options for its eligible beneficiaries:

* TRICARE Prime, a program in which beneficiaries enroll and receive 
care in a managed network similar to a health maintenance organization;

* TRICARE Extra, a program in which beneficiaries receive care from a 
network of preferred providers; and:

* TRICARE Standard, a fee-for-service program that requires no network 
use.

The programs vary according to the amount beneficiaries must contribute 
toward the cost of their care and according to the choices 
beneficiaries have in selecting providers. In TRICARE Prime,[Footnote 
4] the program in which active duty personnel generally must 
participate, the beneficiaries must select a primary care manager 
(PCM)[Footnote 5] who either provides care or authorizes referrals to 
specialists. Most beneficiaries who enroll in TRICARE Prime select 
their PCMs from MTFs, while other enrollees select their PCMs from the 
civilian provider network. Regardless of their status--military or 
civilian--PCMs may refer Prime beneficiaries to providers in either 
MTFs or TRICARE's civilian provider network.[Footnote 6]

Both TRICARE Extra and TRICARE Standard require copayments, but 
beneficiaries do not enroll with or have their care managed by PCMs. 
Beneficiaries choosing TRICARE Extra use the same civilian provider 
network available to those in TRICARE Prime, and beneficiaries choosing 
TRICARE Standard are not required to use providers in any network. 
TRICARE Extra and Standard beneficiaries may receive care at an MTF 
when space is available.

The Office of the Assistant Secretary of Defense for Health Affairs 
(Health Affairs) establishes TRICARE policy and has overall 
responsibility for the program. TMA, under Health Affairs, is 
responsible for awarding and monitoring the TRICARE contracts. DOD has 
delegated oversight of the civilian provider network to regional 
TRICARE lead agents. The lead agent for each region coordinates the 
services provided by MTFs and civilian network providers. The lead 
agents respond to direction from Health Affairs, but report directly to 
their respective Surgeons General. In overseeing the network, lead 
agents have staff assigned to MTFs to provide the local interaction 
with contractor representatives and respond to beneficiary complaints 
as needed and report back to the lead agent.

Currently, DOD employs four civilian health care companies or 
contractors that are responsible for developing and maintaining the 
civilian provider network that complements the care delivered by MTFs. 
The contractors recruit civilian providers into a network of PCMs and 
specialists who provide care to beneficiaries enrolled in TRICARE 
Prime. Contractors are required to establish and maintain the network 
of civilian providers in the following locations: all catchment 
areas,[Footnote 7] base realignment and closure sites,[Footnote 8] 
other contract-specified areas, and noncatchment areas where a 
contractor deems it cost effective. These locations are called prime 
service areas. In the remaining areas, a network is not required. (See 
fig. 1.):

Figure 1: Areas of the United States with a TRICARE Network of Civilian 
Providers:

[See PDF for image]

Note: Shaded areas represent zip codes in which there was a TRICARE 
network of civilian providers as of May 2003.

[End of figure]

This network of civilian providers also serves as the network of 
preferred providers for beneficiaries who use TRICARE Extra. In 2002, 
contractors reported that the civilian provider network included about 
37,000 PCMs and 134,000 specialists.

The contractors are also responsible for ensuring adequate access to 
health care, referring and authorizing beneficiaries for health care, 
educating providers and beneficiaries about TRICARE benefits, ensuring 
that providers are credentialed, and processing claims. In their 
network agreements with civilian providers, contractors establish 
reimbursement rates and certain requirements for submitting claims. 
Reimbursement rates cannot be greater than Medicare rates unless DOD 
authorizes a higher rate.

DOD's four contractors manage the delivery of care to beneficiaries in 
11 TRICARE regions. DOD is currently analyzing proposals to award new 
civilian health care contracts, and when they are awarded in 2003, DOD 
will reorganize the 11 regions into 3--North, South, and West--with a 
single contract for each region. Contractors will be responsible for 
developing a new civilian provider network that will become operational 
in April 2004. Under these new contracts DOD will continue to emphasize 
maximizing the role of MTFs in providing care. See appendix II for maps 
depicting the current and future regions.

DOD Has Standards for Network Adequacy and Requires Contractors' 
Compliance:

DOD has standards intended to ensure that its civilian provider network 
enhances and supports the capabilities of the MTFs in providing care to 
millions of TRICARE Prime beneficiaries. DOD requires that contractors 
have a sufficient number and mix of providers, both primary care and 
specialists, to satisfy the needs of beneficiaries enrolled in the 
Prime option. Specifically, it is the responsibility of the contractors 
to ensure that each prime service area in the network has at least one 
full-time equivalent PCM for every 2,000 TRICARE Prime enrollees and 
one full-time equivalent provider (both PCMs and specialists) for every 
1,200 TRICARE Prime enrollees.[Footnote 9]

In addition, DOD has access-to-care standards that are designed to 
ensure that Prime beneficiaries receive timely care from 
providers.[Footnote 10] Under these standards:

* appointment wait times shall not exceed 24 hours for urgent care, 1 
week for routine care, or 4 weeks for well-patient and specialty care;

* office wait times shall not exceed 30 minutes for nonemergency care; 
and:

* travel times shall not exceed 30 minutes for routine care and 1 hour 
for specialty care.[Footnote 11]

Lead agents are responsible for ensuring that the civilian provider 
network meets these standards so that all TRICARE Prime beneficiaries 
in their region have adequate access to health care. To do so, lead 
agents told us they use network adequacy reports that contractors 
provide each quarter as the primary tool to oversee the network. 
According to DOD's operations manual, these reports are to contain 
information on the status of the network, such as the number and type 
of specialists; data on adherence to the access standards; a list of 
civilian and military primary care managers; and the number of their 
enrollees. The reports may also contain information on steps 
contractors have taken to address any network inadequacies.

However, because the reporting requirements do not specify a standard 
process for collecting information on network adequacy, contractors 
vary in how they obtain this information. For example, lead agents told 
us that one contractor conducts visits of providers' offices to review 
appointment wait times, while another contractor uses an automated 
appointment tracking system to collect this information.

Lead agents told us they also rely on beneficiary complaints to oversee 
the adequacy of the civilian provider network. Beneficiaries may 
complain directly to DOD, the contractor, lead agent, or MTF. DOD 
officials said that when they receive a beneficiary complaint, they 
direct the complaint to either the contractor, lead agent, or MTF, 
depending on the subject of the complaint.

In addition to these tools, lead agents periodically monitor contractor 
compliance by reviewing performance related to specific contract 
requirements, including requirements related to network adequacy. Lead 
agents also told us they periodically schedule reviews of special 
issues related to network adequacy, such as conducting telephone 
surveys of providers to determine whether they are accepting TRICARE 
Prime patients. In addition, lead agents stated they meet regularly 
with MTF and contractor representatives to discuss network adequacy.

If lead agents determine that the network is inadequate, the lead 
agents or TMA may issue enforcement actions to encourage contractors to 
address deficiencies in their region. However, lead agents told us that 
few enforcement actions have been issued. During our review, three 
enforcement actions related to network adequacy were open for the five 
regions we visited.[Footnote 12] Lead agents said they prefer to 
address deficiencies informally rather than take formal actions, 
particularly in areas where they do not believe the contractor can 
correct the deficiency because of local market conditions. For example, 
rather than taking a formal enforcement action, one lead agent worked 
with the contractor to arrange for a specialist from one area to travel 
to another area periodically.

DOD's Oversight of the Civilian Provider Network Has Weaknesses, But 
Additional Tools May Help:

DOD's ability to effectively oversee the TRICARE civilian provider 
network is hindered by (1) flaws in its required provider-to-
beneficiary ratios, (2) incomplete reporting on beneficiaries' access 
to providers, and (3) the absence of a systematic assessment of 
complaints. Although DOD has required the network to meet established 
ratios of providers to beneficiaries, the ratios may underestimate the 
number of providers needed in an area. Similarly, although DOD has 
certain requirements governing Prime beneficiary access to available 
providers, the information reported to DOD on this access is often 
incomplete--making it difficult to assess compliance with the 
requirements. Finally, when beneficiaries complain about availability 
or access in the network, these complaints can be directed to different 
DOD entities, with no guarantee that the complaints will be compiled 
and analyzed in the aggregate to identify possible trends or patterns 
and correct network problems. However, DOD has existing surveys and 
automated reporting systems that, while not designed specifically for 
monitoring the civilian provider network, could provide valuable 
information and potentially improve DOD's ability to oversee the 
civilian provider network.

Provider-to-Beneficiary Ratios May Not Account for Actual Number of 
Beneficiaries or Availability of Providers:

The provider-to-beneficiary ratios contractors report to DOD for a 
prime service area do not always accurately reflect the potential 
health care workload for that area or the provider capability to 
deliver the care. In some cases, the provider-to-beneficiary ratios 
underestimate the number of providers, particularly specialists, needed 
in an area. This underestimation occurs because in calculating the 
ratios, some contractors do not include the total number of Prime 
enrollees within the area. Instead, in some areas contractors base 
their ratio calculations on the total number of beneficiaries enrolled 
with civilian PCMs and do not count beneficiaries enrolled with PCMs in 
MTFs. The ratio is most likely to result in an underestimation of the 
need for providers in areas in which the MTF is a clinic or small 
hospital with a limited availability of specialists. For example, the 
Air Force clinic at Grand Forks, N. Dak. has few specialists on staff 
and must rely on the civilian provider network for a large proportion 
of specialist care. In fiscal year 2002, 90 percent of its specialist 
appointments were referred to the network. In contrast, a large MTF, 
such as Wright Patterson Medical Center in Dayton, Ohio, has many 
specialist providers on staff and referred only 2 percent of its 
specialty appointments to the civilian provider network during fiscal 
year 2002. Incorporating MTF provider capability and the total number 
of Prime enrollees into the network assessment would give DOD a more 
complete and accurate assessment of the adequacy of the network for a 
geographical area.

Moreover, in reporting whether the network meets the established 
ratios, contractors do not make the same assumptions about the level of 
participation on the part of civilian network providers. Contractors 
generally assume that between 10 to 20 percent of their providers' 
practices are dedicated to TRICARE Prime beneficiaries. Therefore, if a 
contractor assumes 20 percent of all providers' practices are dedicated 
to TRICARE Prime rather than 10 percent, the contractor will need half 
as many providers in the network in order to meet the prescribed ratio 
standard. These assumptions may or may not be accurate, and the 
assumptions have a significant effect on the number of providers 
required in the network.

Information Reported on Access Standards Was Incomplete:

In the network adequacy reports we reviewed, the contractors did not 
always report all the information required by DOD to assess compliance 
with the access standards. Specifically, for the network adequacy 
reports we reviewed from 5 of the 11 TRICARE regions, we found that 
contractors reported less than half of the required information on 
access standards for appointment wait, office wait, and travel times. 
Some contractors reported more information than others, but none 
reported all the required access information. Contractors said they had 
difficulties in capturing and reporting information to demonstrate 
compliance with the access standards. They stated that it was not 
practical or feasible to document every appointment and office wait 
time because some beneficiaries make their own appointments directly 
and provider offices are spread throughout the geographic area.

Beneficiary Complaints Are Not Systematically Collected and Evaluated:

Most of the DOD lead agents we interviewed told us that because 
information on access standards is not fully reported, they monitor 
compliance with the access standards by reviewing beneficiary 
complaints. Lead agents and contractors said such complaints may 
include a beneficiary's inability to get an appointment, having to 
drive long distances for care, or a provider not accepting new TRICARE 
Prime patients. Because beneficiary complaints are received through 
numerous venues, often handled informally on a case-by-case basis, and 
not centrally evaluated, it is difficult for DOD to assess the extent 
of any systemic access problems. Separately, TMA has a database of 
complaints that includes some complaints about access to care. TMA has 
received these complaints either directly, through DOD's beneficiary 
survey, or from letters sent by beneficiaries to their congressional 
representatives. However, the usefulness of the database is limited 
because it does not capture complaints sent to MTFs, lead agents, or 
contractors.

While contractor and lead agent officials told us they have received 
few complaints about network access problems, this small number of 
complaints could indicate either an overall satisfaction with care or a 
general lack of knowledge about how or to whom to complain. 
Additionally, a small number of complaints, particularly when spread 
among many sources, limits DOD's ability to identify any specific 
trends of systemic problems related to network adequacy within TRICARE.

The next generation of contracts, called TNEX, may result in a more 
structured approach to collecting complaint information when 
implemented in 2004. Under TNEX, the civilian provider network must be 
accredited in each region by a nationally recognized accrediting 
organization, such as the National Committee for Quality Assurance 
(NCQA) or the Joint Commission on Accreditation of Healthcare 
Organizations (JCAHO). These organizations typically require 
procedures for addressing beneficiary complaints. For example, NCQA 
guidance requires procedures for registering, responding to, and 
investigating complaints. It also requires documentation of actions 
taken to address complaints. JCAHO guidance has similar requirements. 
Such procedures could provide DOD with a basic structure that in turn 
could lead to a more systematic means of collecting and evaluating 
complaint data at the prime service area and regional levels.

Potential Network Oversight Tools:

DOD has some tools that, while not designed specifically for monitoring 
the civilian provider network, could be useful for oversight. For 
example, the Health Care Survey of DOD Beneficiaries (HCSDB) could be 
used as a source of information for overseeing civilian provider 
network adequacy at the national level.[Footnote 13] This quarterly 
survey contains specific questions on all beneficiaries' experiences 
related to access to care.[Footnote 14] For example, our analysis of 
the 2000 HCSDB data for all Prime beneficiaries receiving care from 
civilian providers indicates that over one-third of these beneficiaries 
waited more than DOD's standard of 1 day for access to a provider for 
an illness or an injury. However, the survey's sample design does not 
generally allow for assessing the adequacy of the civilian provider 
network in most prime service areas and the survey's response rate of 
35 percent further limits its usefulness.[Footnote 15]

In addition to DOD's beneficiary survey, contractors conduct surveys of 
providers that could assist in DOD's oversight of the civilian provider 
network. These surveys are intended to assess providers' satisfaction 
with contractors' performance and other TRICARE requirements. However, 
these surveys have very low response rates, ranging from 4 to 19 
percent, and in some cases they reflect unrepresentative samples of 
providers. For example, one contractor surveyed only those providers 
who participated in a contractor-sponsored seminar. Also, we found 
considerable variation among the survey instruments, with some 
assessing provider satisfaction more thoroughly than others. Despite 
these weaknesses, if improved, the surveys could reveal concerns 
providers may have about participating in the TRICARE network. This in 
turn could help DOD address these concerns and mitigate problems that 
might affect the adequacy of the network.

In addition to these existing surveys, DOD is piloting two initiatives 
for collecting information on meeting access standards that could help 
in the oversight of network adequacy. The first, the Enterprise Wide 
Referral and Authorization System (EWRAS), which is currently being 
tested in the Washington D.C. area, captures information on specialty 
care appointments in MTFs and information on some specialty care 
appointments in the civilian provider network. DOD officials said they 
expect EWRAS to be fully implemented in Spring 2004. The second 
initiative, the Access to Care (ATC) Project, gathers information on 
appointments and specialty referrals at or originating from MTFs. 
Specifically, it captures data on whether beneficiaries had a referral, 
declined an appointment that was available, cancelled an appointment, 
or left without being seen. It also records the average number of days 
between when the appointment was made and when the beneficiary was 
seen, as well as clinic cancellations and future appointments. This 
information can help indicate the extent to which MTFs are meeting the 
appointment wait-time access standards. Although the ATC Project is 
currently being piloted at four MTFs, a similar system, if modified to 
accommodate the requirements of the contractors for the civilian 
provider network, could provide valuable information on appointment 
wait time standards--information that is necessary for overseeing the 
adequacy of the network.

DOD and Contractors Report Three Factors That May Contribute to 
Civilian Provider Network Inadequacy:

DOD and its contractors have reported three factors that may contribute 
to potential civilian provider network inadequacy: lack of providers in 
certain geographic locations, low reimbursement rates, and 
administrative requirements. First, DOD and contractors have reported 
regional shortages for certain types of specialists in rural areas. For 
example, they reported shortages for endocrinologists in the Upper 
Peninsula of Michigan, dermatologists in New Mexico, and neurologists 
and allergists in Mountain Home, Idaho. Additionally, in these 
instances, TRICARE officials and contractors have reported difficulties 
in recruiting providers into the TRICARE Prime network because in some 
areas providers, notably specialists, will not join managed care 
programs. For example, contractor network data indicate that there have 
been long-standing specialist shortages in TRICARE in areas such as 
Alaska or eastern New Mexico, where the lead agent stated that the 
providers in those locations have repeatedly refused to join any 
managed care network.

There are certain geographic locations in which DOD has confirmed 
shortages of providers and has raised TRICARE's reimbursement rates as 
a means of remedying such shortages. Although by statute DOD generally 
cannot pay TRICARE network providers more than they would be paid under 
the Medicare fee schedule,[Footnote 16] DOD may make payments of up to 
115 percent of the Medicare fee to ensure the availability of an 
adequate number of qualified healthcare providers.[Footnote 17] In 
2000, DOD increased reimbursement rates in rural Alaska in an attempt 
to entice more providers to join the network. Similarly, in 2002, DOD 
increased reimbursement rates for the rest of Alaska, and in 2003, DOD 
increased the rates for selected specialists in Idaho to address 
documented network shortcomings. These three instances are the only 
times DOD has used its authority to pay above the Medicare rate in 
order to address local area provider shortages,[Footnote 18] and the 
increases have had mixed success. In 2001, for instance, we found that 
the 2000 rate increase in rural Alaska had not increased provider 
participation.[Footnote 19] On the other hand, DOD officials told us 
that with the 2002 increase in Alaska and the 2003 increase in Idaho, 
contractors were experiencing some success in recruiting providers in 
those areas. According to DOD officials, for example, six neurosurgeons 
in Boise, Idaho agreed to join the network, eliminating the 
neurosurgeon shortfall in that prime service area. In Alaska, DOD 
officials reported that since the reimbursement rate increased, 
providers for radiology, thoracic surgery, pediatrics, and other 
specialties have stated they will participate in TRICARE.

The general levels of TRICARE's reimbursement rates are another factor 
that DOD and contractor officials told us may contribute to civilian 
provider network inadequacy. Specifically, according to contractor 
officials, civilian network providers have expressed concerns about the 
decline in Medicare fees in 2002 and the potential for further 
reductions, which they have said will affect their participation in the 
network. In addition, there have been reported instances in which 
groups of providers have banded together and refused to accept TRICARE 
Prime patients due to their concerns with low reimbursement rates. One 
contractor identified low reimbursement rates as the most frequent 
cause of provider dissatisfaction. In addition to provider complaints, 
beneficiary advocacy groups, such as the Military Officers Association 
of America (MOAA), have cited instances of providers refusing care to 
beneficiaries because of low reimbursement rates. However, while 
TRICARE's reimbursement rates may have created dissatisfaction among 
providers, it is not clear how much this has affected civilian provider 
network adequacy except in limited geographic locations, because the 
information contractors provide to DOD is not sufficient to measure 
network adequacy. Additionally, there are indications that 
reimbursement rates have little influence on providers' decisions to 
leave the TRICARE network. Data from one contractor indicated that out 
of the 2,156 providers who left the network between June 2001 and May 
2002, 900 providers cited reasons for leaving and only 10 percent of 
these cited reimbursement rates as a reason for leaving the network.

Contractors report that providers have also expressed dissatisfaction 
with some TRICARE administrative requirements, such as credentialing 
and preauthorizations and referrals--but the effect of these 
requirements on civilian provider network adequacy is also unclear. For 
example, many providers have complained about TRICARE's credentialing 
requirements. In TRICARE, a provider must get recredentialed every 2 
years, compared to every 3 years for the private sector. Providers have 
said that this places cumbersome administrative requirements on them.

Another widely reported concern about TRICARE administrative 
requirements relates to preauthorization and referral requirements. 
Civilian PCM providers are required to get preauthorizations from MTFs 
before referring patients for care. While preauthorization is a 
standard managed care practice, providers complain that obtaining 
preauthorization adversely affects the quality of care provided to 
beneficiaries because it takes too much time. In addition, civilian 
PCMs have expressed concern that they cannot refer beneficiaries to the 
specialist of their choice because of MTFs' "right of first refusal" 
that gives an MTF discretion to care for the beneficiary or refer the 
care to a civilian provider. Nevertheless, there are not direct data 
confirming that administrative burdens translate into widespread 
civilian provider network inadequacies. Further, when reviewing one 
contractor's survey of providers who left the network, we found that 
only 1 percent of providers responding cited administrative burdens as 
a factor.

New Contracts May Address Some Network Concerns, But May Create Others:

DOD's new contracts for providing civilian health care, called TNEX, 
may address some network concerns raised by providers and 
beneficiaries, but may create other areas of concern. Because the new 
contracts had not yet been finalized as of June 2003, the specific 
mechanisms DOD and the contractors will use to ensure network adequacy 
are not known. Under TNEX, DOD plans to retain the requirement that the 
civilian provider network complement the clinical services provided by 
MTFs; the access standards for appointment and office wait times, as 
well as travel-time standards; and the periodic reporting on the 
adequacy of the network. However, the requirement to use provider-to-
beneficiary ratios to measure network adequacy will be eliminated, 
although such ratios may be used during the network accreditation 
process.

Further, TNEX contains a provision intended to encourage contractors to 
develop an adequate civilian provider network. This provision states 
that at least 96 percent of contractor referrals shall be to a MTF or 
network provider with an appointment available within the access 
standards. Failure to achieve the 96 percent standard will affect 
contractors financially.

TNEX may reduce the administrative burden related to provider 
credentialing and patient referrals. Currently, civilian network 
providers must follow TRICARE-specific requirements for credentialing. 
In contrast, TNEX will allow network providers to be credentialed 
through a nationally recognized accrediting organization. DOD officials 
stated this approach is more in line with industry practices. Patient 
referral procedures will also change under TNEX. Referral requirements 
will be reduced, but the MTFs will still retain the right of first 
refusal.

On the other hand, TNEX may be creating a new administrative concern 
for contractors and providers by requiring that all network claims 
submitted by civilian providers be filed electronically.[Footnote 20] 
In fiscal year 2002, only 25 percent of processed claims were submitted 
electronically.[Footnote 21] Contractors stated that such a requirement 
could discourage providers from joining or staying in the network 
because providers may not be willing to modify their systems to submit 
electronic claims for a small volume of TRICARE beneficiaries. DOD 
states that electronic filing will reduce claims-processing costs.

Conclusions:

DOD spends over $5 billion a year for health care delivered by the 
network of civilian providers to complement care provided in the MTFs; 
however, DOD has exercised limited oversight of the adequacy of the 
civilian provider network. The information DOD relies on to assess the 
network does not always accurately reflect the actual numbers of 
beneficiaries or availability of providers. Further, the contractors do 
not report comprehensive data on the network's compliance with DOD's 
access standards, which are key benchmarks in assessing network 
adequacy. This information will be important as DOD oversees the 
transition to the new health care delivery contracts.

Incorporating data on the numbers and types of providers in the MTFs 
and the total number of beneficiaries enrolled in TRICARE Prime would 
give DOD a more accurate and comprehensive report of the potential 
workload the civilian provider network faces in a prime service area 
and the adequacy of the number of PCMs and specialists to deliver that 
care. Similarly, more thorough reporting on beneficiaries' access to 
care within the standard time frames and development of a more 
systematic means of collecting and evaluating complaint data would help 
DOD's oversight of the ability of the civilian provider network to 
deliver timely care to beneficiaries. Further, with improvements in 
response rates and provider representation, the civilian provider 
satisfaction surveys could also be useful in identifying actions DOD 
and the contractors could take to address provider concerns and ensure 
network stability.

Recommendations for Executive Action:

To improve DOD's oversight of the civilian provider network, we 
recommend that the Secretary of Defense direct the Assistant Secretary 
of Defense for Health Affairs to:

* ensure that MTF capabilities and all enrolled Prime beneficiaries in 
prime service areas are accounted for when assessing and documenting 
the adequacy of the civilian provider network;

* ensure that the information reported on the required access standards 
is sufficient and reliable;

* explore ways to ensure that beneficiary complaints are systematically 
evaluated and used to oversee the civilian provider network; and:

* explore options for improving the civilian provider surveys so that 
the results of the surveys could be useful to DOD and the contractors 
in identifying civilian provider concerns and developing actions that 
might mitigate concerns and help ensure the adequacy of the civilian 
provider network.

Agency Comments and Our Evaluation:

DOD provided written comments on a draft of this report. (See app. 
III.) DOD concurred with the report's recommendations.

In its written comments, DOD stressed that strong oversight of the 
civilian provider network is necessary and should be continuously 
monitored for improvements. DOD said that the implementation of TNEX 
will address many of the points raised in our report. DOD said TNEX 
will enhance the reporting of information about network adequacy as 
well as provide powerful financial incentives for contractors to 
optimize the direct care system, maximize the extent of civilian 
provider networks, and achieve the highest level of beneficiary 
satisfaction. However, since the TNEX contracts have not been finalized 
as of July 2003, it is too early to assess whether the contracts will 
result in improved oversight.

In its written comments DOD also said that the report title might 
mislead some into concluding that we found the TRICARE network to be 
inadequate. As we noted in the draft report, we did not assess the 
adequacy of the civilian provider network but focused our work on DOD's 
oversight of the network. We believe the title of the report reflects 
that focus.

DOD also provided technical comments, which we incorporated into the 
report as appropriate.

We are sending copies of this report to the Secretary of Defense, 
appropriate congressional committees, and other interested parties. 
Copies will also be made available to others upon request. In addition, 
the report is available at no charge on the GAO Web site at http://
www.gao.gov. If you or your staff have questions about this report, 
please contact me at (202) 512-7101. Other contacts and staff 
acknowledgments are listed in appendix IV.

Marjorie E. Kanof 
Director, Health Care--Clinical and Military Health Care Issues:

Signed by Marjorie E. Kanof: 

[End of section]

Appendix I: Scope and Methodology:

To describe and evaluate DOD's oversight of the adequacy of the 
civilian provider network, we reviewed and analyzed the information in 
the quarterly network adequacy reports submitted by each contractor. We 
identified the requirements for the content of these adequacy reports 
based upon the general requirements in the TRICARE Operations Manual 
and the additional requirements in contractors' Best and Final Offers. 
We reviewed the contents of five of the contractors' quarterly network 
adequacy reports, submitted between June 2002 and October 2002, and 
compared them to the applicable reporting requirements. Each report was 
evaluated for compliance regarding the provider-to-beneficiary ratios 
and the access-to-care standards.

Because DOD has delegated the oversight of the network to the regional 
lead agents, we discussed civilian provider network oversight with 
officials in 5 of the 11 TRICARE regions--Northeast, Mid-Atlantic, 
Heartland, Central, and Northwest. To discuss network management, we 
interviewed officials from the four contractors--HealthNet, Humana, 
Sierra, and TriWest--that are responsible for developing and 
maintaining the provider network that augments care provided by DOD's 
MTFs. Because concerns regarding network adequacy may also be 
identified at the local level, we met with lead agent and contractor 
officials at MTFs in each of the regions we visited. Finally, we 
interviewed officials at TMA in Falls Church, Va., the office that is 
responsible for ensuring that DOD health policy is implemented, and 
officials at TMA-West in Aurora, Colo., the office that carries out 
contracting functions, including monitoring the civilian contracts and 
writing the request for proposals for the future contracts.

As part of our assessment of DOD's oversight, we also reviewed surveys 
of beneficiaries and providers, as well as DOD data collection 
initiatives as potential tools for overseeing DOD's civilian provider 
network, but did not validate the data in the surveys or collection 
initiatives. Using annual data from the 2000 HCSDB, we analyzed 
beneficiaries' responses to access-to-care questions for those who were 
enrolled in Prime and received most of their health care in the 
civilian provider network. We examined the results of access-to-care 
questions based on whether or not these beneficiaries were seen within 
the TRICARE access-to-care standards. Because we included only Prime 
beneficiaries who received care in the civilian provider network, our 
analysis of access to care does not reflect the entire survey sample. 
To examine the provider surveys as potential oversight tools, we 
obtained and reviewed each contractor's 2001 provider survey and 
assessed the survey's response rate, sample selection, and the 
instrument itself. We also discussed DOD initiatives underway and being 
tested with cognizant officials to assess their potential as oversight 
tools.

To describe factors that may contribute to network inadequacy, we 
interviewed and obtained documentation from DOD and contractor 
officials regarding current network inadequacies, including their 
location, duration, and the type of specialty needed. We also obtained 
provider termination reports from three of the four 
contractors,[Footnote 22] which described providers' reasons for 
leaving the network. To further explore DOD's response to civilian 
provider concerns regarding rates, we interviewed DOD officials on the 
use of their authority to raise reimbursement rates. We also 
interviewed officials from the American Medical Association, The 
Military Coalition, the MOAA, the National Association for Uniformed 
Services, and the National Veteran's Alliance to supplement data on the 
possible causes of network inadequacy.

Finally, we reviewed DOD's request for proposals for the future 
contracts and interviewed DOD and contractor officials to describe how 
the new contracts might affect network adequacy.

We conducted our work from June 2002 through July 2003 in accordance 
with generally accepted government auditing standards.

[End of section]

Appendix II: Comparison of Current and Future TRICARE Regions:

The shaded areas in figure 2 represent the 11 current TRICARE 
geographic regions. The shaded areas in figure 3 represent the 3 
planned TRICARE geographic regions under the TNEX contracts expected to 
be awarded in 2003.

Figure 2: Current TRICARE Regions:

[See PDF for image]

[End of figure]

Figure 3: Future TRICARE Regions After TNEX Implementation:

[See PDF for image]

[End of figure]

[End of section]

Appendix III: Comments from the Department of Defense:

[See PDF for image]

[End of figure]

[End of section]

Appendix IV: GAO Contacts and Staff Acknowledgments:

GAO Contacts:

Kristi Peterson, (202) 512-7951 Allan Richardson, (404) 679-1863:

Acknowledgments:

In addition to those named above, contributors to this report were 
Louise Duhamel, Marc Feuerberg, Krister Friday, Gay Hee Lee, John Oh, 
and Marie Stetser.


FOOTNOTES

[1] MTFs supply most of the health care services TRICARE beneficiaries 
receive. The military health system was funded at about $26.4 billion 
for fiscal year 2003. Approximately 20 percent of this amount, $5.2 
billion, was budgeted for the TRICARE civilian provider network.

[2] Pub. L. No. 107-314, § 712, 116 Stat. 2458, 2588 (2002). See also, 
H.R. Rep. No. 107-436. 

[3] U.S. General Accounting Office, Defense Health Care: Oversight of 
the Adequacy of TRICARE's Civilian Provider Network Has Weaknesses, 
GAO-03-592T (Washington, D.C.: Mar. 27, 2003).

[4] Out of more than 8.7 million eligible beneficiaries, nearly half 
are enrolled in TRICARE Prime.

[5] A primary care manager is a provider or team of providers at an MTF 
or a provider in the civilian network to whom a beneficiary is assigned 
for primary care services when he or she enrolls in TRICARE Prime. 
Enrolled beneficiaries agree to initially seek all nonemergency, 
nonmental health care services from these providers.

[6] DOD's policy is to optimize the use of the MTF. Accordingly, when a 
referral for specialty care is made by a civilian PCM, the MTF retains 
the "right of first refusal" to accommodate the beneficiary within the 
MTF or refer the beneficiary to the civilian provider network for the 
needed medical care.

[7] Catchment areas are geographic areas determined by the Assistant 
Secretary of Defense for Health Affairs that are defined by five-digit 
zip codes, usually within an approximate 40-mile radius of MTFs with 
inpatient care.

[8] Base realignment and closure sites are military installations that 
have been closed or realigned as the result of decisions made by the 
Commissions on Base Realignment and Closure.

[9] In addition, all four contractors generally follow the Graduate 
Medical Education National Advisory Committee recommendation for 
determining the specialty mix requirements for their network.

[10] DOD does not specify access standards for eligible beneficiaries 
who do not enroll in TRICARE Prime. However, DOD requires that 
contractors provide information and/or assist all beneficiaries--
regardless of which option they choose--in finding a participating 
provider in their area.

[11] 32 C.F.R. § 199.17(p)(5)(i), (ii), (iv) and (v) (2002). 

[12] All three enforcement actions were for lack of available providers 
in certain geographical areas. For example, there were shortfalls of 
orthopedic surgeons and neurosurgeons in Spokane, Washington.

[13] This survey was required by the National Defense Authorization Act 
for Fiscal Year 1993, Pub. L. No. 102-484, § 724, 106 Stat. 2315, 2440 
(1992).

[14] These questions ask how many days a beneficiary had to wait to see 
a provider for regular or routine care and how long they had to wait to 
receive treatment for an injury or illness, among other things. Also, 
DOD recently added questions to the survey specifically aimed at 
beneficiaries receiving care from civilian providers. These questions 
ask how difficult it was to obtain care and locate a doctor, and 
whether a civilian provider had left the network.

[15] Even though DOD samples 180,000 beneficiaries annually, the 35 
percent response rate reduces the sample to about 63,000. As a result 
the survey estimates may be biased if those who responded to the survey 
are not representative of the entire surveyed population.

[16] 10 U.S.C. § 1079(h)(1) (2000).

[17] 10 U.S.C. § 1097b (2000).

[18] DOD officials told us that all requests received by Health Affairs 
to increase rates have been approved. Additionally, there are two other 
instances in which DOD increased its reimbursement rates above 
Medicare's, but these increases did not address local area shortages. 
In 1997, DOD increased national reimbursement rates for obstetrical 
care. In April 2002, DOD adopted a policy that will authorize a 10 
percent bonus payment to selected TRICARE providers working in 
medically underserved areas as defined by the Health Resources and 
Services Administration, consistent with Medicare payment policy. DOD 
plans to implement the bonus payment in July 2003.

[19] U.S. General Accounting Office, Defense Health Care: Across-the-
Board Physician Rate Increase Would Be Costly and Unnecessary, 
GAO-01-620 (Washington, D.C.: May 24, 2001).

[20] The Health Insurance Portability and Accountability Act of 1996 
included provisions for the establishment of standards and requirements 
for the electronic transmission of health information. Pub. L. No. 104-
191, § 262, 110 Stat. 1936, 2021. Effective October 16, 2003, Medicare 
claims generally must be submitted electronically.

[21] This percentage does not include pharmacy claims or claims for 
care provided to Medicare-eligible beneficiaries under TRICARE For 
Life.

[22] One contractor does not collect data on provider terminations.

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