GAO

United States General Accounting Office

Report to the Subcommittee on Military

Personnel, Committee on Armed

Services, House of Representatives

August 2000 DEFENSE HEALTH

CARE

Resources, Patient

Access, and

Challenges in Europe

and the Pacific

GAO/HEHS-00-172

Page 1 GAO/HEHS-00-172 Implementation of TRICARE Overseas

Contents

Letter 3

Appendix Appendix I: Comments From the Department of Defense 32

Table Table 1: Estimated Number of Beneficiaries by Category in Europe

and the Pacific, FY 1999 7

Figure Figure 1: O&M Funding for MTFs in Europe and the Pacific,

FY 1995-99 10

Abbreviations

CHAMPUS Civilian Health and Medical Program of the Uniformed Services

DOD Department of Defense

MTF military treatment facility

O&M operations and maintenance
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Page 3 GAO/HEHS-00-172 Implementation of TRICARE Overseas

United States General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-285315 Letr

August 31, 2000

The Honorable Steve Buyer

Chairman

The Honorable Neil Abercrombie

Ranking Minority Member

Subcommittee on Military Personnel

Committee on Armed Services

House of Representatives

The Department of Defense (DOD) maintains a significant military medical

presence in Europe and the Pacific. As in the United States, the primary

mission of DOD’s overseas health care activities is to maintain the health of

military personnel and support U.S. forces during military operations. Also,

when space and resources are available, military treatment facilities (MTF)

provide health care to dependents of active duty members, retirees and

their dependents, and survivors of service members. When an MTF cannot

provide needed health care services, DOD may refer beneficiaries to local

host nation providers or transport patients to military facilities elsewhere.

In 1990, we testified that beneficiaries in both Europe and the Pacific were

having considerable problems obtaining health care at MTFs.1 These

problems were exacerbated during the post-Cold War downsizing of the

U.S. military presence overseas, which included MTF closures. In 1995, we

reported that access problems were continuing at the remaining MTFs in

Germany and Italy, particularly problems with access to specialty care.2 At

that time, DOD committed itself to improving access and in 1997

implemented TRICARE, its managed care program, which better integrates

host nation care into the military health care system.

In September 1999, you asked that we review DOD’s health care system in

Europe and the Pacific to determine whether problems persist. Specifically,

you asked the following: What DOD health care resources are available in

Europe and the Pacific and what is their cost, how does DOD integrate host

1

Access to Medical Care at Overseas Military Hospitals (GAO/T-HRD-90-20, Mar. 29, 1990).

2

Defense Health Care: Problems With Medical Care Overseas Are Being Addressed

(GAO/HEHS-95-156, July 12, 1995).
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nation care into its military health care system, how does DOD ensure the

quality of such care, do beneficiaries have adequate access to medical care,

and do obstacles still exist to obtaining health care?

To answer these questions, we interviewed and obtained relevant

documents from officials of the TRICARE Management Activity, which has

overall responsibility for managing DOD’s military health care system; the

TRICARE Europe and Pacific Lead Agent3 offices; each military service;

and the Department of State. We visited the following MTFs in the

TRICARE Europe and TRICARE Pacific Regions: In Germany, the

Landstuhl Regional Medical Center, the Ramstein Air Base clinic, and the

Army Health Clinic in Wiesbaden; in the United Kingdom, the Navy’s

London clinic and the Air Force’s hospital at Lakenheath; in Italy, the

Navy’s hospital in Naples and the Army Health Clinic in Vicenza; in Turkey,

the Incirlik Air Base hospital; in Japan, the Navy’s hospital in Yokosuka and

the Yokota Air Base hospital; and in Korea, the Army’s 121st General

Hospital in Seoul and the Osan Air Base hospital. At these locations, we

interviewed and obtained relevant documents from hospital and clinic

commanders, senior medical staff, patient liaisons, and health benefits

advisors. We also visited three remote locations—Ankara, Turkey;

Bangkok, Thailand; and Singapore—that have no local MTFs but significant

numbers of beneficiaries. We conducted interviews with about 100

beneficiaries and beneficiary representatives.

Also, we reviewed DOD’s criteria for selecting local providers and hospitals

for use by beneficiaries and observed operations at Homberg University

Klinik and Wiesbaden Stadt Klinik, Germany; Addenbrookes Hospital and

Clementine Churchill Hospital, United Kingdom; San Bortolo Hospital,

Italy; Seyhan Hospital, Turkey; and Bumrungrad Hospital and BNH

Hospital, Thailand. We also interviewed officials from International SOS,

the contractor responsible for coordinating beneficiary care in much of the

western Pacific. We conducted our work between November 1999 and

August 2000 in accordance with generally accepted government auditing

standards.

3

Lead Agents are senior military medical officials responsible for planning and coordinating

peacetime health care operations within their respective regions. The Europe Lead Agent is

responsible for U.S. military personnel stationed in continental Europe, Great Britain,

Iceland, the Middle East, and Africa. The Pacific Lead Agent’s responsibilities include U.S.

military personnel stationed in Guam, Korea, Japan, and other nations throughout Asia and

the western Pacific.
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Results in Brief DOD maintains in Europe and the Pacific an extensive system of 18

hospitals and 69 clinics providing primary and specialty care to about

500,000 beneficiaries in over 100 countries. DOD spends about $1.1 billion

annually to staff, operate, and maintain these overseas MTFs. Most

beneficiaries live near MTFs and receive their care from military

physicians, although host nation providers and facilities are also used to

augment MTF resources. In Europe, MTFs have developed formal

networks of English-speaking host nation providers to serve as referral

specialists. In the Pacific, MTFs have traditionally used less local care and

have not developed formal provider networks. Pacific MTFs, more so than

those in Europe, rely on transporting patients between MTFs for specialty

care. Beneficiaries living in remote areas hundreds of miles from MTFs,

particularly in the Pacific, provide DOD a major care challenge. For such

beneficiaries, DOD relies on various care sources, including Department of

State health clinics and local health care, as well as on transporting

patients to distant MTFs. Also, to improve services in the Pacific remote

areas, DOD recently hired a contractor to arrange for and manage the care

of beneficiaries living there. DOD and the remote beneficiaries have given

high ratings to this contractor’s services.

To ensure host nation provider quality, DOD relies primarily on each

country’s licensing and credentialing requirements, as well as on limited

inspections and monitoring by U.S. military physicians. Differences in

language, culture, and health care practices between the United States and

the Europe and Pacific Regions at times can cause frustrations and

inconveniences for beneficiaries using host nation care. Patient liaisons

play a key role in helping beneficiaries deal with these barriers, serving as

intermediaries between the MTFs and the host nation. Using MTF and local

providers, DOD has generally been able to ensure timely access to both

primary and specialty care for overseas beneficiaries. However, MTFprovided specialty care is not always available within the 4-week TRICARE

access standard, and local specialty providers are not available in all areas.

The medical systems in Europe and the Pacific face continuing challenges.

DOD believes that the aircraft serving the aeromedical evacuation system,

critical for ensuring access to specialty care in each region, may need to be

replaced, at considerable cost. Also, DOD officials told us that the services’

medical screening process for active duty family members does not always

identify individuals with significant health problems. Moreover, DOD

civilians assigned overseas are often not screened at all. As a result,

individuals with complex, recurring medical needs are sometimes assigned
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overseas where local MTFs cannot provide the needed care and local care

is unavailable or unreliable. Beneficiaries also expressed concerns about

the portability of their TRICARE benefits from region to region,

particularly citing difficulties they face in obtaining health care when

temporarily visiting the United States.

DOD is now seeking to expand local care options in some overseas

locations and has begun reviewing alternatives for its aeromedical

evacuation needs. DOD officials also told us that they plan to review

concerns about overseas screening and benefit portability. We are

recommending that DOD complete these actions to improve overseas

health care for its beneficiaries. DOD agrees with our findings and

recommendations.

Background Most DOD health care beneficiaries in Europe and the Pacific are active

duty personnel and their family members, and they are usually stationed

near a military hospital or clinic. MTFs also provide care on a spaceavailable basis4 to thousands of military retirees and their family members

living abroad. U.S. government civilian and DOD contractor employees,

along with their dependents, can register in the Defense Eligibility and

Enrollment System and receive space-available care at rates established by

DOD. Table 1 shows the estimated number and type of beneficiaries in

Europe and the Pacific in fiscal year 1999.

4

Under the terms of the Dependents’ Medical Care Act, enacted in 1956, DOD has the

authority to provide retirees of any age health care in its medical facilities as long as space

and resources are available. This is referred to as “space-available” care.
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Table 1: Estimated Number of Beneficiaries by Category in Europe and the Pacific,

FY 1999

Source: TRICARE Europe and TRICARE Pacific Lead Agents.

DOD’s managed care program, TRICARE, offers two benefit options—

Prime and Standard—for active duty personnel and their families living

overseas in military communities that have MTFs. Under TRICARE Prime,

beneficiaries receive cost-free MTF care supplemented, as needed, by a

civilian host nation provider network. Prime enrollees are assigned to a

local MTF physician who, serving as primary care manager, oversees their

care and authorizes referrals for specialty care. Prime beneficiaries are not

billed for specialty care obtained from network physicians. Rather, DOD

pays for all such services. TRICARE Prime is mandatory for active duty

personnel assigned to the TRICARE Europe and TRICARE Pacific Regions,

and optional for their accompanying family members. According to the

Lead Agents, about 90 percent of eligible beneficiaries enroll in TRICARE

Prime.

Family members choosing not to enroll in TRICARE Prime are

automatically placed in TRICARE Standard, an option that allows

beneficiaries to seek covered care from any MTF or host nation provider.

Standard beneficiaries, however, receive a lower priority for MTF

appointments than Prime beneficiaries do, their host nation care is subject

to cost-sharing and deductibles, and they must often pay for host nation

services in full and wait for reimbursement. Family members who are

citizens of the host country and routinely receive their care through the

host nation health care system often use TRICARE Standard.

Beneficiary

category Europe Pacific Total

Active duty

personnel 110,000 96,534 206,534

Active duty family

members 143,500 59,317 202,817

Retirees and family

members 24,427 18,406 42,833

U.S. civilian

employees, DOD

contractors, and

dependents 27,415 12,500 39,915

Total 305,342 186,757 492,099
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Overseas military retirees under age 65 and their family members may not

enroll in TRICARE Prime but are eligible for TRICARE Standard and costfree MTF care on a space-available basis. Retirees over age 65 may also

obtain cost-free, space-available MTF care, but they are not eligible for

TRICARE Standard and thus are responsible for any host nation care costs

they incur.5 U.S. civilian employees, DOD contractors, and family members

of both may obtain space-available MTF care. These patients, or their

insurance plans, must pay DOD’s established rates for these services.

Approximately 23,000 active duty personnel and family members are now

classified as living in remote areas. DOD defines remote areas as being

“over 30 minutes traveling time from an MTF.” Remote sites in Europe and

the Pacific vary greatly in distance from MTFs, availability and quality of

medical services, and beneficiary populations. For example, several

hundred military personnel are based in Australia and Singapore, where

there are no MTFs but where local health care standards are comparable to

those of the United States. In contrast, small numbers of personnel are

stationed in third-world countries where the nearest MTF may be hundreds

or thousands of miles away and the local health care system cannot

adequately provide all needed services.

All remotely located active duty personnel and their family members may

enroll in a modified TRICARE Prime program that entitles them to cost-free

host nation care. Active duty family members in remote locations who

choose not to enroll in this program participate in TRICARE Standard, with

its cost-sharing and deductibles. Military commanders may authorize the

transport of beneficiaries, when care needs exceed local capability, to

MTFs or other acceptable medical facilities elsewhere.

DOD Uses Significant

Resources in Europe

and the Pacific

DOD spends about $1.1 billion annually to provide health care to

beneficiaries in Europe and the Pacific. In fiscal year 1999, DOD spent

about $463 million to operate and maintain hospitals and clinics in these

areas and to transport beneficiaries between facilities for care. In addition,

DOD spent about $609 million to compensate military personnel who staff

the MTFs. Also, over the past 5 years, DOD has committed about $62

5

In the United States, military retirees over age 65 are also ineligible for TRICARE Prime, but

if they are eligible for Medicare, they may use their Medicare benefits to pay for nonmilitary

provider care. However, Medicare is not available overseas.
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million in military construction funds for projects overseas, and another

$249 million for future projects.

Facilities and Funding DOD operates 18 hospitals and 69 clinics in Europe and the Pacific. Most of

these MTFs are located in Germany, Italy, the United Kingdom, Japan, and

Korea—the countries with the largest U.S. military presence. The

Landstuhl Regional Medical Center in Germany provides many specialty

and subspecialty services not available at other MTFs in the TRICARE

Europe Region. In addition, DOD maintains 10 community hospitals and 41

clinics in Europe and 7 hospitals and 28 clinics in the Pacific. Most

beneficiaries live near MTFs and receive their care from military

physicians.

Clinics are staffed to provide primary care and limited specialty care

services to the local military population. Hospitals offer primary care and a

greater variety of specialty care services and usually serve as referral

centers for a large geographic area. Military hospitals overseas typically

maintain a small inpatient capability—often fewer than 50 beds—but are

expandable to accommodate many additional patients in wartime.

Much of the overseas care system’s funding is provided through the

Defense Health Program budget, which provides operations and

maintenance (O&M) funding for each service to operate MTFs both in the

United States and overseas. Funding for Europe and Pacific MTFs has

remained virtually constant over the past several years (see fig. 1).
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Figure 1: O&M Funding for MTFs in Europe and the Pacific, FY 1995-99

Source: Army, Navy, and Air Force Surgeons General.

Salaries for civilian employees are included in the MTF O&M budgets.

Salaries and benefits for military personnel are paid from separate budget

accounts. According to the military services, a total of 11,700 military

personnel were authorized for MTF operations in fiscal year 1999, with an

estimated cost of salaries and benefits of $609 million.

Military Construction

Funding

In addition to the O&M funds, each service receives military construction

funds to pay for new facilities and additions to existing facilities overseas.

During the early 1990s, funding for overseas construction projects was

halted; since 1995, limited funding has again become available: about $62

million (of a total DOD medical construction authorization of $1.3 billion)

has been earmarked for specific medical projects in Europe and the

Pacific, and an additional $249 million has been proposed for projects to be

initiated during the next 7 years.
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Aeromedical Evacuation

Funding

Both Europe and the Pacific rely on the aeromedical evacuation system to

move patients to obtain care not locally available and to provide emergency

transportation for critical patients. Although the system’s primary mission

is to move combat zone casualties to fixed or field hospitals as needed, the

routine peacetime movement of patients is used, to some extent, to train

personnel for readiness purposes.

The Air Force has stationed one squadron of C-9 evacuation aircraft at

Yokota Air Base in Japan and another squadron at Ramstein Air Base in

Germany. These aircraft fly regular routes between military communities

throughout Europe, the Middle East, and the western Pacific. In many

cases, patients are flown from locations served by a clinic to receive

specialty care at one of the region’s military hospitals. In fiscal year 1999,

the two overseas C-9 squadrons received about $12 million in O&M funds.

An additional $22 million was required to pay the military personnel

carrying out the aeromedical evacuation activities in Germany and Japan.

DOD Has Formalized

Local Care Use

DOD has traditionally relied on some local health care to supplement MTF

care overseas, and with TRICARE’s introduction has expanded and

formalized host nation provider use. MTFs in Europe have established

formal host nation provider networks that serve TRICARE Prime

beneficiaries and bill DOD’s claims processor, not the beneficiaries. In

contrast, TRICARE Pacific, because of cultural differences, concerns about

local provider quality, and other factors, uses less local care, and MTFs

there have not developed provider networks.

For remote beneficiaries, TRICARE Europe often relies on the Department

of State to provide care through embassy or consulate clinics or to

recommend local physicians. TRICARE Pacific relies on State Department

resources to some extent but also uses a contractor to arrange health care

for many remote beneficiaries. Air evacuation is used routinely to move

patients between MTFs for specialty care, and in medical emergencies

evacuation aircraft can be dispatched to assist beneficiaries almost

anywhere in the world.

Europe Host Nation

Network Supplements MTF

Care

For years, DOD has used local providers in Europe to augment MTF care.

In many areas, long-term relationships have developed among local

military communities, MTFs, and local physicians and hospitals. The local

providers have offered mainly specialty, emergency, and inpatient care to
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active duty family members under DOD’s old Civilian Health and Medical

Program of the Uniformed Services (CHAMPUS) program.6 According to

Lead Agent officials, local providers have helped ensure that patients can

be treated near their homes, have cut down on waiting times for specialty

care, and have allowed patients with access to only a military outpatient

clinic to receive inpatient services without being transported to another

MTF.

In 1995, MTFs began entering into written agreements, or memorandums of

understanding, with public and private health care providers and thus

developed a formal provider network to supplement MTF care. Individual

physicians or entire hospitals can be included under the agreements, which

generally define the conditions for providing services to DOD beneficiaries.

Network providers agree not to request payment from U.S. beneficiaries at

the time of the visit and instead to submit their bills directly to DOD for

payment. The memorandums of understanding require that network

physicians be licensed to practice medicine in their host country and that

providers or their staff be able to communicate in English and maintain

medical records for inclusion in patients’ permanent files.

During fiscal year 1999, TRICARE Europe had approximately 750

agreements with providers and facilities. Most network providers are

located in Germany, the United Kingdom, and Italy, with smaller networks

serving the smaller military populations of The Netherlands, Turkey, Spain,

Portugal, and other locations throughout the region. Host nation physicians

provide a significant portion of both inpatient and outpatient care received

by TRICARE Europe beneficiaries. In 1998, for example, host nation

providers conducted over 200,000 outpatient visits with U.S. beneficiaries

(about 10 percent of the region’s total medical visits), and host nation

facilities treated 12,300 inpatients (about 43 percent of all inpatient stays

for the year). According to the TRICARE Europe Lead Agent, about $41.7

million was paid to host nation providers in fiscal year 1999.

Europe Lead Agent officials and military physicians told us they were

generally satisfied with the host nation physicians’ care. Nevertheless, DOD

officials noted that differences in language and health care practices in

6

CHAMPUS was an insurance-like program administered by DOD that paid for a portion of

the care military families and retirees under age 65 received from private sector health care

providers. The benefits available under CHAMPUS were essentially the same as under

TRICARE Standard.
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some European countries occasionally caused frustrations and

inconveniences for beneficiaries. Examples follow.

• The memorandums of understanding require that providers

communicate with beneficiaries in English. However, in Turkey and

Italy, and to a lesser extent in Germany, nurses and administrative staff

do not speak English, and the fluency of the doctors varies. This

language barrier can make it difficult for patients to discuss their

medical problems with host nation personnel. Also, patients expressed

concerns about translation—especially that medical terms might not be

translated accurately.

• Conservative hospital admissions practices and long stays are issues in

some countries we visited. For example, the way Italians practice

medicine is characterized by more inpatient admissions, longer hospital

stays, and greater use of prescribed rest for injuries and illness.

According to an MTF physician, many of the local Italian hospitals’

inpatients would not have been admitted to an MTF as inpatients. He

told us, for example, that patients who visit the local hospital on

weekends or after MTF hours with various aches and pains are often

admitted for observation rather than sent home with a prescription.

Once in the hospital, patients tend to stay longer than in the U.S. system.

Also, routine diagnostic work at the local Italian hospital can be

completed only Monday through Friday, so patients are often kept over

the weekend for procedures such as ultrasound or other diagnostic tests

that would be done on an outpatient basis in the United States. We were

told that as a result, MTF staff occasionally go to the local hospital to

discharge DOD patients who would otherwise be kept longer by Italian

physicians.

• In Europe, physicians are not used to patients who ask questions about

their diagnoses or treatment plans. In the United States, the opposite is

often true: U.S. patients tend to be more involved in their treatment and

often ask questions about treatment strategies, procedures, and

expected outcomes. As a result, American military patients can become

frustrated at times with the more reserved attitude of host nation

physicians.

Patient liaisons play a key role in helping beneficiaries deal with these

language and cultural barriers, serving as intermediaries between the MTF

and the host nation medical community. Liaisons assist beneficiaries by

providing information about host nation care, making host nation

appointments, and serving as translators. In some cases, liaisons also

accompany patients to appointments and handle health care claims and
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billing. At the MTFs we visited, the most effective liaisons spoke the local

language, had completed some health-related training, and were familiar

with the local and the DOD medical systems. For example, at the MTF in

Vicenza, a U.S. doctor who spoke Italian and had been trained at an Italian

medical school served as the primary liaison with the medical community.

In some locations, liaisons had no health-related training and were not

always comfortable discussing complex medical situations with patients.

Host nation providers we interviewed generally were pleased to be

included in the networks, and many had made special efforts to

accommodate DOD beneficiaries. For example, a network dermatologist in

Italy set aside certain hours during the week for DOD patient appointments

to ensure that access would not be a problem. Also, an Italian hospital in

Vicenza now routinely provides U.S. patients epidural anesthesia during

childbirth, which is not the usual practice in Italy. After delivery, U.S.

patients are allowed to stay in the same room with their babies, another

adjustment made by the hospital.

In the United Kingdom, local providers have entered into agreements with

DOD to allow beneficiaries to bypass the often-lengthy waits for specialty

care in the British health care system. Also, a local network hospital in

Turkey provides DOD patients special, larger private rooms that have

Western-style accommodations, such as refrigerators and cable television.

At a German hospital used frequently by U.S. beneficiaries, an Englishspeaking liaison meets regularly with patients to assist them as needed.

Host nation doctors in the European network told us they like treating U.S.

patients and are willing to treat more of them. However, some providers

told us they would prefer more feedback from MTF staff and patients about

their clinical treatment of, and interaction with, U.S. patients. Lead Agent

officials told us they plan to seek ways to increase communication between

host nation physicians and MTF staff to help ensure the local provider

networks’ continued success.

According to Lead Agent officials, the local provider network is continuing

to evolve. In some areas, MTFs had recruited more local physicians than

were needed, and some physicians who were little used by beneficiaries

have been dropped from the network. In other areas, MTF commanders are

seeking additional local providers to augment MTF specialty care. For

example, at Incirlik, Turkey, the MTF is exploring the possibility of using

additional specialists at the local hospital to improve access for its

beneficiaries.
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Beneficiaries we met with who had used local care were generally satisfied

with the care they received. Some told us, however, they would choose to

wait for an MTF appointment or travel to an alternative MTF because they

were generally less comfortable with host nation care. In fiscal year 1999,

the aeromedical evacuation system in Europe moved about 12,000 patients

to MTFs for specialty care. Patients were typically flown to the nearest

MTF offering the needed specialty. Those patients needing more extensive

services than are available at MTFs in Europe are usually transported to

U.S. MTFs via scheduled C-141 flights from Ramstein Air Base, Germany.

Pacific MTFs Use Host

Nation Care Less Frequently

MTFs in the Pacific—particularly Japan and Korea, where most MTFs and

beneficiaries are located—have no formal networks and use much less host

nation health care than in Europe. Pacific Lead Agent officials told us that

differences in host nation medical practices have minimized patient

referrals to local national providers. Examples of obstacles to local care

use include the following:

• MTF officials told us that because no consistent standards exist for

hospital accreditation in the Pacific, officials cannot readily obtain

independent reviews of host nation facilities. And, although Japanese

hospitals were thought to provide good care in many medical areas,

MTF physicians told us they had concerns about the long hospital stays,

routine inpatient admission of noncritical cases, and outdated medical

practices that often preclude aggressive early intervention. Regarding

Korea, MTF officials told us that while quality of care has improved over

the years, few facilities exist there that can offer care that meets U.S.

standards.

• In both Japan and Korea, only a limited number of physicians speak

English well enough to communicate without difficulty with American

patients. Even when physicians can speak English, the nurses and other

support staff usually cannot. Beneficiaries also told us that Japanese

doctors normally do not explain diagnoses or treatment options and

expect not to be questioned. Also, Japanese and Korean nursing care is

significantly different than in the United States: patients’ families

normally provide sheets, towels, and toiletries and stay with and

otherwise assist patients during hospitalizations. Also, beneficiaries

expressed concerns about the comfort of local facilities and the native

foods served there.

• Unlike in Europe, written agreements used to formalize health care

policies are not culturally accepted in Japan and Korea. While MTFs

often have verbal agreements for certain services—usually for
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emergency situations or specialized diagnostics—local facilities have

been reluctant to formalize such agreements in written documents.

• Host nation providers and facilities in Japan and Korea typically require

payment prior to care or before the patient leaves the treatment area.

According to Lead Agent officials, the Japanese particularly do not

tolerate claims delays. In some areas, goodwill with local providers has

eroded as patients have left the host nation without paying what they

owe local providers. Some civilian facilities have banned DOD

beneficiaries from access unless cash is received in advance.

Thus, in the Pacific, DOD uses minimal host nation care and largely

depends on MTFs and the aeromedical evacuation system to move patients

between facilities for specialty care. In fiscal year 1999, for example, the

aeromedical evacuation system transported about 5,400 patients in the

Pacific Region. About 3,600 traveled to other MTFs for treatment, while

another 1,800 were returned via C-141 flights to Hawaii or other U.S.

locations for care. Host nation facilities were used primarily for emergency

cases in which patients could not be moved without risk and for diagnostic

tests not available at the MTF. The Pacific Lead Agent reported that only

$3.7 million (about $20 per beneficiary) was paid to host nation providers

in fiscal year 1999, compared with $41.7 million (about $150 per

beneficiary) in Europe.

Nevertheless, MTFs in Korea have recently begun increasing their efforts to

identify qualified local providers and establish working relations with

them. Military physicians from the Army’s 18th Medical Command in Seoul

have inspected local hospitals in an attempt to determine which of their

services are adequate and appropriate for DOD beneficiaries. The Medical

Command has developed an agreement that outlines U.S. expectations—

English-speaking staff, 24-hour translation services, private rooms, and fulltime nursing care—and makes clear DOD’s intent to promptly pay for

services for active duty personnel. However, Korean hospitals have not yet

agreed to change their billing practices and continue to bill family members

directly. Thus, local care users have to make payments up front and await

DOD reimbursement.7

7

According to DOD officials, MTFs in the Pacific have developed informal arrangements

with some local providers to ensure that MTFs, and not beneficiaries, are billed for medical

services.
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MTFs in Korea have also acted to encourage beneficiaries to use local

facilities for services not available at the MTF. For example, the Army’s

121st General Hospital now provides a shuttle to take patients,

accompanied by a translator when needed, from the MTF to host nation

facilities. Similarly, Osan Air Base now ensures that a patient liaison is

available to greet beneficiaries arriving at local hospitals and assist with

health care claims. According to the hospital’s commander, the greater use

of local resources will (1) improve access to specialty care for patients and

(2) reduce the burdens created for patients and military units when

beneficiaries require extended absences to obtain treatment at other MTFs.

Remote Locations Rely on

Varied Health Care Support

Beneficiaries living at remote sites hundreds of miles from MTFs provide a

significant challenge for DOD’s overseas health system. DOD has an

obligation to ensure that such beneficiaries have adequate access to quality

health care. To do so, DOD uses Department of State health resources,

local health care, and contractor-provided services. DOD also transports

patients to distant MTFs. Under a modified TRICARE Prime program, DOD

pays for medical services that remote beneficiaries receive from host

nation providers.

State Department Assists

Remote Beneficiaries in Europe,

Africa, and the Middle East

According to the Europe Lead Agent, there are about 20,000 remote

beneficiaries in Europe, Africa, and the Middle East who do not have ready

access to an MTF for care. Many of these beneficiaries rely primarily on the

State Department to provide or help arrange their medical care. The Lead

Agent advises remote area beneficiaries to contact the nearest U.S.

embassy or consulate for a list of local providers who meet U.S. medical

standards and have a history of providing quality care. In some cases, DOD

beneficiaries are stationed at or near embassies or consulates that operate

small primary care clinics staffed by U.S. medical personnel. DOD units in

these locations can pay a per-capita fee to provide their personnel access to

the clinic.

For specialty care in remote areas, State Department staff usually refer

beneficiaries to an informal network of host nation practitioners who have

favorable reputations. The State Department does not have contractual

agreements with local providers and does not specifically seek to engage

providers who will forgo advance payment for health care. Instead, patients

that State refers for local care are responsible for their own payment

arrangements and may need to pay for host nation care when they receive

it. Then beneficiaries can file a claim for reimbursement from TRICARE.
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In Ankara, Turkey, for example, the 210 assigned DOD beneficiaries can

receive care from the U.S. Embassy clinic staffed by a U.S. nurse

practitioner and two locally hired bilingual nurses. A State Department

regional medical officer, a physician based in Vienna, makes 3-day visits to

the clinic about every 4 to 5 months. Most beneficiaries are not willing to

seek primary care from local Turkish providers, and several told us they

appreciate having U.S. medical personnel available for them. The nurse

practitioner has made office visits to the local specialty care providers she

uses for referrals. She has determined that these providers can speak

acceptable English and most have some U.S. training. The nurse

practitioner acts as gatekeeper and case manager to the extent possible for

patients referred to Turkish doctors. She gives patients a form to use to

provide feedback on local care, and patients are reporting positive results

from the visits she has referred thus far. In most cases, one of the clinic’s

nurses accompanies patients to appointments primarily for translation

purposes.

In January 2000, TRICARE Europe officials met with State Department

medical personnel to obtain a better understanding of State operations,

share information, and find areas in which to work together to enhance

effectiveness. For example, they discussed procedures for increased

cooperation regarding physician referrals in Europe. According to the

Europe Lead Agent Office, the State Department’s processes for evaluating

referral physicians are similar though not identical to those used by MTFs

for the provider network.

Contractor and State

Department Assist Beneficiaries

in Remote Pacific

As in Europe, much of the Pacific Region’s remote area beneficiary care

traditionally has been provided by or arranged through the State

Department. However, problems such as the frequent unavailability of

regional medical officers due to their travel to cover other areas, and the

up-front payment local providers require of beneficiaries, led the Pacific

Region to hire a contractor to supplement State’s role.

In 1998, DOD contracted with International SOS8 to provide a managed

health care option for active duty personnel and their family members

stationed in the Pacific Region’s remote areas where MTF care is not

available. For each remote site, SOS developed networks of licensed

8

International SOS provides emergency assistance, medical services, and management of

the delivery of health care to corporate travelers and multinational organizations outside

their home country.
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English-speaking physicians for primary and specialty care. Each network

physician must agree not to charge DOD patients at the time of service;

rather, SOS guarantees providers their payment and gets reimbursed by

DOD for covered services. Beneficiaries may schedule their own primary

care appointments with network physicians. For specialty care, however,

beneficiaries must obtain an SOS authorization and use an SOS specialist.

SOS also staffs 24-hour toll-free call centers to assist beneficiaries in

arranging health care and with any emergencies that may arise.

DOD beneficiaries we interviewed expressed high overall satisfaction with

SOS’ health care operations, adding that SOS and its contractor network

were highly responsive to their health care needs. For example, in

Singapore, SOS arranged to have a local doctor practice at a small clinic

located near the military’s primary housing area, and specialty care is

available in Singapore within 24 hours. Also, Singapore network providers

speak English, most specialists are trained in Western countries, and

patient care is similar to that in the United States.

In Bangkok, DOD officials told us that many public hospitals are crowded

and not up to U.S. standards, but that beneficiaries are very pleased with

the SOS network private hospitals’ quality. At these facilities, many

physicians and nurses are U.S.-trained, English-speaking, and

accommodating to U.S. patients’ needs. Nursing care is generally good, and

medical education standards are high. Beneficiaries told us that when they

first arrived in Bangkok, they were reluctant to use local care; however,

after using local providers, they had confidence in the local care available

through the network. Also, beneficiaries told us they had no problems

obtaining primary care appointments and no language difficulties with

network doctors. They told us that their visits went smoothly and that the

paperwork was handled properly.

Although SOS regional call centers have the primary role of coordination,

the Bangkok and Singapore DOD remote unit staff also help beneficiaries

access care. For example, in Singapore, DOD has an active duty medic to

help coordinate local care. In Bangkok, the Pacific Lead Agent hired local

health benefits advisors, including a local nurse with a long history of

working with the U.S. military and a sound grasp of the local care options,

the military health care system, and beneficiary concerns. Some of these

staff have duties that replicate SOS contract responsibilities—for example,

the medic is also on call 24 hours a day. Nonetheless, beneficiaries clearly
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appreciated the health care assistance and coordination options available

to them while stationed in these foreign countries.

The SOS contract has complicated DOD’s health care relationship with the

Department of State. Currently, the SOS contract covers all DOD

beneficiaries stationed in the Pacific areas without MTF access. In places

where military personnel are stationed at or near U.S. embassies, individual

military units can decide whether to continue using State Department

health clinics or to rely on SOS network physicians for their care. In

Singapore, for example, all DOD units have withdrawn from the State

Department system, and the SOS network provides all local care. In

Bangkok, one DOD unit has withdrawn from the State-sponsored health

program,9 but other DOD beneficiaries may still use the embassy clinic.

Remote Beneficiaries Can Travel

to MTFs

In addition to host nation and State Department care, DOD beneficiaries in

remote areas can sometimes arrange travel to MTFs elsewhere for care.

Consistent with each service’s guidance, military commanders may

authorize patient transport to MTFs when beneficiaries need care that is

beyond local capabilities. For routine care, military beneficiaries often

arrange medical appointments to coincide with planned leave or official

travel to MTF locations. In some areas, beneficiaries can travel via military

aircraft that stop at their remote duty station. In other cases, travel via

commercial carriers is authorized. In life-threatening medical emergencies,

DOD can dispatch a medical evacuation aircraft to move a patient from a

remote site to an MTF.

DOD and State Rely on

Local Standards and

Patient Feedback to

Ensure Quality of Care

The TRICARE Europe and Pacific regions cover large geographic areas,

and countries and local areas differ in their provider and facility quality

standards. To determine network physician and facility qualifications, DOD

generally relies on local certification and licensing practices, which vary

from country to country. DOD’s monitoring of local patient care varies, and

the level of scrutiny is often based on overall confidence in the host

nation’s medical system. For remote locations, DOD relies primarily on the

State Department and SOS to ensure that beneficiaries are referred to

competent providers.

9

Because the operating costs of the consulate and embassy health clinics are shared among

participating agencies, the decision by DOD units to withdraw increases the amount paid by

the State Department and other U.S. government agencies operating out of the U.S. mission.
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MTFs Provide Limited

Oversight of Local Health

Care

In Europe, both the Lead Agent and MTF commanders are responsible for

ensuring that doctors brought into the provider network can deliver

acceptable care. Before allowing local providers into the network, the MTF

commander verifies that the providers are licensed to practice in the

country and requests other documentation on their specialty training.

Providers joining the network must provide to the MTF commander copies

of their educational degree(s); medical credentials, including licenses,

registration, and other certification; work history for the last 10 years; and

any history of adverse action taken against them regarding clinical

privileges or any other disciplinary action.

According to the TRICARE Europe Lead Agent, in many areas of Europe,

medical care systems are comparable to the U.S. medical system. In the

United Kingdom, for example, medical facilities are accredited, and

specialists receive rigorous training prior to being licensed for independent

medical practice. Germany has similar training and licensing requirements

for specialists, and in northern Italy, the health care quality and technology

available are comparable to those in the United States. Many local

physicians have received specialty training in the United States or

participated in exchange programs and are familiar with U.S. care

standards. Thus, DOD makes frequent use of local care in these areas.

According to DOD and State Department officials, however, the medical

systems in some parts of Europe, the Middle East, and Africa often lack

processes for ensuring care that meets U.S. quality standards. In these

areas, medical facilities sometimes lack competent clinical nursing staff

and do not always have effective quality control procedures to assure U.S.

medical personnel that the health care meets U.S. standards. In some cases,

physicians are not licensed, and continuing education is not required;

therefore, assessing physician qualifications is particularly difficult. In

addition, according to MTF physicians, local hospitals do not always use

the most stringent sterilization and quality control techniques. As a result,

DOD uses local care in these areas much less often.

Once local providers and facilities enter the TRICARE Europe network, the

extent of MTF monitoring of their care delivery generally reflects the MTF

commanders’ confidence in the local quality of care. For example, in the

United Kingdom, Germany, and northern Italy, much of the care provided to

U.S. beneficiaries is not closely monitored. In most cases, MTF staff review

local providers’ reports of treatment results to ensure the care is

appropriate. In other areas, where managers are more wary of the local
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care, MTF staff make more frequent visits to hospitalized patients and

more closely scrutinize the care provided.

MTFs in Europe are also required to obtain beneficiary feedback on local

care. According to Europe Lead Agent officials, providers who do not meet

DOD expectations and receive poor patient appraisals are reevaluated and,

if necessary, dropped from the network. These officials told us that while

MTFs do not receive much feedback, what they do receive is generally

favorable. Europe Lead Agent officials told us they have dropped two

network providers since 1997 because of beneficiary feedback that

identified inadequate treatment.

In the Pacific, where MTFs have no formal host nation provider networks,

MTF commanders and their staffs have sought to develop and cultivate

relationships with local providers and facilities and have done so over time

by making occasional site visits to facilities. MTF officials are more

confident of Japanese providers and facilities than they are of Korean

health care. In the relatively few cases when local facilities are used, MTF

staff monitor the care by maintaining liaison with the attending physician,

visiting inpatients, and reviewing treatment results. Mindful of the normally

longer hospital stays in these countries, MTF staff act to remove inpatients

from local hospitals and transfer them to MTFs as soon as is medically

possible.

Various Sources Ensure

Quality of Local Health Care

in Remote Areas

In remote locations, the Department of State provides guidance to embassy

and consulate medical units on how to assess providers and facilities, but

implementation of this guidance is not consistent. According to State

Department health officials, each post is responsible for assessing its

country’s health care resources and identifying competent local providers

to provide care. These officials told us that each embassy or consulate

health unit should request a provider’s medical license and credentials and

maintain patient feedback on each provider. For hospitals, State staff

should also perform a facility evaluation that addresses the facility’s

location, capacity, services offered, hours of operation, and equipment, as

well as the credentials of its nurses. Providers and health care facilities are

to be reviewed every 2 years, but State Department officials told us that

this is not necessarily done at each location. State is currently developing

an electronic database of provider and country profiles that should help

ensure more consistent data for each of its overseas locations.
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For DOD beneficiaries in remote Pacific areas, SOS assesses the quality of

its primary and specialty care provider network by reviewing providers’

credentials and conducting facility inspections. The SOS contract requires

that the medical practice quality for network physicians and facilities meet

or exceed reasonable care standards as determined by the local licensing

and oversight authorities. Network physicians must also meet the

credentialing requirements set forth in the contract; for example, they must

have graduated from an approved medical school, have completed a

residency program, and be licensed to practice medicine in the host

country. The contract encourages SOS to recruit physicians who follow

medical standards similar to those of the United States or other developed

countries.

The contract also requires SOS to continuously monitor the provider

network. Monitoring activities must include verification of the availability

of network providers and their adherence to contract requirements, as well

as investigation and resolution of specific provider and beneficiary

complaints or concerns. SOS also reviews and approves all specialty care

referrals to ensure that recommended treatments are both medically sound

and reimbursable under TRICARE.

TRICARE Overseas

Has Improved

Beneficiary Access to

Care

With the implementation of TRICARE overseas and the increased use of

host nation care to augment MTF care, beneficiaries have better access to

medical care. At the MTFs we visited, patients and hospital administrators

told us that most appointments meet the TRICARE access standards

governing waiting times for scheduled appointments. The most recent

appointment data show that most primary care clinics at the facilities we

visited have appointments available to be booked. MTF specialty care

appointments are not always available within the TRICARE access

standard, but MTF staff told us that referrals made to local providers,

especially for active duty family members in Europe, help eliminate

appointment delays.
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DOD Meets Access

Standards for Most Primary

Care Appointments

Access to medical care has improved since we reported on overseas health

care in 199010 and 1995.11 In our previous work, we found that beneficiaries,

especially non-active-duty patients, often faced long waiting times and

significant air or ground travel for routine appointments and surgeries. To

help ensure timely access to care, DOD established appointment timeliness

standards for TRICARE Prime enrollees similar to the standards used in

private sector managed care programs. The standards were made

applicable to the overseas regions in 1997 with TRICARE’s implementation

and can be met by using either MTF or local civilian care. The primary care

standards are a wait of no longer than 1 day for urgent care, 1 week for

routine care, and 4 weeks for a wellness visit. The standard for specialty

care referrals is 4 weeks.

At the MTFs we visited in Europe and the Pacific, MTF staff and TRICARE

Prime beneficiaries told us that most primary care appointments took place

within the TRICARE access standards. The available appointment data for

the MTFs we visited confirmed that most primary care clinics had sameday appointments available for patients who needed urgent care. Even

when all same-day appointments are filled, MTF doctors told us, urgent

care patients are treated, regardless of whether this requires working

extended duty hours. For routine care and wellness visits, the data

confirmed that most clinics had appointments available within the 1-week

and 4-week standards. In a few of the busier primary care clinics, however,

the data showed that routine and wellness appointments were not available

within the access standards.

MTF staff and beneficiaries also told us that most of the time specialty care

appointments took place within the 4-week access standard, usually in the

MTF specialty clinic. However, for some MTF specialty clinics, the most

recent data showed few appointments available for new patients during the

next 4-week period. In addition, some specialty clinics occasionally place

restrictions on access for some beneficiary groups. For example, for

capacity reasons, the otolaryngology, orthopedic, and podiatry clinics at

the Landstuhl Regional Medical Center at times treat only active duty

patients, so family members and others are referred to host nation

providers. Also, appointments at Landstuhl’s orthopedic clinic have been

booked as much as 48 days in advance, and the waiting lists have grown

10GAO/T-HRD-90-20, Mar. 29, 1990.

11GAO/HEHS-95-156, July 12, 1995.
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lengthy. Pacific Lead Agent officials also reported occasional problems

with long waits for specialty care in Pacific MTFs, especially in highdemand areas such as orthopedics.

In Europe, efforts to establish a host nation provider network have

improved overall access to specialty care for beneficiaries. According to

TRICARE policy, when MTF specialty clinics cannot offer patients

appointments within the 4-week access standard, beneficiaries should be

offered a referral to the host nation network. Beneficiaries in Europe told

us they generally had adequate access to local providers in those cases

when MTF specialty care was not available. Nonetheless, some patients

prefer to wait for an MTF appointment instead of using the host nation

network, thus waiving their right to an appointment within the access

standards.

In the remote areas we visited, beneficiaries told us that primary care

doctors were readily available for appointments. In the Pacific, we were

told that SOS quickly reviewed and approved referrals to specialists so that

these appointments could also be completed within the DOD access

standards.

Overseas Health Care

Faces Challenges

DOD’s overseas medical system faces continued challenges as DOD seeks

to maintain access to care for beneficiaries. The aeromedical evacuation

system is critical for ensuring access to specialty care in each region, and

the system’s aircraft need to be replaced, at considerable cost. Also, DOD

officials told us that the services’ medical screening process for family

members of active duty personnel assigned overseas does not always

identify individuals with significant health problems and that DOD civilians

often are not screened at all. As a result, individuals with complex,

recurring medical needs are being assigned overseas where local MTFs

cannot provide the needed care. In addition, overseas beneficiaries

complained to us about accessing health care benefits when traveling in the

United States.

Aging Aeromedical Aircraft According to a recent Air Force study, the fleet of dedicated C-9s currently

being used for aeromedical evacuation within the regions needs to be

replaced. According to the study, the C-9s’ future is being called into

question for numerous reasons:
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• the aging C-9s are experiencing corrosion problems, particularly the C-9

squadron in the Pacific, and have an uncertain remaining service life;

• the C-9s do not comply with U.S. and international aircraft noise

restrictions; and

• the C-9s do not meet all Global Air Traffic Management requirements for

improved communications, guidance, and surveillance systems.

Also, the C-9s have a limited flying range that is especially problematic in

the Pacific, where distances are considerable and there are few alternate

airfields on overwater routes. According to the Air Force study, C-9s do not

have sufficient range to meet all regional patient movement requirements

without refueling, and frequent fuel stops can be detrimental to patients.

Seasonal winds also play a large role in planning routes for patient

movement.

Further complicating the situation, the C-141 fleet—which currently moves

most patients between the overseas regions and U.S. MTFs—is undergoing

retirement, which is scheduled for completion in fiscal year 2006.

Breakdowns by aging C-141s cause frequent delays on flights to and from

the overseas regions. For example, Air Force officials told us that during

fiscal year 1999, 25 percent of C-141 missions returning from Europe were

delayed 24 hours or more because of breakdowns.

In response to these challenges, the Air Force undertook an analysis to

determine which aircraft are best suited to perform aeromedical

evacuation for the next 30 years. After considering eight potential

solutions, the analysis team focused on two preferred alternatives: (1)

modifying existing military transport aircraft to be used for peacetime

evacuation missions or (2) purchasing a dedicated fleet of 737-700 aircraft,

which have sufficient range to complete all evacuation missions currently

performed by C-9s and C-141s. The analysis team noted that patient

movement could suffer if modified aircraft are used, because these aircraft

might also be needed to move cargo and refuel other aircraft. Therefore,

the team recommended that the Air Force purchase a fleet of 737-700

aircraft, a procurement that would require several billion dollars.

The Air Force has yet to reach a final decision, and the Lead Agents have

been involved in the assessment of proposed changes to patient movement

in Europe and the Pacific. The Lead Agents recognize that greater use of

commercial aircraft or local health care might be required to ensure that

beneficiaries receive timely care.
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Concerns Exist About

Overseas Medical Screening

According to MTF commanders in Europe and the Pacific, the process for

screening family members of personnel assigned overseas does not always

identify individuals with extensive medical requirements. The presence of

such patients overseas can potentially strain MTF resources, increase

health care costs, and reduce readiness and morale.

Each military service has its own screening mechanism to ensure that

family members accompanying active duty troops overseas do not have

medical problems that exceed the capacity of local health care providers.

However, DOD officials told us this medical screening is often inadequate

and sometimes does not take place at all. Officials note that family

members occasionally arrive with serious physical and psychological

problems, requiring continuous follow-up from MTF specialists. In some

cases in which the required care exceeds MTF capabilities, dependents

might need extensive and potentially expensive local treatment, care that

must be coordinated and reviewed by MTF staff. In other cases, patients

might be returned to the United States for care, resulting in additional

expense; strain on military families; and, in some cases, the need for active

duty members to take extensive leave to manage family medical problems.

According to DOD officials, readiness suffers when active duty troops are

absent from duty or distracted by the problems of coordinating care for

family members.

In addition, DOD officials told us that currently no requirement exists for

medical screening of DOD civilian employees, contractors, or their families

prior to being selected for an overseas position. According to medical

personnel in Europe and the Pacific, civilian employees and family

members have arrived with serious medical conditions—including chronic

heart disease, spinal bifida, congenital heart deformities, and psychiatric

disorders—that exceeded community health resources. Furthermore, for

these beneficiaries, MTF care is on a space-available basis, and the

TRICARE Management Activity notes that “many civilians have unrealistic

expectations of on-base medical support.” These patients might require

extensive and often costly local care or returning to the United States for

treatment. Civilian employees often perform critical functions overseas,

and coordinating medical care for themselves or their family members

could result in financial hardship, extended leave, and other strains that

could compromise their effectiveness.

DOD officials agree that overseas medical screening needs to be improved,

noting that while the number of individual cases is small, these cases can

create significant problems for MTFs. Officials said that a DOD committee
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will review current policies regarding overseas screening for active duty

family members and civilian employees in an effort to improve the process.

Beneficiaries Are

Concerned About TRICARE

When They Travel

Accessing health care while away from their home base has reportedly

been a problem for some beneficiaries. In fact, beneficiaries we spoke with

recurrently complained that they have had difficulty accessing MTF care

when traveling back in the United States. Beneficiaries told us that U.S.-

based MTFs have sometimes denied them access to care, referred them to

civilian providers, or demanded authorization from a primary care manager

at the overseas duty station.

According to TRICARE Management Activity officials, DOD beneficiaries

are encouraged to obtain most of their care at their duty station’s MTF.

However, TRICARE program guidance states that overseas beneficiaries

enrolled in TRICARE Prime should not be denied care when visiting MTFs

in the United States. Overseas Prime enrollees have the same access

priority at U.S. MTFs as stateside enrollees, and preauthorization from

their primary care manager is not required. TRICARE Management Activity

officials acknowledged that overseas beneficiaries do not always receive

uniform access to MTF care when traveling in the United States. They

added that DOD is planning to develop a new policy letter reinforcing

access standards for all enrollees and emphasizing the commitment to

provide services to overseas personnel traveling outside their home region.

Conclusions The military health care system in Europe and the Pacific has undergone

considerable downsizing during the past decade and continues to face

operational challenges. Yet the system appears to have largely overcome

the extensive access to care and other problems we reported in 1990 and

1995 and generally to be satisfactorily caring for beneficiaries.

Nevertheless, routine and specialty care at some MTFs is still sometimes

unavailable within the TRICARE access standards, resulting in care delays

for some beneficiaries.

Host nation care options help MTFs meet TRICARE access standards for

specialty care and allow beneficiaries to be treated nearer their duty

stations and their families, reducing the stress and extra costs that can be

associated with the transport of patients between MTFs. Bilingual patient

liaisons play an important role in increasing local care acceptance by

breaking down cultural and language barriers between local doctors and

DOD patients, reassuring patients being treated locally, and otherwise
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serving as a reliable link between the military health care system and local

providers. Efforts to expand local care options, such as those under way in

Turkey and Korea, can help improve access to specialty care and should be

extended to other locations where possible.

DOD is currently reviewing aeromedical utilization and options but has not

yet identified the best long-term approach for transporting overseas

patients needing care not available locally. Also, DOD’s current screening

process does not always prevent DOD civilians, contractors, or family

members of active duty personnel with complex or chronic medical

requirements from being sent overseas, and some overseas beneficiaries

have had difficulty obtaining health care services when traveling outside

their region.

Recommendations We recommend that the Secretary of Defense direct the Assistant Secretary

of Defense (Health Affairs) to

• complete the analysis of aeromedical utilization and implement the best

long-term approach identified for transporting overseas patients

needing care not available locally;

• improve medical screening policies to help ensure that beneficiaries

overseas do not have medical problems exceeding the capacity of MTFs

or local health care providers;

• complete the development of policies reinforcing standards to ensure

health care access for overseas beneficiaries when they travel outside

their TRICARE regions; and

• continue working to expand, where possible, the use of host nation

providers and provide feedback to such providers on the quality of care.

Agency Comments and

Our Evaluation

We obtained comments on this report from DOD. DOD agreed with our

findings and recommendations, acknowledging that while improvements

have been made since our last review of overseas health care, issues

requiring attention remain. DOD said, for example, that it is continuing to

evaluate alternatives to the C-9 airframe to improve, streamline, and costeffectively meet the needs of patients needing medical evacuation. Also,

DOD indicated that the medical screening matter is under review and that a

solution will require extensive coordination among the services and with

the medical and personnel communities. DOD also stated that a new policy

letter to help ensure health care access for overseas beneficiaries when
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they travel across TRICARE regions is being drafted and will be issued

shortly. Finally, DOD said it would work with the overseas Lead Agents to

expand the use of host nation providers where possible and to implement a

formal feedback mechanism for such providers.

DOD outlined its plans to address our recommendations in its comments,

which appear in the appendix. DOD also provided several technical

comments, which we incorporated into the report as appropriate.

We are sending copies of this report to the Honorable William S. Cohen,

Secretary of Defense; appropriate congressional committees; and other

interested parties. We will also make copies available to others upon

request.

If you or your staff have any questions about this report, please contact me

at (202) 512-7101 or Daniel M. Brier at (202) 512-6803. Jon Chasson and

Linda S. Lootens also made key contributions to this report.

Stephen P. Backhus

Director, Veterans’ Affairs and

Military Health Care Issues
Page 31 GAO/HEHS-00-172 Implementation of TRICARE Overseas
Page 32 GAO/HEHS-00-172 Implementation of TRICARE Overseas

Appendix I

Comments From the Department of Defense ApApenednxidexiIs
Appendix I

Comments From the Department of Defense

Page 33 GAO/HEHS-00-172 Implementation of TRICARE Overseas

Now on p. 29.

Now on p. 29.
Appendix I

Comments From the Department of Defense

(101632) Letr Page 34 GAO/HEHS-00-172 Implementation of TRICARE Overseas

Now on p. 29.

Now on p. 29.
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