GAO

United States General Accounting Office

Subcommittee on Military Personnel,

Committee on Armed Services, House of

Representatives

July 2000 MILITARY HEALTH

CARE

Factors Affecting

Contractors' Ability to

Schedule

Appointments

GAO/HEHS-00-137

Page 1 GAO/HEHS-00-137 TRICARE Central Appointing

Contents

Letter 3

Tables Table 1: Percentage of Appointments Scheduled by Contractor Staff 6

Table 2: Percentage of Primary and Specialty Clinic Appointments

Scheduled by Contractor Staff 7

Abbreviations

DOD Department of Defense

MTF military treatment facility
Page 2 GAO/HEHS-00-137 TRICARE Central Appointing
Page 3 GAO/HEHS-00-137 TRICARE Central Appointing

United States General Accounting Office

Washington, D.C. 20548

Health, Education, and Human

Services Division

B-285758 Letr

July 14, 2000

The Honorable Steve Buyer

Chairman

The Honorable Neil Abercrombie

Ranking Minority Member

Subcommittee on Military Personnel

Committee on Armed Services

House of Representatives

For most people, the initial contact with a health care system occurs when

they call their physician’s office to schedule an appointment. For years,

Department of Defense (DOD) beneficiaries seeking to make appointments

in military treatment facilities (MTF) gained access to care this way—by

calling the clinic directly. Over the past several years, however, DOD has

been moving toward a centralized appointment system. In some MTFs, an

appointment center has been created, and beneficiaries call that center to

schedule various types of appointments. In addition, in four areas of the

country that DOD refers to as TRICARE regions, the TRICARE contractors

have established regional appointment centers which beneficiaries call to

schedule appointments with physicians in MTFs.1 Centralized appointment

scheduling is intended to provide beneficiaries with improved appointment

services and increase efficiency by consolidating the appointment function

such that MTF clinic staff will be less involved in the process. The

contractors perform this function as part of their administrative tasks

under their contracts with DOD.

As you requested, this report provides information on (1) the proportion of

appointments scheduled by TRICARE contractors for beneficiaries in the

four TRICARE regions with centralized systems, and (2) the factors that

affect the contractors’ ability to schedule appointments.

To determine the extent to which the contractors scheduled appointments,

we obtained and analyzed data for appointments scheduled between

1

DOD has organized its health care system into 11 geographic regions. In four of those

regions—region 1 (the Northeast), region 2 (the mid-Atlantic), region 5 (the Midwest), and

region 11 (the Northwest)—a regionwide centralized appointment system has been

implemented.
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Page 4 GAO/HEHS-00-137 TRICARE Central Appointing

November 1 and November 30, 1999, in each MTF in the four TRICARE

regions.2 We visited the contractors’ appointment centers in three of the

four regions to observe appointment scheduling and met with contractor

officials and appointment staff to discuss the appointment process. We also

discussed issues regarding the contractor’s role and ability to schedule

appointments with DOD officials, and with MTF physicians and medical

staff at five MTFs. We did our work from September 1999 to June 2000 in

accordance with generally accepted government auditing standards.

Results in Brief Our analysis of DOD data shows that contractors scheduled only about

one-quarter of the appointments during November 1999 in the four regions

where TRICARE contractors have appointment-making responsibility. The

percentage of appointments scheduled by the contractors varied among the

regions, ranging from about 17 percent to about 63 percent. In general,

contractors scheduled a higher percentage of appointments for clinics that

provide primary care services (42 percent) than for clinics providing

specialty care, such as dermatology, cardiology, and orthopedics (17

percent).

In the four regions, DOD and its MTFs have restricted the types and

number of appointments available to the contractors for scheduling. Some

MTF physicians and other professional staff told us that they want to retain

control over the appointing process because they do not trust contractors

to accurately schedule appointments and to ensure that any medical

instructions can be provided prior to the visit, such as instructions about

fasting. When comparing like clinics within different MTFs the percentage

of appointments scheduled by contractors varies substantially, suggesting

that physicians’ and other staff’s desire to retain appointment control may

be the driving factor, rather than the need to provide medical instructions.

When contractors do not have access to appointments because of DOD and

MTF restrictions, beneficiaries requesting appointments from contractors

may be transferred from the appointment center to the MTF clinic, or told

to call MTF clinics themselves. Thus, what was meant to be a simplified,

more user-friendly appointment process is now a complex and confusing

process in which beneficiaries are unsure whether to call the contractor or

the MTF to schedule appointments.

2

The November data were the most recent complete data available to us at the time we

requested them.
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To improve its appointment system, DOD is in the process of reducing and

standardizing the number of appointment types and names used

throughout the military health care system. Currently thousands of

appointment types and names are used. Although reduction and

standardization could simplify the appointment-making process, until DOD

decides on and implements a more uniform process for making

appointments, there will continue to be differences in how beneficiaries

access the military health care system.

Background DOD health care, referred to as TRICARE, is provided in military-operated

hospitals and clinics worldwide, supplemented by civilian providers.

TRICARE is organized geographically into 11 health care regions

administered by five contractors. In TRICARE regions 1, 2, 5, and 11, the

contractors’ administrative tasks include scheduling appointments for the

MTFs within their region. In each of these four regions, the contractor has

established a central appointment center. Centralized appointment-making

is intended to provide beneficiaries with improved appointment services,

including the ability to make multiple appointments during a single phone

call, and increased access to appointment clerks, because the appointment

centers typically are open before, during, and after MTF clinic hours. To

schedule an appointment at any of the MTFs in the region, beneficiaries

call a regionwide toll-free number. In November 1999, contractor staff in

the four regions answered more than 393,000 calls and scheduled about

211,000 appointments.

In regions 2 and 5, beneficiaries calling the toll-free number may be routed

first to contractor staff located in the TRICARE service center closest to

where the call originated. If that line is not available, the call is

automatically routed back to the contractor’s central appointment center.

This rerouting is invisible to the caller, occurring in a few seconds. In

regions 1 and 11, calls to the toll-free number are answered in the

contractors’ regional appointment center. Regardless of where the

contractors’ appointment clerks are located, the process for making

appointments is the same: the contractors’ clerks view computer screens

showing schedules developed by the MTFs that include information on

appointment availability and other descriptive information, such as the

type of patient or procedure that should be scheduled into a particular

appointment slot.

Although the TRICARE contracts require the contractors to schedule

appointments, they do not specify the appointment workload. Each of the
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Page 6 GAO/HEHS-00-137 TRICARE Central Appointing

contractors we met with stated that they schedule all the appointments

provided to them by the MTFs and that this service was included in the

administrative fees paid under the contract. Some of the contracts also

include standards related to telephone responsiveness, such as a maximum

number of rings before which incoming calls should be answered, or a

maximum time callers should be placed on hold.

Proportion of

Appointments

Scheduled by

Contractors

Our analysis of appointment data from the TRICARE regions reviewed

indicates that only about one-quarter of the appointments in the MTFs were

scheduled by contractor staff. As shown in table 1, the percentage of

appointments scheduled by contractor staff varied among the regions.

Regions 1, 2, and 5 have less experience than region 11 with central

appointment scheduling, and the percentage scheduled by the contractors

in those regions—17, 29, and 22 percent, respectively—is notably lower

than the 63 percent of appointments scheduled by the contractor in region

11.3

Table 1: Percentage of Appointments Scheduled by Contractor Staff

Note: Data are for appointments scheduled between November 1 and November 30, 1999.

a

Percentage is calculated by dividing the number of appointments scheduled by the contractor by the

total number of appointments scheduled by the contractor and MTF staff.

b

The average is based on the total appointments for all four regions combined.

c

The 26 percent represents about 211,000 appointments.

3

Region 11 began performing the appointment function in March 1995, regions 2 and 5 began

in May 1998, and region 1 in June 1998.

Region Contractor

Percentage

scheduled by

contractora

1 Sierra Military Health Services, Inc. 17

2 Anthem Alliance Health Insurance Co. 29

5 Anthem Alliance Health Insurance Co. 22

11 Foundation Health Federal Services, Inc. 63

Weighted average for all four regionsb 26c
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Page 7 GAO/HEHS-00-137 TRICARE Central Appointing

We also found that, in general, contractors scheduled a higher percent of

appointments for primary care clinics than for specialty clinics.4 Overall,

about 42 percent of the appointments for primary care clinics were

scheduled by contractor staff, as compared to about 17 percent of the

appointments for specialty care clinics. These percentages also varied

among the regions, as shown in table 2.

Table 2: Percentage of Primary and Specialty Clinic Appointments Scheduled by

Contractor Staff

Note: Data are for appointments scheduled between November 1 and November 30, 1999.

a

Percentage is calculated by dividing the number of appointments scheduled by the contractor by the

total number of appointments scheduled by the contractor and MTF staff.

b

We defined specialty care clinics as all clinics not identified by the MTFs as primary care clinics.

These include the full range of specialty medicine, such as cardiology, dermatology, and orthopedics;

and some ancillary services that required an appointment, such as radiology.

c

The average is based on the total appointments for all four regions combined.

Factors Limiting

Contractors’ Ability to

Schedule

Appointments

The primary factor limiting contractors’ ability to schedule appointments is

the limited number of appointments that are allocated to them for

scheduling. DOD has given the region 1, 2, 5, and 11 contractors authority

to schedule only certain types of appointments, and MTFs have further

reduced the number of appointments available to contractors for

4

It is reasonable to expect some portion of specialty appointments to be scheduled by MTF

staff. Visits to specialists normally occur as a result of a referral from a primary care

provider, and the clinic staff may call the specialty clinic within the MTF directly on behalf

of the patient at the time the referral is made. Also, follow-up visits to specialists may be

booked directly with clinic staff as patients leave the clinic.

Region Contractor

Percentage of

primary clinic

appointments

scheduled by

contractora

Percentage of

specialty clinic

appointments

scheduled by

contractora,b

1 Sierra Military Health Services, Inc. 33 9

2 Anthem Alliance Health Insurance Co. 44 19

5 Anthem Alliance Health Insurance Co. 37 11

11 Foundation Health Federal Services, Inc. 76 54

Weighted average for all four regionsc 42 17
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Page 8 GAO/HEHS-00-137 TRICARE Central Appointing

scheduling. For example, in region 1, the contractor is authorized to

schedule eight appointment types, including those for initial primary and

specialty care, physical exams, and well-baby care. For the month of

November 1999, these eight appointment types represented about twothirds of all the appointments, with the remaining one-third not available

for contractor scheduling. In regions 2 and 5, the contractor can schedule 9

and 12 appointment types, respectively.5 At one MTF in region 5, the 12

authorized appointment types represented about 60 percent of total, and

thus about 40 percent of the appointments were unavailable to the

contractor for scheduling.

The number of appointments available for contractor scheduling has been

further reduced because of MTF-imposed restrictions. For example, in

region 1, of the 314 appointment openings in one MTF’s optometry clinic in

the month of November 1999, 222 were of the type that the contractor was

authorized to schedule. However, the MTF further limited the contractors’

scheduling ability by designating 300 of the 314 appointments as

appointments that should be scheduled only by MTF staff. Therefore, only

14 appointments were available to the contractor’s staff to schedule.

In region 11, each MTF has identified specific appointment types that

should be scheduled by the contractor, and developed guidance for the

contractor’s appointment staff to follow when scheduling appointments.

This guidance provides detailed descriptions of the various appointments,

including the types of patients that should be scheduled in the different

appointment slots, and whether the appointment can be scheduled by the

contractor or by MTF clinic staff. The contractor told us that this guidance

is cumbersome and confusing for the clerks to follow. The original

appointment guidance totaled almost 900 pages for all the MTFs combined,

and although the contractor and DOD have worked to reduce the number

of pages, it is still about 300 pages long, providing appointment

requirements for more than 100 clinics in the region’s MTFs. Adding to the

cumbersome nature of the long and prescriptive guidance is the fact that

the appointment guidance and appointment names are not uniform among

the MTFs. For example, at one MTF, contractor staff can schedule

appointments for new patients in the ophthalmology clinic; however, in

another MTF, appointments for new ophthalmology patients cannot be

5

DOD has identified 12 appointment types that the contractor can schedule in region 5.

However, each MTF determines which of the 12 types the contractor will schedule for each

clinic.
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Page 9 GAO/HEHS-00-137 TRICARE Central Appointing

scheduled by the contractor. Additionally, over 100 different appointment

names are used by the MTFs in region 11. For example, 10 different

appointment names are used to designate well-care visits—2-, 4-, 6-, 9-, and

12-month-old well-baby checkups; well-child checkups; well visits; 15- or

30-minute well visits; and follow-up well visits.

In September 1999, we reported on the lack of standardized appointment

names throughout the military health care system, and recommended that

DOD standardize appointment types across the system.6 DOD established a

group to undertake this task, and it has recommended using nine standard

appointment types across the military health care system—a significant

reduction from the thousands currently used. DOD has accepted the

group’s recommendation and expects to begin standardizing the

appointment names used in the appointment system in the fall of 2000.

Standardizing and reducing the number of appointment types will simplify

the appointment process not only in the MTFs but also for contractors who

are responsible for scheduling appointments in regions 1, 2, 5, and 11.

Beneficiaries can encounter unnecessary burdens and delays when the

contractor’s staff is restricted from scheduling certain appointments. For

example, if the contractor’s appointment clerk cannot schedule an

appointment requested by a beneficiary because the MTF has not made the

appointment type available to the contractor, the clerk might transfer the

call to the MTF, put the caller on hold while he or she contacts the MTF to

determine if the appointment can be scheduled, call the patient back after

contacting the MTF, or tell the beneficiary to call the MTF directly. Thus

what was intended to be a relatively straightforward procedure becomes a

complicated process for beneficiaries seeking medical care in the military

health care system.

In meetings with MTF physicians and medical staff, they told us they

withhold or restrict appointments due to their concern about the accuracy

of the appointment-making performed by contractor staff. MTF physicians

and medical staff provided anecdotal accounts of appointments incorrectly

scheduled by contractor staff, such as scheduling patients with the wrong

primary care manager, not scheduling enough time for certain appointment

types, and scheduling the wrong type of patient into an appointment slot

(such as an adult into a pediatrics slot). The physicians and medical staff

6

Defense Health Care: Appointment Timeliness Goals Not Met; Measurement Tools Need

Improvement (GAO/HEHS-99-168, Sept. 30, 1999).
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Page 10 GAO/HEHS-00-137 TRICARE Central Appointing

could not quantify the number of times such errors occurred, however, and

acknowledged that they usually did not report the errors to the contractor.

The contractors told us that when they learn of such errors, the

appointment clerks are counseled and provided additional instruction.

While DOD does not require contractors to report the extent to which their

clerks incorrectly schedule appointments, one contractor did monitor its

clerks’ errors and found appointment error rates of less than 1 percent.

MTF physicians also told us that some specialty and primary care

appointments should only be scheduled by MTF clinic staff to ensure the

availability of medical personnel to answer any questions the patient may

have and to provide any medical instructions. We recognize these may be

valid reasons for the MTF clinic to schedule some appointments. However,

when comparing like clinics in different MTFs, we found considerable

difference in the percentage of appointments scheduled by the contractors,

suggesting that the appointing process could be strongly influenced by

physician or medical staff preference to retain control over appointments

rather than the need to provide medical instructions. For example, the

percentage of dermatology appointments scheduled by contractors ranged

from 88 percent in one MTF to 0 percent at six other MTFs. Similarly, the

contractor scheduled 97 percent of the optometry appointments at one

MTF, while 0 percent were scheduled at eight other MTFs.

Because of concerns raised about contractor performance, we also

obtained information on the extent to which beneficiaries had difficulty

getting through to the contractors’ appointment clerks or were placed on

hold for long periods of time. The data indicate that most beneficiaries do

not encounter busy signals or unreasonable hold times when calling for

appointments. In all four regions, the contractors’ performance standard is

that 90 percent of the callers will speak with the clerk within 120 seconds.

In November 1999, contractors in two regions exceeded the standard, with

100 and 97 percent of the callers speaking to contractor staff within 120

seconds. In the other two regions, the contractors fell slightly short of the

standard at 89 percent. The data also indicate that a small percentage of

callers received busy signals or were put on hold. For example, one region

reported that about 3 percent of the callers encountered busy signals, with

the other three regions reporting 1 percent or less. In terms of hold times,

one region reported that only 2 percent of the callers experienced a hold
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time of more than 5 minutes, and two other regions reported average hold

times of about 1 minute or less.7

Conclusions Inconsistencies exist across the military health care system in terms of

whom beneficiaries should call to make an appointment, resulting in a

confusing process for beneficiaries. While improvements could be made in

the central appointing process and the contractors’ access to appointments

increased, at this juncture a larger issue exists for DOD resolution—what

type of appointment scheduling process best serves the needs of the

military health care system and its beneficiaries.

DOD has not evaluated the appointment-making processes currently in

place across the military health care system, including the advantages and

disadvantages of using contractor versus MTF staff, nor developed criteria

or guidance to be used uniformly across the military health care system.

The appointment process should be transparent to all beneficiaries and

based on solid evidence that it is providing beneficiaries with the best

possible service. Congress is considering legislation that would authorize

$20 million to support procurement of a local appointment-scheduling

system and would direct that the planning and installation of such a system

be coordinated with the contractors in order to integrate and synchronize

the local systems with regional applications to the maximum extent

possible. As a first step toward implementing such a requirement, DOD

needs to assess and decide on the respective roles of contractors and MTF

staff in the appointment process.

Recommendations To clarify and standardize the appointment-making process to the extent

practical, we recommend that the Secretary of Defense direct the Assistant

Secretary of Defense (Health Affairs) to assess the effectiveness of the

current appointment-scheduling process and determine how that process

could be optimized, including a determination of the role contractors

should play. The Assistant Secretary should then implement the selected

appointment-scheduling process system-wide.

7

One region does not collect data on caller hold times.
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Agency Comments We provided DOD with a draft of this report and discussed it with the

Deputy Executive Director, TRICARE Management Activity. He agreed with

the information presented and our recommendations, and said that DOD is

in the process of determining the specific actions needed to implement the

recommendations.

We will send copies of this report to the Honorable William S. Cohen,

Secretary of Defense, and others who are interested.

If you have any questions or would like additional information, please call

me on (202) 512-7101, or Michael T. Blair, Jr., on (404) 679-1944. Other

major contributors to this report were Nancy T. Toolan and Lisa M. Moore.

Stephen P. Backhus

Director, Veterans’ Affairs and

Military Health Care Issues

(101636) Letr
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