Testimony

Before the Subcommittee on Military Personnel,

Committee on Armed Services, House of

Representatives

United States General Accounting Office

GAO

For Release on Delivery

Expected at 9:00 a.m. Thursday,

May 17, 2001 DEFENSE HEALTH CARE

Lessons Learned From

TRICARE Contracts and

Implications for the Future

Statement of Stephen P. Backhus

Director, Health Care—Veterans'

 and Military Health Care Issues

GAO-01-742T
Page 1 GAO-01-742T

Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today to discuss lessons learned from the

Department of Defense’s (DOD) TRICARE contracts and their implications

for the future. TRICARE, implemented in 1994, offers beneficiaries a

choice of three options through which they can receive health care from

either military treatment facilities (MTF) or civilian providers. Care from

civilian providers is arranged and paid for by five TRICARE contractors.

Today, over 8 million active duty personnel, their dependents, and retirees

are eligible to receive care through TRICARE. The military health system

is funded at about $18 billion for fiscal year 2001. Approximately 30

percent of this amount, $5 billion, was budgeted for the TRICARE

contracts.

Since TRICARE’s inception, we have issued numerous products on DOD’s

progress in implementing it. Over the years, TRICARE has matured in its

delivery of health care. For example, 90 percent of beneficiaries surveyed

report being satisfied with the overall quality of care; over 80 percent of

surveyed beneficiaries reported satisfaction with access to care; and 96

percent of medical claims are processed within 30 days. These successes

are due, in large part, to the partnership efforts of DOD and the TRICARE

contractors. Not withstanding these successes, daunting challenges

confront DOD and its contractors, including the implementation of major

benefit changes recently directed by Congress. Additionally, DOD is in the

process of rethinking its own contract approach for the TRICARE

contracts. We identified contract management (including TRICARE

contracts) as a high-risk and major management challenge facing DOD.1

My statement today (1) describes shortcomings with the current

contracting approach and (2) issues to be considered in developing future

TRICARE contracts. It is based on a substantial body of ongoing work and

work completed over the past 7 years on the TRICARE program and its

contracts. (A list of our products related to TRICARE appears at the end of

this statement.)

In summary, TRICARE’s successes and maturity reflect the ability of DOD

and its contractors to work within the current contract structure.

However, it has not been easy, and there are important lessons from

current contract shortcomings that need to be addressed in designing

 1

High Risk Series: An Update (GAO-01-263, January 2001); Major Management Challenges

and Program Risks: Department of Defense (GAO-01-244, January 2001).
Page 2 GAO-01-742T

future TRICARE contracts. Most, including DOD, feel that the current

contracts are too large, complex, and prescriptive in nature, limiting

innovation and competition. Also, numerous adjustments to these

contracts have created an unstable program, and program costs have been

difficult to predict, contributing to annual funding shortfalls. Additionally,

financial incentives, accountability, and data quality need to be

strengthened to achieve greater efficiencies. To address these weaknesses,

DOD redesigned its solicitation for the next round of TRICARE contracts;

however, the initial issuance was withdrawn due to internal concerns and

reservations about its costs and specifications. The Assistant Secretary of

Defense for Health Affairs (ASD/HA) is now reassessing how to structure

the TRICARE contracts and is considering the views and

recommendations of the Defense Medical Oversight Committee (DMOC), a

group formed by the Deputy Secretary of Defense to provide oversight to

TRICARE. Separately, DOD has an ambitious initiative underway to

develop an overall medical resource strategy designed to improve fiscal

incentives, accountability, and data quality that should provide valuable

information to help shape future TRICARE contracts. In developing a

viable contract approach, the ASD/HA is considering several other

important issues, including the degree of prescriptiveness needed; the

frequency of and process for contract adjustments; the size of the

contracts and their impact on the level of competition; and whether the

current contract structure provides the right incentives and predictability

to obtain needed efficiencies.

DOD has the unique dual mission of maintaining adequate medical

readiness capability while providing peacetime health care. During the

early 1990s, in a time of military downsizing, medical cost escalation, and

budgetary constraints, DOD restructured its system into TRICARE to

improve beneficiaries’ access to health care while maintaining quality and

controlling costs. TRICARE gives beneficiaries a choice among a health

maintenance organization (TRICARE Prime), a preferred provider

network (TRICARE Extra), and a fee-for-service benefit (TRICARE

Standard). TRICARE Prime, the option in which care is most actively

managed, is the only option requiring beneficiaries to enroll.

Under TRICARE, DOD supplements care provided in its MTFs with

civilian providers. To do so, DOD contracts with civilian health care

companies to administer its TRICARE program on a regional basis. The

primary responsibilities of these TRICARE contractors include: developing

civilian provider networks (includes credentialing providers and

negotiating reimbursement discounts), ensuring adequate access to health

Background
Page 3 GAO-01-742T

care, enrolling beneficiaries, referring and authorizing beneficiaries for

health care, processing health care claims, conducting utilization

management and quality management programs, and educating providers

and beneficiaries.

The TRICARE Management Activity (TMA), under the ASD/HA, is

responsible for procuring and administering the TRICARE contracts. Since

1994, TMA has sequentially awarded 7 contracts covering 11 geographic

TRICARE regions. These contracts were competitively bid and awarded as

fixed-price, at-risk contracts.2

 Nonetheless, DOD designed them to include

adjustments for health care cost increases beyond the contractors’ control,

while other costs, such as administrative, remain fixed. All of the contracts

were awarded for a base period and 5 option years.3

 (See table 1.) Four of

the contracts have used all of the option years and three of these have

been extended for an additional 2 years. The negotiation for the fourth

contract’s extension is expected to be completed in June 2001. TMA

anticipates that all of its contracts will be extended; however, the

TRICARE contracts will eventually need to be resolicited and awarded

because they are only authorized to be extended a maximum of 4 option

years.4

 2

At-risk features of the contract provide for the sharing of financial gains and losses

between the contractor and the government. For example, contractors are at risk for health

care cost overruns up to 1 percent of health care prices. Beyond that, the contractor and

the government share in losses until an amount prepledged by the contractor, called

contractor equity, is totally depleted, at which time the government assumes full

responsibility for further losses.

3

The base period, which varies by contract, consists of a transition period, ranging from 6-9

months, and the early months of health care delivery.

4

Floyd D. Spence National Defense Authorization Act for Fiscal Year 2001 (P.L. 106-398,

§ 724).
Page 4 GAO-01-742T

Table 1: TRICARE Contractors, Regions, Date of Initial Award, and Extensions

TRICARE Contractor

Region name

 and number

Date of initial

award Extensions

Health Net Federal

Servicesa

Northwest/11 September 1994 Yes

Health Net Federal

Services

Southwest/6 April 1995 Yes

Health Net Federal

Services

Golden Gate, Southern

California, and Pacific/9,

10, and 12

August 1995 Under

negotiation

Humana Military

Healthcare Services

Southeast and Gulf

South/3 and 4

November 1995 Yes

TriWest Healthcare

Alliance

Central/(formerly 7 and 8) June 1996 N/Ab

Anthem AlliancecMid-Atlantic and

Heartland/2 and 5

September 1997 N/Ab

Sierra Military Healthcare

Services

Northeast/1 September 1997 N/Ab

a

Health Net Federal Services, formerly Foundation Health Federal Services, changed its name in

February 2001.

b

Not applicable.

c

In April 2001, DOD announced that Humana Military Healthcare Services acquired Anthem Alliance

and will assume responsibility for the Mid-Atlantic and Heartland regions.

Source: TMA.

In August 1999, the Deputy Secretary of Defense formed DMOC to provide

greater oversight in the operation of the TRICARE program. Its

membership consists of the Under Secretary of Defense (Personnel and

Readiness), the four service Vice Chiefs, the military department Under

Secretaries, the Under Secretary of Defense (Comptroller), the Director

for Logistics from the Joint Staff, the Surgeons General, and the Assistant

Secretary of Defense (Health Affairs). As part of its responsibilities, DMOC

undertook a review of TMA’s contract approach for the TRICARE

contracts.

DOD’s current contracting approach for TRICARE poses several

administrative challenges, and has contributed to significant funding

shortfalls. To be considered for a contract award, offerors were required,

in effect, to submit voluminous, expensive-to-produce proposals, which

has limited competition. Offerors have stated that complicating the

preparation of proposals was the need to address DOD’s overly

Shortcomings

With the Current

Contracting Approach
Page 5 GAO-01-742T

prescriptive requirements, restricting its ability to use best practices to

achieve the same results with greater cost efficiency. Furthermore,

TRICARE contracts were awarded while DOD was realigning and reducing

its MTF capability during a time of budgetary concerns. The resulting shift

to greater reliance on civilian providers as well as frequent changes to the

program resulted in numerous adjustments to the TRICARE contracts,

both planned and unplanned. The effect and cost of these numerous

adjustments created an unstable program and contributed to annual

budget shortfalls.

Under DOD’s contract approach, the TRICARE contracts were

competitively bid. Because the required proposals were large, complex,

lengthy, and preparation involved significant sums of money, offerors

incurred substantial expense to participate. In preparing the proposal,

offerors were required to address 13 different tasks, including enrollment

and beneficiary services, fiscal management and controls, program

integrity, and automated data processing. The proposals were also to

address seven cost factors including utilization management, provider

reimbursement discounts, and coordination of third party liability. To

illustrate the size and complexity of the resulting proposals, one complete

proposal consisted of 33,000 pages.

In 1995, we reported that several offerors stated that it cost them between

$1 million and $3 million just to develop their proposals.5

 More recently,

one contractor official told us that it cost the company he worked for

about $5 million to bid. As a result of the large contract size and

complexity, competition has been limited to large companies with

significant resources. Further, because of the large cost to develop a

proposal, losing contractors stated they had everything to gain by

protesting the award even at substantial cost to them and DOD. All seven

contract awards have been protested; three were sustained.

 5

Defense Health Care: Despite TRICARE Procurement Improvements, Problems Remain

(GAO/HEHS-95-142, August 3, 1995).

Large, Complex Proposals

Costly To Bid
Page 6 GAO-01-742T

The requests for proposal (RFP) DOD used to solicit TRICARE contracts

have been very prescriptive. DOD officials stated that highly detailed

proposals were needed to ensure a uniform nationwide program under

which beneficiaries and providers would be subject to the same

requirements and processes regardless of region. For example, utilization

management is used to ensure that patients receive all necessary care in

the most cost-effective manner. DOD’s proposal required the offerors to

perform utilization management functions, such as pre-authorization,

concurrent and retrospective reviews, and waiver considerations, for all

types of health care in all settings. These activities were to be performed

using a uniform set of criteria determined by DOD. However, offerors have

often cited utilization management as the area in which more relaxed DOD

requirements would enable them to implement effective techniques with

greater savings. Offerors said that this could be achieved with an RFP that

emphasized health care outcomes desired rather than mandate the

processes to achieve them. They believe it would allow them more

innovation and flexibility in devising approaches to economically achieve

such outcomes without adversely affecting the quality of care delivered.

Such an approach deserves DOD’s careful consideration, but would also

require provisions such as appropriate, evidence-based reviews performed

by qualified health care professionals to ensure that all desired outcomes

are achieved.

In addition, prescriptive requirements for utilization management review

have contributed to claims processing inefficiencies. As we reported in

June 2000, DOD’s contractual requirements for prepayment review of

claims are manifested as thousands of edits in the adjudication logic of the

claims processing system.6

 These edits result in claims being “kicked out”

of the system for manual review, which extends processing time and

increases administrative costs. However, not all of these edits are needed,

especially since contractors are at risk for some health care dollars. For

example, claims for electrocardiograms—14,000 for one contractor

alone—were being manually reviewed, but in every case at the time of our

evaluation, the claims were paid after review. As we reported, over half of

TRICARE’s claims were manually reviewed, a rate significantly higher than

the industry average of 25 percent. In its claims improvement initiative,

DOD has been partnering with its contractors to review the need for these

edits.

 6

Defense Health Care: Opportunities to Reduce TRICARE Claims Processing and Other

Costs (GAO/T-HEHS-00-138, June 22, 2000).

Prescriptive Requirements

May Limit Offerors’ Use of

Best Practices and

Increase Costs
Page 7 GAO-01-742T

Further complicating the design of the TRICARE contracts is the fact that

DOD designed them to have periodic adjustments to the contract price,

which are called bid price adjustments (BPA). These adjustments are

based on shifts in workload between the MTFs and civilian providers as

well as other operating conditions of the contract, such as changes in the

number of beneficiaries caused by the frequent geographic rotation of

active-duty members and their dependents. To calculate these

adjustments, DOD uses a formula that incorporates factors including cost,

population shifts, inflation, and utilization. However, these determinations

have been a source of contention with contractors. For example,

contractors have been concerned with DOD’s use of inaccurate and

incomplete data, such as that used to determine the MTF workload. In

addition, contractors were concerned about some of the factors used in

the BPA formula. As a result, in recent negotiations, DOD agreed to modify

its inflation index and other adjustment factors. Outside of the regularly

scheduled BPA process, TRICARE contractors have also initiated

additional adjustments in the contract price called requests for equitable

adjustment, which are used to redress unforeseen changes in contract

conditions, such as higher than anticipated claim submissions, that

subsequently increased their administrative expenses.

In addition, DOD has made a total of over 1,000 unscheduled modifications

to these contracts via contract change orders—an average of 156 per

contract as of June 30, 2000. Change orders may result from new laws or

regulations, or from DOD initiatives. They range in scope from

administrative changes, such as changes to home health care billing

procedures, to significant benefit expansions, such as the elimination of

copayments for active duty dependents that will significantly add to

program costs. Until recently, DOD directed its contractors to implement

change orders prior to negotiation of the final terms of the modification,

including payment. As we recently reported, DOD’s management of the

change order process resulted in a large backlog of outstanding change

orders, which was mostly eliminated under a recent short-term effort by

DOD and the contractors to settle all outstanding contract adjustments.7

Negotiated settlements for this initiative totaled about $900 million for

 7

Defense Health Care: Continued Management Focus Key to Settling TRICARE Change

Orders Quickly (GAO-01-513, April 30, 2001).

Numerous Contract

Adjustments Lead To An

Unstable Program and

Funding Shortfalls
Page 8 GAO-01-742T

current and prior fiscal years.8 DOD hopes to avoid future problems with

change order backlogs by using a new process to negotiate and settle

changes prior to implementation. However, it is premature to evaluate the

effectiveness of this process because TMA has not yet issued any change

orders under it.

Change orders and other contract adjustments have contributed to

program instability and have led, in part, to DOD’s having to request

additional funding from Congress to address health program budget

shortfalls. These requests have called into question DOD’s financial

management practices for estimating and budgeting costs. In fiscal year

2000, Congress provided a supplemental appropriation of $1.3 billion—

nearly half of which was designated for contract adjustments. Likewise, in

fiscal year 2001, TMA estimates a shortfall of $1.4 billion—over a third of

which is due to the recent settlement of contract adjustments. As we have

reported in our high-risk series, accurate financial information is crucial to

making sound decisions so that DOD’s missions and goals are efficiently

and effectively accomplished.9

Based on knowledge gained during the first several years of operation and

anticipating contract expirations, TMA undertook an effort to redesign the

TRICARE contract approach. A new RFP was developed, but was

withdrawn by the Under Secretary of Defense for Personnel and

Readiness shortly after issuance because of serious concerns about its

design. The ASD/HA is currently reassessing future contract approaches

for TMA to employ and is considering DMOC’s recommendations.

Separately, DOD has initiated an effort to determine overall medical

resource needs, which could provide valuable information that will help

shape future TRICARE contracts. However, to successfully accomplish

this initiative, DOD needs to address pervasive problems with its financial

management and workload data.

 8

It is not possible to identify the amounts related specifically to change orders for each of

the contracts because the change orders and other contract adjustments were jointly

settled.

9

High Risk Series: An Update (GAO-01-263, January 2001).

Future Design of

Tricare Contracts

is Uncertain
Page 9 GAO-01-742T

TMA officials spent 3 years developing a new TRICARE contract vehicle,

commonly referred to as TRICARE 3.0, for the next round of contracts.

They created TRICARE 3.0 using a partnership approach, which included

input from numerous military and private industry representatives,

including the current TRICARE contractors, as well as health care

consultants. The intent behind TRICARE 3.0 was to address shortcomings

of the current contracts. For example, as we recommended in 1995, TMA

attempted to develop less prescriptive requirements with a shift in focus

from process to outcomes.10 This shift was intended to provide contractors

with the incentive to employ their best practice techniques to achieve

needed outcomes with improved cost efficiency while maintaining quality

of care. TMA also hoped that a less prescriptive approach would result in a

more stable contract with fewer unplanned changes and adjustments.

Using TRICARE 3.0, TMA issued an RFP for the Northwest Region in

February 2000. However, 6 months later, the Under Secretary of Defense

for Personnel and Readiness withdrew it because of (1) the absence of a

valid cost estimate and (2) requirements that offerors develop proposals

based on DOD business processes that were changing. The contractors felt

that the requirements under TRICARE 3.0 were more prescriptive than

they had anticipated. They were also concerned about the fairness of the

structure for financial penalties and incentives. Financial penalties were to

be based on measurable, quantitative standards; however, the financial

incentives were to be based on beneficiary satisfaction surveys—-which

the contractors believe are a less reliable measure of performance.

DOD is developing an overall medical resource strategy that encompasses

the direct health care provided through the MTFs as well as the civilian

TRICARE contracts that potentially will provide valuable information in

designing future procurement strategy. The medical resources strategy

begins with defining the military readiness needs and optimizing care

delivery throughout the military health system. DOD has recognized the

need for this fundamental strategy to more completely establish how large

the military medical infrastructure needs to be, including where resources

should be placed and used to best support readiness and provide

peacetime care. In essence, DOD would determine what resources are

needed to meet readiness requirements, and this determination would

 10Defense Health Care: Despite TRICARE Procurement Improvements, Problems Remain

(GAO/HEHS-95-142, August 3, 1995).

TRICARE 3.0 Withdrawn

New Medical Resource

Strategy Could Provide

Key Data for Future

Contracts
Page 10 GAO-01-742T

drive all decisions for how best to provide peacetime care—whether in the

direct care system or from the TRICARE contractors, commonly referred

to as make-or-buy decisions.

As we reported in November 1999, DOD established a tri-service team of

senior officers to develop a strategy, called Optimization, to clearly define

readiness needs and costs in order to make better decisions about

peacetime care using make-or-buy analyses.11 The team’s goals consisted

of devising an approach to determine each military treatment facility’s

correct size, identifying excesses and shortages of medical personnel by

specialty, and determining the right provider mix for each facility. DOD

officials agreed with us that until this is done, it is not possible to judge the

need for nor relative efficiency of their direct care system—-information

that is critical to the development of a contract approach.

Optimization is an ambitious undertaking that is dependent upon accurate

and reliable information. However, key health care cost and workload data

problems have been pervasive, and DOD continues to struggle with its

data systems’ inaccuracies. As we and others have reported, the root cause

has been DOD’s and the services’ lack of oversight and incentives to

ensure the data’s accuracy, timeliness, and completeness.12 These

impediments make it critical that the implementation of Optimization is

closely monitored.

Attaining sufficient competition may be key to obtaining the best quality

for the best price for the TRICARE contracts. In determining a contract

approach, DOD needs to carefully weigh the impact of its decisions on

competition, including whether to carve out elements of TRICARE, such

as pharmacy or enrollment, for separate, national contracts. Other

considerations, such as smaller contracts covering smaller geographic

areas, could also influence competition. Also, it should recognize the

effect that the complexity of earlier contracts, with the resulting high

contractor proposal costs, had on competition and simplify the contracts

as much as feasible. The challenge for DOD, in other words, is to decide

 11Defense Health Care: Tri-Service Strategy Needed to Justify Medical Resources for

Readiness and Peacetime Care (GAO/HEHS-00-10, November 3, 1999).

12GAO/HEHS-00-10, November 3, 1999.

New TRICARE Contract

Approach Considerations
Page 11 GAO-01-742T

whether to continue to use fewer large and complex contracts versus

managing smaller and potentially simpler contracts, each of which has

unique management challenges.

DOD’s continued partnering with private industry to reach agreement on

the degree of prescriptiveness needed, by identifying the specific functions

in which the use of best practice techniques would be most practical, is a

worthwhile endeavor. In determining this, DOD and the contractors

recognize that the contract needs to be flexible to maintain a balance

between DOD’s goal of providing uniform benefits nationwide with the

realization that the delivery of health care is local. Conversely, some

contract functions may benefit from more specific requirements, such as

performance measurement to assess how well contractors are meeting

requirements.

In light of the complexity and difficulties with adjustments to the current

contracts, such as negotiating and settling almost a thousand contract

change orders, a more stable environment for future contracts is needed.

For example, modifications to the contract could be made on a regularly

scheduled basis, such as annually, rather than on a continual ad hoc basis.

However, with recent benefit changes, including Senior Pharmacy,

TRICARE for Life, and the elimination of copayments for family members

in Prime, the program will be in a state of flux with numerous anticipated

contract adjustments that will be needed to implement them. We hope that

once the changes have been incorporated, the TRICARE program and

contracts will become more stable.

Given long-range budget pressures and escalating health care costs, DOD

faces a formidable challenge in creating a new contract approach. The

current approach is considered to be overly complicated, prescriptive, and

given the frequent adjustments, has created an unstable program. This

approach may not be the best way to satisfy TRICARE contracting needs

or achieve optimal competition. DOD’s Optimization effort is an important

step in ultimately developing a contract approach and warrants close

scrutiny as it is being implemented. The extent to which DOD is

contemplating other business process changes for TRICARE could further

complicate planning a new contract approach. Moreover, DOD is planning

in an environment of substantial ongoing and future changes to the

TRICARE program, including the expansion of benefits to Medicareeligible beneficiaries and the removal of copayments for family members

enrolled in Prime. To ensure that progress continues, sustained

management and congressional oversight will be necessary.

Concluding

Observations
Page 12 GAO-01-742T

Mr. Chairman, this concludes my prepared statement. I will be happy to

respond to any questions you or other members of the Subcommittee may

have.

For more information regarding this testimony, I can be contacted at

(202) 512-7101. Key contributors to this testimony include Michael T. Blair,

Bonnie W. Anderson, and Allan C. Richardson.

GAO Contact and

Staff

Aknowledgments
Page 13 GAO-01-742T

Defense Health Care: Continued Management Focus Key to Settling

TRICARE Change Orders Quickly (GAO-01-513, April 30, 2001).

Military Health Care: Factors Affecting Contractors’ Ability to Schedule

Appointments (GAO/HEHS-00-137, July 14, 2000).

Defense Health Care: Opportunities to Reduce TRICARE Claims

Processing and Other Costs (GAO/HEHS-00-138T, June 22, 2000).

DOD and VA Health Care: Jointly Buying and Mailing Out Pharmaceuticals

Could Save Millions of Dollars (GAO/HEHS-00-121T, May 25, 2000).

VA and Defense Health Care: Evolving Health Care Systems Require

Rethinking of Resource Sharing Strategies (GAO/HEHS-00-52, May 17,

2000).

Defense Health Care: Observations on Proposed Benefit Expansion and

Overcoming TRICARE Obstacles (GAO/HEHS/NSIAD-00-129T, March 15,

2000).

TRICARE’s Civilian Provider Networks (GAO/HEHS-00-64R, March 13,

2000).

Defense Health Care: Tri-Service Strategy Needed to Justify Medical

Resources for Readiness and Peacetime Care (GAO/HEHS-00-10,

November 3, 1999).

Defense Health Care: Fully Integrated Pharmacy System Would Improve

Service and Cost-Effectiveness (GAO/HEHS-98-176, June 12, 1998).

Defense Health Care: Reimbursement Rates Appropriately Set; Other

Problems Concern Physicians (GAO/HEHS-98-80, February 26, 1998).

Defense Health Care: Operational Difficulties and System Uncertainties

Pose Continuing Challenges for TRICARE (GAO/T-HEHS-98-100, February

26, 1998).

Defense Health Care: TRICARE Resource Sharing Program Failing to

Achieve Expected Savings (GAO/HEHS-97-130, August 22, 1997).

Defense Health Care: Actions Underway to Address Many TRICARE

Contract Change Order Problems (GAO/HEHS-97-141, July 14, 1997).

Related GAO Products
Page 14 GAO-01-742T

Defense Health Care: New Managed Care Plan Progressing, But Cost and

Performance Issues Remain (GAO/HEHS-96-128, June 14, 1996).

Defense Health Care: TRICARE Progressing, But Some Costs and

Performance Issues Remain (GAO/T-HEHS-96-100, March 7, 1996).

Defense Health Care: Despite TRICARE Procurement Improvements,

Problems Remain (GAO/HEHS-95-142, August 3, 1995).

Defense Health Care: Issues and Challenges Confronting Military Medicine

(GAO/HEHS-95-104, March 22, 1995).

(290055)