Defense Health Care: Access to Care for Beneficiaries Who Have Not Enrolled in TRICARE's Managed Care Option
Published: 2006-12-22T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Defense (DOD) provides health care through its TRICARE program. Under TRICARE, beneficiaries may obtain care through a managed care option that requires enrollment and the use of civilian provider networks, which are developed and managed by contractors. Beneficiaries who do not enroll may receive care through TRICARE Standard, a fee-for-service option, using nonnetwork civilian providers or through TRICARE Extra, a preferred provider organization option, using network civilian providers. Nonenrolled beneficiaries in some locations have reported difficulties finding civilian providers who will accept them as patients. The National Defense Authorization Act (NDAA) for fiscal year 2004 directed GAO to provide information on access to care for nonenrolled TRICARE beneficiaries. This report describes (1) how DOD and its contractors evaluate nonenrolled beneficiaries' access to care and the results of these evaluations; (2) impediments to civilian provider acceptance of nonenrolled beneficiaries, and how they are being addressed; and (3) how DOD has implemented the NDAA fiscal year 2004 requirements to take actions to ensure nonenrolled beneficiaries' access to care. To address these objectives, GAO examined DOD's survey results and DOD and contractor documents and interviewed DOD and contractor officials.
section_title: What GAO Found
paragraphs: DOD and contractor officials use various methods to evaluate access to care, and according to these officials, their methods indicate that access is generally sufficient for nonenrolled beneficiaries. For example, in its 2005 survey of civilian providers DOD found that 14 percent of civilian providers surveyed in 20 states were not accepting new patients from any health plan. Of those accepting new patients, about 80 percent would accept nonenrolled TRICARE beneficiaries as new patients. DOD's contractors use various methods to monitor access to care. While these methods were not designed specifically to evaluate access for nonenrolled beneficiaries, they provide information that allows contractors to monitor the availability of both network and nonnetwork civilian providers for this population. According to contractor officials, their measures indicate that nonenrolled beneficiaries' access to care is sufficient overall. DOD, its contractors, and beneficiary and provider representatives cited various factors as impediments to network and nonnetwork civilian providers' acceptance of nonenrolled TRICARE beneficiaries and ways to address them. These impediments include concerns specific to TRICARE, including reimbursement rates and administrative issues, as well as issues not specific to TRICARE, such as providers without sufficient practice capacity for additional patients. DOD and its contractors have specific ways to address impediments related to reimbursement rates and administrative issues, but issues that are not specific to TRICARE are more difficult to resolve. For example, DOD has authority to increase reimbursement rates for network and nonnetwork civilian providers in areas where access to care has been impaired. Furthermore, other impediments not specific to TRICARE, such as provider practices at capacity and few providers in geographically remote locations, cannot be readily resolved and create access difficulties for all local residents, including TRICARE beneficiaries. Various DOD offices as well as DOD's contractors are already carrying out the responsibilities outlined by the NDAA for fiscal year 2004--such as educating civilian providers and recommending reimbursement rate adjustments--actions that help ensure nonenrolled beneficiaries' access. However, a senior official was not formally designated to have responsibility for these mandated actions. DOD commented on the report, stating that GAO's approach was insightful, but disagreeing with GAO's finding that a senior official was not formally designated to be responsible for taking actions to ensure TRICARE beneficiaries' access to care as outlined in the NDAA. DOD said that an existing directive designating a senior official to serve as program manager for TRICARE met this requirement. However, the directive does not specifically designate an official responsible for ensuring access as specified in the NDAA. Nor did DOD take other actions to designate that a senior official have such responsibilities.

section_title: Letter
paragraphs: The Department of Defense (DOD) offers health care to almost 10 million  beneficiaries, including active duty personnel, retirees, and their  dependents, through its regionally structured TRICARE program, which is  expected to cost about $37 billion in fiscal year 2006. Under TRICARE,  health care is available through the military services’ system of military  hospitals and clinics, referred to as military treatment facilities (MTFs)  and through civilian providers. Although DOD and the military services  strive to maximize the use of MTFs, TRICARE beneficiaries have received  an increasing amount of care through civilian providers. Between fiscal  years 2000 and 2005, the percent of inpatient care delivered to TRICARE  beneficiaries by civilian providers increased from about 50 percent to an  estimated 75 percent. During the same time frame, the percent of  outpatient care delivered by civilian providers increased from 39 percent  to an estimated 65 percent.
TRICARE has three options for its beneficiaries: Prime, Standard, or  Extra. These options vary according to enrollment requirements, the  choices beneficiaries have in selecting civilian and MTF providers, and the  amount they must contribute towards the cost of their care. Prime, a  program in which beneficiaries receive care in a managed care provider  network similar to a health maintenance organization, is the only option  requiring enrollment and has the lowest copayments. Beneficiaries who  enroll in Prime usually obtain health care from the MTF, but they may also  obtain care from a network civilian provider when MTF care is not  available. Beneficiaries do not need to enroll to receive care under  Standard, a fee-for-service option, or Extra, a preferred provider  organization option. Under Standard, nonenrolled beneficiaries can obtain  health care from civilian providers who do not belong to the TRICARE  network but agree to accept TRICARE beneficiaries as patients.  Beneficiaries have the highest copayments under Standard. Under Extra,  nonenrolled beneficiaries may obtain health care from network civilian  providers. Nonenrolled beneficiaries cannot be categorized as belonging to  an Extra or Standard group because each time they seek care, they can  choose to see either a network or nonnetwork civilian provider, and this  choice determines whether they receive coverage under Extra or  Standard. Under any option, TRICARE beneficiaries may receive care at  an MTF when space is available. Priority for MTF usage is given first to  active duty personnel and then to beneficiaries enrolled in Prime.
DOD’s TRICARE Management Activity (TMA) uses managed care support  contractors (MCSC) to develop networks of civilian providers and perform  other customer service functions, such as claims processing, and to ensure  that all beneficiaries—including nonenrolled beneficiaries—receive  satisfactory service under TRICARE, such as assistance with finding  providers. Currently, there is one MCSC for each of TRICARE’s three  regions—North, South, and West. For each region, TMA has established a  TRICARE Regional Office (TRO) and has designated the TRO directors as  the health plan managers for their regions with responsibilities such as  monitoring provider network quality and adequacy, overseeing the MCSCs,  and monitoring customer satisfaction.
Since TRICARE began in 1995, nonenrolled TRICARE beneficiaries in  some locations have complained about difficulties finding nonnetwork  civilian providers who will accept them as patients. In addition, TRICARE  beneficiaries have cited concerns that TMA has focused more attention on  the Prime option, which allows TMA to manage beneficiaries’ care, and  has given less attention to the options available for nonenrolled TRICARE  beneficiaries. In response to these concerns, the National Defense  Authorization Act (NDAA) for fiscal year 2004 directed DOD to monitor  nonenrolled TRICARE beneficiaries’ access to care through a survey of  civilian providers. In addition, the NDAA required DOD to designate a  senior official to take actions to ensure access to care for nonenrolled  TRICARE beneficiaries.
The NDAA for fiscal year 2004 also directed GAO to review the processes,  procedures, and analysis used by DOD to determine the adequacy of the  number of network and nonnetwork civilian providers and the actions  taken to ensure access to care for nonenrolled TRICARE beneficiaries.  Specifically, as discussed with the committees of jurisdiction, this report  describes (1) how TMA and its MCSCs evaluate nonenrolled TRICARE  beneficiaries’ access to care and the results of these evaluations; (2) the  impediments to civilian provider acceptance of nonenrolled TRICARE  beneficiaries, and how they are being addressed; and (3) how DOD has  implemented the fiscal year 2004 NDAA requirements to take actions to  ensure nonenrolled TRICARE beneficiaries’ access to care.
To determine how TMA evaluates nonenrolled TRICARE beneficiaries’  access to care, we interviewed and obtained documentation from TMA  officials about the civilian provider survey, which included a random,  representative sample of civilian providers in selected geographic  locations and therefore included both network and nonnetwork civilian  providers. We also reviewed information from TMA’s annual beneficiary  health care survey, which includes information on beneficiaries’ access to  care. In addition, we met with TRO and MCSC officials for each of the  three regions, TMA officials, and representatives from each of the services’  Surgeons General to identify and evaluate the tools used for monitoring  access to care. To identify the impediments to network and nonnetwork  civilian providers’ acceptance of nonenrolled TRICARE beneficiaries and  how these impediments are being addressed, we obtained information  from TMA, TRO, and MCSC officials. We also met with representatives of  TRICARE beneficiaries and the American Medical Association to discuss  their concerns about impediments to health care access for nonenrolled  TRICARE beneficiaries. In addition, we obtained and analyzed data related  to TMA’s implementation of reimbursement rate increases in specific  locations for the purpose of improving access to care. However, we did  not evaluate the extent to which the rate increases improved civilian  providers’ acceptance of TRICARE beneficiaries as patients. To examine  how DOD has implemented the fiscal year 2004 NDAA requirements to  take actions to ensure nonenrolled TRICARE beneficiaries’ access to care,  we obtained information from TMA, TRO, and MCSC officials. Through  our review of the relevant documentation and our discussions with TMA,  TRO, and MCSC officials, we determined that the data presented in this  report were sufficiently reliable for our purposes. We conducted our work  from July 2005 through December 2006 in accordance with generally  accepted government auditing standards. Appendix I contains more details  about our scope and methodology, and appendix II contains more detail  about the scope and methodology of DOD’s civilian provider survey.
subsections: section_title: Background
paragraphs: In fiscal year 2005, almost 10 million beneficiaries were eligible to receive  health care under TRICARE, DOD’s regionally structured health care  program. Under TRICARE, beneficiaries have choices among three  different benefit options and may obtain care from either MTFs or civilian  providers. The NDAA for fiscal year 2004 directed DOD to conduct a  survey to monitor access to care for beneficiaries who chose not to use  TRICARE’s managed care option and to appoint a senior official to take  actions to ensure that these beneficiaries have adequate access to care.
subsections: section_title: Composition of TRICARE’s Beneficiary Population
paragraphs: TRICARE beneficiaries fall into various categories, including active duty  personnel and their dependents and retirees and their dependents.  Retirees and certain dependents and survivors who are entitled to  Medicare Part A and enrolled in Part B, and who are generally age 65 and  older, are eligible to obtain care under a separate program called  TRICARE for Life (TFL). As shown in figure 1, active duty personnel and  their dependents represent 42 percent of the beneficiary population.  Retirees and their dependents who are not entitled to Medicare (generally  under age 65) comprised 44 percent of the TRICARE beneficiary  population while retirees and dependents over 65 represented 14 percent  of the beneficiary population.
section_title: Network and Nonnetwork Civilian Providers Under TRICARE
paragraphs: TRICARE beneficiaries can choose to obtain health care through MTFs or  through civilian providers, which includes providers who belong to the  TRICARE provider network as well as nonnetwork providers who agree to  accept TRICARE beneficiaries as patients. Individual civilian providers  must be licensed by their state, accredited by a national organization, if  one exists, and meet other standards of the medical community to be  authorized to provide care under TRICARE. Individual TRICARE- authorized civilian providers can include attending physicians, certified  nurse-practitioners, clinical nurse specialists, dentists, clinical  psychologists, physician assistants, podiatrists, and optometrists, among  others. There are two types of authorized civilian providers—network and  nonnetwork providers. Network civilian providers are TRICARE- authorized providers who enter a contractual agreement with the regional  MCSC to provide health care to TRICARE beneficiaries. By law, TRICARE  maximum allowable reimbursement rates must generally mirror Medicare  rates, but network providers may agree to accept lower reimbursements  as a condition of network membership. In some cases, they agree to  accept negotiated reimbursement rates, which are usually discounts off of  the TRICARE reimbursement rates, as payment in full for medical care or  services. Network civilian providers are reimbursed at their negotiated  rate regardless of whether they are providing care to enrolled TRICARE  beneficiaries under the Prime option or nonenrolled TRICARE  beneficiaries under the Extra option. Network civilian providers file claim  forms for TRICARE beneficiaries and follow other contractually required  processes, such as those for obtaining referrals. However, network civilian  providers are not obligated to accept all TRICARE beneficiaries seeking  care. For example, a network civilian provider may decline to accept  TRICARE beneficiaries as patients because the provider’s practice does  not have sufficient capacity or for other reasons.
Nonnetwork civilian providers are TRICARE-authorized providers who do  not have a contractual agreement with an MCSC to provide care to  TRICARE beneficiaries. Nonnetwork civilian providers may accept  TRICARE beneficiaries as patients on a case-by-case basis. These  providers may choose to accept the TRICARE reimbursement rate as  payment in full for their services on a case-by-case basis. This practice is  referred to as “participating” or accepting assignment on a claim.  Nonnetwork civilian providers also have the option of charging up to   15 percent more than the TRICARE reimbursement rate for their services  on a case-by-case basis—a practice referred to as “non-participating.”  However, when a nonnetwork civilian provider bills more than the  TRICARE reimbursement rate, TRICARE beneficiaries are responsible for  paying the extra amount billed in addition to their required copayments.  TROs and MCSCs told us that this authority is infrequently used, in part,  because when providers bill the additional 15 percent, they usually collect  their total reimbursement from the TRICARE beneficiaries, who may not  always pay promptly. When nonnetwork civilian providers “participate”  on a claim and agree to accept the TRICARE reimbursement amount as  payment in full, the MCSCs usually pay them directly, ensuring timely  payment of the claim.
section_title: TRICARE’s Benefit Options
paragraphs: TRICARE provides its benefits through three main options for its non- Medicare eligible beneficiary population that vary according to TRICARE  beneficiary enrollment requirements, the choices TRICARE beneficiaries  have in selecting civilian and MTF providers, and the amount TRICARE  beneficiaries must contribute towards the cost of their care. However,  while there are three main options, there are only two types of TRICARE  beneficiaries—enrolled and nonenrolled—and two types of civilian  providers—network and nonnetwork. (See table 1.) All beneficiaries may  also obtain care at MTFs although priority is given to active duty  beneficiaries and Prime enrollees.
The three main options with their corresponding enrollment requirements  and provider categories are as follows:    TRICARE Prime: This managed care option is the only TRICARE option  requiring enrollment. Active duty servicemembers are required to enroll in  this option while other TRICARE beneficiaries may choose to enroll.  Prime enrollees receive most of their care from providers at MTFs,  augmented by network civilian providers who have agreed to meet  specific access standards for appointment wait times among other  requirements. Prime enrollees have a primary care manager who either  provides care or authorizes referrals to specialists. Beneficiaries can be  assigned to a primary care manager at the MTF or, if the MTF is at  capacity or no MTF is available, Prime enrollees may select a civilian  primary care manager. Prime offers lower out-of-pocket costs than the  other TRICARE options. Active duty personnel and their dependents do  not pay enrollment fees, annual deductibles, or copayments for care  obtained from network civilian providers. Retirees and their dependents  who are not entitled to Medicare pay an annual enrollment fee and small  copayments for care obtained from network civilian providers.
TRICARE Standard: TRICARE beneficiaries who choose not to enroll in  Prime may obtain health care using this fee-for-service option, which is  designed to provide maximum flexibility in selecting providers. Under  Standard, nonenrolled TRICARE beneficiaries may obtain care from  TRICARE-authorized nonnetwork civilian providers of their choice.  TRICARE beneficiaries using this option do not need a referral for most  specialty care. Under Standard, all TRICARE beneficiaries must pay an  annual deductible and copayments, which vary among active duty  dependents and retirees and their dependents, and there is no annual  enrollment fee. In addition, nonnetwork providers are not required to  meet access standards, such as those for appointment wait times.
TRICARE Extra: Similar to a preferred-provider organization,  nonenrolled TRICARE beneficiaries may also obtain health care from a  TRICARE network civilian provider for lower copayments than they would  have under the Standard option—about 5 percent less. TRICARE  beneficiaries choosing to use Extra must pay towards the same annual  deductible as Standard and are responsible for copayments. Similar to  Standard, there is no annual enrollment fee. Additionally, network civilian  providers caring for nonenrolled TRICARE beneficiaries must adhere to  the same access standards for appointment wait times that they use for  enrolled TRICARE beneficiaries under Prime.
Among TRICARE beneficiaries who were not Medicare eligible in fiscal  year 2005, about 5.5 million or 65 percent of TRICARE’s beneficiaries were  enrolled in Prime and thereby declared their intent to use their TRICARE  benefit. In contrast, TMA does not know whether nonenrolled  beneficiaries intend to use their TRICARE benefit. In fiscal year 2005,  claims data showed that about 1.2 million or 14 percent of nonenrolled  TRICARE beneficiaries obtained care with 66 percent of this care being  delivered through the Standard option and 34 percent delivered through  the Extra option. The remaining 1.8 million or 21 percent of nonenrolled  beneficiaries were eligible for TRICARE benefits but did not use them  during this time period. At any time, this population of eligible nonusers  could elect to use Standard or Extra, and DOD would reimburse claims  submitted for their health care after annual deductibles are met.
section_title: TRICARE Contracts and Regional Structure
paragraphs: TMA uses three MCSCs to provide civilian health care under the TRICARE  program. Each MCSC is responsible for the delivery of care to TRICARE  beneficiaries in one of three geographic regions—North, South, and West.  The MCSCs are contractually required to establish and maintain networks  of civilian providers in designated locations within these regions that are  referred to as Prime Service Areas. (See fig. 2 for the location of Prime  Service Areas in each of the three TRICARE regions.) Prime Service Areas  include all MTF enrollment areas, Base Realignment and Closure sites,  and additional areas where either TMA or the MCSC deems networks to be  cost effective. As a result, each region may contain multiple Prime Service  Areas. In these areas, civilian provider networks are required to be large  enough to provide access for all TRICARE beneficiaries regardless of  enrollment status or Medicare-eligibility. TMA contractually requires that  MCSCs’ civilian provider networks meet specific access standards, such as  travel times or wait times, for both primary and specialty care. For  example, TRICARE beneficiaries seeking primary care should not have to  drive more than 30 minutes to get to their appointment locations. In  addition to contractual requirements, the MCSCs can add additional  access standards that they strive to meet.
MCSCs are also responsible for performing other customer service  functions, such as processing claims and helping TRICARE beneficiaries  locate providers. They also are required to operate TRICARE Service  Centers, which are frequently located within MTFs, to provide TRICARE  beneficiaries with information on the different TRICARE options,  information on benefit coverage, assistance with finding network and  nonnetwork civilian providers, determining eligibility status, and other  activities. MCSCs provide customer service to any TRICARE beneficiary  who requests assistance, regardless of their enrollment status.
In each of the three regions, TMA uses a TRO to manage health care  delivery. TRO directors are considered the health plan managers for the  regions and are responsible for overseeing the MCSCs, including  monitoring network quality and adequacy, monitoring customer  satisfaction outcomes, and coordinating appointment and referral  management policies. TRO directors and staff also provide customer  service to all TRICARE beneficiaries who request assistance regardless of  their enrollment status.
Although they vary in the size of the geographic area covered, each  TRICARE region has approximately the same number of TRICARE  beneficiaries. However, the number of nonenrolled TRICARE beneficiaries  varies by region as does their access to network providers under the Extra  option depending on their proximity to a Prime Service Area. (See fig. 3 for  the number and distribution of nonenrolled beneficiaries by region.)
Throughout the three regions, about 16 percent of nonenrolled TRICARE  beneficiaries reside outside of Prime Service Areas. In the North region,   23 percent of nonenrolled TRICARE beneficiaries live outside of Prime  Service Areas, and in the West Region, 21 percent of nonenrolled  TRICARE beneficiaries live outside of Prime Service areas. Because the  South Region has extensive Prime Service Areas, no TRICARE  beneficiaries live in locations without a civilian provider network.
Although most nonenrolled TRICARE beneficiaries nationwide live in a  Prime Service Area, making Extra a readily available option, nonenrolled  TRICARE beneficiaries have used Standard more frequently than Extra for  each fiscal year from 2001 through 2005. (See fig. 4.)
section_title: Requirements in the NDAA for Fiscal Year 2004 Related to Nonenrolled TRICARE Beneficiaries
paragraphs: The NDAA for fiscal year 2004 directed DOD to monitor nonenrolled  TRICARE beneficiaries’ access to care under the TRICARE Standard  option and to designate a senior official to take the actions necessary to  ensure access to care for nonenrolled TRICARE beneficiaries.  Specifically, the NDAA required surveys to be done in 20 market areas  each fiscal year until all markets were surveyed to determine how many  civilian providers were accepting nonenrolled TRICARE beneficiaries as  new patients. Although the law focused on Standard, TMA officials told us  that since nonenrolled TRICARE beneficiaries can receive care through  both the Standard and Extra options, they designed the survey to monitor  access to care from both network and nonnetwork providers.
When developing the survey’s methodology, TMA defined market areas as  individual states and determined that all states could be surveyed within a  3-year period. TMA implemented its survey in fiscal year 2005 for the first  20 states. The survey collected data from the billing and insurance  specialists of selected civilian providers, both network and nonnetwork, to  determine how many were accepting nonenrolled TRICARE beneficiaries  as new patients and to identify the reasons providers cite for not accepting  these TRICARE beneficiaries. About 17 percent of the providers in the  sample belonged to a TRICARE network while the remaining 83 percent of  providers in the sample were nonnetwork providers. Because about   14 percent of all civilian providers belong to the TRICARE network, TMA’s  sample of civilian providers is fairly representative of the network and  nonnetwork civilian provider population serving all TRICARE  beneficiaries, including nonenrolled beneficiaries who can use the  Standard and Extra options. TMA’s four-question survey focused on a  given provider’s awareness of TRICARE, whether the provider was  accepting nonenrolled beneficiaries as new patients, and if not, the  reasons why they were not. (See app. II for a detailed discussion of the  methodology used for this survey and app. III for the complete survey  instrument.)
The NDAA for fiscal year 2004 also required DOD to designate a senior  official to take actions necessary for achieving and maintaining the  participation of nonnetwork civilian providers in a number adequate to  ensure care for nonenrolled TRICARE beneficiaries in each market area.  According to this legislation, the senior official would have the following  responsibilities:    educating nonnetwork civilian providers about TRICARE,    encouraging nonnetwork civilian providers to accept nonenrolled  TRICARE beneficiaries as patients,   ensuring that nonenrolled TRICARE beneficiaries have the information  necessary to locate nonnetwork civilian providers readily, and recommending adjustments in reimbursement rates that the official  considers necessary to ensure adequate availability of nonnetwork civilian  providers for nonenrolled TRICARE beneficiaries.
section_title: TMA and Its MCSCs Use Various Methods to Evaluate Access to Care That Indicate Sufficient Access for Nonenrolled TRICARE Beneficiaries
paragraphs: TMA and its MCSCs use various methods for evaluating access to care,  and according to TMA and MCSC officials, the resulting measures indicate  that access to care is generally sufficient for nonenrolled TRICARE  beneficiaries. TMA is administering the civilian provider survey required  by the NDAA for fiscal year 2004, which is designed to obtain information  on network and nonnetwork civilian providers’ willingness to accept  nonenrolled TRICARE beneficiaries as new patients. TMA also obtains  information about access to care through its annual health care survey of  all TRICARE beneficiaries and through the anecdotal beneficiary feedback  they receive from the TROs, which monitor access in their respective  regions. MCSCs also use a variety of approaches to evaluate access to  care, including inquiries from beneficiaries, analyses of claims data, and  monitoring of the capacity of civilian provider networks.
subsections: section_title: TMA Uses Various Methods for Evaluating Access to Care
paragraphs: TMA uses multiple methods of evaluating access to care for its  nonenrolled TRICARE beneficiaries, including the recently implemented  survey of civilian providers and its annual health care survey of TRICARE  beneficiaries. In addition, TMA monitors centrally received beneficiary  complaints and inquiries, and each TRO monitors access to care in its  respective region.
subsections: section_title: TMA’s Survey of Civilian Providers
paragraphs: In fiscal year 2005, TMA completed the first phase of its mandated survey  of civilian health care providers. (See app. II for discussion of technical  aspects of this survey’s methodology.) Although the survey was designed  to determine the extent to which providers were willing to accept  nonenrolled TRICARE beneficiaries as new patients, it is premature to  interpret the results because this is the first of three rounds of the survey,  and TMA does not have an established benchmark for determining the  number of civilian providers that are needed for nonenrolled beneficiaries.  During this initial round, TMA randomly selected a representative sample  of over 40,000 providers in 20 states. TMA found that the majority of the  providers surveyed were accepting new patients, including nonenrolled  TRICARE beneficiaries. Specifically, only 14 percent of providers  reported that they were not accepting new patients, including TRICARE  patients, privately insured patients, or patients who were paying for their  own care. Of the remaining 86 percent accepting new patients, the percent  that would accept nonenrolled TRICARE beneficiaries as new patients  averaged 80 percent for all 20 states. (See table 2 for overall results by  state.) An additional comparison of the acceptance rate for two categories  of providers—primary care providers and specialists—in each of these  20 states revealed very little difference between the two categories. Of  those accepting new patients, 78 percent of primary care providers and   81 percent of specialists would accept nonenrolled TRICARE beneficiaries  as new patients.
In addition to the statewide sample, TMA also sampled civilian providers  in several smaller geographic locations, defined as hospital service areas  (HSA), in order to respond to concerns about access to care that were  specific to certain locations. TMA selected 29 HSAs—12 that were  randomly selected from within the 20 states evaluated for fiscal year 2005  and 17 based on beneficiary concerns about specific locations. As in the  20-state survey, TMA found that most providers in the selected HSAs were  accepting new patients, including nonenrolled TRICARE beneficiaries.  Specifically, only 13 percent of surveyed providers reported that they were  not accepting new patients. Of the remaining 87 percent accepting new  patients, 81 percent were accepting nonenrolled TRICARE beneficiaries as  new patients. (See table 3.) An additional comparison of the acceptance  rates for primary care providers and specialists who were accepting new  patients revealed that 75 percent of the surveyed primary care providers  and 85 percent of the surveyed specialists would accept nonenrolled  TRICARE beneficiaries as new patients. A further comparison of  providers accepting nonenrolled TRICARE beneficiaries as new patients  between the HSAs selected based on TRICARE beneficiaries’ concerns  and the HSAs randomly selected from the 20 surveyed states showed  minimal difference in acceptance rates—80 percent and 83 percent,  respectively.
In both the states and HSAs, civilian providers who indicated that they  were not accepting nonenrolled TRICARE beneficiaries as new patients  were asked to identify why they made this decision in their own words,  and were permitted to provide as many reasons as they wanted. More than  half of both network and nonnetwork respondents cited not having a  provider available or reimbursement issues as reasons. For providers  citing nonavailability as a reason, many explained that they were either in  the process of retiring or were too busy to accept any new patients at this  time. Providers citing reimbursement issues most often stated an opinion  that TRICARE’s reimbursement rates were low and that claims payment  was slow. (See app. IV for TMA’s summary of the aggregate results by  category.)
Although there is no benchmark with which to compare the results of the  initial civilian provider survey effort, TMA officials stated that their  analysis of the 2005 survey results did not indicate widespread problems  with nonenrolled TRICARE beneficiaries’ access to care. Nonetheless,  TRO officials used the survey results to identify specific cities in their  regions where civilian providers’ acceptance of nonenrolled TRICARE  beneficiaries and knowledge about TRICARE were low in comparison to  the other locations surveyed. To assist in this effort, the Assistant  Secretary of Defense (ASD) for Health Affairs directed TMA’s  Communications and Customer Service Directorate to work with the  TROs and other TMA officials to develop a strategic marketing plan for  these locations. The cities selected by the TROs are as follows:    West region: Olympia, Washington (2,732 nonenrolled beneficiaries),  Monterey, California (1,180 nonenrolled beneficiaries), Seattle,  Washington ( 2,358 nonenrolled beneficiaries), and Anchorage, Alaska  (3,381 nonenrolled beneficiaries);   North region: Brooklyn, New York (4,276 nonenrolled beneficiaries) and  Eau Claire, Wisconsin (902 nonenrolled beneficiaries); and   South region: Arlington, Texas (3,025 nonenrolled beneficiaries), Houston,  Texas (6,415 nonenrolled beneficiaries), and Boca Raton, Florida (447  nonenrolled beneficiaries).
TMA officials and TRICARE beneficiaries have stated that additional  survey questions could have yielded useful information. For example, the  survey did not ask providers whether they are accepting new Medicare  patients—an important proxy because TRICARE reimbursement rates are  established using Medicare reimbursement rates, and a comparison of the  two programs could provide information on whether providers are more  concerned with the amount of reimbursement or other issues.  Furthermore, the survey did not ask providers how much of their current  practice consists of TRICARE beneficiaries, to capture whether or not  providers may already have TRICARE beneficiaries in their practices.  However, a provision in the NDAA for fiscal year 2006 instructs TMA to  add the following questions to its civilian provider survey:  1.  What percentage of Dr. X’s current patient population uses any form of  TRICARE?  2.  Does Dr. X accept patients under the Medicare program?  3.  Would Dr. X accept additional Medicare patients?
section_title: TMA’s Beneficiary Health Care Survey
paragraphs: In addition to its civilian provider survey that covered 20 states, TMA  gathers worldwide information on nonenrolled TRICARE beneficiaries’  access to care through its annual Health Care Survey of DOD  Beneficiaries, which covers all TRICARE beneficiaries and all TRICARE  options. According to survey results from 2003 through 2005, about   77 percent of nonenrolled TRICARE beneficiaries who obtained care  reported that “getting needed care” was not a problem for them. Similarly,  over 80 percent of these TRICARE beneficiaries reported that they could  “get care quickly.” For the same time period, TMA compared its survey  results with the results of a civilian health plan survey, the Consumer  Assessment of Healthcare Providers and Systems (CAHPS®), which  asked participants the same questions on access to care under their plans.  From this comparative analysis, TMA found that a similar percentage of  civilian health plan participants—about 80 percent—responded that  “getting needed care” was not a problem and that they could “get care  quickly.” TMA uses this survey as a benchmark to compare TRICARE  against civilian plans.
section_title: Beneficiary Feedback
paragraphs: Anecdotal information about access to care is available through TMA’s  centralized Beneficiary and Provider Services office, which collects and  monitors information on TRICARE beneficiaries’ complaints and general  inquiries, including issues about access to care. TRICARE beneficiaries  may contact this office by telephone, e-mail, written correspondence, or  through their congressional representatives. TMA officials broadly  categorize each contact by issue and use this information to monitor  trends in the feedback they receive through these contacts. A TMA official  stated that if the number of contacts they receive related to an issue rises,  the appropriate program officials—such as the TROs—are notified and  encouraged to investigate the issue. Furthermore, TMA maintains a record  of TRICARE beneficiary and provider contacts that have been addressed  and those that remain open and continue to require attention. Although  the Beneficiary and Provider Services office does not specifically track  access-to-care issues as a separate issue, one of the TMA officials  responsible for tracking the contacts told us that TRICARE beneficiary  complaints and inquiries relating to access issues have been minimal.  Overall, concerns and inquiries for the “contractor service complaint”  category, which could include access-to-care issues for both enrolled and  nonenrolled TRICARE beneficiaries, represented about 1 percent of about  6,900 total contacts about the MCSCs for 2005.
In addition, on a regional level, the TROs collect and monitor TRICARE  beneficiary feedback gathered from e-mails and phone calls, as well as  correspondence they receive from TRICARE beneficiary groups. However,  the TROs told us that detailed information on each of these contacts is not  routinely maintained. For example, one TRO told us that when a TRICARE  beneficiary contacts them for assistance in locating a provider, they track  the general reason for the call, but do not document the specific concerns.  TRO officials told us that they receive only a small number of contacts  from nonenrolled TRICARE beneficiaries who are unable to obtain care  from nonnetwork civilian providers. For example, one TRO told us that  they received approximately 34 requests for assistance locating a provider  in calendar year 2005 from the over 600,000 nonenrolled TRICARE  beneficiaries in this region. TRO officials indicated that sometimes these  requests are due to TRICARE beneficiaries’ inability to obtain care from a  specific provider at a specific time and are not necessarily indicative of  access problems because that provider may be available at another time or  other providers may be available. The TROs told us that they also monitor  nonenrolled TRICARE beneficiaries’ access to care retrospectively by  evaluating claims data as a record of health care usage. For example, the  TROs use these data to identify how many network and nonnetwork  providers have accepted nonenrolled TRICARE beneficiaries as patients  and to evaluate the use of the different TRICARE options.
Finally, the TROs and military services are in the process of implementing  a new method of monitoring TRICARE beneficiary feedback. The  Assistance Reporting Tool (ART) is a computer database that when fully  operational will be used to archive and manage TRICARE beneficiary  feedback on all aspects of health care. Currently each of the three TROs,  all Army MTFs, and a portion of Navy and Air Force MTFs use this system  as either their primary or one of several tools for managing and archiving  TRICARE beneficiary feedback. Because ART is not mandatory for all  MTFs, the TROs also rely on other feedback mechanisms to capture the  most complete record of TRICARE beneficiary concerns and questions.  These other mechanisms include e-mails from TRICARE beneficiaries to  MTFs and data requests that the TROs periodically make to MTFs. In  addition, while the MCSCs are not required to use ART because it was  introduced after TRICARE’s current health care delivery contracts were  awarded, one of the MCSCs is currently using it. In the next cycle of  TRICARE contracts, TMA officials told us that they plan to require that all  MCSCs use this system. TMA officials who have reviewed the preliminary  information captured by ART told us that the tool has obtained very little  feedback that would indicate nonenrolled TRICARE beneficiaries are  having problems with access to care.
section_title: MCSCs Have Approaches for Monitoring Access to Care Though They Are Not Specific to Nonenrolled TRICARE Beneficiaries
paragraphs: Each of the three MCSCs has developed its own methods for monitoring  whether TRICARE beneficiaries in its region have access to care both in  Prime Service Areas and in areas where provider networks do not exist.  According to the MCSCs, while their methods for evaluating access to care  were not designed to evaluate access specifically for nonenrolled  TRICARE beneficiaries, they do provide some information that they use to  monitor the availability of both network and nonnetwork civilian  providers for this population, which is one component of access to care.
The MCSCs also monitor access to care through beneficiary inquiries.  Each maintains a data system to archive and tabulate anecdotal TRICARE  beneficiary feedback received through some or all of the following  methods: telephone, e-mail, congressional correspondence, or walk-in  visits to a TRICARE Service Center. The MCSCs organize TRICARE  beneficiary feedback into subject categories and then monitor changes in  the frequency of contacts in these categories to identify trends and  important issues. At our request, each of the MCSCs reviewed their most  recent TRICARE beneficiary complaint data and found very small numbers  of comments pertaining to health care access. The MCSCs told us this was  an indication that TRICARE beneficiaries—both enrolled and  nonenrolled—were not experiencing any widespread problems with  access to care. For example, one MCSC identified fewer than 40  complaints related to access out of one million contacts with TRICARE  beneficiaries in a 1-month period. The second MCSC reported that for the  last two quarters of 2005 they received an average of 355 inquiries and  complaints each month about access to care. Officials from this MCSC told  us that while their TRICARE beneficiary feedback system could not  quantify the total number of inquiries received, these 355 inquiries  represented a small percentage of all contacts. The third MCSC reported  that out of more than 250,000 phone calls and walk-in visits to TRICARE  Service Centers during the month of December 2005, 71 contacts, or less  than 1 percent of the total contacts, were related to access.
The MCSCs also determine how many civilian providers have accepted at  least one TRICARE beneficiary by analyzing claims data to examine the  extent to which both network and nonnetwork civilian providers are  accepting TRICARE beneficiaries as patients. Each MCSC has concluded  that more than half of all licensed civilian providers—both network and  nonnetwork—in their respective regions have accepted at least one  TRICARE beneficiary, regardless of enrollment status, as a patient in the  last year. According to MCSCs, access to care appears to be generally  sufficient because the percentage of all licensed civilian providers in each  region who have submitted at least one TRICARE claim during the past  year are as follows: 90 percent in the South region, where TRICARE  beneficiaries represent 3.7 percent of the entire region’s population;   56 percent in the West region, where TRICARE beneficiaries represent   3.1 percent of the region’s population; and 52 percent in the North region,  where all TRICARE beneficiaries represent an estimated 2.1 percent of the  region’s population.
Each MCSC told us that one of the primary ways they ensure sufficient  access to care for both enrolled and nonenrolled TRICARE beneficiaries is  by monitoring whether their civilian provider networks have the capacity  to provide care to all beneficiaries in their Prime Service Areas.  Throughout the three regions, the majority of nonenrolled TRICARE  beneficiaries—84 percent—live within Prime Service Areas, making the  choice of using a civilian network provider through Extra a readily  available option for them. In the South region, all TRICARE beneficiaries  reside in Prime Services Areas. In this region, the MCSC monitors access  to care through geographic analyses of provider and TRICARE beneficiary  locations to determine whether its networks meet the needs of both  enrolled and nonenrolled TRICARE beneficiaries using TRICARE’s access  standards. In another region, where not all TRICARE beneficiaries live in  Prime Service Areas, the MCSC will assist nonenrolled TRICARE  beneficiaries in finding nonnetwork civilian providers on an as-needed  basis. In the third region where the Prime Service Areas also do not  encompass all TRICARE beneficiaries, the MCSC recruits and contracts  with providers outside of Prime Service Areas who are available and  willing to deliver care to nonenrolled TRICARE beneficiaries living there.  Network providers who deliver care in locations outside of Prime Service  Areas currently account for 25 percent of this MCSCs’ network providers.
section_title: Various Factors Impede Providers’ Acceptance of Nonenrolled TRICARE Beneficiaries, and TMA and MCSCs Have Different Ways to Address Them
paragraphs: TMA, MCSCs, and provider representatives have cited various factors as  impediments to civilian providers’ willingness to accept nonenrolled  TRICARE beneficiaries as patients, and TMA and its MCSCs have different  ways to address them. Some impediments are specific to TRICARE,  including concerns about reimbursement rates and administrative issues,  and TMA and its MCSCs have specific ways to address these issues. For  example, TMA has the authority to increase reimbursement rates in  certain circumstances, and both TMA and MCSCs conduct outreach efforts  targeted to assist civilian providers with administrative issues. Other  impediments—such as providers’ practices being at maximum patient  capacity and provider shortages in certain locations—are not specific to  TRICARE and are therefore inherently more difficult for TMA and the  MCSCs to address.
subsections: section_title: Providers Cite Concerns about TRICARE’s Reimbursement Rates as a Reason for Denying Nonenrolled TRICARE Beneficiaries’ Access to Care, but TMA Has Authority to Adjust Rates When Needed
paragraphs: Since TRICARE was implemented in 1995, some civilian providers—both  network and nonnetwork—have complained that TRICARE’s  reimbursement rates tend to be lower than those of other health plans, and  as a result, some of these providers have been unwilling to accept  nonenrolled TRICARE beneficiaries as patients. According to the results  of the initial round of TMA’s civilian provider survey, concern about  reimbursement amounts was one of the primary reasons that both  network and nonnetwork civilian providers cited for not accepting  nonenrolled TRICARE beneficiaries as new patients. In the 2005 civilian  provider survey, of those who gave reasons for not accepting nonenrolled  TRICARE beneficiaries as new patients, 20 percent of network providers  and 25 percent of nonnetwork providers cited concerns about  reimbursement amounts. However, TMA has the authority to adjust  reimbursement rates in areas where it determines that reimbursement rate  amounts have been negatively impacting TRICARE beneficiaries’ ability to  obtain care.
subsections: section_title: Providers’ Concerns about TRICARE Reimbursement Rates
paragraphs: One of providers’ main reasons for not accepting nonenrolled TRICARE  beneficiaries as patients is providers’ concern about low reimbursement  amounts. TRICARE’s reimbursement rates generally mirror  reimbursement rates paid by the Medicare program. Beginning in fiscal  year 1991, in an effort to control escalating health care costs, Congress  instructed DOD to gradually lower its reimbursement rates for individual  civilian providers to mirror those paid by Medicare—an adjustment that  has saved hundreds of millions of dollars since the conversion. As of  January 2006, the transition to Medicare rates was nearly complete, and  reimbursement rates for only 48 services remain higher than Medicare  reimbursement rates. (See app. V for a list of these services.)
According to TMA and MCSC officials, civilian providers, including both  network and nonnetwork, generally seek to develop a practice that  includes patients with higher-paying private insurers to compensate for  the acceptance of patients with lower-paying health plans, including  Medicare, Medicaid, and TRICARE. However, according to TMA and  MCSC officials, TRICARE generally has little leverage to encourage  network and nonnetwork civilian provider acceptance of its patients  because the TRICARE population is small and transient. Further, in  locations where the demand for providers’ services exceeds the supply— such as in Alaska—providers can be selective about who they accept as  patients.
TMA and MCSC officials have also cited providers’ concerns that  TRICARE’s pediatric and obstetric rates are lower than Medicaid rates for  these services. To investigate these concerns, TMA conducted a  comparative analysis that found TRICARE’s reimbursement rates for  selected pediatric and obstetric procedures were generally higher than  Medicaid’s rates in many states for March 2006. TMA compared the  TRICARE reimbursement rate for the service most commonly billed by  pediatricians—an office visit for an established patient—with Medicaid  rates for this service and found that in 41 of the 45 states for which  Medicaid data were available, the TRICARE reimbursement rate exceeded  Medicaid’s rate for this service. In addition, TMA compared its  reimbursement rates for 14 commonly used maternity and delivery  services with Medicaid rates and found that in 35 of the 45 states for which  Medicaid data were available, TRICARE reimbursement rates for these  services exceeded the Medicaid payment rates.
TMA also analyzed reimbursement rates for pediatric immunizations based  on MCSCs’ concerns that providers viewed these rates as too low.  However, when TMA compared TRICARE’s reimbursement rates with the  cost of the vaccine for the 10 most frequently used pediatric vaccines and  for the hepatitis A vaccine, TMA’s analysts concluded that the TRICARE  reimbursement rates were generally reasonable and not undervalued in  relation to what a provider might actually pay to obtain them. Only one  vaccine—the pediatric hepatitis A vaccine—appeared to be priced lower  than the reasonable cost of obtaining the vaccine. In this instance, the  TRICARE reimbursement rate was $22.64, while pediatricians were paying  between $27.41 and $30.37 for the vaccine. As a result of this discrepancy,  TMA used its general authority to deviate from Medicare rates, and  starting May 1, 2006, TMA instructed the MCSCs to reimburse pediatric  hepatitis A vaccines nationally at a new reimbursement rate of $30.40.
section_title: TMA Has Authority to Use Waivers to Adjust Reimbursement Rates
paragraphs: TMA has the authority to increase TRICARE reimbursement rates for  network and nonnetwork civilian providers to ensure that all beneficiaries,  including nonenrolled beneficiaries, have adequate access to care. TMA’s  authorities include (1) waiving reimbursement rate reductions for both  network and nonnetwork providers that resulted when TRICARE  reimbursement rates were lowered to Medicare levels, (2) issuing locality  waivers that increase rates for specific procedures in specific localities,  and (3) issuing network-based waivers that increase some network civilian  providers’ reimbursements. Once implemented, waivers remain in effect  indefinitely until TMA officials determine they are no longer needed. As of  August 2006, TMA had approved 15 waivers in total—2 waiving  reimbursement rates reductions that resulted when TRICARE  reimbursement rates were lowered to Medicare levels, 7 locality waivers,  and 6 network waivers.
TMA can use its authority to waive reimbursement rate reductions to  restore TRICARE reimbursement rates in specific localities to the levels  that existed before a reduction was made to align TRICARE rates with  Medicare rates. On two occasions, TMA has used this authority in Alaska  to encourage both network and nonnetwork civilian providers to accept  TRICARE beneficiaries as patients in an effort to ensure adequate access  to care. In 2000, TMA used this waiver authority to uniformly increase  reimbursement rates for network and nonnetwork civilian providers in  rural Alaska, and in 2002 TMA implemented this same waiver for network  and nonnetwork civilian providers in Anchorage. The use of these waivers  resulted in an average reimbursement rate increase of 28 percent for all of  Alaska. However, in 2001, we studied the effect of the 2000 waiver on  access to care in rural Alaska and found that it did not increase TRICARE  beneficiaries’ access to care.
Locality waivers may be used to increase rates for specific medical  services in specific areas where access to care has been severely impaired.  Reimbursement rate increases for this type of waiver can be established in  one of three ways: by adding a percentage factor to the existing TRICARE  reimbursement rate, by calculating a prevailing charge, or by using  another government reimbursement rate, such as rates used by the  Department of Veterans Affairs to purchase health care from civilian  providers. The resulting rate increase would be applied to both network  and nonnetwork civilian providers for the medical services identified in  the areas where access is severely impaired. A total of nine applications  for locality-based waivers have been submitted to TMA between January  2003 and August 2006. (See table 4.) Of these, seven locality waivers have  been approved by TMA and two are still pending. Six of the approved  locality waivers as well as one pending application are for locations in  Alaska. This includes one approved waiver to adjust the reimbursement  rates for obstetric services to match Medicaid rates in Alaska and nine  additional states based on TMA’s comparative analysis of reimbursement  rates for 14 obstetrical procedures.
Network waivers are used to increase reimbursement rates for network  providers up to 15 percent above the TRICARE reimbursement rate in an  effort to ensure an adequate number and mix of primary and specialty care  network civilian providers for a specific location. Between January 2002  and August 2006, 10 applications for network waivers have been submitted  to TMA. Of these, 6 network waivers have been approved by TMA and 4  have been denied. (See table 5.)
Providers, TRICARE beneficiaries, MCSCs, as well as TRO directors may  apply for a reimbursement rate waiver by submitting written requests  supporting the need for reimbursement rate increases on the grounds that  access to health care services is impaired due to low reimbursement rates.  These requests must contain specific justifications to support the claim  that access problems are related to reimbursement rates and must include  information such as the number of providers and TRICARE beneficiaries  in a location, the availability of MTF providers, geographic characteristics,  and cost effectiveness of granting the waiver. All waiver requests are  submitted to the TRO directors, who review the application and make a  decision whether to forward the request to the Director of TMA through  TMA’s contracting officers, who are responsible for administering the  MCSCs’ contracts. According to a TMA official, the contracting officers  work with TMA analysts to review the submitted requests and verify  whether there is an insufficient number of providers in the area and  conduct a cost-benefit analysis before making a recommendation to the  Director of TMA that the waiver be accepted or denied. Each analysis is  tailored to the specific concerns outlined in the waiver requests.  According to this official, TMA conducts these additional analyses to  ensure that an increase in reimbursement rates would actually alleviate  access problems and that access was not impaired due to such things as  administrative problems or providers’ unhappiness with claims payment  timeliness or accuracy.
Once a waiver is granted, there is no mechanism that automatically  terminates it. According to a TMA official, there was an expectation within  TMA that the continued need for existing waivers would be evaluated on  an annual basis. However, waivers have been reviewed on a periodic, ad  hoc basis rather than on an annual basis as expected. When TMA  implemented new MCSC contracts in fiscal years 2004 and 2005, TMA and  the MCSCs discussed existing waivers and mutually agreed to extend all of  them because they continued to believe that these waivers were necessary  to ensure access to care. However, without a formal analysis of how these  waivers have impacted access in the areas in which they were  implemented, the actual extent of their effect is unclear.
section_title: Providers Cite Concerns About TRICARE’s Administrative Issues as Reasons for Not Accepting Nonenrolled TRICARE Beneficiaries, but MCSCs Use Various Methods to Address These Concerns
paragraphs: Since the inception of TRICARE, both network and nonnetwork civilian  providers have expressed concerns about administrative issues or  “hassles” associated with the program, which, when combined with low  reimbursement rates, make them less likely to accept nonenrolled  TRICARE beneficiaries as patients. TMA and MCSC officials stated that  because TRICARE beneficiaries usually represent only a small percentage  of a provider’s practice, both network and nonnetwork civilian providers  may not be as knowledgeable about the program and its unique  administration requirements. Adding to the potential for confusion, while  some administrative requirements apply to all TRICARE beneficiaries, the  TRICARE program also has separate and distinct administrative  requirements for enrolled and nonenrolled TRICARE beneficiaries. For  example, network providers must meet specific time frame and  documentation requirements when referring enrolled TRICARE  beneficiaries for specialty care or when delivering specialty care to  enrolled TRICARE beneficiaries. However, referral standards usually do  not apply to nonenrolled TRICARE beneficiaries. Additionally, according  to the initial round of TMA’s civilian provider survey, 15 percent of  network respondents and 7 percent of nonnetwork respondents who gave  explanations for why they were not accepting nonenrolled TRICARE  beneficiaries as new patients cited administrative inconveniences as a  reason. These administrative inconveniences included too much  paperwork, problems understanding the benefits and policies, and a  lengthy referral process.
MCSC and TMA officials also told us that providers’ past experiences with  TRICARE administrative issues may have biased their opinion of the  program, while, in some cases, there have been improvements. For  example, according to MCSCs and TMA officials, some providers perceive  that previously identified claims processing problems persist and cite  problems with timeliness and claims payment decisions as reasons for not  accepting TRICARE patients. While claims processing problems plagued  the TRICARE program in its early years, we reported in 2003 that efforts  had been made to improve claims processing efficiency, and as a result,  claims were being processed in a more timely manner, though some  inefficiencies remained. In addition, some TRO officials and providers  said that TRICARE claims payment decisions sometimes are not always  clear to providers and, as a result, they may believe problems with claims  processing exist. This is due in part to the fact that TRICARE’s claims  processing outcomes may differ from Medicare’s—despite the programs’  similarities in reimbursement rates—due to different benefit structures  and different claims processing tools that are used to prevent  overpayment. Furthermore, because they do not always understand the  program, providers and TRICARE beneficiaries may complain about  adjudication decisions on claims that have been processed correctly.  Problems may also occur because providers and TRICARE beneficiaries  may make mistakes when filing their claims.
In efforts to address problems related to administrative issues, MCSCs  conduct a variety of outreach efforts to educate nonnetwork civilian  providers on TRICARE requirements and assist with both actual and  perceived administrative concerns. For example, MCSCs provide on-line  tools and toll-free telephone support to mitigate administrative issues.  Also, one MCSC works with state medical associations to address provider  concerns and to ensure that information about TRICARE requirements is  included in medical association newsletters. Each of the MCSCs has  provider relations representatives located in areas throughout the region  outside of their central office. These provider relations representatives  schedule opportunities to meet with nonnetwork civilian providers that  include booths or speaking engagements at health fairs, conferences, and  other provider events and, when necessary, work one-on-one with  network and nonnetwork civilian providers to provide instructions on  ways to respond to TRICARE’s administrative requirements and to help  eliminate the burden of unnecessary paperwork. According to MCSCs,  these efforts have been helpful because they are not experiencing  widespread problems with TRICARE beneficiaries’ access to care.  However, similar to the use of waivers, the actual extent to which these  efforts have improved access to care is unclear.
section_title: Though TMA and MCSCs Attempt to Address Impediments That Are Not Specific to TRICARE, These Issues Cannot Always be Resolved
paragraphs: TMA and MCSCs attempt to address impediments to network and  nonnetwork provider acceptance of nonenrolled TRICARE beneficiaries  that are not specific to the TRICARE program. However, TMA and MCSCs  cannot always resolve access problems related to these impediments.  Some network and nonnetwork civilian providers may be unwilling to  accept TRICARE beneficiaries as patients because their practices are  already at capacity. For example, the initial round of TMA’s civilian  provider survey found that 14 percent of providers in the 20 states  surveyed were not available to accept any new patients, including  TRICARE patients, privately insured patients, or patients who were paying  for their own care. According to the MCSCs, access problems related to  practice capacity are more likely to occur in geographically remote areas  that have few providers than in more densely populated areas with more  providers. However, one MCSC stated that access problems related to  practice capacity can also occur in urban areas where the medical needs  of the population exceed the supply of specific specialties, such as  dermatology.
TRICARE beneficiaries’ access to care is also impeded in areas where  there are insufficient numbers and types of civilian providers, both  network and nonnetwork, to cover the local demand for health care. In  these locations, the entire community is impacted by provider shortages.  Consequently, TRICARE beneficiaries, as well as all other local residents,  must sometimes travel long distances to obtain health care. MCSC officials  stated that each TRICARE region includes areas with civilian provider  shortages. For example, in TRICARE’s North Region, Watertown, New  York, has an insufficient number of certain specialty providers for its  population, which includes TRICARE beneficiaries stationed at a nearby  military installation whose MTF is too small to handle all of their health  care needs. TRICARE’s South Region contains many rural areas with few  providers, including multiple locations in Oklahoma and Texas. Likewise,  in TRICARE’s West Region, MCSC officials stated that there are provider  shortages in various locations, including Cheyenne, Wyoming, and  Mountain Home, Idaho.
TMA and the MCSCs have limited means of responding to access-to-care  impediments in areas with network and nonnetwork civilian provider  shortages, although TMA has adopted two bonus payment systems that  mirror those used by Medicare for these areas. In June 2003, TMA began  paying providers a 10 percent bonus payment for the services rendered in  Health Professional Shortage Areas, which the Department of Health and  Human Services has identified as having a shortage of primary care,  dental, or mental health providers. Also, in January 2005, TMA followed  Medicare in initiating payment of a 5 percent bonus for services rendered  by primary care providers in geographic areas designated by the  Department of Health and Human Services as Physician Scarcity Areas, a  program that is only operational through 2007. Providers who are eligible  for and wish to receive either of these bonus payments must include a  specific code on every claim they submit to obtain these additional  payments. According to a TMA official, TMA does not know the extent to  which these payments have been used and has not evaluated the  effectiveness of these bonus payments on access to care.
TMA and the MCSCs have attempted to overcome obstacles related to  practice capacity and provider shortages by using high-ranking military  personnel and field provider relation representatives to make personal  appeals to network and nonnetwork civilian providers. In August 2004, the  ASD for Health Affairs wrote a letter to providers appealing to their  patriotism and asking them to accept TRICARE beneficiaries as patients.  One MCSC official claimed that this letter has resulted in additional  providers accepting both enrolled and nonenrolled TRICARE beneficiaries  as patients. In addition, in certain areas where access is problematic,  MCSC provider relations representatives or TRO officials personally call  on providers to solicit their support of military personnel through  TRICARE.
section_title: NDAA Responsibilities for Nonenrolled TRICARE Beneficiaries’ Access to Care Are Being Carried Out by TMA and the MCSCs, but Were Not Formally Designated to a Senior Official
paragraphs: Various TMA offices, including the TROs, and the MCSCs are carrying out  the responsibilities that are outlined in the NDAA for fiscal year 2004 to  take actions to ensure nonenrolled beneficiaries’ access to care, such as  educating civilian providers and recommending reimbursement rate  adjustments—though these responsibilities were not formally designated  to a single, senior official. For example, TMA’s Communications and  Customer Service Directorate has primary responsibility for education and  marketing activities for all civilian providers—including nonnetwork  providers—although the TROs and MCSCs also share this responsibility.  (See table 6.) This office oversees a national contract for marketing and  education materials with input from the TROs and the MCSCs. As part of  this responsibility, this office designs and prepares marketing and  education materials in conjunction with its contractor. On a regional level,  the TROs and MCSCs also have responsibilities for educating both  network and nonnetwork civilian providers. As part of these efforts, each  TRO works with its region’s MCSC to host town-hall meetings and to  provide briefings for network and nonnetwork civilian providers. In  addition, the MCSCs contact, support, educate, and market to both  network and nonnetwork civilian providers. For example, one MCSC  distributes its monthly provider newsletter or bulletin to nonnetwork  civilian providers who submit 25 or more TRICARE claims in 1 year.  MCSCs also provide educational materials to civilian providers, including  nonnetwork providers, and, in some instances, schedule provider seminars  for nonnetwork providers.
Actions to encourage both network and nonnetwork civilian providers to  accept nonenrolled TRICARE beneficiaries as patients are currently being  addressed by the MCSCs. First, in areas with network civilian providers,  MCSCs are required by contract to ensure that the networks are robust  enough to provide health care to both enrolled and nonenrolled TRICARE  beneficiaries in that location. As a result, MCSCs strive to ensure adequate  numbers of network civilian providers who could also provide care to  nonenrolled TRICARE beneficiaries. In addition, when nonenrolled  TRICARE beneficiaries request assistance with finding providers, MCSCs  work to encourage civilian providers, who could be either network or  nonnetwork, to accept these TRICARE beneficiaries as patients. In some  instances when a provider cannot be easily identified for a TRICARE  beneficiary, MCSCs told us their provider relations representatives, who  are knowledgeable about providers in their regions, will call on individual  providers to encourage them to accept these TRICARE beneficiaries as  patients. Nonetheless, as contractually required, MCSCs are focused on  recruiting civilian providers for their networks and do not proactively  recruit nonnetwork civilian providers to accept TRICARE beneficiaries as  patients. Efforts to obtain nonnetwork civilian providers for nonenrolled  TRICARE beneficiaries using the Standard option are initiated on an as- needed basis.
Additionally, TMA, its TROs, and the MCSCs all have procedures and tools  in place aimed at ensuring that nonenrolled TRICARE beneficiaries can  readily locate both network and nonnetwork civilian providers. A central  TMA office maintains an online directory of both network and nonnetwork  civilian providers who have accepted TRICARE beneficiaries as patients in  the last 2 years. MCSCs’ Web sites provide a link to this TMA directory and  also provide a directory of network civilian providers in their regions.  Also, the TROs provide services, including assistance with locating civilian  providers, to any TRICARE beneficiary who contacts them. Among other  services they provide, Beneficiary Service Representatives at MCSC- operated TRICARE Service Centers assist “walk-in” TRICARE  beneficiaries—regardless of their enrollment status—to locate providers.  In addition, all MCSCs are contractually required to have representatives  available by phone 24 hours a day, 7 days a week to assist with locating a  network provider. One MCSC told us that if a network provider is not  available, the phone representatives will help locate nonnetwork providers  in the area.
Finally, the TROs currently are responsible for recommending  reimbursement rate adjustments—that have been initiated by their offices,  MCSCs, providers, and TRICARE beneficiaries—to increase provider  reimbursement rates in areas where access to care is impaired for both  enrolled and nonenrolled TRICARE beneficiaries. Since the TROs were  established in 2004, two of the three TROs have recommended such  increases to provider reimbursement rates in their regions.
Nonetheless, TMA has not formally designated a senior official to take  responsibilities for nonenrolled TRICARE beneficiaries and nonnetwork  civilian providers as outlined in the NDAA for fiscal year 2004. According  to TMA officials, this role was assumed by the ASD for Health Affairs, who  is responsible for overseeing DOD’s health programs and resources,  because these responsibilities are included in the official directive for this  position. According to senior TMA officials, the ASD for Health Affairs  intended to delegate these responsibilities to the TRO directors. However,  while this intent was communicated verbally, the delegation was never  formalized in writing. TRO officials told us that while they were aware of  the ASD for Health Affairs’ intent, they never received official notification  or designation outlining these responsibilities and expectations. As a  result, at the time of our site visits, the TROs had not undertaken any  efforts beyond the level of assistance they were already providing to  nonenrolled TRICARE beneficiaries and nonnetwork civilian providers.  Nonetheless, during the time of our review, each TRO was in the process  of assigning responsibilities for nonenrolled beneficiaries to a specific  staff member in accordance with the staffing plan TMA established for the  TROs. Additionally, officials at each of the TROs told us that they provide  services and assistance to all TRICARE beneficiaries regardless of  enrollment status.
To more directly assign responsibilities for nonenrolled beneficiaries’  access to care to the TROs, the NDAA for fiscal year 2006 specifically  instructs the TROs to (1) identify nonnetwork providers who will accept  nonenrolled TRICARE beneficiaries as patients; (2) communicate with  nonenrolled TRICARE beneficiaries; (3) conduct outreach to nonnetwork  providers, encouraging their acceptance of TRICARE beneficiaries as  patients; and (4) publicize which nonnetwork providers in each region  accept nonenrolled TRICARE beneficiaries as patients. It also requires  that DOD submit annual reports to Congress on efforts to implement these  activities.
section_title: Agency Comments and Our Evaluation
paragraphs: We received comments on a draft of this report from DOD (see app. VI). In  its comments DOD stated that it appreciated the collaborative, insightful,  and thorough approach that was taken with this important issue. However,  DOD disagreed with our finding that it had not formally designated a  senior official to ensure nonenrolled beneficiaries’ access to care,  including adequate participation by nonnetwork providers, as required by  the NDAA for fiscal year 2004. DOD stated that DOD directive 5136.12  assigned these duties to the TMA director and the TROs by designating the  TMA Director as the program manager for TRICARE health and medical  resources and other responsibilities. DOD stated that this responsibility  clearly encompasses provision of care to nonenrolled beneficiaries and  therefore meets the NDAA requirement.
We continue to believe that DOD has not adequately addressed the  requirement in the mandate. First, in multiple interviews and e-mail  exchanges during our audit work, senior DOD officials told us that no  specific actions had been taken to designate a senior official and that, by  default, the duties fell to the ASD for Health Affairs who is responsible for  overseeing DOD’s health programs and resources. Further, during our site  visits, TRO officials told us they had never been officially notified of their  responsibilities and expectations for nonenrolled beneficiaries and  nonnetwork providers. As a result, at the time of our site visits the TROs  told us they had not undertaken any efforts beyond the level of assistance  they had already been providing to nonenrolled beneficiaries and  nonnetwork civilian providers. Second, we do not agree with DOD that the  terms of the pre-existing directive satisfy the requirements of the mandate.  Contrary to the requirement in the law that one official be designated, the  directive generally assigns responsibilities to TMA, as well as to multiple  TROs on a geographic basis. While part of the TROs’ responsibilities  include developing a plan for the delivery of healthcare within the  geographic region, the mandate contemplated a more global approach to  addressing provider participation, specifically requiring one senior official  to ensure provider participation in each market area.
DOD also provided technical comments that we incorporated where  appropriate.
We are sending copies of this report to the Secretary of Defense,  appropriate congressional committees, and other interested parties. We  will also make copies available to others upon request. In addition, the  report is available at no charge on the GAO Web site at  http://www.gao.gov. If you or your staff have questions about this report,  please contact me at (202) 512-7119. Contact points for our Office of   Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions are listed in  appendix VII.
section_title: Appendix I: Scope and Methodology
paragraphs: The National Defense Authorization Act (NDAA) for fiscal year 2004  directed GAO to review the processes, procedures, and analysis used by  the Department of Defense (DOD) to determine the adequacy of the  number of network and nonnetwork civilian providers and the actions  taken to ensure access to care for nonenrolled TRICARE beneficiaries.  Specifically, this report describes (1) how TRICARE Management Activity  (TMA) and its managed care support contractors (MCSC) evaluate  nonenrolled TRICARE beneficiaries’ access to care and the results of these  evaluations; (2) the impediments to civilian provider acceptance of  nonenrolled TRICARE beneficiaries, and how they are being addressed;  (3) how DOD has implemented the fiscal year 2004 NDAA requirements to  take actions to ensure nonenrolled TRICARE beneficiaries’ access to care.
subsections: section_title: TMA and MCSCs’ Evaluation of Nonenrolled Beneficiaries’ Access to Care and the Status of Access
paragraphs: To describe how TMA evaluates nonenrolled TRICARE beneficiaries’  access to care, we interviewed and obtained documentation from officials  in TMA’s Health Program Analysis and Evaluation Directorate about its  civilian provider survey, called the Survey on Continued Viability of  TRICARE Standard. Although DOD was required to conduct a survey to  assess nonenrolled beneficiaries’ access to care under the Standard  option, the survey was administered to both network and nonnetwork  civilian providers since nonenrolled beneficiaries can receive care from  these providers under both the Extra and Standard options. We reviewed  the survey methodology, including the methods for selecting respondents,  the survey’s response rate, the designation of TRICARE market areas, and  the survey instrument itself. We also reviewed TMA’s methods for  randomly sampling market areas and providers and their administration of  the survey instrument and found these decisions methodologically sound  and statistically valid. In addition, we reviewed the survey results,  including the published results and analysis. While we did not  independently validate the survey data, we did assess the reliability of the  data by reviewing survey documentation and internal controls and by  interviewing knowledgeable agency officials and found that the data were  sufficiently reliable for our purposes. To obtain information on how the  civilian provider survey was developed, we interviewed officials at the  Office of Management and Budget (OMB) because the Paperwork  Reduction Act required OMB approval before it could administered. We  also interviewed TRICARE beneficiary group representatives who had  recommended sites for inclusion in the survey where nonenrolled  TRICARE beneficiaries’ access to health care may be impaired. To identify  how the civilian provider survey results would be used to evaluate access  to care, we met with officials of TMA’s Office of Health Plan Operations,  the director of TMA’s Standard Programs Division, and officials from the  three TRICARE Regional Offices (TROs).
We also reviewed TMA’s annual Health Care Survey of Defense  Beneficiaries and compared it with a survey conducted by the Department  of Health and Human Services’ Consumer Assessment of Health Care  Providers and System of individuals who received health care through  civilian health insurers. These surveys include identical questions on  access-to-care issues that allowed for comparative analysis of the opinions  expressed by TRICARE beneficiaries and civilian health plan users. Using  data from the 2003-2005 surveys we analyzed nonenrolled TRICARE  beneficiaries’ responses to access to care and compared them with results  from the Consumer Assessment of Health Care Providers and Systems. We  did not independently verify the data from each of these surveys; however,  we did assess the reliability of these data by reviewing related  documentation and interviewing knowledgeable agency officials and  found that they were sufficiently reliable for our purposes.
To further identify and describe other methods TMA and MCSCs used to  evaluate care access for nonenrolled TRICARE beneficiaries, we met with  officials of TMA, the TROs, MCSCs, and each of the services’ Office of the  Surgeon General to obtain information on the systems they use for  monitoring TRICARE beneficiary feedback and conducting other types of  analyses, such as monitoring health care claims. The TROs and military  services provided information on the Assistance Reporting Tool, a system  that is being developed to monitor and archive TRICARE beneficiary  feedback. The MCSCs also shared information about their independent  systems for maintaining TRICARE beneficiary feedback. TMA, MCSC, and  military service officials provided us with examples of TRICARE  beneficiary feedback reports and health care claims data for nonenrolled  TRICARE beneficiaries that TMA uses to evaluate access to care for this  population. We did not independently verify data from the MCSCs’  TRICARE beneficiary feedback systems and TMA’s claims data files;  however, we did assess the reliability of these data by interviewing  knowledgeable officials and reviewing previous GAO work using these  data and found that they were sufficiently reliable for our purposes. To  identify how the MCSCs monitor access to care both in Prime Service  Areas and in areas where networks have not been established, we  obtained information about their techniques for network development and  for civilian provider recruitment.
section_title: Impediments to Provider Acceptance of Nonenrolled TRICARE Beneficiaries and How They Are Being Addressed
paragraphs: To identify and describe the impediments to providers’ acceptance of  nonenrolled TRICARE beneficiaries, we obtained information from TMA  Health Plan Operations, TMA Health Program Analysis and Evaluation  Directorate, TRO, and MCSC officials on the possible reasons that  providers were unwilling to accept nonenrolled TRICARE beneficiaries as  patients. We also met with representatives of TRICARE beneficiary groups  and the American Medical Association to obtain anecdotal information  about impediments to health care access and to supplement our data on  possible access-to-care problems.
To identify and describe how impediments, such as TRICARE  reimbursement rates and administrative issues, are being addressed, we  reviewed TRICARE’s reimbursement policies and authorities as well as  provider outreach strategies and marketing and education efforts of TMA  and its MCSCs. We also reviewed the procedures for issuing waivers used  to increase reimbursement rates in areas where TMA determines that  access to care is impaired, including the application, review, and decision  process. We then obtained information from TMA’s Office of Medical  Benefit and Reimbursement Systems on all of the completed and pending  requests for reimbursement waivers. Finally, we interviewed MCSC and  TRO officials to identify the administrative issues that impact provider  acceptance of TRICARE beneficiaries and how they conduct outreach  efforts to alleviate problems and/or educate providers about these issues.  However, we did not assess the extent to which these efforts improved  civilian providers’ acceptance of nonenrolled beneficiaries as patients.
section_title: DOD Implementation of NDAA Fiscal Year 2004 Requirements for Oversight of Nonenrolled Beneficiaries’ Access to Care
paragraphs: To examine how DOD has implemented the NDAA fiscal year 2004  requirements for oversight of nonenrolled TRICARE beneficiaries’ access  to care, we reviewed pertinent sections of this legislation outlining the  tasks that DOD must perform to comply with the law. We interviewed  officials in TMA’s office of Health Plan Operations, the director of the  TRICARE Standard Programs Division, and officials in each of the TROs.  To identify whether and how the oversight responsibilities outlined in the  NDAA were being managed, we obtained information from TRO and  MCSC officials for each of the three regions and TMA’s Communications  and Customer Service Directorate to identify activities in place to educate  network and nonnetwork providers about TRICARE Standard, to  encourage network and nonnetwork providers to treat nonenrolled  TRICARE beneficiaries, and to ensure that nonenrolled TRICARE  beneficiaries have the information necessary to locate providers readily.
We conducted our work from July 2005 through December 2006 in  accordance with generally accepted government auditing standards.
section_title: Appendix II: Methodology Used for TMA’s Civilian Provider Survey
paragraphs: The National Defense Authorization Act (NDAA) for fiscal year 2004  required that the TRICARE Management Activity (TMA) conduct surveys  in TRICARE market areas within the United States to determine how many  health care providers are accepting new patients under TRICARE  Standard in each market area. The NDAA did not stipulate how TMA  should define a market area but specified that 20 market areas should be  completed each fiscal year until all market areas in the United States have  been surveyed. Although the mandate focused on Standard, TMA officials  designed the survey to monitor access to care from both network and  nonnetwork providers since nonenrolled TRICARE beneficiaries can  receive care through both the Standard and Extra options.
Before TMA could begin administering the civilian provider survey, it  required review and clearance from the Office of Management and Budget  (OMB) under the Paperwork Reduction Act. Subsequent to this review,  OMB approved a four-item questionnaire for the study administered in  fiscal year 2005. (See app. III for the approved questionnaire.)
In designing the Survey on Continued Viability of TRICARE Standard (the  civilian provider survey), TMA defined the individual states and the  District of Columbia as 51 market areas—a definition that will allow TMA  to complete the survey of all markets within a 3-year period and to develop  estimates of access to health care at both the state and national levels.  However, in order to provide information on smaller geographic areas  where nonenrolled TRICARE beneficiaries may be having problems  finding either network or nonnetwork providers, TMA supplemented the  statewide samples by oversampling from submarkets within each state  called Hospital Service Areas (HSA). The HSA geographic designation is  derived from a Dartmouth University study that groups zip codes into  distinct sets based on the analysis of patient travel patterns to the hospital  or hospitals they use most often. TMA endorsed the HSA submarket  methodology because these areas are nonoverlapping and encompass all  of the United States. In addition, nonenrolled TRICARE beneficiaries  reside in almost all of the 3,436 HSAs. TMA’s methodology asks for  oversamples from HSAs in the 24 states where 80 percent of nonenrolled  TRICARE beneficiaries reside. When the study is complete in fiscal year  2007, TMA will have survey data from 2 HSAs selected randomly from  each of the 24 states where the majority of nonenrolled TRICARE  beneficiaries live, as well as information from HSAs purposively selected  because TRICARE beneficiaries or TROs were concerned with access in  these areas.
To select the market areas that would be surveyed in fiscal year 2005, TMA  randomly selected sites from the individual states and the District of  Columbia and randomly selected 12 submarket HSAs within the 20 market  areas. In addition, in order to be able to respond to TRICARE beneficiary  concerns that access in some locations was impaired, TMA selected 17  additional submarket HSAs that TRICARE beneficiaries had identified as  problem areas in terms of access to health care. Four of these 17 sites  were outside the 20 selected state-wide market areas because TRICARE  beneficiaries had raised concerns about access issues in these locations.
TMA selected its sample for the civilian provider survey from the  American Medical Association Masterfile, a data set of U.S. providers that  includes data on all providers who have the necessary educational and  credentialing requirements. This Masterfile did not differentiate between  TRICARE’s network and nonnetwork civilian providers. However, TMA  selected this file because it is widely recognized as one the best  commercially available lists of providers in the United States and contains  over 600,000 active providers along with their addresses, phone numbers,  and information on practice characteristics, such as their specialty.  Although the Masterfile is considered to contain most providers,  deficiencies in coverage and inaccuracies in detail remain. Therefore, TMA  attempted to update providers’ addresses and phone numbers and to  ensure that providers were eligible for the survey.
From this Masterfile, TMA expected to randomly sample about 1,000  providers from each market and submarket area—a sample size that  would achieve TMA’s desired margin of error. However, in some  instances, a sample of 1,000 exceeded the number of providers in the  market or submarket area, in which case TMA attempted to contact all  providers in that area. Overall, TMA initially sampled about 41,000  providers, including both network and nonnetwork civilian providers.  After verifying phone numbers and eliminating ineligible providers, TMA  attempted to contact about 33,000 office-based providers in the 20 states  and 29 HSAs evaluated in fiscal year 2005. When analyzing provider  responses, TMA weighted each response so that the sampled providers  represented the population from which they were selected.
To administer the civilian provider survey TMA hired a contractor, who  conducted the fieldwork for this project. The contractor mailed a  combined cover letter and questionnaire to the billing managers for all  providers in their sample. If the provider did not respond to the mailed  questionnaire, TMA followed up with a second mailing 3 weeks later and  conducted a telephone interview within 30 days of the first mailing for  those who did not respond to the mailed survey. During the survey period,  telephone interviewers called each provider’s office up to 10 times in an  attempt to obtain a completed survey.
Because the overall response rate to the survey was 55 percent, TMA  conducted an analysis of their findings to determine whether the results  were biased by a high percentage of providers not responding. Although  TMA officials told us that OMB’s approval for the fiscal year 2005 survey  did not specify a required response rate, OMB’s public guidance specifies  that if response rates are lower than 80 percent, agencies need to conduct  a nonresponse analysis. Such an analysis is used to verify that  nonrespondents to the survey would not answer differently from those  who did respond and that the respondents are representative of the target  population, thus ensuring that the data are statistically valid. When  conducting this analysis, TMA interviewed a sample of providers who did  not respond to the original survey and compared their responses and  demographics with the original survey respondents. TMA also compared  nonrespondents’ demographics with those of the target population of  health care providers. The results of TMA’s nonresponse analysis indicate  that the survey respondents are representative of the target population of  providers.
The nonresponse analysis provided additional useful information for TMA.  First, it did not show a difference in the rate that responding and  nonresponding network civilian providers were aware of the TRICARE  program. However, it did show a statistically significant difference in the  rate of awareness between responding and nonresponding nonnetwork  civilian providers. These results indicate that having a familiarity with  TRICARE increases a provider’s incentive to respond to the survey. In  order to adjust for this bias, TMA could have calculated an adjustment to  the sampling weights—an adjustment that has not been applied to the  survey results. As a result, the unweighted survey results tend to overstate  civilian providers’ awareness and acceptance of TRICARE. Nonetheless,  TMA’s survey contractor noted that the survey results are not problematic  if the survey is used to compare changes in awareness and acceptance  from year to year. Further, TMA’s use of the unadjusted results of the  initial survey phase as indicators of areas in which to focus marketing and  outreach efforts is appropriate because TMA is using it to make relative  comparisons of the areas surveyed.
TMA’s survey of civilian providers continues, and their analysts expect to  complete data collection for the nation over a 3-year period ending in  fiscal year 2007. Although TMA’s efforts meet the mandate’s requirement  of surveying 20 market areas each fiscal year until all market areas were  surveyed, collecting survey results over this period may limit TMA’s stated  goal of deriving an overall national estimate because the national estimate  will combine data collected over several years rather than during one  relatively short time period, as well as the likelihood different instruments  will be used over time. For example, four additional questions may be  added to the fiscal year 2006 survey. TMA officials told us that the time lag  could potentially impact the results used to derive a national estimate, but  that their limited resources for this study prevent them from conducting a  nationwide survey under a shorter time frame.
section_title: Appendix III: Civilian Provider Survey Instrument
paragraphs: The National Defense Authorization Act (NDAA) for fiscal year 2004 directed the  Department of Defense (DOD) to monitor nonenrolled TRICARE beneficiaries’ access  to care under the TRICARE Standard option. Although the mandate focused on  Standard, nonenrolled TRICARE beneficiaries can receive care from both  nonnetwork civilian providers through the Standard option and from network civilian  providers through the Extra option. Beneficiaries can move freely between these  options depending on their choice of civilian provider each time they receive care.  Therefore, DOD’s survey was designed to monitor nonenrolled beneficiaries’ access  to care from both network and nonnetwork providers. As each cycle of the survey is  completed, TMA will be able to project survey results to the sampled market areas.  When all cycles of the survey are complete, TMA will be able to project the survey  data at the national level.
Following is the actual survey instrument that was used to obtain information from  civilian providers. The staff administering this survey were not aware of whether the  civilian providers they contacted were network or nonnetwork, and the same survey  questions, which specifically mentioned the Standard option, were asked of all  respondents. Nonetheless, if network civilian providers were to deliver care to  nonenrolled beneficiaries, the responding providers’ staff would likely understand  that this care would be provided under the Extra option. Therefore, for the purposes  of the survey, the term “Standard” referred to both the Standard and Extra option.
section_title: Appendix IV: Categorized Responses to the Civilian Provider Survey’s Open-ended Question
section_title: Appendix V: TRICARE Reimbursement Rates That Remain Higher than Medicare Reimbursement Rates
paragraphs: CPT codeProcedure or service performed  Biopsy, vertebral body, open; thoracic  Bone marrow or blood-derived peripheral stem cell transplantation; allogenic  Bone marrow or blood-derived peripheral stem cell transplantation; autologous  Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or  renal pelvic tumor  Litigation or transaction of fallopian tube(s), abdominal or vaginal approach, unilateral or  bilateral  Litigation or transaction of fallopian tube(s), abdominal or vaginal approach, postpartum,  unlaterial or bilateral, during same hospitalization (separate procedure)
Occlusion of fallopian tube(s) by device (eg. Band, clip, Galope ring) vaginal or suprapubic  approach  Cordocentesis (intrauterine), any method  Fetal monitoring during labor by consulting physician (ie, non-attending physician) with  written report; supervision and interpretation  Fetal monitoring during labor by consulting physician (ie, non-attending physician) with  written report; interpretation only  Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or  oophorectomy, abdominal or vaginal approach  Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total  hysterectomy  Surgical treatment of ectopic pregnancy; cervical, with evacuation  Cerciage of cervix, during pregnancy; vaginal  Cerciage of cervix, during pregnancy; abdominal  Vaginal delivery only (with or without episiotomy and/or forceps)
Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum car  External cephalic version, with or without tocolysis  Delivery of placenta (separate procedure)
Cesarean delivery only; including postpartum care  Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or  forceps)
Cesarean delivery only, following attempted vaginal delivery after previous cesarean  delivery  Cesarean delivery only, following attempted vaginal delivery after previous cesarean  delivery; including postpartum care  Treatment of incomplete abortion, any trimester, completed surgically  Induced abortion, by dilation and curettage  Induced abortion, by one or more intra-amniotic injuctions (amniocentesis-injections),  including hospital admission and visits, delivery of fetus and secundines  Induced abortion, by one or more intra-amniotic injuctions (amniocentesis-injections),  including hospital admission and visits, delivery of fetus and secundines; with dilation and  curettage and/or evacuation  Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without  cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus  and secudines  Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without  cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus  and secudines; with dilation and curettage and/or evacuation  Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without  cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus  and secudines; with hysterotomy (failed medical evacuation)
Multifetal pregnancy reduction(s) (MPR)
Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or  retroperitoneal approach with decompression of spinal cord, cauda equine or nerve  root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in  addition to code for primary procedure)
Strabismus surgery by posterior fixation suture technique, with or without muscle  recession (List separately in addition to code for primary procedure)
Injection procedure during cardiac catheterization; for pulmonary angiography  Injection procedure during cardiac catheterization; for selective right ventricular or right  atrial angiography (eg.internal mammary), whether native or used for bypass.
Injection procedure during cardiac catheterization; for selective left ventricular or left atrial  angiography  Injection procedure during cardiac catheterization; for aortography  Injection procedure during cardiac catheterization; for selective coronary angiography  (injection of radiopaque material may be by hand)
section_title: Appendix VI: Comments from the Department of Defense
section_title: Appendix VII: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Bonnie Anderson, Assistant  Director, Kevin Dietz, Cathleen Hamann, Lois Shoemaker, Robert Suls,  and Suzanne Worth made key contributions to this report.