Network and Nonnetwork Civilian Providers Under TRICARE

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. Requirements in the NDAA for Fiscal Year 2004 Related to Nonenrolled TRICARE Beneficiaries

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. TMA and Its MCSCs Use Various Methods to Evaluate Access to Care That Indicate Sufficient Access for Nonenrolled TRICARE Beneficiaries

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. 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. 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. Various Factors Impede Providers’ Acceptance of Nonenrolled TRICARE Beneficiaries, and TMA and MCSCs Have Different Ways to Address Them

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. 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. 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. Locality waivers may be used to increase rates for specific medical  services in specific areas where access to care has been severely impaired. 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. 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

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. 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. 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. Appendix III: Civilian Provider Survey Instrument

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.
Why GAO Did This Study

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.

What GAO Found

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.