DOD has delegated oversight of the  civilian provider network to regional TRICARE lead agents. DOD requires that contractors  have a sufficient number and mix of providers, both primary care and  specialists, to satisfy the needs of beneficiaries enrolled in the Prime  option. In addition, DOD has access-to-care standards that are designed to ensure  that Prime beneficiaries receive timely care from providers. DOD’s Oversight of the Civilian Provider Network Has Weaknesses, But Additional Tools May Help

DOD’s ability to effectively oversee the TRICARE civilian provider  network is hindered by (1) flaws in its required provider-to-beneficiary  ratios, (2) incomplete reporting on beneficiaries’ access to providers, and  (3) the absence of a systematic assessment of complaints. However, DOD  has existing surveys and automated reporting systems that, while not  designed specifically for monitoring the civilian provider network, could  provide valuable information and potentially improve DOD’s ability to  oversee the civilian provider network. Specifically, for the network adequacy reports  we reviewed from 5 of the 11 TRICARE regions, we found that contractors  reported less than half of the required information on access standards for  appointment wait, office wait, and travel times. DOD and Contractors Report Three Factors That May Contribute to Civilian Provider Network Inadequacy

DOD and its contractors have reported three factors that may contribute  to potential civilian provider network inadequacy: lack of providers in  certain geographic locations, low reimbursement rates, and administrative  requirements. In 2000, DOD increased  reimbursement rates in rural Alaska in an attempt to entice more  providers to join the network. On the other hand, DOD officials told us  that with the 2002 increase in Alaska and the 2003 increase in Idaho,  contractors were experiencing some success in recruiting providers in  those areas. In  addition, there have been reported instances in which groups of providers  have banded together and refused to accept TRICARE Prime patients due  to their concerns with low reimbursement rates. However, while TRICARE’s reimbursement rates  may have created dissatisfaction among providers, it is not clear how  much this has affected civilian provider network adequacy except in  limited geographic locations, because the information contractors provide  to DOD is not sufficient to measure network adequacy. Incorporating data on the numbers and types of providers in the MTFs and  the total number of beneficiaries enrolled in TRICARE Prime would give  DOD a more accurate and comprehensive report of the potential workload  the civilian provider network faces in a prime service area and the  adequacy of the number of PCMs and specialists to deliver that care. Recommendations for Executive Action

To improve DOD’s oversight of the civilian provider network, we  recommend that the Secretary of Defense direct the Assistant Secretary of  Defense for Health Affairs to    ensure that MTF capabilities and all enrolled Prime beneficiaries in prime  service areas are accounted for when assessing and documenting the  adequacy of the civilian provider network;    ensure that the information reported on the required access standards is    explore ways to ensure that beneficiary complaints are systematically  evaluated and used to oversee the civilian provider network; and    explore options for improving the civilian provider surveys so that the  results of the surveys could be useful to DOD and the contractors in  identifying civilian provider concerns and developing actions that might  mitigate concerns and help ensure the adequacy of the civilian provider  network. Finally, we reviewed DOD’s request for proposals for the future contracts  and interviewed DOD and contractor officials to describe how the new  contracts might affect network adequacy.
Why GAO Did This Study

Testifying before Congress in 2002, military beneficiary groups described problems accessing care from TRICARE's civilian medical providers. Providers also testified on their dissatisfaction with the TRICARE program, specifying low reimbursement rates and administrative burdens. The Bob Stump National Defense Authorization Act of 2003 required GAO to review the oversight of the TRICARE network of civilian providers. Specifically, GAO describes how the Department of Defense (DOD) oversees the adequacy of the civilian provider network, evaluates DOD's oversight of the civilian provider network, and describes the factors that have been reported to contribute to network inadequacy. GAO analyzed TRICARE Prime--the managed care component of TRICARE. To describe and evaluate DOD's oversight, GAO reviewed and analyzed information from reports on network adequacy and interviewed DOD and contractor officials in 5 of 11 TRICARE regions.

What GAO Found

For the 8.7 million TRICARE beneficiaries, DOD relies on the civilian provider network to supplement health care delivered by its military treatment facilities. To ensure the adequacy of the civilian provider network, DOD has standards for the number and mix of providers, both primary care and specialists, necessary to satisfy TRICARE Prime beneficiaries' needs. In addition, DOD has standards for appointment wait, office wait, and travel times to ensure that TRICARE Prime beneficiaries have timely access to care. DOD has delegated oversight of the civilian provider network to the local level through regional TRICARE lead agents. DOD's ability to effectively oversee the TRICARE civilian provider network is hindered in several ways. First, the measurement used to determine if there is a sufficient number and mix of providers in a geographic area does not always account for the total number of beneficiaries who may seek care or the availability of providers. This may result in an underestimation of the number of providers needed in an area. Second, incomplete contractor reporting on access to care makes it difficult for DOD to assess compliance with these standards. Finally, DOD does not systematically collect and analyze beneficiary complaints, which might assist in identifying inadequacies in the civilian provider network. However, DOD has tools, such as surveys of network providers and automated reporting systems which, while not designed specifically for monitoring the civilian provider network, could, if modified, improve DOD's ability to oversee the network. DOD and its contractors have reported that a lack of providers in certain geographic locations, low reimbursement rates, and administrative requirements contribute to potential civilian provider network inadequacy. DOD and contractors have reported long-standing provider shortages in some geographic areas. In areas where DOD determines that access to care is severely impaired, DOD has the authority to increase reimbursement rates. Since 2002, DOD has used its reimbursement authority to increase rates in Alaska and Idaho in an attempt to entice more providers to join the network. DOD officials told us that the contractors have achieved some success in recruiting additional providers by using this authority. Additionally, civilian providers have expressed concerns that TRICARE's reimbursement rates are generally too low and administrative requirements too cumbersome. However, while reimbursement rates and administrative requirements may have created provider dissatisfaction, it is not clear how much this has affected civilian provider network adequacy except in limited geographic locations, because the information contractors provide to DOD is not sufficient to measure network adequacy.