The Pentagon's method for measuring the ratio of Tricare health providers to beneficiaries is flawed and could result in a shortage of providers in heavily populated areas, according to a new report from the General Accounting Office.
Contractors managing Tricare, the Defense Department's health insurance plan, try to make sure there are enough providers for all the beneficiaries in each region, according to Tricare spokeswoman Jenny Stathis. But according to the GAO report (03-592T), the Defense Department does not always receive complete information on service standards from Tricare contractors managing the regional networks.
For instance, GAO found quarterly reports from contractors in five of 11 Tricare regions that included less than half of the required data that Defense needs to assess whether the health insurance plan is meeting service standards. Under the service standards, beneficiaries should be able to see a doctor for urgent care within a day of requesting an appointment and should not have to spend more than 30 minutes in the doctor's office waiting room for scheduled nonemergency visits. They also should not have to travel more than 30 minutes to reach a doctor's office for routine care.
The report also recommended that the Defense Department set up a centralized system to handle beneficiary complaints. Currently, complaints arrive through a variety of venues and are "often handled informally or on a case-by-case basis," the report said. Because there is no central evaluation process, Defense has difficulty identifying broader access problems, according to GAO.
Stathis said that beneficiaries can relay their concerns to Tricare management through e-mail, letter, fax or phone. The complaints are then filed in a customer service tracking database and are analyzed, she said. Also, Tricare management conducts a beneficiary satisfaction survey and monitors the results closely, Stathis said.
Defense Department managers need to fix these administrative problems associated with Tricare before awarding new contracts for health care providers in June, the GAO report said.
Draft versions of the new contracts would streamline the process for credentialing providers and simplify patient referral procedures, but requirements to file all claims electronically could discourage some providers from participating, the report cautioned. Some providers are unable to file claims electronically: in fiscal 2002, providers filed roughly one quarter of claims electronically, according to the report.
The Defense Department defended the e-filing requirement, saying it would cut claims processing costs.