GAO to Pentagon: More oversight needed for Tricare

The Defense Department needs to boost oversight of Tricare to ensure that the program's beneficiaries have sufficient access to health care services, according to a new report by the General Accounting Office.

Contractors managing Tricare, the Defense Department's health insurance plan, are required to have a sufficient number and mix of health care providers, both primary care and specialists, to treat all beneficiaries. Tricare contractors must also guarantee that beneficiaries have adequate access to health care and send periodic reports on the program to regional Defense officials or lead agents.

But the information provided to lead agents is not wholly reliable because there is no uniform process or standard for collecting the information, GAO concluded in its report (03-928). According to the watchdog agency, one contractor forwards information compiled through site visits, while another contractor uses an automated tracking system to collect information.

"The information reported to DoD on this access is often incomplete, making it difficult to assess compliance with the requirements," the report said.

According to GAO, quarterly reports from contractors in five of 11 Tricare regions provided 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.

Contractors told GAO auditors "it was not practical or feasible to document every appointment and office wait time because some beneficiaries make their own appointments directly and provider offices are spread throughout the geographic area."

GAO also found that there was no one place or person designated to receive participant complaints.

"When beneficiaries complain about availability or access in the network, these complaints can be directed to different DoD entities, with no guarantee that the complaints will be compiled and analyzed in the aggregate to identify possible trends or patterns and correct network problems," the report found.

These problems may not be corrected when new Tricare health care provider contracts are awarded later this year, so GAO recommended that Defense officials take steps to ensure all beneficiaries are accounted for when assessing and documenting the adequacy of the civilian provider network and make sure that the information is sufficient and reliable.

Defense officials should also look at different ways to receive and evaluate beneficiary complaints, the report said.

In a written response, William Winkenwerder, assistant secretary of Defense for health affairs, said the issues identified by GAO would be corrected under the new health care provider contracts and that many program improvements are already under way.

Winkenwerder also noted that provider access problems in the Tricare system "are rare and typically relate to a lack of specialty providers in a rural area."