PROJECT REPORT HCSDB Annual Report 2003: Results from …Fabrice Smieliauskas 600 Maryland Avenue,...

HCSDB Annual Report2003: Results from the Health Care Survey of DoD Beneficiaries

March 2004

Natalie Justh

Sylvia Kuo

Rebecca Nyman

Eric Schone

Fabrice Smieliauskas

P R O J E C T R E P O R T

HCSDB Annual Report2003: Results from the Health Care Survey of DoD Beneficiaries

March 2004

Natalie Justh

Sylvia Kuo

Rebecca Nyman

Eric Schone

Fabrice Smieliauskas

600 Maryland Avenue, S.W., Suite 550Washington, DC 20024-2512(202) 484-9220www.mathematica-mpr.com


This report benefited from the contributions ofLt. Col. Michael Hartzell,Dr. Richard Guerin, andPatricia Golson of theHealth Program Analysis& Evaluation Directorateof the TRICAREManagement Activity.

Contents

iii

Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 2: Health Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Chapter 3: Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Chapter 4: Personal Doctor or Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter 5: Preventive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Chapter 6: Chronic Health Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Chapter 7: Children in TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Issue Briefs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Issue Brief: Network Adequacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Issue Brief: Claims Processing and Customer Service in TRICARE . . . . . . . . . 26

Issue Brief: Prescription Drug Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Issue Brief: Reservists and TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32


Chapter 1: Introduction

1

The TRICARE Annual Report presents a summary of results from the Health Caresurvey of DoD Beneficiaries (HCSDB) for 2003. According to the 2003 HCSDB:

• Health plan ratings for all TRICARE enrollment groups, including active dutyPrime enrollees, non-active duty enrollees and users of Standard or Extra haveincreased from their levels in 2001

• Since the implementation of TRICARE for Life, health plan ratings of Medicareusers have improved sharply

• Active duty enrollees rate their health plan lowest and report more problemsgetting access to referrals or needed care than do other enrollment groups.

• Standard/Extra users are more likely than either Prime enrollees or users ofcivilian insurance to report problems with paperwork and problems gettinginformation about their health plan

• Military treatment facility (MTF) users are no more likely than users of civilianor Veterans Administration (VA) facilities to report long waits in the doctor’soffice, but are more likely to report long waits for appointments and more likelyto report their doctors’ visits are too short

• Most active duty Prime enrollees do not have a personal doctor or nurse, nor doone-third of non-active duty enrollees

• Breast and cervical cancer screening rates of both active duty women anddependents of active duty exceed Healthy People 2010 goals, but rates of firsttrimester pregnancy care do not

• TRICARE users, both children and adults, encounter substantially greaterproblems getting access to therapy than do users of civilian plans

• Of beneficiaries who rely on TRICARE’s civilian network for most of their care,30 percent report problems getting the care they need from the network. Ofbeneficiaries who have tried the network but do not depend on it, 60 percentreport problems

• Since 1999, the proportion of TRICARE users who report that claims handlingis correct and timely has gone up every year

• Sixty percent of MHS beneficiaries who filled a prescription in the past 90 daysfilled at least one at a MTF pharmacy, including 38 percent of those who are cov-ered by civilian commercial plans and 48 percent of those with Medicare coverage

• Since mobilization, 16 percent of reservists’ family members report it is harderto find a personal doctor and 19 percent report it is harder to find a specialist


About the HCSDB

The HCSDB is a worldwide survey of militaryhealth system (MHS) beneficiaries conducted each yearsince 1995 by the Office of the Assistant Secretary ofDefense/TRICARE Management Activity (TMA).Congress mandated the survey under the NationalDefense Authorization Act for fiscal year 1993 (P.L.102-484) to ensure regular monitoring of MHS benefi-ciaries’ satisfaction with their health care options.

The survey is administered each quarter to astratified random sample of adult beneficiaries andonce each year to the parents of a sample of childbeneficiaries. Any beneficiary eligible to receive carefrom the military health system on the date thesample is drawn may be selected. Eligible beneficiariesinclude members of the Army, Air Force, Navy,Marines, Coast Guard, Public Health Service,National Oceanic and Atmospheric Administration,and mobilized members of the National Guard andReserves. Though many of the beneficiaries useTRICARE Prime, TRICARE Standard or TRICAREExtra, others rely on Medicare or on civilian healthinsurance as their health plan.

The samples are drawn from the DefenseEnrollment Eligibility Reporting System (DEERS)and are stratified by the location of the beneficiary’shome, health plan, and reason for eligibility. In 2003,a total of 180,000 beneficiaries from both inside andoutside the United States were sampled for the adultsurvey. A total of 35,000 beneficiaries from the UnitedStates were sampled for the child survey. Samplingmethods are described in the 2003 HCSDB AdultSample Report and 2003 Child Sample Report. TheNational Research Corporation administers thesurvey, allowing beneficiaries to respond by mail or ona secure web site. Unweighted response rates were 29 percent for adults and 31 percent for children.Weighted response rates were 44 percent for adultsand 32 percent for children.

Responses to the survey are coded, cleaned andedited and assembled in a database. Duplicate andincomplete surveys are removed. A sampling weight isassigned to each observation, adjusted for non-response. The contents of the database are describedin the 2003 HCSDB Codebook and Users Guide.

Questions in the 2003 HCSDB have been devel-oped by TMA or taken from other public domainhealth care surveys. Many questions were taken fromthe Consumer Assessment of Health Plans Survey(CAHPS), Version 2.0. CAHPS contains core andsupplemental survey questions that are used by com-mercial health plans, the Center for Medicare andMedicaid Services (CMS) and state Medicaid programsto assess consumer satisfaction with their health plans.

Most survey questions change little from quarter toquarter so that responses can be followed over time.Supplementary questions are added each quarter tolearn more about the latest health policy issues. In2003, questions were added to address the adequacyof TRICARE’s civilian network, beneficiaries’ ratingsof their pharmacy options, the experience of benefici-aries with chronic conditions, reservists’ health cover-age, and a number of other topics.

About this Report

This report presents results for all surveys adminis-tered in 2003, 2002 and 2001. It includes responsesfrom all beneficiaries eligible for MHS benefits,including children, who reside in the US.

Beneficiaries are eligible for military health benefitsif they are currently active duty or dependents of activeduty. Groups eligible due to active duty status includeNational Guard and Reserves mobilized for more than30 days and their dependents. Beneficiaries are alsoeligible if they have retired following a career in theuniformed services or are the dependents of a retiree.MHS beneficiaries may receive care from militaryfacilities or MTFs that are financed and operated bythe uniformed services or from civilian facilities thatare reimbursed by the Department of Defense.

2


3

Eligible beneficiaries may choose from severalhealth plan options. TRICARE Prime is a point ofservice HMO that centers on military facilities orcivilian facilities that are members of TRICARE’scivilian network. Active duty and their family mem-bers are automatically eligible for free enrollment inPrime. Retirees under age 65 may enroll if they pay apremium. TRICARE Standard offers cost sharing forcare received from civilian doctors on a fee-for-servicebasis. TRICARE Extra offers enhanced cost sharingfor fee-for-service care received from network doc-tors. Many retirees and some active duty dependentsalso have non-military coverage. For Medicare-eligible retirees, Medicare has primary responsibility.However, since the start of TRICARE for Life inOctober 2001, TRICARE Standard has been secondpayer to, and paid most costs left over after Medicare.Many retirees under 65 and some active duty depend-ents rely on civilian commercial insurance as theirprincipal coverage. A smaller number rely on theVeterans Administration.

Graphs in this report compare responses of thesedifferent beneficiary groups. The results are presentedas percentages calculated using adjusted samplingweights. Several graphs compare responses relating tohealth plan performance according to the health planoption that beneficiaries use most. Preventive caremeasures are broken down according to beneficiaries’reason for eligibility. Health care performance meas-ures are presented according to the most used type offacility or the branch of service providing care. Whenresults are compared between groups or betweenyears or compared to an external benchmark, thedifference is tested for statistical significance, account-ing for the complex sample design. Results that differsignificantly from an external benchmark (p < .05) areitalicized and appear in red.

Results from CAHPS questions are compared toresults from the National CAHPS BenchmarkingDatabase (NCBD) for 2002, which assembles resultsfrom surveys administered to hundreds of civilian

health plans. Benchmarks are adjusted for age andhealth status to correspond to the characteristics ofbeneficiaries who use TRICARE Prime, Plus, orStandard/Extra. For preventive care measures, such asthe proportion of women screened for cervical cancer,results are compared with Healthy People 2010 goals.Healthy People 2010 goals are set by the government topromote good health by healthy behavior, such asimmunization, screening for illness, and avoidingunhealthy habits. Benchmarks are described in moredetail in the 2003 HCSDB Technical Manual.

Other reports prepared from the HCSDB are theTRICARE Beneficiary Reports and TRICARE ConsumerWatch. The Beneficiary Reports is an interactive web-based document that compares TRICARE Regionsand MTFs using scores calculated from survey results.The Consumer Watch contains a brief summary ofresults from the Beneficiary Reports and an issue briefthat uses survey questions to address health policyissues affecting the MHS. Both appear quarterly.

Often based on supplementary survey questions,the issue briefs investigate special topics of immediateinterest to beneficiaries and MHS leadership. Theissue briefs for 2003 concerned 1) beneficiaries’perceptions of the adequacy of TRICARE’s civiliannetworks, 2) claims processing and customer serviceratings under TRICARE, 3) beneficiaries’ options forusing their pharmacy benefits, and 4) the experienceof recently mobilized reservists and their families.These issue briefs make up the last four chapters ofthis report.


4

Chapter 2: Health Plans

Slightly more than half (56 percent) of MHS benefi-ciaries surveyed rely on a TRICARE plan for most

of their health care. However, as shown in Figure 1,beneficiaries use a variety of health care coverageoptions. Twenty-four percent are active duty, 24 per-cent are active duty dependents or retirees and theirdependents enrolled in Prime and another 8 percentuse Standard or Extra for most of their care. Medicareis most frequently used for those who do not rely onTRICARE, covering nearly a quarter (23 percent) ofthose surveyed. Eighteen percent rely on privatecivilian insurance and 3 percent rely on the Veterans’Administration (VA) for most of their coverage.

Beneficiaries who use TRICARE plans for most oftheir care rate their health plan lower than do benefici-aries of other health plans. Figure 2 shows that in 2003,when beneficiaries rated their health plans, 44 percent of active duty and 59 percent of non-active

duty Prime enrollees rated Prime 8 or higher on a 0 to 10 scale. Fifty-four percent of Standard/Extrausers rated their plan 8 or higher. By contrast, 84 percent with Medicare and 66 percent with otherprivate civilian insurance gave their plans high ratings.

TRICARE users’ plan ratings have increasedsubstantially. The proportion of active duty ratingtheir plan 8 or higher increased from 39 in 2001 to itscurrent level of 43, while the proportion of non-activeduty rating Prime high went from 54 to 60 percentduring the same time. The increase for Standard/Extra was still larger, from 40 to 54 percent. Medicareusers’ plan ratings have also risen sharply in conjunc-tion with TRICARE for Life benefits extended toMedicare-eligible beneficiaries. By contrast, amongbeneficiaries covered by private civilian plans, highratings changed little, increasing only 2 percent from2001 to 2003.

VA 3%

Prime-active duty24%

Prime-non active duty

23%Standard/ Extra 8%

Medicare 23%

Other civilian 18%

Figure 1: Health plan used for most care 2003

0

20

40

60

80

100%

200320022001

Perc

ent

Rati

ngPl

an8

orab

ove

Prime- Prime-non Standard/ Medicare Other VA active active Extra civilian duty duty

39

Benchmark (60%)

41 43

54 5560

40

4854

73

82 84

65 66 67

NA

65 64

Figure 2: Health plan ratings


5


Active duty Prime enrollees are the most likely ofall enrollment groups to report problems gettingreferrals or getting needed care. Figures 3 and 4indicate access to care as the percentage reportingrespectively getting referrals without problems andgetting care believed necessary by the beneficiary or adoctor. In 2003, 57 percent of active duty reported noproblems getting referrals and 67 percent reported noproblems getting needed care. By comparison, thepercentage of beneficiaries in other enrollment groupsreporting no referral problems ranged from 65 per-cent of non-active duty Prime enrollees to 91 percentwith Medicare coverage and the percentage reportingno problems getting needed care ranged from 74 percent of non-active duty Prime enrollees and VA users to 91 percent of Medicare users.

Relative to other enrollment groups, TRICAREusers were more likely to report referral problemsthan problems getting needed care. The proportionreporting referral problems exceeded the proportionreporting problems getting needed care by 10 percentamong active duty, and 8 percent of non-active dutyPrime enrollees and Standard/Extra users. By con-trast, among users of civilian private insurance, refer-ral problems exceeded problems getting needed careby only 2 percent. Among all groups, access as meas-ured by both referral problems and problems gettingneeded care improved between 2001 and 2003.

Customer service problems among TRICARE usersdiminished between 2001 and 2003 as shown inFigures 5A-5C. Prime enrollees were less likely thanwere Standard/Extra users to encounter problemswith paperwork or problems getting health planinformation from written materials or customerservice lines.

Users of Standard or Extra are the TRICARE usersmost likely to report customer service problems. In2003, 44 percent of Standard/Extra users found theinformation they needed in written materials withoutproblems compared to 51 percent of Prime users and63 percent who used civilian insurance, while

Perc

ent

wit

hno

prob

lem


200320022001 Benchmark (74%)

0

20

40

60

80

100%

54 545763 64 65

73 79 76

8992 91

85 87 87

NA

73 71

Figure 3: Getting referrals

Perc

ent

wit

hno

prob

lem


0

20

40

60

80

100%

200320022001 Benchmark (80%)

66 65 6771 73 74

7883 84

89 91 9187 90 89

NA

73 75

Figure 4: Access to needed care

6


50 percent of Standard/Extra users made problem-freeuse of the customer service line compared to 54 percent of Prime enrollees and 69 percent whoused civilian insurance. This pattern has persisted from2001 to 2003, though it was most pronounced in 2001.From 2001 to 2003, the proportion of Standard/Extrausers with no problem getting information fromwritten materials and from the customer service lineincreased by 10 percent and 11 percent respectively.

The timeliness and correctness of TRICAREclaims handling has improved since 2001, accordingto both Prime enrollees and users of Standard/Extra.Standard/Extra users report correct claims handling atrates exceeding the civilian benchmark. As shown inFigure 6A, in 2003, 87 percent of Standard/Extrausers reported that their claims were usually or alwayshandled correctly. As shown in Figure 6B, timelinessin claims handling according to Prime enrollees liesslightly below the benchmark, at 80 percent. Theclaims handling scores given by both Prime enrolleesand Standard/Extra users, however, exhibit substantialimprovement. The proportion of Standard/Extra usersreporting timely claims handling rose from 70 percentto 80 percent, and the proportion reporting correctclaims handling went from 81 to 87 percent; similarly,

Perc

ent

wit

hno

prob

lem

200320022001 Benchmark (59%)

30

40

50

60

70

80%

4948 48

42

46 46

61 5962

Prime Standard/Extra Other civilian

Figure 5A: Getting customer service: paperwork

Perc

ent

wit

hno

prob

lem

200320022001 Benchmark (59%)

Prime Standard/Extra Other civilian30

40

50

60

70

80%

4849

54

39

49 50

65

69 69

Figure 5B: Getting customer service: telephone line

Perc

ent

wit

hno

prob

lem

200320022001 Benchmark (55%)

Prime-active duty Standard/Extra Other civilian30

40

50

60

70

80%

33

4244

5962 63

46

50 51

Figure 5C: Getting customer service: written materials

7


the share of Prime enrollees reporting timely claimshandling increased from 71 percent to 80 percent, andthe share reporting correct handling rose from 75 to82 percent.

Perc

ent

who

secl

aim

sar

eus

ually

oral

way

spa

idon

tim

e


50

60

70

80

90

100%

70

82 80

90 91 92

71

7780

200320022001 Benchmark (81%)

Figure 6B: Timely claims processing

Perc

ent

who

secl

aim

sar

eus

ually

oral

way

spa

idco

rrec

tly


50

60

70

80

90

100%

81

85 87

94 94 94

75

8082

200320022001 Benchmark (85%)

Figure 6A: Correct claims processing

8

Chapter 3: Health Care

The majority of Prime enrollees, including 85 percent of active duty and 69 percent of non-

active duty, use primarily MTFs, but substantialmajorities of both groups use civilian facilities (CTFs).Some also have the option of using VA facilities.Figure 7 shows how the health plan used by benefici-aries is related to the type of facility that providesmost of their health care. Fourteen percent of activeduty and 30 percent of non-active duty enrollees relyon civilian facilities for most of their care. Amongother enrollment groups, the majority of care isprovided by civilian facilities. Ninety-six percent ofthose with private civilian insurance, 86 percentcovered by Medicare and 90 percent of Standard/Extra users get most of their care from civilian facili-ties. However, 9 percent of Standard/Extra users and12 percent of Medicare users say they get more oftheir care from MTFs than civilian facilities.

When taken together, 36 percent of all MHSbeneficiaries reported using a military treatmentfacility (MTF), 50 percent used a civilian treatmentfacility (CTF), and 4 percent used a Veterans Affairsfacility (VA). The remainder reported not using any ofthese sources of care.

Beneficiaries who get most of their care fromMTFs are less likely to rate their health care highlythan are users of other facility types. As shown byFigure 8, health care ratings vary by usual source ofcare. When asked to rate their health care from 0 to10, where 10 is best, 56 percent of MTF users ratedtheir care 8 or above, compared to 65 percent of VAusers and 79 percent of CTF users. Moreover, ratingsof health care at civilian and VA facilities improvedrelative to MTF ratings between 2001 and 2003.

VACTFMTF

Perc

ent

gett

ing

mos

tof

thei

rca

refr

omea

chso

urce


0

20

40

60

80

100%

85

14

1

69

30

19

89

2

11

87

2 2

97

1 3 3

95

Figure 7: Source of care by health plan 2003

Perc

ent

rati

nghe

alth

care

8or

abov

e

200320022001 Benchmark (69%)

MTF CTF VA0

20

40

60

80

100%

56 56 56

7477 79

6369 65

Figure 8: Rating of health care


9


Beneficiaries are no more likely to experience longwaits at MTFs than at civilian facilities and less likelythan at VA facilities. Figures 9 and 10 describe benefi-ciaries’ experiences with waiting for care. Sixty-sevenpercent of both MTF users and CTF users reportednever or sometimes waiting more than 15 minutes atthe doctor’s office to be seen, compared to 61 percentof VA users.

MTF users are less likely than CTF or VA users toreport that they can get appointments when they wantthem. Sixty-seven percent of MTF users reportedusually or always getting routine appointments whenthey wanted them compared to 89 percent of CTFand 79 percent of VA users.

Timeliness for MTF users improved less thantimeliness for CTF or VA users. The proportion ofMTF users rarely waiting long at the doctor’s officeincreased only 1 percent from 2001 to 2003, whileamong CTF and VA users, the proportion rose by4 percent and 3 percent respectively. Similarly, a

1 percent rise among MTF users in appointmenttimeliness compares with rises of 3 percent for CTFusers and 4 percent for VA users.

MTF users were less likely than were CTF users toreport that doctors spent enough time with them orexplained things so that they could understand. InFigure 11, 80 percent of MTF users reported usuallyor always getting enough of their doctor’s time at anoffice visit, compared to 89 percent of CTF users and86 percent of VA users.

Percent never or sometimes waiting >15 minutes

VACTFMTF Benchmark (63%)

2001

2002

2003

0 20 40 60 80 100%

66

63

58

67

67

60

67

67

61

Figure 9: Waiting in the doctor's office

Percent usually or always getting an appointment when they need it

2001

2002

2003

0 20 40 60 80 100%

66

86

75

67

89

78 67

89

79


Figure 10: Waiting for appointments

10


Between 2001 and 2003, doctors’ time with patientsat MTFs did not change, while at CTFs and VAfacilities, the proportion usually or always gettingenough time increased by 2 percent and 3 percentrespectively.

In Figure 12, 91 percent of MTF users reportedthat doctors usually or always explained things so thatthey could understand compared with 95 percent ofCTF and 91 percent of VA users.

Percent whose doctor usually or always spends enough time with them

2001

2002

2003

0 20 40 60 80 100%

80

87

83

80

89

87 80

89

86


Figure 11: Doctors spend enough time with you

Percent who can usually or always understand their doctor

2001

2002

2003

0 20 40 60 80 100%

90 94 89 91 95 90 91 95 91


Figure 12: Doctors explain things so you can understand

11

Chapter 4: Personal Doctor or Nurse

TRICARE users are less likely than are beneficiariesof other plans to have a single doctor or nurse they

regard as their personal provider. Thirty-nine percentof active duty and 67 percent of non-active duty Primeenrollees report that they have a personal doctor ornurse, as do 80 percent of Standard/Extra users. Theseproportions are much lower than the proportions ofMedicare users (92 percent), users of civilian insurance(89 percent), or the VA (85 percent). As shown byFigure 13, in most enrollment groups, the proportionwho say they have personal doctors has increased since2001, though changes have been small.

Prime enrollees who are enrolled to an Air ForceMTF are slightly more likely to have personal doctorsand slightly less likely to rate their doctors highlythan those enrolled to other service types. Fifty-fourpercent of those with an Air Force sponsor, 51 per-cent with an Army sponsor and 49 percent with aNavy sponsor have a personal doctor or nurse, asshown by Figure 14. In each service, the proportion

reporting that they have a personal doctor or nursehas increased by 2 percent since 2001. Ratings ofthese personal doctors, presented in Figure 15, varylittle by service. The proportion rating their doctors 8 or better on a 10-point scale ranges from 63 in theArmy and Air Force to 60 percent in the Navy. Highpersonal doctor ratings in the Navy have declinedfrom 64 percent to 60 percent since 2001.

Perc

ent

wit

ha

pers

onal

doct

or

Air ForceNavyArmy

2001 2002 2003 0

20

40

60

80%

49 4954

5149

54

49 4752

Figure 14: Has a personal doctor: prime enrollee withmilitary PCM

200320022001

Perc

ent

wit

ha

pers

onal

doct

or


0

20

40

60

80

100%

39 38 39

65 66 6773

78 80

91 91 9289 89 89

NA

8285

Figure 13: Has a personal doctor by health plan

Perc

ent

rati

ngpe

rson

aldo

ctor

8or

abov

e

Air ForceNavyArmy Benchmark (73%)

2001 2002 20030

20

40

60

80%

62 64 63 63 64 63 63 60 63

Figure 15: Rating of personal doctor: prime enrollee withmilitary PCM


12

The low proportion of TRICARE users with personaldoctors does not appear to reduce access to preven-

tive care. Healthy People 2010, a government initiative toimprove population health through healthy behaviorsincludes goals for preventive care in the US in the formof a set of benchmark rates for different types of pre-ventive care. Figures 16 through 18 compare preventiveservice rates for women, pap smears, mammograms andprenatal care, with Healthy People 2010 targets.

For active duty women and dependents of activeduty, Pap smear rates and mammography ratesexceeded the Healthy People 2010 goal. The HealthyPeople 2010 goal is a Pap smear every three years for90 percent of women over 18. As shown in Figure 16,active duty rates from 2001 to 2003 exceeded the goalby 6 to 8 percent, while retirees and their dependentsunder age 65 received Pap smears at a rate slightlybelow the target.

The Healthy People 2010 mammography goal ismammography every other year for 70 percent ofwomen over 40. In each year, rates were highest for

retirees over 65. Though both active duty women andwomen who are the dependents of active duty haverates well above the target, the mammography rate inboth groups has declined 5 percent since 2001, whileit has held steady among the retired. The current rateamong retirees (84 percent) now substantially exceedsthe rates for active duty dependents (75 percent).

Chapter 5: Preventive Care

Perc

ent

gett

ing

pap

smea

r

Benchmark (90%)

2001 2002 2003

98

96 96

85

90

95

100%

87

86

89

94 9495

Active duty Active duty dependentsRetirees < 65

Figure 16: Cervical cancer screening within 3 years

Benchmark (70%)

2001 2002 2003

84 84 84

8075 75

8382 82

Active duty Active duty dependentsRetirees < 65

65

75

85

95%

Perc

ent

gett

ing

mam

mog

raph

y

Figure 17: Women 40 and over with biannualmammography

Benchmark (90%)

2001 2002 2003

87

82 82

89

88 88

Active duty Active duty dependents

Perc

ent

gett

ing

pren

atal

care

70

80

90

100%

Figure 18: Pregnant women getting first trimester care


13


Prenatal care for both active duty and active dutydependents has fallen short of the target. The HealthyPeople 2010 goal is care in the first trimester of pregnancyfor 90 percent of pregnant women. As shown in Figure18, prenatal care of both active duty and their dependentslie slightly below this goal for 2001 through 2003.

Other preventive services fall somewhat short ofHealthy People 2010 goals. Figure 19 indicates that choles-terol screening rates among active duty are substantiallyhigher than rates among their dependents. In 2003, 76 percent of active duty reported that they had beentested for high cholesterol in the past 5 years compared to60 percent of active duty dependents. Among retirees andtheir dependents, an older population more likely to bescreened, 87 percent reported cholesterol tests in the past5 years. Active duty and active duty dependents’ rates arebelow the Healthy People 2010 goal of 80 percent.

Ninety percent of active duty, 89 percent of theirdependents and 93 percent of retirees and theirdependents have been screened for hypertension(Figure 20). These rates are slightly below the HealthyPeople 2010 target of 95 percent and there has beenlittle change in the screening rate since 2001. Hyper-tension screening is measured as the proportion ofbeneficiaries who report that their blood pressure has

been measured in the past 2 years and who knowwhether their blood pressure is too high or not.

The results in Figure 21 indicate an upward trendin smoking cessation counseling among active dutyand their dependents. Figure 21 shows the proportionof smokers with office visits who have been counseledto quit. Among active duty, the proportion that hasbeen counseled to quit increased from 64 percent to66 percent between 2001 and 2003, while dependentcounseling rates increased from 63 percent to 68 percent. Both active duty and dependent counselingrates are lower than the retiree rate, which was 72 percent in 2001 and 2002 and 74 percent in 2003.

2001 2002 2003

76

59 6058

76 76

Perc

ent

wit

hch

oles

tero

lscr

eeni

ng

50

60

70

80

90

100%

Benchmark (80%)Active duty Active duty dependentsRetirees < 65

85 8487

Figure 19: Cholesterol screening within 5 years

2001 2002 2003

89

8990

89

8990

Perc

ent

wit

hhy

pert

ensi

onsc

reen

ing


92 92

93

85

90

95

100%

Figure 20: Blood pressure tested within 2 years and know results

2001 2002 2003

64

6466

63

64

68

Perc

ent

ofsm

oker

sco

unse

lled

toqu

it


72 72

74

60

65

70

75

80%

Figure 21: Smokers with office visits counselled to quit

14

Chapter 6: Chronic Health Problems

Though most TRICARE beneficiaries are healthy, asubstantial minority is affected by health problems

that require long-term management. As shown inFigure 22, in the past 12 months, a proportion rang-ing from 4 percent of active duty to 34 percent of VAusers has experienced health problems serious enoughto limit their independence. Because conditions of thisseverity become more prevalent with age, 21 percentof beneficiaries covered by Medicare also reportindependence-limiting conditions.

Chronic conditions require special health careservices of different types, including therapy, medicalequipment and assistance with personal needs. Asshown by Figure 23, the service most needed by mostbeneficiary types is special therapy (such as physical,occupational or speech therapy). Surprisingly, theproportion of active-duty Prime enrollees with healthproblems requiring special therapy was similar in sizeto that of Medicare enrollees. In 2003, 23 percent of

active-duty Prime enrollees had such conditions,compared to 22 percent of Medicare users. The highprevalence among active duty may reflect physicaltherapy for work-related injuries. Among otherenrollment groups, need for therapy was somewhatless, ranging from 14 percent of non-active dutyPrime enrollees to 18 percent of VA users.

TRICARE users were substantially less likely toreport having health problems requiring home healthcare compared to Medicare users. In 2003, 6 percentof active duty and 8 percent of non-active duty Primeenrollees reported needing assistance with theirpersonal needs. Ten percent of Standard/Extra usersreported needing help. Need for home health carewas greatest among Medicare enrollees (15 percent).By contrast VA users were the enrollment group mostlikely to report they needed special medical equip-ment (31 percent).

0

10

20

30

40

50

60%

200320022001

Perc

ent

wit

hph

ysic

alor

men

talc

ondi

tion

inte

rfer

ing

wit

hin

depe

nden

ce


5 5 48 6 6

149 9

2420 21

107 9

NA

39

34

Figure 22: Condition interfering with independencePercent with special health care needs

Need medical

equipment

Need home

health

Need special

therapy

0 10 20 30 40 50 60%

Prime-active Prime-non Standard/Extra duty active duty

Medicare Other civilian VA

988

20 11 31

68

1015

11 10

23 14 14 22 16 18

Figure 23: Needs for equipment or services 2003


15


Similar to the overall health plan ratings in Figure 2,beneficiaries who use TRICARE plans for most oftheir care rate their plans lower in providing access toequipment, therapy and home health care than dobeneficiaries of other plans. Figure 24 shows that in2003, 49 percent of active duty and 65 percent of non-active duty Prime enrollees rated Prime 8 or higher forproviding special health services. Sixty percent ofStandard/Extra users rated their plan 8 or higher. Incontrast, 85 percent of Medicare and 72 percent withcommercial insurance gave their plans high ratings.

These rates represent substantial improvement inTRICARE beneficiaries’ plan ratings since 2001. Thegreatest improvement was exhibited by Standard/Extrausers, among whom high plan ratings increased from44 percent to 60 percent. A comparable improvementoccurred among beneficiaries enrolled in Medicare.The proportion giving their plan a high ratingincreased from 75 to 85 percent. The increase inratings for serving special needs mirrors the increase ingeneral plan ratings and probably reflects the impact

of TRICARE for Life in reducing the cost of care forTRICARE’s Medicare eligibles.

Plan ratings also increased among Prime enrollees,from 45 percent and 60 percent in 2001 to 49 percentand 65 percent in 2003 for active duty and non-activeduty Prime enrollees, respectively. On the other hand,plan ratings for private civilian plans changed littlefrom 2001 to 2003.

TRICARE users were more likely to report problemsgetting special care than were Medicare or commercialinsurance users in 2003. The extent of these problemsvaries depending on the care needed. TRICARE userswere more likely to report easy access to medicalequipment than to therapy or home health care.

Among TRICARE users, the proportion describingtheir access to medical equipment as problem-free,shown by Figure 25, ranged from 76 percent of activeduty to 79 percent of Standard/Extra users in 2003.By contrast 82 percent of commercially insured and84 percent of VA users reported easy access, as did 89 percent of Medicare enrollees. Since 2001, accesshas improved most for Medicare enrollees, from 79 to89 percent, followed by active duty Prime enrollees,from 69 to 76 percent.0

20

40

60

80

100%

Perc

ent

rati

ngpl

an8

orab

ove


45 4549

60 6065

4451

60

75

86 85

70 73 72

NA

71 71

200320022001

Figure 24: Health plan rating for providing neededequipment, services and assistance

0

20

40

60

80

100%

Perc

ent

wit

hno

prob

lem


69 7176

7176 77 78

71

79 77

86 8983

72

82

NA

83 84

200320022001

Figure 25: Access to needed medical equipment

16


As shown by Figure 26, TRICARE users laggedfarthest behind users of civilian health plans in accessto therapy. In 2003, the proportion of TRICARE userswith no problems getting access to therapy rangedfrom 58 percent of Standard/Extra users to 69 percentof non-active duty Prime enrollees. By contrast, 81 percent of VA users, 84 percent who used commer-cial insurance and 91 percent of Medicare usersdescribed their access to therapy as free from prob-lems. These values represented improvement overlevels in 2001 for all groups but Standard/Extra.

Access to home health care is easiest for Medicareusers and users of commercial insurance according toFigure 27. In 2003, 93 percent of Medicare enrolleesreported that they could get special help withoutproblems as did 87 percent who use commercialinsurance. Among other enrollment groups, theproportion reporting no problems ranged from 65 percent of VA users to 76 percent of non-activeduty Prime enrollees.

0

20

40

60

80

100%

Perc

ent

wit

hno

prob

lem


60 6164 64

68 69

6166

58

8691 91

83 85 84

NA

7581

200320022001

Figure 26: Access to needed therapy

0

20

40

60

80

100%

Perc

ent

wit

hno

prob

lem


6558

72

49

7176

81

54

7174

83

93

60

87 87

NA

74

65

200320022001

Figure 27: Access to needed personal assistance

17

Chapter 7: Children in TRICARE

Approximately 1.8 million CONUS children areeligible for health benefits through TRICARE.

Figure 28 shows that 83 percent use one ofTRICARE’s three options as their health plan. The vast majority is covered by Prime.

As shown in Figure 29, parents who rely on civilianinsurance to provide coverage for their children ratetheir health plan higher than do TRICARE users. In2003, 68 percent of parents who relied on civilianinsurance rated their health plan 8 or above comparedto 60 percent of Prime users and 50 percent ofStandard/Extra users. The difference in health planratings has narrowed since 2001. Ratings for all healthplan types have increased since 2001, but Primeratings and Standard/Extra ratings have risen morethan ratings of civilian plans.

Beneficiaries whose children use civilian healthplans report fewer problems getting their childrenreferrals than do parents of children covered by Primeor Standard/Extra. As shown in Figure 30, parentsrelying on Prime reported that they could get their

Prime 70%

Standard/ Extra 13%

Other civilian 17%

Figure 28: Children’s health coverage 2003

Perc

ent

rati

ngpl

an8

orhi

gher

200320022001

0

20

40

60

80

100%

54 5660

4043

50

64 66 68


Figure 29: Health plan ratings

Perc

ent

wit

hno

prob

lem

200320022001

0

20

40

60

80

63 65 6572 74

7782 84

82


100%

Figure 30: Getting referrals


18


children problem-free access to referrals at a rate 17 percent below the civilian rate of 82 percent in2003. Among children covered by Standard or Extra,the difference was less, as 77 percent of their parentsreported no problems getting referrals. Childrencovered by both Prime and Standard/Extra obtainedreferrals more easily in 2003 than in 2001, by 2 per-cent for Prime and 5 percent for Standard/Extra.

Figure 31, shows that parents who rely on civilianinsurance report accessing needed health care withfewer problems than do parents who rely on Prime orStandard/Extra. Ninety-two percent of parents whosechildren relied on civilian coverage reported noproblems getting needed care in 2003, compared to80 percent who relied on Prime and 87 percent whorelied on Standard/Extra. Reported access improvedslightly in all three groups since 2001.

Use of TRICARE Prime means use of militaryfacilities for about two out of three children who relyon Prime. However, a sizable minority of Prime users,30 percent, gets most of their care from civilians. By

contrast, almost all who relied on Standard/Extra orcivilian coverage also relied on civilian providers. Thisresult, shown in Figure 32, means that about half ofthe parents surveyed rely on MTFs and half oncivilian facilities to care for their children and thatmore than half of those who use civilian facilitiesreceive care through a TRICARE plan. A smallproportion of those covered by civilian insurance getcare from Uniformed Services Family Health Plan(USFHP) clinics.

Parents who relied on civilian facilities for healthcare were more likely to give their children’s care arating of 8 or above than were parents who relied onMTFs, as shown in Figure 33. The difference was 13 percent in 2001, 2002 and 2003. The differenceremained constant over these three years as theproportion rating their care highly increased at MTFsfrom 60 to 65 percent and at civilian facilities from 73 to 78 percent during that time.

Among children with needs for special care, parentswho used TRICARE were less likely to report prob-

Perc

ent

wit

hno

prob

lem

200320022001

0

20

40

60

80

100%

77 78 8085 86 87

90 91 92


Figure 31: Getting needed care

Perc

ent

gett

ing

mos

tof

thei

rca

refr

omea

chso

urce

MTF CTF USFHP

0

20

40

60

8069

30

0

8

92

0 1

96

3


100%

Figure 32: Source of care by health plan 2003

19


lem free access than were parents of children withcivilian coverage. As shown by Figure 34, access forTRICARE children lagged farthest behind access incivilian plans when children needed therapy. Only 50 percent of Prime children had problem-free access to therapy compared to 57 percent ofStandard/Extra children and 73 percent of childrenwith civilian coverage.

Among other types of special needs, access forTRICARE children was comparable to access for

children with civilian coverage. Sixty-six percent ofparents relying on Prime reported no problem gettingmedical equipment compared to 71 percent withcivilian coverage, while 54 percent covered by Primereported no problem getting counseling for theirchildren compared to 59 percent relying on civiliancoverage. Prescription drugs were easiest to access forall three enrollment groups, with problem-free accessrates ranging from 80 percent for Prime users up to87 percent for users of civilian coverage.

Percent with no problem getting treatment


Medical equipment

Therapy

Counseling

Prescriptiondrugs

0 20 40 60 80 100%

66 64 71

50 57 73

54 51 59

80 83 87

Figure 34: Getting treatment 2003

Percent rating care 8 or higher

MTFCTF

2003

2002

2001

0 20 40 60 80 100%

78

65

74

61

73

60

Figure 33: Health care ratings

21

Issue Briefs

These issue briefs first appeared in TRICARE Consumer Watch:• Network Adequacy appeared in May 2003• Claims Processing and Customer Service in TRICARE appeared in August 2003• Prescription Drug Benefits appeared in November 2003• Reservists and TRICARE appeared in February 2004


23

Issue Brief: Network Adequacy

Like other health plans, TRICARE provides carethrough networks of physicians and other health

care providers who contract to treat its beneficiaries.TRICARE’s contracts with civilian health plans requirethe plans to establish “adequate” networks. Plans mustinclude primary physicians and specialists proportionalto the number of Prime enrollees living nearby whouse civilian doctors. They also must meet contractualstandards for timely access to appointments. In recentyears, beneficiary groups have complained of accessproblems and physicians have cited low reimbursementand administrative burdens as reasons for avoidingTRICARE patients (G.A.O., 2003). This issue briefdescribes how TRICARE beneficiaries view the ade-quacy of their civilian networks.

Background

In the civilian health care market, increasing num-bers of consumers and providers have pushed backagainst the most restrictive forms of managed care andtheir cost-containment strategies. Health plans haveresponded by expanding networks and looseningrestrictions. Rather than traditional HMOs, healthplans now offer looser managed care products such asopen HMOs, PPOs and point-of-service plans, whichfeature broader provider networks and more affordableuse of out-of-network providers. Health plans haveincreased the stability of their networks by reducingdoctors’ exposure to financial risk.

Movement away from restrictive managed carereflects the importance consumers attach to accessand freedom of choice. Surveys of adult health planenrollees in the general population also point to

networks as a critical element in consumer’s satisfac-tion with their health plans. For example, whenchoosing between two competing health plans, accessto specialists and participation of one’s own physicianin the network are among the most important factorsweighed by consumers (Harris, 2002).

Other trends have weakened networks, however.Contract disputes and insolvencies of large providerorganizations have made networks less stable (Short etal, 2001). In 2001, about 13 percent of the insured in anational sample said they either delayed care or leftmedical needs unmet due to access problems. Of thosereporting problems, about half cited the high cost ofcare, even though cost was reduced by health insur-ance. A third reported they could not make a timelyappointment and 12 percent could not find a conve-niently located doctor. A survey of civilian health plansfound that 9 percent of those that visited a doctor inthe past year had to spend more than 30 minutestraveling to the doctor’s office (Reschovsky, 2000).

Findings

The TRICARE civilian network currently providesmuch, if not most of the care for retired beneficiariesand their dependents and for active duty dependentswho choose TRICARE. Of non-active duty benefici-aries who received care from a TRICARE plan in thepast year, 35 percent say they use only the civiliannetwork, while another 30 percent use the civiliannetwork for some or most of their healthcare.

Beneficiaries who try to use the civilian networkreport a variety of access problems. The frequency ofaccess problems appears to exceed the frequency of


24


problems encountered in civilian plans, and may bepreventing beneficiaries who would otherwise preferit, from using the network. Among the non-activeduty beneficiaries who wanted care, a total of 30 percent reported problems and 9 percent reportedbig problems in getting the care they wanted from thecivilian network. Among those who did not use thecivilian network but have tried to use it, 43 percentreported big problems getting the care they wanted,suggesting that problems getting care from thenetwork had kept them from using it.

Many beneficiaries who use the civilian networkreport problems finding care that is convenient. Ofthose who tried to find a doctor in the civilian net-work, 30 percent encountered problems and 12 percent encountered big problems in finding adoctor who was convenient to visit. One-fifth of thebeneficiaries who had big problems finding a conven-ient doctor elected not to use the civilian network.

Access to other health care services appears to be alesser problem in TRICARE: of non-active dutybeneficiaries who tried to use labs or x-ray facilities inthe network, 17 percent had problems and 7 percenthad big problems in finding convenient locations.

For many, the ability to continue seeing doctorswith whom they have established relationships is acrucial component of health care quality. For thatreason, the stability of physician networks is at least asimportant as its range of specialists and geographiccoverage. In recent surveys, only 1 percent of allprivately insured persons in a national sample reportedthey had been forced to change their primary doctorsbecause that doctor left their network (Reed, 2000). Bycontrast, results from the HCSDB show that 22percent of beneficiaries who tried to use doctors fromthe civilian network found that a doctor they wantedto see was no longer a network member. This suggests

All healthcare 35%

Most healthcare9%Some healthcare

21%

No healthcare 35%

Figure 1: Proportion of care from the civilian network

Table 1. Problems getting careBeneficiaries with

All beneficiaries no care from network

Big problem 9% 43%

Small problem 21% 17%

No problem 70% 40%

Big problem

Small problem

Noproblem

0 20 40 60 80 100%

7

8

83

Figure 2: Problems finding lab/x-ray

Table 2: Problems finding convenient doctorOf whom:

beneficiaries withAll beneficiaries no care from network

Big problem 12% 21%

Small problem 18% 5%

No problem 70% 2%

25


TRICARE’s problems are greater than those of civilianplans, though the HCSDB finding includes not onlyprimary doctors, but also specialists, who are oftenharder for beneficiaries to access.

Conclusions

Access limitations, inconveniently located doctors,and doctors who leave the network all appear to affectTRICARE’s civilian network to a greater degree thanthey affect networks serving privately insured popula-tions. The effects of network instability may worsenwhen new contracts are negotiated in the comingyear. Like our HCSDB findings, evidence collected byG.A.O. also indicates TRICARE network problems.G.A.O. attributes problems to low reimbursement forphysicians, and a staffing formula that underestimatesthe needs of network users for care, particularly fromspecialists (G.A.O., 2003).

Besides increasing reimbursement and the numberof network specialists required per beneficiary, TRI-CARE can take measures to reduce the effects ofinstability. Regulators are fighting network instabilityin civilian markets by closely monitoring providers’financial health, and employers by including perform-ance guarantees in their contracts to reduce physicianturnover (Short et al, 2001). Regulations and contractsthat increase burdens on providers may increase

upward pressure on health costs. Like those in thecivilian world, TRICARE’s decision makers have toweigh the benefits in access, convenience and conti-nuity of care against the added costs.

ReferencesHarris, K.M. Can High Quality Overcome Consumer

Resistance to Restricted Provider Access? Evidencefrom a Health Plan Choice Experiment (2002).Health Services Research, 37 (3):551.

Reed, M.C. Why People Change Their Health CareProviders. Data Bulletin #16 (2000). Center forStudying Health System Change.

Reschovsky, J.D. Do HMOs Make a Difference?Access to Health Care. Inquiry (1999/2000),36:390.

Short, A.C., Mays, G.P., Lake, T.K. ProviderNetwork Instability: Implications for Choice,Costs and Continuity of Care. Issue Brief #39(2001). Center for Studying Health SystemChange.

Strunk, B.C., Cunningham, P.J. Treading Water:Americans’ Access to Needed Medical Care, 1997-2001. Tracking Report #1 (2002). Center forStudying Health System Change.

United States General Accounting Office. Oversightof the Adequacy of TRICARE’s civilian networkhas weaknesses. Testimony. March 27, 2003.

Yes

No

0 20 40 60 80 100%

22

78

Figure 3: Wanted to see doctor who left network

26

Issue Brief: Claims Processing and Customer Service in TRICARE

In TRICARE, claims processing and customerservice have long been the source of dissatisfaction

and complaints among both beneficiaries andproviders1 and a cause of network instability amongproviders.2 In response to beneficiary complaints andcongressional mandates, TRICARE adopted claimsprocessing standards similar to those in Medicare andthe commercial market. Claims administrators mustpay 95 percent of routine claims within 30 days ofreceipt, and 100 percent of routine claims within 60 days of receipt.3 More recently, congress mandatedthat 50 percent of claims, and all claims from high-volume providers, be electronically submitted.4

TRICARE beneficiary ratings of claims handlingtimeliness and correctness have risen steadily in recentyears, and are now similar to the commercial norm.As shown in Figure 1, since 1999, the percentage ofTRICARE users who think TRICARE’s claimshandling is usually or always timely has increasedfrom 69 to 81. The percentage who think claims areusually or always processed correctly has improvedfrom 74 to 84. Despite this improvement, providersand TRICARE administrators continue to expressfrustration with the speed and accuracy of claimsprocessing.5 Electronic processing lags: WisconsinPhysicians Service (WPS) notes that 53 percent of itsTRICARE claims are submitted electronically, com-pared with 62 percent in the commercial market and88 percent for Medicare.6 Continued improvement inTRICARE’s claims handling performance will requireincreasing the proportion of claims filed electronicallyand adjudicated automatically.

Beneficiaries or their providers file TRICAREclaims for care from civilian providers through one ofTRICARE’s Managed Care Support Contractors. Theclaims are administered by one of two subcontractors:

Palmetto Government Benefits Administrators(PGBA), which processes 85 percent of TRICAREclaims, and WPS.

Once received by the claims administrator, thespeed with which claims are processed depends onwhether they are adjudicated automatically or by aclaims adjudicator. In 2000, 47 percent of TRICAREclaims were automatically adjudicated, compared withcurrent rates of 66 to 75 percent for industry leaderssuch as Humana and Anthem.7,8 One reason TRICARE claims are less often adjudicated automati-cally is TRICARE’s complexity. TRICARE’s threeplan options each have different benefits, co-pay-ments, and adjudication procedures; provider reim-bursement rules are complicated and frequentlychange, and since TRICARE is often a second payer,TRICARE payments often depend on members’ otherhealth insurance policies.9

Technological and regulatory changes shouldincrease electronic submission and speed adjudicationof claims. These new developments include:

1999 2000 2001 2002 200365

67

69

71

73

75

77

79

81

83

85%

69

71

78

7475

81

Timely Correct

77

81

84

70

Claims processing is usually or always:

Figure 1: TRICARE claims processing


27


• HIPAA’s universal standards for electronicclaims. Many physicians submit paper claims forTRICARE patients because of the cost of modi-fying their computer systems to file electronicTRICARE claims, which differ from otherelectronic claims.9 However, starting October16, 2003, universal claims standards will remove this barrier and increase rates of elec-tronic submission.10

• Financial incentives. Following current practicein Medicare, as of 2000, TRICARE contractorsare allowed to provide financial incentives totheir providers for electronic claims filing. DoDalso allows providers to demand that interest bepaid on claims unprocessed after 30 days.11

• Reduced utilization management require-ments. Requirements such as preauthorizationand certification complicate claims processingand are frequent sources of error.12 As TRICARE and the rest of the health care indus-try drop these requirements, they will reduceerror and delay.4

• The T-Nex program. By collapsing TRICARE’s11 CONUS regions and 7 managed care supportcontracts into three regions, with one managedcare organization in charge of each region, T-Nex will simplify adjudication and increaseelectronic filing and claims processing.5

• Web-based claims filing. Since July 2002,PGBA has operated a web-based TRICAREclaims processing system, XpressClaim, thatpermits real-time claims adjudication. Thesystem permits claims to be submitted, edited,and, in many cases, adjudicated while the patientis in the doctor’s office.

As shown by Figure 2, ratings of TRICARE cus-tomer service and paperwork have also improved, butmore slowly than have claims handling ratings. Forty-six percent of TRICARE users in 1999 reported noproblem getting help from the customer service phone

line, compared to 52 percent in 2003, while the pro-portion reporting no problems with TRICARE paper-work has increased from 42 percent to 50 percent inthe same period. The proportion able to find theinformation they need in TRICARE’s written materialshas increased most, from 39 percent to 50 percent.

Much of the information and assistance that benefi-ciaries need can be found on the new interactiveTRICAREonline website, as well as the TRICARE,WPS, or PGBA websites. The websites contain toolsto perform many services for enrollees and providersbesides claims submission. Beneficiaries can enroll inTRICARE Prime, set up appointments with a pri-mary care manager, check the status of their claims,check out of pocket expenses, send secure mail to theclaims administrator, and access plan information onsuch things as benefits and lists of networkproviders.13 Beginning next year, beneficiaries will beable to fill prescriptions on the web.

Increased website use may produce claims handlingand customer service improvements. Beneficiaries whouse these services and on-line plan information willhave fewer problems with paperwork or writtenmaterials and less need for other forms of customerservice. They will make fewer mistakes about their

1999 2000 2001 2002 200335

40

45

50

55%

4243

484645

50

Written materials PaperworkCustomer service line

4849

52

42

No problems with:

39

4246

48 50

Figure 2: TRICARE customer service

28


benefits and, as a result, have fewer problems withtheir claims. Simultaneously, use of the website forother purposes will spur electronic claims filing.

TRICARE can encourage website use by incorpo-rating features useful to enrollees and providers and byarranging these features so that they are easily foundand used. The design, accessibility and usability ofTRICARE’s website could greatly influence beneficiar-ies’ claims handling and customer service experiencesand, ultimately, their satisfaction with TRICARE.

Notes1 “TRICARE Provider Network Connects Military,

Local Communities”, http://www.tricare.osd.mil/plaintalk/plain_talk_2001_06.html

2 Defense Health Care: Claims Processing ImprovementsAre Underway but Further Enhancements Are Needed(Letter Report, 08/23/1999, GAO/HEHS-99-128):Washington, DC: General Accounting Office, August 1999.

3 The Managed Care Support Contractors OperationsManual, March 2001.

4 FY2001 Defense Authorization Act (Public Law 106-398, 10/30/00).

5 Tieman, J. “Marching Orders” in Modern Healthcare,May 19, 2003.

6 http://www.wpsic.com/edi/edi_home.shtml7 Defense Health Care: Observations on Proposed

Benefit Expansion and Overcoming TRICARE Obstacles(Testimony, 03/15/2000, GAO/T-HEHS/NSIAD-00-129):Washington, DC: General Accounting Office, March 2000.

8 “Insurers Boost Electronic Transactions In Bid to CutAdministrative Costs”, Managed Care Week 13 (6).Washington, DC: Atlantic Information Services, February10, 2003.

9 Defense Health Care: Opportunities to ReduceTRICARE Claims Processing and Other Costs (Testimony,06/2//2000, GAO/T-HEHS-00-138): Washington, DC:General Accounting Office, June 2000.

10 “Marry Internet, HIPAA Strategies to Pull Ahead inE-Commerce”, Managed Care Week, Washington, DC:Atlantic Information Services, May 1, 2000.

11 FY2000 Defense Authorization Act (Public Law 106-65, 10/5/99).

12 McElfatrick R.L., and Eichler, R.S.,“Chapter 21:Claims and Benefits Administration”, p.504, in Kongstvedt,P.R., Essentials of Managed Health Care 4th ed.,Gaithersburg, MD: Aspen, 2001.

13 www.tricareonline.com, various webpages

29

Issue Brief: Prescription Drug Benefits

Spending on prescription drugs makes up thefastest growing share of health care costs. The

share of prescription drugs has grown from 5 percentof US health spending in 1980 to 10 percent in 2001.Rapid drug spending growth is projected to continuefor the foreseeable future1. To hold down premiums,civilian health plans increasingly offer three (or more)tiers of pharmacy copayments, charging beneficiariesleast for generic drugs, more for preferred branddrugs, and most for non-preferred brand drugs. Sixty-three percent of beneficiaries with employer-spon-sored coverage now have three-tier plans2. Mail-orderpharmacies also reduce the cost of drug benefits. In arecently surveyed national sample, 22 percent withcoverage had filled at least one prescription throughthe mail in the previous 6 months3.

The military health system (MHS) offers its benefi-ciaries several options that completely or partly coverthe cost of drugs. Beneficiaries may fill prescriptionsfrom the MHS formulary at military treatment facility(MTF) pharmacies for no charge. They may pay $3for generic drugs and $9 for non-generics at TRI-CARE retail network pharmacies, or the same copay-ments for 90-day supplies of drugs from the TRI-CARE Mail-Order Pharmacy (TMOP). If not Primeenrollees, beneficiaries may pay the greater of $9 or20 percent coinsurance at non-network pharmacies.Prime enrollees must pay 50 percent of the retail costto use non–network pharmacies.

The MHS prescription drug benefits are richerthan the benefits available to most civilians. Though99 percent of US beneficiaries with employer-spon-sored health coverage have drug benefits, they pay anaverage coinsurance of 20 percent for generic drugsand 29 percent for drugs that are not on the formula-ry list2. Medicare beneficiaries generally have morelimited coverage, if they have coverage at all.

As shown in Figure 1, MHS beneficiaries use MTFpharmacies more than any other of their choices.Sixty percent of beneficiaries that filled prescriptionsin the past 3 months filled one or more of them at aMTF pharmacy. The next most frequently usedoption was the network pharmacy, where 38 percentfilled prescriptions. Twenty-four percent used non-network pharmacies and 25 percent used the mailorder pharmacy.

Of all beneficiary types, Active Duty and Primeenrollees were most likely to use MTF pharmacies.Table 1 shows where MHS beneficiaries with differentcoverage types fill their prescriptions. Eighty-threepercent of active duty and 78 percent of non-activeduty enrollees who filled prescriptions in the past 90 days used an MTF pharmacy at least once.Beneficiaries who got their care from the VA or wereenrolled in TRICARE Plus also used MTF pharma-cies frequently – 70 percent and 69 percent, respec-tively. The retail network was the most used option of

Perc

ent

Pharmacy Option

MTF Retail network Non-network TMOP 15

25

35

45

55

65%

24 25

60

38

Figure 1: Percent of MHS beneficiaries filling prescriptionsby pharmacy option


30


beneficiaries who rely on Standard/Extra (63 percent)or Medicare (56 percent), while non-network pharma-cies were the usual choice of beneficiaries covered byother civilian health insurance (61 percent).

MTF pharmacies were the first or second choice ofbeneficiaries with all coverage types, including 38 percent of beneficiaries with other civilian insur-ance and nearly half of Medicare beneficiaries.Though non-network pharmacies were the least-usedoption of most enrollment groups, in all groupsexcept Active Duty and Prime enrollees, at least 20 percent had filled prescriptions out-of-network. In spite of the high cost of non-network pharmaciesto Prime enrollees, nearly 10 percent of theseenrollees filled at least one prescription in a non-network pharmacy. Forty-five percent of Primeenrollees who used non-network pharmacies said theydid so because they were unaware that the pharmacywas outside the network (not shown).

Beneficiaries of all types used the mail orderpharmacy but use was greatest among those withMedicare. Forty-two percent of Medicare enrolleesused the mail order pharmacy at least once. For mostenrollment groups, TMOP was the third choice,behind MTF and network pharmacies.

Figure 2 shows that beneficiaries choose MTFs forboth cost and convenience. Sixty-nine percent of MTFpharmacy users said that they chose their pharmacybecause of its low cost, and a similar number, 68 percent, because of its convenience. Thirty-fourpercent said that the quality of service was a factor.

MTF users were more likely than users of otherpharmacy options to have experienced long waits forprescription drugs. As shown by Figure 3, 31 percentof those who used MTFs reported they usually oralways waited 30 minutes or more at the pharmacy forprescriptions to be filled compared to 26 percent ofthose who used the retail network. However, MTFpharmacy users were most likely to report theyreceived both oral and written instruction about theirdrugs. Sixty-one percent of MTF users got informationin both forms, compared to 55 percent of retail net-work and 53 percent of non-network pharmacy users.

The highest rated pharmacy option was the mailorder pharmacy, rated at least 8 out of 10 by 79 percent of those who used it. By contrast, theproportion giving other pharmacy options ratings of 8or above ranged from 71 percent of MTF pharmacyusers to 78 percent of retail network pharmacy users.

Table 1: Pharmacy options by enrollment groupPercent using pharmacy option

Coverage type MTF1 TRN2 NNC3 TMOP4

Active duty 83.4 24.1 9.5 12.1

Non-active duty Prime 77.7 37.0 8.3 16.9

Standard/Extra 34.7 62.8 20.3 28.3

Medicare 47.6 55.9 23.9 42.0

Other civilian insurance 37.5 22.4 61.4 21.5

VA 70.1 21.8 22.2 35.3

TRICARE Plus 68.8 33.1 25.3 30.1

1MTF = Military treatment facility2TRN = TRICARE network pharmacy3NNC = Non-network pharmacy4TMOP = TRICARE mail-order pharmacy

Service

Convenience

Cost

0 20 40 60 80%

34

68

69

Percent

Figure 2: Reasons for using MTFs

31


Prescriptions filled by mail cost the MHS less thanprescriptions filled at civilian pharmacies and benefici-aries are encouraged to use the TMOP4. Most whouse mail-order are satisfied, but many who might useit use network pharmacies instead. Figure 4 shows thereasons given by beneficiaries filling long-term pre-scriptions at network pharmacies instead of TMOP.Forty percent chose the network pharmacy for con-venience, while 28 percent chose it for its servicequality. In all, 24 percent listed problems with the

mail order pharmacy as a reason for their choice: nottrusting mail-order pharmacies, not understanding themail-order benefit, or being unable to get a drugthrough the mail because it is not on the formulary.

Most beneficiaries rate their pharmacies highly,more than 70 percent rating each pharmacy option 8 or more. Some who use network or non-networkpharmacies, particularly Standard/Extra users or non-active duty Prime enrollees, might switch to MTFpharmacies or the TMOP if encouraged. Changes inpolicy or procedure that shorten waits at MTF phar-macies might encourage more beneficiaries to fillprescriptions there. More beneficiaries might use themail-order option if they are better informed on howto use it and, by using it, gain favorable experience.

Notes1 Centers for Medicare and Medicaid Services, National

Health Expenditures Tables http://www.cms.gov/statistics/nhe/2 Kaiser Family Foundation and Health Research and

Educational Trust. Employer Health Benefits, 2003 AnnualSurvey. 2003. Menlo Park, CA and Chicago, IL.

3 Stergachis A., Maine L.L., Brown L. The 2001National Pharmacy Consumer Survey. J Am Pharm Assoc.2002 Jul-Aug; 42(4):568-76.

4 “New TRICARE Mail-Order Pharmacy to OpenMarch 1, 2003”, http://www.defenselink.mil/news/Dec2002/n12132002_200212134.html

0

20

40

60

80%

Perc

ent

71

7874

79

3126

61

55

NA

53

NA NA

MTF Retail network

Non-network TMOP

Rating pharmacy Usually or always waiting Getting written and 8 or above 30 minutes or more oral instruction

Figure 3: Pharmacy ratings

Problems with mail-order pharmacy

Service

Convenience

15 25 35 45 55%

24

28

40

Percent

Figure 4: Reasons for using network pharmacies instead of TMOP

32

Issue Brief: Reservists and TRICARE

Since September 11, 2001, over 300,000 NationalGuard and Reserve personnel (“reservists”) have

been called to active duty, and the reserve forces areexpected to see heavy duty over the foreseeable future.In this context, compensation programs for reservists,including health benefits, have come under increasedscrutiny and Congress recently passed legislation toexpand reservists’ coverage.1 The Health Care Surveyof DoD Beneficiaries (HCSDB) for October, 2003included supplementary questions to learn more aboutreservists’ experiences with TRICARE.

Under the new laws, reservists placed on activeduty orders for 31 days or more are automaticallyenrolled in TRICARE Prime, and their family mem-bers also become eligible for TRICARE.2 Reservistsand their families face several complicated choices, asthey compare TRICARE benefits with their civilianoptions. First, coverage options available to reservists’families differ depending on their circumstances.Families who live near military treatment facilities(MTFs) are eligible for TRICARE Prime, as well asTRICARE Standard/Extra. Families who live morethan 50 miles from MTFs are eligible for TRICAREPrime Remote for Active Duty Family Members, withfree access to civilian network and TRICARE certi-fied providers. In addition, families of reservistsmobilized for Operations Noble Eagle, EnduringFreedom, and Iraqi Freedom can participate in theTRICARE Reserve Family Demonstration Project,which offers TRICARE Standard/Extra benefitswithout deductibles or other barriers to civilian careaccess. The change in benefits is intended to make iteasier for families to maintain their existing relation-ships with physicians.

As well, the generosity of health insurance benefitsoffered by employers to reservists and family membersmay vary. Under the Uniformed Services Employment

and Reemployment Rights Act (USERRA) of 1994,employers must allow reservist employees to keepinsurance for up to 18 months after call-up, butemployers may charge up to 102% of the full premi-um, including the employee share, employer share,and a 2% administrative fee.3 Many employers, how-ever, continue or even increase their contributions totheir employees’ premiums following mobilization.4

Transition to TRICARE

As shown in Table 1, according to the HCSDB, 85 percent of reservists and 86 percent of their familymembers had health insurance coverage prior tomobilization, higher than reported levels for thegeneral population (83 percent).5,6 Of reservist familymembers with employer-based coverage, 56 percentmaintained that coverage following mobilization, with33 percent using only civilian coverage and 23 percentusing a mix of TRICARE and civilian coverage.7

Forty-five percent of reservists and 34 percent of theirfamily members state that their employers continue tocover all or part of their insurance premiums.

Reservist families are far more likely to live inremote areas (areas more than 50 miles from anMTF) than are other active duty families. Seventypercent of reservists live more than 50 miles from anMTF, compared with only 5 percent of other activeduty families.8 As a result, reservist family membersare much less likely to use MTFs than are otheractive duty family members. As shown in Figure 1,

Table 1: Sources of coverageCivilian Kept

coverage civilian Usebefore mobilization coverage civilian only

Reservists 85% 44% NA

Reservist family 86% 56% 33%


33


only 18 percent of reservist family members get mostof their care from MTFs compared to 68 percent ofother active duty family members. To reservist fami-lies, maintaining a relationship with the civiliandoctors they enjoyed before mobilization is often keyto a successful transition.

Access to physiciansTRICARE coverage offers reservist family membersaccess to any civilian provider, with reduceddeductibles and coinsurance. However, in some areas,TRICARE’s reimbursement rates and additionaladministrative requirements may discourage physi-cians from participating and may result in accessproblems. Some beneficiaries may find that the needto get referrals from a PCM under TRICARE Primemakes access to specialists more difficult. Figure 2shows that, while mobilization has improved access topersonal doctors and specialists for some reservistfamily members, a greater number report worsenedaccess. Sixteen percent of TRICARE users amongreservist family members report that it has becomemore difficult to see the personal doctor they want tosee, compared to 9 percent who say it is easier.Nineteen percent report that it is now more difficult

to see a desired specialist, compared to 12 percentwho say it is easier.

Getting Information

Because of the complex choices they face, access tohealth benefits information is crucial to reservists andtheir families.9 As shown in Table 2, reservists andtheir family members are much more likely than otheractive duty members to have looked for information inTRICARE’s written materials (36 percent comparedwith 24 percent), to have called on the TRICAREcustomer service line (46 percent compared with 33 percent), or to have experiences with TRICAREpaperwork (40 percent compared with 26 percent). As shown, about half of all who have these experi-ences, both reservists and other active duty, encounterproblems. As a result, simply because their needs forassistance and information are greater, a reservist orreservist family member is much more likely overall toreport problems getting information or problemsdealing with their paperwork. In response to theseproblems and to the recent changes in reservist bene-fits, TRICARE has added information for reservists tothe TRICARE web site, and has begun implementingvarious communications programs aimed at educating

Perc

ent

Reservist family members Other active duty family members

0

20

40

60

80

100%

68

27

18

72

MTF CTF

Figure 1: Usual source of health care

Perc

ent

Finding a personal doctor Finding a specialist since mobilization since mobilization

0

5

10

15

20

25

30%

12

19

9

16

Gotten easier Gotten harder

Figure 2: Access to physicians for reservist family membersin TRICARE

34


reservists and their family members about their healthcare benefits.10

Notes1 Many of the provisions are set to expire on December

31, 2004. (FY 2004 Defense Authorization Act (Public Law108-136, 11/24/03)).

2 FY 2004 Defense Authorization Act3 Reservists performing military service for 30 days or

fewer can maintain coverage at the same cost as beforetheir short service.

4 The federal government, for example, waives theemployee share of the premium for up to 18 months whenreservist federal employees are called up.

5 Fronstin, P. “Sources of Health Insurance andCharacteristics of the Uninsured : Analysis of the March2003 Current Population Survey” (EBRI Issue Brief #264).Washington, DC: Employee Benefit Research Institute,December 2003.

6 The 2004 NDAA allows reservists without access toemployer-based coverage to purchase TRICARE coverageat subsidized rates, and may well increase coverage forreservists even higher.

7 In an earlier survey, it was found that 72 percent ofreservists maintained commercial coverage during mobiliza-tion. (Most Reservists Have Civilian Coverage but MoreAssistance is Needed When TRICARE Is Used. (GAO-02-829). Washington, DC: General Accounting Office,September 2002.)

8 DOD Needs More Data to Address Financial andHealth Care Issues Affecting Reservists. (GAO-03-1004).Washington, DC: General Accounting Office, September2003.

9 In the past, roughly 40 percent of the problemsreservists have reported involve understanding TRICARE’sbenefits and obtaining assistance when problems arise.(GAO-03-1004).

10 GAO-03-1004.

Table 2: Experience and problems with TRICARE:reservists/non-reservists

With info Within written customer Withmaterials service paperwork

Has experience 36%/24% 46%/33% 40%/26%

Of those with experience, has had problems 55%/54% 49%/49% 45%/52%

Of all respondents,has had problems 20%/13% 22%/16% 18%/14%

PR INCETON OFF I C E

PO Box 2393Princeton, NJ 08543-2393

(609) 799-3535Fax: (609) 799-0005

WASH INGTON OFF I C E

600 Maryland Avenue, S.W., Suite 550Washington, DC 20024-2512

(202) 484-9220Fax: (202) 863-1763

CAMBR IDGE OFF I C E

955 Massachusetts Avenue, Suite 801Cambridge, MA 02139

(617) 491-7900Fax (617) 491-8044

Mathematica strives to improve publicwell-being by bringing the highest

standards of quality, objectivity, and excellenceto bear on the provision of informationcollection and analysis to our clients.

Visit our website atwww.mathematica-mpr.com

PROJECT REPORT HCSDB Annual Report 2003: Results from …Fabrice Smieliauskas 600 Maryland Avenue,...

Documents

Transcript of PROJECT REPORT HCSDB Annual Report 2003: Results from …Fabrice Smieliauskas 600 Maryland Avenue,...