oversight

Defense Health Care: Oversight of the TRICARE Civilian Provider Network Should Be Improved

Published by the Government Accountability Office on 2003-07-31.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

             United States General Accounting Office

GAO          Report to Congressional Committees




July 2003
             DEFENSE HEALTH
             CARE
             Oversight of the
             TRICARE Civilian
             Provider Network
             Should Be Improved




GAO-03-928
                                                July 2003


                                                DEFENSE HEALTH CARE

                                                Oversight of the TRICARE Civilian
Highlights of GAO-03-928, a report to           Provider Network Should Be Improved
congressional committees




Testifying before Congress in 2002,             For the 8.7 million TRICARE beneficiaries, DOD relies on the civilian
military beneficiary groups                     provider network to supplement health care delivered by its military
described problems accessing care               treatment facilities. To ensure the adequacy of the civilian provider
from TRICARE’s civilian medical                 network, DOD has standards for the number and mix of providers, both
providers. Providers also testified             primary care and specialists, necessary to satisfy TRICARE Prime
on their dissatisfaction with the
TRICARE program, specifying low
                                                beneficiaries’ needs. In addition, DOD has standards for appointment wait,
reimbursement rates and                         office wait, and travel times to ensure that TRICARE Prime beneficiaries
administrative burdens.                         have timely access to care. DOD has delegated oversight of the civilian
                                                provider network to the local level through regional TRICARE lead agents.
The Bob Stump National Defense
Authorization Act of 2003 required              DOD’s ability to effectively oversee the TRICARE civilian provider network
GAO to review the oversight of the              is hindered in several ways. First, the measurement used to determine if
TRICARE network of civilian                     there is a sufficient number and mix of providers in a geographic area does
providers. Specifically, GAO                    not always account for the total number of beneficiaries who may seek care
describes how the Department of                 or the availability of providers. This may result in an underestimation of the
Defense (DOD) oversees the                      number of providers needed in an area. Second, incomplete contractor
adequacy of the civilian provider
network, evaluates DOD’s
                                                reporting on access to care makes it difficult for DOD to assess compliance
oversight of the civilian provider              with these standards. Finally, DOD does not systematically collect and
network, and describes the factors              analyze beneficiary complaints, which might assist in identifying
that have been reported to                      inadequacies in the civilian provider network. However, DOD has tools,
contribute to network inadequacy.               such as surveys of network providers and automated reporting systems
                                                which, while not designed specifically for monitoring the civilian provider
GAO analyzed TRICARE Prime—                     network, could, if modified, improve DOD’s ability to oversee the network.
the managed care component of
TRICARE. To describe and                        DOD and its contractors have reported that a lack of providers in certain
evaluate DOD’s oversight, GAO                   geographic locations, low reimbursement rates, and administrative
reviewed and analyzed information               requirements contribute to potential civilian provider network inadequacy.
from reports on network adequacy
and interviewed DOD and
                                                DOD and contractors have reported long-standing provider shortages in
contractor officials in 5 of 11                 some geographic areas. In areas where DOD determines that access to care
TRICARE regions.                                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
GAO recommends that DOD                         success in recruiting additional providers by using this authority.
improve its oversight of the civilian           Additionally, civilian providers have expressed concerns that TRICARE’s
provider network by ensuring
                                                reimbursement rates are generally too low and administrative requirements
sufficient information is reported
and by exploring options for                    too cumbersome. However, while reimbursement rates and administrative
evaluating beneficiary complaints               requirements may have created provider dissatisfaction, it is not clear how
and improving provider survey                   much this has affected civilian provider network adequacy except in limited
data. DOD concurred with the                    geographic locations, because the information contractors provide to DOD is
recommendations.                                not sufficient to measure network adequacy.
www.gao.gov/cgi-bin/getrpt?GAO-03-928.

To view the full product, including the scope
and methodology, click on the link above.
For more information, contact Marjorie Kanof
at (202) 512-7101.
Contents


Letter                                                                                    1
               Results in Brief                                                           3
               Background                                                                 4
               DOD Has Standards for Network Adequacy and Requires
                 Contractors’ Compliance                                                  8
               DOD’s Oversight of the Civilian Provider Network Has
                 Weaknesses, But Additional Tools May Help                              10
               DOD and Contractors Report Three Factors That May Contribute
                 to Civilian Provider Network Inadequacy                                14
               New Contracts May Address Some Network Concerns, But May
                 Create Others                                                          17
               Conclusions                                                              18
               Recommendations for Executive Action                                     19
               Agency Comments and Our Evaluation                                       19

Appendix I     Scope and Methodology                                                    21



Appendix II    Comparison of Current and Future TRICARE
               Regions                                                                  23



Appendix III   Comments from the Department of Defense                                  25



Appendix IV    GAO Contacts and Staff Acknowledgments                                   29
               GAO Contacts                                                             29
               Acknowledgments                                                          29


Figures
               Figure 1: Areas of the United States with a TRICARE Network of
                        Civilian Providers                                               7
               Figure 2: Current TRICARE Regions                                        23
               Figure 3: Future TRICARE Regions After TNEX Implementation               24




               Page i                          GAO-03-928 TRICARE Civilian Provider Network
Abbreviations

ATC               Access To Care Project
DOD               Department of Defense
EWRAS             Enterprise Wide Referral and Authorization System
HCSDB             Health Care Survey of DOD Beneficiaries
JCAHO             Joint Commission on Accreditation of Healthcare
                  Organizations
MOAA              Military Officers Association of America
MTF               military treatment facility
NCQA              National Committee for Quality Assurance
PCM               primary care manager
TMA               TRICARE Management Activity




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Page ii                                 GAO-03-928 TRICARE Civilian Provider Network
United States General Accounting Office
Washington, DC 20548




                                   July 31, 2003

                                   The Honorable John Warner
                                   Chairman
                                   The Honorable Carl Levin
                                   Ranking Minority Member
                                   Committee on Armed Services
                                   United States Senate

                                   The Honorable Duncan L. Hunter
                                   Chairman
                                   The Honorable Ike Skelton
                                   Ranking Minority Member
                                   Committee on Armed Services
                                   House of Representatives

                                   The primary mission of TRICARE, the Department of Defense’s (DOD)
                                   health care system, is to provide care for eligible active duty personnel,
                                   retirees, and dependents. These beneficiaries, currently numbering more
                                   than 8.7 million, can receive their care through military hospitals and
                                   clinics called military treatment facilities (MTFs) or through TRICARE’s
                                   civilian provider network. The civilian provider network is developed by
                                   managed care support contractors and is designed to complement the
                                   availability of care offered by MTFs.1

                                   DOD faces new challenges in ensuring that the TRICARE civilian provider
                                   network can provide adequate access to care that complements the
                                   capabilities of MTFs. In 2003, DOD intends to award new contracts for the
                                   delivery of care in the civilian provider network because the current
                                   contracts will expire. As a result, the providers who choose to participate
                                   in the network may change, while those who remain will operate under
                                   new policies and procedures. During this transition, DOD is still
                                   responsible for ensuring that the civilian provider network provides
                                   adequate access to care, even if beneficiaries must change providers.



                                   1
                                    MTFs supply most of the health care services TRICARE beneficiaries receive. The military
                                   health system was funded at about $26.4 billion for fiscal year 2003. Approximately 20
                                   percent of this amount, $5.2 billion, was budgeted for the TRICARE civilian provider
                                   network.



                                   Page 1                                  GAO-03-928 TRICARE Civilian Provider Network
TRICARE also faces beneficiary and provider dissatisfaction with the
existing civilian provider network. During April 2002 testimony before the
Subcommittee on Personnel of the House Armed Services Committee,
beneficiary groups described problems with access to care from
TRICARE’s civilian providers. Also, providers testified about their
dissatisfaction with the TRICARE program, specifying low reimbursement
rates and administrative burdens.

In response to these concerns, the Bob Stump National Defense
Authorization Act of 2003 required that we review DOD’s oversight of the
adequacy of the TRICARE civilian provider network.2 As agreed with the
committees of jurisdiction we focused on DOD’s oversight and did not
assess the adequacy of the network. Also, we analyzed TRICARE Prime,
the managed care component of the TRICARE health delivery system.
Specifically, we agreed to (1) describe how DOD oversees the adequacy of
the civilian provider network, (2) evaluate DOD’s oversight of the
adequacy of the civilian provider network, (3) describe the factors that
have been reported to contribute to network inadequacy, and (4) describe
how the new contracts might affect network adequacy. We testified before
the Subcommittee on Total Force of the House Committee on Armed
Services on March 27, 2003, about our findings at that time.3

To describe and evaluate DOD’s oversight of the TRICARE civilian
provider network, we reviewed and analyzed information from five
network adequacy reports submitted between June and October of 2002.
We reviewed at least one report from each of the contractors who develop
and maintain the network of providers to augment the care provided by
MTFs. We also interviewed DOD regional officials, known as lead agents,
and MTF officials from 5 of 11 TRICARE regions. In addition, we
interviewed officials from each of the four contractors. As part of our
assessment of DOD’s oversight, we reviewed surveys of beneficiaries and
providers, as well as DOD data collection initiatives that could be used by
DOD to oversee its civilian provider network. We did not validate the data
in the surveys or collection initiatives. We also interviewed officials at
TRICARE Management Activity (TMA) in Falls Church, Va., the office with
responsibility for ensuring that DOD health policy is implemented, and



2
Pub. L. No. 107-314, § 712, 116 Stat. 2458, 2588 (2002). See also, H.R. Rep. No. 107-436.
3
 U.S. General Accounting Office, Defense Health Care: Oversight of the Adequacy of
TRICARE’s Civilian Provider Network Has Weaknesses, GAO-03-592T (Washington, D.C.:
Mar. 27, 2003).



Page 2                                    GAO-03-928 TRICARE Civilian Provider Network
                   officials at TMA-West, the office that carries out contracting functions,
                   including monitoring the civilian contracts and writing the requests for
                   proposals for the future contracts. To describe factors that may contribute
                   to network inadequacy, we interviewed DOD, contractor, and professional
                   health association officials. In addition, we met with groups representing
                   TRICARE beneficiaries to discuss their concerns. Finally, we reviewed
                   DOD’s request for proposals for the new health care contracts and
                   interviewed DOD and contractor officials to determine how the new
                   contracts might affect network adequacy. Appendix I contains more
                   details about our scope and methodology. We conducted our work from
                   June 2002 through July 2003 in accordance with generally accepted
                   government auditing standards.


                   To oversee the adequacy of the civilian provider network, DOD has
Results in Brief   standards that are designed to ensure that the network has a sufficient
                   number and mix of providers, both primary care and specialists, to satisfy
                   TRICARE Prime beneficiaries’ needs. In addition, DOD has standards for
                   appointment wait, office wait, and travel times that are designed to ensure
                   that TRICARE Prime beneficiaries have adequate access to care. DOD has
                   delegated oversight of the civilian provider network to lead agents, who
                   are responsible for ensuring that these standards have been met.

                   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 of providers for the beneficiaries
                   in an area does not always account for the actual number of beneficiaries
                   who may seek care or the availability of providers. In some cases, 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 TRICARE civilian provider
                   network. However, DOD has surveys of TRICARE beneficiaries and
                   network providers and automated reporting systems on appointments and
                   referrals that, while not designed specifically for monitoring the civilian
                   provider network, could provide information and potentially improve
                   DOD’s ability to oversee the civilian provider network.

                   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. DOD and contractors have reported long-standing provider


                   Page 3                            GAO-03-928 TRICARE Civilian Provider Network
                 shortages in some geographic areas because providers in certain areas
                 may refuse to join any network. 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 this authority to increase
                 reimbursement rates in Alaska and Idaho in an attempt to remedy such
                 provider shortages. DOD told us that the contractors have achieved some
                 success in recruiting additional providers by using this authority.
                 Additionally, civilian providers have expressed concerns about TRICARE’s
                 reimbursement rates being too low and administrative requirements being
                 too cumbersome. However, while reimbursement rates and administrative
                 requirements may have created dissatisfaction among providers, it is not
                 clear that these factors have resulted in insufficient numbers of providers
                 in the civilian network because the information contractors provide to
                 DOD is not sufficient to measure network adequacy.

                 The new contracts, which DOD expects to award during the summer of
                 2003, may result in improved civilian provider network participation by
                 addressing some network providers’ concerns about administrative
                 requirements. For example, the new contracts may simplify requirements
                 for provider credentialing and referrals, two administrative procedures
                 providers have complained about. However, according to contractors, the
                 new contracts may also create requirements that could discourage
                 provider participation, such as the new requirement that all network
                 claims submitted by civilian providers be filed electronically. Currently,
                 only about 25 percent of such claims are submitted electronically.

                 We are recommending that the Secretary of Defense direct the Assistant
                 Secretary of Defense for Health Affairs to improve DOD’s oversight of the
                 civilian provider network by ensuring sufficient information is reported to
                 assess network adequacy and by exploring options for evaluating
                 beneficiary complaints and improving provider survey data. In
                 commenting on a draft of this report, DOD concurred with the report’s
                 recommendations.


                 TRICARE has three options for its eligible beneficiaries:
Background
             •   TRICARE Prime, a program in which beneficiaries enroll and receive care
                 in a managed network similar to a health maintenance organization;
             •   TRICARE Extra, a program in which beneficiaries receive care from a
                 network of preferred providers; and
             •   TRICARE Standard, a fee-for-service program that requires no network
                 use.



                 Page 4                            GAO-03-928 TRICARE Civilian Provider Network
The programs vary according to the amount beneficiaries must contribute
toward the cost of their care and according to the choices beneficiaries
have in selecting providers. In TRICARE Prime,4 the program in which
active duty personnel generally must participate, the beneficiaries must
select a primary care manager (PCM)5 who either provides care or
authorizes referrals to specialists. Most beneficiaries who enroll in
TRICARE Prime select their PCMs from MTFs, while other enrollees select
their PCMs from the civilian provider network. Regardless of their
status—military or civilian—PCMs may refer Prime beneficiaries to
providers in either MTFs or TRICARE’s civilian provider network.6

Both TRICARE Extra and TRICARE Standard require copayments, but
beneficiaries do not enroll with or have their care managed by PCMs.
Beneficiaries choosing TRICARE Extra use the same civilian provider
network available to those in TRICARE Prime, and beneficiaries choosing
TRICARE Standard are not required to use providers in any network.
TRICARE Extra and Standard beneficiaries may receive care at an MTF
when space is available.

The Office of the Assistant Secretary of Defense for Health Affairs (Health
Affairs) establishes TRICARE policy and has overall responsibility for the
program. TMA, under Health Affairs, is responsible for awarding and
monitoring the TRICARE contracts. DOD has delegated oversight of the
civilian provider network to regional TRICARE lead agents. The lead agent
for each region coordinates the services provided by MTFs and civilian
network providers. The lead agents respond to direction from Health
Affairs, but report directly to their respective Surgeons General. In
overseeing the network, lead agents have staff assigned to MTFs to
provide the local interaction with contractor representatives and respond
to beneficiary complaints as needed and report back to the lead agent.



4
 Out of more than 8.7 million eligible beneficiaries, nearly half are enrolled in TRICARE
Prime.
5
 A primary care manager is a provider or team of providers at an MTF or a provider in the
civilian network to whom a beneficiary is assigned for primary care services when he or
she enrolls in TRICARE Prime. Enrolled beneficiaries agree to initially seek all
nonemergency, nonmental health care services from these providers.
6
 DOD’s policy is to optimize the use of the MTF. Accordingly, when a referral for specialty
care is made by a civilian PCM, the MTF retains the “right of first refusal” to accommodate
the beneficiary within the MTF or refer the beneficiary to the civilian provider network for
the needed medical care.




Page 5                                    GAO-03-928 TRICARE Civilian Provider Network
Currently, DOD employs four civilian health care companies or
contractors that are responsible for developing and maintaining the
civilian provider network that complements the care delivered by MTFs.
The contractors recruit civilian providers into a network of PCMs and
specialists who provide care to beneficiaries enrolled in TRICARE Prime.
Contractors are required to establish and maintain the network of civilian
providers in the following locations: all catchment areas,7 base
realignment and closure sites,8 other contract-specified areas, and
noncatchment areas where a contractor deems it cost effective. These
locations are called prime service areas. In the remaining areas, a network
is not required. (See fig. 1.)




7
 Catchment areas are geographic areas determined by the Assistant Secretary of Defense
for Health Affairs that are defined by five-digit zip codes, usually within an approximate 40-
mile radius of MTFs with inpatient care.
8
 Base realignment and closure sites are military installations that have been closed or
realigned as the result of decisions made by the Commissions on Base Realignment and
Closure.




Page 6                                    GAO-03-928 TRICARE Civilian Provider Network
Figure 1: Areas of the United States with a TRICARE Network of Civilian Providers




Source: DOD.

                                         Note: Shaded areas represent zip codes in which there was a TRICARE network of civilian providers
                                         as of May 2003.




                                         Page 7                                      GAO-03-928 TRICARE Civilian Provider Network
                        This network of civilian providers also serves as the network of preferred
                        providers for beneficiaries who use TRICARE Extra. In 2002, contractors
                        reported that the civilian provider network included about 37,000 PCMs
                        and 134,000 specialists.

                        The contractors are also responsible for ensuring adequate access to
                        health care, referring and authorizing beneficiaries for health care,
                        educating providers and beneficiaries about TRICARE benefits, ensuring
                        that providers are credentialed, and processing claims. In their network
                        agreements with civilian providers, contractors establish reimbursement
                        rates and certain requirements for submitting claims. Reimbursement
                        rates cannot be greater than Medicare rates unless DOD authorizes a
                        higher rate.

                        DOD’s four contractors manage the delivery of care to beneficiaries in 11
                        TRICARE regions. DOD is currently analyzing proposals to award new
                        civilian health care contracts, and when they are awarded in 2003, DOD
                        will reorganize the 11 regions into 3—North, South, and West—with a
                        single contract for each region. Contractors will be responsible for
                        developing a new civilian provider network that will become operational
                        in April 2004. Under these new contracts DOD will continue to emphasize
                        maximizing the role of MTFs in providing care. See appendix II for maps
                        depicting the current and future regions.


                        DOD has standards intended to ensure that its civilian provider network
DOD Has Standards       enhances and supports the capabilities of the MTFs in providing care to
for Network             millions of TRICARE Prime beneficiaries. DOD requires that contractors
                        have a sufficient number and mix of providers, both primary care and
Adequacy and            specialists, to satisfy the needs of beneficiaries enrolled in the Prime
Requires Contractors’   option. Specifically, it is the responsibility of the contractors to ensure that
                        each prime service area in the network has at least one full-time equivalent
Compliance              PCM for every 2,000 TRICARE Prime enrollees and one full-time
                        equivalent provider (both PCMs and specialists) for every 1,200 TRICARE
                        Prime enrollees.9




                        9
                         In addition, all four contractors generally follow the Graduate Medical Education National
                        Advisory Committee recommendation for determining the specialty mix requirements for
                        their network.




                        Page 8                                   GAO-03-928 TRICARE Civilian Provider Network
    In addition, DOD has access-to-care standards that are designed to ensure
    that Prime beneficiaries receive timely care from providers.10 Under these
    standards

•   appointment wait times shall not exceed 24 hours for urgent care, 1 week
    for routine care, or 4 weeks for well-patient and specialty care;
•   office wait times shall not exceed 30 minutes for nonemergency care; and
•   travel times shall not exceed 30 minutes for routine care and 1 hour for
    specialty care.11

    Lead agents are responsible for ensuring that the civilian provider network
    meets these standards so that all TRICARE Prime beneficiaries in their
    region have adequate access to health care. To do so, lead agents told us
    they use network adequacy reports that contractors provide each quarter
    as the primary tool to oversee the network. According to DOD’s operations
    manual, these reports are to contain information on the status of the
    network, such as the number and type of specialists; data on adherence to
    the access standards; a list of civilian and military primary care managers;
    and the number of their enrollees. The reports may also contain
    information on steps contractors have taken to address any network
    inadequacies.

    However, because the reporting requirements do not specify a standard
    process for collecting information on network adequacy, contractors vary
    in how they obtain this information. For example, lead agents told us that
    one contractor conducts visits of providers’ offices to review appointment
    wait times, while another contractor uses an automated appointment
    tracking system to collect this information.

    Lead agents told us they also rely on beneficiary complaints to oversee the
    adequacy of the civilian provider network. Beneficiaries may complain
    directly to DOD, the contractor, lead agent, or MTF. DOD officials said
    that when they receive a beneficiary complaint, they direct the complaint
    to either the contractor, lead agent, or MTF, depending on the subject of
    the complaint.



    10
     DOD does not specify access standards for eligible beneficiaries who do not enroll in
    TRICARE Prime. However, DOD requires that contractors provide information and/or
    assist all beneficiaries—regardless of which option they choose—in finding a participating
    provider in their area.
    11
     32 C.F.R. § 199.17(p)(5)(i), (ii), (iv) and (v) (2002).




    Page 9                                      GAO-03-928 TRICARE Civilian Provider Network
                        In addition to these tools, lead agents periodically monitor contractor
                        compliance by reviewing performance related to specific contract
                        requirements, including requirements related to network adequacy. Lead
                        agents also told us they periodically schedule reviews of special issues
                        related to network adequacy, such as conducting telephone surveys of
                        providers to determine whether they are accepting TRICARE Prime
                        patients. In addition, lead agents stated they meet regularly with MTF and
                        contractor representatives to discuss network adequacy.

                        If lead agents determine that the network is inadequate, the lead agents or
                        TMA may issue enforcement actions to encourage contractors to address
                        deficiencies in their region. However, lead agents told us that few
                        enforcement actions have been issued. During our review, three
                        enforcement actions related to network adequacy were open for the five
                        regions we visited.12 Lead agents said they prefer to address deficiencies
                        informally rather than take formal actions, particularly in areas where they
                        do not believe the contractor can correct the deficiency because of local
                        market conditions. For example, rather than taking a formal enforcement
                        action, one lead agent worked with the contractor to arrange for a
                        specialist from one area to travel to another area periodically.


                        DOD’s ability to effectively oversee the TRICARE civilian provider
DOD’s Oversight of      network is hindered by (1) flaws in its required provider-to-beneficiary
the Civilian Provider   ratios, (2) incomplete reporting on beneficiaries’ access to providers, and
                        (3) the absence of a systematic assessment of complaints. Although DOD
Network Has             has required the network to meet established ratios of providers to
Weaknesses, But         beneficiaries, the ratios may underestimate the number of providers
                        needed in an area. Similarly, although DOD has certain requirements
Additional Tools May    governing Prime beneficiary access to available providers, the information
Help                    reported to DOD on this access is often incomplete—making it difficult to
                        assess compliance with the requirements. Finally, 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. However, DOD
                        has existing surveys and automated reporting systems that, while not



                        12
                         All three enforcement actions were for lack of available providers in certain geographical
                        areas. For example, there were shortfalls of orthopedic surgeons and neurosurgeons in
                        Spokane, Washington.




                        Page 10                                  GAO-03-928 TRICARE Civilian Provider Network
                            designed specifically for monitoring the civilian provider network, could
                            provide valuable information and potentially improve DOD’s ability to
                            oversee the civilian provider network.


Provider-to-Beneficiary     The provider-to-beneficiary ratios contractors report to DOD for a prime
Ratios May Not Account      service area do not always accurately reflect the potential health care
for Actual Number of        workload for that area or the provider capability to deliver the care. In
                            some cases, the provider-to-beneficiary ratios underestimate the number
Beneficiaries or            of providers, particularly specialists, needed in an area. This
Availability of Providers   underestimation occurs because in calculating the ratios, some
                            contractors do not include the total number of Prime enrollees within the
                            area. Instead, in some areas contractors base their ratio calculations on
                            the total number of beneficiaries enrolled with civilian PCMs and do not
                            count beneficiaries enrolled with PCMs in MTFs. The ratio is most likely to
                            result in an underestimation of the need for providers in areas in which the
                            MTF is a clinic or small hospital with a limited availability of specialists.
                            For example, the Air Force clinic at Grand Forks, N. Dak. has few
                            specialists on staff and must rely on the civilian provider network for a
                            large proportion of specialist care. In fiscal year 2002, 90 percent of its
                            specialist appointments were referred to the network. In contrast, a large
                            MTF, such as Wright Patterson Medical Center in Dayton, Ohio, has many
                            specialist providers on staff and referred only 2 percent of its specialty
                            appointments to the civilian provider network during fiscal year 2002.
                            Incorporating MTF provider capability and the total number of Prime
                            enrollees into the network assessment would give DOD a more complete
                            and accurate assessment of the adequacy of the network for a
                            geographical area.

                            Moreover, in reporting whether the network meets the established ratios,
                            contractors do not make the same assumptions about the level of
                            participation on the part of civilian network providers. Contractors
                            generally assume that between 10 to 20 percent of their providers’
                            practices are dedicated to TRICARE Prime beneficiaries. Therefore, if a
                            contractor assumes 20 percent of all providers’ practices are dedicated to
                            TRICARE Prime rather than 10 percent, the contractor will need half as
                            many providers in the network in order to meet the prescribed ratio
                            standard. These assumptions may or may not be accurate, and the
                            assumptions have a significant effect on the number of providers required
                            in the network.




                            Page 11                           GAO-03-928 TRICARE Civilian Provider Network
Information Reported on   In the network adequacy reports we reviewed, the contractors did not
Access Standards Was      always report all the information required by DOD to assess compliance
Incomplete                with the access standards. 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. Some contractors reported
                          more information than others, but none reported all the required access
                          information. Contractors said they had difficulties in capturing and
                          reporting information to demonstrate compliance with the access
                          standards. They stated that 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.


Beneficiary Complaints    Most of the DOD lead agents we interviewed told us that because
Are Not Systematically    information on access standards is not fully reported, they monitor
Collected and Evaluated   compliance with the access standards by reviewing beneficiary
                          complaints. Lead agents and contractors said such complaints may include
                          a beneficiary’s inability to get an appointment, having to drive long
                          distances for care, or a provider not accepting new TRICARE Prime
                          patients. Because beneficiary complaints are received through numerous
                          venues, often handled informally on a case-by-case basis, and not centrally
                          evaluated, it is difficult for DOD to assess the extent of any systemic
                          access problems. Separately, TMA has a database of complaints that
                          includes some complaints about access to care. TMA has received these
                          complaints either directly, through DOD’s beneficiary survey, or from
                          letters sent by beneficiaries to their congressional representatives.
                          However, the usefulness of the database is limited because it does not
                          capture complaints sent to MTFs, lead agents, or contractors.

                          While contractor and lead agent officials told us they have received few
                          complaints about network access problems, this small number of
                          complaints could indicate either an overall satisfaction with care or a
                          general lack of knowledge about how or to whom to complain.
                          Additionally, a small number of complaints, particularly when spread
                          among many sources, limits DOD’s ability to identify any specific trends of
                          systemic problems related to network adequacy within TRICARE.

                          The next generation of contracts, called TNEX, may result in a more
                          structured approach to collecting complaint information when
                          implemented in 2004. Under TNEX, the civilian provider network must be
                          accredited in each region by a nationally recognized accrediting


                          Page 12                           GAO-03-928 TRICARE Civilian Provider Network
                    organization, such as the National Committee for Quality Assurance
                    (NCQA) or the Joint Commission on Accreditation of Healthcare
                    Organizations (JCAHO). These organizations typically require procedures
                    for addressing beneficiary complaints. For example, NCQA guidance
                    requires procedures for registering, responding to, and investigating
                    complaints. It also requires documentation of actions taken to address
                    complaints. JCAHO guidance has similar requirements. Such procedures
                    could provide DOD with a basic structure that in turn could lead to a more
                    systematic means of collecting and evaluating complaint data at the prime
                    service area and regional levels.


Potential Network   DOD has some tools that, while not designed specifically for monitoring
Oversight Tools     the civilian provider network, could be useful for oversight. For example,
                    the Health Care Survey of DOD Beneficiaries (HCSDB) could be used as a
                    source of information for overseeing civilian provider network adequacy
                    at the national level.13 This quarterly survey contains specific questions on
                    all beneficiaries’ experiences related to access to care.14 For example, our
                    analysis of the 2000 HCSDB data for all Prime beneficiaries receiving care
                    from civilian providers indicates that over one-third of these beneficiaries
                    waited more than DOD’s standard of 1 day for access to a provider for an
                    illness or an injury. However, the survey’s sample design does not
                    generally allow for assessing the adequacy of the civilian provider network
                    in most prime service areas and the survey’s response rate of 35 percent
                    further limits its usefulness.15

                    In addition to DOD’s beneficiary survey, contractors conduct surveys of
                    providers that could assist in DOD’s oversight of the civilian provider
                    network. These surveys are intended to assess providers’ satisfaction with
                    contractors’ performance and other TRICARE requirements. However,


                    13
                     This survey was required by the National Defense Authorization Act for Fiscal Year 1993,
                    Pub. L. No. 102-484, § 724, 106 Stat. 2315, 2440 (1992).
                    14
                     These questions ask how many days a beneficiary had to wait to see a provider for regular
                    or routine care and how long they had to wait to receive treatment for an injury or illness,
                    among other things. Also, DOD recently added questions to the survey specifically aimed at
                    beneficiaries receiving care from civilian providers. These questions ask how difficult it
                    was to obtain care and locate a doctor, and whether a civilian provider had left the
                    network.
                    15
                     Even though DOD samples 180,000 beneficiaries annually, the 35 percent response rate
                    reduces the sample to about 63,000. As a result the survey estimates may be biased if those
                    who responded to the survey are not representative of the entire surveyed population.




                    Page 13                                  GAO-03-928 TRICARE Civilian Provider Network
                       these surveys have very low response rates, ranging from 4 to 19 percent,
                       and in some cases they reflect unrepresentative samples of providers. For
                       example, one contractor surveyed only those providers who participated
                       in a contractor-sponsored seminar. Also, we found considerable variation
                       among the survey instruments, with some assessing provider satisfaction
                       more thoroughly than others. Despite these weaknesses, if improved, the
                       surveys could reveal concerns providers may have about participating in
                       the TRICARE network. This in turn could help DOD address these
                       concerns and mitigate problems that might affect the adequacy of the
                       network.

                       In addition to these existing surveys, DOD is piloting two initiatives for
                       collecting information on meeting access standards that could help in the
                       oversight of network adequacy. The first, the Enterprise Wide Referral and
                       Authorization System (EWRAS), which is currently being tested in the
                       Washington D.C. area, captures information on specialty care
                       appointments in MTFs and information on some specialty care
                       appointments in the civilian provider network. DOD officials said they
                       expect EWRAS to be fully implemented in Spring 2004. The second
                       initiative, the Access to Care (ATC) Project, gathers information on
                       appointments and specialty referrals at or originating from MTFs.
                       Specifically, it captures data on whether beneficiaries had a referral,
                       declined an appointment that was available, cancelled an appointment, or
                       left without being seen. It also records the average number of days
                       between when the appointment was made and when the beneficiary was
                       seen, as well as clinic cancellations and future appointments. This
                       information can help indicate the extent to which MTFs are meeting the
                       appointment wait-time access standards. Although the ATC Project is
                       currently being piloted at four MTFs, a similar system, if modified to
                       accommodate the requirements of the contractors for the civilian provider
                       network, could provide valuable information on appointment wait time
                       standards—information that is necessary for overseeing the adequacy of
                       the network.


                       DOD and its contractors have reported three factors that may contribute
DOD and Contractors    to potential civilian provider network inadequacy: lack of providers in
Report Three Factors   certain geographic locations, low reimbursement rates, and administrative
                       requirements. First, DOD and contractors have reported regional
That May Contribute    shortages for certain types of specialists in rural areas. For example, they
to Civilian Provider   reported shortages for endocrinologists in the Upper Peninsula of
                       Michigan, dermatologists in New Mexico, and neurologists and allergists in
Network Inadequacy     Mountain Home, Idaho. Additionally, in these instances, TRICARE officials


                       Page 14                           GAO-03-928 TRICARE Civilian Provider Network
and contractors have reported difficulties in recruiting providers into the
TRICARE Prime network because in some areas providers, notably
specialists, will not join managed care programs. For example, contractor
network data indicate that there have been long-standing specialist
shortages in TRICARE in areas such as Alaska or eastern New Mexico,
where the lead agent stated that the providers in those locations have
repeatedly refused to join any managed care network.

There are certain geographic locations in which DOD has confirmed
shortages of providers and has raised TRICARE’s reimbursement rates as
a means of remedying such shortages. Although by statute DOD generally
cannot pay TRICARE network providers more than they would be paid
under the Medicare fee schedule,16 DOD may make payments of up to 115
percent of the Medicare fee to ensure the availability of an adequate
number of qualified healthcare providers.17 In 2000, DOD increased
reimbursement rates in rural Alaska in an attempt to entice more
providers to join the network. Similarly, in 2002, DOD increased
reimbursement rates for the rest of Alaska, and in 2003, DOD increased the
rates for selected specialists in Idaho to address documented network
shortcomings. These three instances are the only times DOD has used its
authority to pay above the Medicare rate in order to address local area
provider shortages,18 and the increases have had mixed success. In 2001,
for instance, we found that the 2000 rate increase in rural Alaska had not
increased provider participation.19 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. According to DOD officials, for example, six neurosurgeons in
Boise, Idaho agreed to join the network, eliminating the neurosurgeon
shortfall in that prime service area. In Alaska, DOD officials reported that


16
 10 U.S.C. § 1079(h)(1) (2000).
17
 10 U.S.C. § 1097b (2000).
18
 DOD officials told us that all requests received by Health Affairs to increase rates have
been approved. Additionally, there are two other instances in which DOD increased its
reimbursement rates above Medicare’s, but these increases did not address local area
shortages. In 1997, DOD increased national reimbursement rates for obstetrical care. In
April 2002, DOD adopted a policy that will authorize a 10 percent bonus payment to
selected TRICARE providers working in medically underserved areas as defined by the
Health Resources and Services Administration, consistent with Medicare payment policy.
DOD plans to implement the bonus payment in July 2003.
19
 U.S. General Accounting Office, Defense Health Care: Across-the-Board Physician Rate
Increase Would Be Costly and Unnecessary, GAO-01-620 (Washington, D.C.: May 24, 2001).




Page 15                                  GAO-03-928 TRICARE Civilian Provider Network
since the reimbursement rate increased, providers for radiology, thoracic
surgery, pediatrics, and other specialties have stated they will participate
in TRICARE.

The general levels of TRICARE’s reimbursement rates are another factor
that DOD and contractor officials told us may contribute to civilian
provider network inadequacy. Specifically, according to contractor
officials, civilian network providers have expressed concerns about the
decline in Medicare fees in 2002 and the potential for further reductions,
which they have said will affect their participation in the network. 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. One contractor identified
low reimbursement rates as the most frequent cause of provider
dissatisfaction. In addition to provider complaints, beneficiary advocacy
groups, such as the Military Officers Association of America (MOAA), have
cited instances of providers refusing care to beneficiaries because of 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. Additionally, there
are indications that reimbursement rates have little influence on providers’
decisions to leave the TRICARE network. Data from one contractor
indicated that out of the 2,156 providers who left the network between
June 2001 and May 2002, 900 providers cited reasons for leaving and only
10 percent of these cited reimbursement rates as a reason for leaving the
network.

Contractors report that providers have also expressed dissatisfaction with
some TRICARE administrative requirements, such as credentialing and
preauthorizations and referrals—but the effect of these requirements on
civilian provider network adequacy is also unclear. For example, many
providers have complained about TRICARE’s credentialing requirements.
In TRICARE, a provider must get recredentialed every 2 years, compared
to every 3 years for the private sector. Providers have said that this places
cumbersome administrative requirements on them.

Another widely reported concern about TRICARE administrative
requirements relates to preauthorization and referral requirements.
Civilian PCM providers are required to get preauthorizations from MTFs
before referring patients for care. While preauthorization is a standard
managed care practice, providers complain that obtaining


Page 16                            GAO-03-928 TRICARE Civilian Provider Network
                    preauthorization adversely affects the quality of care provided to
                    beneficiaries because it takes too much time. In addition, civilian PCMs
                    have expressed concern that they cannot refer beneficiaries to the
                    specialist of their choice because of MTFs’ “right of first refusal” that gives
                    an MTF discretion to care for the beneficiary or refer the care to a civilian
                    provider. Nevertheless, there are not direct data confirming that
                    administrative burdens translate into widespread civilian provider
                    network inadequacies. Further, when reviewing one contractor’s survey of
                    providers who left the network, we found that only 1 percent of providers
                    responding cited administrative burdens as a factor.


                    DOD’s new contracts for providing civilian health care, called TNEX, may
New Contracts May   address some network concerns raised by providers and beneficiaries, but
Address Some        may create other areas of concern. Because the new contracts had not yet
                    been finalized as of June 2003, the specific mechanisms DOD and the
Network Concerns,   contractors will use to ensure network adequacy are not known. Under
But May Create      TNEX, DOD plans to retain the requirement that the civilian provider
                    network complement the clinical services provided by MTFs; the access
Others              standards for appointment and office wait times, as well as travel-time
                    standards; and the periodic reporting on the adequacy of the network.
                    However, the requirement to use provider-to-beneficiary ratios to measure
                    network adequacy will be eliminated, although such ratios may be used
                    during the network accreditation process.

                    Further, TNEX contains a provision intended to encourage contractors to
                    develop an adequate civilian provider network. This provision states that
                    at least 96 percent of contractor referrals shall be to a MTF or network
                    provider with an appointment available within the access standards.
                    Failure to achieve the 96 percent standard will affect contractors
                    financially.

                    TNEX may reduce the administrative burden related to provider
                    credentialing and patient referrals. Currently, civilian network providers
                    must follow TRICARE-specific requirements for credentialing. In contrast,
                    TNEX will allow network providers to be credentialed through a nationally
                    recognized accrediting organization. DOD officials stated this approach is
                    more in line with industry practices. Patient referral procedures will also
                    change under TNEX. Referral requirements will be reduced, but the MTFs
                    will still retain the right of first refusal.

                    On the other hand, TNEX may be creating a new administrative concern
                    for contractors and providers by requiring that all network claims


                    Page 17                            GAO-03-928 TRICARE Civilian Provider Network
              submitted by civilian providers be filed electronically.20 In fiscal year 2002,
              only 25 percent of processed claims were submitted electronically.21
              Contractors stated that such a requirement could discourage providers
              from joining or staying in the network because providers may not be
              willing to modify their systems to submit electronic claims for a small
              volume of TRICARE beneficiaries. DOD states that electronic filing will
              reduce claims-processing costs.


              DOD spends over $5 billion a year for health care delivered by the network
Conclusions   of civilian providers to complement care provided in the MTFs; however,
              DOD has exercised limited oversight of the adequacy of the civilian
              provider network. The information DOD relies on to assess the network
              does not always accurately reflect the actual numbers of beneficiaries or
              availability of providers. Further, the contractors do not report
              comprehensive data on the network’s compliance with DOD’s access
              standards, which are key benchmarks in assessing network adequacy. This
              information will be important as DOD oversees the transition to the new
              health care delivery contracts.

              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.
              Similarly, more thorough reporting on beneficiaries’ access to care within
              the standard time frames and development of a more systematic means of
              collecting and evaluating complaint data would help DOD’s oversight of
              the ability of the civilian provider network to deliver timely care to
              beneficiaries. Further, with improvements in response rates and provider
              representation, the civilian provider satisfaction surveys could also be
              useful in identifying actions DOD and the contractors could take to
              address provider concerns and ensure network stability.




              20
                The Health Insurance Portability and Accountability Act of 1996 included provisions for
              the establishment of standards and requirements for the electronic transmission of health
              information. Pub. L. No. 104-191, § 262, 110 Stat. 1936, 2021. Effective October 16, 2003,
              Medicare claims generally must be submitted electronically.
              21
               This percentage does not include pharmacy claims or claims for care provided to
              Medicare-eligible beneficiaries under TRICARE For Life.




              Page 18                                  GAO-03-928 TRICARE Civilian Provider Network
                         To improve DOD’s oversight of the civilian provider network, we
Recommendations for      recommend that the Secretary of Defense direct the Assistant Secretary of
Executive Action         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
                         sufficient and reliable;
                     •   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.


                         DOD provided written comments on a draft of this report. (See app. III.)
Agency Comments          DOD concurred with the report’s recommendations.
and Our Evaluation
                         In its written comments, DOD stressed that strong oversight of the civilian
                         provider network is necessary and should be continuously monitored for
                         improvements. DOD said that the implementation of TNEX will address
                         many of the points raised in our report. DOD said TNEX will enhance the
                         reporting of information about network adequacy as well as provide
                         powerful financial incentives for contractors to optimize the direct care
                         system, maximize the extent of civilian provider networks, and achieve the
                         highest level of beneficiary satisfaction. However, since the TNEX
                         contracts have not been finalized as of July 2003, it is too early to assess
                         whether the contracts will result in improved oversight.

                         In its written comments DOD also said that the report title might mislead
                         some into concluding that we found the TRICARE network to be
                         inadequate. As we noted in the draft report, we did not assess the
                         adequacy of the civilian provider network but focused our work on DOD’s
                         oversight of the network. We believe the title of the report reflects that
                         focus.

                         DOD also provided technical comments, which we incorporated into the
                         report as appropriate.




                         Page 19                           GAO-03-928 TRICARE Civilian Provider Network
We are sending copies of this report to the Secretary of Defense,
appropriate congressional committees, and other interested parties.
Copies will also be made available to others upon request. In addition, the
report is available at no charge on the GAO Web site at
http://www.gao.gov. If you or your staff have questions about this report,
please contact me at (202) 512-7101. Other contacts and staff
acknowledgments are listed in appendix IV.




Marjorie E. Kanof
Director, Health Care—Clinical
 and Military Health Care Issues




Page 20                            GAO-03-928 TRICARE Civilian Provider Network
             Appendix I: Scope and Methodology
Appendix I: Scope and Methodology


             To describe and evaluate DOD’s oversight of the adequacy of the civilian
             provider network, we reviewed and analyzed the information in the
             quarterly network adequacy reports submitted by each contractor. We
             identified the requirements for the content of these adequacy reports
             based upon the general requirements in the TRICARE Operations Manual
             and the additional requirements in contractors’ Best and Final Offers. We
             reviewed the contents of five of the contractors’ quarterly network
             adequacy reports, submitted between June 2002 and October 2002, and
             compared them to the applicable reporting requirements. Each report was
             evaluated for compliance regarding the provider-to-beneficiary ratios and
             the access-to-care standards.

             Because DOD has delegated the oversight of the network to the regional
             lead agents, we discussed civilian provider network oversight with
             officials in 5 of the 11 TRICARE regions—Northeast, Mid-Atlantic,
             Heartland, Central, and Northwest. To discuss network management, we
             interviewed officials from the four contractors—HealthNet, Humana,
             Sierra, and TriWest—that are responsible for developing and maintaining
             the provider network that augments care provided by DOD’s MTFs.
             Because concerns regarding network adequacy may also be identified at
             the local level, we met with lead agent and contractor officials at MTFs in
             each of the regions we visited. Finally, we interviewed officials at TMA in
             Falls Church, Va., the office that is responsible for ensuring that DOD
             health policy is implemented, and officials at TMA-West in Aurora, Colo.,
             the office that carries out contracting functions, including monitoring the
             civilian contracts and writing the request for proposals for the future
             contracts.

             As part of our assessment of DOD’s oversight, we also reviewed surveys of
             beneficiaries and providers, as well as DOD data collection initiatives as
             potential tools for overseeing DOD’s civilian provider network, but did not
             validate the data in the surveys or collection initiatives. Using annual data
             from the 2000 HCSDB, we analyzed beneficiaries’ responses to access-to-
             care questions for those who were enrolled in Prime and received most of
             their health care in the civilian provider network. We examined the results
             of access-to-care questions based on whether or not these beneficiaries
             were seen within the TRICARE access-to-care standards. Because we
             included only Prime beneficiaries who received care in the civilian
             provider network, our analysis of access to care does not reflect the entire
             survey sample. To examine the provider surveys as potential oversight
             tools, we obtained and reviewed each contractor’s 2001 provider survey
             and assessed the survey’s response rate, sample selection, and the



             Page 21                             GAO-03-928 TRICARE Civilian Provider Network
Appendix I: Scope and Methodology




instrument itself. We also discussed DOD initiatives underway and being
tested with cognizant officials to assess their potential as oversight tools.

To describe factors that may contribute to network inadequacy, we
interviewed and obtained documentation from DOD and contractor
officials regarding current network inadequacies, including their location,
duration, and the type of specialty needed. We also obtained provider
termination reports from three of the four contractors,1 which described
providers’ reasons for leaving the network. To further explore DOD’s
response to civilian provider concerns regarding rates, we interviewed
DOD officials on the use of their authority to raise reimbursement rates.
We also interviewed officials from the American Medical Association, The
Military Coalition, the MOAA, the National Association for Uniformed
Services, and the National Veteran’s Alliance to supplement data on the
possible causes of network inadequacy.

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.

We conducted our work from June 2002 through July 2003 in accordance
with generally accepted government auditing standards.




1
One contractor does not collect data on provider terminations.




Page 22                                 GAO-03-928 TRICARE Civilian Provider Network
                                      Appendix II: Comparison of Current and
Appendix II: Comparison of Current andFuture TRICARE Regions



Future TRICARE Regions

                                      The shaded areas in figure 2 represent the 11 current TRICARE geographic
                                      regions. The shaded areas in figure 3 represent the 3 planned TRICARE
                                      geographic regions under the TNEX contracts expected to be awarded in
                                      2003.

Figure 2: Current TRICARE Regions




  Northwest


                                                                                       Heartland
                                                                                                                     Northeast




Golden
Gate



                                                                                                               Mid-Atlantic


       Southern
       California


                                                                                                   Southeast
                            Central

                                                                                Gulfsouth

                                                           Southwest




   Alaska (Northwest)                             Hawaii Pacific

Source: DOD.




                                      Page 23                                  GAO-03-928 TRICARE Civilian Provider Network
                                      Appendix II: Comparison of Current and
                                      Future TRICARE Regions




Figure 3: Future TRICARE Regions After TNEX Implementation




                                                                                                                      North
    West




                                                                                  South




  Alaska (West)                                                 Hawaii (West)

Source: DOD.




                                      Page 24                                   GAO-03-928 TRICARE Civilian Provider Network
              Appendix III: Comments from the Department
Appendix III: Comments from the
              of Defense



Department of Defense




              Page 25                               GAO-03-928 TRICARE Civilian Provider Network
Appendix III: Comments from the Department
of Defense




Page 26                               GAO-03-928 TRICARE Civilian Provider Network
Appendix III: Comments from the Department
of Defense




Page 27                               GAO-03-928 TRICARE Civilian Provider Network
Appendix III: Comments from the Department
of Defense




Page 28                               GAO-03-928 TRICARE Civilian Provider Network
                  Appendix IV: GAO Contacts and Staff
Appendix IV: GAO Contacts and Staff
                  Acknowledgments



Acknowledgments

                  Kristi Peterson, (202) 512-7951
GAO Contacts      Allan Richardson, (404) 679-1863


                  In addition to those named above, contributors to this report were Louise
Acknowledgments   Duhamel, Marc Feuerberg, Krister Friday, Gay Hee Lee, John Oh, and
                  Marie Stetser.




(290203)
                  Page 29                               GAO-03-928 TRICARE Civilian Provider Network
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