oversight

DOD Health Care: Improvements Needed for Tracking Coordination of Specialty Care Referrals for TRICARE Prime Beneficiaries

Published by the Government Accountability Office on 2019-06-12.

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

             United States Government Accountability Office
             Report to Congressional Committees




             DOD HEALTH CARE
June 2019




             Improvements
             Needed for Tracking
             Coordination of
             Specialty Care
             Referrals for
             TRICARE Prime
             Beneficiaries




GAO-19-488
                                               June 2019

                                               DOD HEALTH CARE
                                               Improvements Needed for Tracking Coordination of
                                               Specialty Care Referrals for TRICARE Prime
Highlights of GAO-19-488, a report to
                                               Beneficiaries
congressional committees




Why GAO Did This Study                         What GAO Found
Specialty care referrals are a key             The Department of Defense’s (DOD) Defense Health Agency (DHA) has limited
component of care coordination for             information about the extent to which the referral management process facilitates
TRICARE Prime beneficiaries. Each              the coordination of primary and specialty care for beneficiaries enrolled in
Prime beneficiary is assigned to a             TRICARE Prime—a managed care option—because information about their
primary care manager either at an MTF          specialty care referrals is not always complete or accurate. The coordination of
or within the civilian provider network.       care for these beneficiaries is important because they may move between
Primary care managers are                      military treatment facilities (MTF) and civilian providers to obtain needed care.
responsible for overseeing all aspects         DHA requires specialty care providers to share documentation about the care
of their patients’ care, which includes
                                               they provided for referring primary care managers to review. This and other
making referrals for specialty care
                                               information is to be documented in the Referral Management Suite (RMS), the
when needed.
                                               information technology system used by MTF officials to track and process
The National Defense Authorization             referrals. However, GAO found that the five MTFs it visited had incomplete and
Act for Fiscal Year 2017 included a            unreliable data in RMS due to lack of training and insufficient staff. For example,
provision for GAO to examine care              GAO found that some MTFs were not tracking referral results in RMS due, in
coordination within and between the            part, to lack of training. Officials with each of the military services told GAO that
direct and purchased care systems.             they are aware of RMS reliability issues and have been working to address them
Among other objectives, this report            through system updates, training, and hiring staff.
examines the extent to which the
referral management process                    DHA has begun to replace RMS and other existing information technology
facilitates the coordination of primary        systems with Military Health System (MHS) Genesis, a new electronic health
and specialty care for TRICARE Prime           record system. The implementation of MHS Genesis began in 2017 at four
beneficiaries. GAO examined relevant           MTFs, which have experienced difficulties with system implementation, including
policies; analyzed current referral data       with referral management.
from five MTFs it visited, selected for
variety in military service, geographic        •   GAO found that the four MTFs using MHS Genesis were not adequately
location, and numbers of referrals; and            trained on how to use its referral management component prior to the
interviewed officials with DHA and the             system’s deployment. This limited the MTFs’ ability to process and track
military services. GAO also discussed              referrals, and led to concerns about the reliability of the system’s referral
the implementation of MHS Genesis                  data. While MHS Genesis training on referral management has been
with officials at DOD and the four                 redesigned for the next round of MTFs slated for implementation in summer
MTFs where it has been implemented.                2019, officials said that it remains unclear whether this training will provide
                                                   the guidance needed for MTF officials to accurately process and capture
What GAO Recommends
                                                   information on specialty care referrals. Without adequate training, DHA
GAO recommends that the Secretary                  cannot ensure that the referral data in MHS Genesis accurately reflects the
of Defense ensure that (1) MTF referral            referral experiences of its Prime beneficiaries, potentially impacting the
staff are trained to process and                   timeliness and quality of care they receive.
accurately document information in
MHS Genesis about specially care               •   DHA and military service officials who are responsible for developing
referrals and (2) MHS Genesis is                   standardized referral management guidance for the department—the
configured to produce reports with                 Referral Management Working Group—said that they have not been able to
reliable data on the referral process.             obtain reports about referrals for the four MTFs that use MHS Genesis. The
DOD concurred with both of these                   system would need to be configured to produce the types of referral reports
recommendations.                                   needed, according to these officials, who told GAO they have been working
                                                   with the DHA officials responsible for system implementation to develop such
                                                   reports. Without reliable reports on referrals, DHA will continue to lack the
View GAO-19-488. For more information,
                                                   information it needs about the coordination of care for its TRICARE Prime
contact Debra A. Draper at (202) 512-7114 or       beneficiaries, impeding its ability to manage referrals, as well as ensuring
DraperD@gao.gov.                                   these beneficiaries receive needed care.


                                                                                        United States Government Accountability Office
Contents


Letter                                                                                  1
              Background                                                                6
              DHA Has Limited Information about the Extent to Which the
                Referral Process Facilitates the Coordination of Care between
                the Direct and Purchased Care Systems for TRICARE Prime
                Beneficiaries                                                         13
              DHA’s Monitoring of TRICARE Prime Specialty Care Referrals in
                the Direct Care System Is Expected to Evolve and in the
                Purchased Care System Is Focused on Contractors’ Reports              19
              Conclusions                                                             21
              Recommendation for Executive Action                                     22
              Agency Comments                                                         22

Appendix I    Comments from the Department of Defense                                 24



Appendix II   GAO Contact and Staff Acknowledgments                                   25


Figures
              Figure 1: Process for Making a Specialty Care Referral for a
                       TRICARE Prime Beneficiary from the Purchased to the
                       Direct Care System                                               9
              Figure 2: Process for Making a Specialty Care Referral for a
                       TRICARE Prime Beneficiary from the Direct to the
                       Purchased Care System                                          11




              Page i                                    GAO-19-488 TRICARE Prime Referrals
Abbreviations

CLR               clear and legible report
DHA               Defense Health Agency
DOD               Department of Defense
NDAA 2017         National Defense Authorization Act for Fiscal Year 2017
MHS               Military Health System
MTF               military treatment facility
RMS               Referral Management Suite




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Page ii                                              GAO-19-488 TRICARE Prime Referrals
                       Letter




441 G St. N.W.
Washington, DC 20548




                       June 12, 2019

                       The Honorable James M. Inhofe
                       Chairman
                       The Honorable Jack Reed
                       Ranking Member
                       Committee on Armed Services
                       United States Senate

                       The Honorable Adam Smith
                       Chairman
                       The Honorable Mac Thornberry
                       Ranking Member
                       Committee on Armed Services
                       House of Representatives

                       In fiscal year 2018, the Department of Defense (DOD) offered health care
                       services to more than 9 million eligible beneficiaries in the United States
                       and abroad through TRICARE, its regionally structured health care
                       program. 1 Under TRICARE, the department contracts with private sector
                       companies—referred to as managed care support contractors
                       (contractors)—to develop and maintain civilian provider networks and
                       provide other services, such as specialty care referrals and claims
                       processing. 2 Eligible beneficiaries can obtain primary and specialty health
                       care services through the department’s direct care system of military
                       hospitals and clinics, referred to as military treatment facilities (MTF), or
                       through its purchased care system of civilian providers.

                       Beneficiaries enrolled in TRICARE Prime, DOD’s managed care option,
                       must generally obtain referrals for their specialty care. 3 Referral
                       1
                        Eligible beneficiaries include active duty personnel and their dependents, medically
                       eligible National Guard and Reserve servicemembers and their dependents, and retirees
                       and their dependents and survivors. Active duty personnel include Reserve component
                       members on active duty for at least 30 days.
                       2
                           DOD has two TRICARE regions (East and West), and each region has its own contractor.
                       3
                        Beginning on Jan. 1, 2018, TRICARE’s non-Medicare-eligible beneficiary population
                       could be enrolled in one of two basic health plan options—TRICARE Prime (a managed
                       care option) or TRICARE Select (a self-managed, preferred provider option). This
                       population includes all beneficiaries who do not meet the requirements for obtaining health
                       care coverage under Medicare, which is generally available to people age 65 or older,
                       younger people with disabilities, and people with end-stage renal disease.




                       Page 1                                                GAO-19-488 TRICARE Prime Referrals
management is a key component of care coordination for these
beneficiaries because they may move between the direct and purchased
care systems to obtain the care they need. TRICARE Prime beneficiaries
are assigned to a primary care manager either at an MTF or within the
civilian provider network. Primary care managers are responsible for
overseeing all aspects of their patients’ care, which includes making
referrals for specialty care. To ensure the continuity of care for these
beneficiaries, specialty care providers are required to share
documentation about the care they provided during patients’ visits for the
referring primary care managers to review. 4 As of March 2019, 5.1 million
beneficiaries—over half of the eligible population—were enrolled in
TRICARE Prime.

DOD’s Defense Health Agency (DHA) administers the TRICARE
program, which includes overseeing the contracts and setting policy for
both the direct and purchased care systems, among other responsibilities.
DHA is currently in the process of making changes to its information
technology systems and to its organizational responsibilities—both of
which will impact referral management. Since 2008, MTFs have primarily
used an information technology system, called the Referral Management
Suite (RMS), to process and track their specialty care referrals, according
to DHA officials. In 2017, DHA began implementing Military Health
System (MHS) Genesis, a new system that is designed to standardize
electronic health records throughout DOD, and which will replace existing
systems, including RMS. The implementation of MHS Genesis began at
four MTFs, each of which has reportedly experienced difficulties with the
system. 5

Additionally, the National Defense Authorization Act for Fiscal Year 2017
(NDAA 2017), as amended, transferred administrative and management
responsibility for MTFs from the military services’ (Army, Navy, and Air
Force) medical commands to DHA, including responsibility for referral



4
  The process for submitting documentation of beneficiaries’ care differs in the direct and
purchased care systems. For example, MTF specialty care providers submit beneficiary
information through the MTF’s referral management center, which is responsible for
processing and tracking all referrals.
5
 DHA plans to continue implementation at four additional sites on the West Coast by the
end of calendar year 2019. The implementation of MHS Genesis is scheduled to be
complete for all MTFs by the end of 2024.




Page 2                                                 GAO-19-488 TRICARE Prime Referrals
management. 6 On Oct. 1, 2018, DHA initiated an incremental process for
assuming these responsibilities and plans to complete this process by
Oct. 1, 2021. 7

The NDAA 2017 included a provision for GAO to examine several issues
related to DOD’s delivery of health care, such as the coordination of care
within and between the direct and purchased care systems. 8 In this
report, we examine to what extent

1. the referral management process facilitates the coordination of
   primary and specialty care between the direct and purchased care
   systems for TRICARE Prime beneficiaries; and
2. DHA monitors TRICARE Prime specialty care referrals for the direct
   and purchased care systems.

To determine the extent to which the referral management process
facilitates the coordination of care between the direct and purchased care
systems for TRICARE Prime beneficiaries, we conducted site visits to a
non-generalizable sample of five MTFs and reviewed and analyzed
available RMS data on their specialty care referrals. The five MTFs
included three MTFs representing each of the military services and an
enhanced multi-service market area with two MTFs—Raymond W. Bliss
Army Health Center (Fort Huachuca, Arizona), Naval Medical Center-San
Diego (San Diego, California), 78th Medical Group (Robins Air Force
Base, Georgia), and Brooke Army Medical Center and 59th Medical Wing
Wilford Hall Ambulatory Surgical Center (Joint Base, San Antonio,
Texas). 9 These MTFs were selected based on geographic diversity and a
range in the numbers of specialty care referrals from the direct to the
6
 Within the direct care system, most MTFs are under the direction and control of their
respective military service medical commands, including the Army Medical Command, the
Navy Bureau of Medicine and Surgery, and the Air Force Major Commands. The
Department of the Navy delivers health care to the Marine Corps. Pub. L. No. 114-328,
§ 702(a)(1), 130 Stat. 2000, 2193 (2016), codified, as amended, at 10 U.S.C. § 1073c.
7
 The John S. McCain National Defense Authorization Act for Fiscal Year 2019 (NDAA
2019) extended the date for the transfer of the administration of the MTFs to the DHA to
September 30, 2021. Pub. L. No. 115-232, § 711 (a)(1). 132 Stat. 1636, (2018).
8
    Pub. L. No. 114-328, § 751, 130 Stat. 2000, 2244-2245 (2016).
9
 Enhanced multi-service markets are multiple MTFs within the same geographic location
that are organized under a single market manager and a unified business performance
plan. Enhanced multi-service markets include San Antonio, Texas and the National
Capitol Area, among others.




Page 3                                                 GAO-19-488 TRICARE Prime Referrals
purchased care system. For these five MTFs, we analyzed RMS data on
the extent to which documentation of beneficiaries’ visits were submitted
by the civilian specialty care providers for the MTF primary care
managers from February 2017 to February 2018. 10 We also analyzed the
available RMS data, for the MTFs we visited, from the MTF specialty care
providers for the civilian network primary care managers. 11 Additionally,
we reviewed RMS data, for the MTFs we visited, on MTF’s closure of
specialty care referrals made from the direct to the purchased care
system from December 2017 through July 2018. 12 We reviewed relevant
documentation about RMS and interviewed knowledgeable officials about
the accuracy and completeness of the system’s data, which is discussed
further in the report. We also reviewed DHA’s July 2018 guidance for
standardizing appointments and specialty care referrals, and relevant
sections of the TRICARE Operations Manual. 13 We interviewed DHA and
military service officials who participate in the Referral Management
Working Group, which produces the department’s referral management
guidance, about how they use specialty care referral data in RMS to track
the coordination of primary and specialty care. 14 We also reviewed
documentation and interviewed relevant DHA and Referral Management
Working Group officials about the department’s transition to the new
10
   Per DHA guidance, MTFs must close a referral with or without documentation of the
beneficiary’s visit to the civilian provider network within 180 days of the referral’s issuance.
Therefore, we requested data for a complete year (February 2017-February 2018)
because the end date was around 180 days prior to the July 2018 date of our data
request.
11
  Civilian specialty care providers can be within or outside of the contractor’s provider
network and primary care managers are always within the contractor’s provider network.
As a result, we use the terms “civilian network primary care manager” and “civilian
specialty care provider” throughout this report. A network provider is an individual or
institutional provider that has a contract with the TRICARE contractor to provide care to
TRICARE eligible beneficiaries.
12
  At the time of our review, DOD’s guidance only addressed the closure of referrals from
the direct to the purchased care system. Therefore, we did not examine data on the
closure of other referrals, such as those made between providers in the direct care
system. Further, in requesting a report with data on closure of referrals in August 2018,
DHA officials told us that they had changed the report’s methodology, and prior to
December 2017, some data on this report would not be reliable.
13
  Defense Health Agency, Standard Appointing Processes, Procedures, Hours of
Operation, Productivity, Performance Measures and Appointment Types in Primary,
Specialty, and Behavioral Health Care in Medical Treatment Facilities (MTFs). Interim
Procedures Memorandum 18-001 (Washington, D.C.: July 2018).
14
 While specialty care referrals can be made between civilian providers in the purchased
care system, DHA and the military services do not play a role in coordinating this care.




Page 4                                                   GAO-19-488 TRICARE Prime Referrals
electronic health record system, MHS Genesis, to determine how this
new system may impact the referral management process. Furthermore,
we interviewed officials at the four MTFs where MHS Genesis has been
implemented, and we compared how the MTFs’ staff were trained to
process referrals in MHS Genesis to federal standards for internal control
related to developing competent individuals. 15 Finally, we interviewed an
official that represents military beneficiaries about their concerns
regarding the referral process. 16

To determine the extent to which DHA monitors TRICARE Prime
specialty care referrals for the direct and purchased care systems, we
reviewed the methodology DHA developed for assessing MTFs’
performance with referrals generated in the direct care system, as well as
the two subsequent quarterly performance reports using this methodology
(April 2018 and August 2018). 17 We also reviewed DHA’s July 2018
guidance for standardizing appointments and specialty care referrals that
describes the monitoring responsibilities of DHA leadership, and we
interviewed DHA officials about the data they use to monitor referrals. For
purchased care referrals, we reviewed relevant sections of the managed
care support contracts to identify contractors’ referral management
requirements, as well as their required monthly reports on referrals for the
East Region (January through July 2018) and the West Region (May
2018 through July 2018). 18 We reviewed relevant documentation and
interviewed DHA’s TRICARE Health Plan officials, who conduct
contractor oversight, about contractors’ referral management
requirements, and DHA’s oversight structure and activities. We also


15
  GAO, Standards for Internal Control in the Federal Government, GAO-14-704G
(Washington, D.C.: September 2014). Internal control is a process effected by an entity’s
oversight body, management, and other personnel that provides reasonable assurance
that the objectives of an entity will be achieved.
16
  The Military Coalition is a group comprised of 32 organizations representing more than
5.5 million members of the uniformed services, including active duty, reservists, retirees,
veterans, and their survivors and families.
17
   DHA developed the methodology in response to legislative requirements to standardize
its medical appointment process. At the time of our study, the quarterly performance
reports issued in April and August 2018 were the only two reports DHA had issued using
that methodology.
18
   The shortened time frame for the West region was due to referral issues that began at
the start of health care delivery in January 2018. These issues resulted in a waiver of
certain requirements to help ensure timely access to specialty care through April 2018.




Page 5                                                 GAO-19-488 TRICARE Prime Referrals
                      interviewed relevant contractor officials for both TRICARE regions about
                      DHA’s oversight of contract requirements for specialty care referrals.

                      We conducted this performance audit from April 2018 to June 2019 in
                      accordance with generally accepted government auditing standards.
                      Those standards require that we plan and perform the audit to obtain
                      sufficient, appropriate evidence to provide a reasonable basis for our
                      findings and conclusions based on our audit objectives. We believe that
                      the evidence obtained provides a reasonable basis for our findings and
                      conclusions based on our audit objectives.



Background
Referral Management   DHA and the military services work together on issues related to specialty
Working Group         care referrals through the Referral Management Working Group, which
                      was established in September 2013. 19 According to its charter, the
                      working group provides a forum for evaluating the referral process and
                      making department-wide recommendations to

                      •    optimize referral management through improved coordination within
                           the direct care system and between the direct and purchased care
                           systems;
                      •    develop policies, business rules, training and other guidance on the
                           management of referrals;
                      •    establish new initiatives, technology, system changes, and electronic
                           workflows related to the management of referrals; and
                      •    establish department-wide performance measures, including data
                           sources, definitions and reports related to the management of
                           referrals.

Referral Management   As part of DHA’s efforts to standardize the medical appointment process,
Guidance and          including referral management, the Referral Management Working Group
                      developed standardized guidance for the direct care system in 2017 that
Requirements
                      all of the military services are required to follow. Updated in July 2018,
                      this guidance supersedes existing military-service-specific referral
                      management policies. It outlines how the MTFs 1) process referrals within
                      19
                        The working group includes members from each of the military services (Army, Navy,
                      and Air Force) and DHA.




                      Page 6                                              GAO-19-488 TRICARE Prime Referrals
the direct care system, 2) how they send referrals to the purchased care
system, and 3) how they process referrals received from the purchased
care system. The guidance also addresses how these processes are to
be documented in both RMS and MHS Genesis.

Each MTF has a referral management center that is responsible for
processing specialty care referrals for its facility. DHA’s guidance outlines
how the MTFs’ referral management centers are to facilitate the sharing
of documentation about TRICARE Prime beneficiaries’ care

•    from MTF specialty care providers: When a referral management
     center accepts a specialty care referral from a civilian network primary
     care manager, the center is required to submit documentation of the
     beneficiary’s visit—called “referral results”—from the MTF specialty
     care provider back to the civilian network primary care manager, and
     to track this submission in RMS or MHS Genesis.
•    to MTF primary care managers: When an MTF primary care
     manager sends a referral to a civilian specialty care provider, the
     referral management center must follow up on required
     documentation the civilian specialty care provider is to submit about
     the beneficiary’s visit, called a clear and legible report (CLR). 20 The
     receipt of the report is documented in RMS or MHS Genesis. 21

Historically, the contractors were responsible for following up on civilian
specialty care providers’ submission of CLRs to the MTFs’ referral
management centers. However, ultimately in 2013, the responsibility for
this function was transferred to the MTFs’ referral management centers.
In order to follow up on a CLR, MTF officials must follow several steps,
including checking the contractors’ claims database to determine if the
referral was used and contacting the specialty care provider multiple
times to request the CLR. MTFs were given additional funding to address
this new responsibility, and many continue to hire staff to carry out this
function, according to Referral Management Working Group officials.
Under the most current TRICARE contracts, DHA is requiring the

20
   CLRs are specialty care consultation and referral reports, histories and physicals,
progress notes, notes on episodes of care, other beneficiary information (such as
laboratory reports), and discharge summaries for beneficiaries referred by MTFs to civilian
specialty care providers.
21
  The CLRs are to be uploaded into DOD’s Health Artifact and Image Management
Solutions system, which is DOD’s general repository for loading medical documentation,
including consultation, laboratory, and radiology results.




Page 7                                                GAO-19-488 TRICARE Prime Referrals
                             contractors to have a process in place to address civilian specialty care
                             providers that do not submit CLRs as required.

                             Separately, the TRICARE Operations Manual outlines referral
                             requirements that both MTFs and the contractors must follow. The
                             requirements are similar to those in DHA’s July 2018 guidance, but
                             include additional information for the contractors. For example, the
                             manual includes specific requirements contractors must follow to ensure
                             that specialty care referrals from a civilian network primary care manager
                             are first offered to the local MTF to determine whether that MTF has the
                             capability and capacity to provide the care. This process is called the
                             “right of first refusal.” 22


Process for Specialty Care   The process for referrals made by civilian network primary care managers
Referrals Made by Civilian   varies depending on whether the referring MTFs have the capability and
                             capacity to provide the specialty care:
Network Primary Care
Managers                     •    If a civilian network primary care manager generates a referral for
                                  specialty care, the contractor is required to contact the local MTF for
                                  the “right of first refusal.” If the MTF does not have the capability and
                                  capacity to provide the care, the TRICARE Prime beneficiary obtains
                                  his or her care from a civilian specialty care provider who must submit
                                  a record of the beneficiary’s visit to the referring primary care
                                  manager. Each contractor specifies its own requirements for civilian
                                  specialty care providers to submit this information to civilian network
                                  primary care managers.
                             •    If a civilian network primary care manager generates a referral for
                                  specialty care that the MTF does have the capability and capacity to
                                  provide, the TRICARE Prime beneficiary may obtain his or her
                                  specialty care at the MTF. 23 After the beneficiary obtains care from
                                  the MTF specialty care provider, the MTF’s referral management
                                  center is required to submit the referral results to the referring civilian
                                  network primary care manager. (See fig. 1.)


                             22
                               According to the TRICARE Operations Manual, capability is the scope of services the
                             provider is both capable of performing and willing to perform, and capacity is the amount
                             of time or number of services a provider is able to perform. MTFs’ provide information on
                             capability and capacity in documentation provided to the contractor.
                             23
                              The contractor consults current lists of MTF specialty care capabilities maintained by the
                             MTF referral management center in order to facilitate the “right of first refusal” process.




                             Page 8                                                GAO-19-488 TRICARE Prime Referrals
Figure 1: Process for Making a Specialty Care Referral for a TRICARE Prime
Beneficiary from the Purchased to the Direct Care System




Note: Direct care is the care received at military hospitals and clinics, referred to as MTFs, and
purchased care is care received through a system of civilian provider networks. The Department of
Defense (DOD) contracts with private sector companies—contractors— to develop and maintain
civilian provider networks and provide other services, such as processing specialty care referrals.
This figure represents the general process followed when a civilian network primary care manager
makes a specialty care referral to the direct care system. However, these steps may change
depending on several factors, such as whether the beneficiary lives near a military installation.
a
 Beneficiaries enrolled in TRICARE Prime, a managed care option, are assigned to a primary care
manager either at an MTF or within the civilian provider network. Primary care managers are
responsible for overseeing all aspects of their beneficiaries’ care, which includes making referrals for
specialty care when needed. Civilian primary care managers are within the contractor’s provider
network.
b
 Each MTF has a referral management center that is responsible for processing specialty care
referrals for its facility. TRICARE defines capability as the scope of services the provider is both
capable of performing and willing to perform, and capacity as the amount of time or number of
services a provider is able to perform. As part of determining capacity, the referral management




Page 9                                                         GAO-19-488 TRICARE Prime Referrals
                             center must ensure that the specialty care appointment can be provided within TRICARE Prime’s
                             access-to-care standard of 28 days or less.




Process for Specialty Care   Similarly, the process for referrals made by MTF primary care managers
Referrals Made by MTF        depends on whether the local MTF has the capability and capacity to
                             provide the care:
Primary Care Managers
                             •    If a primary care manager at the MTF generates a referral for
                                  specialty care that the MTF has the capability and capacity to provide,
                                  the TRICARE Prime beneficiary obtains his or her care from the MTF
                                  specialty care provider. MTF specialty care providers are not required
                                  to submit documentation of the beneficiary’s visit to the referring
                                  primary care manager because they share the same electronic health
                                  record system.
                             •    If a primary care manager at the MTF generates a referral for
                                  specialty care that the MTF does not have the capability and capacity
                                  to provide, the TRICARE Prime beneficiary may obtain his or her care
                                  from a civilian specialty care provider, who must submit a CLR to the
                                  MTF for the primary care manager to review. Each contractor
                                  specifies the time frame in which the CLR must be provided. 24 The
                                  required time frame is the same for both TRICARE regions—2 days
                                  for urgent care referrals, and 7 to 10 days for all other referrals. (See
                                  fig. 2)




                             24
                               Each contractor develops a provider handbook to outline the roles and responsibilities of
                             civilian providers both within and outside of its network.




                             Page 10                                                   GAO-19-488 TRICARE Prime Referrals
Figure 2: Process for Making a Specialty Care Referral for a TRICARE Prime
Beneficiary from the Direct to the Purchased Care System




Page 11                                          GAO-19-488 TRICARE Prime Referrals
                         Note: Direct care is the care received at military hospitals and clinics, referred to as MTFs, and
                         purchased care is care received through a system of civilian provider networks. The Department of
                         Defense (DOD) contracts with private sector companies—contractors— to develop and maintain
                         civilian provider networks and provide other services, such as processing specialty care referrals.
                         This figure represents the general process followed when an MTF primary care manager makes a
                         specialty care referral to the purchased care system.
                         a
                          Beneficiaries enrolled in TRICARE Prime, a managed care option, are assigned to a primary care
                         manager either at an MTF or within the civilian provider network. Primary care managers are
                         responsible for overseeing all aspects of their beneficiaries’ care, which includes making referrals for
                         specialty care when needed. Each MTF has a referral management center that is responsible for
                         processing specialty care referrals for its facility.
                         b
                          The TRICARE program defines capability as the scope of services the provider is both capable of
                         performing and willing to perform, and capacity as the amount of time or number of services a
                         provider is able to perform. As part of determining capacity, the referral management center must
                         ensure that the specialty care appointment can be provided within TRICARE Prime’s access to care
                         standards of 28 days or less.
                         c
                          CLRs are specialty care consultation and referral reports, histories and physicals, progress notes,
                         notes on episodes of care, other beneficiary information (such as laboratory reports), and discharge
                         summaries for beneficiaries referred by MTFs to civilian specialty care providers.




MTFs’ Requirements for   MTFs’ referral management centers are required to enter referral
Closing Referrals        disposition information into RMS (or MHS Genesis, once implemented) to
                         indicate whether the referral was used. According to DHA’s guidance,
                         referral management centers are responsible for closing referrals from
                         their facilities to civilian specialty care providers within 180 days of the
                         referrals’ issuance. In contrast, MTFs currently are not explicitly required
                         to close referrals made by their primary care manager to their specialty
                         care providers or referrals generated by the “right of first refusal” process.
                         However, DHA plans to include additional requirements for closing these
                         referrals in its updated guidance, according to officials. 25




                         25
                           Officials from the Referral Management Working Group told us that they are currently
                         developing an update to this guidance that should be completed by July 2019.
                         Additionally, DOD is in the process of making changes to streamline its TRICARE Prime
                         referral process in response to recent legislation. For example, the NDAA 2017 requires
                         DOD to allow non-active duty TRICARE Prime beneficiaries to use urgent care facilities
                         without the need for a specialty care preauthorization. In addition, the NDAA 2019
                         requires DOD to streamline the referral process for TRICARE Prime beneficiaries in
                         calendar year 2019.




                         Page 12                                                        GAO-19-488 TRICARE Prime Referrals
DHA Has Limited
Information about the
Extent to Which the
Referral Process
Facilitates the
Coordination of Care
between the Direct
and Purchased Care
Systems for
TRICARE Prime
Beneficiaries
Referral Data Was            DHA has limited information about the extent to which the referral process
Incomplete and Unreliable    facilitates the coordination of care for TRICARE Prime beneficiaries
                             between the direct and purchased care system based on issues we
for the MTFs Reviewed,
                             identified with the completeness and reliability of the data and reports we
and the Reports Examined     reviewed from RMS. Specifically, we found that the five MTFs we visited
Did Not Accurately Reflect   had incomplete and unreliable data in RMS about receipt of CLRs, the
the Referral Process         submission of specialty care referral results, and the closure of specialty
                             care referrals. In addition, we found that the RMS reports used by the
                             Referral Management Working Group were not reliable for assessing
                             certain aspects of the referral process due, in part, to unreliable data in
                             RMS as well as a flawed methodology. The Referral Management
                             Working Group, which includes officials from DHA and the military
                             services’ medical commands, acknowledged the limitations of this referral
                             data in RMS. Officials with the military services’ medical commands told
                             us that they have been meeting routinely with their MTFs’ referral
                             management centers to help address issues with the reliability of RMS
                             data.

                             CLRs: We found that the CLR data in RMS for the five MTFs we visited
                             were incomplete. As a result, the referral management center officials at
                             these MTFs could not accurately determine if they received CLRs for all
                             referrals they sent to civilian specialty care providers as required by
                             DHA’s guidance. For example, the RMS data we reviewed indicated that
                             these MTFs received between 20 to 77 percent of the CLRs they




                             Page 13                                     GAO-19-488 TRICARE Prime Referrals
expected. 26 Officials from one MTF told us that their CLR data in RMS
was incomplete because the MTF did not have enough staff to follow up
on CLRs that had not been received, which they described as a time-
intensive process. These officials told us that they recently hired contract
staff to begin the process of following up on CLRs for specialty care
referrals. In addition, the RMS data for another MTF indicated that they
had received less than half of their CLRs (45 percent), but officials from
this MTF told us they thought they had received almost all of their CLRs
and could not explain the difference.

Specialty care referral results: We found that the submission of
specialty care referral results was generally not being tracked in RMS, as
required by DHA’s guidance for the three MTFs we visited that accept
these referrals. 27 As a result, information in RMS about the submission of
referral results is incomplete, limiting MTFs’ ability to determine whether
MTFs have been submitting all specialty care referral results as required.
Officials from the three MTFs told us that although they submitted their
referral results, they generally had not been using RMS to track the
submission of this information. Instead, officials with two of the MTFs told
us that they used the contractors’ database to track referral results
because RMS has had ongoing issues with receiving required data from
its administrative system, which is used for scheduling appointments,
among other things. 28 However, officials from the two MTFs told us that
these issues have been resolved as of January 2019, and since that time
they had begun using RMS to track referral results. Further, officials with
the remaining MTF told us that they previously tracked this information in
a spreadsheet, but they recently learned how to track it in RMS.
According to a Referral Management Working Group official, RMS is
capable of tracking the submission of specialty care referral results, but
MTF officials may not understand how to use this capability.

Closure of specialty care referrals: We found that RMS data on the
closure of specialty care referrals (from MTF primary care managers to
civilian specialty care providers) for the five MTFs we visited was

26
     Our analysis of CLRs received did not include referrals that had not been used.
27
  Two of the five MTFs we visited are small facilities and do not accept purchased-to-
direct care referrals because they do not have the capability.
28
   The Composite Health Care System allows clinicians to electronically perform patient
appointment processes and scheduling, order laboratory tests, authorize radiology
procedures, and prescribe medications.




Page 14                                                  GAO-19-488 TRICARE Prime Referrals
unreliable due to inconsistencies we identified between the RMS data we
reviewed and MTF officials’ statements about the closed referrals for their
facility. As a result, these MTFs may have difficulty determining whether
their referrals had been used and whether they closed these referrals
within 180 days as required by DHA guidance. For example, one MTF
had closed around 75 percent of its referrals in RMS as “not used.”
However, officials at this MTF told us that many of these referrals were
likely used, but were closed as “not used” because staff needed to close
referrals in RMS quickly and did not have time to determine the referrals’
status. Officials we spoke with at another MTF told us they did not
understand the full capabilities of RMS and had not been using this data
to determine whether or not they had closed their specialty care referrals.
A third MTF told us they closed all of its referrals within the required time
frame of 180 days; however, we found that only about half of its referrals
were documented as closed in RMS. Officials at this MTF could not
explain this discrepancy. 29

RMS reports: In 2017, the Referral Management Working Group began
monitoring MTFs’ RMS data as part of its effort to develop DHA’s initial
standardized guidance for appointments and referral management.
Officials with the Referral Management Working Group told us that two
reports from RMS—the CLR Percent Received Report and the Referral
Performance Report—have been used to assess the receipt of CLRs and
closure of specialty care referrals. 30 For the MTFs we visited, we found
the CLR Percent Received Report to be unreliable in determining whether
CLRs were received due to both the report’s flawed methodology and
MTFs’ input of inaccurate information into RMS. 31 Officials with the
working group acknowledged the limitations of this report and told us that
they supplement this information with another RMS report, the Referral
Performance Report, which they use to review the closure of specialty
care referrals. However, when we reviewed the CLR and specialty care
referral closure data in the Referral Performance Report, we also

29
   In April 2019, an official from this MTF told us that the MTF has fixed this discrepancy in
RMS, although officials still could not explain why it occurred.
30
  DHA officials who maintain information technology systems develop the methodology for
these reports in consultation with the Referral Management Working Group, according to
working group officials.
31
  The methodology for the CLR Percent Received report removes referrals from the
denominator when the referrals have been closed as either “not used” or “without a CLR.”
Therefore, the results on the number CLRs received may be artificially inflated because
the number of referrals without a CLR are removed from the overall calculation.




Page 15                                                 GAO-19-488 TRICARE Prime Referrals
                            identified inaccuracies with these data. 32 For example, we found that
                            several MTFs had closed more direct-to-purchased care referrals than
                            they had issued. Officials with the Referral Management Working Group
                            explained that some MTFs are inaccurately inputting data into RMS. As a
                            result, there are inaccuracies in the Referral Performance Reports, such
                            as referrals that are double counted. Officials said that these MTFs will
                            need to be trained on how to accurately input data into RMS.

                            Officials with each of the military services’ medical commands who
                            participate in the Referral Management Working Group told us that they
                            began taking steps to address their concerns about the reliability of RMS
                            data in an effort to implement the standardized appointment and referral
                            guidance at their MTFs. They have worked with DHA on two updates to
                            RMS—one in March 2018 and one in January 2019—in an effort to
                            address some of these data concerns. 33 In addition, they have been
                            reviewing and discussing data with their MTFs’ referral management
                            center officials, sometimes through their regional officials, on a monthly or
                            quarterly basis to discuss available RMS data, including data on CLRs
                            and closures of referrals, among other things. Further, the military service
                            medical commands are working to help their MTFs obtain more staff to
                            pursue outstanding CLRs. In addition, the medical commands are
                            focused on teaching their MTFs’ referral management center staff to
                            correctly input referrals and avoid inadvertent double counting.


Inadequate Training on      DHA’s initial implementation of MHS Genesis—which will replace RMS
Processing Referrals in     and other systems—did not include adequate training for referral
                            management, resulting in concerns about data reliability. Specifically,
MHS Genesis Has
                            referral management center officials with the four MTFs using MHS
Contributed to Data         Genesis told us that although training was provided on the use of the
Reliability Concerns for    system, this training did not adequately address the use of the system’s
Four Pilot MTFs; Updates    referral management component prior to its deployment. These officials
to the System Are Planned   told us they generally trained themselves and most developed their own
                            training materials on the system, which requires a different referral
                            processing workflow than RMS. This lack of training limited MTFs’ ability
                            to use MHS Genesis to evaluate their performance and led to MTF
                            32
                               The Referral Performance Reports have more than 40 data elements. We reviewed the
                            six elements in the report that related to the closure of direct-to-purchased care referrals
                            and obtaining CLRs.
                            33
                             These updates included improved transmission of data from the Composite Health Care
                            System and updates to beneficiary categories.




                            Page 16                                                GAO-19-488 TRICARE Prime Referrals
officials’ concerns about the reliability of the system’s referral data. For
example, officials at two of the MTFs told us that their staff had not been
provided training on how to aggregate data on the receipt of CLRs even
though MHS Genesis is capable of generating this report. As a result,
their staff manually tracked the receipt of individual CLRs, not only
increasing the risk of errors, but also making it more difficult to assess
their facilities’ overall performance. An MTF official at one of these
facilities told us that the CLR report from MHS Genesis was likely
unreliable because staff had not received formal training on how to
accurately use the system to input and process referral data. Federal
standards for internal control highlight the importance of training to
develop staff competencies appropriate for key roles. 34 Without adequate
training, DHA cannot ensure that the data and reports derived from MHS
Genesis accurately reflect the referral experiences of its TRICARE Prime
beneficiaries, or whether any remediation is needed with regard to the
process.

MTF officials also told us that it took longer to process referrals in MHS
Genesis, and as a result, some MTFs had to add staff to their referral
management centers or extend the centers’ hours to process referrals
within required time frames. The Referral Management Working Group
told us that they are working with DHA officials to upgrade the referral
management component of the MHS Genesis system to help improve the
referral process. A DHA official responsible for system implementation
stated that standardized training will be developed and provided to MTF
staff to correspond with the upgrade, which the official anticipates will be
implemented in summer 2020. In the interim, this official told us that they
have redesigned the MHS Genesis training on referral management,
which DHA plans to use for the MTFs included in the next wave of MHS
Genesis implementation in summer 2019. However, Referral
Management Working Group officials are unclear whether the redesigned
training will address the concerns expressed by the MTFs currently using
the system.

Furthermore, Referral Management Working Group officials told us that
they have not been able to obtain reports about referrals for MTFs that
use MHS Genesis. Working group officials explained that MHS Genesis
may be capable of producing the types of referral reports they need, but
the system would need to be configured by DHA to do so. These officials

34
 GAO-14-704G.




Page 17                                      GAO-19-488 TRICARE Prime Referrals
told us that they have been working with the DHA officials who are
overseeing system implementation to identify the data and methodology
needed to develop reports on specialty care referrals, including
information on CLRs, referral results, and specialty care referral closures.
Working group officials said that they were aware that MHS Genesis
already produces a report on CLRs received, but they were concerned
about using it because they had been cautioned by MTF officials that the
report contained inaccurate data. As an initial step, these officials told us
that they requested the methodology for this report in order to determine
its accuracy; however, as of March 2019, they had not received this
information. Federal standards for internal control state that management
should use quality information to achieve its objectives. Quality
information is obtained through relevant data from reliable sources in a
timely manner based on the identified information requirements. 35 Without
reliable reports on specialty care referrals, the Referral Management
Working Group may have difficulties not only determining TRICARE
Prime beneficiaries’ use of referrals, but also fulfilling its goals of
optimizing and standardizing the referral management process.




35
     GAO-14-704G.




Page 18                                       GAO-19-488 TRICARE Prime Referrals
DHA’s Monitoring of
TRICARE Prime
Specialty Care
Referrals in the Direct
Care System Is
Expected to Evolve
and in the Purchased
Care System Is
Focused on
Contractors’ Reports
DHA’s Monitoring of         DHA, through its Clinical Business Operations branch, monitors
TRICARE Prime Specialty     TRICARE Prime specialty care referrals for the direct care system.
                            Specifically, DHA uses one of the 15 metrics it established based on its
Care Referrals for the
                            requirement to standardize appointments across MTFs—the average
Direct Care System Is       number of days elapsed from referral to appointment booked. 36 This
Limited, but Expected to    metric is derived from the MHS Dashboard, which contains MTF health
Evolve as DHA Assumes       care performance measures based on data from DHA’s current electronic
Administrative              health record system. 37 DHA plans to monitor a second metric related to
                            referrals—average days from referral to appointment decision or send to
Responsibilities for MTFs   a civilian specialty care provider—when they obtain additional staff.

                            DHA’s current approach for monitoring direct care system referrals is
                            expected to evolve as it assumes administrative responsibilities for the
                            remaining MTFs, but DHA has not yet determined its new organizational
                            structure or its corresponding staffing needs. DHA’s July 2018
                            standardized appointment and referral management guidance assigned
                            oversight responsibilities for referrals to Regional Commands, which
                            would be a new organizational structure within DHA. However, according

                            36
                               Other measures include the percent of demand for care that was unmet within a given
                            month and the percentage of appointments that were leaked to the network, which occurs
                            when the MTF has the capability to provide specialty care, such as orthopedics but sends
                            the referral to a civilian specialty care provider.
                            37
                               Data posted to the MHS Dashboard is extracted from the MHS Data Repository. The
                            MHS Dashboard does not contain data for the four MTFs at which MHS Genesis has been
                            deployed.




                            Page 19                                              GAO-19-488 TRICARE Prime Referrals
                             to a DHA official, the Regional Command structure is no longer being
                             considered, and DHA is now pursuing a different organizational structure
                             that is in the process of being approved. As a result, DHA has not
                             determined the staffing it would need, including the staff needed to
                             monitor specialty care referrals for TRICARE Prime beneficiaries. In
                             addition, DHA has not yet determined the monitoring activities that would
                             be conducted by its staff versus the military services, according to DHA
                             officials.


DHA Uses Required            Within DHA’s TRICARE Health Plan Division, referral management
Monthly Reports from Its     officials monitor contractors’ performance on purchased care referrals by
                             reviewing data in three required referral management reports the
Contractors to Oversee
                             contractors submit on a monthly basis. These reports include:
Referrals in Its Purchased
Care System                  1. the “preauthorization/authorization and referral timeliness/accuracy”
                                report that provides information on the total number of referrals that
                                met timeliness and accuracy requirements in the previous month;
                             2. the “right of first refusal” report that indicates the number of referrals
                                accepted and declined by each MTF via this process in the previous
                                month; and
                             3. the “directed referrals” report that provides information on care
                                provided by network and non-network specialty care providers in a
                                geographic area where a specific specialty may not be available from
                                a network specialty care provider.

                             When any of the reports demonstrate that a contractor is not meeting its
                             requirements, DHA officials said that they may ask the contractor to
                             implement a corrective action plan. For example, at the January 2018
                             start of health care delivery to TRICARE beneficiaries in the West region,
                             DHA officials found that the contractor’s performance on referral
                             processing timeliness failed to meet contract requirements and was
                             inadequate to meet the overall demand for specialty care referrals.
                             According to DHA officials, the contractor was managing about 8,000
                             referrals a day, and within a few weeks, the contractor had a queue of
                             70,000 referrals that needed to be processed. DHA officials instituted a
                             corrective action requiring the contractor to submit daily referral
                             processing status reports in addition to their monthly reports. They also
                             instituted a waiver that allowed TRICARE Prime beneficiaries to see a
                             civilian specialty care provider without an authorized referral from the
                             contractor. The waiver was removed in April 2018 based on information in
                             the contractor’s daily reports, which indicated that the contractor had



                             Page 20                                        GAO-19-488 TRICARE Prime Referrals
              eliminated the backlog and was meeting referral processing timeliness
              requirements.

              As DHA’s organizational structure evolves, it plans to modify its
              organizational responsibilities for monitoring contractors’ performance.
              DHA’s TRICARE Health Plan Division has been using a regional
              structure—the TRICARE Regional Offices (East and West)—to conduct
              oversight of contractors’ performance in meeting certain contract
              requirements, including those for referrals. However, in 2018, DHA began
              the process of collapsing oversight responsibilities across the regions. 38
              As a result, certain regional officials now oversee their specific area of
              responsibility, such as specialty care referrals, for the entire U.S. and do
              not focus solely on their individual region.


              The referral management process is a key component of care
Conclusions   coordination for TRICARE Prime beneficiaries who may move between
              the direct and purchased care systems to obtain needed specialty care.
              However, our review of selected MTFs’ referral data revealed that DHA
              does not know the extent to which care is being coordinated for this
              population because MTFs’ referral management centers do not always
              document accurate and complete referral information in RMS due to a
              lack of staff and the need for additional training. Furthermore, some of the
              RMS reports used by the Referral Management Working Group are
              based on data that are not reliable and a methodology that does not
              accurately reflect key information. Consequently, military service officials
              with the Referral Management Working Group have been working with
              DHA and their MTFs to improve the reliability of RMS data through
              system updates, training, and hiring staff.

              It will also be important for DHA to ensure that the types of problems
              experienced with RMS do not recur with MHS Genesis. However, the four
              MTFs using MHS Genesis have already experienced difficulties with
              processing and tracking referral information due, at least in part, to the
              lack of adequate training. While MHS Genesis training on referral
              management has been redesigned for the next round of MTFs slated for

              38
                DHA’s TRICARE Health Plan office is organized into several components, each of which
              is responsible for distinct areas of contractor oversight for a distinct region (East and
              West). As part of its reorganization in 2018, DHA began moving away from a regional
              division of responsibility for its staff. While some components have implemented this
              change, as of March 2019, not all components have done so.




              Page 21                                              GAO-19-488 TRICARE Prime Referrals
                     implementation in summer 2019, it remains unclear whether this training
                     will provide the guidance needed for MTF officials to accurately process
                     and capture information on specialty care referrals. Without adequate
                     training on processing referrals in MHS Genesis, DHA increases its risk
                     that the data and reports derived from the system may not accurately
                     reflect the referral experiences of its TRICARE Prime beneficiaries.

                     As DHA assumes administrative responsibilities for all MTFs, developing
                     reports for MHS Genesis that accurately reflect TRICARE Prime
                     beneficiaries’ referral experiences will become even more paramount.
                     Without this, the Referral Management Working Group will continue to be
                     hampered in its ability to update DHA’s referral management guidance
                     that is intended to standardize the referral management process across
                     all MTFs. Further, DHA will continue to lack accurate information it needs
                     to determine whether the referral management process is facilitating the
                     delivery of timely and quality care to its TRICARE Prime beneficiary
                     population through effective care coordination.


                         The Secretary of Defense should direct DHA to ensure that MTFs’
Recommendation for   •
                         referral management center staff are trained to process and
Executive Action         accurately document information in MHS Genesis about specialty
                         care referrals, including the receipt of CLRs, the submission of referral
                         results, and the closure of referrals. (Recommendation 1)
                     •   The Secretary of Defense should direct DHA to ensure that MHS
                         Genesis is configured to produce reports that accurately reflect the
                         use and outcomes of specialty care referrals. (Recommendation 2)

                     DOD provided written comments on a draft of this report, which are
Agency Comments      reprinted in appendix I. DOD also provided technical comments, which we
                     incorporated as appropriate. In its written comments, DOD concurred with
                     both of our recommendations and noted that DHA has worked with the
                     MHS Genesis program office to improve training and reporting. DOD
                     stated that DHA will assess the effectiveness of the improved training
                     when MHS Genesis is rolled out to the next wave of MTFs starting in
                     fiscal year 2020 and will make additional training and reporting
                     improvements as subsequent waves of MTFs are transitioned to MHS
                     Genesis through fiscal year 2024.




                     Page 22                                       GAO-19-488 TRICARE Prime Referrals
We are sending copies of this report to the Acting Secretary of Defense
and appropriate congressional committees. In addition, the report will be
available at no charge on GAO’s website at http://www.gao.gov.

If you or your staffs have any questions about this report, please contact
me at (202) 512-7114 or at draperd@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs can be found on the
last page of this report. Other major contributors to this report are listed in
appendix II.




Debra A. Draper
Director, Health Care




Page 23                                        GAO-19-488 TRICARE Prime Referrals
Appendix I: Comments from the Department
             Appendix I: Comments from the Department of
             Defense



of Defense




             Page 24                                       GAO-19-488 TRICARE Prime Referrals
Appendix II: GAO Contact and Staff
                  Appendix II: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Debra A. Draper, (202) 512-7114 or draperd@gao.gov
GAO Contact
                  In addition to those named above, key contributors to this report were:
Staff             Bonnie Anderson, Assistant Director; Danielle Bernstein, Analyst-in-
Acknowledgments   charge; Jennie Apter; Jacquelyn Hamilton; Jennel Lockley; and Vikki
                  Porter.




(102752)
                  Page 25                                     GAO-19-488 TRICARE Prime Referrals
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