Points of Interest: TRICARE's Fatal Flaw?

By Tom Philpott

Yet the complaints by departing physicians provide valuable insight into what could be the Achilles' heel of the TRICARE concept: a requirement to push patients and participating doctors through extra layers of bureaucracy to take full advantage of local military treatment facilities.

For the short term, the unanimous vote by Physicians Network's 12-member board of directors forced beneficiaries either to leave TRICARE Prime within two months or accept a new health care provider.

TriWest officials vowed to find replacement doctors, in part by re-signing some Physicians Network doctors to individual contracts. Meanwhile, hospitals at Fort Carson and Peterson Air Force Base made room for 3,700 more TRICARE Prime enrollees.

"We're very positive we'll have sufficient capacity, either at military facilities or with civilian providers," said TriWest spokesman Dan Springer.

Physicians Network doctors had experienced many of the start-up difficulties that marred TRICARE launches in other regions: lower-than-expected fees; claim processing problems including long delays in payment and frequent mistakes in claim amounts; many hours lost by physicians' staffs on telephones trying to coordinate care with the military system.

But all these problems were being addressed, said Dr. David Wolf, chairman of the board of Physicians Network. What couldn't be eased were his physicians' concerns that quality and continuity of care suffered under a system intent on making maximum use of military staff and facilities.

TRICARE civilian doctors cannot order x-rays or lab tests or refer patients to specialists without authorization. That's typical of most HMOs. Unique to TRICARE, however, is how powerless physicians feel to keep patient care from being delayed or interrupted as the system strains to take advantage of lower costs at military hospitals.

Consider a young man with an injured ankle, Wolf said. If military X-ray technicians are busy, a civilian doctor is allowed to take a quick X-ray and begin treatment. But at another time, with the same patient, a military X-ray might be ordered even if one couldn't be scheduled for several days. The patient, who might need a cast, has to wait.

"That's not the way one would normally practice medicine" Wolf said. All managed-care programs strive for efficiencies, but with civilian HMOs, "docs still can direct care of the patients through their system in a timely manner," Wolf said.

Given delays in patient referrals and the release of military lab results, some physicians worried about legal liabilities.

"Say there was an abnormality on a Pap smear and, for some reason, it dropped through the crack and never got followed up," said Wolf. "Sooner or later, if that patient had a problem, it would come back to his doctor. ‘Why didn't you follow up on this?' Well, that doctor might not have known there was a problem."

TRICARE Prime probably works better where there are fewer military hospitals, Wolf said. In Colorado Springs, with facilities at Peterson, Fort Carson, and the Air Force Academy, he said, "Patients get booted around."

Representative Joel Hefley (R-CO) demanded a report from TriWest on how many physicians it expected to re-sign.

Wolf expected some specialists to re-sign with the program, because they have not faced the same hassles as family practitioners in trying to arrange referrals for specialty care through the TRICARE gatekeepers.

Patients could stick with their current private-sector doctors if they were willing to pay for higher fee-for-service coverage under TRICARE Standard, formerly known as CHAMPUS. That's what retired Air Force Lieutenant Colonel Bill Crist said he would do. "I am completely satisfied with my doctor," Crist said. The rest of TRICARE Prime, he added, needs work.

"I don't know who's to blame-the government or the contractor-but somebody is trying to control the way these physicians perform medical care," Crist said.

Wolf sees TRICARE facing more struggles as it tries to protect a military medical system sized too large for anticipated wartime needs and too small to care for all beneficiaries.

"There's really no great mandate for every military base to have its own hospital and its own docs. It's an added expense," Wolf said. "In Colorado Springs, I would anticipate military bases very rapidly downsizing medical capabilities to take care of wartime needs, dispensary needs, possibly care of active duty," he continued.

"But the rest of the care, for dependents and retirees, will be turned over lock, stock and barrel to the civilian market," Wolf speculated. "Then it won't be a problem. It's while we try to do half-and-half that problems arise."

Representative Hefley said TRICARE officials claim the system works fine elsewhere. His constituents, however, are in Colorado Springs, and their anxiety is high.

"If a year from now we're still having these kinds of problems," Hefley said, "we need to do something else."

"I hear a lot of concern" from TRICARE users, Hefley said. "They think it's not working. There's anxiety over whether or not they're going to get care or, if they get care, are they going to have to continually change doctors. They will adjust to the system whatever it is, if they know what to count on."


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