TriCare always was one of the lowest and slowest paying insurance companies, but when it began routinely to deny coverage—and thus care—one orthopaedic surgeon (and Marine wife) decided it was time to terminate her contract.
During World War II, training camps were erected all over the United States, some in rather remote places. Because young soldiers often came with wives who needed obstetrical care, local hospitals and physicians were overtaxed. In response to this problem, the Department of Defense began a program of dependent medical care. This program has changed character many times over the years and now is termed "TriCare"-a federally funded care plan managed by civilian healthcare networks in the manner of other health maintenance organizations (HMOs).
As an orthopaedic spinal surgeon and the wife of a retired Marine Corps colonel, I have been both a provider and a recipient of TriCare. On 15 June 2000, I terminated my TriCare contract. This puts me in the strange position of no longer accepting my own health insurance. Many factors brought me to this sad but necessary decision, and most could apply to any number of HMOs, but unlike other insurance programs, TriCare supports our national defense. Recently many HMOs have failed, leaving behind large debts and patients without access to care. I believe that TriCare is similarly in jeopardy of total collapse as other dedicated physicians leave the program. Reimbursement & Rationing
My Navy odyssey began as a Naval School of Health Sciences Education and Training Command (HSETC) scholarship student. After graduating from medical school, I completed an internship at Bethesda Naval Hospital, did two years as a general medical officer at Iwakuni, Japan, and Quantico, Virginia, then completed four years of orthopaedic residency at Balboa Naval Hospital. After two years as an orthopaedist at Camp Lejeune I left the Navy to accept a position as the Louis A. Goldstein Fellow of Spinal Surgery at Rochester, New York, and later joined a large private practice group in the Washington, D.C., area while my husband worked at the Pentagon. When my husband was ordered to Yuma, Arizona, I followed reluctantly, but I remained here to begin my own private practice. At the time of my husband's retirement, my fellow Marine Corps wives gave me a send-off, which included presentation of the following poem:
... I know you'll do well
And things will be fine
'Cause everyone in Yuma
Really does have a spine.
Before you leave
Can you make one thing clear?
Will you accept Champus
While practicing here?
"Of course!" I thought, "I must take the military insurance." For the next five years I saw active-duty trauma patients and dependents for emergent and non-urgent problems, trying always to make myself available to the base physicians. Even when not "on call" for the emergency room, I would accept new emergent problems, because I told my office to give "one-stop shopping service" to the Navy physicians, who otherwise might have to make several calls to get their patients cared for.
During these five years TriCare was the lowest paying insurance company with which I dealt—paying 85% of the Medicare fee schedule. To understand what this level of reimbursement means, consider the cost of putting on a long-arm cast. The federal government via the Health Care Finance Administration has codified medical services according to Relative Value Units (RVUs). Every office visit and procedure is assigned a number of RVUs, presumably on the basis of the cost and time to provide the service. Therefore, any physician can take his office overhead, divide it by the number of RVUs performed during the course of a year, and develop an idea of his cost per procedure, amortizing office costs across the various procedures.
The total cost not including my salary is $69.06. From 1995 to 1998, TriCare has reimbursed me approximately $57.70. This rate recently was increased, but this has been at the expense of lowering other rates, for a $0 sum gain. An anesthesiologist recently showed me his reimbursement for a TriCare general anesthesia case where he was paid $60 an hour for keeping the patient alive. My plumber makes more than that, as does the veterinarian who anesthetized my cat for $75 an hour.
Added to this is the difficulty getting paid in a reasonable time frame. My son underwent surgery in March 1993 at Children's Hospital in Washington, D.C. The (at that time) Champus office told me and the doctor's office and hospital that no preauthorization for his particular type of surgery was required. Afterward, the bill was refused because "no authorization was obtained." I wisely had recorded the name of the Champus representative who gave the approval for surgery, but still it took the hospital, the doctor's office, and me three years of letter writing and phone calls to get the bill paid. I am expected to pay my creditors within 30-90 days.
Nonetheless, I did not jettison TriCare over this financial situation, and I continued to see patients because I felt a certain patriotic obligation.
So what has changed? Over the past year and a half, the system for authorization has changed—new policies have been implemented covertly. Nothing has been communicated to me as a provider, but the change has been noted by both staff and patients. Authorization always has been required for most surgical procedures, and in the past, this was made in a fairly rational way. Sometimes more information had to be sent, but one could deal with the system. In this past 18 months, however, every spinal surgery case for which I requested authorization initially was denied. The same denial letter—a form letter—was sent to me:
This case has been reviewed by a peer reviewer clinical specialist in the appropriate field. Based solely on the medical documentation submitted, coverage for the requested service has been determined not to be medically indicated by the reviewer.
This is now sent routinely to me and other surgeons who are TriCare providers. At this point, care is either terminated or delayed by months as the patient and I argue our case to the distant bureaucracy.
Let me site an example. Last year I cared for a retired Marine who was in very good health but who developed cervical radiculopathy-—a nerve root "pinched" by either bone or disc encroaching into the spinal canal leading to symptoms in one or both arms. I had seen this patient over a period of nine months and had treated him with every conservative approved modality. In spite of this, he continued to have pain, weakness, and wasting of the arm. MRI and electrical studies confirmed the clinical diagnosis. By anyone's criteria this patient had clear indication for surgery. We began the authorization process on 29 July 1999 and received the letter of denial quoted above. When we questioned the denial we were sent the following note:
... to meet the criteria, need to know, 1) Is there nontraumatic instability without neural compression? 2) If so, is there instability on flexion extension xrays showing sagittal plane translation greater than 3.5 mm or 20% of vertebral body width? And 3) Has the patient had a rehabilitation exercise program? Please fax back to ....
We sent answers, but as any physician will recognize, these questions do not really pertain to this patient. This patient has neural compromise, so the fusion is being requested, not for segmental instability as suggested by the questions, but as part of a routine anterior cervical discectomy and decompression. Clearly, the person reviewing the case was just going down a checklist from a book of criteria, but we were told the reviewer was a "clinical specialist in the appropriate field." Approval was granted only after I wrote a two-page letter including, "Should you deny this upon appeal, I feel it is only fair to ask that the reason for the denial be given, and that the background of the reviewer is specified in better terms than a `peer review clinical specialist."' (Other patients who requested the name of the physician reviewers and their state of licensure were denied that information on the grounds that the information was federally protected.)
Finally, another letter was received saying, "After careful reconsideration of this case, including all additional information, the second physician reviewer, an orthopaedic surgeon, determined that the cervical arthrodesis with graft is 'medically appropriate."' Note that this time an orthopaedic surgeon reviewed the case. Who was the "peer review clinical specialist" before? Surgery was completed two months later, and the patient did well.
Needless to say, this case took a great deal of staff time. Seven pages of my medical record are devoted to letters, counter-letters, and faxes related to this case—a case sent to me from the Marine Base Clinic, by a Navy physician who felt referral to a spinal surgeon was appropriate.
Cases such as these markedly increase my cost for delivering standard care and produce angry patients who do not always believe our explanations for the delays. In this case, the delay was not harmful to the outcome, but this is not always true. Recently, I tried to convince TriCare of the urgency of a patient's problem, but the request was relegated to the standard two-to-three week authorization queue. During this period, the patient decompensated—in addition to having some bowel and bladder dysfunction, she developed decreased sensation in the legs and weakness to the point where she could not care for herself at home. I admitted her through the emergency room. Because this patient's surgery was not "planned" at this point, she was stabilized for a few days in the hospital while specialized equipment was obtained and the case was coordinated with a vascular surgeon assistant. TriCare subsequently has denied the admission (leaving the patient responsible for the hospital bill), stating that the problem was emergent and should have been surgically treated on the day of admission. In sum, TriCare denied payment for the care because of its "urgency" after refusing to consider it "urgent" when I called to expedite authorization. Where is the white rabbit?
On a personal note, I broke my clavicle in a colorful, high-energy fashion, resulting in wide displacement of the bone fragments. According to the standard te—which would be a significant disability in my profession. After a month no clear diminution in the mobility of the fragments was noted, so I consulted a colleague who recommended ultrasound home therapy to stimulate healing and diminish risk of nonunion. I was unable to get TriCare to authorize this for myself!
Benefits of Termination of the Contract
By terminating my contract with TriCare I have accomplished several things. First, I have made the office a more pleasant place. In psychiatry, we learn about transference—the process whereby patients transfer their anxieties and fears to the physician. Every day, these patients' frustration and anger in dealing with TriCare was transferred to us. An office of angry patients and disgruntled staff makes it difficult to deliver pleasant care.
Second, I have improved my financial outlook. As other physician groups recently bankrupted have discovered, no increase in the volume of patients will offset losses on every patient.
Third, I believe I have upheld the prime directive of Hippocrates—first of all do no harm. As a medical student I assumed this aphorism meant do not stick the needle in the wrong place, or do not prescribe the wrong medicine. In fact, the meaning is much greater. It includes not supporting a system that ultimately is bad for patients. It includes drawing the line when patient care is compromised by an absurd and dishonest system. As Hippocrates also said, "It is the duty of the physician not only to do that which immediately belongs to him, but likewise to secure the cooperation of the sick, of those who are in attendance, and of all the external agents" (italics added).
Honesty and Dishonesty in Medical Delivery
Cost does matter. There is not an infinite pot of gold for medical care, and it is honest and appropriate to limit dollars to health care in the same way that budgets are set for submarine building or missile technology. When I was a resident in orthopaedics at Balboa Naval Hospital, we were budgeted a certain number of total joint implants. When the year's allotment was used, anyone awaiting a total hip or total knee replacement would be placed on the list on a first-come, first-served basis for the next fiscal year. We may not like to delay such non-emergent care, but at least this method of rationing is honest.
In contrast, it is dishonest to ration care using the ruse of medical necessity. To suggest that a "peer reviewer" thousands of miles away, who has neither questioned or examined the patient nor reviewed the actual pathologic slides or radiographs, can make better medical decisions than the treating physician is more than absurd—it is patently dishonest. The aim is to delay care, and therefore financial outlay, while purporting to benefit the system as a whole by careful stewardship of resources.
At the beginning, these programs function reasonably well, but as time goes on, care slowly is eroded to meet the bottom line, as treatments or medications that once were allowed are deemed no longer necessary. Furthermore, labeling care to be "not medically necessary" not only prevents the patient from getting care through TriCare, but also often results in the patients' other insurance not paying—thereby denying care. Dependents of active-duty service members do not have a choice of insurance. They are at some level automatically enrolled in TriCare, which is paid for indirectly (as is all workplace-based insurance), in lieu of other benefit or salary.
Considering the Solutions
Clearly the issue is complex, and the answers will not be easy to develop. But the complexity of the issue should not be used to justify the unethical system now in place. Using honesty as a guideline, I offer DoD the following recommendations:
- Decide on the scope of dependent medical care. Should it be given to no dependents, every dependent, or earned with a service members longevity or rank? It is more honest to limit the dependants covered than to indirectly ration care.
- Skip first-dollar coverage and concentrate on last-dollar coverage—the traditional role of market-driven insurance policies. The goal is to limit any person's catastrophic outlay when ill, not to cover every doctor's visit for a sniffly nose, which encourages overuse and waste. When people must spend their own money, they consult Mom or the neighbor with experience first. When they are spending someone else's money—the government's or the insurer's—patients (or parents of patients) do not need to accept any risk or exercise judgment, and they can take themselves or the child with the mild temperature elevation to the emergency room or the doctor's office.
There is no free lunch, and the price of freedom is individual responsibility. Everyone needs to realize, in some way, the cost of their own medical care. It is more honest to increase a patient's cost share up front than to exercise back-door rationing.
Of course, doctor's office fees no longer are financially innocuous; they have been inflated to deal with the increased cost of billing and fighting with insurance companies. It also is easier to charge the hidden payer than the customer at the window. I routinely give a sizeable discount for cash payment. I believe most physicians would cut office fees if the bill, or most of the bill, were paid up front, and the remainder was handled in a timely and honest fashion.
- Trust our physicians. And deal with violations of that trust on a case-by-case basis. In many civilian HMOs nearly 30% of the funds paid into the system are diverted to oversight—rather than contributing to the care of the patient. How much is being diverted to the civilian overseers for TriCare? Medicare has very low administrative overhead because it does not require authorization for care from an off-site agency. Even most private insurers have dispensed with the mandatory second opinion because it proved not to be cost effective. It is more honest to ration the types of care offered (in a clearly defined way) than to dispute the local physician's judgment about what care is indicated.
- Make contracts with physicians and hospitals fair. In the past, we have been coerced into signing one-sided contracts that allow insurers to contract our services without agreeing to any payment scale and to change reimbursement at will and without notification. We have been contractually required to provide timely care, but they have been allowed to delay payment ad lib—sometimes for years. TriCare has a unique "Claim Check System" that reviews bills and denies payment for many services that other federal insurance covers. A physician may send in a protest, but it is denied universally. There is no way to make human contact to discuss any issue of payment with TriCare, even to verify that claims have been received. No company in the world would do business with another firm under these conditions. If I supply a product that is fairly priced and well delivered I expect honesty in paying my bill.
- Avoid the newspeak of today's medical businessmen wherein patients become "covered lives" and physicians, phlebotomists, speech pathologists, and all manner of people become grouped equally under the rubric of "health care provider." A "peer reviewer" may not have an ethical obligation to "covered lives," but physicians will always shoulder the ethical obligation to treat patients according to the rules passed down to us from ancient times.
Dr. Hieb is an orthopaedic spinal surgeon in Yuma, Arizona, and the wife of a Marine Corps officer.