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10-25-05, 02:50 PM
October 31, 2005
Tricare troubles continue
Low payouts, referral problems dominate House panel hearing
By Deborah Funk
Times staff writer

Ten years after its creation, Tricare continues to struggle with administrative hassles and low payment for some specialists — lower even than Medicaid, the health care system for the poor — according to doctors and program managers.

Dr. Holly Puritz, an obstetrician-gynecologist in Tidewater, Va., told members of the House Armed Services personnel subcommittee in an Oct. 19 hearing that Tricare rules, practices and low payments forced her practice, Mid-Atlantic Women’s Care, to make “the very difficult decision” to drop out of Tricare early this year.

“Washington, we have a problem,” Puritz said.

One particular problem stemmed from difficulties her practice’s doctors had in getting authorization to refer patients for other care, she said.

By design, Tricare tries to make the most use of the military’s hospitals and clinics, so civilian doctors must first try to get their patients seen at those facilities.

James Woys, president of Health Net Federal Services Inc., which manages Tricare in the Tidewater area, said most health care companies have eliminated referral processes, and Tricare probably sticks with its process only because it seeks to use the military’s brick-and-mortar facilities.

Mid-Atlantic Women’s Care had to refer high-risk patients to Portsmouth Naval Hospital, Va., “where we frequently have trouble getting timely consultative appointments for ultrasound, diabetic evaluations or other high-risk conditions,” Puritz said.

“We get minimum feedback from those referrals,” she said, adding that high-risk pregnant women have waited up to four weeks for a diabetic consultation.

Tricare’s reimbursement rate also “is woefully inadequate” — about two-thirds what other insurers pay, Puritz said.

A commercial plan pays $2,281.39 for nine months of care for the expectant mother and unborn child and the child’s delivery. Tricare pays $1,537.10.

Witnesses at the hearing said Tricare sometimes makes it difficult to provide even routine care. Under the old contracts and a different Tricare manager for the Tidewater region, Puritz’s group was paid $300 for ultrasound images taken 20 weeks into a pregnancy, a test considered routine.

Now, after Tricare has reorganized and issued new contracts, doctors were told the cost of the ultrasound is included in a lump sum for obstetrics care, and Puritz’s practice had to pay for the procedure itself to maintain its standard of care.

The testimony was reminiscent of past Tricare hearings. Several years ago, an Arkansas doctor cited the same issues — low, slow payments and administrative hassles.

“I feel like we’re replaying a movie from three years ago,” said Rep. Vic Snyder, D-Ark., a physician by training.

The money Tricare pays doctors is about the same as Medicare’s reimbursement rates. But some specialties, such as obstetrics and pediatrics, have no good parallel, since Medicare pays primarily for senior citizens’ health care.

While Medicare does not have good matches to set doctor payments for the care of children and pregnant women, Medicaid does provide pediatric and obstetrics services. But Tricare’s payment rates often do not match Medicaid’s, either.

TriWest Healthcare Alliance manages Tricare services in the Western United States. In Everett, Wash., an obstetrics practice wanted out of Tricare because Tricare paid less than Medicaid, said David McIntyre Jr., president of TriWest.

TriWest conducted a survey in its region and found that in five of 11 states surveyed to date, Tricare’s reimbursement rate to doctors was 69 percent to 91 percent of what Medicaid pays for obstetrics care, McIntyre said.

Dr. William Winkenwerder Jr., assistant secretary of defense for health affairs, promised to look at the issues and noted that the survey consisted of “preliminary” data from a handful of states.

“It’s an indication that we need to look at it. We’re going to look at it,” Winkenwerder said after the hearing.

“If we need to make adjustments, we will.”