Doctor payment cut could limit access for military families

Washington -- Eliot Light, MD, a family physician of 21 years, is facing one of his toughest decisions thanks to a military insurance program doctors say suffers from red tape, low payments and baffling rules.

If Medicare cuts proceed next year, his practice in Pacific Grove, Calif., will consider dropping the quarter of its patients covered by TRICARE, the Dept. of Defense insurer, because Medicare and TRICARE pay are linked.

It would be a painful choice given the commitment he feels to military patients in a time of war. But unless the cuts are scrapped or replaced with a cost of living increase, he said, "I, along with most physicians I know, would have to look seriously at reconsidering our commitment."

Many doctors are unhappy with the program for 9 million active duty, National Guard, Reserve and retired patients and their dependents. In a recent AMA Member Connect survey, 43% said they would limit or stop their acceptance of new TRICARE patients in 2007, when the program's reimbursement, mirroring Medicare, is expected to fall 5%.

TRICARE not only pays poorly, it also follows the old gatekeeper model, requiring authorization for specialists. It is "just odious," Dr. Light said.

Monterey County Medical Society, of which Dr. Light is secretary, had great difficulty persuading ob-gyns to sign up, and they did so out of patriotism, he said. "With the race to the bottom of the reimbursement scale, we are just not sure how long the specialists can continue to see these patients," he added.

TRICARE covers only his costs, or less, for childhood vaccinations. It robs staff of time in drumming up approvals. The program that covers government employees pays between 13% and 15% more and presents fewer bureaucratic hassles. "We don't understand why families of our fighting forces should have less access to care and why their physicians should be paid less," Dr. Light said.

Change needed

Physicians are calling for reform.

"They need to overhaul this program," Dr Light said. "They need to attach it to the federal employees' program and decouple it from Medicare."

John H. Armstrong, MD, an AMA trustee who devoted 17 years to the U.S. Army Medical Corps, said it was "difficult to engage" with TRICARE as a patient or physician.

"The TRICARE situation is a microcosm of the entire physician payment system, where physician payment is indexed to a flawed Medicare physician payment formula, which does not meet practice costs and does not account for investments in health care information technology and new equipment," he said.

The AMA is urging Congress to overhaul the Medicare payment formula, which would in turn improve TRICARE reimbursement.

The military program's payment rates are set by the Dept. of Defense and can exceed Medicare only in limited instances in which access is proven to have become a problem and an increase is approved by William Winkenwerder, MD, assistant secretary of defense for health affairs.

Some doctors reported few problems. Martin Menosky, MD, an Ohio family physician and member of the Reserves on duty at Fort Dix, N.J., said TRICARE was "no worse" than any other insurer in most respects. But he also has difficulty connecting patients with specialists, especially ob-gyns and general surgeons, despite the fact the program has 220,000 network physicians.

Military organizations are keenly focused on TRICARE. Jim Young, deputy director of government relations at the 370,000-strong Military Officers' Assn. of America, said his group had been asked to participate in a TRICARE survey that would investigate access concerns. This shows the Pentagon understands there are problems, he said.

The physician reimbursement issue has drawn attention in Washington. This year's defense authorization bill ordered the comptroller general to deliver by May 1 a study on program payments to children's hospitals and for obstetrical services. The Dept. of Defense is studying the difficulties, and one source said a proposal to make Medicaid the floor for delivery payments was making its way to Dr. Winkenwerder's desk and could be approved within months. The Government Accountability Office is also studying physician TRICARE payments.

Army Brig. Gen. Elder Granger, deputy head of TRICARE Management Activity, said his organization was "working hard" to overcome the difficulties, which he said only existed in some locations. He noted an increase in the number of network participants to 100,391 from 65,000 in 2004 in the West.

Pushed to the limit

Peter E. Lavine, MD, orthopedic surgeon and chair of the Medical Society of the District of Columbia, said his military patients find TRICARE's approval process particularly cumbersome. TRICARE refused to cover treatment for one patient with a torn quadriceps tendon because the patient was enrolled in the wrong part of the program.

"It not easy to get in direct contact with people when claims bounce back," he said.

Although he has a number of unresolved surgical claims, Dr. Lavine, born on a base in Japan where his father was serving as a military doctor, said he feels an "obligation" toward TRICARE. But he scoffed at the government's defense that payments are linked to Medicare.

"When you're taking care of people who have been in the military and become eligible through their service, you'd like it to be a program which people can be proud of -- especially with our country in a conflict, whether you agree with it or not."

Mitchell Miller, MD, a family physician in Virginia Beach and past president of the Medical Society of Virginia, said it had become much tougher to reach TRICAREwhen problems arose.

Having cut some Medicare patients, his practice was struggling to avoid restricting TRICARE, which covers one-fifth of its patients. "We are as patriotic as the next person, but we also have to run a small business, and that's hard to do when the numbers don't work."

The problems had major consequences in the Tidewater, Va., area last year when Mid-Atlantic Women's Care, with 72 physicians at 28 sites and four imaging centers in North Carolina and Virginia, dropped most TRICARE patients.

Holly Puritz, MD, testified about the decision before Congress in October. A key catalyst had been a policy change that required an authorized medical indication for 20-week ultrasounds. The practice viewed this as a breach in the standard of care.

"This was a very difficult decision," she said. "But our state Medicaid pays us better than TRICARE."