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Civilian Physician Acceptance of New Patients Under TRICARE Standard FY 2007 Survey Results

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Title: Civilian Physician Acceptance of New Patients Under TRICARE Standard FY 2007 Survey Results


1
  • Civilian Physician Acceptance of New Patients
    Under TRICARE Standard FY 2007 Survey Results
  • January 29, 2007

2
Background
  • Fiscal Year (FY) 2004 National Defense
    Authorization Act (NDAA) Section 723 Public Law
    (P.L.) 108-136
  • Required Conduct surveys in US TRICARE market
    areas to determine how many providers are
    accepting new patients under TRICARE Standard.
  • Response Gained Office of Management and Budget
    (OMB) approval for pilot survey of 20 locations
    in 2004, then obtained OMB approval of 3-year
    methodology (FY 2005- FY 2007) using mail survey
    telephone follow-up
  • Required Survey at least 20 market areas
    annually, until all surveyed.
  • Response Survey 20 states in 2006 and 2006
    (Standard Market Area, 1,000 doctors/state
    randomly sampled), 10 states WA DC in final
    year, 2007.
  • Exceeded by also surveying local Hospital Service
    Areas (HSA) up to 1,000 randomly sampled
    doctors/HSA.
  • Required Consult with representatives of
    TRICARE beneficiaries/providers to identify
    locations experiencing significant levels of
    access-to-care problems under TRICARE Standard
    and give high priority.
  • Response Met each year with Beneficiary Panel
    and obtained desired survey locations exceeded
    through collaboration with TRICARE Regional
    Offices to identify their locations of concern.
  • Required Government Accountability Office (GAO)
    semi-annual review. Response GAO-07-48
    completed Dec 06.
  • FY2006 NDAA (Section 711 P.L. 109-163) added
    questions. Included 2006.

3
FY 2004 FY 2007 Survey Locations by State and
Sub-Market Hospital Service Areas (HSAs)
FY 2005-FY 2007 Surveys Physician sample each
year was 40,000 with an annual response of about
18,000 in 2005, almost 19,000 in 2006, and over
19,000 in 2007 for an adjusted response rate of
greater than 50 each year. In FY 2005 (with 29
HSAs) and 2006 (with 38 HSAs) the sample frame
was about equally split among HSA and State-wide
samples with 20 states surveyed each year. In
2007, with surveying 11 states and 53 HSAs, the
sample was higher for HSAs .
4
Summary of Findings Survey Results After Three
Years
  • Between 18,000 (2005) and 19,000 (18,900 in 2006,
    19,000 in 2007) eligible physicians responded
    each year to the survey with annual response
    rates of 50.
  • Sampling all 50 states, Washington DC and over
    100 local Hospital Service Areas
  • There appears to be a high level of physician
    awareness with 9 of 10 physicians reporting
    awareness of the TRICARE program in general (87
    nationally, weighted, /- 0.7).
  • About 8 of 10 physicians accept new TRICARE
    Standard patients if they accept any patients at
    all (81.3 nationally, weighted, /- 0.7).
  • Of the remaining 2 of 10 physicians who do not
    accept new TRICARE Standard, the most commonly
    cited reason is due to reimbursement related
    issues (one fourth of their comments).
  • And, of those accepting new TRICARE Standard
    patients, 9 in 10 do so for all claims, rather
    than on a case-by-case basis (90.7 /- 0.6).
  • Between 8 and 9 of 10 physicians accepting
    Medicare also accept new TRICARE Standard.
  • But there is variability in these results, across
    HSAs, states, and specialties reflecting
    opportunities for improving the general knowledge
    and acceptance of TRICARE
  • State level- Focus on acceptance for Alaska and
    perhaps, Maryland also Colorado, Hawaii,
    Oklahoma (2006 survey) and New York, New Jersey
    and Texas (2005 survey)
  • HSA-level Washington DC New York City (esp.
    Brooklyn), Raleigh, NC Seattle and Olympia WA,
    Lihue/Kealakekua/Wailuku, HI Dallas, TX.
    Denver, CO and Falls Church, VA.
  • Medical specialty- level Psychiatrists lowest in
    awareness and acceptance.
  • Special study of Alaska and effect of Mar 07
    increase in reimbursement Compared to 2005,
    Awareness and Acceptance rates appear to have
    increased, excluding Anchorage, but acceptance of
    other insurance may have increased faster, so
    about the same acceptance of new TRICARE of those
    accepting any new more work needs to be done to
    improve acceptance in Anchorage.

5
FY 2007 Physician Awareness of TRICARE (53
Hospital Service Areas, HSAs)
  • 1st column Average of all 53 HSAs
  • 2nd column Average of those identified by the
    Beneficiary Panel
  • 3rd Column Average of TRO identified HSAs.
  • 4th Column (green) WA DC
  • 2007 average of almost 93 across 53 HSAs
    (ranging from 77 to 100)
  • Compared to 93 in FY 2006 (38 HSAs) ranging from
    84-100
  • 90 in FY 2005 (29 HSAs), ranging from 55 -
    99. Not asked in FY 2004.

Lowest Cleveland, Ohio (77) 2nd Lowest (WA
DC) 81
Lowest in 2006 Mt Clemens, Michigan
Charlottesville, Virginia (84), Lowest in 2005-
Brooklyn New York (NY) (55)
Note data are not adjusted or weighted for non
response.
6
Physicians Accepting New TRICARE
Standard Patients of those Accepting ANY New
Patients (53 HSAs- unadjusted)
2007 Lowest Olympia, Washington 40.7 (but
small Dr.s since surveyed in 2005) WA DC
(62.1) Destin, Florida (67) Houston, Texas
(70)
Lowest 2006- Lihue, Hawaii (HI) (44) Lowest
2005 Brooklyn, NY (60)
  • 2007 average of 84 ranges from 41 to 100
    accepted new TRICARE Standard patients of those
    accepting any new patients.
  • Compared to 82 in 2006 in 38 HSAs patients
    ranging from 44 to 100 (Lowest Lihue, HI
    (44), Raleigh, North Carolina and Kealakekua,
    HI ( both 67) and Dallas, TX (70).
  • And 81 (29 HSAs) in FY 2005 (60 to 96, lowest
    in Brooklyn, NY and Seattle, WA).
  • 82 in 20 FY 2004 sites in two survey rounds,
    ranging from 60 (Anchorage, AK). To 95
    (Fayetteville, TN).

Note data are not adjusted or weighted for non
response.
7
Physicians Accepting TRICARE Standard
Reimbursement for All claims (53 HSAs)
Prescott, AZ 80 Joplin, MO- 81
  • In 2007 almost 92 of all physicians in the 53
    HSAs accepting new TRICARE Standard patients do
    so for all claims ranging from 80 to 100 Low
    Prescott, AZ (80) and Joplin, MO (81)
  • Compared to almost 91 (38 HSAs) in FY 2006
    (72-100)- Low Salem, Oregon (72.3) and
    Wailuku, HI (75).
  • 93 in FY 2005 (29 HSAs) ranging from 79
    (Monterey, CA) to 99 and 89 in FY 2004
    baseline study across 20 sites, ranging from 71
    (Anchorage, AK) to 94.

Note data are not adjusted or weighted for non
response.
8
HSA Physician Comments What are the reasons
for not accepting new TRICARE Standard patients?
(FY 2004-2007)
  • Reimbursement most frequently cited by the 20
    of doctors not accepting new TRICARE Standard
    (about one-fourth of all doctors and all comments
    received each year) includes low and
    insufficient fees or fee schedules, does not
    cover overhead costs or write off too high,
    takes too long to get paid.
  • Other reasons include Not accepting patients
    (accepting no new patients or panel is full) and
    Miscellaneous (e.g. not a signed provider,
    compromise confidentiality requirements, Drs
    policy, pay cash and get reimbursed through own
    insurance) and Inconvenience" which includes
    claims-related problems other than payment (e.g.
    authorization, rejection, difficulty
    processing/billing).
  • Note Comparisons between fiscal year results
    (e.g. FYs 2004, 2005, 2006 and 2007) should be
    used with caution, given noted differences in
    survey instrument, methodology and, possibly,
    even coding of qualitative comments. Data are
    not adjusted or weighted for non response.

9
Percentage of Patients Physicians See Using Any
Form of TRICARE (across HSAs States)
Little Rock, AR
  • In general, across most HSAs, TRICARE (any form)
    tends not to be a substantial part of the typical
    doctors practice 7 average across the 53 HSAs
    (blue line above) and 3 median (red line).
  • But variation up to high of 20 across some
    HSAs (e.g. Clarksville, TN (26)- Ft Campbell
    area Jacksonville, AR (22)- Little Rock AFB)
    and very low in others (e.g. Madison, WI and
    Ainsworth, NE- 1-2).
  • Little Rock AR represents both the mean and the
    median across the 53 HSAs in 2007.

10
HSA Physicians Accepting New TRICARE Standard
Patients of those Accepting New Medicare Patients
2007 Low Olympia, WA (45), but low doctors
sampled (surveyed in 2005)
  • In 2007 almost 84 of all HSA physicians accepted
    new Medicare patients (not shown), and of those,
    almost 88 accepted new TRICARE Standard
    patients.
  • 2006, 81 of all HSA physicians accepted new
    Medicare patients (low in Lihue, HI (43),
    Virginia Beach (70)), and 86 of those doctors
    accepted new TRICARE Standard patients, ranging
    from 76 to 100
  • Lowest Dallas, TX (almost 76), and Wailuku, HI
    (78).

Note data are not adjusted or weighted for non
response.
11
Physician Awareness and Acceptance of TRICARE
By Specialty
  • Awareness Across the 11 states, awareness by
    Specialty ranges from 80 to 95
  • Highest for OB-GYN (95), Ophthalmology,
    Surgery, Medicine, Lowest for Psychiatry (
    80).
  • Acceptance Below, left as a group,
    psychiatrists lowest in accepting any new
    patients (89), and any new TRICARE Standard
    patients (49).
  • Below combined accepting TRICARE of accepting
    any (55) All other specialties accept TRICARE
    if accept any new patients at rates of 80 or
    higher.

Note data are adjusted and weighted for non
response.
12
Stable Results Across Annual Surveys- With
Different States/HSAs 2004 Pilot FY 2005-2007
Accept New TRICARE Std If Accept New Medicare
Accept Any New Patients
Accept New TRICARE Std Patients
Accept New TRICARE Std If Accept Any
Accept TRICARE Std For All Claims
AWARE
Accept New Medicare
13
Comparison of HSA Population Size and Acceptance
of Either TRICARE Standard Patients or Any New
Patients
Jacksonville, FL- (19,643)
(1,049)
(5,128)
(4,336 )
14
Conclusions and Recommendations
  • After three years of surveying civilian
    physicians the FY 2007 results appear consistent
    with prior year findings
  • 9 of 10 doctors are aware of the TRICARE program
    in general.
  • And 8 of 10 doctors report acceptance of new
    TRICARE Standard patients if they accept any new
    patients at all.
  • And, when they do accept TRICARE Standard, 9 of
    10 do so for all claims.
  • But, there is variation at the state, HSA and
    medical specialty levels, indicating awareness
    and acceptance are not uniform, and offering
    opportunity for improvement.
  • Reimbursement is cited in one-fourth the comments
    provided by those two of ten doctors not
    accepting new TRICARE Standard patients, with
    other reasons offered at lower frequency.
  • Recommendation
  • Continue efforts focusing on improving those
    areas with lowest awareness and acceptance, as
    well as psychiatrists in general.
  • Disseminate results to TMA staff, including the
    Regional Offices, to the Surgeons General, and to
    outside entities including the Beneficiary Panel,
    Congressional representatives, and to the public
    (e.g. MHS Conference).

15
Next Steps
  • Coordinate FY 2007 results
  • Memo to ASD(HA), Information paper to
    Congressional Staff
  • Brief results to TROs (Dec 07)
  • Brief SG staff (10 Jan 08) send results to
    Service and Joint Staff Surgeons General
  • Brief results externally
  • Brief TRICARE Beneficiary Panel (Jan 2, 08)
  • MHS National Conference (Jan 29 08)
  • AMA Government Rep
  • GAO, if requested
  • Continue more detailed analyses to support TRO
    understanding and action (Jan Mar 08)
  • Support TRICARE Operations, CCS and the TROs in
    continuing the focused TRICARE Standard
    Communications Strategy begun last year, refined
    with this years findings.
  • Provide brief summary in CCS Standard newsletter
    (Feb 07).
  • Focused mailings (thanks for the support and
    need your help) to selected County/State
    medical Societies and major city Newspapers
  • Monitor FY 2008 Legislation for effect on
    extension of survey requirements (NDAA Conference
    Report, Section 711) establish future survey
    strategy as necessary, acquire contract support,
    provide public notice and OMB 120-day review
    process (began Nov 07).
  • Requires surveys from FY 2008 2011 focus on
    Prime Service Areas and non-prime identifies
    mental health providers as intended recipients
    requires benchmarks to be established for primary
    and specialty provider availability, including
    mental health providers.

16
Questions?
17
FY 2005-2007 Survey Methodology
  • OMB reviewed and approved the multi-year survey
    methodology (6 July 06)
  • FY 2004 Pilot study of 20 locations.
  • Three-year methodology (FY 2005- FY 2007) using
    mail survey telephone follow-up
  • Instrument increased number of questions 3 (FY
    04- Pilot), 4 (FY 05) 8 (FY 06 and FY 07)
  • Is the doctor aware of the TRICARE program?
    (added FY 2005).
  • Is the doctor accepting new TRICARE Standard
    patients (Yes all claims Yes case by case, no)?
  • If no, what are the reasons the doctor is not
    accepting new TRICARE Standard patients?
  • What percentage of patients the doctor currently
    sees use any form of TRICARE? (added FY 06).
  • Does the doctor accept any Medicare patients?
    (added FY 06).
  • Is the doctor accepting new Medicare patients?
    (added FY 06).
  • If no, what are the reasons the doctor is not
    accepting new Medicare patients? (added FY 06).
  • Is the doctor accepting any new patients?
  • Who Surveyed?
  • Billing Managers surveyed on behalf of about
    40,000/year randomly selected full-time (20
    hours/week) office-based non-federal civilian
    physicians (MDs and DOs) using the American
    Medical Association Physician database.
  • How Selected?
  • State-Wide samples (Standard Market Area)
    1,000 doctors/state randomly sampled 20
    states/year in FYs 2005 and 2006 finish in
    FY2007 with 10 states and WA D.C.
  • Local Hospital Service Area (HSA) samples (up to
    1,000 random doctors/HSA) these sub-market
    samples at city/town-level address local areas of
    beneficiary concern, supplement state-wide
    samples

18
FY 2007 Survey Sites
  • 53 HSA Survey Sites
  • 23 selected by beneficiary representatives (PB)
  • 11 by TRO staff (pt) plus 3 also by PT)
  • 18 randomly selected, plus 2 also by PB)
  • WA D.C- Base Sample)
  • And 11 States (bolded- ST) also have state-wide
    random sample
  • WA DC
  • Alabama (AL)- Mobile (R)
  • AL- Montgomery (R)
  • Arkansas (AR)- Jacksonville (R)
  • Arizona,(AZ)- Little Rock (R)
  • AZ- Mesa (R)
  • AZ- Phoenix (R)
  • AZ- Prescott (PT)
  • Florida (FL)- Destin (PB)
  • FL- Jacksonville (R)
  • FL- Orlando (R)
  • FL- Sarasota (PT)
  • Mississippi (MS)- Biloxi (PB PT)
  • Nebraska (NE)- Ainsworth (PB)
  • New Mexico (NM)- Las Cruces (PB)
  • New York (NY)- Plattsburg (PB)
  • Ohio (OH)- Cincinnati (R)
  • OH- Cleveland (PB)
  • OH- Dayton (R)
  • OH- Lima (PT)
  • OH- Toledo (PT)
  • Oregon (OR)- Madras (PB)
  • OR- Prineville (PB)
  • Rhode Island (RI)- Newport (PB)
  • RI- Providence (PB)
  • South Carolina (SC)- Charleston (PB PT)
  • SC- Columbia (PB PT)
  • Tennessee (TN)- Chattanooga (PT)
  • TN- Clarksville (R)
  • TN- Greensville (PT)
  • TN- Nashville (R )
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