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[H.A.S.C. No. 106–41]



FOR FISCAL YEAR 2001—H.R. 4205






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FEBRUARY 28, 2000




STEVE BUYER, Indiana, Chairman

J.C. WATTS, Jr., Oklahoma
LINDSEY GRAHAM, South Carolina
JIM RYUN, Kansas
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MARY BONO, California
JOSEPH PITTS, Pennsylvania
ROBIN HAYES, North Carolina

MARTIN T. MEEHAN, Massachusetts
JOHN B. LARSON, Connecticut

John D. Chapla, Professional Staff Member
Thomas E. Hawley, Professional Staff Member
Michael R. Higgins, Professional Staff Member
Edward P. Wyatt, Professional Staff Member
Debra S. Wada, Professional Staff Member
Nancy M. Warner, Staff Assistant



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    Monday, February 28, 2000, Fiscal Year 2001 National Defense Authorization Act—Removing the Barriers to TRICARE


    Monday, February 28, 2000



    Abercrombie, Hon. Neil, a Representative from Hawaii, Ranking Member, Military Personnel Subcommittee

    Buyer, Hon. Steve, a Representative from Indiana, Chairman, Military Personnel Subcommittee

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    Balsam, RDML. Marion, U.S. Navy, Commander, Naval Medical Center Portsmouth/Lead Agent, Region 2

    Braaten, Maj. Gen. Thomas A., U.S. Marine Corps, Commanding General, Marine Corps Air Bases East, Marine Corps Air Station, Cherry Point, North Carolina

    Bryant, Michael, M.D., President, Sand Hills Physician Associates

    Butler, Glenna G.

    Butts, Command Sgt. Maj. Aubrey, U.S. Army, Command Sergeant Major, 1st Battalion, 505th, Fort Bragg, North Carolina

    Cole, RADM. Christopher, U.S. Navy, Commander, Navy Region Mid-Atlantic, Norfolk, Virginia

    Dickson, Steve, Administrator, Village Surgical Associates

    Farmer, MSgt. Russell C., U.S. Air Force (Ret.)

    Fazekas, Maj. Scott, U.S. Marine Corps, Public Affairs Officer, II Marine Expeditionary Force, Camp Lejeune, North Carolina

    Fazekas, Tracy
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    Ford, James D., Regional Vice President, Anthem Alliance Health Insurance Company

    Garman, Lt. Col. Robert, U.S. Army (Ret.)

    Gottardi, Brig. Gen. Larry, U.S. Army, Commander, XVIII Airborne Corps Artillary, Ft. Bragg, North Carolina

    Heckert, John, Practice Administrator, Cumberland Anesthesia Associates, P.A.

    Maffey, Alice

    McClain, Marjorie

    McClelland, Senior Airman Glenn, U.S. Air Force, Weapons Loader, 74th Fighter Wing, Pope AFB, North Carolina

    Murray, MSgt. Janet E., U.S. Air Force, 1st Sergeant, 43rd Civil Engineering Squadron, Fort Bragg, North Carolina

    Nemeth, Master Chief James F., Jr., U.S. Navy, Shore Intermediate Maintenance Facility, Norfolk, Virginia

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    Otto, LCDR. Jamie, U.S. Navy, Catapult and Arresting Gear Officer, USS Roosevelt (CVN–71)

    Overman, CDR. William J., U.S. Navy (Ret.)

    Reichler, HMC. Randy, U.S. Navy (Ret.)

    Seip, Brig. Gen. Norman R., U.S. Air Force, Commander, 4th Fighter Wing, Seymour Johnson AFB, North Carolina

    Togiai, Sgt. Timothy, U.S. Army, C Company, 37th Engineer Battalion, Fort Bragg, North Carolina

    Tucker, CMSgt. John, U.S. Air Force (Ret.)

[The Prepared Statements submitted for the Record can be viewed in the hard copy.]

Abercrombie, Hon. Neil

Buyer, Hon. Steve

Farmer, MSgt. Russell C. (Ret.)

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Fazekas, Maj. Scott

Fazekas, Ms. Tracy

Ford, James D.

Hayes, Hon. Robin, a Representative from North Carolina

Heckert, John

Overman, CDR. William J. (Ret.)

Reichler, HMC. Randy (Ret.)

[The Documents submitted for the Record can be viewed in the hard copy.]

High Cost Outpatient Procedures and Prospective Review Requirements submitted by Steve Dickson
Children's Health Network letter to Hon. Steve Buyer from Lawrence Bates

[The Questions and Answers are pending.]


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House of Representatives,
Committee on Armed Services,
Military Personnel Subcommittee,
Washington, DC, Monday, February 28, 2000.

    The Subcommittee met, pursuant to call, at 9:00 a.m. in the Ballroom, Fort Bragg Officers Club, Totten & Armisted Streets, Fort Bragg, North Carolina, Hon. Steve Buyer (Chairman of the Subcommittee) presiding.


    Mr. BUYER. This is a hearing of the Military Personnel Subcommittee of the House Armed Services Committee, and will come to order.

    The first panel may take their seats.

    We appreciate the attendance at this Congressional field hearing today, and would announce to the audience that this is not a town meeting; this is a formal Congressional hearing.

    This is the second of three hearings the Subcommittee on Military Personnel will conduct on the subject of TRICARE this year. All of the hearings will be focused on finding ways to remove barriers to TRICARE for our military personnel and their families, both active and retired.
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    The first two hearings are field hearings during which we will receive testimony from individuals intimately involved in the system as users, providers, troop leaders, and TRICARE managers.

    Today we will first hear from active duty personnel and their families. The second panel of witnesses will be retired personnel. Our third panel today includes local health care providers and the TRICARE Region 2 Lead Agent and managed care support contractors. During our last panel we will hear from senior troop leaders from each of the services.

    By way of opening I would like to thank the Commander of the 18th Airborne Corps, General Kernan and his staff, for hosting this field hearing, and for providing all of the on-site support. I would also like to thank my colleagues and ranking member of the Subcommittee, Mr. Neil Abercrombie. It took him 22 hours to travel here from Hawaii last night, and I do not know if you are coming or going, but we appreciate you being here.

    A little bit later we will also be joined by Mr. McIntyre who is on his way as I understand, but we need to proceed.

    I am especially thankful to Mr. Hayes for inviting us to his district, and for giving us this important opportunity to see firsthand how TRICARE is working within this particular region.

    Today thousands of 18th Airborne Corps are deployed in the Balkans, more than 2,000 soldiers from the 10th Mountain Division from Fort Drum, New York are in Bosnia for peacekeeping operations. That is more than one-quarter of the unit. Approximately 2,100 soldiers of the 101st Airborne, Fort Campbell, Kentucky, the 82nd Airborne Division here at Fort Bragg, as well as other soldiers from Fort Bragg support units are performing peacekeeping missions in Kosovo. Twenty percent of the Corps' military police are deployed. In all, nearly 5,600 Corps soldiers are deployed around the world today. The last thing these soldiers need to have on their minds is whether or not their families are being taken care of and are able to meet their health care services.
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    The quality of care in the Military Treatment Facilities and among the TRICARE civilian providers is generally considered quite good. However, obtaining access to that care can be frustrating. The vast majority of the TRICARE complaints my colleagues and I receive are from individuals who have a hard time getting an appointment with a medical professional in a reasonable manner. There are also issues about claim processing, access, payments.

    Our objective today is to better understand how TRICARE is operating here in the field. The perspective we get in Washington can be very different from what we experience around the country. It is only by getting out to where the men and women of the armed forces are doing their duty day in and day out that we have the opportunity to speak with them and to hear firsthand their experiences with the military health care system.

    I am also looking forward to hearing testimony from several of the retired personnel, some of whom use Medicare instead of TRICARE for their health care. As you all know, we are trying to right size the military health care system, and it is squeezing retired personnel out of the ''space available care'' that is available in many of the Medical Treatment Facilities, and on which many of our military retirees and their families depend for their health care.

    The Department of Defense's efforts to relieve this pressure included implementing TRICARE. In some parts of the country this managed care model has had some success, but unfortunately the same measure of success as I have been informed is not necessarily here in TRICARE Region Number 2. Like managed care in general, in this part of the country TRICARE appears to have enjoyed some limited success.

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    We have a very ambitious schedule today with four panels of witnesses, and I know each of my colleagues will have questions to ask. First I would like to yield to my ranking member of the Subcommittee, Mr. Abercrombie, for any opening comments or statements he may make. Mr. Abercrombie, you are now recognized.

    [The prepared statement of Mr. Buyer can be found in the Appendix.]


    Mr. ABERCROMBIE. Thank you very much, Mr. Chairman.

    I am very pleased to be here with you. I am pleased that I could come from Hawaii yesterday, and I bring you and everyone gathered here today greetings of your colleagues in Hawaii.

    I wanted to participate in today's hearing because it is so important that we hear from the troops and their families. I wanted to listen and learn firsthand about the problems, and I hope some of the successes of our military health care system and what we can do to improve the system. The Joint Chiefs of Staff, the Secretary of Defense, and numerous Members of Congress, including our good friend Mr. Hayes, and most importantly, Mr. Chairman, you have all indicated the importance of resolving this pressing issue. Access to quality health care has had an impact on our ability to recruit and retain qualified personnel. For those men and women who accept the call to duty we want to ensure that these volunteers are provided a fair quality of life.
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    The establishment of TRICARE has had its share of problems. I remember when the system was first implemented in Hawaii. Although Hawaii is a leader in managed health care, we have had difficulties with the system, particularly with respect to claims processing and provider participation. As you have indicated, and I understand as well that these same problems are being experienced here at Fort Bragg and other regions. While there are problems with the current system, we need to focus on fixing those problems rather than creating another new program in my estimation.

    Mr. Chairman, we need to keep pressure on the Department of Defense (DOD), and Health Affairs to make sure that they continue efforts to improve and streamline the TRICARE program, one of the largest health care systems in the world with fifteen different regions. What we are seeking to achieve, and I know that it is your goal as well, is to make it seamless for the beneficiaries. That of course is one of the objects of our hearing today. No matter where you go in the world, no matter where you are stationed, you should be treated fairly and equitably, and have the ability to access quality health care.

    Last year, Mr. Chairman, I think it is fair to say that our Personnel Subcommittee characterized it at that time as the year of the troops, and we worked together on efforts to improve pay and retirement benefits, and to improve the quality of life in that respect for our men and women in uniform. This year I think it is fair to characterize our efforts as the year of health care.

    I of course want to work with you, Mr. Chairman, and I commend you and congratulate you for what you were able to accomplish last year, and I know that is going to form a foundation for what we pursue this year. I am pleased to be sitting with you and other members of the Committee as we improve the military health care system for all, including your Medicare-eligible retirees and their families.
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    I am looking forward, ladies and gentlemen, to hearing from you today. As the Chairman indicated, this is a formal hearing. What you say, and the information that you can give us today will play a key role in our determination as to what we should do, how we will do it, and the legislation that will be forthcoming. Every word I can say I am certain not just on behalf of the Chairman, but of all the members, that is recorded here today will be gone over very, very thoroughly and will help produce the foundation for the legislation that we think will accomplish the task that the Chairman has outlined.

    By working together we can assure that our military personnel, retirees, and their families receive the world class health care services not only that they have earned and deserve, but we expect to be able to provide as your representatives in the United States Congress.

    Thank you very much, Mr. Chairman.

    [The prepared statement of Mr. Abercrombie can be found in the Appendix.]

    Mr. BUYER. Thank you, Mr. Abercrombie. Mr. Hayes.

    Mr. HAYES. Thank you, Mr. Chairman.

    First let me welcome you and Congressman Abercrombie to Fort Bragg, one of the finest installations in our military service today.

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    Mr. Chairman, you have showed a willingness and eagerness to come here today, and I am sure our folks appreciate that. I want to thank Mr. Abercrombie and, by the way, lest any of you make a mistake, he lives in Hawaii, he was not there for a vacation. I want to make that perfectly clear for the record. I appreciate his being here. He was one of the first people that greeted me when I arrived in Washington, and I appreciate his friendship. He is known, justifiably so, as an outspoken, plainspoken advocate for our men and women both in uniform and the retirees, and I appreciate his being here.

    I want to thank Fort Bragg, Colonel Murphy and his staff who have worked so hard to put this meeting together today. Their presence here and your presence indicates our strong interest in doing the right thing for our men and women in uniform. You are very important to us and the nation.

    I will enter my lengthy statement in the record, and I will take a minimum of your time because we want to hear your testimony. I have got a microphone and a hearing aid; I am going to use the hearing aid much more than the microphone. I think that is important.

    There are a number of things that we have corrected. This has been known as the year of the soldier. It is a good time to be on the Armed Services Committee because we are doing the right thing. There are some problems that have not been corrected. The basic allowance for housing is in the process of being corrected is one. The others you are familiar with.

    Last year my wife Barbara and I came to Fort Bragg, and we sat down and listened to couples who are in the military and experiencing certain challenges, opportunities, and problems with the system, so we appreciate your input, we are very glad to be here.
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    Again thank you to our Chairman, Mr. Buyer, the ranking member Neil Abercrombie, and Mr. McIntyre will be here shortly. This hearing is for you, and we appreciate your willingness to participate.

    Thank you, Mr. Chairman.

    [The prepared statement of Mr. Hayes can be found in the Appendix.]

    Mr. BUYER. Thank you, Mr. Hayes.

    Mr Abercrombie, I would like to associate myself with your comments. I think that if we approached the military health care issue the same way that you and I have approached the issues of reforms in the retirement system, the pay, the benefits, our pursuit on reducing the out-of-pocket housing costs, even though we could not get the Senate to agree with us, I think now the Secretary of Defense agrees with our initiatives. If we focus on those things in a bipartisan manner, which we did last year, I think the result can be very good for the men and women in uniform and their families.

    Publicly, you know, I will share for the audience, the press likes to focus on differences in Congress. While Mr. Abercrombie and I on some other issues may cancel out each other's votes, when it deals with these particular issues we are very well focused, and I think we shocked some of our colleagues on how well we both worked together. When we do that it becomes a very powerful force.

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    Mr. ABERCROMBIE. They have not caught up with us yet, I think.

    Mr. BUYER. Well, I guess you are right, they have not figured it out. But I think, Mr. Abercrombie, I can say publicly and personally I enjoy that working relationship, and if we are able to maintain the focus, you and I, and then can channel the energies of the Subcommittee toward a productive solution on health care; we have a unique opportunity.

    Mr. ABERCROMBIE. You can count on my support, Mr. Chairman.

    Mr. BUYER. Thank you.

    Let us turn to our first panel. Mr. McIntyre.

    Mr. MCINTYRE. Welcome to North Carolina.

    Mr. BUYER. Thank you. The story I am giving back in Indiana, it was cold and rainy when I arrived. Like I say, it is blue sky and beautiful out today.

    Do you have any opening comments you would like to make?

    Mr. MCINTYRE. I would like to not only thank all the panelists who we will be hearing from shortly and welcome my colleagues who have joined Congressman Hayes and myself to this great place of Fort Bragg here in southeastern North Carolina that we together represent, but also I would like to particularly welcome the members that are here of our Military and Veterans Advisory Committee. One of the first committees I formed in addition to my Agriculture Committee which Mr. Hayes and I also serve on and is so important to this part of North Carolina, was to make sure that I had a military and veterans advisory committee in place, and they have been with me from day one since I took office. Many of them are in the audience today, or will be joining us from time to time, and we meet on a regular basis to talk about these very issues. So I want our panelists now and those who are yet to come before us today to understand that we have an ongoing discussion about these issues on a regular basis so that we can have eyes and ears on the ground and here at home that are dealing with the issues facing our retirees, and our veterans, and our active servicemen and women.
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    I am also pleased that just as last year was, as many of us said, the year of the troops, trying to make improvements in the basic pay and other concerns, the quality of life as well as readiness for our military, that this is really a year I think of health care, that we have absolutely got to make sure that we are doing right by health care for our men and women in uniform as well as veterans and the retirees.

    This is going to be a great emphasis for us, and we know that the proposed budget from the White House did not have enough money in it to do what we need to do about health care, and I am confident that we on the Armed Services Committee in Washington are going to be taking up the necessary additional discussion of authorization for appropriations to help with the health care needs.

    So the field hearing today, Mr. Chairman, is very timely and appropriate, I am very excited about it, and I want to say that in the words to paraphrase the great statesman from World War II Winston Churchill when he said: ''Never has so much been owed by so many to so few,'' and I think today more than ever so many of us owe so much to those who put themselves out there every day for what we all enjoy as Americans in terms of our freedom. And as President Kennedy once said about our military being the watchmen on the walls of world freedom, indeed you are the watchmen and we should be doing everything we can to help support you in every way, not only from the equipment, but also from the quality of life and personnel issues.

    Thank you for the opportunity to speak, and we look forward to hearing from you.

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    Mr. BUYER. Thank you very much. I suppose, to cover the waterfront on quotes, and I am a Citadel graduate, I will quote Robert E. Lee and say that ''duty is the sublimest word of the English language.'' And I would cover the waterfront on quotes.

    Let us go to the first panel. And when you have got a name that is spelled like Buyer and it is pronounced Booyer I am always very careful on pronunciations of names, but T-o-g-i-a-i, how do you pronounce it?

    Sergeant TOGIAI. Togiai.

    Mr. BUYER. What is the origin?

    Sergeant TOGIAI. American Samoa.

    Mr. BUYER. Say again.

    Sergeant TOGIAI. American Samoa, sir.

    Mr. BUYER. Sergeant Timothy Togiai, C Company, 37th Engineer Battalion, Fort Bragg, North Carolina; Lieutenant Commander Jamie Otto, a Catapult and Arresting Gear Officer of the USS Theodore Roosevelt; Senior Airman Glenn McClelland, Weapons Loader, 74th Fighter Wing of Pope Air Force Base, North Carolina; Major Scott Fazekas—I did not do anything about the seating arrangements here, but I take it Tracy is your wife.

    Major FAZEKAS. That is correct.
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    Mr. BUYER. Now, had it been me I would have put her right next to you.

    Ms. Alice Maffey, Ms. Glenna Butler, Ms. Marjorie McClain, and Ms. Tracy Fazekas.

    Each of you I know have prepared statements, they will be entered into the record, and because we have four panels and many witnesses today I would ask that you summarize your testimony and try to keep your remarks within five minutes so then we can have a free-flowing discussion. This is also equally important.

    We will open, and we will go from right to left on down the line. Sergeant.


    Sergeant TOGIAI. Good morning, gentlemen. My name is Sergeant Timothy Togiai, I am from Tula, American Samoa. I am currently serving with Charlie Company, Charlie ROC, 37th Engineer Battalion, 20th Engineer Brigade. I first enlisted in 1990 in the United States Marine Corps, in which I was discharged honorably in 1998 in March. I got out and went back to Samoa for a year, and I came back into the United States Army. I am currently serving with Charlie Company, Charlie ROC.
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    My experiences with TRICARE are very limited being that I have only been in the Army going on a year come April, but the things that I have experienced with TRICARE was first of all I enrolled in TRICARE in November of last year, and I kept calling back in November, December, and January, and the beginning of February when it finally hit the system, gentlemen, and I was calling the whole time, but the Army does have a backup system where you can go to a medical center if you are not enrolled in TRICARE, and so that is where I was sending my family as well as my care.

    I had a good experience. This past three weeks I sent my wife for an appointment; I set up an appointment for her for eye care, and we called and they gave me a couple of options whether to go on the base or out in town. They gave me several options, they set up the appointment, and all they said was I would have to go out and find, choose from which facility that I would want to go to, and call them back so that they could approve my appointment. We did that, and it was fairly easy, and we took care of her eyes.

    The only thing the problem was we paid the $12 fee that we had to pay them, and then we had to pay for the material, the glasses are the things that we had to pay for for my wife's eye care.

    But like I said again, gentlemen, my experience with TRICARE is very limited, but I have spoken to several of my colleagues, and they have had a lot of problems with TRICARE as far as them making claims and the regional issues.

    I have spoken to a lot of my colleagues, and that was basically the problem was the regional, the places where their coverage would have to be for their family. I had one staff sergeant, Staff Sergeant Lewis, he resides here and his family resides in New York, and it was a problem for him to—
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    Mr. BUYER. Sergeant, I do not want you to testify about other people's experiences with TRICARE.

    Sergeant TOGIAI. Why is that, sir?

    Mr. BUYER. My first reaction here is you are testifying here today as an Army soldier, and someone who has limited experience with TRICARE.

    Now I have to ask, who selected you to testify on this panel?

    Sergeant TOGIAI. My battalion, sir.

    Mr. BUYER. Your battalion?

    Sergeant TOGIAI. Yes, sir.

    Mr. BUYER. Why would the battalion choose someone to testify at a Congressional hearing that only had limited experience with TRICARE? Did you ask why you were asked to testify at a hearing?

    Sergeant TOGIAI. No, sir.

    Mr. BUYER. Can you go get some answers? Can somebody get some answers? John, would you please go talk to someone and maybe we can get some Army testimony on another panel, please.
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    Before we proceed, how were each of you selected to testify before this panel? Lieutenant Commander?

    Commander OTTO. Sir, I was called by a gentleman from Washington, D.C. and asked to testify.

    Mr. BUYER. Senior Airman?

    Senior Airman MCCLELLAND. Sir, I was chosen by my squadron, basically my first sergeant, on the condition I had some issues.

    Mr. BUYER. All right. Major?

    Major FAZEKAS. I volunteered, sir, on the personal experience I have had with TRICARE.

    Mr. BUYER. No personal prejudice, Sergeant, I think you are very accurate with your statements, but if you have only had limited experience with TRICARE it is not very productive for us, though, to be able to have a dialogue if you are the representative of the Army and someone who has limited knowledge of the TRICARE system.

    Sergeant TOGIAI. Yes, sir.

    Mr. BUYER. We would walk away from this hearing and say ''I guess everything is fine.'' Not everyone accesses the system solely for eye care.
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    Sergeant TOGIAI. Yes, sir.

    Mr. BUYER. All right. Mr. Abercrombie?

    Mr. ABERCROMBIE. Sergeant, what was your experience with respect to health care when you were in the Marines?

    Sergeant TOGIAI. Sir, I was under—every time I deployed for my family, sir, they would go to the hospital aboard the base, sir. So as far as we heard something about TRICARE, sir, but I would send them to the hospital, sir.

    Mr. ABERCROMBIE. So that was available?

    Sergeant TOGIAI. Yes, sir.

    Mr. ABERCROMBIE. It was not a question as to whether or not there were not services available at that point?

    Sergeant TOGIAI. No, sir. I just sent them on the base. Every time I had an appointment for my children or my wife, sir, I would send them aboard the base.

    Mr. ABERCROMBIE. Thank you.

    Mr. BUYER. Mr. Abercrombie, so we can get some consensus—I know John just went out the back—do you not believe we perhaps need some other witnesses from the Army?
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    Mr. BUYER. Thank you for your testimony.

    Lieutenant Commander.


    Commander OTTO. Good morning, gentlemen. I am Lieutenant Commander Jamie Otto from Norfolk, Virginia. Thank you for taking time out of your busy schedule to listen to our concerns on TRICARE.

    On learning I was going to have the opportunity to address this forum I began querying the sailors on board the USS Theodore Roosevelt so I could also discuss their concerns. What I learned is that many of them, especially the junior folks or the newlyweds did not even know the different programs to choose from. It seemed the confusion was in the wording used to describe them. Therefore, I would first like to address the nomenclature used to describe the TRICARE program.

    My concern is using the terms ''prime'' and ''standard.'' For the first-time buyer if you will, it would make much more sense to buy the widget prime than it would the widget standard. After all, if both widgets cost the same, free, why not get the prime.
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    Because of this, many of our sailors may be signing on to a program that may not be the best for their particular needs. I suggest we rename the programs to reflect exactly what they are.

    Second, most of the sailors and their families I spoke with were on the TRICARE Prime program. I would like to discuss some of those issues and concerns.

    A common concern for all was the inability to obtain a timely appointment. Many admitted to resorting to arguing or fighting with the scheduling facility in order to get an appointment. Many had problems getting timely appointments for such things as sore throats, flus or colds, illnesses that needed immediate attention. Instead, our sailors were offered appointments one or two weeks later. As you know, by then either the sickness has run its course and the patient is well, or the patient who once had a cold or flu now has pneumonia.

    One junior person who transferred to the Hampton Roads area came with a pregnant spouse and was told the next appointment was in three months. The sailor felt he was forced to send his wife home where she delivered their first child without him using her family's insurance plan. This is not how a young couple should celebrate the birth of their first child.

    A more senior seasoned service member would have pressed the issue, and may have gotten an appointment. This sailor took what he was told concerning the lack of appointments as gospel and carried on much to the dismay of this young bride.

    Many other sailors even confessed to resorting to lying; they informed me that if their child were running a temperature of 104 they would get an appointment for the next day. A young child vomiting or with diarrhea would also get the same special treatment. Miraculously, however, when the family arrived at the Medical Treatment Facility, the child no longer has those symptoms, but still has the original sore throat and is treated for that.
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    Still many others have resorted to using the emergency room (ER). When all else fails they know they will be seen at the ER. The patient is seen at a considerable cost to the service, and adding more strain to an already overstressed medical facility.

    Also appointment problems are the most common theme for the TRICARE Prime user. The problem I encountered with TRICARE Prime occurred during my Permanent Change of Station, (PCS), from Sicily. I was enrolled in TRICARE European Prime at the time when I left Sicily. During my outbriefing, I was informed that my benefits were still in effect until sixty days after the day I disenrolled from European Prime. I left Sicily on the 24th of February 1998.

    On April 1st my daughter became very ill with vomiting and a high temperature. My wife and I decided to take her to the civilian hospital located near our home. We provided the hospital with all the pertinent information so they could file a claim with TRICARE. Soon we started getting bills from the hospital and the other service providers because TRICARE had not paid toward the claim.

    After much phone calling I was able to discover that the European region and the region covering Virginia were debating to which region was responsible for paying the claim. Meanwhile I continued to receive the statements, as I was ultimately responsible for paying for the services provided.

    I was able to successfully explain to the providers what was going on within the TRICARE system, and was not labeled delinquent. Eventually the bills were paid in May of 1999, one year and one month after the treatment.
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    On a positive note, all of those interviewed were extremely happy with their medical provider, i.e. the doctors. Many of the doctors who know of the scheduling problems have even given their phone numbers to the patients and instructions for them to call if they were in need of additional care.

    Also, all of those service members and their spouses were elated with the new medical facility at Portsmouth, and loved the doctors there. Again, the problem lies with the appointment scheduling which is directly related to the number of persons on the staff. I am assuming Portsmouth Naval Hospital is extremely understaffed considering the large military presence in the Hampton Roads area.

    Since returning to the States I have chosen to participate in the TRICARE Standard program. I had heard of the scheduling nightmare, and also I feel it gives us more flexibility to choose our health care providers. Of course, that freedom to choose does not come without additional costs. To help offset the potential costs I may incur with a major medical problem I have purchased a TRICARE supplement.

    A concern I have with the Standard plan is in the billing process. I will use an example. Suppose you went to a medical service provider and she charged you $50. TRICARE would pay 80 percent, and you would pay 20 percent provided your deductible was met for that year. Therefore, you would be responsible for paying $10, and TRICARE would pay $40. After TRICARE processes the claim, however, it is determined that the TRICARE-approved amount for the services provided is only $20. Therefore, TRICARE determines that the cost share will be $4 and TRICARE will pay $16 to the provider. If the provider accepts the TRICARE-approved amount for services, they are required to write off the difference between what they charged and what is approved. As you can see, in this scenario you have paid $6 too much to the provider, and should have a credit with them. In this example $6 is not a lot of money, but the potential is there for much larger sums.
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    Some who do not understand how the program works may be paying too much for services, and may not even know they are due a refund or a credit. This can be substantial to a junior person who is not paid very much to begin with.

    I currently have a $12.11 credit with one of our health care providers, and have had the credit since 25 September 1999.

    The other side of the coin is that the provider may not accept the reduced charge as determined by TRICARE. In our example, TRICARE will still expect you to pay $4 and they will pay $16. However, the provider will still bill you the balance of $30. The additional $30 is totally transparent to TRICARE, and you will not get credit toward your deductible or the catastrophic amount of $1,000.

    It is instances like this where the TRICARE supplement comes in handy, but should I really have to have a supplement, or should my health care be good enough so that I should not require it?

    While many are quick to blame the military services recruiting and retention problems on a good economy, easy access to other sources of college funding, a reduced propensity to enlist, and a shortage of quality recruits, I believe there are other issues stressing the force, among these being the health care program.

    As the spouse of one of my sailors said, the pay is not good, we rely on other benefits to make up for that, and right now they are falling short.
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    Another concern is seen with the erosion of retirement benefits. Our retirees are now asked to go on Medicare at age 65. Medicare is seen as a welfare program. Do we really want our retirees, those who gave unselfishly go our great country to have to resort to welfare? Especially since free health care for the rest of their life was promised to them? Do we not want them to enjoy at least the same if not better medical benefits than what is offered to other retired government employees?

    Gentlemen, our health care system has its flaws. If we were civilian workers we would be allowed to unionize, picket, go on strike to possibly change the things we feel are wrong. We are not allowed to do that by law, and rightly so.

    We do, however, rely on you to look out for our interests. We rely on you to do the right thing. Health care is not cheap, and we realize that, but you get what you pay for and you reap what you sow.

    Thank you.

    Mr. BUYER. Thank you. Senior Airman.


    Senior Airman MCCLELLAND. Mr. Chairman and members of the Committee, thank you for giving me this opportunity to testify before you.
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    I have a wife, two small children, and I was stationed in Alaska, Eielson Air Force Base up in Fairbanks, and during a PCS move to Pope Air Force Base back in June of 1998 my son needed immediate care in an emergency room in Los Angeles, and I went through all the routes to get the approval for the hospital that— TRICARE gave me a list of who to go to, so I just chose one of those. We went to the hospital, and the treatment was excellent on my son, and it took about a year before I got a bill, and I got a bill for $88 which I thought was unfair. I was supposed to only pay a $30 co-pay for that emergency visit. I tried to contact my TRICARE here, and my TRICARE here said that they cannot deal with the issue because it was in a different region. So they gave me the 800 number to call back to, I think it was Sacramento, which deals with that region, and they have told me that due to the PCS my TRICARE here should be able to handle the paperwork.

    So I went back to the TRICARE office here, and they refused to help me with it saying that it was not the North Carolina region. So to be honest with you I kind of fell short on trying to get this resolved. Eventually they stopped sending bills and it just fell off.

    Approximately a year and three months after the service, I had gotten another bill from a different portion of the medical services offered, and after dealing with TRICARE the first time and not getting resolved to the problems I just kind of put it aside, and about three months later I was getting bills directly from an attorney of the hospital that I guess had been starting to run a lawsuit of suing me for like a $44 fee.

    I believe that all I was due to pay was my $30 co-pay, and after not getting much response from TRICARE and their cooperation in trying to deal with the matter I just sloughed it off, and unfortunately, not understanding the repercussion that it would cause my credit and my future for a credit report, I have put my credit in jeopardy. I have since been showing up as a negative on my credit report, and I am still trying to work the issue. However, I have to work it through the Sacramento office, and I am kind of running around. I have so many commitments at work, and it is extremely awkward for me to deal with the situation that I just tried to slough under the table, and that is probably wrong of me to do.
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    And I also found out last week that the Army for instance does not have to call an 800 number for TRICARE. For me being active duty I do not think it is right that I need to call an 800 number for TRICARE to get treated just down the street at the Pope Air Force Base Clinic.

    And if I were to call—I have a cold right now, and I do everything that I can to avoid making an appointment with them because of the headaches that I get in response trying to make an appointment.

    If my son has an ear infection I can get an appointment four or five days down the road, and if you have a seven-year-old with an ear infection it does not wait for seven days down the road, so I kind of try to cheat the system in calling my clinic direct, and so far it seems to work, but my understanding if we are paying for the service of TRICARE to manage our appointments I do not think we are getting just treatment in dealing with the appointment schedule.

    And I have also spoken with a lot of my personal colleagues at work and such, and they run into the same issues. If it is not an issue of making appointments, it is an issue of making claims, and it is generally making claims from region to region. I have not yet spoken to anybody that has made a claim here at a particular base in that same region.

    Mr. BUYER. Thank you. Major Fazekas.

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    Major FAZEKAS. Thank you, gentlemen, for giving me this opportunity to provide testimony this morning.

    I was really gratified to hear that you are quite aware of our problems with access. This seems to be the major difficulty that I as a leader of Marines and as a father and husband deal with every time we have some sort of medical situation.

    Talking from personal experience, I have found it very frustrating that I have to call the 1-800 number in Virginia, as the senior airman just pointed out, to get an appointment at the Naval Hospital primary care clinic which is less than two miles from my house. I cannot call the Naval primary care clinic and get an appointment through them; I must call Virginia.

    In a personal experience trying to get access to TRICARE Prime, about a month ago my daughter came down with a severe rash. It took us three days to get an appointment. After a week's treatment after the appointment the rash had not improved. It was about this time that Virginia was hit with a very serious snow storm, and the 1-800 service center, the TRICARE service center in Virginia was closed due to the snow storm. No appointments could be made. No appointments could be made at the primary care clinic at the Naval Hospital.

    My wife tried for hours to get an appointment with absolutely no success. Only after I became personally involved and personally contacted the Navy captain who was in charge of clinical services at the hospital was I able to get an appointment for my daughter. I think it is ridiculous that I have to resort to that.
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    As a leader of Marines I have been forced to do the same thing to ensure that my Marines and their family members receive timely quality health care.

    As an example in my own office, I have a young sergeant who is also married to an active duty Marine, and they have a two-year-old son. The boy has repeated ear infections. In one case she tried for three days to get her son an appointment at the Naval Hospital primary care clinic. The boy was running about a 102-degree temperature for three days. She was unsuccessful in getting him an appointment. On the last day she tried she was told to send her son to the emergency room. I do not think the emergency room is the correct place for a 102-degree temperature for an ear infection. Once again, only through my personal involvement was she able to get an appointment that same day.

    I would also like to just briefly address retiree issues because my father is a career Army officer, retired several years ago. He has also had problems with access, but he also has problems with billing, as do I.

    My father and I have both received dunning letters from medical providers out in town because of some of the very same situations that Lieutenant Commander Otto succinctly presented before.

    The bottom line, gentlemen, is that the perception at the user level is that the focus of TRICARE Prime is to keep costs down, and not necessarily to provide timely or quality health care. That is the perception.

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    I will say on the record that once we do get an appointment and do receive health care it is of good quality. As Lieutenant Commander Otto pointed out, this is also a retention issue, not just a quality of life issue, but a retention issue. Many of my Marines who have had these problems scheduling appointments, fighting the system to get their claims paid have mentioned to me that this is playing a very large role in their decision as to whether or not they will reenlist.

    It is also a morale issue. As I said, gentlemen, the perception is out there, and it is affecting morale, and I would very strongly urge you to do everything you can to take a look at solving some of these problems.

    Thank you.

    [The prepared statement of Major Fazekas can be found in the Appendix.]

    Mr. BUYER. Thank you. I want to return to the sergeant from the Army. In the Navy, the Air Force, and the Marine Corps they also provided testimony of individuals who were directly within their command. If you have any individual who is directly a subordinate of you that has had an experience with TRICARE, I will give you that opportunity to present that testimony if you have that.

    Sergeant TOGIAI. They are all single.

    Mr. BUYER. Pardon?

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    Sergeant TOGIAI. No, sir. They all single.

    Mr. BUYER. You do not, or you do?

    Sergeant TOGIAI. No, sir.

    Mr. BUYER. You do not?

    Sergeant TOGIAI. No, sir. They are all single.

    Mr. BUYER. They are all single.

    Sergeant TOGIAI. Yes, sir.

    Mr. HAYES. Mr Chairman, if I may, the hearing that we had six or eight months ago with the married couples was particularly instructive in some of the things that you are looking for, and I would with your permission submit the testimony from that hearing which was very detailed, typically pregnant women had difficulty, they never saw the same OB-GYN doctor. The care was good once they got it, but inconsistency was a problem, and there were a number of other things that followed a pattern of repetition, difficulty in getting specialty care, and with your permission I will provide that testimony as a part of this hearing which I think will go into a lot of detail.

    Mr. BUYER. I will take that under advisement.

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    Ma'am, you are now recognized as Ms. Thomas A. Maffey, but I am sure you have a first name.

    Ms. MAFFEY. Alice.

    Mr. BUYER. Alice. All right, ma'am. Please provide your testimony. You are recognized for five minutes.


    Ms. MAFFEY. Thank you.

    My name is Alice Maffey, I am the wife of Colonel Tom Maffey who is an infantry officer and the commander of the 3rd Brigade of the 82nd Airborne Division here at Fort Bragg.

    My husband has been deployed on contingency operations in Grenada, Panama, Kuwait, many exercises in the United States and overseas.

    During times of his absence like every other military spouse, I have had to manage health care for our family. As the wife of a brigade commander with 2,000 troops under his command, and in my role as the 82nd Airborne Division's liaison to the largest health care clinic on this installation I hear firsthand the difficult experiences that military spouses have had with managing health care.
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    TRICARE promised many things when they came aboard as our new health care provider, and it is my experience that not all of those promises are being kept. In particular, I am concerned about TRICARE's ability to provide responsive access to quality care, and the unresponsive manner in which they settle claims for military families.

    An example of my concern with the access of care follows: TRICARE promises that specialty care will be provided within a one-hour drive from home, and an appointment within four weeks or less as determined by the primary care manager. In this case a patient was referred to a dermatologist, she called TRICARE to get an appointment, and was told that her appointment would be at one of two places, the University of North Carolina (UNC) at Chapel Hill which is more than an hour, and the other location which is somewhat closer. In this case no appointment was available for four weeks.

    She was then told to call back in four weeks to schedule an appointment if any were available. This continued for about six months. She finally notified the TRICARE office in person that she was going to pay out of pocket for an appointment, but that they should know that this was wrong. Someone in the office told her that they could make an appointment in Fayetteville as long as she paid up front and filed her own claim. As we all know, both of these conditions are not required under the TRICARE system.

    When she did go to the appointment in Fayetteville the dermatologist did file her claim and paid for her up front.

    This example illustrates both of my concerns. Not only did this lady experience an unresponsive system in getting access to care, but she was provided bad information on settling her claim.
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    My next example illustrates the problems with TRICARE assisting in the settlement of claims. In 1998 a service member and his spouse were involved in an accident. They were taken to a local hospital. The spouse died, the husband was eventually moved to Womack Army Hospital to complete his care. He started to get bills for his wife's care which he filed with TRICARE. Eventually these overdue accounts were turned over to a collection agency. TRICARE finally paid these bills for him and his deceased spouse, but it took a great deal of effort on his part as well as the help of the hospital personnel.

    This individual suffered not only a personal loss, but also it damaged his credit rating. I can assure you this happens on a regular basis. Our soldiers and their families understand that they can be disciplined for credit problems. In many cases soldiers will pay expenses out of pocket rather than risk the disciplinary action resulting from bill collectors contacting their chain of command. This is particularly true for minor expenses where the service members do not believe the amount of money is worth the headaches involved.

    My final example involves an access to health care when a family is away from the normal health care system, as many of us are when we take leave. If a person is covered by TRICARE Prime, is out of region, she will be covered in emergency care if they call within one working day. If the care is not considered an emergency, they must get a telephonic authorization for the care prior it being provided.

    I have heard more times than I can tell you about of a family member with a sick child with a high fever, not an emergency, but just trying to get a doctor's appointment, tried calling for at least two days, finally gave up, paid out of pocket because they could not get through on the lines, or if they did they were transferred numerous times and eventually were disconnected.
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    In summary, I believe that TRICARE should be held accountable to deliver on is promises, TRICARE should be required to provide quality, timely, and accessible health care, their ability to assist the service members in settling claims, and the speed in which they pay claims should be measured.

    It is my understanding that many of our local health care providers choose not to work with TRICARE because they are unresponsive in paying claims in a timely manner. If TRICARE were more responsive to the needs of their clients as well as the health care providers we would have ready access to high quality health care.

    Thank you very much.

    Mr. BUYER. Thank you, ma'am. Ms. Glenna Butler.


    Ms. BUTLER. Thank you very much for allowing me this opportunity today.

    As the spouse of an active duty service member who served for twenty years I have had a great deal of exposure to the issues relating to the change from the previous service to TRICARE.

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    In my former capacity as the ombudsman chairman for the Mid-Atlantic Region I assisted representatives from various commands with resolving family issues. I was asked today to present information on removing those barriers, resolutions rather than specific problems.

    In doing that I would like to reiterate as other panelists have that once you acquire care, or the ability to go to care in a military treatment facility, in general families are very happy with that care. The problem is the access. If they are not happy with that care, there is a reasonable resolution for them, and so that is effective.

    The frustrations and barriers, a lot of those can be resolved through either education or training. The training aspect regarding assisting the contract personnel in having a better proficiency level with the procedures and the requirements, because we often find that family members are misadvised whenever they call for customer service, or as they are trying to access care. And so addressing those issues as well as claims resolution, we find that there is a lack of continuity in families getting assistance with resolving a claim.

    If we had an individual that was able to have an assignment as a responsibility for helping that family member with that specific claim to resolution, it would be beneficial, as well as with our health benefits advisors providing it. You can go to three different health benefits advisors, get three resolutions to the same problem providing the same input and documentation, and we need to have a better continuity which is a training issue for our contract personnel.

    Also, the education of the beneficiaries to help them better understand the procedures and the changes as they take place. If they were aware of the changes in a more timely manner, they would be able to provide additional assistance for themselves without relying on individuals that sometimes provide inaccurate or inadequate information for them.
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    Areas that I believe would not be able to be addressed for resolution by education and training are mental health care issues. We have family members who have chosen not to be a part of Prime because the co-pay for a Prime person is greater than it is for an individual taking part in Standard or Extra.

    In that end, if they have a child or a family member who requires ongoing mental health care, even if it is a simple issue such as a child with Attention Deficit Hyperactivity Disorder (ADHD), those individuals have a substantial cost difference. If we were able to make that an even cost co-pay for all individuals, the individuals with health care issues would not be penalized for that issue.

    Also, individuals who do choose to go with Standard or Extra as their TRICARE choice then are in their view punished for not being able to access appointments in the same way that Prime patients are given priority, so that is a concern.

    Marriage counseling is not a medical issue. However, when a family member is diagnosed with a very simple mental health issue such as depression, they can access marriage counseling, and that is often what they do. When this effort to resolve the marital issue does not prove to be fruitful, what happens is that diagnosis can then be used, because it is required that it be the spouse that is diagnosed with the mental health issue, in custodial issues or legal matters that can be used against the spouse as well as in future employment and future insurance coverage. So that is an issue that has been a concern for some time, and we need to address that differently.

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    Also, claims as many of the panelists have referred it is a significant issue. It has the potential to cause a great deal of difficulty for our service members who relocate often with PCS moves if their credit has been damaged in that regard.

    And remote care and the tremendous out-of-pocket cost for the individuals who are forced to use TRICARE Prime Remote is pretty significant, and then they incur the issue of claims reimbursement.

    When we have a reimbursement rate that is equivalent to Medicare we often find that equality of the health care providers that we have is called into question by the beneficiaries, because if they have a thriving practice and are capable and competent individuals why do they want to take a Medicare rate, and so there is an issue of quality, and so the benefit of having additional active duty physicians would be very helpful.

    One of the suggestions that was made that I found to be rather unique was encouraging active duty corpsmen to pursue their physician's assistant certifications and so forth, since that takes a considerable less period of time than acquiring a doctorate. So little issues like that we can address to present a better quality health care program would be very beneficial, and standardizing the care would help.

    Mr. ABERCROMBIE. Ms. Butler, I am sorry, but time is running out. I missed your background, the reason you are here. I did not catch that if you said it at the beginning.

    Ms. BUTLER. I believe that the reason I was asked to be here is because I formerly served as the ombudsman chairman for the Mid-Atlantic Region.
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    Mr. ABERCROMBIE. You were the ombudsman?

    Ms. BUTLER. I was the ombudsman chair for approximately 500 ombudsmen in our region, yes.

    Mr. ABERCROMBIE. In what capacity were you named to that? What led you to be named?

    Ms. BUTLER. Probably my background and experience as an ombudsman in both the air, submarine, and surface community, and I am also a SAVI, or Sexual Assault Victim Intervention advocate, as well as trained in the family advocacy program, and I currently serve on the process action team on terrorism, and I am one of four ombudsmen trainers for the Bureau of Personnel Command to train certified—

    Mr. ABERCROMBIE. Well, it is clear they do not need us. We will just put you up here. Thank you very much.

    Mr. BUYER. Marjorie McClain.


    Ms. MCCLAIN. Thank you for inviting me to come speak with you.

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    I am married to a captain in the Air Force stationed here at Pope Air Force Base. He is in the 75th Fighter Squadron. My experiences with TRICARE have been both positive and negative. Unfortunately, the negatives have outweighed the positives, and this seems to be the consensus of other spouses to whom I have spoken.

    My background is twelve years in handling unemployment insurance claims, and two years of handling workers' compensation claims. Because of my background, the handling of claims and paying of bills seem to be my major concerns. I know of several active duty servicemen who receive bills for medical treatment that they have received outside of the base because TRICARE has not paid those bills.

    There are spouses I know of, including myself, who have received bills when we have had nonavailability statements with authorization numbers given to us by TRICARE. My eye doctor submitted a claim that took two weeks short of a year to get paid, and they had an authorization number.

    A TRICARE representative has stated that it is TRICARE's unwritten policy to hold claims for over a year so they can be denied on timeliness, if we as claimants do not have paper trails they do not have to pay the claim.

    My personal experience also supports this. I submitted a claim in September of 1998, and to make a very long story short, it took sixteen months for the claim to be processed. During this time I made countless telephone calls, resubmitted the claim to four separate addresses at the request of TRICARE employees, made countless phone calls, and submitted the claim a total of seven times, including one fax before anyone at TRICARE would admit they had actually received the claim.
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    During this time I would call the 800 number to check on the claim, and you never get to talk to the same person twice because the local people do not handle your telephone calls. Not one single person I talked to during this time was able to access all of my claim on their computer, or was able to provide me with how the process works when I receive a determination. When I asked if I could contact someone in claims, I was told that they cannot give out that number. I was also told that they do not have a phone there, and I am sure that is not accurate. I contacted the patient advocate's office who resubmitted my claim, but told me that is all they could do.

    When I tried to make an appointment at the local TRICARE office, again I was told that their number could not be given out. If I wanted to call them, I had to call the 800 number and they would patch me through to the Fayetteville local TRICARE office.

    I do have some suggestions. Eliminating the 800 number except in cases of emergencies would allow the local representatives to handle questions. The TRICARE employees, while very friendly, do not seem very knowledgeable. They need to be trained, they need to be empowered to handle the claims more timely, and be held to that standard.

    It is my suggestion that more medical offices would participate in TRICARE if they were paid more timely. I personally know of several doctors offices who will not accept TRICARE patients because their claims are not paid timely.

    The determinations also need to be more inclusive. Standards for approving or denying claims should be common knowledge. If we knew more information about that, I would not have had to file three appeals and a grievance with Anthem Alliance.
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    Mr. ABERCROMBIE. Could you repeat what you just said? I could not hear you.

    Ms. MCCLAIN. Yes, sir. If the determinations were more inclusive, for example if they explained what is and is not covered, and why your claim is denied, then maybe people would not have to file more appeals. I have had to file three appeals and a grievance with Anthem Alliance over this one claim.

    Mr. BUYER. What is the amount of the claim, and what was it for?

    Ms. MCCLAIN. It was for braces that I had that were a result of a bone deformity that had to be corrected. When they did the surgery here at Womack they had indicated that the surgery of correcting the bones is not going to take care of the problem, and I would need to have braces as well, but because it is braces it went to the dental office, and then to the adjunctive dental, and it bounced back and forth between those offices, and I am still not sure who actually handled the claim.

    Mr. BUYER. Even though it was dental, it was medically necessary; right? An occlusion?

    Ms. MCCLAIN. Correct. And I had statements from the oral surgeon here, an oral surgeon in Maryland, an orthodontist and dentist. The total amount of the claim is $1,500. My understanding is that it should be 80 percent paid by them, which means that I should receive $1,200 back.
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    Mr. BUYER. And in the end what happened?

    Ms. MCCLAIN. It is still in the appeal process, it has not ended.

    Mr. ABERCROMBIE. How long?

    Ms. MCCLAIN. The appeal was filed in January, and the grievances were filed in January. The original claim started, I submitted the first claim in September of 1998. I did not get a final determination on the entire claim until January of 2000.

    If I may just very quickly, if my claim had received as much attention as me coming to testify here today, we would not be having these problems, and TRICARE would not have the reputation that it has.

    If I knew more information about this, or if it had been handled correctly I would not have had to had Mr. Hayes' office get involved in handling of the claim as well, and I thank you, sir.

    On a positive note, the 24-hour—

    Mr. ABERCROMBIE. You cannot imagine how hard he worked to mess you up in order to get you to come and talk to us.

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    Ms. MCCLAIN. And I managed to get here.

    On a positive note, the 24-hour advice nurse line is wonderful. We have used it many times and saved countless times of going go the doctor when I could just get some information over the phone.

    I appreciate you all allowing me to testify today. Thank you.

    Mr. BUYER. Thank you, ma'am.


    Ms. FAZEKAS. Good morning. My name is Tracy, I am, of course, married to Major Fazekas, and I was asked to come here today.

    I think it is very difficult to get timely and quality health care under TRICARE Prime. As a mother, and as a registered nurse, I find that very disturbing and frustrating. To illustrate this I will go into a little bit more depth on one of the examples my husband used, the one where my daughter had a bad rash.

    First, I think it is an utter disgrace and humiliating that I need my husband's help to get an appointment for my children. My daughter received an appointment only after he got involved.

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    Second, the written information provided by the Naval Hospital about TRICARE Prime is confusing and contradictory. Again, using the example of my daughter's rash, the TRICARE Prime newsletter of Fall of 1999, which I have here, states: appointments for urgent care are available 24 hours a day, and will be made within 24 hours.

    When I called the TRICARE service center to get an appointment for my daughter's urgent care needs, I was told none were available. I was told to call back at six o'clock in the morning the next day. When I did so, I was told by the customer service representative that there were no appointments available, and that she could not understand why I had been told to call back. She then transferred me to the Naval Hospital primary care clinic. The receptionist there told me she could not make an appointment, she could not understand why TRICARE service center kept transferring people to her, as she did not make any appointments. When I questioned her further, I was told to go to the emergency room.

    As a registered nurse, I can tell you that that is a ridiculous solution to go to the ER for an urgent, non-emergency condition, in this case my daughter's rash, is absurd. It was at this point my husband got involved.

    The point here is that what is written in the newsletter and what is written here in TRICARE Prime Quick Reference Guide about urgent care and timely care is not at all how it works in practice. This is where my frustration lies. The system in practice does not function anything at all like it is supposed to the way described in writing.

    Another example of how difficult it is to get timely quality health care under TRICARE Prime at the TRICARE service center. I must call a toll-free number to get in contact with the TRICARE service center, it is in Virginia. Why I have to call Virginia to get an appointment in a primary care clinic at the Naval Hospital two miles from my home in Camp Lejeune is beyond me. And as my husband pointed out, during the snow storm the TRICARE service center in Virginia was closed. No other numbers for satellite TRICARE service centers are given in any information that I have. I guess the message is do not get sick in inclement weather.
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    In the TRICARE Prime information given out by the Naval Hospital it describes the TRICARE service center as the one-stop shopping place. I read that I can get appointments there 24 hours a day, and within 24 hours in the case of urgent care, have my questions answered, and get help in resolving billing. But as described above, when I called the TRICARE service center in Virginia I could not get an appointment for urgent care in 24 hours, so I went to the satellite TRICARE service center at the Naval Hospital. This is where the receptionist told me she could not make me an appointment, and when I asked for assistance in resolving my problem in getting an appointment, she referred me to customer relations at the Naval Hospital. When I went to the customer relations at the Naval Hospital, they told me I could write a letter to the commander of the Naval Hospital.

    Therefore, I have found that the TRICARE service center is not at all what it is advertised to be, and that they do not do anything according to the information they hand out. Even when I talk to people at the TRICARE service centers, they admit that the information is a little misleading.

    Finally I would like to address what I think is a serious quality of health care issue. When I call a TRICARE service center, the person I talk to is a customer service representative (CSR). These CSRs schedule appointments. To do so they routinely ask medical questions. I called the TRICARE service center recently to get an appointment for a severe sinus infection which I have had a few in the last two years. The CSR actually began arguing with me about the sinus infection trying to tell me it was chronic and not acute, even though she was informed that I had been seen a week previous, and my condition had not resolved, and I felt I should be seen within 24 hours.
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    I asked her point-blank what her medical qualifications were to make this sort of determination. She replied none. What is happening is that untrained, unlicensed CSRs are making medical decisions. As a nurse, I can tell you that not only is that ridiculous, it is downright dangerous. It is a disaster waiting to happen.

    In the ''Navigation TRICARE'' handbook it states that there is a health care finder at every TRICARE service center. This health care finder is supposed to make the medical decisions, the CSR is not supposed to be making them. The handbook states this health care finder is generally a nurse. This means you can have a situation in which the health care finder is also not a medical professional and trained to make medical decisions.

    Last, in every instance when I have spoken with a CSR I have had to insist on speaking to the health care finder. If the CSR is not supposed to be making medical decisions, I think they should transfer me to the health care finder immediately.

    In closing I would like to read to you from my ''TRICARE Made Simple.'' It states: TRICARE is highly recommended for families who want guaranteed access to timely health care. Every experience I and my family have had with TRICARE Prime leads me to believe there is absolutely no guarantee, and the health care is not at all timely.

    Thank you.

    [The prepared statement of Ms. Fazekas can be found in the Appendix.]

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    Mr. BUYER. Thank you very much.

    I have a few questions by way of opening before I yield to my colleagues.

    Compare this TRICARE region—I want to be very fair here—compare the services and your access in this region to other regions, or is this typical of what you are finding around the country? Let me turn to the spouses here first. I am sorry, guys, but they are the ones who are managing families it seems. Ma'am.

    Ms. FAZEKAS. My first experience was when our son was born in Hawaii, he was born in Kaneohe, and I had no problem with the TRICARE Prime that we received there. My bills were paid, I never received a bill. I could always call the physician that I had out in town, and I could get in within hours.

    The second time we had experience with TRICARE Prime was in California, San Diego. I had a physician out in town, and again I could call that physician, and he says ''Can you be here within twenty minutes?'' I said ''Yes, I can, I am coming in.'' I had no bills to pay, I had my $5 co-pay and I was happy to pay that because I did not want to have to drive half an hour to Balboa, the center there.

    Here, again it is just access, and when you call the 800 number—it says TRICARE service centers and it lists two satellites in Camp Lejeune—on the way here I used my husband's cell phone, and through many phone calls I found a local number, and I politely said ''Oh, I just found some information. I understand that you are able to make appointments for me according to all the pamphlets I received.'' She says ''Oh, no, you need to call the 1-800 number.'' I asked ''Could you please tell me why you are here, then?'' ''Just administration,'' and so she put me through to the 800 number.
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    Mr. BUYER. Do any others have experience with other regions? Yes, ma'am.

    Ms. BUTLER. The families that I have dealt with have indicated that in other regions they have had similar access issues, but the frustration of being in one region and dealing with another is much more frustrating and takes a greater period of time. As the airman was indicating earlier, it can be a nightmare.

    The other regions that I had input on were Regions 4, 5, and 1, I believe. As TRICARE was working through the kinks there were similar access issues for a period of time.

    Mr. BUYER. Often when we are faced with some of these questions, work with some of the contractors they will say ''Well, that was true, and that is what happened twelve months ago, or eighteen months ago, but we have taken corrective action, and that is not the way it is today.''

    Ms. BUTLER. True.

    Mr. BUYER. How do you respond to those types of things?

    Major FAZEKAS. I would say that is not accurate. I would say we are still having these same access problems. This one example I gave you of the sergeant with the two-year-old boy, that happened less than four weeks ago.

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    Mr. BUYER. Mr. Abercrombie.

    Mr. ABERCROMBIE. Thank you very much.

    Ladies and gentlemen, our time for asking questions or making observations to get a response from you is very, very short, so I am going to ask you some things, and if it seems like I am pushing you along, I am, and not because I am not interested, but if you could try to just zero in as quick as you can I would be appreciative.

    Ms. Fazekas, I want to make absolutely sure I understood. You think it is the common experience that when you call this 800 number for appointments, that you are primarily in the hands of customer service representatives as opposed to a licensed, trained, knowledgeable person who can connect you directly with the medical services that you seek?

    Ms. FAZEKAS. Yes, and I have it in writing.

    Mr. ABERCROMBIE. Okay. Similar to other questions in other areas in which someone calls and they said it is the insurance company, somebody working for the insurance company starts making a medical decision in terms of appointments? I am drawing a parallel. Some of the arguments about HMOs are you do not get to actually talk to somebody who can help you get to a doctor, or a nurse, or a pharmacist, or anything, you are dealing with somebody who has been hired to make sure that the costs stay down for the insurance company. Is it the same kind of thing? I am drawing a parallel.

    Ms. FAZEKAS. Yes, the same type.
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    Mr. ABERCROMBIE. That is your experience?

    Ms. FAZEKAS. Yes, it is.

    Mr. ABERCROMBIE. You heard the other people, is this a common experience? I will just ask in general and you can nod. This 800 number seems to come up in six or seven presentations here as being a source of indifference, frustration; is that correct?

    Ms. FAZEKAS. Correct.

    Mr. ABERCROMBIE. And that has to do with regional requirements? That is to say you are dealing with a region rather than a person in a specific place?

    Ms. FAZEKAS. Correct.

    Mr. ABERCROMBIE. Is that what you are told, you have to deal regionally to get an appointment?

    Ms. FAZEKAS. I was told when I called the 800 number, they say there are sixteen different places where we could get patched into. We may not always get Virginia, but—

    Mr. ABERCROMBIE. Okay. Well, back to Hawaii. Hawaii was its own region, and I am not setting that up to say ''Oh, great, it worked in Hawaii,'' but I am thinking of the geography there, the region there. If you are in Kaneohe that is small, about the most you would have to do is cross over the Koolaus and go into Honolulu; right?
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    Ms. FAZEKAS. Correct.

    Mr. ABERCROMBIE. So maybe a lot of this has to do with this idea of efficiency being associated with size, of geography. In other words, if you are doing two states how the hell can you make an appointment in two states, or three states?

    Ms. FAZEKAS. And how do they know which physicians do what?

    Mr. ABERCROMBIE. Okay. Let me move very quickly to Ms. McClain. I am very interested in your proposals, your suggestions. Thank you very much.

    Ms. MCCLAIN. Thank you.

    Mr. ABERCROMBIE. A lot of times a raft of complaints come in about something, and then we are scrambling to figure out what to do exactly, so I wanted to ask you about that.

    Do you think a lot of this would clear up if a way could be found to in a sense eliminate the 800 number by making it clear that even though there may be a regional—and I am not going to say authority—a responsibility, a regional responsibility, but nonetheless if a way could be found to localize the appointment requests and the claims problem resolution, seeking the resolution? Do you think that would solve—? If appointments could be made, and then claims adjustments be made all on the local level, say base by base, or area by area?
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    Ms. MCCLAIN. Yes, sir, I do. As a parallel, in unemployment insurance in North Carolina claims are handled in Raleigh. However, there is a local office where a person walks in, provides the information, they talk to the people in that office. Those people are responsible for contacting the centralized claims area who are making the determinations on the claim, and for getting back to that person.

    It seems with an 800 number that is transferred to sixteen different offices, no one takes responsibility for doing follow up.

    Mr. ABERCROMBIE. Let me move to Ms. Butler real quick, then. You have got the ombudsman experience, and we may come back and talk to you later, stay in touch with you on this.

    Why cannot each area have someone assigned from the service that you can contact, that a family can contact that is going to act as your facilitator, your catalyst, your coordinator? How distant does that get?

    Ms. BUTLER. What we did was we established a time frame in ombudsman training specifically to address education for the ombudsmen on the TRICARE program so that they could act as that catalyst for the families within their command.

    Mr. ABERCROMBIE. It sounds like you might need an ombudsman for the TRICARE provider, not for the family.

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    Ms. BUTLER. You have to take that up with the admiral, sir.

    Mr. ABERCROMBIE. I mean you can see educating the families, but what good does it do to be educated if you are talking to somebody who says ''I am going to refer you to the customer rep person in Richmond.''

    Ms. BUTLER. Oftentimes as we educate the families and we educate individuals to help support them we find that the procedures and the guidelines change more quickly than what we are able to keep beneficiaries advised of, or there is misinformation with the individual that we are working with, and that proves to be very disruptive in resolving the issues.

    Mr. ABERCROMBIE. Okay. Thank you. I am not cutting you off, but real quick, Major, and maybe Commander Otto you might comment on this, and this will be my final point, Mr. Chairman.

    Major Fazekas, you made a good point, and I am going to see if this summarizes your statement. Your impression is the idea is to keep costs down, not necessarily provide care, even though when the care is finally gotten it seems to be okay or satisfactory; is that a correct summary of your statement?

    Major FAZEKAS. That is correct, that is a fair summary. That is the perception that has been created because of the difficulties in gaining access.

    Mr. ABERCROMBIE. Let me ask you and Commander Otto, then—and I am going to preface this so that you do not think you are being set up—I have a very strong prejudice against outsourcing and contracting outside the services. I think there ought to be a strong civilian component inside the military responsible to commanding officers inside the military. I do not believe, I have concluded there is no ''efficiency,'' quote-unquote, either for the taxpayers of the United States or the armed services by all this contracting out.
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    Do you think that all these issues could be settled better, or can you comment on this proposition that if we could keep all of the requests for appointments, all of the responsibility and authority for seeing that the health care system works within the military, not necessarily assigning active duty military personnel, but maybe making a combination of civilian and active duty military personnel under the authority and control of the armed services, would that increase the efficiency of being able to both access health care and take care of any claims?

    Major FAZEKAS. It might. It is a bit hard to say.

    Mr. ABERCROMBIE. I understand that. It is a pretty broad stroke.

    Major FAZEKAS. I have had experience on both sides with government workers and with contractors.

    Mr. ABERCROMBIE. Well, let me put it this way, Major, just very quickly, and you can then comment if you care to, Commander. If somebody was working for the military in a civilian capacity and/or was active duty military and something was going wrong, would you not as a major, or you as a commander have a heck of a lot more authority to demand things get done than you would in trying to appeal to a civilian contractor who can come or go, and maybe get fined or reprimanded?

    Major FAZEKAS. That is precisely why I go to the Navy captain at the Naval Hospital every time.
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    Commander OTTO. I would agree with the Major, and that was one point I was going to make. As the Major pointed out, he has had to intervene several times on behalf of his subordinates to get treatment that they should have without his intervention.

    As far as increasing the number of people, instead of using civilian workers why not recruit or otherwise train military members? We can obviously keep them gainfully employed, and in time of crisis we have the medical people necessary to deploy.

    Mr. ABERCROMBIE. I understand that. That is why I said a combination. I mean on the basis—well, I do not want to go into a long explanation and take the rest of the Committee members' time, but just so everybody here understands my position, my philosophical position, I think that the civilian employees of the United States military form a basis of institutional memory and loyalty that cannot be purchased in a contract with an outside agency, no matter how much rhetoric is attached to how they are going to try and do a good job and all that, number one.

    Number two, if you have civilian employees working with active duty, civilian employees of the military, civil service and so on, working for the military and with active duty personnel you have a hierarchy of authority that you can refer to that has teeth in it. In other words, if somebody is giving somebody the run around on an appointment, Major, cannot you then bring that person to account if they are not doing their job right?

    Major FAZEKAS. Yes, I would tend to agree with you.

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    Mr. ABERCROMBIE. Or if you do not, you should not be a major. Right?

    Major FAZEKAS. We defend the Corps.

    Mr. ABERCROMBIE. And I realize there are problems with that, and people start talking about how much it costs and so on, but my view of it is it depends on how you measure cost, and—well, I will defer, that becomes my commentary, and that is not what this is for.

    Thank you all very much. I am very grateful for your testimony, and I can assure you it was very, very enlightening and very precise.

    Mr. BUYER. Mr. Abercrombie, listening to you I am left with the sense that even though we have had these challenges and frustrations with CHAMPUS, it appears as though you are dreaming of the old system, there are such frustrations. I guess we always think there is something better around the corner, so rather than focus on any improvements in CHAMPUS we move into this TRICARE system and we find out that these competitive contracts in all these different regions create portability and integration issues, and lack of accountability and frustration on the beneficiaries, and then we move toward centralization, so it seems like we are going backward.

    Mr. ABERCROMBIE. Well, I do not mean for centralization. I do not think that has to be the case, but in any event—

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    Mr. BUYER. I am not trying to put words in your mouth, I am just trying to figure out where you are—

    Mr. ABERCROMBIE. But being a rock-ribbed conservative as I am, naturally I tend towards the old tried and true.

    Mr. BUYER. Sure. I understand. Mr. Hayes.

    Mr. HAYES. After that exchange, do you all think that the 800 number is being used to shuffle you from one person's plate to another's so that they do not have to deal with you? I mean I heard that very loudly.

    How do we get to the person if you need care for you or your child that has the responsibility? How do we find the ''buck stops here person?'' Glenna.

    Ms. BUTLER. It would be in the clinic itself, the Primary Care Manager (PCM), that that family is a part of, or that particular beneficiary is a member of.

    Mr. HAYES. Where do the TRICARE 800 phone operators go for health care?

    Ms. BUTLER. Well, sir, they have a book that they reference for the information that they give us, and they receive training on how to process and refer those calls, and that is why I said I believe that training is somewhat inadequate and needs to be addressed at the contract level.
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    Mr. HAYES. How often do the phone operators get face time with the people who are receiving the results, or lack thereof of their services?

    Ms. BUTLER. That does not happen, sir.

    Mr. HAYES. Is that a possibility as an improvement to fine tune the system?

    Ms. BUTLER. I do not believe that that would be beneficial in that regard.

    Mr. HAYES. Marjorie.

    Ms. MCCLAIN. In the process of trying to get my claim handled I ended up going down to the TRICARE office. She had no idea how to handle me. She contacted a claims person who gave her an information thing that the provider submitted the claims with the wrong codes on them, and that if I could have the provider resubmit them with the right codes it would be paid.

    The provider never submitted the claims. I did, and there were no codes put on them. But when I asked for her number so I could call her back to talk to her I was not given a number. So the person that I went and actually talked to still, even though I went in person did not have any idea how to help me.

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    Mr. HAYES. Glenna.

    Ms. BUTLER. The Health Benefits Advisors (HBAs), are there to assist us in those issues, and often times they—well, in general there is not continuity in that assistance. If you go once to consult with that HBA you get one and one course of resolution. The next time you go with the same documentation you get another HBA with a different recommendation, and so if we had a case manager who once a claim was not appropriately resolved was responsible to their employer as well as the family to follow that case to resolution I think the families would get a better quality of care and there would be some incentive to pursue that resolution in a more effective manner.

    Mr. HAYES. Thank you all very much for your testimony today, and I would appreciate a follow-up note from any or all of you who would like to do that to give me your thoughts after hearing what you have heard today, what the adjustments are from your point of view that we could make that make sense. We have got a linear system now, this end is not communicating with this end, and how do we close the system?

    So again thank you all for participating, and your follow-up thoughts would be very helpful.

    Mr. BUYER. Thank you, Mr. Hayes. Mr. McIntyre.

    Mr. MCINTYRE. Very quickly, Ms. Fazekas, the 800 number issue, you mentioned about the snow storm, and I believe Ms. McClain did also. We know that could not have been helped by anyone, but is part of your point that we have backup 800 numbers for the regional offices? Do you think that would have been helpful?
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    Ms. FAZEKAS. Yes, because yesterday I called and I inquired if Virginia received the snow storm after North Carolina did, why did they not go back to North Carolina 800 numbers, and they said when they shut down their system it just all shuts down.

    Mr. MCINTYRE. Okay, because that seems like a practical problem that we ought to have addressed right away.

    Second, Ms. McClain, you talked about the appeals process which is appalling concerning the time of the submittal of the claim, then the denial and the great delay there, as well as the appeal process.

    It sounds like when it was originally denied that if there had been a clearer explanation and a more timely explanation forthcoming that then you could have gone ahead and activated the appeals process. Is that part of what you are saying that there was not clarification? This seems like something we could get addressed also rather pointedly.

    Ms. MCCLAIN. Yes, sir. Their determinations say these services are not covered. It does not explain what is covered and have any reasoning as to why in my particular case it would not be covered. Most administrative determinations in unemployment and workers' compensation do that, and in that explanation it gives the power to the people and the understanding to the people to decide whether or not they actually should go ahead through the appeal process.

    My claim may actually should be denied, but because I do not know what the standards are, then I have no other alternative except to go through the appeal process.
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    Mr. MCINTYRE. Thank you. And, Major Fazekas and Sergeant McClelland, there are usually three main issues in health care we deal with. I call them the triple-A effect, but we deal with accessibility, accountability, and affordability. I think you all were trying to hone more in initially to the accessibility; is that correct? These fine ladies then testified a lot about the accountability problem.

    The affordability does not seem to be as much an issue unless you have a small bill, and then you get shafted on the credit rating situation, which I understand, especially having practiced law before going up to Washington, and that is an unfortunate situation. But are the initial problems this accessibility you would say, and then once even that happens we have to deal then with the accountability; is that correct?

    Major FAZEKAS. Pretty much correct, however affordability does come into play a little bit with the perception being created that I talked about. The perception is that they are trying to force people away from TRICARE Prime onto Standard, to transfer the costs to the user.

    Mr. MCINTYRE. From their perspective; right?

    Major FAZEKAS. That is right.

    Mr. MCINTYRE. Okay. All right. Anything else?

    Commander OTTO. My understanding of the accessibility, I have trouble accessing it, and that is why I said before that I try to go through all means not to use TRICARE and to try to call the clinics myself.
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    As far as cost, I am kind of put into a position because I cannot afford a lot to use the Prime. I cannot afford to foot a bill for myself.

    Mr. MCINTYRE. So you feel like the purpose of TRICARE in order to save money actually deters servicemen and women from even attempting to access at times because of the deterrence factor built in and how you have to handle the claim?

    Commander OTTO. Right.

    Mr. MCINTYRE. And then finally, both Major Fazekas and Lieutenant Commander Otto, from what you have said and what one of you, actually the major referred to about the morale issue, I think this is probably one of the greatest concerns we have overall. As I mentioned in my opening statement about this being the year of health care as far as I see it, and many of my colleagues on the Armed Services Committee, and also these gentlemen as well, the morale issue itself, do you feel that this indeed should be a premier issue that needs to be addressed this year? We have so many issues on the table as you know, and I am concerned about readiness, I am concerned about our quality of life for our families, the child care and the other issues, but in terms of quality of life and how it directly affects the morale, do you feel like health care is the number one morale issue so that we can prioritize as to our time in Committee meetings and resources?

    Major FAZEKAS. It is hard for me to say if it is number one. I know it is very high.

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    When our Marines are deployed to trouble spots in the Mediterranean and around the world they want to know that their family members are going to be taken care of.

    Mr. MCINTYRE. Right. Good point. Lieutenant Commander.

    Commander OTTO. Yes, sir, that is exactly the point I was about to make as well. Readiness and health care go hand in hand in my opinion.

    Mr. MCINTYRE. And I wanted to say I enjoyed being aboard the USS Theodore Roosevelt almost a year ago, March 21st, the Monday before you all deployed, and we were told you were going to the Persian Gulf, but we all had a feeling you would stop in the Mediterranean because we know that following Thursday is when the conflict in Kosovo became what it was. But thank you for the excellent job. I know the folks on the USS Theodore Roosevelt were most gracious, and you did an excellent job over in the Mediterranean during the Kosovo crisis.

    With that I thank you, Mr. Chairman.

    Mr. BUYER. Thank you. I will go back to the Army for just a moment here. Sergeant, someone placed you in a very difficult and awkward position here today at no fault of your own. Okay? So I want to make sure we come to an understanding.

    I do not know who did that or placed you in this position. That is unfortunate, but nothing should ever happen to you because of that, because of their actions. All right?
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    Sergeant TOGIAI. Yes, sir.

    Mr. BUYER. So for the Subcommittee members as I look across the witness list I see in Panel 4 there is a command sergeant major who will be providing testimony, and hopefully he is out there and is preparing very well on his testimony. He will be assuming the voice for the entire enlisted Army in this region, so I am sure he will be an excellent witness, and he will assume the breadth of responsibility. Do you not believe that is what sergeant majors do?

    Sergeant TOGIAI. Yes, sir.

    Mr. BUYER. Thank you. Does anyone else have any further questions?

    [No response.]

    Thank you very much for being here today and for your testimony. This panel is now excused.


    Mr. BUYER. Our second panel is composed of retired military personnel, some of whom are now using Medicare as their main source of medical care.

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    Thank you all very much for being here today to provide your testimony. It is important for us to better understand the problems and be able to address and take corrective action.

    We also would like to hear if something is working, let us know. Often we get to hear the negative side, but if there is something that in fact is working let us know.

    Gentlemen, your statements will be entered into the record, and if you would please summarize your testimony within five minutes we would appreciate that. Please recognize yourselves and your backgrounds, and if you are a representative of a particular association please let us know that also. Sir.


    Chief REICHLER. I am Randy Reichler, I am a retired hospital corpsman, independent duty, served 17 years with the Marine Corps out of 24, served with the Marine Corps in Vietnam, Persian Gulf.

    I am also an HBA, Health Benefits Advisor trained in Denver. Did that for nine years as a secondary job at three different duty stations. Had a lot of frustration with that, then moved into TRICARE. I am also the retired affairs officer at Camp Lejeune, the only civil service retired affairs officer for the Marine Corps. I deal with TRICARE pretty often in problems that I run into there.

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    I conduct a three-day orderly pre-retirement seminar. I am one of the few people you will meet that deal with the active duty, getting ready to retire, and also deal with the retirees. I serve as liaison for the retirees to the general, the commanding general of the base, and I handle problems with the retirees and the people getting ready to retire and their families. So I do have a big interest in this.

    I know we are supposed to stay away from the national forum, and I will, but I just want to add three things in. I would encourage Congress to vote for HR 3573, HR 1413, and HR 205 which deal with retiree concerns. It is keeping the promise.

    I would also ask, and this pertains to our current problem there, that you lower the catastrophic cap. The catastrophic cap is at $7,500 retirees, and normal nationally is $3,000 for other companies. We ask that you just lower it to that.

    Now, to go into local problems on TRICARE which I deal with, one big problem we have with TRICARE at the Camp Lejeune area, we have two clinics there. The two clinics have an average no-show rate every month of 1,140 patients. 95.5 percent of that is active duty family members not keeping their appointments. This is a significant problem, and that means 1,140 retirees are prevented from making appointments. I have approached this, I have worked four years as a retired affairs officer, I approached it three years ago with the Naval Hospital. The Naval Hospital says it is a problem TRICARE needs to deal with. TRICARE says ''We do not have to deal with this. We furnished the appointments, we furnished the providers; therefore it is not our problem.''

    1,140 is 12 percent of the people that have appointments. The problem that I see with this, one problem is that we have no local coverage. As was explained here before, there is a 1-800 number that goes to Virginia, so therefore if you call and Virginia says you cannot get in, there is no one standing down at the TRICARE center looking out at an empty waiting room saying ''Come on down, we can see you.'' That is not available.
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    We used to have a local number there, and it worked out pretty good. We had a lower rate. We averaged 980 at that time, so the number was down. I have called Charleston Air Force Base, Womack Army Hospital, I have contacted Seymour Johnson Air Force Base, who just now has stopped being a hospital last year, and I have contacted Northport. All four of these installations have a lower no-show rate than we do at Camp Lejeune, all four put together. That is incredible.

    Now, I have been told ''We are working on a plan for this.'' The plan is we will set up an automated phone system that will call the person the day before their appointment. This would be fine. Their estimated time on this is three to five years. So we continue every month missing 1,140 appointments.

    One abuser, and I did see the list on this—because I had a talk with them before I came here—one abuser has missed 62 appointments in one year. Now, that is three family members in one family have missed 62 appointments in one year. Not one letter or phone call has went to that individual's sponsor or themselves. We have 2,000 people on a chronic abuser list. This needs to be looked at. We have got some fraud, waste, and abuse happening some place.

    Now, the other problem we have: We need a local source phone. As was echoed in here by the major, which I deal with Camp Lejeune, I cannot speak for Fort Bragg. We have a problem. Our problem is we do have to call Virginia, and Virginia cannot see what is going on down at Camp Lejeune, they have no idea. I have dealt with this where I have had to call day after day for an appointment myself, and for my family members, and eventually, yes, you do have to go to the emergency room and sit your four to six hours there and wait for an appointment, which is fine if you can get in.
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    We need a local representative. We do have a TRICARE representative local, but they have nothing to do with appointments. They cannot do anything. Our local manager there, Cal Blazer, who used to run the clinic was very accessible when there was a local phone. He is no longer accessible. They did group it because they can take care of three states by having that phone in Virginia. That is wrong, and I really applaud you for seeing that.

    It is a cost-saving thing, that is all it is. We are dealing with civilian companies that are out to save money. I do not blame them. If I was a civilian company, I would be out to save money too. That is what they are geared to do.

    Another problem we have, when a person is referred out we had 1,500 people that had their mammograms misread—not misread, but they were not read by radiologists at Camp Lejeune. This was a big scandal that came up last year. Out of that they found a load of our female clients that needed to be sent out to get new mammograms done, nine of them—and I have talked with three of them—had to have breast biopsies because, yes, they did find something there.

    The biopsies, they went in, they paid for the doctor to do the surgery, they even paid for the equipment. They would not pay for the anesthesia, so you are going to get a biopsy with no anesthesia. That is the way it looks on the paper.

    They told me when I called up on this ''That is no problem, just put in an appeal, 77 percent of appeals work.'' This is ridiculous. They should have had anesthesia, that is just a common thing.
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    Another problem we have with TRICARE is local. Nationally it costs $480 for an MRI nationally, that is the national average, $480. TRICARE observes $134. Where is the rest of it coming from? Their ceiling price, the ceiling price is atrocious. The ceiling price apparently has not changed in years. It needs to be changed, it needs to be up.

    One of the very good things brought out here was how does it affect recruiting? I will tell you, last year it is real simple, TRICARE and other eroding benefits did affect recruiting. I was also a recruiter for four years. I pretty well covered the gauntlet on this, and I can tell you fifteen years ago 54 percent of recruits brought into the armed forces had a retiree or a veteran in the family, and also had someone as a close family member that talked to them about going into service. Now, it would be very easy to ask all the retirees in here how many now would recommend your son and daughter or a family friend to go into the service now knowing what they know. You would be surprised at your answer.

    Now, last year three out of four, like I said, did not meet recruiting goals. The Marine Corps made recruiting goals, barely, barely. They lost 8,500 the first year, but they made recruiting goals. Now this year according to the fiscal year numbers none of them will make recruiting goals. That is a prediction I made right here from seeing it. And if they do, they will do it from lowering their standards, taking non-high school graduates, or lowering their standards on scores. That is the way they will do it. Now, this is because now you have such a low percentage of people referring the armed services to their kids, or their family friends.

    The other thing is morale. This is definite. Number one problem in the Marine Corps is indebtedness, indebtedness. Now, this is attributable to different things, furniture, cars, things like this, but it also some attribute is TRICARE. That does play a part in it. Some of these bills that you are hearing about they are very legitimate, they are there. Some people do not think ahead and think ''Well, I need to save my credit, so I will pay that hundred dollars myself.'' They do not think like that, but that is the way you have to do it, and sometimes you have to avoid TRICARE to stay out of the indebtedness.
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    I have furnished 75 written statements for you, and on the back of these written statements is a letter, and I am going to quickly just briefly go over it. A woman had three days she tried to get an appointment for her child in TRICARE. Eventually what happened—you will not see it in that editorial, that newspaper editorial, but once she did get the child in civilian care she was threatened with abuse, an abuse case because she had to wait.

    Mr. BUYER. Those will be submitted for the record. We are aware of those.

    Chief REICHLER. Thank you, sir.

    Mr. BUYER. Do you have any other further comment?

    Chief REICHLER. Yes, sir. I would like to close with this: Take a look at the retirees in this room, many of the warriors placed their life on the line to protect the freedoms we cherish. If they had stayed home and mined coal, if they were on welfare, or if they were civil service the government would ensure its promises were kept.

    Al Gore just recently stated ''We will keep our promises to the coal miners.'' Now, obviously defending the Nation also qualified us military retirees for a minimum of similar benefits promised. I ask that you look in your hearts and do the right thing. I heard that echoed in here already, just do the right thing. Support your military retirees that did not hesitate to support you and the country.
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    I will gladly answer any questions you have got, and I will say by failing to keep promises both to active duty and retirees you do adversely affect the retention and recruiting as well as the attitude of the, quote, ''total force.''

    That is all I have. Thank you.

    Mr. BUYER. Thank you very much.

    [The prepared statement of Chief Reichler can be found in the Appendix.]


    Sergeant TUCKER. My name is Chief Master Sergeant John Tucker, Retired, United States Air Force.

    First of all, thank you for the opportunity to testify here today, and I would also like to applaud Randy here for being prepared as much as he is with his statements. I applaud you for that.

    I am proud of the thirty-plus years that I have served the United States Air Force, and if I had to do it all over again I would. While I was in the United States Air Force I received great medical care, both me and my family. I have no complaints about that whatsoever.
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    After retiring I initially had to use the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), program. I had a CHAMPUS supplement program that cost me over $800 a year. I never had to use it. Thank God for that.

    When TRICARE Prime first came out, I enrolled in it immediately. Four weeks after the enrollment, I called the 800 number to find out where my cards were. I was not in the system, they had no record of it, but they took it over the phone, and within three days I had my TRICARE Prime cards. At that time I was assigned to the Jewell Clinic here on Fort Bragg, and I cannot think of a finer institution to be assigned to.

    I hesitate to testify to the following because the system is working for me, and I do not want to lose that. But it is working, I do have a number that I can call. I can call the Jewell Clinic, I have a doctor that takes care of me, and there is a doctor that takes care of my wife and my daughter. Those are the offices that I call. When I call, I have an appointment within 24 to 48 hours. As I say, I hesitate to testify to that, because I sure do not want to lose it.

    One thing I do not like having to do is to pay for it. I believe I was promised the free medical care when I started in the military over thirty years ago. I am paying $460 a year, but I will tell you with the treatment that I am getting, the phone calls, the doctors that we see, I gladly pay that. I would rather not, but I will pay it to get the treatment that I am getting.

    I am a life member of the Noncommissioned Officers Association. I also do volunteer work at the Retired Activities Office at Pope Air Force Base, and I come in contact with many retired members who are not getting the treatment that I get.
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    I hope I am not getting that treatment because of my retired rank. I know we all realize that rank has its privileges (RHIP), and there were many times when I was on active duty that I was treated differently because of my rank. I hope that is not the case here, because what I have heard here today already is not positive comments, but what you are hearing from me is positive. I do hope it is not because of the rank.

    The older ones that I have talked to complain about not being able to get appointments when needed. Some of the individuals I have talked to came into the service before 1956, and they tell me they have something in writing that promised them that guaranteed health care for the rest of their lives. They are having to pay for their prescriptions, they are having to pay to see doctors. The only thing that I have really had to pay for are things that are not stocked at the Womack Army Hospital pharmacy, and those are some strips that my wife uses to test her sugar daily, so I have to buy those on the local economy.

    I believe everyone should be able to see a doctor when they are sick. This 1-800 number, the only time that I had to call that was to actually to get into TRICARE Prime, and the lady there took my information over the phone, and I was enrolled immediately.

    All of us served our country, and some of us still are. We need one program that takes care of all of us, not just active duty, not just retired, but all of us. Not chief master sergeants, but also airmen basic as well.

    I understand that we have to take care of the active duty people first because they are on active duty, but let us face it, at one time we were all on active duty, and we were taking care of the country at that time. Loyalty works both ways. I did not forget the country while I was working on active duty, and I do not expect the country to forget me or my friends when we are not on active duty.
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    I would like to thank you for your time, and I am proud to have served, and I am proud to be part of this inquiry. Thank you.

    Mr. BUYER. Thank you. Colonel.


    Colonel GARMAN. I am Lieutenant Colonel Robert Garman, I entered service in 1952, I exited service finally in July of 1985. That is more than 33 years, part of it active, part of it in the Reserves, part of it National Guard. I tried it all, it all worked.

    I currently am a part of family practice here at Womack. I have not used Medicare at all, I have not had to. I have been seen, not when I had to today, but I could get in tomorrow, or the next day. I have got a patch on my arm from the dermatologist that I saw a week ago. Sometimes you have to wait. I wanted an appointment for urology in June, they said ''Hey, we have got some doctors coming in August if you can wait until then,'' I said ''Yeah, take a Prostrate-Specific Antigen test (PSA), we will go then.'' That works for me. I have got friends who are not in family practice, and they cannot get seen at all. You can go to the emergency room and you can if you have got an emergency.

    There is no dental care. They will give me a pair of glasses, but they will not give me the prescription to get the glasses. You know, old folks have teeth problems, they will not take care of those. Eye problems. These we need, but the TRICARE I have not fooled with at all. The wife just turned 65, and she did not bother to enroll. She fought the curve, and she made it, so she is Medicare now, and I hope we do not have a problem. But in that light personally I have not had a problem with TRICARE at all.
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    Thank you.

    Mr. BUYER. Commander.


    Commander OVERMAN. I am Commander Jack Overman, I am the current president of the North Carolina Council of Retired Officers Associations representing some 16 chapters across the state of North Carolina.

    I retired on 20 years in 1974, and I came under CHAMPUS until 1996, at which time I went on Medicare. I have never been exposed to the TRICARE system. I have enjoyed excellent health through all of this time, and I have used Portsmouth Naval Hospital on a number of occasions, and had an opportunity to speak to Rear Admiral Balsam this morning and thank her for the excellent care that has been provided to me and to my wife.

    We in my chapter on the Outer Banks invited the TRICARE representatives from the Portsmouth vicinity to address our The Retired Officers Association (TROA), chapter and essentially receive the ground rules on TRICARE. We were told that for the old-people type problems, eyes and ears and so forth, no problem getting into the clinics. If you have got the young people's problems that basically involve orthopedics and things of that nature, forget it, go find a civilian doctor.

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    Medicare has provided for my needs quite satisfactorily, very few problems if any. My concern is for the future. My wife's health is on the decline, and I look to some help on long-term care. Long-term care for me and my wife with inflation coverage is over $8,000 a year. There are not too many people that can handle that kind of financial burden.

    TRICARE in its present form and as I understand it is of questionable value to me. I live over a hundred miles from Portsmouth Naval Hospital, so it is quite a drive to get up there. I do it when it is necessary, I do it frequently for drugs. I am provided with most all of my drugs. There are a few that my wife has to take which cost a fortune that we have to buy on the local market.

    For us Medicare subvention Federal Employees Health Benefit Program (FEHBP), would be our choice, and I echo the senior chief in his asking you to support HR 3573, HR 1413, and HR 205.

    In general, we would like to see you return the health care that we were promised back in 1954 when I entered the service. In general, input from the TROA members that I have had a chance to talk to, and I solicited remarks from all of them via e-mail, they say they were promised lifetime care, they liked the CHAMPUS system, they found difficulty navigating the vagaries imposed by TRICARE. They are not eligible for TRICARE any more, they are on Medicare with a supplemental policy which generally suffices, but is a bit costly. They would like FEHBP or Medicare subvention as an option, but they are currently locked out. Would like a long-term care option. An item that has not been mentioned too much here is a need for dental care, something other than the Delta dental care, or at least expand it, because in its present form it is essentially useless.
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    Our recommendation would be if you could publish through phone or whatever those clinics which are currently underutilized and are available for people like myself, the over-65 and Medicare-eligible could take advantage of.

    I thank you for the opportunity to talk to you, and that is all I have.

    Mr. BUYER. Thank you. Master Sergeant Farmer.

    [The prepared statement of Commander Overman can be found in the Appendix.]


    Master Sergeant FARMER. Gentlemen, I am Master Sergeant Russell C. Farmer, United States Air Force (Retired). I entered the Air Force in 1961 and retired in 1987. During my 26 years of service to my country I am proud to say that the medical attention that my family and I received over that period of time was of the highest quality. From 1971 to 1976 I was stationed in the Dallas-Fort Worth, Texas area where I was a U.S. Air Force Recruiter. During my six years as a recruiter I was responsible for the enlistment of many young men and women into the military service. One of the main selling points of enlistment was join the United States Air Force, serve 20 years or more, and your dependents will have free medical service from the Air Force for the rest of your life.

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    We were told to sell the sizzle, the sizzle was medical, dental, exchange, commissary, and educational benefits.

    As the Cold War wound down and threats from adversaries such as North Korea, Vietnam, the Soviet Union become less and less, I began to hear more and more about the noncontinuations of the medical benefits that I had promised all those young men and women that I recruited for the services, promises that my recruiter had also made to me.

    When I retired in 1987 I had to use the CHAMPUS or buy my own family health plan. On the back of my ID card was a statement that in 1999 when I turned 65 years of age I would no longer be eligible for military health benefits and would have to buy into the Medicare program. I have been very fortunate since my retirement. My family and I have been blessed with good health, and for the first eight years following my retirement I was employed by a civilian contractor on Pope Air Force Base and bought into their health care plan. I did not have to rely on the old CHAMPUS system, which in my opinion was not very good.

    In 1996 I was a victim of downsizing and no longer eligible for the civilian company insurance plan. In 1997 I again started to use CHAMPUS as my primary health care provider, and continued with them until I enrolled in TRICARE later that year. From that point until November of 1999 when I turned 65 the service and care that my family received from TRICARE was excellent. My wife and son are still members of TRICARE.

    Knowing that my benefits under TRICARE would expire in November of 1999, I sought out and got full-time employment with the Cumberland County School System as a teacher assistant. This allows me to buy into their health care program which is very good. The plan I feel is better and less expensive than anything that I could buy from Medicare companies.
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    I am fortunate to be in very good health for my age, I enjoy very much being able to give back to my community by being a teacher assistant. I am making what I hope is a positive impression on the lives of young elementary school children here in my community. The opportunity to buy into the school system health care plan is a big plus for me. I will continue to work with the school system as long as I feel I can make a difference and the system has a place for me.

    I know that eventually I will no longer be able to do that work. When that time comes, I will be forced into a Medicare system with very high premium rates and much less coverage than I now have, coverage that I pay for.

    It distresses me that the promises made to me when I enlisted, and the promises that I made to the young men and women that I brought into the service many years ago seem to have been broken. For this reason I would like very much to see the TRICARE program continued for all retirees and their dependents regardless of their age.

    I thank you for the opportunity to be here, and I did a little figuring a minute ago. I am presently paying out in the neighborhood of $4,000 a year for insurance programs that I am buying to include survivors benefit retirement plan, life insurance, dental plan, TRICARE, and medical health programs. Fortunately I am able to afford it right now. I will not be able to much longer.

    Thank you.

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    [The prepared statement of Master Sergeant Farmer can be found in the Appendix.]

    Mr. BUYER. Of that, what do you pay for medical care?

    Master Sergeant FARMER. Of that what I am paying for medical care right now, sir, is in excess of $1,000 a year. I pay about $500, probably close to $600 for the school insurance that I receive, plus $460 a year for my wife and son under TRICARE.

    Mr. BUYER. Let us talk about pharmacy for a moment. What is happening with regard to the pharmacy benefit within this region? Anybody can comment.

    Master Sergeant FARMER. From my standpoint, sir, while I was under TRICARE no problem whatsoever. Presently under my system I have to pay a $10 co-pay when I get prescriptions filled, but my wife and son still receive medical prescriptions from the Fort Bragg-Pope area at no cost.

    Mr. BUYER. I guess my question is in particular to the over-65 military retirees.

    Commander OVERMAN. Let me speak to that, sir. Except for those drugs which are not carried in the formulary at Portsmouth Naval, I have absolutely no problem whatsoever in obtaining what I need.

    Colonel GARMAN. The same here. Fort Bragg fills all the prescriptions we have unless there is something outside of the area that they do not carry, so there is no problem with it.
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    Commander OVERMAN. Mr. Chairman, one point, please. In my case it is a hundred-mile drive. If we had the mail order pharmacy capability it would probably benefit me and the many, many retirees on the Outer Banks.

    Mr. BUYER. Thank you. Chief Reichler, in your testimony you listed the national-level issues which you refer to, and I read through what you have submitted and your comments, so let me comment on them.

    Chief REICHLER. Thank you, sir.

    Mr. BUYER. Since you said you have not heard, I am going to let you have the opportunity to hear. It is very difficult for me from my Hoosier common sense, actually for anyone's common sense to having been lobbied for over three years to deliver an FEHBP test program, to now in the face of the infancy of this program to say ''Oh, well, you do not need to wait for the test, let us just go to permanent—let us do it now.'' Why did you lobby me for three years to put together a test that now you say ''We do not need the test, I want it now''? That does not make a lot of sense to me, so I just want to let you know that.

    There are some concerns that we have with regard to the number of sites: Were they the right sites that were selected? How can we make some adjustments to make sure that we get credible test results? We are going to do that, and I am attentive listener to Congressman Jim Ryun of Kansas on expanding the number of sites into the test, and I think the Subcommittee is going to do that also. But I do not see the Subcommittee taking action to move to a permanent implementation of the FEHBP.
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    When we took this issue on three years ago the Retired Officers Association was more than eager to push this one, but the retired enlisted were saying ''Wait a minute, this might be a good benefit to some of the officers who can afford it, but we cannot necessarily afford it,'' so I think it is very prudent for us to—we are going to go with this test.

    I will share with you the importance of a test. Had we perhaps permitted the TRICARE test to have occurred, maybe a lot of these things could have gotten sorted out, but we did not wait for the test. Congress sometimes jumps into the vein of emotion and it gets so responsive to what you want, ''I have got to have it now,'' that they move the sunami across the country, and we have dealt with seven years of a back side pain in the behind in the implementations of TRICARE.

    So I just want to be very up front here with you. I guess I am going to be very cautious about giving you what you ask for—be careful. So we are going to exercise some prudence, so I want to be very frank with you.

    Chief REICHLER. Thank you, sir.

    Mr. BUYER. The Medicare reimbursement demonstration project, and making permanent the Medicare subvention, the Medicare subvention test also was supposed to be cost neutral. We are now learning that it is costing DOD $2,000 per beneficiary. I am really pleased that we did not just jump into it without us understanding what impact this was going to have. So please let us sort this one out before we move and just say we are going to make it permanent, when in fact we are now discovering we have many different problems that we did not realize we stepped into in the beginning. So I just wanted to be very, very up front with you about those things you just asked.
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    Chief REICHLER. Thank you, sir.

    Mr. BUYER. Let me now yield to Mr. Abercrombie.

    Mr. ABERCROMBIE. Thank you very much, Mr. Chairman.

    Chief Reichler, I want to start with you, and again I think some of you were here before. If I seem to move real fast it is because we are under a time constraint here, so if you could just limit commentary and try to give as direct an answer as you can.

    I am very interested, and I am glad you brought up the question of abuse. It might seem harsh to other people, but if somebody does not show up for their appointment and it is left blank, that leaves somebody else out of the picture.

    What I would like to know is do you have any awareness of local commanders then being informed about people who start missing appointments? Anybody can miss an appointment, but what you are talking about of that 1,100, I will bet a lot of that 1,100 comes from the same people.

    Chief REICHLER. Not one single local commander has been made aware of this.

    Mr. ABERCROMBIE. Is that because there has been no effort made on the part of either the contractor or the customer service representative, is there not a liaison—you are a liaison, you are a liaison to everybody and everything on the planet apparently, but why has that happened? Why has there not been something where somebody goes and visits and says ''Hey, look, you know, if you do not show up you have got to at least call us or let us know, and you cannot keep doing it because you are hurting other people?''
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    Chief REICHLER. When I asked the Commanding Officer (CO) of the Naval Hospital who was there at the time, who is now Admiral Arthur—he was captain at Naval Hospital last year—why they did not notify people directly. He said ''Well, Randy,'' he says ''what I do is I went out to a house, the lady missed 27 appointments in one year, my master chief went out there, she was desolate, she was depressed, her husband was on deployment, and she was emotionally distraught.'' He says ''What do you expect us to do, take away her medical?'' I said ''No. You just need to tell her to use the phone. She used it 27 times to make it, she can use it 27 times to cancel.''

    The thought there is they do not want to offend anybody, but they do not realize they are offending us every month we see these numbers. The numbers are posted, they are posted very clearly right out in the waiting room.

    Mr. ABERCROMBIE. Okay. That sounds like somebody that needs some help, and some outreach needs to go there.

    Chief REICHLER. I would appreciate it.

    Mr. ABERCROMBIE. Okay. Now, I was very impressed when you said that you did not think the 800 number could deal with it, but no local connection source, and was it you, Master Sergeant Tucker, you do have a local number? That was right, was it not?

    Master Sergeant TUCKER. Yes, sir, that is correct.

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    Mr. ABERCROMBIE. Yeah, you said you get local response by phone. What I am hearing today is if we could get a local contact, a local telephone contact at a minimum we could resolve a lot of what the problems are right now, and you have got a back-and-forth locally with somebody that can give you answers, take responsibility, meet obligations, et cetera, right, somebody with authority?

    Master Sergeant TUCKER. It is working for me, sir.

    Chief REICHLER. We had one until two years ago.

    Mr. ABERCROMBIE. If you call my office, I do not have the authority in my office—and I am not being facetious with you, I do not—I have people in my office, they make decisions, and they are authorized to make decisions. My appointment calendar for example is not kept by me; I do not make appointments. Everything in my office is handled, in both offices is handled by somebody who has authority, and does it. Otherwise, I do not have them working for me.

    What I am trying to get at is do you think that would solve it if you could—not solve it, all of it, but a majority of the access problems would be solved if there was a local connection to the primary care physician?

    Chief REICHLER. It would help tremendously. The other thing I would ask is that they add a cancellation number. There is no direct cancellation number in Virginia. So normally you think ''Well, I will just call back the number I made the appointment.'' That seems to be a real crunching problem.
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    Mr. ABERCROMBIE. Well, maybe one of the things there is if you do cancel, or if you need to cancel and you do not let somebody know, the next time you call for an appointment I do not see why you cannot say ''Excuse me, we do not have a cancellation for you from the last time. Unless you have an explanation for that, do not call and expect to be able to move right to the front of the line.''

    Chief REICHLER. I wish you were at Camp Lejeune, sir.

    Mr. ABERCROMBIE. I see, okay. Just a couple more things.

    By the way, I meant to ask you, Master Sergeant, why do you have that and others do not, this local response by phone capacity?

    Master Sergeant TUCKER. I do not know, and please do not share that. [Laughter]

    Mr. ABERCROMBIE. But is it a local decision that has been made by the authorities in your region, or your particular base area?

    Master Sergeant TUCKER. When we were assigned to the Jewell Clinic we were given a particular doctor for my wife and one for myself as well. We call their office, they check their calendar to see what is available, and in many cases within the same day my wife and my daughter have gone to see the doctor, and within 24 to 48 hours I have gone.

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    Mr. ABERCROMBIE. I meant to ask this question of the other panel and I missed it, and I should not have. In the event that—and maybe Ms. Fazekas or somebody can just fill in later, or Ms. Butler—in the event that a spouse and/or a member of the active duty service has an obstetrician, a gynecological physician, and they have to change physicians, do the physicians then get in touch with the people and say ''Look, I am going to have to switch you to Dr. So and So,'' or does the person have to find out on their own when they show up, or call for an appointment? Are you familiar with that at all?

    Master Sergeant TUCKER. I am not, sir. I know when I was on active duty, and when the doctor PCS'd I got notification from that office that he would be leaving, and the person coming in replacing him would be my new doctor.

    Mr. ABERCROMBIE. Okay. I will just say, and for the other members, I want to stay in touch with you because somehow you managed to get into a—you know, maybe you have got the aura about you or something, but you managed to get in from the beginning on the way it should be running all the way around it seems to me. My point being is that if things are running the way you are saying, there is no reason why that cannot become common and across the board.

    Master Sergeant TUCKER. Sir, I have talked to other people who are assigned to the Jewell Clinic, some people that I work with, and they are treated the same way.

    Mr. ABERCROMBIE. Well, I have got an idea that this comes down to leadership, then.
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    Master Sergeant TUCKER. Yes, sir.

    Colonel GARMAN. Sir, may I interject? He is in family practice the same as I am, and you are assigned a doctor. You call that clinic, they take care of you, they will schedule it for you. That is the way family practice works.

    Mr. ABERCROMBIE. Well, then, why do you suppose—can you speculate as to why, then, this is not common across the board?

    Colonel GARMAN. I do not know how they cut it off, no, sir. That is why I have been very quiet. I too am happy.

    Mr. ABERCROMBIE. Okay. Well, I am very pleased that you are speaking here today, because as I indicated during the first panel it does not do us a whole lot of good just to have a whole lot of complaints and negative things just come in, because then it leaves you drifting, and the point is that you have had separate but equal experiences in terms of the way things should be working, or could be working; correct?

    Colonel GARMAN. Yes, sir, but, see, in the family practice the TRICARE takes priority. If his wife who is still under it calls for an appointment, she is going to get it ahead of him if he is not in it, and the same thing in the clinic that I am in. So it is tied together, but it is in family practice. That is the way it works.

    Mr. ABERCROMBIE. Very good.
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    Commander Overman, I want to ask you now, in your particular situation the drugs—I thought you said you were a hundred miles away from—

    Commander OVERMAN. That is correct, sir.

    Mr. ABERCROMBIE. How do you get your drugs? Run over for me your drug acquisition and access.

    Commander OVERMAN. The drugs are prescribed by local doctors which I handle through Medicare. I then go to Portsmouth Naval Hospital, what is known as Scott Center up there, and present my prescriptions, and receive whatever is on there.

    Mr. ABERCROMBIE. But you have to go a hundred miles; is that correct?

    Commander OVERMAN. Yes, sir, it is a hundred-mile drive for me there, and a hundred miles back.

    Mr. ABERCROMBIE. What about your colleagues who are at even a greater distance, then? What happens then?

    Commander OVERMAN. I am sorry, I did not understand the question.

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    Mr. ABERCROMBIE. When you have colleagues who cannot get—

    Commander OVERMAN. They drive a hundred and sixty or more.

    Mr. ABERCROMBIE. So would it not make sense, then, to be able to have the drugs available locally under the same circumstances?

    Commander OVERMAN. Most assuredly.

    Mr. ABERCROMBIE. What do you think is holding that up?

    Commander OVERMAN. Sir?

    Mr. ABERCROMBIE. What holds that up? What prevents that from happening?

    Commander OVERMAN. Well—

    Mr. ABERCROMBIE. Not that I do not know, but I want to know how it is perceived.

    Commander OVERMAN. It would be a supposition on my part.

    Mr. ABERCROMBIE. Pardon me?

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    Commander OVERMAN. I said it would be a supposition on my part. Now, we have a Coast Guard air station which is sixty or seventy-five miles away, and we have Group Cape Hatteras, a Coast Guard station which is in the other direction about another seventy miles.

    Now, their formulary may not carry many of the drugs which are carried at Portsmouth Naval, so if you happen to have a drug which is extremely common and is available at those other two locations then you can get it. However, in my particular case I do not even bother with calling them because most of the time I wind up having to go to Portsmouth anyway.

    Mr. ABERCROMBIE. Okay. Thank you.

    I will conclude with this. Sergeant Farmer, I was impressed by your recitation of both how you came into the service and what you were responsible for with respect to recruiting other people over time.

    With particular respect, then, to the question of the acquisition of prescription drugs—this is a very important aspect of the Chairman's focus before the Committee for some time, and most certainly this year—you are familiar, then, with the circumstance about having to travel long distances to get prescribed drugs, and if they are not immediately available the difficulties associated with that, are you not?

    Master Sergeant FARMER. No, sir, I have not experienced that situation, because I live here in the Fort Bragg area, and—

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    Mr. ABERCROMBIE. But are you familiar with that complaint?

    Master Sergeant FARMER. No, sir, I am not.

    Mr. ABERCROMBIE. Okay. Is anybody on the panel familiar with that? Mr. Reichler, have you run into the question about the availability and accessibility of prescribed drugs?

    Chief REICHLER. Prescribed drugs at Camp Lejeune are based on active duty strengths, and what active duty take solely. They have two review panels per year, and they delete drugs if they are not used by the active duty side. You will find very limited drugs for hypertension, which is a big factor with us retirees, and arthritis. You fill find very little. You will find very little on diabetes medication.

    Mr. ABERCROMBIE. So you think there needs to be some revision?

    Chief REICHLER. Yes, sir, but then we are dealing with the fiscal area there where they have got to spend more money to buy more drugs. It is just easier to tell us they are off the formulary.

    Mr. ABERCROMBIE. Well, there are more people living longer in retirement, are there not? I mean we are trying to deal with this question that you folks are raising about lifelong provision of medical care, which to me includes more particularly as there is an aging population in retirees, and veterans for that matter, is not the question of prescription drugs going to loom larger rather than smaller in the decades to come?
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    Chief REICHLER. Yes, sir, it is, and that is a big question. In fact, when we look at it that is our last right we have got is pharmacy when we look at it, and we are really concerned about this, sir.

    Mr. ABERCROMBIE. Thank you very much. Thank you, Mr. Chairman.

    Mr. BUYER. Mr. Hayes.

    Mr. HAYES. I will have a hard time improving on Mr. Abercrombie's and your questions. I think we can move right along. You all have covered the subject well.

    Mr. BUYER. Thank you. Mr. McIntyre.

    Mr. MCINTYRE. Just one quick comment, and I appreciate Sergeant Farmer stating very bluntly and clearly what we have been told many have said they heard. It is good to hear somebody who was both told this and said it himself about free medical service and the sizzle. Thank you for making that clear. That will help our argument as we go back to Washington with our colleagues to make it clear why it is so important that we honor the need for what has been promised.

    Master Sergeant FARMER. Thank you, sir.

    Mr. MCINTYRE. Thank you. Thank you, Mr. Chairman.
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    Mr. BUYER. Gentlemen, I want to make you aware that we are as a Subcommittee in our third year of the pharmacy redesign. The purpose of the redesign of the pharmacy within the military health delivery system was to derive savings, which then I am able to take those savings and then turn them into the providing of a pharmacy benefit to the over-65 military retiree. Were you aware of that?

    Colonel GARMAN. No.

    Mr. BUYER. I am glad I told you that. That has been our focus, so when Mr. Abercrombie said that we have been working on this we have been doing it for a while. You know, we are not deriving the savings which we thought perhaps we would have achieved at the beginning, but the Subcommittee is going to focus on how we are able to deliver that benefit, and then we need to decide in what manner and form, cost.

    Commander Overman, if this Subcommittee puts together a national mail order pharmacy or a BRAC pharmacy-type benefit, you are going to then have to make a personal business decision whether you want to participate in that program and make the co-pay or drive two hundred miles there and back.

    Commander OVERMAN. That is correct.

    Mr. BUYER. That is going to be your personal decision whether you do that.

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    Commander OVERMAN. Yes, sir. I will answer your question, will the formulary of this mail order pharmacy include the high-priced drugs like five or ten dollars a pill that I currently have to buy through the American Association of Retired Persons (AARP). That is where I have to get them now. So will you include those, will you expand the formulary, or will we still be, quote, stuck with where we have to get it?

    Mr. BUYER. Well, that is a good question. I mean those are the discussions that we have to have. I do not want the Subcommittee to get into that medical judgment. We are not doctors. I mean we are not going to actually do legislation for us to decide what is going to be involved in the formulary. You do not want me making that decision, I can guarantee you.

    Commander OVERMAN. It would be no decision for me if you carried those drugs, I would immediately sign on.

    Mr. BUYER. On top of that is a retail benefit where you can go down to a local pharmacy, again there might be a co-pay involved in that.

    Here is where our struggle is: Our struggle is this theme of keep the faith. Right? Now, put yourselves in our shoes. We want to uphold the honor of keep the faith because in fact you served the country, and now we want to extend what you are asking for. Right? Quid pro quo here, I did it for you, we want it in return, keep the faith. Everybody defines it, though, in their own personal dimension, so let us say if we are able to do that pharmacy benefit whereby it is retail, you can go down to the local pharmacy, or even participate in the national mail order pharmacy, or you can go to a Medical Treatment Facility and get your drugs, do you want or like that type of an option? Let me solicit your comments.
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    Commander OVERMAN. Yes, we should have that kind of an option.

    Master Sergeant FARMER. I think it would be a good option to have, yes, sir.

    Chief REICHLER. It is a good option.

    Colonel GARMAN. Yes.

    Mr. ABERCROMBIE. Okay, the answer is all yes from you folks, and the reason the Chairman is bringing it up is that most of the people here, many of the people here have access even if it is at a hundred miles. There are a lot of people now—you know, right now they are trying to close bases everywhere, and there is a big push to close more bases. A lot of people who were in for some period of time, or came in early, say in the fifties, they may have chosen where they retired on the basis of access to a military community and so on, and then they find that the base gets closed, and the facilities are closed down, and in time to come there is no guarantee, so one of the things the Chairman is thinking about, and what the Committee is thinking about is that retirees are going to be all over the country, all over the place, and so we have got to figure out a way, particularly where drugs are concerned at least, to make them available on a local basis. That costs money, and that is what is figuring into this. Does that make sense to you?

    Chief REICHLER. Yes.

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    Master Sergeant FARMER. Yes.

    Mr. ABERCROMBIE. Do you agree that the likelihood of easy access in terms of physical location is probably going to get less so in the future rather than more so?

    Commander OVERMAN. Yes, sir.

    Mr. ABERCROMBIE. And are you all agreed that the likelihood of people living longer is a real—I am not going to say a problem, a real challenge that has to be met because the actuarial tables if you will are altering significantly?

    Chief REICHLER. Yes.

    Mr. ABERCROMBIE. Okay. Thanks.

    Mr. BUYER. Now let us go to the demonstration programs for a moment. It appears to me that based on your testimony being representative of the military retiree access to available health care that if we were to expand the FEHBP tests, this is probably not a place where there should be a site. Right? Why would anybody want to enter into the FEHBP test if you are already satisfied with the level of care you receive? Would that be accurate?

    Master Sergeant FARMER. No, sir, because people over 65 are pushed out of the system, and we need another system to get into other than Medicare as far as I am concerned. That is where the problem comes in for retirees, once they reach 65 they are no longer eligible for the military benefits, or TRICARE; we are pushed out.
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    Mr. BUYER. But I thought the testimony here is that you are accessing space available care.

    Master Sergeant FARMER. No, sir, not me. I am having to pay for mine out of my pocket because I am gainfully employed with the Cumberland County School System.

    Mr. BUYER. Where are you located?

    Master Sergeant FARMER. Here.

    Mr. BUYER. Here?

    Master Sergeant FARMER. Yes, sir.

    Chief REICHLER. Camp Lejeune is excluded. Anyone over 65 is Medicare, they will not see them at the facility. They do not go in there at all.

    Master Sergeant FARMER. That is the problem. Before you reach 65, and before I was 65 I had wonderful service out of TRICARE.

    Mr. ABERCROMBIE. But if we get subvention you would be able to come in and Medicare would pay, you would be doing exactly the same thing as you were before you were 65 at the same sites with the same people, except it would not even concern you that the reimbursement would be made by Medicare, that is all. That would not have to concern you. Is that your understanding of the Medicare subvention proposal, that over 65 then you could receive the same—and let us assume you were getting the good care, and you were satisfied with it, you could continue in exactly that same glide path; is that your understanding of the subvention proposal?
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    Master Sergeant FARMER. No, sir, but at a lot higher cost too.

    Mr. ABERCROMBIE. Not to you. That is not your concern under the subvention proposal.

    Mr. BUYER. It is the DOD.

    Master Sergeant FARMER. If they would provide a system for me, and I am speaking of—

    Mr. ABERCROMBIE. I am talking about you being able—what we are trying to do here is get you the care without you having to be concerned— Let me tell you, if you get in the FEHBP you are going to pay. Somehow the idea is out there that FEHBP is a noncost system. When you are in the FEHBP you are paying while you are in civil service, and you are paying afterwards and, believe me, you are paying plenty.

    Now, a part of the promise you guys were talking about here is not only that care would be provided, but that it would be, if not free, at a nominal cost. It is not, whereas subvention is aimed at the DOD and the Medicare system taking care of the payment side of it so that you can receive a seamless degree of care pre- and post-65.

    Let me put it this way, if that was able to be achieved you could receive the care that you say you are receiving now with which you are satisfied where you did not have to concern yourself with who was paying who, as long as the care was seamless and good, then would that be something that you at least be willing to countenance?
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    Master Sergeant FARMER. Yes, sir.

    Mr. ABERCROMBIE. Okay. Maybe we could get a little help here because, believe me, we are trying to exercise good will and trying to exercise good judgment, and I have spent the better part of a decade now trying to work on this subvention issue, and if your understanding is the way I am talking about it is not what you understand Medicare subvention to be, then we have got a real problem, because among other things the Retired Officers Association has been pushing Medicare subvention like mad for a while. Am I missing something here? Is there a disconnect?

    Chief REICHLER. No. Subvention is a great idea, it is the best idea, and I have discussed it with the CO of our hospital. Like he says, we hire on additional caretakers under subvention, and therefore it is free to the recipient, and it is no cost there. You are taking the money from the Medicare area and putting it over toward the Army Hospital—

    Mr. ABERCROMBIE. And this will help take care of the space available business, that gets eliminated.

    Chief REICHLER. It is the best thing out there.

    Mr. ABERCROMBIE. You come and get your appointment just like anybody else, you do not have to stand there with your begging bowl.

    Chief REICHLER. It is a good program.
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    Mr. ABERCROMBIE. Okay. That is what we are trying to accomplish, Sergeant, I can assure you that is the object. Okay.

    Mr. BUYER. I know we have to get to the next panel, but, Commander Overman, you have made a comment about—instruct me if I am wrong, I cannot remember, I thought perhaps it was you—that you made a comment on what you were having to pay, and ''I want what was promised the people in 1954,'' and you were not so happy that you are having to pay for care today.

    Commander OVERMAN. I do not think I extended that. My remark was that we would like to receive what we were promised in 1954, which was lifetime care.

    Mr. BUYER. Which was lifetime care?

    Commander OVERMAN. Yes.

    Mr. BUYER. All right. Did anyone ever say that it was free lifetime care, or just lifetime care would be provided?

    Commander OVERMAN. Free as I recall.

    VOICES. Free!

    Mr. BUYER. There is a difference here. I will tell you, I will be very frank here, I mean this is all sort of family. I am a lieutenant colonel in the Army Reserves, I get my twenty-year letter in July, and I will be very frank, nobody ever promised me free lifetime care.
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    I mean there is something out there that people have talked about, I heard it when I was on active duty too about free health care for life and that kind of thing. I have never seen it—I have seen it in some of the recruiting brochures and things like that, it was never on a contract or anything that I ever signed.

    But I do know that what Congress is going to do is try to fulfill what I believe is an implied contract, and what makes it difficult for us is we can be very—we are working very hard and aggressive to try to provide something, yet I am not so certain we will ever achieve satisfaction, because once we do—say for example we are three years out and we do FEHBP, and then individuals find out that FEHBP is costing $1,500 per person and up to $3,000 per family and they say ''Wait a minute, you should be paying that because it is supposed to be free.'' You see what I am saying? Where do we get satisfaction here?

    Mr. ABERCROMBIE. Are you not glad this is a hearing rather than a dialogue and a town meeting? [Laughter.]

    Master Sergeant FARMER. In the 1971 to 1976 area when I served as an Air Force recruiter in the Dallas-Fort Worth, Texas area the big push then, we were just a little bit past the Vietnam era and in the middle of the Vietnam era, the big slogan that the recruiting people, my bosses pushed to us, ''Sell the sizzle. Do not just say we are going to do this, get a nice statement out there,'' and those statements were, ''We would provide you with medical, dental, the exchange, the commissary benefits for you and your family if you retire for the rest of your life.''

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    Mr. BUYER. Thank you very much, gentlemen, for your testimony. I appreciate it. You are now excused.

    We will now move to Panel 3. Panel 3 is local health care provider representatives. I would like to thank all of you for coming today, and I know that your detailed statements are for the record, and that you probably will want to respond to some of the things that you have also heard here today, so I appreciate also that you keep your opening remarks under five minutes. Ma'am, we will begin with you.


    Admiral BALSAM. Thank you, Mr. Chairman and members of the committee for the opportunity to address you.

    I am Rear Admiral Marion Balsam, I am the Commander of Naval Medical Center Portsmouth. I am the Lead Agent for TRICARE for Region 2. I am a pediatrician by trade, and I have four grown children who received their health care through the military system.

    As the Lead Agent I have oversight for the implementation of the TRICARE program in Region 2, which as you know consists of Virginia, except for northern Virginia, and all of North Carolina. We are the most densely-populated TRICARE region with over 830,000 military health care beneficiaries.

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    We have nine Military Treatment Facilities (MTF), in our region: three Army, three Air Force, and three Navy. The nine MTF commanders and myself as the Lead Agent together with the contractor, Anthem Alliance, constitute the TRICARE Mid-Atlantic Region board for oversight of implementation in our region.

    TRICARE began in Region 2 in May 1998, so we have now been on line for about one year and nine months. As you know, the startup of TRICARE in our region was very problematic engendering many negative perceptions. On the other hand, I believe it is fair to say that our patients are generally very satisfied with the care that they receive within our system. All nine facilities have worked hard in partnership with the contractor to enhance the health care services. We have made progress in many areas. We nonetheless share the frustration of many beneficiaries regarding those issues which continue to be of concern. I will briefly address some of these issues, and will mention as well some of our successes.

    First the centralized telephone appointing, the infamous 1-800 number. It has been fraught with frustrating problems from the outset. The major problems at the current time, you have heard about long hold times after the initial electronic answer. That is currently our biggest problem. Beneficiaries are concerned about a call-back system where if there is a long queue they are asked to leave a message, and also you heard about inaccurate information which beneficiaries are concerned about from the 1-800 number. The contractor is aware of the urgent need to fix this.

    Our contract requires that we have a centralized appointing and information process. It is viewed by many as cumbersome, impersonal, and ineffective, despite the efforts of the medical facilities and the contractor.
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    In answer to Mr. Abercrombie's query before to two of the retirees as to why they had no problems making appointments and other people did, the answer is that all the medical facilities have advised our patients, especially for follow-up appointments, to go around the 1-800 number system and call directly to the clinic.

    Appointment availability. Sometimes our clinics are unable to meet the demand for appointments. This is especially true for acute appointments during seasonal periods of increased illness, such as the flu season. This is unsatisfactory to all of us.

    Our system has been in a state of flux since the start of TRICARE one year and nine months ago. There have been continuous ongoing changes with increasing enrollment in our system, and a cumbersome appointment system. The facilities continue intensive initiatives to optimize appointment availability. We have all extended the clinic hours, we have increased efficiencies, we have increased the numbers of appointments.

    A problem that we have is that our budgeting is tight, and we do not have sufficient predicable resourcing for the service medical departments to facilitate our making responsive solutions to these issues, and I will address this more later.

    Untimely claims payment has been an ongoing problem. There are thousands of claims that are unpaid for various reasons over 60, 90, and 120 days, which cause concern for the beneficiaries and civilian providers alike. The contractor has gradually decreased these numbers. However, there still are collection agencies challenging our beneficiaries' credit when these claims remain unpaid. The level of claims assistance provided by the contractor has been a source of concern, as you have heard.
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    The medical facilities utilize our own health benefits advisors to intervene on behalf of our patients. The TRICARE Management Activity (TMA) Health Affairs has developed much-needed claims simplification initiatives, which should be in place shortly.

    Enrollment. A barrier to satisfaction was eliminated by automatic reenrollment within regions. However, portability between regions is not yet automated. Snags encountered enrolling in one region while disenrolling in another lead to frustrating and labor-intensive problems with eligibility for care and with claims adjudication. TMA Health Affairs plans to implement a new national enrollment data base in August 2000. This is expected to resolve many portability problems. The ultimate goal is transparent worldwide portability.

    Mr. ABERCROMBIE. Could you repeat the last sentence about why the portability you think is going to be resolved? Is that what you were talking about?

    Admiral BALSAM. Yes. TRICARE Management Activity Health Affairs is planning to implement in August 2000 a new national enrollment data base. That is known to many of us as Defense Eligibility Enrolling and Reporting System (DEERS)–3. This is expected to resolve many portability problems. There will then be one national data base instead of many regional ones, there will be standardized procedures for entering information into the data base, and we will be alleviating current problems which pertain to software interface problems.

    The next issue is the network. The contractor's role is to develop a network of civilian providers and facilities to supplement military facilities and staff as needed.
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    Unlike the Tidewater and Richmond areas in Virginia, eastern North Carolina does not yet have similar acceptance of managed health care amongst the medical establishment. This causes difficulty in network development. The North Carolina network is at 97 percent for specialists, however the specialists are often a relatively long distance from our military families.

    Retiree care. Medicare-eligible retirees as you know are unfortunately limited to space available care. We want to fulfill the promise, the military medical services want to fulfill the promise through expansion of TRICARE Senior Prime program and Medicare subvention to all our facilities worldwide.

    There have likewise been many successes in Region 2. Outreach programs, case management, appointment types being standardized, excellent cooperation amongst your tri-service facilities sharing staff and sharing business practices, active partnering with the contractor, increased efficiencies, and enhanced services throughout the region. We have diminished many barriers to satisfaction, and are conscientiously addressing those remaining.

    I would like to propose a very short wish list, two wishes. First, dependable, predictable, sufficient funding to the services' medical departments so that we can effect the business practices which we are very skilled at developing.

    Mr. ABERCROMBIE. Will you take that and send it right up the chain of command?

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    Admiral BALSAM. Yes, sir.

    Mr. ABERCROMBIE. Okay.

    Admiral BALSAM. Military medicine is way ahead in business planning, yet so much of our budgets are in fixed costs that our hands are tied by lack of sufficient, predictable funding. We are a service-oriented organization. We in military medicine take great pride in our uniforms and in the military services we support. We have no self-serving or profit motive.

    Those who desire and deserve military health care, and those who pay for the military and for its health care will be well served by providing us the resources, the people and the funding, to effectively optimize our health care system and make responsive, proactive, up-front investments as good stewards of taxpayers' dollars. I believe what I just said addresses some issues that Mr. Abercrombie brought up before.

    My second wish: expand the TRICARE Senior Prime program worldwide. Our care is excellent, we are cost effective. I hope that the complexities of interpreting the data will soon bear this out. By expanding this program worldwide we can better care for all those who deserve it cost effectively while—and this next point is very important—while supporting a military health care system in which talent and skills are maintained in support of our country's contingency and wartime preparedness.

    Our young, talented military physicians, nurses, and corpsmen cannot maintain their skills, and will not remain in the military if the only people they can care for are young, healthy active duty people.
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    In closing I would like to thank you for your support of our health care system, and I will be pleased to answer any questions.

    Mr. BUYER. I would normally jump right into them, but I have to make a comment because you brought it up. You asked about predictability in the fundings and budgets. I will sing your song with you on any street corner. We on the Subcommittee, given we authorize these medical budgets, we are frustrated year in and year out with the modeling that is being done in the Department of Defense to predict what your budgets are. So the Chiefs of each of the services will come and provide their testimony that the number given in the budget is called, quote, ''fully executable.'' We do not know what that means. Is that fully funded, or is it fully executable?

    Now, it does not make sense to us if in fact you, you meaning the services call it fully executable and then the President sends us a budget. He sent us a budget a few weeks ago for 2001. Attached to it is the 2000 supplemental request, recisions and reprogramming, and you are asking for 280-plus million dollars for 2000. We just completed the 2000 budget not long ago, and we to through this every seven months, and we are just getting exhausted by it, so it is very frustrating.

    So if you are asking for the predictability, somewhere someone has got to take a relook at how you do this modeling. It is not working. So I join with you, and I will apply the pressure across the top, the Subcommittee will, and if you can push it from the bottom that is very, very helpful, because I do not like doing this. $280 million off in your predictability is a lot of money to be off, I think.
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    Admiral BALSAM. Yes, Mr. Chairman, I agree with you.

    Mr. BUYER. Mr. Ford.


    Mr. FORD. Yes, sir. My name is Dan Ford, I am the TRICARE Mid-Atlantic Regional Vice President for Anthem Alliance Health Insurance Company, the prime contractor for Region 2 which includes North Carolina and most of Virginia, exclusive of the national capitol area.

    Mr. Chairman, to implement TRICARE in one or more regions is a huge and complex effort from any perspective. The numbers themselves are staggering. In Region 2 we are currently delivering health care to more than 600,000 active duty family members, retirees and their family members. To effectively reach, inform, and enroll an eligible population of this size in only a few weeks is a mammoth undertaking for any managed care company. I am referring to the earliest days of this contract.

    In Region 2, though, we had the additional task of informing and educating a provider population with little experience in managed care in the commercial setting. As one might expect, some problems did surface during that transition, particularly related to enrollment, claims processing, and payments to providers. There was earlier reference to how things go in California and Hawaii.
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    When California and Hawaii started in 1988 I was a Navy Commander representing the armed forces in southern California. They had lots of problems there as well. They are twelve years with experience now; we are two years, almost.

    The vast majority of beneficiaries who live in Region 2 have ready access to quality health care provided by a comprehensive network of providers at an affordable cost to both the beneficiary and the government. I can personally tell you as a retired naval officer with 26 years of experience in military medicine, the TRICARE program is a much better program than before. I also have a wife and three children who are TRICARE Prime beneficiaries.

    Anthem Alliance is in the second year of its contract to provide this network of care. As of January 31st, 2000 Region 2 has 283,000 beneficiaries enrolled in TRICARE Prime. Of these, 92 percent are assigned to the military direct care system, and 8 percent are assigned to a network primary care manager. These numbers represent 101 percent of Anthem Alliance's projected enrollment goals for Region 2.

    To effectively service these enrollees, Anthem Alliance has built a strong infrastructure over the past two years that supports the administration of this contract. We have more than 500 associates staffing some seventeen TRICARE service centers located throughout the two-state region, and a regional operations center located in Hampton, Virginia.

    I would also like to point out that because the regional operations center is located in a very intensely-populated military area a large, a very large percentage of our employees, the people who answer the telephones are in fact TRICARE beneficiaries.
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    Each Military Treatment Facility has a service center either located within the facility itself or within a very short walking distance. As a result, these centers have collectively handled more than 200,000 calls and nearly 12,000 walk-ins each month.

    Since the start of health care delivery in May of 1998, we have delivered more than 1.2 million office visits, 30,000 in-patient admissions, and filled more than 1.3 million prescriptions in Region 2 alone. We have processed to completion more than 9 million claims contract-wide.

    Our network in Region 2 is very strong. It includes nearly 1,000 primary care managers, more than 6,000 specialists, and nearly fifty hospitals. Our network also includes more than 1,200 veterans affairs providers at seven Veterans Administration (VA), hospitals. Anthem Alliance has aggressively pursued these sharing arrangements with the VA as a solution to shortages of certain specialty providers in some areas. The win-win result is greater access to the beneficiary, and a very cost-effective use of existing government resources.

    One of our proudest accomplishments in Region 2 has been our ability to help our military partners optimize the care available in Military Treatment Facilities and military clinics. We have 41 resource sharing agreements underway in the region with a potential savings of more than $130 million annually. Twelve of these projects are under development here at the new Womack Army Medical Center, and 28 projects are near completion at Portsmouth. These arrangements provide greater access to care for the beneficiaries, while at the same time supporting the Department of Defense's goal of optimizing Military Treatment Facility capabilities. The result is improved access and lower cost for both the beneficiary and the government.
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    Over the past several months Secretary Cohen, Chairman Shelton, Assistant Secretary Bailey, and many of your colleagues in Congress have indicated an increasing interest in TRICARE, how it works, and how it can be improved, whether looking at ways to expand access to retirees, lowering out-of-pocket costs, or simplifying how the benefit is administered. This increased attention is good news for all stakeholders in TRICARE—beneficiaries, providers, Congress, and the contractor. All stakeholders in TRICARE are asking for improved access and improved claims processing.

    While each stakeholder group may identify the same issues, their definitions of access and claims processing, and their recommendations for improvement are often very different. Access can involve problems with enrollment, transfers between regions, inability to get timely appointments, or the availability of network physicians. Claims issues on the other hand can involve the complexity of the process, timeliness of payment, and more often than not the level of reimbursement.

    Last year Anthem Alliance participated in a summit on access-related issues convened by Assistant Secretary of Defense (Health Affairs) Sue Bailey. The access summit included the Surgeons General, Lead Agents, Anthem Alliance, and other contractors. Everyone I spoke with afterwards truly felt this summit was very productive in airing problems and focusing on ways to improve the program. This process can and should be replicated to bring all the stakeholders together and find those win-win solutions that exist. This is truly the best way to address the difficult issues we all face together.

    Mr. Chairman, thank you again for inviting me to participate today in this productive forum. I will be happy to answer questions.
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    Mr. BUYER. Doctor.

    [The prepared statement of Mr. Ford can be found in the Appendix.]


    Dr. BRYANT. I am Michael Bryant, I am the representative for the civilian physician sector and, as you know, the civilian physician sector is the overflow resource for those that cannot be seen within the military system.

    I am a general surgeon, but probably more importantly I represent the 270 physicians in a physician organization here in Cumberland County called Sand Hills Physicians.

    As private practitioners we are more than willing to take an active role in the delivery of health care through the TRICARE system. However, the contractual agreement is too onerous for us to administrate in our individual offices.

    Mr. ABERCROMBIE. Excuse me, Doctor. Contractual agreement with Anthem?

    Dr. BRYANT. Yes, sir.

    Mr. ABERCROMBIE. Okay. Your contractual agreement is not with Admiral Balsam?
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    Dr. BRYANT. No.

    Mr. ABERCROMBIE. Okay.

    Dr. BRYANT. The contractual agreement will be accepted, but must have three particular important parts. It must be the best delivery for patient care; it cannot disadvantage the patient or us as providers either from a medical legal, or financial standpoint; and it must be acceptable regarding the business practice of medical practices.

    There are two areas of concern primarily that stand out with regard to the providers, and that is: one, the lack of the continuity of care when referred to the private sector and, two, a potential increase in the medical legal, and/or financial risk to us as the provider, and possibly even to the patient.

    Let me expand upon continuity of care. Referral within the private sector requires a nonavailability as determined by a TRICARE coordinator. Every step of a single episode of care is reevaluated by the availability of being able to be provided within the military system. If that care is not available within that system, then the community private practice providers are commissioned to provide that care. However, we too must conform to the TRICARE availability/nonavailability format. For every referral, procedure, surgery, or significant diagnostic test, the patient has to be screened for availability within the military system. All too often we as private practitioners are given the task of diagnosis, but not the availability for treatment of these patients. Therefore, the patient can lie in limbo within the military system waiting for the referral appointment, for the reassessment, and for definitive treatment. As the private practitioners we are at the mercy of the TRICARE system which fragments in our opinion the continuity of care.
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    Let me give you an example, and this is a real example. A 45-year-old female was seen by a gynecologist on a nonavailability basis for her routine yearly exam. A breast lump was found, and she was referred to a general surgeon for evaluation and treatment in the private sector. Now, she had to seek the nonavailability status to go to that surgeon. That was granted, the surgeon saw the woman, biopsied the breast mass in the office. He saw her back in one week which was the time it took for the pathology to be available, and the biopsy came back as a cancer. She then needs further definitive surgery and must get nonavailability, but was denied that nonavailability and was funneled back into the military system where she waited two to three weeks for an appointment to see a general surgeon, and waited another two to four weeks to be scheduled for her surgery.

    Now, all totaled from the time of diagnosis of a breast lump to her definitive treatment that patient had to wait eight to ten weeks, and I daresay that none of us in this room would want our wives or our daughters to have to wait eight to ten weeks with a diagnosis of breast cancer in for adequate treatment.

    This dilemma poses two significant risks. One is the medical legal risk. Once the private practitioner has entered into a physician-patient relationship, then he or she is medically and ethically responsible for that patient's course of care. Otherwise, it is called abandonment. So if this patient gets lost in the internal system, has a delay of appropriate care, or care within an inappropriate time frame, the private practitioner may well be at significant risk from a medical legal standpoint.

    On the other hand, if the private practitioner decides to continue with the course of care despite not receiving a nonavailability status, then he is assuming the financial risk—that means he will not get paid for his work—but he is also possibly incurring significant financial risk for the patient, that is, unpaid bills because those services, quote-unquote, ''were not covered.''
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    My solution would suggest that a TRICARE patient that enters into a physician-patient relationship with a private practitioner, that physician should have the responsibility and the opportunity to see that patient through the entire episode of care start to finish without additional nonavailability obstructions to the continuity of care. This is just one of the major concerns regarding TRICARE with respect to private practice.

    I would like to address two things, one that Mr. Abercrombie mentioned. Local control of health care, both administratively and medically. That is very important, because there are people that are locally accountable. I think that is part of the failure in the system from the infrastructure in this particular instance.

    With respect to Mr. McIntyre's comments regarding accessibility, accountability, and you said affordability, there is one ''A'' that you have forgotten there, and that is availability. You may have accessibility within the military system—that means that that care does exist, but is that care available in a timely fashion? So I would suggest the four ''A''s of accessibility, accountability, availability, and then affordability.

    I am willing to spend additional time in meetings to work these problems out from a private practice standpoint. I think most of my private practice colleagues are also interested in coming to some resolution so that we can help take care of the military families and the retirees with a sound, simple, and efficient system which they can afford.

    Thank you.

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    Mr. BUYER. Thank you very much.


    Mr. DICKSON. Mr. Chairman, members of the Committee: I thank you for the privilege of being here today to testify on behalf of a surgical practice here in Fayetteville.

    My name is Steve Dickson, I am the Administrator for Village Surgical Associates. I am also the Administrator for Dr. Bryant. In addition to that, I am retired military medical service corps, United States Army.

    What I would like to do today is to discuss the many barriers that currently exist to make it worthwhile for our practice to be a participating provider with the TRICARE program. I want to specifically address three barriers. The first is conflicting guidance, and I will start that with a true story of a patient that was seen in our practice.

    Just a few weeks ago a TRICARE patient came to our practice and was diagnosed with breast cancer. You can imagine this is an emotional time for the patient. Our surgeon scheduled a partial mastectomy to be performed at a local ambulatory surgical center. We did not obtain a precertification because of guidance issued by TRICARE. On the day of surgery when the patient checked in to THE ambulatory surgical center, the ambulatory surgical center staff contacted TRICARE just to verify the benefits. The ambulatory surgical personnel were informed by the TRICARE representative that this procedure needed to be done on an in-patient basis, and would require a precertification.
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    Here we are having a patient thirty minutes away from surgery being told ''Oops, we have to have a recertification.'' The ambulatory surgical center contacted our office immediately to request a recertification. I got involved at that time. At that time I contacted the TRICARE first-level review and explained that there was some coordination, or some conflicts in the guidance and that we needed a precertification number and approval to do this mastectomy immediately.

    The first-level individual that I talked with told me that I would have to contact the second-level review, and that she could not help me, but she could give me a fax number rather than a voice number for the second-level review. I said that was unacceptable, and that she would have to contact the second-level review and have them call me, or we would cancel the surgery.

    Needless to say, I did not get a call back, and we canceled that surgery. Fortunately we were able to reschedule the surgery later that week, and later obtained a precertification for that surgery.

    Before you I have submitted some references, or some examples of the TRICARE guidance, and I would like to walk through that because you may ask what am I talking about as far as conflict in guidance. It is a stapled document, and there are about five or six pages.

    The first document is entitled at the top High Cost Outpatient Procedures and Prospective Review Requirements. I have highlighted breast mass or tumor excision, and I have also highlighted the CPT associated with that. CPT is Common Procedural Terminology, and that is the code that we would charge.
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    The code that this mastectomy fell under was a 19162 which tells us we do not have to obtain a precertification for this procedure.

    A couple of pages back at the bottom you will see Attachment 2. That is the TRICARE standard approved ambulatory surgical procedures. I have highlighted procedure code 19162 which says mastectomy partial, which allows it to be performed at an ambulatory surgical center.

    The conflict comes on the third enclosure where we see TRICARE is using Interqual procedures to determine whether a procedure needs to be done on an in-patient or out-patient basis. This is where the conflict arises. The Interqual says this particular procedure must be done on an in-patient basis, and therefore requires a precertification.

    Now, the problems that arise from this miscommunication or this conflicting guidance are twofold. The first and most obvious is the inconvenience to the patient, and the inconvenience to the physician. Not only does it inconvenience the both of them, but it also increases their risk for delayed treatment.

    The second ramification or problem which probably is more far reaching deals with the finances of the program and the payment to the physician. Physicians are penalized under the TRICARE program a 10 percent penalty for failing to obtain a precertification prior to performing a procedure. One could suggest that physicians are being inappropriately penalized for failing to get a precertification as we did in this case for this procedure.

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    I would recommend that an immediate audit be performed on all of the penalties that have been applied to physician payments due to failing to obtain a precertification. I am under the impression personally that the liability to the TRICARE program could be substantial if it is found that physicians are being penalized because of this conflicting guidance. I am currently researching that in our practice, I stumbled upon this approximately two weeks ago, and have initiated our own process for evaluating to see if we are being penalized for failing to get proper precertification.

    The second barrier is low reimbursement. I have also provided you a handout with some of the reimbursement rates for various procedures. If you will take just a minute to look—I am not going to specify the procedures—but you can certainly see that in some instances TRICARE only pays one-third of what other payers are paying for the same procedures.

    Our practice participates in several managed care plans. Some of these managed care plans have at least twenty different payers. Each one of these plans publishes their own policies, procedures, and schedules. Because the practice of medicine is a business, and because our physicians' time and appointment scheduling and surgical time is finite, we must elect to participate in those managed care plans that, number one, offer a fair return on the services that we provide and, two, limit the administrative burdens placed on the practices.

    These are just two barriers that I have found in our practice that prevent us from participating in the TRICARE program. I have got another example, but because of time I am not going to go over it.

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    I would like to make some recommendations as to what possibly may make the TRICARE program more competitive in this market. TRICARE Prime is a managed care product, and it is competing in a highly competitive market. Competition will differ in each health care market. Therefore, what works in one market may not work in another. The major barriers that keep us from participating in TRICARE are the rigid administrative requirements of the contract, the lack of flexibility to meet the health care demands within a specific market, and the failure to provide the physician with a fair return for the services provided.

    What can TRICARE do to allow it to become competitive in any given health care market? The first, grant authority to local markets to develop competitive fee schedules. The second, reduce or eliminate many of the administrative requirements of the program.

    Some examples of these may be: allow greater authority at the first-level review for issuing surgical precertifications and other precertifications. Number two, reduce the number of procedures requiring precertification. Three, hold the contractor to specific time limits on answering phone calls for precertification requests. I did not cover that as a problem, but it is a tremendous problem having to wait sometimes up to twenty minutes just to get a precertification for a surgery. Number four, publish clear guidance on procedures requiring precertification. And number five, require an audit of all penalties assessed to providers for failing to obtain a precertification.

    The third change would be to change the COB policy to allow TRICARE to pay the difference between what the primary payer allows and what they pay. Again, I did not cover that as a problem because of time, but it is a critical issue that needs to be addressed.

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    Finally, one thing that I believe would help this region is to allow more resource sharing between the Sand Hills Physician group who represents 270 physicians and Womack. I think that we can put together a plan that will reduce the cost to the program, that will also increase the availability and accessibility of care, and will allow Womack as well as the local physicians to develop their utilization management and quality review programs and actually manage care within the area.

    Thank you.

    Mr. BUYER. Mr.Heckert.

    [The information referred to can be found in the Appendix.]


    Mr. HECKERT. Good morning, Mr. Chairman, gentlemen: I am John Heckert, I am the Administrator of Cumberland Anesthesia, and I want to thank you for taking your time to see us today.

    The precursor of TRICARE was the CHAMPUS Reform Initiative which was a demonstration project in Hawaii in the late 1980s and early 1990s. The first TRICARE contract became operational in March of 1995, and the TRICARE Region 2 began May 1st, 1998. It seems the Government TRICARE contractors have had ten years of experience in implementing this program in one form or another. However, it appears that each implementation is the first, not only for the contractor, but also for the Government.
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    For example, the patients and providers are frustrated with the contractor's telephone system and the inability to provide answers to questions.

    A number of beneficiary and provider irritants occur with regularity. These include payments that do not match the published fee schedule or provide explanations of benefits, billing patients for authorized care when they were appropriately referred to nonparticipating providers, and penalizing providers 10 percent of the reimbursement for not having a certification number when one was issued but not properly entered into the TRICARE system.

    Additionally, when TRICARE personnel are questioned about any of the above problems, their responses are usually one of the following: ''We are aware of the problem. We are working on the problem. We have forwarded the problem to the regional office'' or ''You should contact your congressional representative about this program. They are the ones who set this program up, and they are the ones that will be charged with changing it.''

    Patients' expectations of more convenient access to care are among the most difficult challenges facing the implementation and success of the TRICARE program. This is because much of the current system remains vertically structured around the provider's skills, the institution's resources, and a contractor's need to maintain or reduce costs rather than around what the patient needs.

    The TRICARE program can best be characterized as one in which both the patient and the provider are subjected to poor service, increased cost, and reduced satisfaction.
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    Managing health care costs by restricting access, reducing reimbursements, and increasing the administrative burden for the patient and the provider appears to be the norm rather than the exception.

    The previous comments are my general impressions of TRICARE and how they have worked so far. However, I would like to be more specific about my relationship with TRICARE and that of our corporation.

    On February 7th, 1999, Cumberland Anesthesia received notice that our anesthesia bills would be processed utilizing the American Society of Anesthesiologists codes. The effective date of this notice, however, was November 1st, 1998. Five months had passed. The corporation has never received any official notification of that change, only a copy of an e-mail from our TRICARE provider representative. That representative informed Cumberland Anesthesia that we would be required to resubmit all of our claims for every procedure provided after November 1st.

    Mr. BUYER. How many is that?

    Mr. HECKERT. Well, there were in excess of 600.

    Mr. BUYER. What is the total cost?

    Mr. HECKERT. To me, or of those—?

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    Mr. BUYER. Give me an idea, how much is that? 600 claims is how much money?

    Mr. HECKERT. Probably 60 or 70 thousand dollars.

    This action was completed in March. We had to resubmit our claims every thirty days thereafter to make sure that it got there. The Palmetto Government Benefits Administrator (PGBA), continues to inform patients and this corporation to this day that either we are providing an obsolete code or they do not have the claims. This is being done despite the fact that a TRICARE representative verified that the claims are at PGBA and currently have the correct code.

    Additionally, we have received status reports that indicate a claim is in process and would be paid within 21 days. The payment of these claims is a rarity. Cumberland Anesthesia has several examples where PGBA will indicate that they have the claim and are processing the claim. However, an inquiry sent at a later date on the same patient for the same date will result in a return indicating that no claim has ever been filed.

    Cumberland Anesthesia is also being penalized 10 percent for failure to obtain a preauthorization for surgery. This presents a twofold problem. One is that the anesthesiologists do not see the patient until the patient is ready for surgery. The surgeon or the primary care physician or the hospital are charged with that responsibility.

    Second, our research indicates that even when that preauthorization is obtained, TRICARE has not been capable of returning the withheld funds.
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    In addition to the 10 percent penalty which is being withheld, approximately 49 percent of our claims, which represents $84,000 of all of our TRICARE claims, which is $171,000, submitted are more than 60 days old. 35 percent of that, or approximately $60,000 of all of our claims are over 120 days old.

    Each attempt to be reimbursed for the services rendered is met with this corporation being required to provide additional information, obtain records, or refax information which has already been provided.

    The most recent delays in payments result from the TRICARE explanation that the anesthesia bill which precedes the surgeon's bill makes the anesthesiologist responsible for providing the operative notes. They have indicated to us that if this alternative is not acceptable, anesthesia should wait until the surgeon's bill is being sent, or ensure that the surgeon's bill is there prior to resubmitting our bill.

    It should be noted that once PGBA has reviewed a claim and has adjudicated that claim that any subsequent submissions of that claim will be returned with exactly the same response. Their system is not flexible enough to go back and see that other claims have come in and that the status of the patient has changed and payments are billed. You have to get that payment outside of the regular system.

    This corporation has had several visits by TRICARE representatives. The visits have resulted in little, if anything, being done to improve the timeliness or responsiveness of the current contractor.
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    In addition, this corporation has been unsuccessful in obtaining a fee schedule. This means that we do not have any idea what we should expect as reimbursement for services. This situation is exacerbated when we receive two different reimbursement rates for the same service on the same day for two different beneficiaries.

    It is my opinion that TRICARE is making little or no effort to correct the system's problems which result in an inordinate delay of payments. These along with the incidents I have provided have created a climate which has become antagonistic between both the provider and TRICARE.

    I want to thank you for taking time to listen to us today.

    [The prepared statement of Mr. Heckert can be found in the Appendix.]

    Mr. BUYER. I am going to lead with a question. Based on the testimony here from the two administrators, at what point—you have testified about your frustrations in dealing with the contractor, but when you do not get your money at what point do you make the decision that you go after the service member or family? We have got testimony about your going after them.

    Mr. DICKSON. At Village Surgical one of the things that we do is we work with the contractor until we can get those paid. We will not bill the patient until we have exhausted every possible way that we can of getting payment. Once we do that, we will submit the bill to the patient for payment, and I cannot give you a specific time. It may be 90 days, it may be 120 or 180 days.
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    Mr. HECKERT. Actually we have never turned anybody over to collections. However, we have sent several patients letters telling them we are going to, and we direct them to either Mr. McIntyre or Mr. Hayes for assistance because we are not getting any help.

    Mr. BUYER. So are you using bringing the beneficiary, or actually your patient into this equation because you cannot get satisfaction, and when you turn the system on to them somehow you are able to get your moneys? Are you using leverage against the patient? I mean come on, I was in hospital administration.

    Mr. DICKSON. We do do that, but it is very seldom that we do that. We are usually able to get the payment made. It may be later on, but we are usually able to do that, and I am specifically talking with the TRICARE program.

    Getting the payment in a timely manner—getting the payment at all is not a problem. I mean it may not be timely, but we will get the payment.

    The problems that we run into are the administrative burdens on the front end of getting that patient seen, and getting that patient into the office.

    We do run into several penalties, we are being penalized quite a bit because of the issue that I brought up, failure to obtain a precertification, and I have not been able to put my thumb on whether that is because of the inconsistencies in guidance, or whether it is just our failure to comply with the published guidance. So there is some work that needs to be done, but the potential liability is substantial if the conflict in guidance causes this.
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    Mr. BUYER. I know Mr. Ford has put you on a hot seat. I think by way of a system it is unacceptable that payments are not made in timeliness and that in fact our soldiers out there or the beneficiaries when they access the system are being used, or manipulated, or leveraged against in order to receive timely payments, and they are being turned over to collections and that type of thing. That is wrong. That is wrong.

    I mean if there are some deductibles or co-pays or responsibilities on behalf of the service member and they are not meeting their obligations, there are command functions in order to help make those types of responsibilities, but that is not right. Do you want to provide comment on this?

    Mr. FORD. Yes, sir, Mr. Chairman. I agree with you completely. As mentioned in my opening statement in the early days of this contract we absolutely had difficulties with claims processing. We continue to have some difficulties today, though it is not near what it was a couple of years ago.

    If you consider the fact that we have over 8,000 providers, we process over 300,000 claims every month. Problems will occur, there is absolutely no doubt about it.

    Some of the good things for providers these days which has not been mentioned yet, but there is a requirement that we pay penalties if we do not get the claims paid on time.

    Another thing I want to mention is my staff and I have never turned down an opportunity to meet with providers who are having difficulties. Oftentimes I go to those meetings myself because I want to find out what the issue is, I want to work with PGBA who is our subcontractor for claims processing and get those worked out.
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    Another thing that was mentioned concerning the preauthorizations, there is a program that is relatively new, it is called Work Simplification, and it for the first time allows the managed care support contractor, us, Anthem Alliance, to offer some flexibility in the program and control how things are done; we can decide how we are going to do it, we have the opportunity for the first time to incorporate best commercial practices for example, which is a huge benefit of TRICARE 3, and we are looking forward to that opportunity.

    Other than that I have to point out—well, let me finish the thought about the preauthorizations.

    We have already put together a proposal for the Lead Agent to virtually eliminate over 80 percent of the required preauthorizations. We know that that is going to be a benefit to the providers in reducing the hassle factor, it is going to be a benefit to the beneficiaries because they do not have to jump through those hoops to make sure that that happens, and it is a benefit to us. It is going to reduce our talk times for health care finders and, you know, we have heard some concern expressed about waiting on hold to talk to a health care finder who is one of our registered nurses, it will help us tremendously in that area.

    But I would say I need to make the general statement here that the managed care support contractor administers a Department of Defense contract. I do not have the opportunity to set policy, I do not have the opportunity to set reimbursement levels. I administer a program that is established by the Department of Defense.

    Through work simplification I have mentioned I am just starting to get some flexibilities to incorporate good or best commercial practices, and through TRICARE 3 I am looking forward to a lot more opportunities to do just that, streamline the system.
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    Mr. BUYER. Gentlemen, Mr. Ford just testified that they are planning on working out this elimination of 80 percent of the precertifications, and you two guys did not even smile.

    Mr. DICKSON. I am smiling.

    Mr. BUYER. All right.

    Mr. DICKSON. I am smiling. I like the fact that we will not have to get precertification. But I will say that the guidance has got to be clear and concise. As evidenced by the handout that I gave you there are some discrepancies in what procedures require precertification. That has got to be clear.

    Mr. BUYER. Mr. Abercrombie.

    Mr. ABERCROMBIE. Thank you, Mr. Chairman.

    I am going to ask some questions of you, Mr. Heckert and Mr. Dickson, and then Mr. Ford, if you could listen in on it, then I will get to you with it.

    Mr. FORD. Yes, sir.

    Mr. ABERCROMBIE. Now, if the claims do not proceed, and you were also talking about the 10 percent penalty on the precertification, but if the claims do not proceed in a timely basis where is your impression of where the money is for that claim?
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    Mr. HECKERT. My impression is it is in a bank drawing interest.

    Mr. ABERCROMBIE. Yeah, that is what I was figuring. Have you been informed at all as to what bank that money is in drawing interest, and who has the account?

    Mr. HECKERT. No, sir. If you want to talk—

    Mr. ABERCROMBIE. Okay. On the certification for service, Mr. Dickson, if I heard correctly Mr. Ford was saying that the precertification is done by registered nurses. I wanted to ask you, and I have written down to myself here precertification from who? Who do you contact for precertification?

    The reason I ask the question—again I am not trying to set anybody up, I am trying to do this on a—does this mean there is a second opinion sought? In other words, Dr. Bryant, is your or one of your colleagues' opinion sought as to whether something should be certified, or does Mr. Dickson contact somebody who in effect is a service representative as opposed to another physician?

    Mr. DICKSON. We will initially contact their, quote, ''800'' number and request a precertification to do a specific surgery.


    Mr. DICKSON. Because in the guidelines that they give us if a surgery is considered an expensive surgery they want to have an approval authority on that.
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    Mr. ABERCROMBIE. Who is the approval authority? Is it someone who is the equivalent of doctor—not doctor, but who gets it? Is it another physician?

    Mr. DICKSON. I do not know who gets it, Mr. Abercrombie.

    Mr. BUYER. Who do you talk to when you call the 800 number?

    Mr. DICKSON. It is a representative at the TRICARE level.

    Mr. ABERCROMBIE. It could be somebody like me?

    Mr. DICKSON. It could be you, it could be a Registered Nurse (RN), it could be a clerk.

    Mr. ABERCROMBIE. But I do not know jack about a mastectomy.

    Mr. DICKSON. That is exactly right. That is our point.

    Mr. ABERCROMBIE. Okay. In other words, you are not trusted, Dr. Bryant, and the contract with you means that if you decide that there has to be a biopsy or anything else you have to get permission from somebody else because the contract does not include a sense that you are a responsible person—and I am being serious about it, I am not trying to throw curves or be facetious about it. I mean if I contract with you to take care of me, or take care of my family, either I have got confidence in you and your professional abilities or I do not.
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    Now, I do not have any objection to second opinions. I am getting over shoulder surgery right now, and I had second opinions going on, and I wanted to get that because it is serious business contrary to what people might think. They think lasers are magic or something. Well, they are not, and so that is okay. But I sure am not interested in having somebody give me a second opinion who is being paid the minimum wage on part-time work.

    Dr. BRYANT. Generally that precertification or preapproval for procedural things is primarily an accessibility determination.

    Mr. ABERCROMBIE. Okay. That takes us back to—

    Dr. BRYANT. They determine if there is accessibility within the military system to do that.

    Mr. ABERCROMBIE. I understand. That is my next question. Please do not think I am trying to cut you off, it is that our time is limited.

    That takes me back to anther question I have where you are concerned. Now, I have got a primary physician. Look, I am spoiled rotten, number one. I am. I joined the Kaiser system, the Kaiser Permanente system 41 years ago, and as far as I am concerned I have got universal coverage, single-payer system, whatever you want to call it, because I am covered in Washington. I mean 99 percent of my time I am in Washington or I am in Hawaii, or I am landing on the West Coast somewhere and I can get to Kaiser. And let me tell you, I do not know how all the rest of them operate, but I will tell you Kaiser operates like a fine watch. Maybe they do not some places, but my experience has been they do.
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    Now, that said, when you mentioned before if someone is referred to you because there was not space available under the system here, the TRICARE system, do you not then become the physician of record and they go to you for the rest of the time that they are here at Fort Bragg or wherever it has to be? You do not mean to tell me that each time you have got to go through this space available or appointment available and you start bouncing back and forth between physicians, do you?

    Dr. BRYANT. Yes, sir.

    Mr. ABERCROMBIE. Well, what if you are pregnant? Should you not be seeing a gynecologist and someone who sees you through your pregnancy from beginning to end, provided that you are still stationed here?

    Mr. BUYER. Right. Now, that is a state law in fact that a pregnant woman that is referred out for obstetrical care, that physician sees that person through their entire pregnancy.

    Mr. ABERCROMBIE. Now, again with my shoulder, I am being seen—obviously I have got 5,000 miles between and I go back and forth—I had my operation done by Kaiser, but I also am involved in Washington and see a physician, and they work together. Now, is that how you work it with a physician in the military facility and yourself?

    Dr. BRYANT. No, sir.

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    Mr. ABERCROMBIE. But why not? Why would you not consult with one another if you are forced to go back and forth?

    Dr. BRYANT. Well, generally speaking what I will do is I will call the surgeon on duty for the day and say ''I have this patient here, they need surgery. I have done her biopsy, I would like to request nonavailability.''

    Mr. ABERCROMBIE. Time out. Does not the patient that you see have a primary physician in the TRICARE system?

    Dr. BRYANT. Yes, they usually do.

    Mr. ABERCROMBIE. Well, then, why cannot they call the primary physician in the first place, then? Why is the problem with appointments?

    Dr. BRYANT. It is not the primary physician's, under their discretion—

    Mr. ABERCROMBIE. But does not the primary physician handle all appointments and referrals?

    Dr. BRYANT. Yes, but if there is availability within the system then it is mandatory that the primary physician refer it back to the military system.

    Mr. ABERCROMBIE. Okay. Does not the patient here, do not they assign a primary physician?
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    Mr. BUYER. If they are a member of TRICARE Prime they are assigned a primary care physician, yes, sir.

    Mr. ABERCROMBIE. And cannot then the patient just call the primary physician and his or her nurse and schedule appointments and everything else? Why do they have to have an 800 number?

    Mr. FORD. It works differently in different locations.


    Mr. FORD. There is an 800 number that they can call. The example that you heard earlier—

    Mr. ABERCROMBIE. Time out. I do not want to interrupt you, but, look, Dr. Takazawa is my primary physician, and she rules. She does, she rules in Kaiser. I mean Kaiser, the head of Kaiser Permanente cannot overrule Dr. Takazawa, and Doctor—well, it is not Dr. Takazawa, Dr. Takazawa's nurse runs Kaiser, and they do. And I mean I am not being facetious, and it is not just me as a Congressman. Hell, I was a teaching assistant at eighteen hundred bucks a year when I joined Kaiser. I have always had the charm and ability to get people to do things that I want, that is true, but aside from that I mean it from the point of view of access and interchangeability with doctors is that not the way to handle it? Would that not solve a lot of your problems?

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    Mr. FORD. Allow me to answer, please.

    Mr. ABERCROMBIE. Sure.

    Mr. FORD. I know Kaiser very well, I have spent a lot of time, a lot of years in the San Francisco Bay area where the program got started, and in southern California. It is a different model, it is a staff model, it is a closed model. Primary care physicians, hospitals, specialists, are all within the same system. That is not the system that the Department of Defense has designed for TRICARE.

    Mr. ABERCROMBIE. Time out.

    Mr. FORD. We have networks—

    Mr. ABERCROMBIE. Excuse me, Mr. Ford.

    Mr. FORD. Yes.

    Mr. ABERCROMBIE. When I am in Washington, yes, there is a Kaiser system there, but Kaiser contracts out with other people and they pay the bills. My wife had bypass surgery, she and I spent a total of thirty seconds dealing with that. Kaiser took care of everything after that, you know, availabilities and arguments, and running through people like Mr. Dickson or Mr. Heckert, no problem, I am sure the people love to run through you, but you get what I am driving at?

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    Mr. FORD. Yes, sir. There are some select specialty services that Kaiser will contract out with, depending on where you are in the country, where that program is.

    Again, it is not the program that was designed by the Department of Defense. The Department of Defense has asked us, the contractor, to do the appointing for all of their facilities in primary care and specialty care with the exception of Fort Bragg, and you heard earlier today how well things are working at Jewell Clinic, that is right here at Fort Bragg.

    That clinic and the Fort Bragg primary care system does their own local appointing, and it works very well. Actually—

    Mr. ABERCROMBIE. Well, then, why do you not just adopt that?

    Mr. FORD. I have two things I could say about that, both good news.

    One, the current contract requires that 50 percent of the appointments be made locally, and so for us to assume based on what we have heard today that all calls are going to Virginia is an incorrect assumption. 50 percent of appointments are made locally. If they cannot be here, if it is after hours, weekends, holidays, those sorts of things, those appointment requests will roll to Virginia where we have a backup crew that is 24 hours a day, seven days a week. So that is happening.

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    The other thing that I would mention and, you know, it is a matter of public record is that the Department of Defense has recognized that there is value in decentralizing appointment-making, so in the new contract that is coming up for Region 2 they have requested for us, the administrators of the contract, or whomever else comes into this contract, that 95 percent of the appointments will be made locally, so we are right now in the process of redesigning a system that will allow for 95 percent of the appointments to be made locally. I think that will be a good move for everyone, and DOD has recognized that.

    Mr. ABERCROMBIE. Is this your first contract? Is this Anthem Alliance's first contract?

    Mr. FORD. Yes, sir. We have Regions 2 and 5. They both started at the same time.

    Mr. ABERCROMBIE. Anthem Alliance never did a contract like this before?

    Mr. FORD. Not a TRICARE contract, no, sir.

    Mr. ABERCROMBIE. How do you make your profit?

    Mr. FORD. We are at risk for health care dollars. We have a fixed price administration contract piece, and then we have health care dollars.

    Mr. ABERCROMBIE. So you make it two ways, you charge a fee to the taxpayer through the DOD—
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    Mr. FORD. To administer the Government's health care program, yes.

    Mr. ABERCROMBIE. And then you have an additional source of revenue? You said you do it two ways, you charge a fee to the Government—

    Mr. FORD. For administration, right, the administrative aspect.

    Mr. ABERCROMBIE. Then what is the second source?

    Mr. FORD. The other part relates to health care dollars.

    Mr. ABERCROMBIE. Health care dollars, okay.

    Mr. FORD. The Government has projected that we will spend a certain amount of money for health care during a specified period of time.

    Mr. ABERCROMBIE. If I remember your testimony correctly, you said there is $130 million in savings that take place as a result of 41 resource-sharing programs under the military partners act, or military partners—

    Mr. FORD. Resource sharing, yes, sir.

    Mr. ABERCROMBIE. That is part of your contract with the DOD?
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    Mr. FORD. Yes, sir. They have asked us to optimize utilization of the Military Treatment Facilities.

    Mr. ABERCROMBIE. Where did they get the $130 million in savings? Where does that figure come from?

    Mr. FORD. That is a part of our health care dollars.

    Mr. ABERCROMBIE. So are you saying that the DOD has said to you that your profit will be based on a fee charged to the DOD, and that within the service that you provide you are expected to make $130 million? Does that go to you?

    Mr. FORD. No, sir.

    Mr. ABERCROMBIE. Or does that return to the DOD and the taxpayers?

    Mr. FORD. A small portion of that goes to me. The majority of that goes back to the Department of Defense.

    Mr. ABERCROMBIE. What portion goes to you?

    Mr. FORD. It is based on a percentage.

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    Mr. ABERCROMBIE. A percentage of the savings?

    Mr. FORD. Yes, sir.

    Mr. ABERCROMBIE. So there is an incentive to you to save money?

    Mr. FORD. There is an incentive fortunately on the part of the U.S. Government and the Department of Defense to save money. We are helping them administer the program that would do this.

    Mr. ABERCROMBIE. I understand completely. I am not talking about wasting money; I am talking about how one achieves savings.

    Now, would you not say from your own experience, by the way, and I think it is impressive that you have this background, and I give them credit for hiring someone like yourself who has a background, as well as somebody in the system as well, so my questions have no personal tinge to them, believe me they do not. I am trying to find out how this works.

    Mr. FORD. Yes, sir.

    Mr. ABERCROMBIE. I am still not clear, however, on the savings, in order to get the savings. My understanding and my experience has been—and I have served on ways and means committees, and finance committees, and I have been involved in—I was Chairman of the Health and Human Services Committee in the State of Hawaii back when Medicaid had a surplus when I was in charge of it legislatively, so I am quite familiar with all of this, but my problem comes here on the savings side. My experience is that prevention saves real money, but if you have trouble getting in, getting an appointment, or something gets stalled, or worse you end up—if people do not have their insurance in ready access to appointments they end up in emergency rooms, which costs a lot more money, et cetera, so in order to achieve these savings would not improving access and processing claims quickly and so on actually save real money then to the Government?
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    Mr. FORD. Yes, sir, absolutely, and in my opening comment I spoke about the value of the access summit that Dr. Sue Bailey (Assistant Secretary of Defense, [Health Affairs]) called.

    Also I am really happy to report that Admiral Balsam and I have put together a working group made up of her people and my people for the Hampton Roads area of Virginia that have been addressing for the last couple of months the issue of access, and in fact at her insistence and my concurrence we had those people meeting twice a week for three hours each time, six hours a week, addressing access to care issues in the Hampton Roads area.

    Mr. ABERCROMBIE. How many weeks have you been doing that?

    Mr. FORD. Six or eight weeks, and we are still continuing.

    Mr. ABERCROMBIE. Okay. Now, if it has taken you six weeks three to six hours at a time you can imagine what it must be like for the recipients wondering about how it is going to be settled.

    Mr. FORD. Yes, sir. That is why we are there. We recognize there is a problem.

    Mr. ABERCROMBIE. Regardless if the claims finally get paid or not, when those claims are made to you how do you get the money for that claim to pay it? You are paying the claim, right, on behalf of the Government?
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    Mr. FORD. Yes, sir, we get periodic—

    Mr. ABERCROMBIE. Does the DOD give you a quarterly payment, or a claim-by-claim payment to be paid through you? It passes through you?

    Mr. FORD. Yes, sir, I—

    Mr. ABERCROMBIE. When does the money come to you?

    Mr. FORD. It is a periodic payment from the Government based on expected health care costs.

    Mr. ABERCROMBIE. Now, where does that money go when it comes to you periodically? Does it go into a bank?

    Mr. FORD. I would expect that it does, yes, sir.

    Mr. ABERCROMBIE. Is there an interest payment on that?

    Mr. FORD. I would expect that there is.

    Mr. ABERCROMBIE. Does that interest payment go to you, or is it returned to the Government, inasmuch as we are all interested in savings?

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    Mr. FORD. Yes, sir, in the past that direct interest, and I expect now as well goes to us. But as I mentioned a little while ago there is now a requirement that we pay interest on claims that are delinquent, so the Department of Defense has recognized that it may not be reasonable to keep that interest for themselves if providers are having to wait extensive periods of time.

    Mr. ABERCROMBIE. Is there a time period as to what constitutes delinquent? In other words, do you have a time certain you have to pay a bill, 30 days, 45 days, 60?

    Mr. FORD. Over 30 days. The 31st day interest starts accruing.

    Mr. ABERCROMBIE. So if Mr. Dickson submits a claim to you that is argued about, but if in 30 days it is not resolved, then it goes to 40 or 45 days and it is judged then, the claim is legitimate and Mr. Dickson's Village Surgical Associates are paid; they are paid that claim plus 15 days interest?

    Mr. FORD. That is how DOD has designed the system, yes, sir.

    Mr. ABERCROMBIE. Is that the way it is working now, Mr. Dickson?

    Mr. DICKSON. They are not paying interest right now. I do not know when that becomes effective. It may be October the 1st, 2000. I am not sure of the effective date.
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    Mr. ABERCROMBIE. Do you know when that comes into effect, Mr. Ford?

    Mr. FORD. No, sir, I do not recall exactly.

    Mr. ABERCROMBIE. Could you get that for the record and get back to us on it?

    Mr. FORD. Yes, sir.

    Mr. ABERCROMBIE. Okay. You will be glad to know, Mr. Ford, I am going to ask Admiral Balsam a couple of questions, and then we will—

    Mr. FORD. I was having so much fun. [Laughter.]

    Mr. ABERCROMBIE. Admiral, thank you very much. I want to make sure I understood you on your suggestions. You said, ''Expand the TRICARE Senior Prime worldwide.'' In effect you are saying you would like to see Medicare subvention move forward; is that correct?

    Admiral BALSAM. Exactly.

    Mr. ABERCROMBIE. Okay. Now, on the funding for a medical departments military medicine lacking, and you heard Chairman Buyer say that we get a submission from the Department. Are you familiar with the fact that we are routinely asked for supplemental funds? And is that the funding that you are indicating you feel is lacking at least proportionately to your command?
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    Admiral BALSAM. I am aware that you are asked for supplemental funds. From the perspective of a treatment facility commander we do not have predictable funding in advance, and we do not have enough funding so that—for example I, as the commanding officer of Naval Medical Center Portsmouth have 5,000 employees, I am the equivalent of the Chief Executive Officer (CEO), of a substantial corporation. If I were running a business I would use my business planning to put seed money into things that would be profitable for me, or that would be cost avoidance, or that would be problematic before they become big problems. We do not have that latitude because our funding at the Medical Treatment Facility level from the services is so tight and so limited that we really use most of it for fixed costs, and then the amount that we have for health care is fully utilized, so we do not have a lot of flexibility to make decisions that we are really very capable of determining.

    Mr. ABERCROMBIE. Last question for you. Have you been in discussions—I do not know whether it is Mr. Ford in particular, but with the contractor on this 95 percent local appointment making access?

    Admiral BALSAM. Yes, sir.

    Mr. ABERCROMBIE. How soon do you anticipate that coming? I do not know why it is not 100 percent, but I have been in this game long enough to not even think about why they are retaining the 5 percent, but when is that supposed to come into effect?

    Admiral BALSAM. Now, that is part of TRICARE 3, is it not?

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    Mr. FORD. Actually it has been designed into the recompete, and so—

    Mr. ABERCROMBIE. Next fiscal year?

    Admiral BALSAM. Our contract is being rebid because there was a protest over the initial contract. As part of the rebids by both our contractor and the other contractors that are bidding, they have changed the base line from 50–50 to 95–5 for the local TRICARE service center versus the regional.

    Mr. ABERCROMBIE. So whoever gets the bid has to meet that standard?

    Admiral BALSAM. Yes. And that will be—it will be a couple of years from now before that really happens, February 2001, it is supposed to start.

    Mr. ABERCROMBIE. But could you not implement it on your own, Mr. Ford, if you wanted? You are the contractor. If you decide you want to do this, could you not just go ahead and do it?

    Mr. FORD. If the Department of Defense were to decide that they would like for me to make that change, absolutely I would work with them immediately.

    Mr. ABERCROMBIE. You do not have the authority to do that on your own now?
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    Mr. FORD. I do not know that I have the authority, I am not sure that that is the—I do not have the resources to do it. As you can imagine, it is a little different model of providing a service. If the Department of Defense is interested, we are certainly interested in working with them.

    Mr. ABERCROMBIE. The bottom line for the chairman, in some respects what I hear coming is that we have got to go back to the service chiefs and ask them what they hell they are doing, because if I understand you correctly a lot of what you do is DOD policy-driven.

    My impression was that you had a lot more flexibility in terms of what you could do or not do with respect to how the services are provided, particularly if you are in the area of what you call health care dollars. I want to make sure I am correct, because if I go back to see Admiral Johnson and so on about this I want to be absolutely sure when I go to see him and say ''It looks like I am supposed to be talking to you.'' Is that correct? Or is he going to tell me that the health care dollars aspect of your profitability quotient is in your hands and not his?

    Mr. FORD. Through the work simplification program that we are implementing that we got from the Department of Defense we have a lot more flexibility today than we have had in the past year, year and a half of this contract.

    With the development of TRICARE 3 and the modifications that it brings, we will have even more flexibility and the opportunity to implement best practices in the civilian community. That is the kind of flexibility as a contractor we would love to have. We would love to have the opportunity to streamline this system to the maximum extent.
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    Mr. ABERCROMBIE. Thank you.

    Mr. BUYER. Mr Hayes.

    Mr. HAYES. If you have 300,000 claims a month, what percentage of them are questioned? What percentage are problems of the 300,000 a month?

    Mr. FORD. How many of those claims are questioned?

    Mr. HAYES. Right, and how many of them take more than 30 days for one reason or another to get processed?

    Mr. FORD. Congressman, I would have to answer that, I do not have an exact percentage for you, but I can tell you it is a higher percentage than I would like to see, and a reason for that is there are over 900 edits for every claim that comes in. What that means in simple language is that there are 900 opportunities for that claim to fail processing. That is probably the most complex claims processing system in this country, but that is what we have to work with.

    Mr. HAYES. Who designed that?

    Mr. FORD. It is a system that has been working for the 30 years I have been around military health care, and who knows how long before that.

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    Mr. BUYER. It was not designed by the IRS, was it?

    Mr. FORD. It sounds like it, yes, sir.

    Mr. BUYER. And the post office.

    Mr. HAYES. You get a fixed number of dollars to provide health care for a pool of people; is that correct?

    Mr. FORD. Yes, sir.

    Mr. HAYES. I got a yes and a no.

    Mr. FORD. I am sorry.

    Mr. HAYES. The Admiral was shaking her head no, and you said yes.

    Mr. FORD. You asked if I get a fixed number of dollars to provide health care?

    Mr. HAYES. Right, for a known number of people.

    Mr. FORD. Probably what the Admiral was thinking is technically the fixed price piece is the administration part, to pay the salaries for the people that I hire and so on.
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    Mr. HAYES. But the actual cost of care is not—

    Mr. FORD. It will vary, but it is based on what we submitted three years ago in our proposal for this contract when we had to predict what our health care costs would be for the next five years.

    Mr. HAYES. How long does your contract last?

    Mr. FORD. Five years.

    Mr. HAYES. And there is good guy/bad guy between providers and all that. We are trying to figure out how you resolve the issue of cost control versus quality of care. That seems to be always butting its head up against each other.

    Mr. FORD. I would just say I think I have mentioned a few things that are working that are going to cause that relationship to improve—the work simplification, the pre-auths that we talked about on claims, the interest that we now have to pay on claims. All those things will help.

    Mr. HAYES. Thank you.

    Mr. BUYER. Thank you, Mr. Hayes. Based on the testimony within this region we have not heard any complaint with regard to quality of care, it is the access of the care, but you are very close to it.
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    Mr. HAYES. If you can get it, you get it.

    Mr. BUYER. If you can get it. Mr. McIntyre.

    Mr. MCINTYRE. Very quickly, Mr. Dickson, the need to work out the procedures for preadmission certifications you mentioned earlier, is this both? Are you having problems with the turnaround on that both for surgical procedures and other types of hospital admissions?

    Mr. DICKSON. Yes, we have difficulty at times in a turnaround for getting the precertification itself.

    What we are seeing is that—and I am going to compare this if I may with other managed care plans that we participate with, that is my point of reference. There are many procedures that we do without having to get a precertification on an outpatient basis, and even with some procedures that we do have to get a precertification the turnaround from the other managed care companies is quite quick. It may very well be if not that same day very much the next day.

    TRICARE has begun taking some of the procedures that we do routinely, and now rather than approving them at the first level of approval they are sending those to the second level, which requires an additional three, four, or five days to get those approved. And it is a tremendous inconvenience on that patient, and that is important for us.

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    Mr. MCINTYRE. And, Mr. Ford, you mentioned in reference to the 800 number, and we heard a lot of testimony about that from our first panel today, you were saying that there is a redesign of the system so that up to 95 percent of appointments will be able to be made locally. Are you talking about nationwide?

    Mr. FORD. No, sir. I am talking specifically for our contract in Region 2. In fact, to take that another step further, that does not even apply to Region 5 which is another contract that we have for the Great Lakes states.

    It is a request of the local lead agent MTF commanders that in Region 2 they would like to see appointments made locally, and so they are working on a modification to our contract which would require us to do that.

    Mr. MCINTYRE. All right. Thank you for the clarification.

    Mr. FORD. Yes, sir. Also if I could comment on Mr. Dickson's answer, I mentioned earlier that we have submitted a proposal to the Government, and we are going to be working with the contracting officials which would streamline the process for preauthorizations very significantly, and I am hoping for support from the Department of Defense and the contracting officials for our contract here in Region 2 to be able to do that.

    Mr. MCINTYRE. That is good. Thank you. Thank you, Mr. Chairman.

    Mr. BUYER. Mr. Ford, what is the approximate cost per claim to process?
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    Mr. FORD. A very good question. I can give you a number that—well, actually I would rather not because I am not certain. I would rather submit that—

    Mr. BUYER. Give me a range.

    Mr. FORD. The range I believe is somewhere around $8 to $15 per claim, which I would follow with from my experience in the civilian side, though I have been in this industry for 30 years I spent five years in the commercial area before coming back to TRICARE one year ago, it is down around the $2 or $3 range per claim. And I think that is a reflection of the complexities of our claims processing system, and those 900 edits that I talked about. It is a complex system that has been developed. Although I have to let you know, and in fact you are probably aware TMA, Dr. (H. James) Sears, Executive Director at TMA recognizes this, and he is addressing that issue.

    Mr. BUYER. Let me show you an analysis from a conservative Republican. When we view systems in Government, we view them, we put them under the microscope, and we try to bring efficiencies to a particular system. If someone does not like that, then we are called cold, callous, and uncaring. But let me ask you why I just examined this one.

    For Medicare it costs us one dollar to process a Medicare claim, one dollar. You testified it could cost from $8 to $15. Let us just give it the benefit of the doubt. In this region you process 3,600,000 claims approximately. You say you do 300,000 claims per month, 3.6 million claims.
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    Mr. FORD. Yes, sir.

    Mr. BUYER. Let us just do rough figures. Times $10 that is how much money?

    Mr. FORD. A lot of money.

    Mr. BUYER. $36 million? $360 million. $36 million, is that right? $36 million. Wow.

    Mr. FORD. This is not new to the Department of Defense. As I said, we have been doing this for the 30 years I have been around.

    Mr. BUYER. $36 million. Now I can take it 36 times 12—I grew up in a calculator age, hold on a second. $432, is that right, 432 million? Think about that.

    I know this is rough math, and not every region is going to be at $10. Some may be at $7, some may be at $6 or whatever, but that is in excess of $400 million over and above the Medicare standard that we are paying for claims processing, Admiral. That is $400 million annually. That turns into billions of dollars pretty quick, so when we have providers that are also testifying about the low reimbursement, you have got a reimbursement rate that is supposed to be at the Medicare rate, but in fact is lower than Medicare rates. These are dollars that we could—even if we are able to come down to $2, saying that you are even a dollar above the Medicare standard, that is millions of dollars you can pour back into the system, we could have more providers provide care to our beneficiaries, and have them taken care of. Right? That is a lot of money; this is a lot of money.
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    We are going to take this one on. Okay? I am not picking on you here. We have got to do this.

    Mr. FORD. Streamlining the claims processing, sir, you are doing me a service.

    Mr. BUYER. We have got to do this.

    Mr. FORD. Thank you.

    Mr. BUYER. You know, as the Subcommittee looks into the face of hundreds of millions of dollars here, I will tell you what, it is worth the taxpayer to make an investment here up front to bring some efficiencies to an integrated system that derives real benefits to people, and we are going to take this on. I do not know what it is going to cost us to do that, but we are going to take this on, because if we can make the investment it might be millions of dollars investment up front, but if it saves us billions in the out years we are going to do it. We are going to do that.

    Does anyone else have any questions?

    I appreciate your testimony here today, and especially as providers for you to be here it is very important. We had a hearing out at Grissom Air Reserve Base on Friday, and it is a rural area whereby we had an active duty facility that had closed, realigned as a Reserve base. Many of the providers out there, Doctors, were not really wanting to actually provide, they did not want to participate in the TRICARE program any more, but they sure did not want to come on the record and talk about it. And I want to extend to you our appreciation that you came here for a real reason. It is not because you are making a lot of money doing this, you are not. You are providing care, and you are a doctor for a particular reason to provide service to people, and I appreciate your testimony here, and it was very helpful to all of us.
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    Admiral, I am sure you will have some follow-up from this hearing, and we would sure like to hear from you also about how we can reduce the claims cost. And, Mr. Ford, if you have ideas too. We talked about this also in Indianapolis. So take it back to Anthem and we will talk about how to approach this one.

    [The information referred to can be found in the Appendix.]

    Mr. FORD. Yes, sir. I appreciate that.

    Mr. BUYER. All right. Thank you very much, gentlemen, for your testimony and, Mr. Hayes, thank you very much for having us here today. This is a great panel. Mr. McIntyre, you too; it is your back yard.

    This panel is now excused. The fourth panel will now come forward.

    The last words in testimony today will come from the senior troop leaders who have to deal with today's deployment challenges. I want to thank all of you for being here and for your testimony. Gentlemen, you have sat here all morning, and you have heard the testimony of active duty personnel and their spouses, retired personnel, and some of the local providers, and those responsible for managing TRICARE. We are also anxious to hear your testimony and any response you might have to any testimony that you may have heard today.

    I am also pleased that we have the Command Sergeant Major of the Army who is assigned to this area of the—what is your duty position?
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    Command Sergeant Major BUTTS. I am Command Sergeant Major of the 1st of the 505th, 82nd Airborne Division.

    Mr. BUYER. All right. We have got the right man here to testify.

    General, you may proceed.


    General GOTTARDI. Good morning. Mr. Chairman, members of the House Armed Services Committee: I would like to begin by expressing my appreciation for your interest shown in the welfare of the men and women of the armed forces, and for your efforts to improve the quality of life for our soldiers, sailors, airmen, Marines, and their families in the area of health care.

    My name is Larry Gottardi, and I am the Commander of the 18th Airborne Corps Artillery stationed here at Fort Bragg, North Carolina. I have served on active duty for 29 years. This is my fifth assignment at Fort Bragg, so I am relatively familiar with the type of medical care you receive here over a period of about 26 years.

    I am on active duty, so I am enrolled in Prime, as well as my family. It covers my wife and I, plus four of our children, ages 10 to two and a half, so unlike many of my colleagues, I can identify with a lot of the testimony you heard earlier today about the challenges of coping with health care and the requirements of the health of small children.
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    Since I have been asked to and given the opportunity to testify here I have given a lot of thought about TRICARE. I have sort of reviewed in my own mind the sensing sessions that we have had in the past where soldiers have had the opportunity to raise questions or problems with different areas of their life, sort of tried to focus on if there was a common thread running among all those issues that dealt with health care, and at the same time I asked my higher headquarters to put together the TRICARE complaints that they had received in the Dial 6 Boss Line, which is the commander's help line over the last six months to see again if there is some common thread that was not unique just to the corps artillery, but rather was post-wide.

    And I would say there is some good news, and I would say there are some aggravations here. The most recent opportunity I had to talk with soldiers about their satisfaction with health care was last Friday when I had a final group of nine soldiers in, both men and women, ranging in grade from about E–3 up to sergeant first class, one of whom was a victim of a very, very serious car accident in which he is trying to kludge together a whole bunch of different insurance plans and health coverage plans to make sure all his bills are paid, down to a young girl who just arrived here and is about I guess seven and a half months pregnant, and is dealing with that pregnancy through the health care system.

    A lot of the other complaints or issues I would relate to you I think you have already heard today which shows the commonality of the thread that rolls through there, so I would just like to relate to you what were the problems I came across in the corps artillery, and then if given the opportunity I would like to maybe offer some king-for-a-day options, because I asked my soldiers the same question, ''If you were king for a day, what would do? How would you change the system?'' and I think it is worth listening to.
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    All the soldiers I spoke to, as well as myself I found out they are satisfied with the medical care they receive here at Womack, there is no problem with that. And with some pride I will tell you that Womack has done a lot of neat things. One is they have got that call-in line so that your call when you are seeking health care, goes to the clinic you are eventually going to end up with.

    The other thing they have done which is pretty smart is you have got the family practice clinics that are open the extended hours, which I think is just a wonderfully smart thing to do because soldiers work extended hours, and a lot of times you are a single parent, or if you have got both parents out, you know, and you find out that the child has been ill when you get home at 1930, 1945. Well, we have got them open until 2000 so you can call in for an appointment and get them there, and then on the week ends they have got them working extended hours—I am not sure exactly where it starts, but it goes to about 2300 where you can call in for an appointment, and if you have got something that is urgent it will be taken care of.

    If you go outside that area, and even with the telephone line system they have operating here at Bragg you might wait a long time. Last weekend we have, you know, four kids were passing a case of strep throat around, and last weekend I was on the phone for 17 minutes waiting for it to answer, but whenever the phone call was answered I had an appointment for my daughter at 1900 that evening. I think a lot of that has to do with the fact that everything is being done here in-house, and I think that is just a great idea.

    I believe that most of the soldiers I talked to would tell you that they are scared and worried about going outside the purely military medical health care system, and I would agree with that, and I asked sort of why that was. One of the things was they are very comfortable with the military medical system, and I think within the medical system they know that if they have a problem they will be able to get it resolved either through their chain of command or because they are dealing with an in-house system. I think that tells us something about the way we want to supervise and run this thing.
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    But let me offer you some observations, and some of them are questions, and as you will find out some of them are comments that my soldiers made.

    One is when they are not in Prime or they are outside of the hours of the clinics here on post operate and they have to make a 1-800 call nobody believes that—I think in the last stakeholders report it said 90 percent of all calls were answered in 120 seconds. Nobody believes that. And if you talk to everybody's experience, their experience is that is not the case at all.

    Another question that comes up from time to time, and I would like to echo what the Chairman said, if you have got a soldier or a family member that are either holding a green ID card or a family member identification card why is there a question about whether their medical bills will be covered regardless of who provides it? I mean the United States Government has said we are going to pay for this, so that green ID card should be the soldier's, sailor's, airman's, Marine's guarantee that their medical coverage is going to be paid for.

    We need to have a system that works and is transparent to the soldier. You should not have to worry about co-pays or anything else, or whether this is a second provider and I have to go back and get authorization. He has got a green ID card for he and his family, and that means they are covered whatever comes up.

    Now, we have to also operate on the assumption that nothing or nobody in the health care system is going to recommend that there be any type of health care provided that is not required or justified.
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    So I would say if there is anything we need to do we need to make sure that that green ID card, which to me is an act of faith on the part of the United States Government, is honored exactly for that.

    I mean I have been involved in TRICARE both on the West Coast when I was assigned to Fort Lewis, and then here on the East Coast since I was assigned here to Fort Bragg. I mean I have had a provider come after me for an unpaid bill. I was visiting—and, Mr. Chairman, you will have to excuse me because I was visiting Virginia Military Institute (VMI), which you know is the other West Point of the South—I was visiting VMI and I became ill while I was there, so I went to the emergency room at a local hospital.

    Mr. BUYER. I can handle that.

    General GOTTARDI. Unrelated to my visit there, I am sure it was something I had picked up at Fort Lewis.

    Mr. BUYER. Sorry about that.

    General GOTTARDI. But I went to the hospital, I got the medical care. As it turns out it was nothing major, and the fee was relatively small, $75. So I spent about five and a half months trying to push that claim through, and finally I just called them and gave them my Visa card number and said I will take it off my taxes, no problem.

    If it happens to me, it will happen to everybody. Why would anybody, or why would we not forbid a health care provider, whether part of the system or not, to come after the soldier, sailor, airman, Marine or his family member who is just ill? It is not right, as you said.
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    I would say if I was king for a day I would try and find some way to change that. I would try and find some way to make it impossible. Let the provider and let the contractor fight it out. You know, they can duke it out and just let the soldier not worry about it.

    The same thing with the co-pay. If we are providing health care for a soldier and his family, why do we have a co-pay? I heard a yes over there. I mean I do not understand. I have got a green ID card, and the green ID card says as long as it is a valid medical complaint I am covered for the period of time that I am in the United States Army.

    And echoing what we heard I guess earlier from some—

    Mr. BUYER. Co-pays do prevent abuses of the system.

    General GOTTARDI. Sir, I would expect that there are probably some people who would abuse the system for whatever reason. I would say that if you have an after-hours clinic, or if you have a call-in health nurse and things like that you are not going to get an abuse of the emergency room because that is what we heard so often is the emergency room has become an after-hours clinic. Well, one of the reasons they have done that is because at that hour you cannot get the medical care that is causing you some concern. I am sure there is somebody that probably goes in to seek medical care because of some reason other than real need, but that is probably the minority I guess rather than the majority. I mean I have been through four kids, and I am sure you all have had children as well too, and there are some things still that come up and I will say ''Well, I do not know about this, I am going to take them in,'' and I do.
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    Mr. BUYER. Are you concluded?

    General GOTTARDI. Sir?

    Mr. BUYER. Are you concluding?

    General GOTTARDI. Yes, sir, having been led that way.

    The other thing too, some of my soldiers are concerned, whether it is implied or whether it was actually mentioned there is a perception among our soldiers that they do in fact have a guarantee that if they serve for 20 or 30 years that they have life long health care, and I think we ought to be able to do that.

    Thank you, Mr. Chairman.

    Mr. BUYER. Thank you, General. Admiral.


    Admiral COLE. Mr. Chairman, members of the Committee: My thanks also for you being here and being interested.

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    My perspective is as the Commander of the Navy Region Mid-Atlantic; I am also with Hampton Roads, Norfolk, Virginia. My former position was as the Commander of U.S. Naval Forces in Korea where I was also enrolled in TRICARE Prime with my family.

    Like many who have come before, I am a big fan of military medicine, both Navy where my three daughters were born, and most recently in the Army. Once you get the care, it is wonderful. I am a big fan of military health care.

    In general in spite of some of the things we have heard, military medical benefits are a positive recruiting tool. For example, it was one of the top three reasons why sailors come back into the Navy after first having separated, so they get out, they see what the civilian system is like, or how much it costs, and that is one of the top three reasons why they come back.

    But as you have heard today I think there is a real danger that this benefit, positive benefit, is eroding. I think the problems are divided into three types of problems, some of which we need to fix, we in the military need to fix, DOD needs to fix, and some of which we are going to need your help to do.

    The first problem is with the existing system you have heard a lot about today, the appointment system, the billing system, the portability issue, the level of training on the part of the TRICARE representatives, the contractors, and also execution of the contract by the contractor.

    I will say to their credit, the medical community in Hampton Roads has been very responsive to these issues and the trends, and based on my conversations with ombudsmen and those type organizations have indeed been positive.
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    I also believe that the contractor has been responsive to the issues involved, but in any case as you know, the contract is up for rebid, and past performance will certainly be an issue as we award the next contract.

    The second is problems with education. This is a complex system for most young people, they have perhaps never had to deal with health care at all, they have always depended on their folks or someone else to take care of it, and now they come into what I think is a complex system, and I think it is counterintuitive, and of course it is also new and there are growing pains involved with all that.

    The line has expended a great deal of energy on this in educating the people, educating their families, but still much needs to be done. I would like to say that we need more leaders like Major Fazekas and Lieutenant Commander Otto who are doing what leaders always did, and that is get involved when their soldiers, sailors, airmen, and Marines are having any kind of difficulties in medical, difficulties is no exception.

    The third thing is problems with what TRICARE does not do and was never intended to do, and that is where we need your help, and I know you have heard some of this already. We have to do better by our retirees. There is a promise there that we have got to keep somehow, some way, but we have got to do that.

    I think we do have to eliminate the co-payment for active duty family members enrolled in TRICARE Prime and receiving civilian care. I know there can be excesses and abuses of the system, but I think if we tell our people we are going to trust them in combat I think we have to trust them with health care of their families.
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    We also have to extend TRICARE Prime remote to family members, people away from military facilities who can enjoy the full benefits of TRICARE Prime.

    And also something that I heard today, I think we need to open up the mail order prescription system and remove the additional charges that are involved in that to allow the retirees and the family members that are away from us to get prescription drugs that way. Either that, or some hookup with the commercial pharmacy companies.

    That is all I have unless you have any questions, sir.

    Mr. BUYER. Thank you. General.


    General SEIP. Mr. Chairman and members of the Committee: Thank you for the opportunity to comment on TRICARE today.

    We at Seymour Johnson Air Force Base have experienced many of the same issues and concerns that we have heard here today with the implementation of TRICARE, obviously a big cultural change for all of us to include our providers and beneficiaries, but after a lot of hard work and education from our medical group and our contractor staff we have certainly seen some improvement.
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    Our beneficiaries are beginning to understand how to access the health care under this complex system, our customer satisfaction surveys place our clinic at Seymour Johnson Air Force Base at or above the DOD averages, our clinic routinely meets or exceeds access standards for care, and the good news is for a small base like ourselves, the vast majority of our primary care is done right on base.

    That is not to say we do not have our problems. We are a very small beneficiary population in comparison to the other facilities in this region, and our perception at least from the leadership role is that many times the attention is placed on the more densely-populated areas first, and because of this problems unique to our small rural area, such as surrounding Seymour Johnson Air Force base, sometimes do not make it onto the radar screen, so we are glad to be here today to talk to a couple of those.

    I will give you a couple of examples. We suffer from a phrase called the ''donut network.'' Our specialty provider network meets the contractual requirements, but in reality is very weak in the center where Seymour Johnson rests. The majority of our specialty providers are located on the outside perimeter in Greenville, North Carolina which is over an hour away via a one-lane rural highway. Although we have certainly very good specialties in Raleigh-Durham and Chapel Hill, they are more than an hour away and are outside the established access areas.

    Another problem yet unresolved is claims processing. We have beneficiaries come into the clinic daily with bills that have not been paid through the contractor. In fact, since the clinic opened up a claims assistance program in August of this past year we have had over a thousand walk-in customers and an equal amount that have called in over the telephone, and that is 17 percent of our population.
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    Many beneficiaries are receiving notices from collection agencies and have had their good credit ratings threatened because of claims that are not paid in a timely manner.

    And finally we certainly have the difficulty in making specialty appointments through the contractor. We hear of hold times, in fact I heard it from my support group commander's wife just three days ago of being on the phone for an hour and a half waiting for someone to service her call. So many beneficiaries must hang up or call several times until they can finally get through.

    In summary, TRICARE at Seymour Johnson Air Force Base had certainly a rocky start, it has been an uphill struggle, it has shown significant improvement to delivering health care to our airmen and their families, but for us at Seymour, before we can declare TRICARE a success we need a strong local network, claims processing must be fixed, and our access to specialty appointments must be improved in the way of timeliness.

    Thank you, sir.

    Mr. BUYER. Thank you. General.


    General BRAATEN. Mr. Chairman, I am Tom Braaten, the Commanding General at Cherry Point, and the Commander of the Marine Corps Air Bases on the East Coast. Thank you for this opportunity to speak with you today.
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    Retention and recruiting certainly are concerns for us. Unlike one of the panel members earlier who said that we would not make our numbers, we will make our recruiting numbers, and we will not lower our standards, but it sure is going to be difficult.

    In talking to the commanders that live aboard our bases TRICARE is a concern. When they speak to the troops now, that is one of the issues that comes up as something they are concerned about, and some of them use that as a reason why they choose not to stay in the military. So we are concerned with it.

    Overall, the service we receive once we are into the system, as everyone has said, has been very good, the comments are very positive. Unfortunately it is not easy, and some of the concerns that we have are like everyone else, the phone access is not good. People have someone answer the phone relatively quickly, three rings, four rings, but then they are put on hold up to 45 minutes, sometimes in excess of an hour, obviously not an acceptable way for us to do business.

    It would appear to me, and we have talked about it today, that perhaps we should do away with that regional center, and I think if we do that we should put the people who work in Hampton Roads in the regional center and move those billets down to our Military Treatment Facilities so that we can do that better, and I think 95 percent might be a good number, a hundred percent might be a much better number for us to run the appointments by ourselves, and we would like to try that, sir.

    Appointment access. Certainly smaller medical training facilities like we have—
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    Mr. BUYER. General, Mr. Ford is over there writing. I want the record to note that he is taking notes of your recommendations.

    General BRAATEN. Good, sir. I thought he probably was.

    The smaller facilities like we have, one of the difficulties with appointment access is that during the summer months when you have people who transfer away you sometimes have functional areas open for two or three or four months at a time, so maybe you lose your only gynecologist, or maybe you lose your only certain kind of doctor, and as a recommendation we need to work better within our own system, our Bureau of Personnel (BUPERs), to make sure that we keep the right numbers of doctors, because if you are in an area somewhat remote like Cherry Point is, and you do not have that many providers on the outside that can do it, and you lose your own medical personnel, then you create a problem at home. So we will have to work on that some more, sir.

    The claims bills. We have several cases, one I have a major who was deployed, his wife had an emergency appendectomy while he was gone, he was billed fourteen times for that service, so TRICARE did not like the way the codes were filled out, sent it back, the provider went to him, he went—and it just got into a terrible dew loop, and that happens often, and unfortunately I think it happens a lot more than we realize because I think on the small claims the individual just gives up and says it is not worth the pain of going back through the system, and they just eat it and they pay it themselves. So I think that is there, so a recommendation it would appear that if we could simplify the codes, make it easier for the medical provider to file the claim, therefore avoiding the need to go back after the member, or even if it is a vague threat or a false threat to the member, that should not happen to our young troops especially. It is just not fair, sir.
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    Portability. We have talked about that, and we certainly hope that the DEERS 3 is going to fix that for us, because now enrolling and trying to disenroll is a difficult project, and that should not be that hard to do. We ought to be able to run people from one base to another, one region to another without making it painful for them.

    Provider network. Some of the specialty care that we have to get, cancer victims, burns, those kinds of things, if we have to go to non-network providers it is very expensive, and it causes us to have to go back to our headquarters and ask for additional moneys. As an example, we had to use Duke (University) who has very good medical facilities last year to the tune of nearly $8 million worth for Cherry Point and about $4 million for Camp Lejeune. They are outside of the network, and that certainly is money that we cannot afford, so we have to go back then to our higher headquarters and ask for help on it, and I think once TRICARE pays their bills better, makes it easier for the providers to be involved, then more of those organizations will be involved, and I understand there is some reluctance now on the part of several people to play, and we heard that from our witnesses this morning.

    I would like to mention just a few things the hospitals are doing at Camp Lejeune and Cherry Point. Evening clinics has been mentioned before, makes more appointments available. We have tightened up in making sure our doctors' appointments are the right length, we have flu and cold packages so if a person thinks they are sick they can come over and just check one out so the doctor is not spending time with an individual that he knows has the symptoms of flu. That leaves the doctors available for more appointments so we can get more people seen.

    No-shows has been mentioned. There is a large problem. We have been working on that. We have a system that 48 hours in advance we call each individual that has an appointment and remind them of their appointment so they do not just get busy and forget. We published an article in our newspaper and talked about no-shows, you do not hurt yourself, you hurt your fellow Marines, and your fellow retirees, and military family members, so we stressed that. We teach that in our classes to the new wives and to our key volunteers to emphasize to them the importance of making their appointments. And then finally if we have active duty members who are chronic missers we send a letter to their commanding officer and say this individual is costing us the opportunity to provide service to the people that we owe that service to.
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    And we like others have mentioned would be very happy to see TRICARE Senior Prime. I think we owe that to our retirees over 65 age, and we would like to see that incorporated.

    And finally we put patients first, so sometimes we get around the system because our hospital commanders, our doctors want to make it work. Readiness is important, so if the TRICARE does not work we make it work.

    Thank you, sir.

    Mr. BUYER. Thank you. We will save you for last. You are supposed to be the best.

    Master Chief Petty Officer.


    Chief NEMETH. Thank you, Chairman, for giving me the opportunity to share some of the frustrations that my young sailors have.

    I am Master Chief Nemeth, I come from Shore Intermediate Maintenance Activity (SIMA) in Norfolk, Virginia. I have been in the Navy for 22 and a half years, and have been enjoying every bit of it so far.
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    My position is a Command Master Chief there, and that is pretty much the senior enlisted advisor to the commanding officer, so I hear a lot of these complaints, and I do not have much more to add than what has already been said here, because these are all the same things that I hear on a daily basis just about.

    I have 2,200-plus sailors that work for me at SIMA, and all of them are glad to be there. For the most part they really enjoy doing what they are doing, but the hard part for me is trying to figure out how I am going to convince them sometimes to stay in the service, and fortunately for you folks you have done a great job so far of improving some of the compensation and getting back to where we need to be, but TRICARE is an area that we really need to work on hard.

    One as mentioned earlier, improving accessibility to appointments. Now, when I first joined the Navy one of the things that was available to me was the ability to go to a sick call where I could just walk in, a walk-in clinic-type situation. Since TRICARE Prime has taken over that has gone away for the active duty service members as you well know. I would recommend that probably reinstituting that may help alleviate some problems. It provides a little flexibility for the senior leaders, enlisted leadership in allowing their folks to go be seen.

    Right now what they do is they make a phone call. If they cannot be seen in the next couple of days you have an individual that is working for you that is ill. Well, you cannot exactly make them work, you have to send them home, say ''Just keep in touch with me, make your appointment when you can.'' So we have lost a work day there out of an individual.

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    Improving accessibility to specialty care has already been brought up numerous times. I will give you a personal example of one of my sailors, a second class petty officer had a daughter who had inoperable brain cancer. Well, TRICARE went as far as they could, the Navy medical system went as far as it could in taking care of her, and it just got to a point where she ended up being up in, I believe it was Johns Hopkins where they were doing some experimental treatment on her. Well, obviously the Navy was not going to pay for that because it was experimental. What ended up happening, and this second class petty officer, an E–5, went into serious financial debt. It got to the point where we started having fund raisers to help these people get along, very disconcerting on my part.

    I do not know what the solutions are to that. I mean the other thing is that even me as a master chief petty officer in the Navy to get an appointment for specialty care—I had to have my leg looked at, you know, I love to run, I love to do physical therapy (PT), and, you know, being as old as I am, sometimes I overdo it and I got broke, so I had to have my leg looked at. It took me three weeks to see a bone doctor. I do not know, maybe the answer is a few more doctors in the system, and I know that is not an easy answer. That takes time. You know, to generate more Navy doctors takes a little bit of time and takes some money, of course.

    How about contracting out for some more doctors? There are plenty of really good doctors out in the Tidewater area that I am sure that if we could fix the problem with being paid back that they would be more than happy to be part of the TRICARE system.

    Or I guess the other possibility for active duty that I was thinking about maybe, you know, we allow our dependents to go see somebody outside of the Military Treatment Facility, maybe consider allowing that for active duty also.
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    And one last thing that has already been brought up again is the billing problems that we have all the time. I have junior sailors that are definitely having serious financial problems, indebtedness is a big problem in the Navy and in society in general, but it is just like the general said, I know I have got some folks out there that are, you know, just paying it because it is too hard to fix it to get through the system otherwise.

    I believe it ought to be a fairly transparent system where you show your ID card, and you get treated, and you never see a piece of paper in the mail that says you are in trouble because you did not pay a bill.

    In closing I would just like to thank you for the opportunity to speak and share my sailors' views. Thank you.

    Mr. BUYER. Thank you very much. Master Sergeant Murray.


    Sergeant MURRAY. Good evening, Mr. Chairman and members of the Committee:

    I am Master Sergeant Murray, 1st Sergeant, from Pope Air Force Base. I would like to thank you for giving me this opportunity to bring some issues and concerns from Bragg's neighbor.
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    As has been stated today, the region, being out of the region is a main concern. As you know, Pope does a lot of deployment, and some of the wives and/or husbands will go visit the families out of the state of North Carolina, and that is one of the main issues of concern of having to register out of this region into another region to be seen.

    When CHAMPUS was in place you enrolled in DEERS, you had the ID card. As the General said there should not be another form of enrollment just to be seen by a doctor, but that is one of the major concerns.

    It has a big effect because of the simple fact you take new airmen that are just coming in, as I had a case last week, I had an airman that just processed in, his wife was pregnant, been here two weeks, was sent to Chapel Hill to have her baby, the baby was born with a heart condition, and they had to do heart surgery. Well, their release from Chapel Hill come back to Bragg with the paperwork to the TRICARE office instead of talking to them on the phone, and then you have, as stated from the first panel you have the customer service rep making command life-threatening decisions on patients. My airman and his wife were basically told this baby did not need to see a heart specialist for a checkup.

    Well, there are a lot of areas that have to be fixed, worked on, whatever, and we know that it would take forever to get this done, but when you have new troops, soldiers, sailors, or whatever just coming in that have not been in as long as some of us that does not know how to work the system, they should be able to go whether it is face-to-face, pick up the phone and say ''I am just being released from the doctor or my baby or my wife, I need to make an appointment with Dr. Such and Such at the hospital,'' without someone else making the decision that this cannot be done.
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    The other issue that seems to be is appointments. At Pope we have to call the 1–800 number to be seen at our clinic, and then the doctor there has to put a consultation in the system for us to be seen at Womack.

    Well, I personally was sent to a neurosurgeon in Raleigh because the neurosurgeon from Walter Reed would not be here for another 30 days. I drove the hour to Raleigh, was seen for ten minutes, sent back to Pope for my doctor at Pope to make an appointment for me to get a MRI at Womack. Now I have to go all the way back to Raleigh to take a copy of the MRI, when, if I had been sent to the outside to see a physician, then that physician is now my doctor, I should not have to come all the way back to my military physician to get the okay to get an MRI when I was at a hospital in Raleigh and I could have easily gotten an MRI while I was there, and to call TRICARE after 90 days to get approval to go back to Raleigh to see the doctor that I have been put in his hands for care. That personally happened to me. And a lot of the troops do not know that if they are being sent outside to see a doctor they have 90 days, and then they have to get reapproval from TRICARE just to continue to see the doctor that they are seeing. That does not make any sense whatsoever.

    There are a lot of troops that are paying moneys out of their pockets because of the hassle that they are getting from TRICARE. We, as the senior leaders, can talk all day long, but until we actually get into a position or run into a problem that our troops are running into, you know, we do not really know what it is like, what they are going through. Some of them have the means as far as backup from their parents to help them, but we should not have to put them in a position, nor myself in a position, where we have to pay out of pocket. The doctor I was sent to in Raleigh, they wanted a co-payment, and I had an ID card, I just was not in uniform. I did not pay it because I had to keep telling them I am active duty. So there are some things you are trying to figure out, what do I need to carry with me when I am on leave or I am being sent to a doctor in another state, why should I have to be penalized for this care?
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    Personally when we had CHAMPUS in place I could go to a civilian hospital because I was not that close to a military hospital on leave, and I did not have to worry about anything. It is just the opposite with TRICARE. No telling what we will have to worry about next. And even though this is not a part of TRICARE, you know, the dental is just as bad.

    I know again when I came in I was promised my twenty years, I would get my benefits. I have gone over my twenty years, so you know I am not in it for the benefits, but I think it needs to be worked on, because these benefits are saying a lot as to the number of troops that remain in the military, be it Army, Navy, Marine Corps, it does not matter, these benefits have a lot to do with it, because you tell a family of four that is making $20,000 on the inside not to take a $50,000 job on the outside, my honest answer I cannot tell that airman to do that. I cannot do it, because I know they have a family that they have to take care of. They are not in a position like I am.

    I thank you for this opportunity.

    Mr. BUYER. Command Sergeant Major Butts, we have waited four and a half hours to hear your testimony, and I hope you are ready, sir.


    Command Sergeant Major BUTTS. I am ready, sir. Mr. Hayes, Mr. McIntyre, good to see you again. You have visited my unit before.
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    Mr. BUYER. Oh, come on. All right. I am ready for it.

    Command Sergeant Major BUTTS. First of all, in advance I would like to thank you gentlemen for giving me the opportunity to speak for the soldiers that are in the field.

    I have spent my entire adult life in the service of this great nation. I volunteered for this amazing journey some 23 years ago. I have witnessed the transformation of our force from the action in Vietnam to the most capable fighting force that any nation has ever placed in the field. We have dedicated young men and women that will do the mission that they are called on to do the first time and every time.

    I am proud of the force I serve in, and have witnessed some of the changes in the world to a more peaceful and democratic place to live. On this journey we have traveled to Grenada, Panama, and the deserts of southwest Asia to fight for freedom and our way of life. Along my journey, the demographics of the force has changed dramatically. Not only do I have to worry about an 18-year-old fighting man or woman, but in many cases his family. At this point you are probably asking yourself ''Well, Sergeant Major, what does that have to do with TRICARE?'' Sir, I submit to you everything, because by law in my job as the senior enlisted advisor to the commander I must look out for the soldier and his family.

    TRICARE is not a bad system, it is just a system that comes up very short of what is needed by the soldier and their family. If time permits, there are three examples that I would like to share with you. They are co-pay, accessibility, and the distance dependents travel for specialized care.
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    I am glad that Fort Bragg was smart enough and being visionaries that we did not contract with TRICARE that we had to get on a phone to make an appointment. Our appointments are made by our clinics, and each clinic has a representative from our unit there that takes care of most of our problems. In the 82nd at Fort Bragg we do not have that problem like Pope Air Force Base and other places. The problems arises when it is time for specialized care.

    Presently Fort Bragg, the local network, does not have the following specialties: dermatology, cardiology, neurosurgeons, internal medicine, and gastronomy. The problem with these is that most of time the soldiers and their families have to travel well outside the contractual agreement with TRICARE, which is 40 miles. Most of the time the soldier must travel to Chapel Hill, and when we look at it it puts a burden on the soldier. A classic example, and this is from an actual case: a co-pay of $12 to go up there for a diagnosis for the first visit, 40 miles—well, a total round trip of 140 miles. A second consultation, a $12 co-payment. Treatment, four visits, a $12 co-pay and each trip was 140 miles. The medicine that was not in the medical facility, two types of medicine $10. Meals for the child and the wife that did not remove the soldier from the workplace, each trip about $12. For me, a total of about $90-something may be a small investment, but for a soldier who is living from paycheck to paycheck it is a great concern for me as a leader, and I hope a great concern for you and all the people on Capitol Hill. We really need some help in fixing this. But for my soldiers is not about a dollar, it is all about getting the care that they deserve.

    My next statement, I do not have the hard data to support it, only 23 years of being a private all the way to a command sergeant major. The examples I gave you will affect readiness, because every day that I take a soldier way from this job to care for his family he is not training. It affects morale, because he has to worry about his family. It places unneeded stress on the soldier and his family, and a financial burden.
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    As I was coming in I had the opportunity to talk to a lady that is sitting back in the corner. She will not have the opportunity as the widow of a retired person to state her case, but she stopped me, and I will use this opportunity to be her advocate as well. She is 62 years old. To pay for TRICARE and Medicare just to have medical benefits is costing her $755 a year on a fixed income. I do not know how long I will live, but I hope that service to our Nation will mean something. I do not expect to be taken care of the rest of my life, but for the rest of my life that I live I expect to have a high quality of life. Only you can help us with this today.

    You held me until the end, the end has come, and the last talking points that I would like to cover is we must correct the telephone service. There is no excuse for people to profit from soldiers by drawing interest off of money, because if you are not settling my claim and you are not paying the providers, the money is somewhere, so someone is profiting, someone is receiving a profit, and it is not the soldier.

    Holding service members responsible for payments, that is one of the most irresponsible things I ever heard in my life. Most of them cannot their self. I am a sergeant major, I can beat up a lot of people on behalf of the soldier, and you expect me to, and they expect me to, the commanders do.

    Giving soldiers incorrect information over the phone, if you do not track a claim from the beginning to the end and have documentation it is more likely than not that TRICARE will not pay for it. I am giving you the ground truth. I am not paid to tell people what they want to hear, but the truth. Any policy that you give me and any order, my soldiers and I we will execute, anything you ask us to do. The performance of the contractors, if it was anything else in the military, or outside the military, or in the civilian community, an investigation would be launched to find out why we are not receiving the service.
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    The B-1 bomber will not raise a flag, nor a battleship, it must be done the old fashioned way by putting men and women in the mud to raise that American flag. Each time and every time we call we will do it for this nation.

    Thank you for your help.

    Mr. BUYER. Thank you, Sergeant Major. I am going to call you the postman for delivering. Mr. Abercrombie.

    Mr. ABERCROMBIE. I have no questions, Mr. Chairman.

    Mr. BUYER. Mr. Hayes?

    Mr. HAYES. Sergeant Major, a great job. You sound like a father talking about his children. You are not going to let these children get abused by the system, and that is what this is about. Thank you for your testimony.

    Command Sergeant Major BUTTS. Thank you, sir.

    Mr. BUYER. Mr. McIntyre?

    Mr. MCINTYRE. Thank you very much, and I appreciate especially your comments with regard to affecting readiness and morale. This was addressed somewhat earlier in the panels when I questioned them about how it was affecting morale, and also being a member of the Readiness Subcommittee that concerns me greatly.
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    I also just as a particular courtesy, want to thank General Seip and General Braaten for the opportunities they gave me in visiting their bases this past year, and you men, personally, I have witnessed do a wonderful job in maintaining that morale and readiness of your troops as well.

    Thank you, Mr. Chairman.

    Mr. BUYER. Thank you. Just to let all of you know, the President's budget request seeks $17.2 billion for military health care, including $11.2 billion for operations and maintenance, and $5.4 billion in military personnel costs. The balance of the request goes to medical procurement, research and development, and military construction accounts.

    About three-fourths of the requested operation and maintenance dollars go directly to providing or purchasing the health care services. Care in the military treatment facilities represents nearly $4 billion of the request, and about $4.7 billion purchases health services in the private sector. 72 percent of the private sector funds, or about $3.4 billion are allocated to the managed care support contracts.

    So we have been examining a wide array of systems within this budget that we are to deal with, and then we put the microscope on the managed care support contracts, in particular a contractor, Anthem. Anthem wants to be responsive. Why? Because they want to stay in business, I would think. So the testimony that you have provided here today, all panels and all witnesses, is extremely helpful to us in streamlining the system.

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    I would also submit that bringing business practices and principles to the Federal Government should not be a radical concept. So if it requires beating down a few doors within the Pentagon, if it requires even bringing all the Lead Agents to Washington, and all the Surgeon Generals, and let us figure out how we are even able to do this at the Medicare standard, it is well worth it.

    If we are only talking about $3.4 billion annually, and we are talking about wasting over $300 million by claims processing and administration, this is not acceptable because we can take those dollars and put them back into the system to the real benefit of people. So that will be a pursuit of this Subcommittee, and I want all of you to know that so you can take that back to your commands.

    On behalf of the Subcommittee we deal with the people issues in the military, and your families.

    We took on the issues, being a good listener to the force, about the pay, the benefits, not only raising the pay but reforming the pay tables, challenging the Chiefs back in February of 1998 about reform of the retirement system, and I believe we are going to see some benefits of that.

    I will also concur that the Subcommittee is in agreement that this is also a recruiting, and in particular, a retention issue, and recognizing that you serve in the military because of the intangibles, there is something deep in your gut of why you stay and why you serve. And we are not going to take advantage of that. That is how we view this. We are not going to take advantage of your service, so we want to make sure that we extend, and to use the cliche, keep the faith. Whether we ever achieve that satisfaction definition I do not know, but the spirit, the sincerity, and the compassion of our pursuit is real. So whatever is required of this Subcommittee we will take it on.
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    This is not just a one-year issue. This is not an electioneering issue for us. We will take on some issues this year, and they are coming back next year, and this is one we have to keep on. It is not going to go away, we are not going to be able to solve all of these things in one fiscal budget year and, oh, we can move to the next issue. It will require us to be good shepherds and stewards. It will. This is not one that you can just give an order and it is fixed, or, oh great, things go away.

    We also appreciate the spouses' testimony. When I think of the 18th Airborne Corps, in particular Fort Bragg, or whether it is at Fort Campbell, this is a very busy corps, and when you are deployed who is taking care of the family, who is there making all those decisions? Who is taking out the trash? Who is getting the car fixed, taking care of the kids? You have got a strong support there in order for it to happen. Their testimony today was very important to the Subcommittee, and it was very enlightening.

    And please take back to your commands that we are going to take this one on, and I appreciate your service to your country.

    That concludes the panel testimony, and it concludes this hearing today. Thank you.

    [Whereupon, at 1:55 p.m. the Subcommittee adjourned.]


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February 28, 2000
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