THE VIRGINIAN-PILOT
Copyright (c) 1994, Landmark Communications, Inc.
DATE: Saturday, December 17, 1994 TAG: 9412170259
SECTION: FRONT PAGE: A9 EDITION: FINAL
SOURCE: BY DALE EISMAN, STAFF WRITER
DATELINE: WASHINGTON LENGTH: Long : 104 lines
If you're among the 426,000 Hampton Roads residents who receive health care through the military, chances are you're about to hear from friends in uniform around the country.
They're going to want to know about Tricare, the health care system the federal government launched in the area two years ago in an effort to get control of spiraling military health costs.
Do you like it? Do you hate it? Maybe most important, do you understand it?
Tricare is going national, the Pentagon announced this week. There will be some changes, probably by the spring and probably not major, in the program in Hampton Roads. But for military families elsewhere, the ``managed care'' system will dramatically alter the way they get and pay for health care in the civilian market.
``We were the prototype'' for the rest of the Defense Department, Phil Garcia, Tricare's local spokesman, said Friday. In making the program national, ``They're saying `There's something good happening in Tidewater,' '' he said.
Tricare does not change the free care available at service-run hospitals and clinics to active duty personnel and their families.
But a sometimes-confusing system of copayments and deductibles kicks in when service families turn to civilian doctors and hospitals for health services. And Tricare's service centers, the gatekeepers for the system, may steer families to the civilian providers rather than the military facilities.
The Pentagon's claims for Tricare sound almost like magic: better care at lower cost to both military families and the government. For families, the estimated annual savings range from $100 to $240; the Pentagon refuses to say how much it expects Tricare to save the government.
Critics however, warn that Tricare's relatively stingy fee schedule may keep many civilian doctors from contracting with it to serve military families. Doctors in the network have their fees set by Tricare and can charge military families only a small copayment or a discounted rate.
Garcia said about 1,200 Hampton Roads-area doctors - just over one-third of the number practicing in the region - participate in Tricare.
Fewer available doctors can mean longer waits for service; delays already are a major complaint against the military health system.
``What I think physicians are starting to scrutinize is how much service can they give these people when there is such a small (profit) margin,'' said Joseph Olivo, president of PMC Co., a health care consulting firm based in Norfolk.
Olivo, whose firm advises doctors, hospitals and other health care providers, said Tricare is ``a snapshot of what's occurring throughout the industry.'' As large groups of patients, like the military in Hampton Roads, are enrolled in the groups, doctors feel intense pressure to accept the low, group-set fees, he said.
But as those tighter fees pinch doctors' profits, he said, ``you wonder if we're going to get in some sort of system where the reimbursements are so low that the quality of care is not what it would be if the reimbursements were adequate.''
Tricare adds to and replaces CHAMPUS, the military's old counterpart to the Blue Cross and Blue Shield coverage carried by many civilians. It gives, or will give, military families three options for receiving health services.
Tricare Prime, the option most people are expected to choose, will work much like a civilian health maintenance organization. Military dependents will contact a Tricare office - there are three in Hampton Roads - when they need health services, and will be referred to a military facility or a civilian provider in the Tricare network. If a civilian provider is used, the patient's cost will be limited to a small copayment, usually less than $25, even for overnight stays in the hospital.
Tricare Standard, which matches the old CHAMPUS program, lets military families make their own choices from among participating doctors. But patients are responsible for deductibles and co-payments, generally 20 percent of the doctor's charges.
Tricare Extra, a branch of Tricare Standard, provides substantial discounts on doctors' fees and hospital charges when the military family chooses a health provider in a specially approved Tricare network.
In Hampton Roads, the move to take Tricare national will be felt most by officers and enlisted personnel at the rank of E5 or higher. Tricare Prime, now available here only to E4s and below, will be extended to everyone; E5s and above generally will pay higher co-payments than lower-ranking enlisted personnel, however.
Garcia said the changes could be made as soon as the spring. The Pentagon's timetable doesn't call for Tricare to be fully in place throughout Virginia and North Carolina until 1997. ILLUSTRATION: Chart by STEVE STONE/Staff
TRICARE PRIME COSTS
Families Familes Retirees
E4 and below E5 and above and families
Outpatient visits $6 $12 $12
Emergency room $10 $30 $30
Mental health
outpatient $10 $25 $25
Ambulatory
surgery $25 $25 $25
Prescriptions $4 $4 $8
Inpatient
hospital care (per day)
$11 $11 $11
KEYWORDS: MILITARY HEALTH CARE TRICARE HEALTH INSURANCE by CNB