Defense Health Care: Lessons Learned from TRICARE Contracts and  
Implications for the Future (17-MAY-01, GAO-01-742T).		 
								 
This testimony discusses lessons learned from the Department of  
Defense's (DOD) TRICARE contracts and their implications for the 
future. TRICARE's successes and maturity reflect the ability of  
the DOD and its contractors to work within the current contract  
structure. However, it has not been easy, and there are important
lessons from current contract shortcomings that need to be	 
addressed in designing future TRICARE contracts. Most, including 
DOD, feel that the current contracts are too large, complex, and 
prescriptive in nature, limiting innovation and competition.	 
Also, numerous adjustments to these contracts have created an	 
unstable program, and program costs have been difficult to	 
predict, contributing to annual funding shortfalls. Additionally,
financial incentives, accountability, and data quality need to be
strengthened to achieve greater efficiencies. To address these	 
weaknesses, DOD redesigned its solicitation for the next round of
TRICARE contracts; however, the initial issuance was withdrawn	 
due to internal concerns and reservations about its costs and	 
specifications. The Assistant Secretary of Defense for Health	 
Affairs is now reassessing how to structure the TRICARE contracts
and is considering the views and recommendations of the Defense  
Medical Oversight Committee, a group formed by the Deputy	 
Secretary of Defense to provide oversight to TRICARE.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-01-742T					        
    ACCNO:   A01020						        
  TITLE:     Defense Health Care: Lessons Learned from TRICARE	      
             Contracts and Implications for the Future                        
     DATE:   05/17/2001 
  SUBJECT:   Health care programs				 
	     Health care services				 
	     Defense procurement				 
	     Managed health care				 
	     Contract oversight 				 
	     DOD TRICARE Program				 

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GAO-01-742T
     
Testimony Before the Subcommittee on Military Personnel, Committee on Armed
Services, House of Representatives

United States General Accounting Office

GAO For Release on Delivery Expected at 9: 00 a. m. Thursday, May 17, 2001
DEFENSE HEALTH CARE

Lessons Learned From TRICARE Contracts and Implications for the Future

Statement of Stephen P. Backhus Director, Health Care- Veterans'

and Military Health Care Issues

GAO- 01- 742T

Page 1 GAO- 01- 742T

Mr. Chairman and Members of the Subcommittee: I am pleased to be here today
to discuss lessons learned from the Department of Defense?s (DOD) TRICARE
contracts and their implications for the future. TRICARE, implemented in
1994, offers beneficiaries a choice of three options through which they can
receive health care from either military treatment facilities (MTF) or
civilian providers. Care from civilian providers is arranged and paid for by
five TRICARE contractors. Today, over 8 million active duty personnel, their
dependents, and retirees are eligible to receive care through TRICARE. The
military health system is funded at about $18 billion for fiscal year 2001.
Approximately 30 percent of this amount, $5 billion, was budgeted for the
TRICARE contracts.

Since TRICARE?s inception, we have issued numerous products on DOD?s
progress in implementing it. Over the years, TRICARE has matured in its
delivery of health care. For example, 90 percent of beneficiaries surveyed
report being satisfied with the overall quality of care; over 80 percent of
surveyed beneficiaries reported satisfaction with access to care; and 96
percent of medical claims are processed within 30 days. These successes are
due, in large part, to the partnership efforts of DOD and the TRICARE
contractors. Not withstanding these successes, daunting challenges confront
DOD and its contractors, including the implementation of major benefit
changes recently directed by Congress. Additionally, DOD is in the process
of rethinking its own contract approach for the TRICARE contracts. We
identified contract management (including TRICARE contracts) as a high- risk
and major management challenge facing DOD. 1 My statement today (1)
describes shortcomings with the current contracting approach and (2) issues
to be considered in developing future TRICARE contracts. It is based on a
substantial body of ongoing work and work completed over the past 7 years on
the TRICARE program and its contracts. (A list of our products related to
TRICARE appears at the end of this statement.)

In summary, TRICARE?s successes and maturity reflect the ability of DOD and
its contractors to work within the current contract structure. However, it
has not been easy, and there are important lessons from current contract
shortcomings that need to be addressed in designing

1 High Risk Series: An Update (GAO- 01- 263, January 2001); Major Management
Challenges and Program Risks: Department of Defense (GAO- 01- 244, January
2001).

Page 2 GAO- 01- 742T

future TRICARE contracts. Most, including DOD, feel that the current
contracts are too large, complex, and prescriptive in nature, limiting
innovation and competition. Also, numerous adjustments to these contracts
have created an unstable program, and program costs have been difficult to
predict, contributing to annual funding shortfalls. Additionally, financial
incentives, accountability, and data quality need to be strengthened to
achieve greater efficiencies. To address these weaknesses, DOD redesigned
its solicitation for the next round of TRICARE contracts; however, the
initial issuance was withdrawn due to internal concerns and reservations
about its costs and specifications. The Assistant Secretary of Defense for
Health Affairs (ASD/ HA) is now reassessing how to structure the TRICARE
contracts and is considering the views and recommendations of the Defense
Medical Oversight Committee (DMOC), a group formed by the Deputy Secretary
of Defense to provide oversight to TRICARE. Separately, DOD has an ambitious
initiative underway to develop an overall medical resource strategy designed
to improve fiscal incentives, accountability, and data quality that should
provide valuable information to help shape future TRICARE contracts. In
developing a viable contract approach, the ASD/ HA is considering several
other important issues, including the degree of prescriptiveness needed; the
frequency of and process for contract adjustments; the size of the contracts
and their impact on the level of competition; and whether the current
contract structure provides the right incentives and predictability to
obtain needed efficiencies.

DOD has the unique dual mission of maintaining adequate medical readiness
capability while providing peacetime health care. During the early 1990s, in
a time of military downsizing, medical cost escalation, and budgetary
constraints, DOD restructured its system into TRICARE to improve
beneficiaries? access to health care while maintaining quality and
controlling costs. TRICARE gives beneficiaries a choice among a health
maintenance organization (TRICARE Prime), a preferred provider network
(TRICARE Extra), and a fee- for- service benefit (TRICARE Standard). TRICARE
Prime, the option in which care is most actively managed, is the only option
requiring beneficiaries to enroll.

Under TRICARE, DOD supplements care provided in its MTFs with civilian
providers. To do so, DOD contracts with civilian health care companies to
administer its TRICARE program on a regional basis. The primary
responsibilities of these TRICARE contractors include: developing civilian
provider networks (includes credentialing providers and negotiating
reimbursement discounts), ensuring adequate access to health Background

Page 3 GAO- 01- 742T

care, enrolling beneficiaries, referring and authorizing beneficiaries for
health care, processing health care claims, conducting utilization
management and quality management programs, and educating providers and
beneficiaries.

The TRICARE Management Activity (TMA), under the ASD/ HA, is responsible for
procuring and administering the TRICARE contracts. Since 1994, TMA has
sequentially awarded 7 contracts covering 11 geographic TRICARE regions.
These contracts were competitively bid and awarded as fixed- price, at- risk
contracts. 2 Nonetheless, DOD designed them to include adjustments for
health care cost increases beyond the contractors? control, while other
costs, such as administrative, remain fixed. All of the contracts were
awarded for a base period and 5 option years. 3 (See table 1.) Four of the
contracts have used all of the option years and three of these have been
extended for an additional 2 years. The negotiation for the fourth
contract?s extension is expected to be completed in June 2001. TMA
anticipates that all of its contracts will be extended; however, the TRICARE
contracts will eventually need to be resolicited and awarded because they
are only authorized to be extended a maximum of 4 option years. 4

2 At- risk features of the contract provide for the sharing of financial
gains and losses between the contractor and the government. For example,
contractors are at risk for health care cost overruns up to 1 percent of
health care prices. Beyond that, the contractor and the government share in
losses until an amount prepledged by the contractor, called contractor
equity, is totally depleted, at which time the government assumes full
responsibility for further losses.

3 The base period, which varies by contract, consists of a transition
period, ranging from 6- 9 months, and the early months of health care
delivery. 4 Floyd D. Spence National Defense Authorization Act for Fiscal
Year 2001 (P. L. 106- 398,

sect. 724).

Page 4 GAO- 01- 742T

Table 1: TRICARE Contractors, Regions, Date of Initial Award, and Extensions
TRICARE Contractor

Region name and number Date of initial

award Extensions

Health Net Federal Services a Northwest/ 11 September 1994 Yes Health Net
Federal Services Southwest/ 6 April 1995 Yes Health Net Federal Services
Golden Gate, Southern

California, and Pacific/ 9, 10, and 12

August 1995 Under negotiation

Humana Military Healthcare Services Southeast and Gulf

South/ 3 and 4 November 1995 Yes TriWest Healthcare Alliance Central/(
formerly 7 and 8) June 1996 N/ A b Anthem Alliance c Mid- Atlantic and

Heartland/ 2 and 5 September 1997 N/ A b Sierra Military Healthcare Services
Northeast/ 1 September 1997 N/ A b

a Health Net Federal Services, formerly Foundation Health Federal Services,
changed its name in February 2001. b Not applicable.

c In April 2001, DOD announced that Humana Military Healthcare Services
acquired Anthem Alliance and will assume responsibility for the Mid-
Atlantic and Heartland regions. Source: TMA.

In August 1999, the Deputy Secretary of Defense formed DMOC to provide
greater oversight in the operation of the TRICARE program. Its membership
consists of the Under Secretary of Defense (Personnel and Readiness), the
four service Vice Chiefs, the military department Under Secretaries, the
Under Secretary of Defense (Comptroller), the Director for Logistics from
the Joint Staff, the Surgeons General, and the Assistant Secretary of
Defense (Health Affairs). As part of its responsibilities, DMOC undertook a
review of TMA?s contract approach for the TRICARE contracts.

DOD?s current contracting approach for TRICARE poses several administrative
challenges, and has contributed to significant funding shortfalls. To be
considered for a contract award, offerors were required, in effect, to
submit voluminous, expensive- to- produce proposals, which has limited
competition. Offerors have stated that complicating the preparation of
proposals was the need to address DOD?s overly Shortcomings

With the Current Contracting Approach

Page 5 GAO- 01- 742T

prescriptive requirements, restricting its ability to use best practices to
achieve the same results with greater cost efficiency. Furthermore, TRICARE
contracts were awarded while DOD was realigning and reducing its MTF
capability during a time of budgetary concerns. The resulting shift to
greater reliance on civilian providers as well as frequent changes to the
program resulted in numerous adjustments to the TRICARE contracts, both
planned and unplanned. The effect and cost of these numerous adjustments
created an unstable program and contributed to annual budget shortfalls.

Under DOD?s contract approach, the TRICARE contracts were competitively bid.
Because the required proposals were large, complex, lengthy, and preparation
involved significant sums of money, offerors incurred substantial expense to
participate. In preparing the proposal, offerors were required to address 13
different tasks, including enrollment and beneficiary services, fiscal
management and controls, program integrity, and automated data processing.
The proposals were also to address seven cost factors including utilization
management, provider reimbursement discounts, and coordination of third
party liability. To illustrate the size and complexity of the resulting
proposals, one complete proposal consisted of 33,000 pages.

In 1995, we reported that several offerors stated that it cost them between
$1 million and $3 million just to develop their proposals. 5 More recently,
one contractor official told us that it cost the company he worked for about
$5 million to bid. As a result of the large contract size and complexity,
competition has been limited to large companies with significant resources.
Further, because of the large cost to develop a proposal, losing contractors
stated they had everything to gain by protesting the award even at
substantial cost to them and DOD. All seven contract awards have been
protested; three were sustained.

5 Defense Health Care: Despite TRICARE Procurement Improvements, Problems
Remain (GAO/ HEHS- 95- 142 , August 3, 1995). Large, Complex Proposals

Costly To Bid

Page 6 GAO- 01- 742T

The requests for proposal (RFP) DOD used to solicit TRICARE contracts have
been very prescriptive. DOD officials stated that highly detailed proposals
were needed to ensure a uniform nationwide program under which beneficiaries
and providers would be subject to the same requirements and processes
regardless of region. For example, utilization management is used to ensure
that patients receive all necessary care in the most cost- effective manner.
DOD?s proposal required the offerors to perform utilization management
functions, such as pre- authorization, concurrent and retrospective reviews,
and waiver considerations, for all types of health care in all settings.
These activities were to be performed using a uniform set of criteria
determined by DOD. However, offerors have often cited utilization management
as the area in which more relaxed DOD requirements would enable them to
implement effective techniques with greater savings. Offerors said that this
could be achieved with an RFP that emphasized health care outcomes desired
rather than mandate the processes to achieve them. They believe it would
allow them more innovation and flexibility in devising approaches to
economically achieve such outcomes without adversely affecting the quality
of care delivered. Such an approach deserves DOD?s careful consideration,
but would also require provisions such as appropriate, evidence- based
reviews performed by qualified health care professionals to ensure that all
desired outcomes are achieved.

In addition, prescriptive requirements for utilization management review
have contributed to claims processing inefficiencies. As we reported in June
2000, DOD?s contractual requirements for prepayment review of claims are
manifested as thousands of edits in the adjudication logic of the claims
processing system. 6 These edits result in claims being ?kicked out? of the
system for manual review, which extends processing time and increases
administrative costs. However, not all of these edits are needed, especially
since contractors are at risk for some health care dollars. For example,
claims for electrocardiograms- 14,000 for one contractor alone- were being
manually reviewed, but in every case at the time of our evaluation, the
claims were paid after review. As we reported, over half of TRICARE?s claims
were manually reviewed, a rate significantly higher than the industry
average of 25 percent. In its claims improvement initiative, DOD has been
partnering with its contractors to review the need for these edits.

6 Defense Health Care: Opportunities to Reduce TRICARE Claims Processing and
Other Costs (GAO/ T- HEHS- 00- 138, June 22, 2000). Prescriptive
Requirements

May Limit Offerors? Use of Best Practices and Increase Costs

Page 7 GAO- 01- 742T

Further complicating the design of the TRICARE contracts is the fact that
DOD designed them to have periodic adjustments to the contract price, which
are called bid price adjustments (BPA). These adjustments are based on
shifts in workload between the MTFs and civilian providers as well as other
operating conditions of the contract, such as changes in the number of
beneficiaries caused by the frequent geographic rotation of active- duty
members and their dependents. To calculate these adjustments, DOD uses a
formula that incorporates factors including cost, population shifts,
inflation, and utilization. However, these determinations have been a source
of contention with contractors. For example, contractors have been concerned
with DOD?s use of inaccurate and incomplete data, such as that used to
determine the MTF workload. In addition, contractors were concerned about
some of the factors used in the BPA formula. As a result, in recent
negotiations, DOD agreed to modify its inflation index and other adjustment
factors. Outside of the regularly scheduled BPA process, TRICARE contractors
have also initiated additional adjustments in the contract price called
requests for equitable adjustment, which are used to redress unforeseen
changes in contract conditions, such as higher than anticipated claim
submissions, that subsequently increased their administrative expenses.

In addition, DOD has made a total of over 1,000 unscheduled modifications to
these contracts via contract change orders- an average of 156 per contract
as of June 30, 2000. Change orders may result from new laws or regulations,
or from DOD initiatives. They range in scope from administrative changes,
such as changes to home health care billing procedures, to significant
benefit expansions, such as the elimination of copayments for active duty
dependents that will significantly add to program costs. Until recently, DOD
directed its contractors to implement change orders prior to negotiation of
the final terms of the modification, including payment. As we recently
reported, DOD?s management of the change order process resulted in a large
backlog of outstanding change orders, which was mostly eliminated under a
recent short- term effort by DOD and the contractors to settle all
outstanding contract adjustments. 7 Negotiated settlements for this
initiative totaled about $900 million for

7 Defense Health Care: Continued Management Focus Key to Settling TRICARE
Change Orders Quickly (GAO- 01- 513, April 30, 2001). Numerous Contract

Adjustments Lead To An Unstable Program and Funding Shortfalls

Page 8 GAO- 01- 742T

current and prior fiscal years. 8 DOD hopes to avoid future problems with
change order backlogs by using a new process to negotiate and settle changes
prior to implementation. However, it is premature to evaluate the
effectiveness of this process because TMA has not yet issued any change
orders under it.

Change orders and other contract adjustments have contributed to program
instability and have led, in part, to DOD?s having to request additional
funding from Congress to address health program budget shortfalls. These
requests have called into question DOD?s financial management practices for
estimating and budgeting costs. In fiscal year 2000, Congress provided a
supplemental appropriation of $1.3 billion- nearly half of which was
designated for contract adjustments. Likewise, in fiscal year 2001, TMA
estimates a shortfall of $1.4 billion- over a third of which is due to the
recent settlement of contract adjustments. As we have reported in our high-
risk series, accurate financial information is crucial to making sound
decisions so that DOD?s missions and goals are efficiently and effectively
accomplished. 9

Based on knowledge gained during the first several years of operation and
anticipating contract expirations, TMA undertook an effort to redesign the
TRICARE contract approach. A new RFP was developed, but was withdrawn by the
Under Secretary of Defense for Personnel and Readiness shortly after
issuance because of serious concerns about its design. The ASD/ HA is
currently reassessing future contract approaches for TMA to employ and is
considering DMOC?s recommendations. Separately, DOD has initiated an effort
to determine overall medical resource needs, which could provide valuable
information that will help shape future TRICARE contracts. However, to
successfully accomplish this initiative, DOD needs to address pervasive
problems with its financial management and workload data.

8 It is not possible to identify the amounts related specifically to change
orders for each of the contracts because the change orders and other
contract adjustments were jointly settled.

9 High Risk Series: An Update (GAO- 01- 263, January 2001). Future Design of

Tricare Contracts is Uncertain

Page 9 GAO- 01- 742T

TMA officials spent 3 years developing a new TRICARE contract vehicle,
commonly referred to as TRICARE 3.0, for the next round of contracts. They
created TRICARE 3.0 using a partnership approach, which included input from
numerous military and private industry representatives, including the
current TRICARE contractors, as well as health care consultants. The intent
behind TRICARE 3.0 was to address shortcomings of the current contracts. For
example, as we recommended in 1995, TMA attempted to develop less
prescriptive requirements with a shift in focus from process to outcomes. 10
This shift was intended to provide contractors with the incentive to employ
their best practice techniques to achieve needed outcomes with improved cost
efficiency while maintaining quality of care. TMA also hoped that a less
prescriptive approach would result in a more stable contract with fewer
unplanned changes and adjustments.

Using TRICARE 3.0, TMA issued an RFP for the Northwest Region in February
2000. However, 6 months later, the Under Secretary of Defense for Personnel
and Readiness withdrew it because of (1) the absence of a valid cost
estimate and (2) requirements that offerors develop proposals based on DOD
business processes that were changing. The contractors felt that the
requirements under TRICARE 3.0 were more prescriptive than they had
anticipated. They were also concerned about the fairness of the structure
for financial penalties and incentives. Financial penalties were to be based
on measurable, quantitative standards; however, the financial incentives
were to be based on beneficiary satisfaction surveys-- which the contractors
believe are a less reliable measure of performance.

DOD is developing an overall medical resource strategy that encompasses the
direct health care provided through the MTFs as well as the civilian TRICARE
contracts that potentially will provide valuable information in designing
future procurement strategy. The medical resources strategy begins with
defining the military readiness needs and optimizing care delivery
throughout the military health system. DOD has recognized the need for this
fundamental strategy to more completely establish how large the military
medical infrastructure needs to be, including where resources should be
placed and used to best support readiness and provide peacetime care. In
essence, DOD would determine what resources are needed to meet readiness
requirements, and this determination would

10 Defense Health Care: Despite TRICARE Procurement Improvements, Problems
Remain (GAO/ HEHS- 95- 142, August 3, 1995). TRICARE 3.0 Withdrawn

New Medical Resource Strategy Could Provide Key Data for Future Contracts

Page 10 GAO- 01- 742T

drive all decisions for how best to provide peacetime care- whether in the
direct care system or from the TRICARE contractors, commonly referred to as
make- or- buy decisions.

As we reported in November 1999, DOD established a tri- service team of
senior officers to develop a strategy, called Optimization, to clearly
define readiness needs and costs in order to make better decisions about
peacetime care using make- or- buy analyses. 11 The team?s goals consisted
of devising an approach to determine each military treatment facility?s
correct size, identifying excesses and shortages of medical personnel by
specialty, and determining the right provider mix for each facility. DOD
officials agreed with us that until this is done, it is not possible to
judge the need for nor relative efficiency of their direct care system--
information that is critical to the development of a contract approach.

Optimization is an ambitious undertaking that is dependent upon accurate and
reliable information. However, key health care cost and workload data
problems have been pervasive, and DOD continues to struggle with its data
systems? inaccuracies. As we and others have reported, the root cause has
been DOD?s and the services? lack of oversight and incentives to ensure the
data?s accuracy, timeliness, and completeness. 12 These impediments make it
critical that the implementation of Optimization is closely monitored.

Attaining sufficient competition may be key to obtaining the best quality
for the best price for the TRICARE contracts. In determining a contract
approach, DOD needs to carefully weigh the impact of its decisions on
competition, including whether to carve out elements of TRICARE, such as
pharmacy or enrollment, for separate, national contracts. Other
considerations, such as smaller contracts covering smaller geographic areas,
could also influence competition. Also, it should recognize the effect that
the complexity of earlier contracts, with the resulting high contractor
proposal costs, had on competition and simplify the contracts as much as
feasible. The challenge for DOD, in other words, is to decide

11 Defense Health Care: Tri- Service Strategy Needed to Justify Medical
Resources for Readiness and Peacetime Care (GAO/ HEHS- 00- 10, November 3,
1999). 12 GAO/ HEHS- 00- 10, November 3, 1999. New TRICARE Contract

Approach Considerations

Page 11 GAO- 01- 742T

whether to continue to use fewer large and complex contracts versus managing
smaller and potentially simpler contracts, each of which has unique
management challenges.

DOD?s continued partnering with private industry to reach agreement on the
degree of prescriptiveness needed, by identifying the specific functions in
which the use of best practice techniques would be most practical, is a
worthwhile endeavor. In determining this, DOD and the contractors recognize
that the contract needs to be flexible to maintain a balance between DOD?s
goal of providing uniform benefits nationwide with the realization that the
delivery of health care is local. Conversely, some contract functions may
benefit from more specific requirements, such as performance measurement to
assess how well contractors are meeting requirements.

In light of the complexity and difficulties with adjustments to the current
contracts, such as negotiating and settling almost a thousand contract
change orders, a more stable environment for future contracts is needed. For
example, modifications to the contract could be made on a regularly
scheduled basis, such as annually, rather than on a continual ad hoc basis.
However, with recent benefit changes, including Senior Pharmacy, TRICARE for
Life, and the elimination of copayments for family members in Prime, the
program will be in a state of flux with numerous anticipated contract
adjustments that will be needed to implement them. We hope that once the
changes have been incorporated, the TRICARE program and contracts will
become more stable.

Given long- range budget pressures and escalating health care costs, DOD
faces a formidable challenge in creating a new contract approach. The
current approach is considered to be overly complicated, prescriptive, and
given the frequent adjustments, has created an unstable program. This
approach may not be the best way to satisfy TRICARE contracting needs or
achieve optimal competition. DOD?s Optimization effort is an important step
in ultimately developing a contract approach and warrants close scrutiny as
it is being implemented. The extent to which DOD is contemplating other
business process changes for TRICARE could further complicate planning a new
contract approach. Moreover, DOD is planning in an environment of
substantial ongoing and future changes to the TRICARE program, including the
expansion of benefits to Medicareeligible beneficiaries and the removal of
copayments for family members enrolled in Prime. To ensure that progress
continues, sustained management and congressional oversight will be
necessary. Concluding

Observations

Page 12 GAO- 01- 742T

Mr. Chairman, this concludes my prepared statement. I will be happy to
respond to any questions you or other members of the Subcommittee may have.

For more information regarding this testimony, I can be contacted at (202)
512- 7101. Key contributors to this testimony include Michael T. Blair,
Bonnie W. Anderson, and Allan C. Richardson. GAO Contact and

Staff Aknowledgments

Page 13 GAO- 01- 742T

Defense Health Care: Continued Management Focus Key to Settling TRICARE
Change Orders Quickly (GAO- 01- 513, April 30, 2001).

Military Health Care: Factors Affecting Contractors? Ability to Schedule
Appointments (GAO/ HEHS- 00- 137, July 14, 2000).

Defense Health Care: Opportunities to Reduce TRICARE Claims Processing and
Other Costs (GAO/ HEHS- 00- 138T, June 22, 2000).

DOD and VA Health Care: Jointly Buying and Mailing Out Pharmaceuticals Could
Save Millions of Dollars (GAO/ HEHS- 00- 121T, May 25, 2000).

VA and Defense Health Care: Evolving Health Care Systems Require Rethinking
of Resource Sharing Strategies (GAO/ HEHS- 00- 52, May 17, 2000).

Defense Health Care: Observations on Proposed Benefit Expansion and
Overcoming TRICARE Obstacles (GAO/ HEHS/ NSIAD- 00- 129T, March 15, 2000).

TRICARE?s Civilian Provider Networks (GAO/ HEHS- 00- 64R, March 13, 2000).

Defense Health Care: Tri- Service Strategy Needed to Justify Medical
Resources for Readiness and Peacetime Care (GAO/ HEHS- 00- 10, November 3,
1999).

Defense Health Care: Fully Integrated Pharmacy System Would Improve Service
and Cost- Effectiveness (GAO/ HEHS- 98- 176, June 12, 1998).

Defense Health Care: Reimbursement Rates Appropriately Set; Other Problems
Concern Physicians (GAO/ HEHS- 98- 80, February 26, 1998).

Defense Health Care: Operational Difficulties and System Uncertainties Pose
Continuing Challenges for TRICARE (GAO/ T- HEHS- 98- 100, February 26,
1998).

Defense Health Care: TRICARE Resource Sharing Program Failing to Achieve
Expected Savings (GAO/ HEHS- 97- 130, August 22, 1997).

Defense Health Care: Actions Underway to Address Many TRICARE Contract
Change Order Problems (GAO/ HEHS- 97- 141, July 14, 1997). Related GAO
Products

Page 14 GAO- 01- 742T

Defense Health Care: New Managed Care Plan Progressing, But Cost and
Performance Issues Remain (GAO/ HEHS- 96- 128, June 14, 1996).

Defense Health Care: TRICARE Progressing, But Some Costs and Performance
Issues Remain (GAO/ T- HEHS- 96- 100, March 7, 1996).

Defense Health Care: Despite TRICARE Procurement Improvements, Problems
Remain (GAO/ HEHS- 95- 142, August 3, 1995).

Defense Health Care: Issues and Challenges Confronting Military Medicine
(GAO/ HEHS- 95- 104, March 22, 1995).

(290055)
*** End of document. ***