Military Health Care: Factors Affecting Contractors' Ability to Schedule
Appointments (Letter Report, 07/14/2000, GAO/HEHS-00-137).

Pursuant to a congressional request, GAO provided information on TRICARE
centralized appointment scheduling, focusing on the: (1) proportion of
appointments scheduled by TRICARE contractors for beneficiaries in the
four TRICARE regions with centralized systems; and (2) factors that
affect the contractors' ability to schedule appointments.

GAO noted that: (1) contractors scheduled only about one quarter of the
appointments during November 1999 in the four regions where TRICARE
contractors have appointment-making responsibility; (2) the percentage
of appointments scheduled by the contractors varied among the regions,
ranging from about 17 percent to about 63 percent; (3) in general,
contractors scheduled a higher percentage of appointments for clinics
that provide primary care services (42 percent) than for clinics
providing specialty care, such as dermatology, cardiology, and
orthopedics (17 percent); (4) in the four regions, the Department of
Defense (DOD) and its military treatment facilities (MTF) have
restricted the types and number of appointments available to the
contractors for scheduling; (5) some MTF physicians and other
professional staff told GAO that they want to retain control over the
appointing process because they do not trust contractors to accurately
schedule appointments and to ensure that any medical instructions can be
provided prior to the visit, such as instructions about fasting; (6)
when comparing like clinics within different MTFs the percentage of
appointments scheduled by contractors varies substantially, suggesting
that physicians' and other staff's desire to retain appointment control
may be the driving factor, rather than the need to provide medical
instructions; (7) when contractors do not have access to appointments
because of DOD and MTF restrictions, beneficiaries requesting
appointments from contractors may be transferred from the appointment
center to the MTF clinic, or told to call MTF clinics themselves; (8)
thus, what was meant to be a simplified, more user-friendly appointment
process is now a complex and confusing process in which beneficiaries
are unsure whether to call the contractor or the MTF to schedule
appointments; (9) to improve its appointment system, DOD is in the
process of reducing and standardizing the number of appointment types
and names used throughout the military health care system; (10)
currently thousands of appointment types and names are used; and (11)
although reduction and standardization could simplify the
appointment-making process, until DOD decides on and implements a more
uniform process for making appointments, there will continue to be
differences in how beneficiaries access the military health care system.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-00-137
     TITLE:  Military Health Care: Factors Affecting Contractors'
	     Ability to Schedule Appointments
      DATE:  07/14/2000
   SUBJECT:  Military hospitals
	     Health services administration
	     Health care programs
	     Department of Defense contractors
	     Customer service
	     Beneficiaries
	     Health care facilities
	     Standards and standardization
	     Centralization
IDENTIFIER:  DOD TRICARE Program

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Testimony.                                               **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
GAO/HEHS-00-137

Table 1: Percentage of Appointments Scheduled by Contractor Staff 6

Table 2: Percentage of Primary and Specialty Clinic Appointments Scheduled
by Contractor Staff 7

DOD Department of Defense

MTF military treatment facility

Health, Education, and Human
Services Division

B-285758

July 14, 2000

The Honorable Steve Buyer
Chairman
The Honorable Neil Abercrombie
Ranking Minority Member
Subcommittee on Military Personnel
Committee on Armed Services
House of Representatives

For most people, the initial contact with a health care system occurs when
they call their physician's office to schedule an appointment. For years,
Department of Defense (DOD) beneficiaries seeking to make appointments in
military treatment facilities (MTF) gained access to care this way--by
calling the clinic directly. Over the past several years, however, DOD has
been moving toward a centralized appointment system. In some MTFs, an
appointment center has been created, and beneficiaries call that center to
schedule various types of appointments. In addition, in four areas of the
country that DOD refers to as TRICARE regions, the TRICARE contractors have
established regional appointment centers which beneficiaries call to
schedule appointments with physicians in MTFs.1 Centralized appointment
scheduling is intended to provide beneficiaries with improved appointment
services and increase efficiency by consolidating the appointment function
such that MTF clinic staff will be less involved in the process. The
contractors perform this function as part of their administrative tasks
under their contracts with DOD.

As you requested, this report provides information on (1) the proportion of
appointments scheduled by TRICARE contractors for beneficiaries in the four
TRICARE regions with centralized systems, and (2) the factors that affect
the contractors' ability to schedule appointments.

To determine the extent to which the contractors scheduled appointments, we
obtained and analyzed data for appointments scheduled between November 1 and
November 30, 1999, in each MTF in the four TRICARE regions.2 We visited the
contractors' appointment centers in three of the four regions to observe
appointment scheduling and met with contractor officials and appointment
staff to discuss the appointment process. We also discussed issues regarding
the contractor's role and ability to schedule appointments with DOD
officials, and with MTF physicians and medical staff at five MTFs. We did
our work from September 1999 to June 2000 in accordance with generally
accepted government auditing standards.

Our analysis of DOD data shows that contractors scheduled only about
one-quarter of the appointments during November 1999 in the four regions
where TRICARE contractors have appointment-making responsibility. The
percentage of appointments scheduled by the contractors varied among the
regions, ranging from about 17 percent to about 63 percent. In general,
contractors scheduled a higher percentage of appointments for clinics that
provide primary care services (42 percent) than for clinics providing
specialty care, such as dermatology, cardiology, and orthopedics (17
percent).

In the four regions, DOD and its MTFs have restricted the types and number
of appointments available to the contractors for scheduling. Some MTF
physicians and other professional staff told us that they want to retain
control over the appointing process because they do not trust contractors to
accurately schedule appointments and to ensure that any medical instructions
can be provided prior to the visit, such as instructions about fasting. When
comparing like clinics within different MTFs the percentage of appointments
scheduled by contractors varies substantially, suggesting that physicians'
and other staff's desire to retain appointment control may be the driving
factor, rather than the need to provide medical instructions. When
contractors do not have access to appointments because of DOD and MTF
restrictions, beneficiaries requesting appointments from contractors may be
transferred from the appointment center to the MTF clinic, or told to call
MTF clinics themselves. Thus, what was meant to be a simplified, more
user-friendly appointment process is now a complex and confusing process in
which beneficiaries are unsure whether to call the contractor or the MTF to
schedule appointments.

To improve its appointment system, DOD is in the process of reducing and
standardizing the number of appointment types and names used throughout the
military health care system. Currently thousands of appointment types and
names are used. Although reduction and standardization could simplify the
appointment-making process, until DOD decides on and implements a more
uniform process for making appointments, there will continue to be
differences in how beneficiaries access the military health care system.

DOD health care, referred to as TRICARE, is provided in military-operated
hospitals and clinics worldwide, supplemented by civilian providers. TRICARE
is organized geographically into 11 health care regions administered by five
contractors. In TRICARE regions 1, 2, 5, and 11, the contractors'
administrative tasks include scheduling appointments for the MTFs within
their region. In each of these four regions, the contractor has established
a central appointment center. Centralized appointment-making is intended to
provide beneficiaries with improved appointment services, including the
ability to make multiple appointments during a single phone call, and
increased access to appointment clerks, because the appointment centers
typically are open before, during, and after MTF clinic hours. To schedule
an appointment at any of the MTFs in the region, beneficiaries call a
regionwide toll-free number. In November 1999, contractor staff in the four
regions answered more than 393,000 calls and scheduled about 211,000
appointments.

In regions 2 and 5, beneficiaries calling the toll-free number may be routed
first to contractor staff located in the TRICARE service center closest to
where the call originated. If that line is not available, the call is
automatically routed back to the contractor's central appointment center.
This rerouting is invisible to the caller, occurring in a few seconds. In
regions 1 and 11, calls to the toll-free number are answered in the
contractors' regional appointment center. Regardless of where the
contractors' appointment clerks are located, the process for making
appointments is the same: the contractors' clerks view computer screens
showing schedules developed by the MTFs that include information on
appointment availability and other descriptive information, such as the type
of patient or procedure that should be scheduled into a particular
appointment slot.

Although the TRICARE contracts require the contractors to schedule
appointments, they do not specify the appointment workload. Each of the
contractors we met with stated that they schedule all the appointments
provided to them by the MTFs and that this service was included in the
administrative fees paid under the contract. Some of the contracts also
include standards related to telephone responsiveness, such as a maximum
number of rings before which incoming calls should be answered, or a maximum
time callers should be placed on hold.

Our analysis of appointment data from the TRICARE regions reviewed indicates
that only about one-quarter of the appointments in the MTFs were scheduled
by contractor staff. As shown in table 1, the percentage of appointments
scheduled by contractor staff varied among the regions. Regions 1, 2, and 5
have less experience than region 11 with central appointment scheduling, and
the percentage scheduled by the contractors in those regions--17, 29, and 22
percent, respectively--is notably lower than the 63 percent of appointments
scheduled by the contractor in region 11.3

 Region Contractor                         Percentage scheduled by
                                           contractora

 1      Sierra Military Health Services,   17
        Inc.

 2      Anthem Alliance Health Insurance   29
        Co.

 5      Anthem Alliance Health Insurance   22
        Co.

 11     Foundation Health Federal          63
        Services, Inc.

        Weighted average for all four      26c
        regionsb

Note: Data are for appointments scheduled between November 1 and November
30, 1999.

aPercentage is calculated by dividing the number of appointments scheduled
by the contractor by the total number of appointments scheduled by the
contractor and MTF staff.

bThe average is based on the total appointments for all four regions
combined.

cThe 26 percent represents about 211,000 appointments.

We also found that, in general, contractors scheduled a higher percent of
appointments for primary care clinics than for specialty clinics.4 Overall,
about 42 percent of the appointments for primary care clinics were scheduled
by contractor staff, as compared to about 17 percent of the appointments for
specialty care clinics. These percentages also varied among the regions, as
shown in table 2.

                            Percentage of primary  Percentage of specialty
                            clinic appointments    clinic appointments
 Region Contractor
                            scheduled by           scheduled by
                            contractora            contractora,b
        Sierra Military
 1      Health Services,    33                     9
        Inc.
        Anthem Alliance
 2      Health Insurance    44                     19
        Co.
        Anthem Alliance
 5      Health Insurance    37                     11
        Co.
        Foundation Health
 11     Federal Services,   76                     54
        Inc.
        Weighted average
        for all four        42                     17
        regionsc

Note: Data are for appointments scheduled between November 1 and November
30, 1999.

aPercentage is calculated by dividing the number of appointments scheduled
by the contractor by the total number of appointments scheduled by the
contractor and MTF staff.

bWe defined specialty care clinics as all clinics not identified by the MTFs
as primary care clinics. These include the full range of specialty medicine,
such as cardiology, dermatology, and orthopedics; and some ancillary
services that required an appointment, such as radiology.

cThe average is based on the total appointments for all four regions
combined.

The primary factor limiting contractors' ability to schedule appointments is
the limited number of appointments that are allocated to them for
scheduling. DOD has given the region 1, 2, 5, and 11 contractors authority
to schedule only certain types of appointments, and MTFs have further
reduced the number of appointments available to contractors for scheduling.
For example, in region 1, the contractor is authorized to schedule eight
appointment types, including those for initial primary and specialty care,
physical exams, and well-baby care. For the month of November 1999, these
eight appointment types represented about two-thirds of all the
appointments, with the remaining one-third not available for contractor
scheduling. In regions 2 and 5, the contractor can schedule 9 and 12
appointment types, respectively.5 At one MTF in region 5, the 12 authorized
appointment types represented about 60 percent of total, and thus about 40
percent of the appointments were unavailable to the contractor for
scheduling.

The number of appointments available for contractor scheduling has been
further reduced because of MTF-imposed restrictions. For example, in region
1, of the 314 appointment openings in one MTF's optometry clinic in the
month of November 1999, 222 were of the type that the contractor was
authorized to schedule. However, the MTF further limited the contractors'
scheduling ability by designating 300 of the 314 appointments as
appointments that should be scheduled only by MTF staff. Therefore, only 14
appointments were available to the contractor's staff to schedule.

In region 11, each MTF has identified specific appointment types that should
be scheduled by the contractor, and developed guidance for the contractor's
appointment staff to follow when scheduling appointments. This guidance
provides detailed descriptions of the various appointments, including the
types of patients that should be scheduled in the different appointment
slots, and whether the appointment can be scheduled by the contractor or by
MTF clinic staff. The contractor told us that this guidance is cumbersome
and confusing for the clerks to follow. The original appointment guidance
totaled almost 900 pages for all the MTFs combined, and although the
contractor and DOD have worked to reduce the number of pages, it is still
about 300 pages long, providing appointment requirements for more than 100
clinics in the region's MTFs. Adding to the cumbersome nature of the long
and prescriptive guidance is the fact that the appointment guidance and
appointment names are not uniform among the MTFs. For example, at one MTF,
contractor staff can schedule appointments for new patients in the
ophthalmology clinic; however, in another MTF, appointments for new
ophthalmology patients cannot be scheduled by the contractor. Additionally,
over 100 different appointment names are used by the MTFs in region 11. For
example, 10 different appointment names are used to designate well-care
visits--2-, 4-, 6-, 9-, and 12-month-old well-baby checkups; well-child
checkups; well visits; 15- or 30-minute well visits; and follow-up well
visits.

In September 1999, we reported on the lack of standardized appointment names
throughout the military health care system, and recommended that DOD
standardize appointment types across the system.6 DOD established a group to
undertake this task, and it has recommended using nine standard appointment
types across the military health care system--a significant reduction from
the thousands currently used. DOD has accepted the group's recommendation
and expects to begin standardizing the appointment names used in the
appointment system in the fall of 2000. Standardizing and reducing the
number of appointment types will simplify the appointment process not only
in the MTFs but also for contractors who are responsible for scheduling
appointments in regions 1, 2, 5, and 11.

Beneficiaries can encounter unnecessary burdens and delays when the
contractor's staff is restricted from scheduling certain appointments. For
example, if the contractor's appointment clerk cannot schedule an
appointment requested by a beneficiary because the MTF has not made the
appointment type available to the contractor, the clerk might transfer the
call to the MTF, put the caller on hold while he or she contacts the MTF to
determine if the appointment can be scheduled, call the patient back after
contacting the MTF, or tell the beneficiary to call the MTF directly. Thus
what was intended to be a relatively straightforward procedure becomes a
complicated process for beneficiaries seeking medical care in the military
health care system.

In meetings with MTF physicians and medical staff, they told us they
withhold or restrict appointments due to their concern about the accuracy of
the appointment-making performed by contractor staff. MTF physicians and
medical staff provided anecdotal accounts of appointments incorrectly
scheduled by contractor staff, such as scheduling patients with the wrong
primary care manager, not scheduling enough time for certain appointment
types, and scheduling the wrong type of patient into an appointment slot
(such as an adult into a pediatrics slot). The physicians and medical staff
could not quantify the number of times such errors occurred, however, and
acknowledged that they usually did not report the errors to the contractor.
The contractors told us that when they learn of such errors, the appointment
clerks are counseled and provided additional instruction. While DOD does not
require contractors to report the extent to which their clerks incorrectly
schedule appointments, one contractor did monitor its clerks' errors and
found appointment error rates of less than 1 percent.

MTF physicians also told us that some specialty and primary care
appointments should only be scheduled by MTF clinic staff to ensure the
availability of medical personnel to answer any questions the patient may
have and to provide any medical instructions. We recognize these may be
valid reasons for the MTF clinic to schedule some appointments. However,
when comparing like clinics in different MTFs, we found considerable
difference in the percentage of appointments scheduled by the contractors,
suggesting that the appointing process could be strongly influenced by
physician or medical staff preference to retain control over appointments
rather than the need to provide medical instructions. For example, the
percentage of dermatology appointments scheduled by contractors ranged from
88 percent in one MTF to 0 percent at six other MTFs. Similarly, the
contractor scheduled 97 percent of the optometry appointments at one MTF,
while 0 percent were scheduled at eight other MTFs.

Because of concerns raised about contractor performance, we also obtained
information on the extent to which beneficiaries had difficulty getting
through to the contractors' appointment clerks or were placed on hold for
long periods of time. The data indicate that most beneficiaries do not
encounter busy signals or unreasonable hold times when calling for
appointments. In all four regions, the contractors' performance standard is
that 90 percent of the callers will speak with the clerk within 120 seconds.
In November 1999, contractors in two regions exceeded the standard, with 100
and 97 percent of the callers speaking to contractor staff within 120
seconds. In the other two regions, the contractors fell slightly short of
the standard at 89 percent. The data also indicate that a small percentage
of callers received busy signals or were put on hold. For example, one
region reported that about 3 percent of the callers encountered busy
signals, with the other three regions reporting 1 percent or less. In terms
of hold times, one region reported that only 2 percent of the callers
experienced a hold

time of more than 5 minutes, and two other regions reported average hold
times of about 1 minute or less.7

Inconsistencies exist across the military health care system in terms of
whom beneficiaries should call to make an appointment, resulting in a
confusing process for beneficiaries. While improvements could be made in the
central appointing process and the contractors' access to appointments
increased, at this juncture a larger issue exists for DOD resolution--what
type of appointment scheduling process best serves the needs of the military
health care system and its beneficiaries.

DOD has not evaluated the appointment-making processes currently in place
across the military health care system, including the advantages and
disadvantages of using contractor versus MTF staff, nor developed criteria
or guidance to be used uniformly across the military health care system. The
appointment process should be transparent to all beneficiaries and based on
solid evidence that it is providing beneficiaries with the best possible
service. Congress is considering legislation that would authorize $20
million to support procurement of a local appointment-scheduling system and
would direct that the planning and installation of such a system be
coordinated with the contractors in order to integrate and synchronize the
local systems with regional applications to the maximum extent possible. As
a first step toward implementing such a requirement, DOD needs to assess and
decide on the respective roles of contractors and MTF staff in the
appointment process.

To clarify and standardize the appointment-making process to the extent
practical, we recommend that the Secretary of Defense direct the Assistant
Secretary of Defense (Health Affairs) to assess the effectiveness of the
current appointment-scheduling process and determine how that process could
be optimized, including a determination of the role contractors should play.
The Assistant Secretary should then implement the selected
appointment-scheduling process system-wide.

We provided DOD with a draft of this report and discussed it with the Deputy
Executive Director, TRICARE Management Activity. He agreed with the
information presented and our recommendations, and said that DOD is in the
process of determining the specific actions needed to implement the
recommendations.

We will send copies of this report to the Honorable William S. Cohen,
Secretary of Defense, and others who are interested.

If you have any questions or would like additional information, please call
me on (202) 512-7101, or Michael T. Blair, Jr., on (404) 679-1944. Other
major contributors to this report were Nancy T. Toolan and Lisa M. Moore.

Stephen P. Backhus
Director, Veterans' Affairs and
Military Health Care Issues

(101636)

Table 1: Percentage of Appointments Scheduled by Contractor Staff 6

Table 2: Percentage of Primary and Specialty Clinic Appointments Scheduled
by Contractor Staff 7
  

1. DOD has organized its health care system into 11 geographic regions. In
four of those regions--region 1 (the Northeast), region 2 (the
mid-Atlantic), region 5 (the Midwest), and region 11 (the Northwest)--a
regionwide centralized appointment system has been implemented.

2. The November data were the most recent complete data available to us at
the time we requested them.

3. Region 11 began performing the appointment function in March 1995,
regions 2 and 5 began in May 1998, and region 1 in June 1998.

4. It is reasonable to expect some portion of specialty appointments to be
scheduled by MTF staff. Visits to specialists normally occur as a result of
a referral from a primary care provider, and the clinic staff may call the
specialty clinic within the MTF directly on behalf of the patient at the
time the referral is made. Also, follow-up visits to specialists may be
booked directly with clinic staff as patients leave the clinic.

5. DOD has identified 12 appointment types that the contractor can schedule
in region 5. However, each MTF determines which of the 12 types the
contractor will schedule for each clinic.

6. Defense Health Care: Appointment Timeliness Goals Not Met; Measurement
Tools Need Improvement (GAO/HEHS-99-168 , Sept. 30, 1999).

7. One region does not collect data on caller hold times.
*** End of document. ***