Defense Health Care: Resources, Patient Access, and Challenges in Europe
and the Pacific (Letter Report, 08/31/2000, GAO/HEHS-00-172).

Pursuant to a congressional request, GAO reviewed the Department of
Defenses (DOD) health care system in Europe and the Pacific, focusing
on: (1) what DOD health care resources are available in Europe and the
Pacific and what is their cost; (2) how does DOD integrate host nation
care into its military health care system; (3) how does DOD ensure the
quality of such care; (4) whether beneficiaries have adequate access to
medical care; and (5) whether beneficiaries encounter obstacles when
obtaining healthcare.

GAO noted that: (1) DOD maintains in Europe and the Pacific an extensive
system of 18 hospitals and 69 clinics providing primary and specialty
care to about 500,000 beneficiaries in over 100 countries; (2) DOD
spends about $1.1 billion annually to staff, operate, and maintain these
overseas military treatment facilities (MTF); (3) most beneficiaries
live near MTFs and receive their care from military physicians, although
host nation providers and facilities are also used to augment MTF
resources; (4) in Europe, MTFs have developed formal networks of
English-speaking host nation providers to serve as referral specialists;
(5) in the Pacific, MTFs have traditionally used less local care and
have not developed formal provider networks; (6) Pacific MTFs, more so
than those in Europe, rely on transporting patients between MTFs for
specialty care; (7) beneficiaries living in remote areas hundreds of
miles from MTFs particularly in the Pacific, provide DOD a major care
challenge; (8) for such beneficiaries, DOD relies on various care
sources, including Department of State health clinics and local health
care, as well as on transporting patients to distant MTFs; (9) to
improve services in the Pacific remote areas, DOD recently hired a
contractor to arrange for and manage the care of beneficiaries living
there; (10) DOD and the remote beneficiaries have given high ratings to
this contractor's services; (11) to ensure host nation provider quality,
DOD relies primarily on each country's licensing and credentialing
requirements, as well as on limited inspections and monitoring by U.S.
military physicians; (12) differences in language, culture, and health
care practices between the U.S. and the Europe and Pacific Regions at
times can cause frustrations and inconveniences for beneficiaries using
host nation care; (13) using MTF and local providers, DOD has generally
been able to ensure timely access to both primary and specialty care,
however, specialty care is not always available within the 4-week
TRICARE access standard, and local specialty providers are not available
in all areas; (14) the medical systems in Europe and the Pacific face
continuing challenges; (15) DOD believes that aircraft serving the
aeromedical evacuation system may need to be replaced soon; (16) DOD is
now seeking to expand local care options in some overseas locations and
has begun reviewing alternatives for its aeromedical evacuation needs;
and (17) DOD officials plan to review concerns about overseas screening
and benefit portability.

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

 REPORTNUM:  HEHS-00-172
     TITLE:  Defense Health Care: Resources, Patient Access, and
	     Challenges in Europe and the Pacific
      DATE:  08/31/2000
   SUBJECT:  Military hospitals
	     Armed forces abroad
	     Health care services
	     Foreign governments
	     Health resources utilization
IDENTIFIER:  DOD TRICARE Program

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GAO/HEHS-00-172

Report to the Subcommittee on Military Personnel, Committee on Armed
Services, House of Representatives

August 2000 DEFENSE HEALTH CARE

Resources, Patient Access, and Challenges in Europe and the Pacific

GAO/HEHS-00-172

Letter 3 Appendix Appendix I: Comments From the Department of Defense 32
Table Table 1: Estimated Number of Beneficiaries by Category in Europe

and the Pacific, FY 1999 7 Figure Figure 1: O& M Funding for MTFs in Europe
and the Pacific,

FY 1995- 99 10

Abbreviations

CHAMPUSCivilian Health and Medical Program of the Uniformed Services DOD
Department of Defense MTF military treatment facility O& M operations and
maintenance

Health, Education, and Human Services Division

Lett er

B- 285315 August 31, 2000 The Honorable Steve Buyer Chairman The Honorable
Neil Abercrombie Ranking Minority Member Subcommittee on Military Personnel
Committee on Armed Services House of Representatives

The Department of Defense (DOD) maintains a significant military medical
presence in Europe and the Pacific. As in the United States, the primary
mission of DOD's overseas health care activities is to maintain the health
of military personnel and support U. S. forces during military operations.
Also, when space and resources are available, military treatment facilities
(MTF) provide health care to dependents of active duty members, retirees and
their dependents, and survivors of service members. When an MTF cannot
provide needed health care services, DOD may refer beneficiaries to local
host nation providers or transport patients to military facilities
elsewhere.

In 1990, we testified that beneficiaries in both Europe and the Pacific were
having considerable problems obtaining health care at MTFs. 1 These problems
were exacerbated during the post- Cold War downsizing of the U. S. military
presence overseas, which included MTF closures. In 1995, we reported that
access problems were continuing at the remaining MTFs in Germany and Italy,
particularly problems with access to specialty care. 2 At that time, DOD
committed itself to improving access and in 1997 implemented TRICARE, its
managed care program, which better integrates host nation care into the
military health care system.

In September 1999, you asked that we review DOD's health care system in
Europe and the Pacific to determine whether problems persist. Specifically,
you asked the following: What DOD health care resources are available in
Europe and the Pacific and what is their cost, how does DOD integrate host

1 Access to Medical Care at Overseas Military Hospitals( GAO/ T- HRD- 90-
20, Mar. 29, 1990). 2 Defense Health Care: Problems With Medical Care
Overseas Are Being Addressed (GAO/ HEHS- 95- 156, July 12, 1995).

nation care into its military health care system, how does DOD ensure the
quality of such care, do beneficiaries have adequate access to medical care,
and do obstacles still exist to obtaining health care?

To answer these questions, we interviewed and obtained relevant documents
from officials of the TRICARE Management Activity, which has overall
responsibility for managing DOD's military health care system; the TRICARE
Europe and Pacific Lead Agent 3 offices; each military service; and the
Department of State. We visited the following MTFs in the TRICARE Europe and
TRICARE Pacific Regions: In Germany, the Landstuhl Regional Medical Center,
the Ramstein Air Base clinic, and the Army Health Clinic in Wiesbaden; in
the United Kingdom, the Navy's London clinic and the Air Force's hospital at
Lakenheath; in Italy, the Navy's hospital in Naples and the Army Health
Clinic in Vicenza; in Turkey, the Incirlik Air Base hospital; in Japan, the
Navy's hospital in Yokosuka and the Yokota Air Base hospital; and in Korea,
the Army's 121st General Hospital in Seoul and the Osan Air Base hospital.
At these locations, we interviewed and obtained relevant documents from
hospital and clinic commanders, senior medical staff, patient liaisons, and
health benefits advisors. We also visited three remote locations- Ankara,
Turkey; Bangkok, Thailand; and Singapore- that have no local MTFs but
significant numbers of beneficiaries. We conducted interviews with about 100
beneficiaries and beneficiary representatives.

Also, we reviewed DOD's criteria for selecting local providers and hospitals
for use by beneficiaries and observed operations at Homberg University
Klinik and Wiesbaden Stadt Klinik, Germany; Addenbrookes Hospital and
Clementine Churchill Hospital, United Kingdom; San Bortolo Hospital, Italy;
Seyhan Hospital, Turkey; and Bumrungrad Hospital and BNH Hospital, Thailand.
We also interviewed officials from International SOS, the contractor
responsible for coordinating beneficiary care in much of the western
Pacific. We conducted our work between November 1999 and August 2000 in
accordance with generally accepted government auditing standards.

3 Lead Agents are senior military medical officials responsible for planning
and coordinating peacetime health care operations within their respective
regions. The Europe Lead Agent is responsible for U. S. military personnel
stationed in continental Europe, Great Britain, Iceland, the Middle East,
and Africa. The Pacific Lead Agent's responsibilities include U. S. military
personnel stationed in Guam, Korea, Japan, and other nations throughout Asia
and the western Pacific.

Results in Brief DOD maintains in Europe and the Pacific an extensive system
of 18 hospitals and 69 clinics providing primary and specialty care to about

500,000 beneficiaries in over 100 countries. DOD spends about $1.1 billion
annually to staff, operate, and maintain these overseas MTFs. Most
beneficiaries live near MTFs and receive their care from military
physicians, although host nation providers and facilities are also used to
augment MTF resources. In Europe, MTFs have developed formal networks of
English- speaking host nation providers to serve as referral specialists. In
the Pacific, MTFs have traditionally used less local care and have not
developed formal provider networks. Pacific MTFs, more so than those in
Europe, rely on transporting patients between MTFs for specialty care.
Beneficiaries living in remote areas hundreds of miles from MTFs,
particularly in the Pacific, provide DOD a major care challenge. For such
beneficiaries, DOD relies on various care sources, including Department of
State health clinics and local health care, as well as on transporting
patients to distant MTFs. Also, to improve services in the Pacific remote
areas, DOD recently hired a contractor to arrange for and manage the care of
beneficiaries living there. DOD and the remote beneficiaries have given high
ratings to this contractor's services.

To ensure host nation provider quality, DOD relies primarily on each
country's licensing and credentialing requirements, as well as on limited
inspections and monitoring by U. S. military physicians. Differences in
language, culture, and health care practices between the United States and
the Europe and Pacific Regions at times can cause frustrations and
inconveniences for beneficiaries using host nation care. Patient liaisons
play a key role in helping beneficiaries deal with these barriers, serving
as intermediaries between the MTFs and the host nation. Using MTF and local
providers, DOD has generally been able to ensure timely access to both
primary and specialty care for overseas beneficiaries. However, MTFprovided
specialty care is not always available within the 4- week TRICARE access
standard, and local specialty providers are not available in all areas.

The medical systems in Europe and the Pacific face continuing challenges.
DOD believes that the aircraft serving the aeromedical evacuation system,
critical for ensuring access to specialty care in each region, may need to
be replaced, at considerable cost. Also, DOD officials told us that the
services' medical screening process for active duty family members does not
always identify individuals with significant health problems. Moreover, DOD
civilians assigned overseas are often not screened at all. As a result,
individuals with complex, recurring medical needs are sometimes assigned

overseas where local MTFs cannot provide the needed care and local care is
unavailable or unreliable. Beneficiaries also expressed concerns about the
portability of their TRICARE benefits from region to region, particularly
citing difficulties they face in obtaining health care when temporarily
visiting the United States.

DOD is now seeking to expand local care options in some overseas locations
and has begun reviewing alternatives for its aeromedical evacuation needs.
DOD officials also told us that they plan to review concerns about overseas
screening and benefit portability. We are recommending that DOD complete
these actions to improve overseas health care for its beneficiaries. DOD
agrees with our findings and recommendations.

Background Most DOD health care beneficiaries in Europe and the Pacific are
active duty personnel and their family members, and they are usually
stationed

near a military hospital or clinic. MTFs also provide care on a
spaceavailable basis 4 to thousands of military retirees and their family
members living abroad. U. S. government civilian and DOD contractor
employees, along with their dependents, can register in the Defense
Eligibility and Enrollment System and receive space- available care at rates
established by DOD. Table 1 shows the estimated number and type of
beneficiaries in Europe and the Pacific in fiscal year 1999.

4 Under the terms of the Dependents' Medical Care Act, enacted in 1956, DOD
has the authority to provide retirees of any age health care in its medical
facilities as long as space and resources are available. This is referred to
as “space- available” care.

Table 1: Estimated Number of Beneficiaries by Category in Europe and the
Pacific, FY 1999

Beneficiary category Europe Pacific Total

Active duty personnel 110, 000 96, 534 206, 534

Active duty family members 143, 500 59, 317 202, 817

Retirees and family members 24,427 18, 406 42, 833

U. S. civilian employees, DOD contractors, and dependents 27,415 12, 500 39,
915

Total 305, 342 186, 757 492, 099

Source: TRICARE Europe and TRICARE Pacific Lead Agents.

DOD's managed care program, TRICARE, offers two benefit options- Prime and
Standard- for active duty personnel and their families living overseas in
military communities that have MTFs. Under TRICARE Prime, beneficiaries
receive cost- free MTF care supplemented, as needed, by a civilian host
nation provider network. Prime enrollees are assigned to a local MTF
physician who, serving as primary care manager, oversees their care and
authorizes referrals for specialty care. Prime beneficiaries are not billed
for specialty care obtained from network physicians. Rather, DOD pays for
all such services. TRICARE Prime is mandatory for active duty personnel
assigned to the TRICARE Europe and TRICARE Pacific Regions, and optional for
their accompanying family members. According to the Lead Agents, about 90
percent of eligible beneficiaries enroll in TRICARE Prime.

Family members choosing not to enroll in TRICARE Prime are automatically
placed in TRICARE Standard, an option that allows beneficiaries to seek
covered care from any MTF or host nation provider. Standard beneficiaries,
however, receive a lower priority for MTF appointments than Prime
beneficiaries do, their host nation care is subject to cost- sharing and
deductibles, and they must often pay for host nation services in full and
wait for reimbursement. Family members who are citizens of the host country
and routinely receive their care through the host nation health care system
often use TRICARE Standard.

Overseas military retirees under age 65 and their family members may not
enroll in TRICARE Prime but are eligible for TRICARE Standard and costfree
MTF care on a space- available basis. Retirees over age 65 may also obtain
cost- free, space- available MTF care, but they are not eligible for TRICARE
Standard and thus are responsible for any host nation care costs they incur.
5 U. S. civilian employees, DOD contractors, and family members of both may
obtain space- available MTF care. These patients, or their insurance plans,
must pay DOD's established rates for these services.

Approximately 23,000 active duty personnel and family members are now
classified as living in remote areas. DOD defines remote areas as being
“over 30 minutes traveling time from an MTF.” Remote sites in
Europe and the Pacific vary greatly in distance from MTFs, availability and
quality of medical services, and beneficiary populations. For example,
several hundred military personnel are based in Australia and Singapore,
where there are no MTFs but where local health care standards are comparable
to those of the United States. In contrast, small numbers of personnel are
stationed in third- world countries where the nearest MTF may be hundreds or
thousands of miles away and the local health care system cannot adequately
provide all needed services.

All remotely located active duty personnel and their family members may
enroll in a modified TRICARE Prime program that entitles them to cost- free
host nation care. Active duty family members in remote locations who choose
not to enroll in this program participate in TRICARE Standard, with its
cost- sharing and deductibles. Military commanders may authorize the
transport of beneficiaries, when care needs exceed local capability, to MTFs
or other acceptable medical facilities elsewhere.

DOD Uses Significant DOD spends about $1. 1 billion annually to provide
health care to

Resources in Europe beneficiaries in Europe and the Pacific. In fiscal year
1999, DOD spent

about $463 million to operate and maintain hospitals and clinics in these
and the Pacific

areas and to transport beneficiaries between facilities for care. In
addition, DOD spent about $609 million to compensate military personnel who
staff the MTFs. Also, over the past 5 years, DOD has committed about $62

5 In the United States, military retirees over age 65 are also ineligible
for TRICARE Prime, but if they are eligible for Medicare, they may use their
Medicare benefits to pay for nonmilitary provider care. However, Medicare is
not available overseas.

million in military construction funds for projects overseas, and another
$249 million for future projects.

Facilities and Funding DOD operates 18 hospitals and 69 clinics in Europe
and the Pacific. Most of these MTFs are located in Germany, Italy, the
United Kingdom, Japan, and

Korea- the countries with the largest U. S. military presence. The Landstuhl
Regional Medical Center in Germany provides many specialty and subspecialty
services not available at other MTFs in the TRICARE Europe Region. In
addition, DOD maintains 10 community hospitals and 41 clinics in Europe and
7 hospitals and 28 clinics in the Pacific. Most beneficiaries live near MTFs
and receive their care from military physicians.

Clinics are staffed to provide primary care and limited specialty care
services to the local military population. Hospitals offer primary care and
a greater variety of specialty care services and usually serve as referral
centers for a large geographic area. Military hospitals overseas typically
maintain a small inpatient capability- often fewer than 50 beds- but are
expandable to accommodate many additional patients in wartime.

Much of the overseas care system's funding is provided through the Defense
Health Program budget, which provides operations and maintenance (O& M)
funding for each service to operate MTFs both in the United States and
overseas. Funding for Europe and Pacific MTFs has remained virtually
constant over the past several years (see fig. 1).

Figure 1: O& M Funding for MTFs in Europe and the Pacific, FY 1995- 99

Source: Army, Navy, and Air Force Surgeons General.

Salaries for civilian employees are included in the MTF O& M budgets.
Salaries and benefits for military personnel are paid from separate budget
accounts. According to the military services, a total of 11,700 military
personnel were authorized for MTF operations in fiscal year 1999, with an
estimated cost of salaries and benefits of $609 million.

Military Construction In addition to the O& M funds, each service receives
military construction

Funding funds to pay for new facilities and additions to existing facilities
overseas.

During the early 1990s, funding for overseas construction projects was
halted; since 1995, limited funding has again become available: about $62
million (of a total DOD medical construction authorization of $1.3 billion)
has been earmarked for specific medical projects in Europe and the Pacific,
and an additional $249 million has been proposed for projects to be
initiated during the next 7 years.

Aeromedical Evacuation Both Europe and the Pacific rely on the aeromedical
evacuation system to

Funding move patients to obtain care not locally available and to provide
emergency

transportation for critical patients. Although the system's primary mission
is to move combat zone casualties to fixed or field hospitals as needed, the
routine peacetime movement of patients is used, to some extent, to train
personnel for readiness purposes.

The Air Force has stationed one squadron of C- 9 evacuation aircraft at
Yokota Air Base in Japan and another squadron at Ramstein Air Base in
Germany. These aircraft fly regular routes between military communities
throughout Europe, the Middle East, and the western Pacific. In many cases,
patients are flown from locations served by a clinic to receive specialty
care at one of the region's military hospitals. In fiscal year 1999, the two
overseas C- 9 squadrons received about $12 million in O& M funds. An
additional $22 million was required to pay the military personnel carrying
out the aeromedical evacuation activities in Germany and Japan.

DOD Has Formalized DOD has traditionally relied on some local health care to
supplement MTF

Local Care Use care overseas, and with TRICARE's introduction has expanded
and

formalized host nation provider use. MTFs in Europe have established formal
host nation provider networks that serve TRICARE Prime beneficiaries and
bill DOD's claims processor, not the beneficiaries. In contrast, TRICARE
Pacific, because of cultural differences, concerns about local provider
quality, and other factors, uses less local care, and MTFs there have not
developed provider networks.

For remote beneficiaries, TRICARE Europe often relies on the Department of
State to provide care through embassy or consulate clinics or to recommend
local physicians. TRICARE Pacific relies on State Department resources to
some extent but also uses a contractor to arrange health care for many
remote beneficiaries. Air evacuation is used routinely to move patients
between MTFs for specialty care, and in medical emergencies evacuation
aircraft can be dispatched to assist beneficiaries almost anywhere in the
world.

Europe Host Nation For years, DOD has used local providers in Europe to
augment MTF care.

Network Supplements MTF In many areas, long- term relationships have
developed among local

Care military communities, MTFs, and local physicians and hospitals. The
local

providers have offered mainly specialty, emergency, and inpatient care to

active duty family members under DOD's old Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS) program. 6 According to Lead
Agent officials, local providers have helped ensure that patients can be
treated near their homes, have cut down on waiting times for specialty care,
and have allowed patients with access to only a military outpatient clinic
to receive inpatient services without being transported to another MTF.

In 1995, MTFs began entering into written agreements, or memorandums of
understanding, with public and private health care providers and thus
developed a formal provider network to supplement MTF care. Individual
physicians or entire hospitals can be included under the agreements, which
generally define the conditions for providing services to DOD beneficiaries.
Network providers agree not to request payment from U. S. beneficiaries at
the time of the visit and instead to submit their bills directly to DOD for
payment. The memorandums of understanding require that network physicians be
licensed to practice medicine in their host country and that providers or
their staff be able to communicate in English and maintain medical records
for inclusion in patients' permanent files.

During fiscal year 1999, TRICARE Europe had approximately 750 agreements
with providers and facilities. Most network providers are located in
Germany, the United Kingdom, and Italy, with smaller networks serving the
smaller military populations of The Netherlands, Turkey, Spain, Portugal,
and other locations throughout the region. Host nation physicians provide a
significant portion of both inpatient and outpatient care received by
TRICARE Europe beneficiaries. In 1998, for example, host nation providers
conducted over 200,000 outpatient visits with U. S. beneficiaries (about 10
percent of the region's total medical visits), and host nation facilities
treated 12,300 inpatients (about 43 percent of all inpatient stays for the
year). According to the TRICARE Europe Lead Agent, about $41.7 million was
paid to host nation providers in fiscal year 1999.

Europe Lead Agent officials and military physicians told us they were
generally satisfied with the host nation physicians' care. Nevertheless, DOD
officials noted that differences in language and health care practices in

6 CHAMPUS was an insurance- like program administered by DOD that paid for a
portion of the care military families and retirees under age 65 received
from private sector health care providers. The benefits available under
CHAMPUS were essentially the same as under TRICARE Standard.

some European countries occasionally caused frustrations and inconveniences
for beneficiaries. Examples follow.

The memorandums of understanding require that providers communicate with
beneficiaries in English. However, in Turkey and Italy, and to a lesser
extent in Germany, nurses and administrative staff do not speak English, and
the fluency of the doctors varies. This language barrier can make it
difficult for patients to discuss their medical problems with host nation
personnel. Also, patients expressed concerns about translation- especially
that medical terms might not be translated accurately. Conservative hospital
admissions practices and long stays are issues in

some countries we visited. For example, the way Italians practice medicine
is characterized by more inpatient admissions, longer hospital stays, and
greater use of prescribed rest for injuries and illness. According to an MTF
physician, many of the local Italian hospitals' inpatients would not have
been admitted to an MTF as inpatients. He told us, for example, that
patients who visit the local hospital on weekends or after MTF hours with
various aches and pains are often admitted for observation rather than sent
home with a prescription. Once in the hospital, patients tend to stay longer
than in the U. S. system. Also, routine diagnostic work at the local Italian
hospital can be completed only Monday through Friday, so patients are often
kept over the weekend for procedures such as ultrasound or other diagnostic
tests that would be done on an outpatient basis in the United States. We
were told that as a result, MTF staff occasionally go to the local hospital
to discharge DOD patients who would otherwise be kept longer by Italian
physicians. In Europe, physicians are not used to patients who ask questions
about

their diagnoses or treatment plans. In the United States, the opposite is
often true: U. S. patients tend to be more involved in their treatment and
often ask questions about treatment strategies, procedures, and expected
outcomes. As a result, American military patients can become frustrated at
times with the more reserved attitude of host nation physicians.

Patient liaisons play a key role in helping beneficiaries deal with these
language and cultural barriers, serving as intermediaries between the MTF
and the host nation medical community. Liaisons assist beneficiaries by
providing information about host nation care, making host nation
appointments, and serving as translators. In some cases, liaisons also
accompany patients to appointments and handle health care claims and

billing. At the MTFs we visited, the most effective liaisons spoke the local
language, had completed some health- related training, and were familiar
with the local and the DOD medical systems. For example, at the MTF in
Vicenza, a U. S. doctor who spoke Italian and had been trained at an Italian
medical school served as the primary liaison with the medical community. In
some locations, liaisons had no health- related training and were not always
comfortable discussing complex medical situations with patients.

Host nation providers we interviewed generally were pleased to be included
in the networks, and many had made special efforts to accommodate DOD
beneficiaries. For example, a network dermatologist in Italy set aside
certain hours during the week for DOD patient appointments to ensure that
access would not be a problem. Also, an Italian hospital in Vicenza now
routinely provides U. S. patients epidural anesthesia during childbirth,
which is not the usual practice in Italy. After delivery, U. S. patients are
allowed to stay in the same room with their babies, another adjustment made
by the hospital.

In the United Kingdom, local providers have entered into agreements with DOD
to allow beneficiaries to bypass the often- lengthy waits for specialty care
in the British health care system. Also, a local network hospital in Turkey
provides DOD patients special, larger private rooms that have Western- style
accommodations, such as refrigerators and cable television. At a German
hospital used frequently by U. S. beneficiaries, an Englishspeaking liaison
meets regularly with patients to assist them as needed. Host nation doctors
in the European network told us they like treating U. S. patients and are
willing to treat more of them. However, some providers told us they would
prefer more feedback from MTF staff and patients about their clinical
treatment of, and interaction with, U. S. patients. Lead Agent officials
told us they plan to seek ways to increase communication between host nation
physicians and MTF staff to help ensure the local provider networks'
continued success.

According to Lead Agent officials, the local provider network is continuing
to evolve. In some areas, MTFs had recruited more local physicians than were
needed, and some physicians who were little used by beneficiaries have been
dropped from the network. In other areas, MTF commanders are seeking
additional local providers to augment MTF specialty care. For example, at
Incirlik, Turkey, the MTF is exploring the possibility of using additional
specialists at the local hospital to improve access for its beneficiaries.

Beneficiaries we met with who had used local care were generally satisfied
with the care they received. Some told us, however, they would choose to
wait for an MTF appointment or travel to an alternative MTF because they
were generally less comfortable with host nation care. In fiscal year 1999,
the aeromedical evacuation system in Europe moved about 12, 000 patients to
MTFs for specialty care. Patients were typically flown to the nearest MTF
offering the needed specialty. Those patients needing more extensive
services than are available at MTFs in Europe are usually transported to U.
S. MTFs via scheduled C- 141 flights from Ramstein Air Base, Germany.

Pacific MTFs Use Host MTFs in the Pacific- particularly Japan and Korea,
where most MTFs and

Nation Care Less Frequently beneficiaries are located- have no formal
networks and use much less host

nation health care than in Europe. Pacific Lead Agent officials told us that
differences in host nation medical practices have minimized patient
referrals to local national providers. Examples of obstacles to local care
use include the following:

MTF officials told us that because no consistent standards exist for
hospital accreditation in the Pacific, officials cannot readily obtain
independent reviews of host nation facilities. And, although Japanese
hospitals were thought to provide good care in many medical areas, MTF
physicians told us they had concerns about the long hospital stays, routine
inpatient admission of noncritical cases, and outdated medical practices
that often preclude aggressive early intervention. Regarding Korea, MTF
officials told us that while quality of care has improved over the years,
few facilities exist there that can offer care that meets U. S. standards.
In both Japan and Korea, only a limited number of physicians speak

English well enough to communicate without difficulty with American
patients. Even when physicians can speak English, the nurses and other
support staff usually cannot. Beneficiaries also told us that Japanese
doctors normally do not explain diagnoses or treatment options and expect
not to be questioned. Also, Japanese and Korean nursing care is
significantly different than in the United States: patients' families
normally provide sheets, towels, and toiletries and stay with and otherwise
assist patients during hospitalizations. Also, beneficiaries expressed
concerns about the comfort of local facilities and the native foods served
there. Unlike in Europe, written agreements used to formalize health care

policies are not culturally accepted in Japan and Korea. While MTFs often
have verbal agreements for certain services- usually for

emergency situations or specialized diagnostics- local facilities have been
reluctant to formalize such agreements in written documents. Host nation
providers and facilities in Japan and Korea typically require

payment prior to care or before the patient leaves the treatment area.
According to Lead Agent officials, the Japanese particularly do not tolerate
claims delays. In some areas, goodwill with local providers has eroded as
patients have left the host nation without paying what they owe local
providers. Some civilian facilities have banned DOD beneficiaries from
access unless cash is received in advance.

Thus, in the Pacific, DOD uses minimal host nation care and largely depends
on MTFs and the aeromedical evacuation system to move patients between
facilities for specialty care. In fiscal year 1999, for example, the
aeromedical evacuation system transported about 5,400 patients in the
Pacific Region. About 3,600 traveled to other MTFs for treatment, while
another 1, 800 were returned via C- 141 flights to Hawaii or other U. S.
locations for care. Host nation facilities were used primarily for emergency
cases in which patients could not be moved without risk and for diagnostic
tests not available at the MTF. The Pacific Lead Agent reported that only
$3. 7 million (about $20 per beneficiary) was paid to host nation providers
in fiscal year 1999, compared with $41. 7 million (about $150 per
beneficiary) in Europe.

Nevertheless, MTFs in Korea have recently begun increasing their efforts to
identify qualified local providers and establish working relations with
them. Military physicians from the Army's 18th Medical Command in Seoul have
inspected local hospitals in an attempt to determine which of their services
are adequate and appropriate for DOD beneficiaries. The Medical Command has
developed an agreement that outlines U. S. expectations- English- speaking
staff, 24- hour translation services, private rooms, and fulltime nursing
care- and makes clear DOD's intent to promptly pay for services for active
duty personnel. However, Korean hospitals have not yet agreed to change
their billing practices and continue to bill family members directly. Thus,
local care users have to make payments up front and await DOD reimbursement.
7

7 According to DOD officials, MTFs in the Pacific have developed informal
arrangements with some local providers to ensure that MTFs, and not
beneficiaries, are billed for medical services.

MTFs in Korea have also acted to encourage beneficiaries to use local
facilities for services not available at the MTF. For example, the Army's
121st General Hospital now provides a shuttle to take patients, accompanied
by a translator when needed, from the MTF to host nation facilities.
Similarly, Osan Air Base now ensures that a patient liaison is available to
greet beneficiaries arriving at local hospitals and assist with health care
claims. According to the hospital's commander, the greater use of local
resources will (1) improve access to specialty care for patients and (2)
reduce the burdens created for patients and military units when
beneficiaries require extended absences to obtain treatment at other MTFs.

Remote Locations Rely on Beneficiaries living at remote sites hundreds of
miles from MTFs provide a

Varied Health Care Support significant challenge for DOD's overseas health
system. DOD has an

obligation to ensure that such beneficiaries have adequate access to quality
health care. To do so, DOD uses Department of State health resources, local
health care, and contractor- provided services. DOD also transports patients
to distant MTFs. Under a modified TRICARE Prime program, DOD pays for
medical services that remote beneficiaries receive from host nation
providers.

State Department Assists According to the Europe Lead Agent, there are about
20, 000 remote

Remote Beneficiaries in Europe, beneficiaries in Europe, Africa, and the
Middle East who do not have ready

Africa, and the Middle East access to an MTF for care. Many of these
beneficiaries rely primarily on the

State Department to provide or help arrange their medical care. The Lead
Agent advises remote area beneficiaries to contact the nearest U. S. embassy
or consulate for a list of local providers who meet U. S. medical standards
and have a history of providing quality care. In some cases, DOD
beneficiaries are stationed at or near embassies or consulates that operate
small primary care clinics staffed by U. S. medical personnel. DOD units in
these locations can pay a per- capita fee to provide their personnel access
to the clinic.

For specialty care in remote areas, State Department staff usually refer
beneficiaries to an informal network of host nation practitioners who have
favorable reputations. The State Department does not have contractual
agreements with local providers and does not specifically seek to engage
providers who will forgo advance payment for health care. Instead, patients
that State refers for local care are responsible for their own payment
arrangements and may need to pay for host nation care when they receive it.
Then beneficiaries can file a claim for reimbursement from TRICARE.

In Ankara, Turkey, for example, the 210 assigned DOD beneficiaries can
receive care from the U. S. Embassy clinic staffed by a U. S. nurse
practitioner and two locally hired bilingual nurses. A State Department
regional medical officer, a physician based in Vienna, makes 3- day visits
to the clinic about every 4 to 5 months. Most beneficiaries are not willing
to seek primary care from local Turkish providers, and several told us they
appreciate having U. S. medical personnel available for them. The nurse
practitioner has made office visits to the local specialty care providers
she uses for referrals. She has determined that these providers can speak
acceptable English and most have some U. S. training. The nurse practitioner
acts as gatekeeper and case manager to the extent possible for patients
referred to Turkish doctors. She gives patients a form to use to provide
feedback on local care, and patients are reporting positive results from the
visits she has referred thus far. In most cases, one of the clinic's nurses
accompanies patients to appointments primarily for translation purposes.

In January 2000, TRICARE Europe officials met with State Department medical
personnel to obtain a better understanding of State operations, share
information, and find areas in which to work together to enhance
effectiveness. For example, they discussed procedures for increased
cooperation regarding physician referrals in Europe. According to the Europe
Lead Agent Office, the State Department's processes for evaluating referral
physicians are similar though not identical to those used by MTFs for the
provider network.

Contractor and State As in Europe, much of the Pacific Region's remote area
beneficiary care

Department Assist Beneficiaries traditionally has been provided by or
arranged through the State

in Remote Pacific Department. However, problems such as the frequent
unavailability of

regional medical officers due to their travel to cover other areas, and the
up- front payment local providers require of beneficiaries, led the Pacific
Region to hire a contractor to supplement State's role.

In 1998, DOD contracted with International SOS 8 to provide a managed health
care option for active duty personnel and their family members stationed in
the Pacific Region's remote areas where MTF care is not available. For each
remote site, SOS developed networks of licensed

8 International SOS provides emergency assistance, medical services, and
management of the delivery of health care to corporate travelers and
multinational organizations outside their home country.

English- speaking physicians for primary and specialty care. Each network
physician must agree not to charge DOD patients at the time of service;
rather, SOS guarantees providers their payment and gets reimbursed by DOD
for covered services. Beneficiaries may schedule their own primary care
appointments with network physicians. For specialty care, however,
beneficiaries must obtain an SOS authorization and use an SOS specialist.
SOS also staffs 24- hour toll- free call centers to assist beneficiaries in
arranging health care and with any emergencies that may arise.

DOD beneficiaries we interviewed expressed high overall satisfaction with
SOS' health care operations, adding that SOS and its contractor network were
highly responsive to their health care needs. For example, in Singapore, SOS
arranged to have a local doctor practice at a small clinic located near the
military's primary housing area, and specialty care is available in
Singapore within 24 hours. Also, Singapore network providers speak English,
most specialists are trained in Western countries, and patient care is
similar to that in the United States.

In Bangkok, DOD officials told us that many public hospitals are crowded and
not up to U. S. standards, but that beneficiaries are very pleased with the
SOS network private hospitals' quality. At these facilities, many physicians
and nurses are U. S.- trained, English- speaking, and accommodating to U. S.
patients' needs. Nursing care is generally good, and medical education
standards are high. Beneficiaries told us that when they first arrived in
Bangkok, they were reluctant to use local care; however, after using local
providers, they had confidence in the local care available through the
network. Also, beneficiaries told us they had no problems obtaining primary
care appointments and no language difficulties with network doctors. They
told us that their visits went smoothly and that the paperwork was handled
properly.

Although SOS regional call centers have the primary role of coordination,
the Bangkok and Singapore DOD remote unit staff also help beneficiaries
access care. For example, in Singapore, DOD has an active duty medic to help
coordinate local care. In Bangkok, the Pacific Lead Agent hired local health
benefits advisors, including a local nurse with a long history of working
with the U. S. military and a sound grasp of the local care options, the
military health care system, and beneficiary concerns. Some of these staff
have duties that replicate SOS contract responsibilities- for example, the
medic is also on call 24 hours a day. Nonetheless, beneficiaries clearly

appreciated the health care assistance and coordination options available to
them while stationed in these foreign countries.

The SOS contract has complicated DOD's health care relationship with the
Department of State. Currently, the SOS contract covers all DOD
beneficiaries stationed in the Pacific areas without MTF access. In places
where military personnel are stationed at or near U. S. embassies,
individual military units can decide whether to continue using State
Department health clinics or to rely on SOS network physicians for their
care. In Singapore, for example, all DOD units have withdrawn from the State
Department system, and the SOS network provides all local care. In Bangkok,
one DOD unit has withdrawn from the State- sponsored health program, 9 but
other DOD beneficiaries may still use the embassy clinic.

Remote Beneficiaries Can Travel In addition to host nation and State
Department care, DOD beneficiaries in

to MTFs remote areas can sometimes arrange travel to MTFs elsewhere for
care.

Consistent with each service's guidance, military commanders may authorize
patient transport to MTFs when beneficiaries need care that is beyond local
capabilities. For routine care, military beneficiaries often arrange medical
appointments to coincide with planned leave or official travel to MTF
locations. In some areas, beneficiaries can travel via military aircraft
that stop at their remote duty station. In other cases, travel via
commercial carriers is authorized. In life- threatening medical emergencies,
DOD can dispatch a medical evacuation aircraft to move a patient from a
remote site to an MTF.

DOD and State Rely on The TRICARE Europe and Pacific regions cover large
geographic areas,

Local Standards and and countries and local areas differ in their provider
and facility quality

standards. To determine network physician and facility qualifications, DOD
Patient Feedback to

generally relies on local certification and licensing practices, which vary
Ensure Quality of Care

from country to country. DOD's monitoring of local patient care varies, and
the level of scrutiny is often based on overall confidence in the host
nation's medical system. For remote locations, DOD relies primarily on the
State Department and SOS to ensure that beneficiaries are referred to
competent providers.

9 Because the operating costs of the consulate and embassy health clinics
are shared among participating agencies, the decision by DOD units to
withdraw increases the amount paid by the State Department and other U. S.
government agencies operating out of the U. S. mission.

MTFs Provide Limited In Europe, both the Lead Agent and MTF commanders are
responsible for

Oversight of Local Health ensuring that doctors brought into the provider
network can deliver

Care acceptable care. Before allowing local providers into the network, the
MTF

commander verifies that the providers are licensed to practice in the
country and requests other documentation on their specialty training.
Providers joining the network must provide to the MTF commander copies of
their educational degree( s); medical credentials, including licenses,
registration, and other certification; work history for the last 10 years;
and any history of adverse action taken against them regarding clinical
privileges or any other disciplinary action.

According to the TRICARE Europe Lead Agent, in many areas of Europe, medical
care systems are comparable to the U. S. medical system. In the United
Kingdom, for example, medical facilities are accredited, and specialists
receive rigorous training prior to being licensed for independent medical
practice. Germany has similar training and licensing requirements for
specialists, and in northern Italy, the health care quality and technology
available are comparable to those in the United States. Many local
physicians have received specialty training in the United States or
participated in exchange programs and are familiar with U. S. care
standards. Thus, DOD makes frequent use of local care in these areas.

According to DOD and State Department officials, however, the medical
systems in some parts of Europe, the Middle East, and Africa often lack
processes for ensuring care that meets U. S. quality standards. In these
areas, medical facilities sometimes lack competent clinical nursing staff
and do not always have effective quality control procedures to assure U. S.
medical personnel that the health care meets U. S. standards. In some cases,
physicians are not licensed, and continuing education is not required;
therefore, assessing physician qualifications is particularly difficult. In
addition, according to MTF physicians, local hospitals do not always use the
most stringent sterilization and quality control techniques. As a result,
DOD uses local care in these areas much less often.

Once local providers and facilities enter the TRICARE Europe network, the
extent of MTF monitoring of their care delivery generally reflects the MTF
commanders' confidence in the local quality of care. For example, in the
United Kingdom, Germany, and northern Italy, much of the care provided to U.
S. beneficiaries is not closely monitored. In most cases, MTF staff review
local providers' reports of treatment results to ensure the care is
appropriate. In other areas, where managers are more wary of the local

care, MTF staff make more frequent visits to hospitalized patients and more
closely scrutinize the care provided.

MTFs in Europe are also required to obtain beneficiary feedback on local
care. According to Europe Lead Agent officials, providers who do not meet
DOD expectations and receive poor patient appraisals are reevaluated and, if
necessary, dropped from the network. These officials told us that while MTFs
do not receive much feedback, what they do receive is generally favorable.
Europe Lead Agent officials told us they have dropped two network providers
since 1997 because of beneficiary feedback that identified inadequate
treatment.

In the Pacific, where MTFs have no formal host nation provider networks, MTF
commanders and their staffs have sought to develop and cultivate
relationships with local providers and facilities and have done so over time
by making occasional site visits to facilities. MTF officials are more
confident of Japanese providers and facilities than they are of Korean
health care. In the relatively few cases when local facilities are used, MTF
staff monitor the care by maintaining liaison with the attending physician,
visiting inpatients, and reviewing treatment results. Mindful of the
normally longer hospital stays in these countries, MTF staff act to remove
inpatients from local hospitals and transfer them to MTFs as soon as is
medically possible.

Various Sources Ensure In remote locations, the Department of State provides
guidance to embassy

Quality of Local Health Care and consulate medical units on how to assess
providers and facilities, but

in Remote Areas implementation of this guidance is not consistent. According
to State

Department health officials, each post is responsible for assessing its
country's health care resources and identifying competent local providers to
provide care. These officials told us that each embassy or consulate health
unit should request a provider's medical license and credentials and
maintain patient feedback on each provider. For hospitals, State staff
should also perform a facility evaluation that addresses the facility's
location, capacity, services offered, hours of operation, and equipment, as
well as the credentials of its nurses. Providers and health care facilities
are to be reviewed every 2 years, but State Department officials told us
that this is not necessarily done at each location. State is currently
developing an electronic database of provider and country profiles that
should help ensure more consistent data for each of its overseas locations.

For DOD beneficiaries in remote Pacific areas, SOS assesses the quality of
its primary and specialty care provider network by reviewing providers'
credentials and conducting facility inspections. The SOS contract requires
that the medical practice quality for network physicians and facilities meet
or exceed reasonable care standards as determined by the local licensing and
oversight authorities. Network physicians must also meet the credentialing
requirements set forth in the contract; for example, they must have
graduated from an approved medical school, have completed a residency
program, and be licensed to practice medicine in the host country. The
contract encourages SOS to recruit physicians who follow medical standards
similar to those of the United States or other developed countries.

The contract also requires SOS to continuously monitor the provider network.
Monitoring activities must include verification of the availability of
network providers and their adherence to contract requirements, as well as
investigation and resolution of specific provider and beneficiary complaints
or concerns. SOS also reviews and approves all specialty care referrals to
ensure that recommended treatments are both medically sound and reimbursable
under TRICARE.

TRICARE Overseas With the implementation of TRICARE overseas and the
increased use of

Has Improved host nation care to augment MTF care, beneficiaries have better
access to

medical care. At the MTFs we visited, patients and hospital administrators
Beneficiary Access to

told us that most appointments meet the TRICARE access standards Care

governing waiting times for scheduled appointments. The most recent
appointment data show that most primary care clinics at the facilities we
visited have appointments available to be booked. MTF specialty care
appointments are not always available within the TRICARE access standard,
but MTF staff told us that referrals made to local providers, especially for
active duty family members in Europe, help eliminate appointment delays.

DOD Meets Access Access to medical care has improved since we reported on
overseas health

Standards for Most Primary care in 1990 10 and 1995. 11 In our previous
work, we found that beneficiaries,

Care Appointments especially non- active- duty patients, often faced long
waiting times and

significant air or ground travel for routine appointments and surgeries. To
help ensure timely access to care, DOD established appointment timeliness
standards for TRICARE Prime enrollees similar to the standards used in
private sector managed care programs. The standards were made applicable to
the overseas regions in 1997 with TRICARE's implementation and can be met by
using either MTF or local civilian care. The primary care standards are a
wait of no longer than 1 day for urgent care, 1 week for routine care, and 4
weeks for a wellness visit. The standard for specialty care referrals is 4
weeks.

At the MTFs we visited in Europe and the Pacific, MTF staff and TRICARE
Prime beneficiaries told us that most primary care appointments took place
within the TRICARE access standards. The available appointment data for the
MTFs we visited confirmed that most primary care clinics had sameday
appointments available for patients who needed urgent care. Even when all
same- day appointments are filled, MTF doctors told us, urgent care patients
are treated, regardless of whether this requires working extended duty
hours. For routine care and wellness visits, the data confirmed that most
clinics had appointments available within the 1- week and 4- week standards.
In a few of the busier primary care clinics, however, the data showed that
routine and wellness appointments were not available within the access
standards.

MTF staff and beneficiaries also told us that most of the time specialty
care appointments took place within the 4- week access standard, usually in
the MTF specialty clinic. However, for some MTF specialty clinics, the most
recent data showed few appointments available for new patients during the
next 4- week period. In addition, some specialty clinics occasionally place
restrictions on access for some beneficiary groups. For example, for
capacity reasons, the otolaryngology, orthopedic, and podiatry clinics at
the Landstuhl Regional Medical Center at times treat only active duty
patients, so family members and others are referred to host nation
providers. Also, appointments at Landstuhl's orthopedic clinic have been
booked as much as 48 days in advance, and the waiting lists have grown

10 GAO/ T- HRD- 90- 20, Mar. 29, 1990. 11 GAO/ HEHS- 95- 156, July 12, 1995.

lengthy. Pacific Lead Agent officials also reported occasional problems with
long waits for specialty care in Pacific MTFs, especially in highdemand
areas such as orthopedics.

In Europe, efforts to establish a host nation provider network have improved
overall access to specialty care for beneficiaries. According to TRICARE
policy, when MTF specialty clinics cannot offer patients appointments within
the 4- week access standard, beneficiaries should be offered a referral to
the host nation network. Beneficiaries in Europe told us they generally had
adequate access to local providers in those cases when MTF specialty care
was not available. Nonetheless, some patients prefer to wait for an MTF
appointment instead of using the host nation network, thus waiving their
right to an appointment within the access standards.

In the remote areas we visited, beneficiaries told us that primary care
doctors were readily available for appointments. In the Pacific, we were
told that SOS quickly reviewed and approved referrals to specialists so that
these appointments could also be completed within the DOD access standards.

Overseas Health Care DOD's overseas medical system faces continued
challenges as DOD seeks

Faces Challenges to maintain access to care for beneficiaries. The
aeromedical evacuation

system is critical for ensuring access to specialty care in each region, and
the system's aircraft need to be replaced, at considerable cost. Also, DOD
officials told us that the services' medical screening process for family
members of active duty personnel assigned overseas does not always identify
individuals with significant health problems and that DOD civilians often
are not screened at all. As a result, individuals with complex, recurring
medical needs are being assigned overseas where local MTFs cannot provide
the needed care. In addition, overseas beneficiaries complained to us about
accessing health care benefits when traveling in the United States.

Aging Aeromedical Aircraft According to a recent Air Force study, the fleet
of dedicated C- 9s currently being used for aeromedical evacuation within
the regions needs to be replaced. According to the study, the C- 9s' future
is being called into question for numerous reasons:

the aging C- 9s are experiencing corrosion problems, particularly the C- 9
squadron in the Pacific, and have an uncertain remaining service life; the
C- 9s do not comply with U. S. and international aircraft noise

restrictions; and the C- 9s do not meet all Global Air Traffic Management
requirements for

improved communications, guidance, and surveillance systems. Also, the C- 9s
have a limited flying range that is especially problematic in the Pacific,
where distances are considerable and there are few alternate airfields on
overwater routes. According to the Air Force study, C- 9s do not have
sufficient range to meet all regional patient movement requirements without
refueling, and frequent fuel stops can be detrimental to patients. Seasonal
winds also play a large role in planning routes for patient movement.

Further complicating the situation, the C- 141 fleet- which currently moves
most patients between the overseas regions and U. S. MTFs- is undergoing
retirement, which is scheduled for completion in fiscal year 2006.
Breakdowns by aging C- 141s cause frequent delays on flights to and from the
overseas regions. For example, Air Force officials told us that during
fiscal year 1999, 25 percent of C- 141 missions returning from Europe were
delayed 24 hours or more because of breakdowns.

In response to these challenges, the Air Force undertook an analysis to
determine which aircraft are best suited to perform aeromedical evacuation
for the next 30 years. After considering eight potential solutions, the
analysis team focused on two preferred alternatives: (1) modifying existing
military transport aircraft to be used for peacetime evacuation missions or
(2) purchasing a dedicated fleet of 737- 700 aircraft, which have sufficient
range to complete all evacuation missions currently performed by C- 9s and
C- 141s. The analysis team noted that patient movement could suffer if
modified aircraft are used, because these aircraft might also be needed to
move cargo and refuel other aircraft. Therefore, the team recommended that
the Air Force purchase a fleet of 737- 700 aircraft, a procurement that
would require several billion dollars.

The Air Force has yet to reach a final decision, and the Lead Agents have
been involved in the assessment of proposed changes to patient movement in
Europe and the Pacific. The Lead Agents recognize that greater use of
commercial aircraft or local health care might be required to ensure that
beneficiaries receive timely care.

Concerns Exist About According to MTF commanders in Europe and the Pacific,
the process for

Overseas Medical Screening screening family members of personnel assigned
overseas does not always

identify individuals with extensive medical requirements. The presence of
such patients overseas can potentially strain MTF resources, increase health
care costs, and reduce readiness and morale.

Each military service has its own screening mechanism to ensure that family
members accompanying active duty troops overseas do not have medical
problems that exceed the capacity of local health care providers. However,
DOD officials told us this medical screening is often inadequate and
sometimes does not take place at all. Officials note that family members
occasionally arrive with serious physical and psychological problems,
requiring continuous follow- up from MTF specialists. In some cases in which
the required care exceeds MTF capabilities, dependents might need extensive
and potentially expensive local treatment, care that must be coordinated and
reviewed by MTF staff. In other cases, patients might be returned to the
United States for care, resulting in additional expense; strain on military
families; and, in some cases, the need for active duty members to take
extensive leave to manage family medical problems. According to DOD
officials, readiness suffers when active duty troops are absent from duty or
distracted by the problems of coordinating care for family members.

In addition, DOD officials told us that currently no requirement exists for
medical screening of DOD civilian employees, contractors, or their families
prior to being selected for an overseas position. According to medical
personnel in Europe and the Pacific, civilian employees and family members
have arrived with serious medical conditions- including chronic heart
disease, spinal bifida, congenital heart deformities, and psychiatric
disorders- that exceeded community health resources. Furthermore, for these
beneficiaries, MTF care is on a space- available basis, and the TRICARE
Management Activity notes that “many civilians have unrealistic
expectations of on- base medical support.” These patients might
require extensive and often costly local care or returning to the United
States for treatment. Civilian employees often perform critical functions
overseas, and coordinating medical care for themselves or their family
members could result in financial hardship, extended leave, and other
strains that could compromise their effectiveness.

DOD officials agree that overseas medical screening needs to be improved,
noting that while the number of individual cases is small, these cases can
create significant problems for MTFs. Officials said that a DOD committee

will review current policies regarding overseas screening for active duty
family members and civilian employees in an effort to improve the process.

Beneficiaries Are Accessing health care while away from their home base has
reportedly

Concerned About TRICARE been a problem for some beneficiaries. In fact,
beneficiaries we spoke with

When They Travel recurrently complained that they have had difficulty
accessing MTF care

when traveling back in the United States. Beneficiaries told us that U. S.
based MTFs have sometimes denied them access to care, referred them to
civilian providers, or demanded authorization from a primary care manager at
the overseas duty station.

According to TRICARE Management Activity officials, DOD beneficiaries are
encouraged to obtain most of their care at their duty station's MTF.
However, TRICARE program guidance states that overseas beneficiaries
enrolled in TRICARE Prime should not be denied care when visiting MTFs in
the United States. Overseas Prime enrollees have the same access priority at
U. S. MTFs as stateside enrollees, and preauthorization from their primary
care manager is not required. TRICARE Management Activity officials
acknowledged that overseas beneficiaries do not always receive uniform
access to MTF care when traveling in the United States. They added that DOD
is planning to develop a new policy letter reinforcing access standards for
all enrollees and emphasizing the commitment to provide services to overseas
personnel traveling outside their home region.

Conclusions The military health care system in Europe and the Pacific has
undergone considerable downsizing during the past decade and continues to
face

operational challenges. Yet the system appears to have largely overcome the
extensive access to care and other problems we reported in 1990 and 1995 and
generally to be satisfactorily caring for beneficiaries. Nevertheless,
routine and specialty care at some MTFs is still sometimes unavailable
within the TRICARE access standards, resulting in care delays for some
beneficiaries.

Host nation care options help MTFs meet TRICARE access standards for
specialty care and allow beneficiaries to be treated nearer their duty
stations and their families, reducing the stress and extra costs that can be
associated with the transport of patients between MTFs. Bilingual patient
liaisons play an important role in increasing local care acceptance by
breaking down cultural and language barriers between local doctors and DOD
patients, reassuring patients being treated locally, and otherwise

serving as a reliable link between the military health care system and local
providers. Efforts to expand local care options, such as those under way in
Turkey and Korea, can help improve access to specialty care and should be
extended to other locations where possible.

DOD is currently reviewing aeromedical utilization and options but has not
yet identified the best long- term approach for transporting overseas
patients needing care not available locally. Also, DOD's current screening
process does not always prevent DOD civilians, contractors, or family
members of active duty personnel with complex or chronic medical
requirements from being sent overseas, and some overseas beneficiaries have
had difficulty obtaining health care services when traveling outside their
region.

Recommendations We recommend that the Secretary of Defense direct the
Assistant Secretary of Defense (Health Affairs) to

complete the analysis of aeromedical utilization and implement the best
long- term approach identified for transporting overseas patients needing
care not available locally; improve medical screening policies to help
ensure that beneficiaries

overseas do not have medical problems exceeding the capacity of MTFs or
local health care providers; complete the development of policies
reinforcing standards to ensure

health care access for overseas beneficiaries when they travel outside their
TRICARE regions; and continue working to expand, where possible, the use of
host nation

providers and provide feedback to such providers on the quality of care.
Agency Comments and

We obtained comments on this report from DOD. DOD agreed with our Our
Evaluation

findings and recommendations, acknowledging that while improvements have
been made since our last review of overseas health care, issues requiring
attention remain. DOD said, for example, that it is continuing to evaluate
alternatives to the C- 9 airframe to improve, streamline, and
costeffectively meet the needs of patients needing medical evacuation. Also,
DOD indicated that the medical screening matter is under review and that a
solution will require extensive coordination among the services and with the
medical and personnel communities. DOD also stated that a new policy letter
to help ensure health care access for overseas beneficiaries when

they travel across TRICARE regions is being drafted and will be issued
shortly. Finally, DOD said it would work with the overseas Lead Agents to
expand the use of host nation providers where possible and to implement a
formal feedback mechanism for such providers.

DOD outlined its plans to address our recommendations in its comments, which
appear in the appendix. DOD also provided several technical comments, which
we incorporated into the report as appropriate.

We are sending copies of this report to the Honorable William S. Cohen,
Secretary of Defense; appropriate congressional committees; and other
interested parties. We will also make copies available to others upon
request.

If you or your staff have any questions about this report, please contact me
at (202) 512- 7101 or Daniel M. Brier at (202) 512- 6803. Jon Chasson and
Linda S. Lootens also made key contributions to this report.

Stephen P. Backhus Director, Veterans' Affairs and

Military Health Care Issues

Appendi Appendi xes xI Comments From the Department of Defense

Now on p. 29. Now on p. 29.

Now on p. 29. Now on p. 29.

(101632) Lett er

GAO United States General Accounting Office

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Page 32 GAO/ HEHS- 00- 172 Implementation of TRICARE Overseas

Appendix I

Appendix I Comments From the Department of Defense

Page 33 GAO/ HEHS- 00- 172 Implementation of TRICARE Overseas

Appendix I Comments From the Department of Defense

Page 34 GAO/ HEHS- 00- 172 Implementation of TRICARE Overseas

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