Barriers to Sub-Specialty Care in Military Managed Care

Children with developmental disabilities visit physicians at twice the rate of children without impairments. The most important changes in military health care include the transition into managed care, intended to minimize expense. The medical requirements of children with special health care needs (CSHCN) may offer little incentive for providers to care for them. Thus the potential that managed care organizations may reduce the quality of care for CSHCN and their families is significant to policy makers, providers, and consumers. This study analyzed the TRICARE provider manual and benefits package to determine if referral barriers and exclusion of benefits impede access to pediatric sub-specialty care for military-dependent CSHCN in a managed care environment.

The TRICARE Southwest Health Plan offered three options for active duty military families and retirees, but only TRICARE PRIME provided a Program for People with Disabilities, with a maximum benefit of $1,000 per month, available only to active duty family members. TRICARE PRIME provides other services, including access to any CHAMPUS-authorized civilian provider through a POS option, whereas TRICARE EXTRA and TRICARE STANDARD allow access to network providers only. Retirees in TRICARE PRIME pay an annual enrollment fee. Members have no deductibles unless exercising the POS option, whereas TRICARE EXTRA and TRICARE STANDARD have deductibles and cost-shares based on rank. All three plans have an out-of-pocket expenditure cap (unless members exercise their POS option).

Because of inadequate reimbursement rates, and no risk adjustment or stop-loss protection, providers of care for CSHCN are at financial risk when serving this population. Approximately 40% of charges were adjusted, families were responsible for over 30% of the DDC charges, and 10% of the population referred to the DDC was not registered on DEERS, required for reimbursement. How much of the self-pay amount was written off as not collectible was not determined.

Final Report is available on NTRL: https://ntrl.ntis.gov/NTRL/dashboard/searchResults/titleDetail/PB2007107...