I'm a private practice doc and would love to treat Tricare patients. But I'm blocked out.

[Socrates25]

We have a strong military presence in my area, and we get phone calls every day asking if we accept Tricare. I have been fully credentialed with Tricare since I opened the practice. I want to serve our military families and I'm willing to get paid less to do so. I'm fine with accepting Tricare even though it pays about 40% less than commercial insurances.

But despite my willingness to do so, Tricare has set up insurmountable roadblocks to this:

1. Tricare wont authorize me to see their patients because my office is not on a military base. Problem is that the military base clinic is so overwhelmed that they dont have any capacity to treat their own patient panel as it exists now.

2. Tricare pays pennies on the dollar for vaccines. For example it costs me about $200 per dose to buy prevnar vaccine. Tricare's reimbursement for prevnar, which is an ESSENTIAL vaccine, is only $62.19. If my entire panel was Tricare this under reimbursement would end up costing my practice $215k per year, if tricare is only 25% of my panel that's still a loss of >50k. I'm sorry that's just not feasible.

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[pawprint]

And this is why our model of relying on the civilian healthcare system to treat active duty and dependents isn’t working.

I am in a military heavy area and also have a hard time finding anyone who will take Tricare because of its abysmal reimbursement. Someone thought that sending the work to the civilian sector would be better than training our own people, but come and find out, the civilian sector won’t/can’t even see our patients because we aren’t willing to pay the costs to do so.

Meanwhile our GMO’s with a single year of residency training will be stuck with managing everything complex because no civilian subspecialists will accept our payment.

This only ends when enough people are hurt by this process. Although maybe not, it seems like people up top only care enough until they move on to their next billet.

 

[DrMetal]

1. Tricare wont authorize me to see their patients because my office is not on a military base.

This doesn't make any sense. Of course your civilian office isn't on a military base. Most civilian offices aren't! Are you sure about this? What specialty?

 

[Socrates25]

This doesn't make any sense. Of course your civilian office isn't on a military base. Most civilian offices aren't! Are you sure about this? What specialty?

Correction -- the office is not close enough to a military base. I think they use a 3 mile or 5 mile distance or something arbitrary like that to restrict civilian offices

 

[Chonal Atresia]

We have a strong military presence in my area, and we get phone calls every day asking if we accept Tricare. I have been fully credentialed with Tricare since I opened the practice. I want to serve our military families and I'm willing to get paid less to do so. I'm fine with accepting Tricare even though it pays about 40% less than commercial insurances.

But despite my willingness to do so, Tricare has set up insurmountable roadblocks to this:

1. Tricare wont authorize me to see their patients because my office is not on a military base. Problem is that the military base clinic is so overwhelmed that they dont have any capacity to treat their own patient panel as it exists now.

2. Tricare pays pennies on the dollar for vaccines. For example it costs me about $200 per dose to buy prevnar vaccine. Tricare's reimbursement for prevnar, which is an ESSENTIAL vaccine, is only $62.19. If my entire panel was Tricare this under reimbursement would end up costing my practice $215k per year, if tricare is only 25% of my panel that's still a loss of >50k. I'm sorry that's just not feasible.

Yeah, we call it Tricaid because the reimbursement is a joke. We "accept" Tricare but restrict the number of clinics slots per day to 2. We have a waiting list over 6 months right now for Tricare/Medicaid patients (2-3 weeks for everyone else).

The military base clinics aren't overwhelmed, they simply are institutionalized not to work hard. No private practice (or hospital-employed position for that matter) in the world would survive seeing 10-12 patients per day but that is what these clinics do on a routine basis. It's laziness pure and simple.

 

[pgg]

The military base clinics aren't overwhelmed, they simply are institutionalized not to work hard. No private practice (or hospital-employed position for that matter) in the world would survive seeing 10-12 patients per day but that is what these clinics do on a routine basis. It's laziness pure and simple.

I agree with the effects you describe, but I don't know if I'd call it laziness.

1) They're burdened with many non-clinical time suckers.

2) They don't have any kind of concierge-level service to handle ancillary tasks or support issues. Trivial example: if I had computer problems in the OR while on active duty, usually I had to put in a trouble ticket and wait for help. In private practice, I call the help desk and if they can't fix it on the phone in a couple minutes, some guy would get in a bunny suit and come to the OR to fix it.

3) Support staff is often nonexistent, or undertrained to the point of uselessness. A common phenomenon is that as soon as an E-something gets the hang of their check-in, vital taking, or other preliminary customer service function, they PCS away or get deployed or some SNCO rotates their game piece to another part of the board for cross-training or some other dumb reason.

4) Completely backwards sense of who's supporting who. Every non-clinical department thinks it's the reason the building exists. Another trivial example: at my last Navy command, they moved the scrub machines about 100 yards away from the locker room to make stocking them more convenient for the linen department. (There was also the believable rumor that the DSS directed the move to make it harder for people to "sneak out early" undetected.) At one point, those bitches revoked my scrub card because they determined that I had too many sets checked out at once. I had to go down to the basement and ask some petty tyrant clown to give me scrubs. They also never stocked tall sizes (just XXXL types), because only a few of us tall people weren't morbidly obese, and it wasn't worth the effort to get correctly sized scrubs for us. At my current private practice job, the scrub people ordered tall scrubs for me, keep them separate, and stock my personal locker with them several times per week.

5) "Half a day's work for half a day's pay, crammed into a full day." I wouldn't judge people as "lazy" if they're salaried at a (low) flat rate and don't want to work that hard. In the private practice world, we call lower-paying / lower-hour / low-or-no-call jobs as "mommy track" jobs, and while the label is a little bit derogatory, there really ain't nothing wrong with choosing to earn less so you can work less. There are active duty and contractor people who've made that bargain. That doesn't make them lazy.


I hear what you're saying. I closed out my career as the chief scheduler for our department and the need to assign multiple people to the "give other people breaks so they can get snacks or go to meetings" role every day was like a knife in my spleen. The system inflicts inefficiency. But I rarely felt like the AD people were lazy. The great majority of us desperately wanted to get more OR time and do more cases.

 

[Chonal Atresia]

I agree with the effects you describe, but I don't know if I'd call it laziness.

1) They're burdened with many non-clinical time suckers.

2) They don't have any kind of concierge-level service to handle ancillary tasks or support issues. Trivial example: if I had computer problems in the OR while on active duty, usually I had to put in a trouble ticket and wait for help. In private practice, I call the help desk and if they can't fix it on the phone in a couple minutes, some guy would get in a bunny suit and come to the OR to fix it.

3) Support staff is often nonexistent, or undertrained to the point of uselessness. A common phenomenon is that as soon as an E-something gets the hang of their check-in, vital taking, or other preliminary customer service function, they PCS away or get deployed or some SNCO rotates their game piece to another part of the board for cross-training or some other dumb reason.

4) Completely backwards sense of who's supporting who. Every non-clinical department thinks it's the reason the building exists. Another trivial example: at my last Navy command, they moved the scrub machines about 100 yards away from the locker room to make stocking them more convenient for the linen department. (There was also the believable rumor that the DSS directed the move to make it harder for people to "sneak out early" undetected.) At one point, those bitches revoked my scrub card because they determined that I had too many sets checked out at once. I had to go down to the basement and ask some petty tyrant clown to give me scrubs. They also never stocked tall sizes (just XXXL types), because only a few of us tall people weren't morbidly obese, and it wasn't worth the effort to get correctly sized scrubs for us. At my current private practice job, the scrub people ordered tall scrubs for me, keep them separate, and stock my personal locker with them several times per week.

5) "Half a day's work for half a day's pay, crammed into a full day." I wouldn't judge people as "lazy" if they're salaried at a (low) flat rate and don't want to work that hard. In the private practice world, we call lower-paying / lower-hour / low-or-no-call jobs as "mommy track" jobs, and while the label is a little bit derogatory, there really ain't nothing wrong with choosing to earn less so you can work less. There are active duty and contractor people who've made that bargain. That doesn't make them lazy.


I hear what you're saying. I closed out my career as the chief scheduler for our department and the need to assign multiple people to the "give other people breaks so they can get snacks or go to meetings" role every day was like a knife in my spleen. The system inflicts inefficiency. But I rarely felt like the AD people were lazy. The great majority of us desperately wanted to get more OR time and do more cases.

Point taken….maybe apathy/institutionalization is a better description. I don’t mean apathy toward patient care…I mean apathy toward seeing more patients/working people in.

I am right next door to the largest army post in the country with 4 ENTs. They make no effort to increase volume or even retain active duty soldiers at this point. My staff have to tell Tricare patients who call on the phone complaining about the time it takes to get in to see me that they have two options: 1) pay out of pocket for better insurance or 2) go to another ENT clinic (closest that accepts Tricare is 75 miles away).

 

[militaryPHYS]

Most of the issues mentioned already have working solutions.

Although, OP’s concerns are unfortunately a reality for primary care services. It’s not something that we want to be deferring out. Plus, why would tricare pay more money out in town for the same vaccine that we can give on base?

We are in a primary care shortage across the nation. Current goal is to increase enrollment capacity to maintain as well as bring back services.

 

[backrow]

Most of the issues mentioned already have working solutions.

Although, OP’s concerns are unfortunately a reality for primary care services. It’s not something that we want to be deferring out. Plus, why would tricare pay more money out in town for the same vaccine that we can give on base?

We are in a primary care shortage across the nation. Current goal is to increase enrollment capacity to maintain as well as bring back services.

I think you’re forgetting about Tricare Select.

 

[pawprint]

Most of the issues mentioned already have working solutions.

I wouldn’t say we have working solutions for the OP’s underlying issue. When my nearest GI doctor who takes Tricare is 7 hours away, that’s a problem. Many GI docs in my town, just none of them take Tricare because of issues like the OP mentioned. Access to care is in the toilet right now largely due to insurance coverage, not local specialty availability. The specialists are there, we just don’t pay them enough to see our patients.

My last duty station was a nightmare for finding dependents OB care. Tricare kept assuming that all the civilian family med docs in the area could also function as OB’s, which wasn’t true. I constantly had dependents being late to OB care due to dead end referrals.

And also is pretty sad that we are giving our pregnant dependents the bare minimum for their OB care. “We don’t have any obstetricians around who take our insurance but there’s a guy who learned how to deliver a baby 20 years ago in his residency so just go see him, it’ll be fine and checks the box”. Turns out, that doesn’t work.

Tricare is awful, when I hear people try to encourage folks to join or stay in the military because it’s “free medical insurance for your family”…I cringe. It’s probably the worst insurance out there, and good luck finding folks who will even take it.

 

[militaryPHYS]

There have been lots of issues when they did this transition. Location access to care is highly variable and when on base access also took a hit it created a real problem, especially in more remote areas.

Just saying that these issues have been identified. Definitely won’t be a quick fix

 

[MedicalCorpse]

There have been lots of issues when they did this transition...

Just saying that these issues have been identified. Definitely won’t be a quick fix

Bottom Line Up Front (BLUF): Identifying the issues means nothing.

No one in power wants to fix things. That would cost money.

We've known about these issues since the inception of TRICARE back in the 1990s. My Air Force Family Practice ex-wife had to deal with retired O-7s and others loudly complaining in the late 1990s that they were kicked out to Medicare and could no longer get their medicines from the Military Treatment Facility (MTF) pharmacy as they had been promised when they joined in the 1960s. This took years to "fix" under TRICARE-For-Life, which is still not what the government had promised to our service members: space-available care for life at your local MTF near where you had chosen to retire because of the existence of your familiar MTF (which has now been right-sized to a clinic or bulldozed).

No one has done anything about these "identified issues" because the bigwigs in both the military and DHA want to give all our taxpayer money to civilian companies instead of using it to fix the broken system.

The primary reason is corruption. Our civilian leaders in Congress count on piles of money from insurance companies to maintain the status quo to fund their own campaigns. Moreover, too many high ranking Pentagon officers leave the military only to be rewarded with cushy jobs "working" for the very insurance companies and other civilian entities that they had aided and abetted in murdering what used to be military medicine while they were in uniform.

This is not to mention the government's nearly billion dollar contract with the International SOS corporation to use civilians to provide TRICARE coverage overseas precisely because of the inadequacy of U.S. military health care staffing and funding:

TRICARE Select Overseas | TRICARE

"Send your TRICARE Select Enrollment Form to International SOS:

International SOS Government Services
TOP Select Enrollments
(redacted)"

International SOS Wins $960M Contract to Support DHA's Overseas Military Health Care Program - GovCon Wire

"DHA awarded the single-award, indefinite-delivery/indefinite-quantity contract after a full and open competition."

Of course, one of the Senior Vice Presidents of International SOS (now CEO of its subsidiary) was the former commander of the Army Medical Services Corps...

TRICARE

"It is a true honor and privilege to serve our nation's military overseas, ensuring access to high-quality health care services no matter where their work or travels take them."
COL (Ret.) Rafael E. De Jesus, CEO, Military Health Services, International SOS Government Services

In conclusion: provision of medical care to military dependents and retirees is job number 76,732 for the U.S. military.

In fact, deep down inside, the leaders of our broken system know that delaying or preventing care for retirees (and veterans) saves a lot of money when we ex-military geezers croak prematurely from bad care (or, preferably, none at all). Ideally, we would all do our patriotic duties and drop dead the moment we separated. This would free up lots of cash for Congressional Delegations to the Caribbean, Trinidad, Tobago, Provence, and other nice places with free umbrella drinks.

Plus, if a few mouthy active duty majors or senior NCOs leave without retiring due to bad or no care given to their families, well, cha-ching! It just means that many fewer retirements we have to fund. We can always promote that new E-2 to Senior Enlisted Advisor...no one will know the difference.

Problem identified: Providing medical care costs money.

Solution identified: Do not provide medical care.

Q.E.D.

 

[Gastrapathy]

There have been lots of issues when they did this transition. Location access to care is highly variable and when on base access also took a hit it created a real problem, especially in more remote areas.

Just saying that these issues have been identified. Definitely won’t be a quick fix

This isn’t a DHA issue. Much like the GMO issue which was “identified” in the 90s, this is actually the solution. I complained about this a decade ago and it hasn’t been changed. The VA made a quick fix when they were forced to but why would DoD ever “fix” this. Control costs by paying so poorly that no one will see the patients and they just go without. They can’t just deny care so they make it extremely difficult to obtain.