All Branch Topic (ABT) The End of Tricare Maybe?

[Red Lobster Actual]

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Thoughts?

http://www.militarytimes.com/story/...9/retirement-commission-health-care/22531203/

 

[colbgw02]

Thanks for posting. My two initial thoughts are:

1) The article doesn't mention it, but this would be the death knell for military GME.

2) I am not convinced that the incentives they propose would be sufficient to attract patients to MTFs. I could easily imagine the remaining volume and acuity drying up even at large MEDCENs, much less smaller MTFs.

 

[Red Lobster Actual]

1) The article doesn't mention it, but this would be the death knell for military GME.

I'm curious about this part. I was under the impression Tricare already farmed out most of the high acuity cases away from the military hospitals...so if Tricare is completely gone there will basically be no patients anymore? Except for the healthy 21 year old Marines...

 

[colbgw02]

I was under the impression Tricare already farmed out most of the high acuity cases away from the military hospitals

Not really. If you're within the geographic catchment, then the MTF often gets right of first refusal. Dependents can enroll in Tricare Standard, pay copays, and go to a local civilian place, but that's not a popular option in most cases, in my experience. I'm not sure about retirees. In any case, if an MTF is seeing too little volume, it's not necessarily because Tricare is referring beneficiaries to the network. It's more likely that it's because there is too little volume among the beneficiaries within the catchment to begin with.

...so if Tricare is completely gone there will basically be no patients anymore? Except for the healthy 21 year old Marines...

The way I read it, the only patients that have to go to MTFs are the active duty folks, with incentives designed to lure dependents and retirees. I'm skeptical that these incentives, whatever they may be, will be sufficient to get these patients to MTFs. A lot of military GME programs are already marginal with respect to volume, and I don't see how this proposal does anything except make things worse. The DoD may try to hang onto GME for awhile, but if this goes through, then it's only a matter of time before the ACGME shuts things down.

 

[Cooperd0g]

"Out of recognition for their service ..." we would very much like to take away the benefits you earned where you quite possibly put your life on the line for at least 20 freaking years.

 

[Red Lobster Actual]

It's more likely that it's because there is too little volume among the beneficiaries within the catchment to begin with.

I'm going through the Committee's report and Congress seems to be aware of the low case load problem in mil med but judging from the language of the report no one really has an idea on definitively solving this problem still. Sigh. (Source: Page 65-66)

Seems like the Surgeon Generals are recommending to Congress about ridding the catchment regions altogether. (Source: Page 72, last paragraph)

Several ways of financial incentives to attract patients to MTFs. Will it work? Not sure... (Source: Page 76)

"Permanent Change of Station assignments of the medical force to civilian hospitals or VA facilities to offer alternative venues for skill maintenance." Interesting. (Source: Page 76)

Pages 57-77 Talks about the proposed changes to mil med. The Tricare changes are in the section right after.
Source: http://mldc.whs.mil/public/docs/report/MCRMC-FinalReport-29JAN15-HI.pdf
EMC = Essential Medical Capability. Medical skills needed in war. (In case anyone bothers reading the Congressional findings)

 

[BigNavyPedsGuy]

Yeah, this would kill specialities like Peds and OB. Military docs are going to be funneled to just seeing sick call.

Join the Navy, you can only do a few specialties.

There's no way that pre-meds grasp how much of a big deal this is or there would be HUGE recruitment shortages.

Actually I think OB (and by extension peds and nursery) might survive, at least for a while.

I would be THRILLED if they started requiring copays and patients got billed for no-shows. It would save millions.

 

[a gray man]

Thoughts?

http://www.militarytimes.com/story/...9/retirement-commission-health-care/22531203/

Wow, as a service member in the pipeline to become a mil doc, this report could have broad implications. A few things that stick out to me:

-Page 65 highlights a few of the chief complaints of mil med today, high deployment rates for combat relevant specialties and case frequency levels which result in skill degradation. At least they are acknowledging these.

-the creation of "EMC's", as mentioned above, would focus on those specialties with the highest demand in combat. This, coupled with the loss of tricare could result in a huge limit in potential specialties.

-page 67 mentions expanding training to be conducted at civilian hospitals in order to fix the issues of low case load, low acuity, etc. Sounds great in theory IF you are interested in one of the EMC specialties, or more specifically "trauma care training" as mentioned on page 73. Page 76 actually mentions "PCS assignments to civilian or VA hospitals to offer alternative venues for skill maintenance".

-page 76 also mentions "services should not substitute medical specialties required for EMC's." You mean, they won't ask us to do something we aren't trained to do??

Overall I could envision a greatly reduced system where most MTF's are run by mid-level practitioners because of the greatly reduced patient demographics and with EMC specialties being much more broadly dispersed. This could be good if you are one of those folks looking to get into one of the EMC specialties. Additionally, the need for other than "EMC" specialties will negate the need for a lot of the current GME and possibly even specialties which are designated EMC. I could see this greatly affecting the number of active duty docs needed and maybe even the number of folks going through USU/HPSP.

I can't help but wonder how this will affect the training opportunities which might exist in the future. In addition how will this affect those folks who are currently in the pipeline and are looking into specialties which aren't EMC's? I could see a whole other level of disgruntled docs who are forced to train in something which they have absolutely no interest in. Not that this doesn't occur already but the scale which this report promotes is something totally different. But, maybe this will be an early exit opportunity for docs in specialties which don't fall under the EMC's? HA!

In any event, who knows how much of this will actually get put into action and what the timeline would be.

 

[Apollyon]

Older folks might remember CHAMPUS and CHAMPVA, which TriCare replaced. It's one bad system replaced by another. I have little hope. It's pathetic how we treat our vets here in the US.

 

[idq1i]

It wouldn't be a bad idea for DoD to get rid of all specialties except FP and ER, maybe GS and keep those as a deployable pool. Rest of the stuff gets sent out to real hospitals anyway. Well, maybe not at SAMMC/Bethesda/San Diego, but I wouldn't know, thanks to COL Specialty Consultant. I spent some time at one of those MTFs that everyone is scared to get sent to. They spent 7 digits on a ICU that they currently use as an overflow for med-surg floor...when med-surg's census exceeds 3 or so.

Plus, I wouldn't mind paying for a PoS plan that is more widely accepted than Tricare. I've been geographically separated from my wife for 3 years thanks to the Army. She is in a major metropolitan area where the only physician offices that accept Tricare are the same ones that accept medicaid and have a welfare office next door.

 

[HighPriest]

I can't speak for other MTFs, but I can say that the outhouse in which I currently work is already playing on this field. We couldn't handle any high-acuity cases if we wanted to do so, and so all of that goes out to the network. If I wanted to perform a larger surgery, I have the option of doing is at the local hospital. I don't, because those patients never even make it into my office. We may have RFR, but even after expressing my desire to see these patients for 2 years to my command, the patients never make it here. The only difference is that I do see a lot of family members. That being said, most of them don't want to be at a military MTF. About 50% of the time, they have decided that they're going to get substandard care at an MTF before they even meet me. My complication rates, return-to-OR rates, and outcomes are the same or better than the two civilians in town, but patients by-and-large assume that they're going to be mistreated. So the idea that you'll be able to incentivise them to come to a MTF for treatment is questionable at best. This probably would be the nail in the coffin for GME, however. But frankly, maybe that's not a bad thing even if it is a sad thing.

 

[a gray man]

It wouldn't be a bad idea for DoD to get rid of all specialties except FP and ER, maybe GS and keep those as a deployable pool. Rest of the stuff gets sent out to real hospitals anyway. Well, maybe not at SAMMC/Bethesda/San Diego, but I wouldn't know, thanks to COL Specialty Consultant. I spent some time at one of those MTFs that everyone is scared to get sent to. They spent 7 digits on a ICU that they currently use as an overflow for med-surg floor...when med-surg's census exceeds 3 or so.

Plus, I wouldn't mind paying for a PoS plan that is more widely accepted than Tricare. I've been geographically separated from my wife for 3 years thanks to the Army. She is in a major metropolitan area where the only physician offices that accept Tricare are the same ones that accept medicaid and have a welfare office next door.

I agree about the paring down of specialties, I just wish they would do it sooner than later so those of us in the pipeline know what we are getting ourselves into.

 

[HighPriest]

Frankly, you had to see this coming with the ACA. I actually think this is all a good thing, save that I don't feel like "discounting" retirees healthcare is reasonable. That's just another phrasing for "shafting." But yeah, this will kill military residencies - or at least require that the military pay for a deferred civilian residency.

My question is: are they planning on screwing over everyone who's already 18 years in by making them pay for "some" (read: most) of their healthcare and then dumping them into Medicare once they're old enough? History says "yes, that is exactly what they're going to do." Considering what a large part healthcare coverage plays into the decision to stay in for 20+, that's a travesty.

 

[idq1i]

I agree about the paring down of specialties, I just wish they would do it sooner than later so those of us in the pipeline know what we are getting ourselves into.

It sounds like you've been around the military for a while. Surely you know the "needs of the military" clause. They will always find a use for you. You are scrambling to get on a sinking ship that most people are escaping. I know that people have different situations, but dealing with military BS as an enlisted is different than dealing with the military as a certified, trained terminal degree-holding professional.

 

[Red Lobster Actual]

Considering what a large part healthcare coverage plays into the decision to stay in for 20+, that's a travesty.

Seems like they are keeping Tricare for Life intact. Otherwise, non-Medicare eligible retirees are enrolled into Tricare Choice (the proposed new system) with 5% - 20% premium cost share. First year out of retirement starts at 5% and each year tacks on another 1% until capping at 20%. TBH, I really have no clue what premium cost share is, but I am assuming rising percentages (unless it's my ROI) is a bad thing.

In comparison active duty family members in Tricare Choice have a 28% premium cost share and higher out-of-pocket expenses but the service member will have a Basic Allowance Health Care (BAHC) to offset these costs. Retirees will not have BAHC.

Maybe by the time the retiree's Tricare Choice hits 20% then the retiree can enroll into Tricare for Life?

Source: http://mldc.whs.mil/public/docs/report/MCRMC-FinalReport-29JAN15-HI.pdf (Pages 112-115)

 

[Gastrapathy]

This kind of thing comes round every few years. Respect the power of the weebees to keep this from going anywhere.

 

[BigNavyPedsGuy]

This kind of thing comes round every few years. Respect the power of the weebees to keep this from going anywhere.

The weebees are bankrupting us!

 

[a gray man]

The weebees are bankrupting us!

Agreed. We can either stay on the ship until the last possible moment or we can do something about it before it sinks.

 

[HighPriest]

DoD policy is to fly a crashing plane directly into the ground at full speed. In fact, once the plane is nose-down, it is preferrable to hit the afterburner. No one gets off until the plane is destroyed and everyone in it is dead.

Prefer a Naval analogy? DoD policy in case of a sinking ship is to put everyone as close to the hull as possible so that they can stick their fingers in the holes. Then all lifeboats are jettisoned to help stay afloat. When the boat hits bottom, you are free to swim to the surface.

 

[a gray man]

DoD policy is to fly a crashing plane directly into the ground at full speed. In fact, once the plane is nose-down, it is preferrable to hit the afterburner. No one gets off until the plane is destroyed and everyone in it is dead.

Prefer a Naval analogy? DoD policy in case of a sinking ship is to put everyone as close to the hull as possible so that they can stick their fingers in the holes. Then all lifeboats are jettisoned to help stay afloat. When the boat hits bottom, you are free to swim to the surface.

Obviously still too complicated for most to understand. I liken it to a game of hot potato with much larger stakes:

Everyone knows there is a big ball of S*** being passed around which keeps growing and growing. Leadership tries to hold onto it without getting their hands dirty. Sooner or later it explodes in spectacular fashion, completely soiling whoever is holding it. Then, everyone who had the good fortune of "getting off the ship, ejecting, etc" laughs at the last person holding it.

The unfortunate reality is that millions of folks' lives are affected by whatever clown is in charge when the ball of S*** finally explodes.

 

[Kingfisher]

I don't see this stuff getting passed in the near future (year or two), because there just would be too much controversy right now. I think we WILL see some of the proposals within 10 years. That would give everyone a chance to stew about it for a while. The same goes for the proposals to our retirement benefits. I can imagine what the retention would be like for physicians if they take away pay benefits and use 401k option.

 

[a gray man]

I don't see this stuff getting passed in the near future (year or two), because there just would be too much controversy right now. I think we WILL see some of the proposals within 10 years. That would give everyone a chance to stew about it for a while. The same goes for the proposals to our retirement benefits. I can imagine what the retention would be like for physicians if they take away pay benefits and use 401k option.

There has been talk about imposing this system (401k, reduced pension percentage, and early retirement options) for the last 4 or 5 years that i know of. This is the first time I have seen it wrapped into such a large report which was issued directly to congress though.

I actually think they need to set most of these actions in motion in the near term. I really don't see an issue with anything that isn't retroactive.

 

[Gastrapathy]

I bet they take away the BAH part of the GI bill transfer. Probably a couple months before I can first use it.

 

[j4pac]

The military is broke. The physicians are being squeezed by higher-ups. The moral has fallen significantly in the past 5 years. Constant deployments were just a warmup to the BS that now exists in military medicine. Now you have physicians LOOKING FORWARD to leaving their families to deploy because the malignancy at military hospitals. There has been an enormous move to prove that military medicine is financially viable. But in order to do so they have had to create metric-driven medicine that squeezes you even tighter. Now being a good doc isn't good enough...it's more important to play the metric numbers game. Physicians now spend an absurd about of their time with administrative responsibilities in order to prove milmed's viability. And if you do well with the metrics game...no "that a boy"...they will just raise the bar higher. You feel like what you do is never good enough and people eventually stop caring.

Eventually you end up throwing your hands up in the air and say, "if this is what it takes to keep this BS alive...then maybe it SHOULD die."

GME may be able to stay afloat...but it is going to be a malignant experience and I question whether or not it will be a decent learning experience. I refuse to bring my family to our local military hospital because I know first hand that everyone in that hospital is tired, hate their jobs, and are underappreciated. I don't care what the metrics say...that isn't going to lead to good medicine.

 

[j4pac]

Yeah, this would kill specialities like Peds and OB. Military docs are going to be funneled to just seeing sick call.

Join the Navy, you can only do a few specialties.

There's no way that pre-meds grasp how much of a big deal this is or there would be HUGE recruitment shortages.

Actually I think OB (and by extension peds and nursery) might survive, at least for a while.

I would be THRILLED if they started requiring copays and patients got billed for no-shows. It would save millions.

LOL. At my hospital Peds and OB/GYN have more cases they can handle. That is because the entire civilian workforce, including desk clerks bailed ship about 6 months to a year ago.

 

[a gray man]

The military is broke. The physicians are being squeezed by higher-ups. The moral has fallen significantly in the past 5 years. Constant deployments were just a warmup to the BS that now exists in military medicine. Now you have physicians LOOKING FORWARD to leaving their families to deploy because the malignancy at military hospitals. There has been an enormous move to prove that military medicine is financially viable. But in order to do so they have had to create metric-driven medicine that squeezes you even tighter. Now being a good doc isn't good enough...it's more important to play the metric numbers game. Physicians now spend an absurd about of their time with administrative responsibilities in order to prove milmed's viability. And if you do well with the metrics game...no "that a boy"...they will just raise the bar higher. You feel like what you do is never good enough and people eventually stop caring.

Eventually you end up throwing your hands up in the air and say, "if this is what it takes to keep this BS alive...then maybe it SHOULD die."

GME may be able to stay afloat...but it is going to be a malignant experience and I question whether or not it will be a decent learning experience. I refuse to bring my family to our local military hospital because I know first hand that everyone in that hospital is tired, hate their jobs, and are underappreciated. I don't care what the metrics say...that isn't going to lead to good medicine.

Out of curiosity, how prevelant is this viewpoint among active duty docs?

I have spoken and worked with a few docs but they are in an insulated organization and may be more of an exception to the rule.

I will say though that a lot of what we have been talking about is fairly pervasive. Leadership not really concerned with the reality of life on the ground and more concerned with arbitrary matrix, unfair promotions, a focus on the "idea" of what right is as opposed to the reality.

I guess what I'm saying is that a lot of these problems seem to be fairly systemic and not limited to the medical corps. It is unfortunate to hear how they are manifested in the care of our soldiers though.
I can tell you from experience that these same issues can cost soldiers' lives on the battlefield as well.

 

[a gray man]

Having said all that, if the ship really is going down then the best we can do is affect change within our circle of influence and hope to still be standing in the end!

 

[j4pac]

Out of curiosity, how prevelant is this viewpoint among active duty docs?

I have spoken and worked with a few docs but they are in an insulated organization and may be more of an exception to the rule.

I will say though that a lot of what we have been talking about is fairly pervasive. Leadership not really concerned with the reality of life on the ground and more concerned with arbitrary matrix, unfair promotions, a focus on the "idea" of what right is as opposed to the reality.

I guess what I'm saying is that a lot of these problems seem to be fairly systemic and not limited to the medical corps. It is unfortunate to hear how they are manifested in the care of our soldiers though.
I can tell you from experience that these same issues can cost soldiers' lives on the battlefield as well.

It is military wide. Moral is falling fast after the budget cuts. I love my squadron and generally most of the staff members share that sentiment. The near-by hospital is far more dysfunctional than we are right now. But with that said...our command feels the strain as well. People are more squeezed and tired. The tighter things get...the less the above shows appreciation to those below them.

It really is a perfect storm right now. We have an ongoing war with continued deployments. We have an ending war, so manning is falling. Then you have the financial issues...which leads to ton of pressure from above and this also hurts both civilian and military manning. I also think that the VA fraud situation has inadvertently put a strain on military hospitals.

 

[j4pac]

Having said all that, if the ship really is going down then the best we can do is affect change within our circle of influence and hope to still be standing in the end!

Leave that to the ones currently in this mess. If you haven't signed up yet...don't. This is coming from a guy who loves the military and couldn't envision doing less than 20 years.

 

[Kingfisher]

I think opinions and problems are specialty as well as service dependent.

I am actually happy with where I'm at. I have some great colleagues that I enjoy working with. I have a great patient population that I enjoy seeing every day. My job difficulties are very similar to the problems I would be having as a civilian Doc (unless I owned my own practice, and the whole NKO/collateral duties stuff). My pay is pretty close as well. Is this system perfect? Absolutely not! From where I am sitting, I don't have that "ship sinking" feeling from military medicine. It just keeps trudging along.

I like the operational side of this business and had fun while deployed (don't tell my wife). Of course my job doesn't change that much and my skills don't necessarily atrophy like the surgical specialties would (yes this happens). I do have more time to exercise when I am operational. 🙂

 

[pgg]

It is military wide.

Dude, with respect, you're a flight surgeon / GMO. 🙂 You probably spend more time on this forum than you do in a military hospital. 😉

I think opinions and problems are specialty as well as service dependent.

I am actually happy with where I'm at. I have some great colleagues that I enjoy working with. I have a great patient population that I enjoy seeing every day. My job difficulties are very similar to the problems I would be having as a civilian Doc (unless I owned my own practice, and the whole NKO/collateral duties stuff). My pay is pretty close as well. Is this system perfect? Absolutely not! From where I am sitting, I don't have that "ship sinking" feeling from military medicine. It just keeps trudging along.

I like the operational side of this business and had fun while deployed (don't tell my wife). Of course my job doesn't change that much and my skills don't necessarily atrophy like the surgical specialties would (yes this happens). I do have more time to exercise when I am operational. 🙂

I agree with all of this. Perhaps a little less enthusiasm for another deployment ... 🙂

 

[Chonal Atresia]

I think opinions and problems are specialty as well as service dependent.

I am actually happy with where I'm at. I have some great colleagues that I enjoy working with. I have a great patient population that I enjoy seeing every day. My job difficulties are very similar to the problems I would be having as a civilian Doc (unless I owned my own practice, and the whole NKO/collateral duties stuff). My pay is pretty close as well. Is this system perfect? Absolutely not! From where I am sitting, I don't have that "ship sinking" feeling from military medicine. It just keeps trudging along.

I like the operational side of this business and had fun while deployed (don't tell my wife). Of course my job doesn't change that much and my skills don't necessarily atrophy like the surgical specialties would (yes this happens). I do have more time to exercise when I am operational. 🙂

You are completely correct, it is specialty and service dependent. However, in my former service and specialty (and including all surgical subspecialties) things are not so rosy.

I just had a urologist friend who was tasked (non-voluntary) with a 2-year non-clinical brigade surgeon tour several months after giving birth. So not only does she get paid in the <3% percentile for her specialty, she is not even allowed to practice her specialty for 2 full years. Good times!

I also have an ENT buddy who was tasked with a 9-month deployed DCCS position. He actually told me that he would be more than happy if he was demoted to a 2LT for the last 2 years of his ADSO as long he were allowed to practice clinical medicine.

I wonder if recruiters tell prospective candidates these stories. I guess some on this forum feel that candidates should know these risks before joining which in my mind is completely ridiculous.

Moral of the story is if you don't want the military to f$%^ up your professional life, the only power you have is to leave. This is coming from someone who was a USUHS grad (2002) and completed a military residency (Madigan).

And yes, PGG, this is an anti-military medicine rant. I don't have anything positive to say after being in for 12 years other than those in clinical positions by and large try to do the best job for our actice duty troops that they can despite those in admin positions.

 

[j4pac]

Dude, with respect, you're a flight surgeon / GMO. 🙂 You probably spend more time on this forum than you do in a military hospital. 😉





I agree with all of this. Perhaps a little less enthusiasm for another deployment ... 🙂

Granted...I am only one person, capable of being only one place at one time. But I have lots of friends...and their experiences are very similar. LOL...I do frequent SDN, but I do also work my butt off. 🙂 I am very closely associated with a military hospital and it is not hard to see the malignancy from the outside looking in.

I love my job...and most Flight Surgeons do as well. GMOs often have a very different experience. The major MTFs are doing better...but are being crunched by the same metric driven medicine as the smaller hospitals. The hospital malignancy at the smaller hospitals is getting so bad that the entire civilian workforce is LEAVING. The local hospitals peds department once had 3 civilian pediatricians...every single one of them have left within the last 6 months. Only a few of the civilian nursing staff and desk clerks have stayed. So now...the corpsman are suppose to be doing desk work, Triage, getting vitals/soap note, while also being available to answer phones, perform a number of BS taskers, and write notes into AHLTA. It is an overwhelming job and the corpsmen do their best...but it is just physically impossible. EVERYONE is overworked and underappreciated at the local hospital and there is no doubt in my mind that the inpatient unit will be closing within the next two years. Extraordinary measures are being made to keep it alive...but it really does deserve to die.

I have flight surgeon/GMO friends who complain to me frequently about the local military hospitals (both large and small) pulling them away from their own responsibilities to keep the military hospital mission afloat. So trust me...the malignancy is spreading to the fleet units that are located near military hospitals. I would imagine that resources are better at the major MTFs and those docs may not feel the strain quite as much as those who are affiliated with the smaller hospitals. The last time I was at a major MTF was before the major financial issues...so I am not as up on it.

I strongly believe that the major MTFs should remain open, but the rest should close. The only reason the MTFs should be around is for the war mission. The focus needs to be on taking care of our active duty servicemembers. That is what military physicians do best, and the rest (including retiree care) can be easily handled on the civilian sector. GME can stay alive but most of the training should be conducted in the civilian sector...with only the major MTFs keeping their residency programs.

 

[Chonal Atresia]

't

Granted...I am only one person, capable of being only one place at one time. But I have lots of friends...and their experiences are very similar. LOL...I do frequent SDN, but I do also work my butt off. 🙂 I am very closely associated with a military hospital and it is not hard to see the malignancy from the outside looking in.

I love my job...and most Flight Surgeons do as well. GMOs often have a very different experience. The major MTFs are doing better...but are being crunched by the same metric driven medicine as the smaller hospitals. The hospital malignancy at the smaller hospitals is getting so bad that the entire civilian workforce is LEAVING. The local hospitals peds department once had 3 civilian pediatricians...every single one of them have left within the last 6 months. Only a few of the civilian nursing staff and desk clerks have stayed. So now...the corpsman are suppose to be doing desk work, Triage, getting vitals/soap note, while also being available to answer phones, perform a number of BS taskers, and write notes into AHLTA. It is an overwhelming job and the corpsmen do their best...but it is just physically impossible. EVERYONE is overworked and underappreciated at the local hospital and there is no doubt in my mind that the inpatient unit will be closing within the next two years. Extraordinary measures are being made to keep it alive...but it really does deserve to die.

I have flight surgeon/GMO friends who complain to me frequently about the local military hospitals (both large and small) pulling them away from their own responsibilities to keep the military hospital mission afloat. So trust me...the malignancy is spreading to the fleet units that are located near military hospitals. I would imagine that resources are better at the major MTFs and those docs may not feel the strain quite as much as those who are affiliated with the smaller hospitals. The last time I was at a major MTF was before the major financial issues...so I am not as up on it.

I strongly believe that the major MTFs should remain open, but the rest should close. The only reason the MTFs should be around is for the war mission. The focus needs to be on taking care of our active duty servicemembers. That is what military physicians do best, and the rest (including retiree care) can be easily handled on the civilian sector. GME can stay alive but most of the training should be conducted in the civilian sector...with only the major MTFs keeping their residency programs.

You are assuming that Tricare for the working retired/dependents(< 65 years old) will be accepted in the civilian sector and this is not the case in many areas of the country. Those cities/towns that have patients with higher-paying insurance by and large do not accept Tricare. For instance, there are exactly ZERO ENTs in the entire urban center of Raleigh/Cary/Durham, NC that accept Tricare patients. Just like Medicaid expansion with the ACA - just because you have insurance doesn't mean that you have access to medical care.

 

[j4pac]

't


You are assuming that Tricare for the working retired/dependents(< 65 years old) will be accepted in the civilian sector and this is not the case in many areas of the country. Those cities/towns that have patients with higher-paying insurance by and large do not accept Tricare. For instance, there are exactly ZERO ENTs in the entire urban center of Raleigh/Cary/Durham, NC that accept Tricare patients. Just like Medicaid expansion with the ACA - just because you have insurance doesn't mean that you have access to medical care.

I agree that it is an issue. Many retirees have either had to move closer to local military hospitals, or move to tricare standard. If hospitals close...more will have to be forced to move to Tricare Standard. It's already happening.

 

[dr zaius]

 

[Gastrapathy]

Neither of the two largest HMOs in San Diego (Kaiser and Sharp Rees Stealy) take Tricare. SRS takes TFL but that's really just a Medicare supplement.

There's a GAO report on this subject from 2013 that said that 4/10 physicians won't take tricare at all (more limit their exposure) and 31% of beneficiaries who use civilian provide networks have trouble finding a doctor.

 

[backrow]

Neither of the two largest HMOs in San Diego (Kaiser and Sharp Rees Stealy) take Tricare. SRS takes TFL but that's really just a Medicare supplement.

There's a GAO report on this subject from 2013 that said that 4/10 physicians won't take tricare at all (more limit their exposure) and 31% of beneficiaries who use civilian provide networks have trouble finding a doctor.

But UCSD does. Those two you cited are some of the most "stingy" when it comes to referrals from my limited experience.

I think the one of the reasons Tricare isn't taken in some areas is simply due to a lack of demand making it not worth the time to go through the process of being a Tricare provider.

 

[Chonal Atresia]

But UCSD does. Those two you cited are some of the most "stingy" when it comes to referrals from my limited experience.

I think the one of the reasons Tricare isn't taken in some areas is simply due to a lack of demand making it not worth the time to go through the process of being a Tricare provider.

Tricare isn't taken by many doctors because reimbursement rates are tied to Medicaid which isn't s$&@. I believe UCSD is public so they have no choice in declining Tricare. That is the real reason they take Tticare.

 

[backrow]

Tricare isn't taken by many doctors because reimbursement rates are tied to Medicaid which isn't s$&@.

I agree reimbursement is crap, but if you have a big enough population 'demanding' services in an area I bet more would take it. The volume increase (if the practice has the room) would offset the reimbursement level a little.

I believe UCSD is public so they have no choice in declining Tricare. That is the real reason they take Tticare.

Is that a rule? I've never heard that mentioned in any Tricare regulations. Rady Childrens also takes it, and they are separate from any University. There are also many private groups that accept Tricare in the SD area.

I think it has some to do with being a "military town", some to do with demand, and some to do with a large volume of physicians (desirable area) which means some feel they need Tricare patients to fill their schedules.

Take that to say Montana and the patient demand isn't there and the "one" patient with Tricare isn't going to make a practice add another insurance because they aren't bringing in many more patients.

I think the same thing could be said for any insurance that doesn't have a large population in an area.

Also, can't you go out of network and pay a copay with standard or extra? So it's not like one can't get healthcare, but they have to pay a little more.

 

[Chonal Atresia]

I agree reimbursement is crap, but if you have a big enough population 'demanding' services in an area I bet more would take it. The volume increase (if the practice has the room) would offset the reimbursement level a little.



Is that a rule? I've never heard that mentioned in any Tricare regulations. Rady Childrens also takes it, and they are separate from any University. There are also many private groups that accept Tricare in the SD area.

I think it has some to do with being a "military town", some to do with demand, and some to do with a large volume of physicians (desirable area) which means some feel they need Tricare patients to fill their schedules.

Take that to say Montana and the patient demand isn't there and the "one" patient with Tricare isn't going to make a practice add another insurance because they aren't bringing in many more patients.

I think the same thing could be said for any insurance that doesn't have a large population in an area.

Also, can't you go out of network and pay a copay with standard or extra? So it's not like one can't get healthcare, but they have to pay a little more.

It is not a rule of Tricare but rather that of public hospitals that accept state money - you can't turn patients away when they are referred to you because of type/lack of insurance (unless hospital is on divert, etc). I don't believe you can say "no" to clinic patients (at least in NC) like private practices and hospitals can do.

 

[backrow]

It is not a rule of Tricare but rather that of public hospitals that accept state money - you can't turn patients away when they are referred to you because of type/lack of insurance (unless hospital is on divert, etc). I don't believe you can say "no" to clinic patients (at least in NC) like private practices and hospitals can do.

That is not true for their individual clinics. Yes, they have to see the ED consults no matter the insurance; however, the clinic can choose which insurances they accept for regular consults and patients.

Those patients who come with the "wrong"/no insurance are self pay.

 

[Chonal Atresia]

That is not true for their individual clinics. Yes, they have to see the ED consults no matter the insurance; however, the clinic can choose which insurances they accept for regular consults and patients.

Those patients who come with the "wrong"/no insurance are self pay.

May be true in CA but in NC, clinics at UNC all required to see all insurance.

 

[notdeadyet]

I agree reimbursement is crap, but if you have a big enough population 'demanding' services in an area I bet more would take it. The volume increase (if the practice has the room) would offset the reimbursement level a little.

I doubt it. If this were true, you'd find lots of profitable shops running with Medicaid (there are LOTS of patients with that) and it is horrible trying to find these folks care so many wind up at the county centers. Kaiser (at least in CA) runs Medicaid shops, but the volume you're talking is enormous. You will not find normal practices chomping at the Medicaid bit, nor will you with Tricare.


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[backrow]

I doubt it. If this were true, you'd find lots of profitable shops running with Medicaid (there are LOTS of patients with that) and it is horrible trying to find these folks care so many wind up at the county centers. Kaiser (at least in CA) runs Medicaid shops, but the volume you're talking is enormous. You will not find normal practices chomping at the Medicaid bit, nor will you with Tricare.


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The why does anyone accept Tricare at all? Obviously there are innumerable reasons behind why or why not a practice accepts Tricare.

We could argue each side and both have very good arguments. Not sure how to prove/disprove either side.

 

[Chonal Atresia]

The why does anyone accept Tricare at all? Obviously there are innumerable reasons behind why or why not a practice accepts Tricare.

We could argue each side and both have very good arguments. Not sure how to prove/disprove either side.

IMO, I think there are 2 (maybe 3) main reasons for this.

1. Many practices around large military bases ( especially Peds) have no choice because the volume is so high. If they dumped Tticare, half their business would go away.

2. Tricare Standard pays better than Prime (I don't understand why but I know it does) so many practices will accept standard and not prime.

3. Sense of duty to those that serve. However, if Tricare keeps cutting reimbursement even this sense of duty will go by the wayside. You still need to pay overhead.

 

[Gastrapathy]

We take Tricare because my group has a bunch of ex military and we like the patients. I'm too low on the totem pole to really understand whether we win or lose on that but I'm told it's a marginal win (but a loss when lost business is included).

There are frequent discussions about being done with Tricare and they even did away with it for awhile before I joined.

 

[a gray man]

One step closer to this becoming a reality. Obama supports but just how much he supports is TBD.

Sounds like they are probably doing a focus group to see what the political impact would be before they release their true thoughts at the end of the month.

http://www.militarytimes.com/story/...pport-military-pay-benefits-changes/70680340/

 

[DD214_DOC]

IMO, GME is already on its way out. The new, "business" model focuses on RVU generation and makes little accomodations for providers who are involved in GME. The focus on productivity would be all well and good if the providers had adequate ancillary staff to support such levels of productivity. GME is, at least from what I can see, starting to interfere with generating RVUs, and residents within GME are feeling more pressure to help, "lighten the load", which is interfereing with the eduction process. This all really is a perfect storm.

 

[Shikima]

IMO, GME is already on its way out. The new, "business" model focuses on RVU generation and makes little accomodations for providers who are involved in GME. The focus on productivity would be all well and good if the providers had adequate ancillary staff to support such levels of productivity. GME is, at least from what I can see, starting to interfere with generating RVUs, and residents within GME are feeling more pressure to help, "lighten the load", which is interfereing with the eduction process. This all really is a perfect storm.

le sigh. I can see it.