The Real Story on Quality of Care under the Demonstration

The TRICARE Management Activity (TMA) likes to claim, “You will have access to providers who deliver high-quality medical care.” when they brag about their failing project.

We all know based on a very long history of examples that TMA tends to believe, because they are overpaid bureaucrats in Washington D.C. where 90% of what is said inside the beltway is pure spin, they can make it up as they go and expect beneficiaries will believe it. This also demonstrates their contempt towards beneficiaries.

While they make this claim of quality care over and over in multiple formats, they refuse to respond to questions about what specific criteria is used to quantify the level of quality of care offered by the limited providers they force us to use and in violation of DOD directives. One extremely good indicator that what they claim is nothing more than spin is when they refuse to provide a direct answers to direct questions; in other words if you ask them why the sky is blue they will discuss cloud formations and claim they answered your question. We did however get one individual, in an unrelated email conversation, to admit that overseas providers are not checked for quality which we have on file.

We posed the question of quality checks to ISOS during their first briefing on the Demo. We got the usual run-a-round when Frewen responded that only “Certified Providers” could be Approved providers. That was kind of like saying only Philippine providers could be Approved providers and carried just as much weight towards demonstrating quality standards used to select providers. This is also known as “begging the question” and a common practice among TMA and their contractor staff.

Later we posed the same question in writing to Global 24, see response, and received the typical non-answer; again “begging the question”. So we went back in great detail and explained quality standards, how they are applied in the states and specifically asked “Given your comment below please provide the specific reviews that are conducted. Please be specific and list each item and area reviewed including the expected standards providers are required to meet. If standards are applied due to membership, such as JCI or a local association, please provide a link to their specific standards. Since requirements for hospitals and physicians should be significantly different, please provide two lists, one for hospitals and one for physicians.”

I’m sure you guessed it. We got yet another gobbledygook answer, “Providers selected for the Demonstration Project have undergone quality and credentialing checks in line with the requirements of the TRICARE Overseas Program. It has been clearly defined at all stages that the Approved Providers have also met all requirements to be certified providers.” Obviously this is “begging the question” once again because, if they answered honestly, they would have to admit there are essentially no quality checks. If there were we know they would be the first to point them out by answering the specific questions we asked.

If one reads through the TRICARE Overseas Program (TOP) requirements one will find references to quality checks and if one reads through the requirements for Certification of Philippine providers one will find the same references. However, if one reads further through the TRICARE Operations Manual 6010.56-M Chapter 24, Section 4, Host Nation Providers, one will find the following;

“2.1 The TOP contractor will be responsible for provider certification oversight, and monitoring of provider/institution quality. The contractor shall use Chapter 4, 32 CFR 199.6, and TPM, Chapter 11 to the maximum extent possible for the certification of host nation providers. The contractor is not required to follow TRICARE requirements for United States (U.S.) credentialing standards [quality checks], except that services that are specifically linked to the Medicare program…”

What this says is the TOP contractor is exempt from the quality standards when the provider is not part of the Medicare program. Since Medicare does not apply in the Philippines they have no requirement to do quality checks; they do insist they are licensed. But they would prefer you not know that because then you would know that TMA’s claim ““You will have access to providers who deliver high-quality medical care.” is completely bogus.

So what are the real requirements to become an Approved Provider? The obvious answer, beyond being licensed by the government, is there are only administrative requirements. They have to sign a secret agreement, which Frewen claims the content of which is none of our business. Essentially they have to show a willingness to collect deductibles and copays and acknowledge they know they can submit claims if they want and perhaps be willing to increase fees for Demo patients; nothing more, nothing less.

So what does this mean to the average beneficiary?

It is essential that they be extremely careful which providers they use. Demand the provider supply proof that they attend CME and are a member of the national professional association for their specialty. Ask other beneficiaries, who used the provider, how they felt about the quality of care and were their outcomes satisfactory. Ask Filipinos you trust the same questions. Search the provider’s credentials on the internet; those that have better quality credentials often can be found listed. If you find nothing be suspicious. If you have doubts about the quality of care you will receive demand a waiver to see another provider. If that is refused write your representative asking for their assistance and hope you can postpone the care until the issue is resolved.

In your waiver request and/or appeal to your representative quote from the following sources:

DOD Instruction 6000.14 that states in Enclosure 2, DOD Patient Bill of Rights and Responsibilities, Para 1.d. Provider Information, that patients have the right to receive information about the providers who are providing their care including professional credentials which Global 24 has refused to provide in the past when requested.

TRICARE’s published Patient Rights that clearly states, “As a patient in the Military Health System, you have the right to: Your choice of health care providers”