What Constitutes a Semi-Private Room under the Demonstration?

According to the TRICARE Management Activity (TMA) Demo patients are not entitled to use private rooms at Approved hospitals unless the hospital certifies that they have no Semi-Private Rooms.

A recent incident involving the wife of a retiree who was undergoing surgery brought this abomination to our attention when she was placed in a room with six beds and six cots for watchers. In addition these 12 people plus multiple family members shared two commodes and wash basins. For showers these patients shared 3 male and 3 female showers with 30 patients and 30 watchers as well as any staff that felt the need to shower and the showers were some 10 meters down the hall from the so called semi-private room.

Multiple attempts by the sponsor to address the issue with Global 24 only resulted in him being told his wife’s accommodations met the standards for the Demo but he was welcome to pay for a private room if he wanted. Later Frewen from International SOS (ISOS) refused to allow discussion of what constitutes a semi-private bed under the Demo during a scheduled teleconference. See Ward Accommodations for our request and Denied for their response. In spite of his refusal to discuss what local hospitals feel constitute a Semi-Private Room, the representative from the RAO Manila still brought it up. And while he still refused to discuss the issue, Frewen did make a startling comment when he claimed that any room with six beds was a ward and not Semi-Private and in apparent direct contradiction to what TMA thinks. As you will see later he was overruled by both TMA and Makati Medical Center (MMC). But it does clearly show that even Frewen didn’t buy into what MMC calls Semi-Private.

So what do you feel constitutes a Semi-Private Room? We found there are a number of definitions from around the world that tend to all agree. But we found a total absence of what Philippine hospitals define as Semi-Private on the web. The following definition pretty much matched what we did find.

As defined by The Free Dictionary; semiprivate – “Shared with usually one to three other hospital patients: a semiprivate room.” They also reference their source as, The American Heritage® Dictionary of the English Language, Fourth Edition copyright ©2000 by Houghton Mifflin Company. Updated in 2009.

After the teleconference we attempted to address the issue with TMA. In response they said 32 CFR, Part 199.4(b) (5)(i), which states “A semiprivate accommodation is a room containing at least two beds. Therefore, if a room publicly is designated by the institution as a semiprivate accommodation and contains multiple beds, it qualifies as semiprivate for the purpose of CHAMPUS.”  They further said if a beneficiary was unhappy with what TMA provides they are always free to pay for the difference in cost.

Before we continue with this discussion everyone should read and understand the following as it should have, for caring administrators, a significant effect on their decisions involving care under the Demo. However it seems the bureaucrats at TMA feel they can totally disregard this provision within their own manuals and make medical care decisions, as administrators, that can have significant adverse medical affects and result in increased hospital acquired infections for Demo patients.

TRICARE Policy Manual 6010.57-M, February 1, 2008 Chapter 12, Section 1.1 TRICARE Overseas Program (TOP) indicates the following will be considered when making decisions.

3.2 While “appropriate medical care” references the norm for medical practice in the U.S., TOP gives consideration to the significant cultural differences unique to foreign countries. The TOP contractor shall exercise reasonable judgment to accommodate cultural differences relevant to the practices and delivery of host nation health care services. Services and supplies which otherwise fall within the range of TRICARE benefits (including, but not limited to, clinical preventive services, prescription drugs, and durable medical equipment) may be eligible for coverage under TOP when the diagnosis or description of illness supports the reasonableness of the procedure, service, or supply and is commonly accepted practice in a host country or overseas region. Services and supplies which are specifically excluded from TRICARE coverage cannot be covered under TOP simply because of cultural differences. A specific waiver is required if the service or supply would not normally be considered a TRICARE benefit. Refer to Section 1.2 for a list of authorized benefit variations for TOP.

3.3 Cultural differences may apply to things like location of care (provider comes to the patient’s home) or the manner in which care is provided (services commonly done by a provider class in the U.S. may be performed by a provider assistant or physician overseas, depending on the country). Cultural differences may also apply to the manner in which claims are submitted to TRICARE. For example, certain countries (e.g., Germany) may require a separate delineation of charges for health care delivery and administrative practices that are attendant to the delivery of health care. These charges may be payable under TRICARE if they are determined to be reasonable and customary for a particular overseas location. Also, due to cultural differences, host nation providers may, and frequently do submit claims containing narrative summaries in lieu of diagnostic and/or procedural codes. These claims may be payable under TRICARE; however, the TOP contractor shall establish processes to ensure that narrative claims are converted to codes that accurately describe the services rendered and billed by the host nation provider.

ISOS refused to discuss the issue and TMA quoted the first reference, above, to what they feel removes them from any responsibility for defining Semi-Private Rooms and in essence said that whatever any hospital anywhere in the world defines as a Semi-Private Room is, as far as they are concerned, good enough for them and TRICARE beneficiaries.

So if a local hospital claims a Nipa hut, in their back parking lot, like this one constitutes semi-private accommodations, the TMA bureaucrats will declare it meets the requirements of both references above. Don’t laugh; based on their decision, this could easily be a reality. As anyone who has been here for awhile knows Filipinos often feel if they declare something to be true it is true. For example we know of an instance a few years back where a retiree was hospitalized at one of the currently Approved hospitals and was placed on an open ward. When he complained they placed him in a broom closet and declared he was in a private room. As soon as he was able he left the hospital but they charged him for a private room.

The case that initiated this issue and the resulting attempt to discuss it with TMA was when MMC declared a room with six beds and six watcher cots that shared two commodes with these 12 people and shared common showers 10 meters from the room with more than 60 individuals as a Semi-Private Room. This picture could easily represent MMC’s room. Both ISOS and TMA supported their claim that this constituted a Semi-Private Room because MMC declared it to be so.

We didn’t give up and still felt, if we dealt with TMA honestly and addressed the issue clearly and pointing out the reality of their decision they would reconsider. So we sent them a Request for Reconsideration through TRICARE Area Office-Pacific (TAO-P) that offered multiple examples of what hospitals around the world defined as Semi-Private and that matched the common definition as described above. Further we addressed the local issues of watchers and even others living 24/7 with patients and the requirement to share commodes and showers with more than 60 people. We related it to the actual example from MMC. We further related these types of accommodations and the increased incident of both hospital and community acquired infections that would result under these crowded conditions and cited multiple legitimate studies done by qualified medical personnel proving these increased infections. These studies came from the U.S., other countries and the World Health Organization and all drew the same conclusions.

However, as we usually find with interaction with these senior bureaucrats at TMA, they completely ignored the overwhelming evidence and disregarded their own policy guidance and declared and I quote, “32 CFR, Part 199.4(b) (5)(i) sets semiprivate accommodations as the TRICARE inpatient stay benefit.  TAO-Pacific checked with TMA and received confirmation that semiprivate accommodation is defined as a room containing at least two beds and which is publicly designated by the institution as semiprivate accommodation.  TMA indicated that in the instance of Makati Medical Center (MMC), if a 2 bed room is unavailable at MMC yet a 4 or 6 bed room is classified as semiprivate and available, that is the benefit payable by TRICARE.  Of course, beneficiaries have the option of paying the difference in room charges if they wish to stay in a private room instead.”

Remember those pictures above? Be prepared to endure something similar under the Demo as the senior bureaucrats at TMA have declared whatever an overseas hospital claims is Semi-Private, is Semi-Private and meets all U.S. standards of Semi-Private per the policy manual requirements for overseas standards and they have no concerns with the inevitable increases in hospital and community acquired infections Demo patients will find they are infected with. After all, why should they worry about these infections? Their civil service plans do not require them to use a Nipa hut or 6 bed, 6 watcher “Semi-Private” room with shared showers down the hall.

Anyone want to bet what would happen if a beneficiary in the U.S. found themselves in the same situation? Do you think TMA would be dancing to a different tune? But we are a small group that is isolated and therefore at the mercy of uncaring senior bureaucrats that dehumanized us long ago when they told congress and the service organizations that most of us are defrauding TMA and the taxpayer.