Insider Threats to the Military Health System: A Systematic Background Check of TRICARE West Providers

Background

To address the pandemic, the Defense Health Agency (DHA) expanded its TRICARE civilian provider network by 30.1%. In 2022, the DHA Annual Report stated that TRICARE's provider directories were only 80% accurate. Unlike Medicare, the DHA does not publicly reveal National Provider Identification (NPI) numbers. As a result, TRICARE's 9.6 million beneficiaries lack the means to verify their doctor's credentials. Since 2013, the Department of Health and Human Services' (HHS) Office of Inspector General (OIG) has excluded 17,706 physicians and other providers from federal health programs due to billing fraud, neglect, drug-related convictions, and other offenses. These providers and their NPIs are included on the OIG's List of Excluded Individuals and Entities (LEIE). Patients who receive care from excluded providers face higher risks of hospitalization and mortality.

Objective

We sought to assess the extent to which TRICARE screens health care provider names on their referral website against criminal databases.

Methods

Between January 1-31, 2023, we used TRICARE West's provider directory to search for all providers within a 5-mile radius of 798 zip codes (38 per state, ≥10,000 residents each, randomly entered). We then copied and pasted all directory results' first and last names, business names, addresses, phone numbers, fax numbers, degree types, practice specialties, and active or closed statuses into a CSV file. We cross-referenced the search results against US and state databases for medical and criminal misconduct, including the OIG-LEIE and General Services Administration's (GSA) SAM.gov exclusion lists, the HHS Office of Civil Rights Health Insurance Portability and Accountability Act (HIPAA) breach reports, 15 available state Medicaid exclusion lists (state), the International Trade Administration's Consolidated Screening List (CSL), 3 Food and Drug Administration (FDA) debarment lists, the Federal Bureau of Investigation's (FBI) list of January 6 federal defendants, and the OIG-HHS list of fugitives (FUG).

Results

Our provider search yielded 111,619 raw results; 54 zip codes contained no data. After removing 72,156 (64.65%) duplicate entries, closed offices, and non-TRICARE West locations, we identified 39,463 active provider names. Within this baseline sample group, there were 2398 (6.08%) total matches against all exclusion and sanction databases, including 2197 on the OIG-LEIE, 2311 on the GSA-SAM.gov list, 2 on the HIPAA list, 54 on the state Medicaid exclusion lists, 69 on the CSL, 3 on the FDA lists, 53 on the FBI list, and 10 on the FUG.

Conclusions

TRICARE's civilian provider roster merits further scrutiny by law enforcement. Following the National Institute of Standards and Technology 800, the DHA can mitigate privacy, safety, and security clearance threats by implementing an insider threat management model, robust enforcement of the False Claims Act, and mandatory security risk assessments. These are the views of the author, not the Department of Defense or the US government.

Weight loss medication prescription prevalence in the active component, 2018-2023

The U.S. military has witnessed rising obesity among active component service members. The Department of Defense authorized coverage of weight loss medications in 2018, but no study has evaluated prescription prevalence within the active component. This descriptive retrospective cohort study analyzed data from active component U.S. military service members from January 2018 through June 2023. The study used data from the Defense Medical Surveillance System to determine prescription period prevalence of weight loss medication. Data on demographics, body mass index, and history of diabetes were considered. The study revealed a 100-fold increase in the prescription period prevalence of weight loss agents in the active component from their initial authorization date. Demographics associated with higher prescription period prevalence were non-Hispanic Black race and ethnicity, female sex, and older age. Service members in the health care occupations and the Navy had higher prevalence compared to other service branches and occupations. The findings indicate a significant rise in the period prevalence of weight loss prescriptions over time. Further research is recommended to assess the effectiveness, safety, and use in austere military environments.

Ivermectin prescription fill rates among U.S. Military members during the coronavirus disease 2019 (COVID-19) pandemic

This report describes ivermectin prescription fill rates among U.S. active component service members (ACSM) over time during the early phases of the COVID-19 pandemic. Information about the unsubstantiated benefits of ivermectin for coronavirus 2019 (COVID-19) prevention and treatment was widely available online early in the COVID-19 pandemic. Ivermectin prescription fill rates increased among ACSM during periods of Alpha and Delta coronavirus variant predominance, but not during the predominance of the Omicron variant. At the peak of the fill rate curve, in August 2021, rates were higher among men compared to women, older compared to younger age groups, senior officers compared to junior officers, senior enlisted compared to junior enlisted service members, and those with a bachelor's or advanced degree compared to those without a bachelor's degree. Ivermectin prescriptions were more likely to have been filled at a retail pharmacy than at a military hospital or clinic. During the COVID-19 pandemic fill rates for ivermectin prescriptions among ACSM increased, including those without a qualifying diagnosis. Rates peaked in August 2021 but subsequently declined. The decrease in ivermectin fill rates was coincident with vigorous efforts to correct previous misinformation and implement pre-authorization requirements for prescriptions. Research on the impact of unproven online claims about clinical and public health interventions has potential to curtail future unnecessary and potentially harmful treatments.

The Impact of Mammography Screening Guideline Changes in a Universally Insured Population

Background: The U.S. Preventive Services Task Force (USPSTF) modified breast cancer screening guidelines in November 2009. The impact has been studied among privately and Medicare insured populations, but not among universally insured women. Materials and Methods: This study compared the proportion of TRICARE beneficiaries aged 40-64 receiving mammograms from fiscal years 2006 to 2015 using an interrupted time series analysis to determine the impact of the 2009 USPSTF guideline changes. Stratified analyses evaluated differences by age (ages 40-49, 50-64), race, care setting, beneficiary type, and military status. Results: The proportion of women receiving mammograms increased from October 2005 through September 2009. A small, but significant decrease of 65-66 fewer women screened per 10,000 occurred in the first quarter of 2010 (October 1 to December 31) following the screening guideline update publication. The proportion screened then remained unchanged through 2015. Comparative analysis revealed no differences in impact between age groups, blacks and whites, or military dependents and active-duty/retirees. Conclusions: This study determined that the USPSTF guideline updates had a small, but immediate and lasting impact that was not different across age groups, beneficiary type, or race. No racial disparities in the proportion screened or in the impact of the guideline change were noted in our universally insured population.

In defense of Direct Care: Limiting access to military hospitals could worsen quality and safety

OBJECTIVE

Ongoing health care reforms within the US Military Health System (MHS) are expected to shift >1.9 million MHS beneficiaries from military treatment facilities (MTFs) into local civilian hospitals over the next 1-2 years. The objective of this study was to examine how such health care reforms are likely to affect the quality of MHS care.

DATA SOURCES

Adult MHS beneficiaries, aged 18-64 years, treated in MTFs (under a program known as Direct Care) were compared against (1) MHS beneficiaries treated in locally available civilian hospitals (under a program known as Purchased Care) and (2) similarly-aged adult civilian patients across the United States. MHS beneficiaries in Direct and Purchased Care were identified from fiscal-year 2016-2018 MHS inpatient claims. National inpatients were identified in the 2017 Nationwide Readmissions Database.

STUDY DESIGN

Retrospective cohort.

DATA COLLECTION

Differences in quality were compared using two sets of quality metrics endorsed by the US Agency for Healthcare Research and Quality (AHRQ): Inpatient Quality Indicators, 19 quality metrics that look at differences in in-hospital mortality, and Patient Safety Indicators, 18 quality metrics that look at differences in in-hospital morbidity and adverse events. Among MHS beneficiaries (Direct and Purchased Care), we further simulated what changes in quality indicators might look like under various proposed scenarios of reduced access to Direct Care.

PRINCIPAL FINDINGS

A total of 502,252 MHS admissions from 37 MTFs and surrounding civilian hospitals were included (326,076 Direct Care, 179,176 Purchased Care). Nationwide, 9.34 million adult admissions from 2453 hospitals were included. On average, MHS beneficiaries treated in MTFs experienced better inpatient quality and improved patient safety compared with MHS beneficiaries treated in locally available civilian hospitals (e.g., summary observed-to-expected ratio for medical mortality: 0.98 vs. 1.03, p < 0.001) and adult patients across the United States (0.98 vs. 1.02, p < 0.001). Simulations of proposed changes resulted in consistently worse outcomes for MHS patients, whether reducing MTF access by 10%, 20%, or 50% nationwide; limiting MTF access to active-duty beneficiaries; or closing MTFs with the worst performance on patient safety (p < 0.001 for overall quality indicators for each).

CONCLUSIONS

Reducing access to MTFs could result in significant harm to MHS patients. The results underscore the importance of health-policy planning based on evidence-based evaluation and the need to consider the consequential downstream effects caused by changes in access to care.

Use of low-value pediatric services in the Military Health System

BACKGROUND

Low-value care (LVC) is understudied in pediatric populations and in the Military Health System (MHS). This cross-sectional study applies previously developed measures of pediatric LVC diagnostic tests, procedures, and treatments to children receiving care within the direct and purchased care environments of the MHS.

METHODS

We queried the MHS Data Repository (MDR) to identify children (n = 1,111,534) who received one or more of 20 previously described types of LVC in fiscal year 2015. We calculated the proportion of eligible children and all children who received the service at least once during fiscal year 2015. Among children eligible for each measure, we used logistic regressions to calculate the adjusted odds ratios (AOR) for receiving LVC at least once during fiscal year 2015 in direct versus purchased care.

RESULTS

All 20 measures of pediatric LVC were found in the MDR. Of the 1,111,534 eligible children identified, 15.41% received at least one LVC service, and the two most common procedures were cough and cold medications in children under 6 years and acid blockers for infants with uncomplicated gastroesophageal reflux. Eighteen of the 20 measures of pediatric LVC were eligible for comparison across care environments: 6 were significantly more likely to be delivered in direct care and 10 were significantly more likely to be delivered in purchased care. The greatest differences between direct and purchased care were seen in respiratory syncytial virus testing in children with bronchiolitis (AOR = 21.01, 95% CI = 12.23-36.10) and blood tests in children with simple febrile seizure (AOR = 24.44, 95% CI = 5.49-108.82). A notably greater difference of inappropriate antibiotic prescribing was seen in purchased versus direct care.

CONCLUSIONS

Significant differences existed between provision of LVC services in direct and purchased care, unlike previous studies showing little difference between publicly and privately insured children. In fiscal year 2015, 1 in 7 children received one of 20 types of LVC. These proportions are higher than prior estimates from privately and publicly insured children, suggesting the particular need to focus on decreasing wasteful care in the MHS. Collectively, these studies demonstrate the high prevalence of LVC in children and the necessity of reducing potentially harmful care in this vulnerable population.

Factors Associated With the Acceptance of New TRICARE and Medicare Patients by Health Care Providers

We use data from the 2012-2015 TRICARE Standard Survey to examine factors that affect civilian health care providers' acceptance of patients covered by the U.S. Department of Defense's TRICARE insurance program and Medicare. We find that 74% of physicians report that they accept new TRICARE patients compared with 83% accepting new Medicare patients; in contrast, only 36% of mental health providers report that they accept new Medicare and/or TRICARE patients. Among the most common reasons provided by both physicians and mental health providers for not accepting either insurance type are insufficient reimbursement or their specialty not being covered; lack of awareness of TRICARE is also frequently cited, particularly among mental health providers. These findings suggest that successful strategies to increase provider acceptance of TRICARE and Medicare may include improving reimbursement rates and specialty coverage and increasing provider awareness of TRICARE through outreach programs.

Racial Differences in Extremity Soft Tissue Sarcoma Treatment in a Universally Insured Population

BACKGROUND

In prior reports from population-based databases, black patients with extremity soft tissue sarcoma (ESTS) have lower reported rates of limb-sparing surgery and adjuvant treatment. The objective of this study was to compare the multimodality treatment of ESTS between black and white patients within a universally insured and equal-access health care system.

METHODS

Claims data from TRICARE, the US Department of Defense insurance plan that provides health care coverage for 9 million active-duty personnel, retirees, and dependents, were queried for patients younger than 65 y with ESTS who underwent limb-sparing surgery or amputation between 2006 and 2014 and identified as black or white race. Multivariable logistic regression analysis was used to evaluate the impact of race on the utilization of surgery, chemotherapy, and radiation.

RESULTS

Of the 719 patients included for analysis, 605 patients (84%) were white and 114 (16%) were black. Compared with whites, blacks had the same likelihood of receiving limb-sparing surgery (odds ratio [OR], 0.861; 95% confidence interval [95% CI], 0.284-2.611; P = 0.79), neoadjuvant radiation (OR, 1.177; 95% CI, 0.204-1.319; P = 0.34), and neoadjuvant (OR, 0.852; 95% CI, 0.554-1.311; P = 0.47) and adjuvant (OR, 1.211; 95% CI, 0.911-1.611; P = 0.19) chemotherapy; blacks more likely to receive adjuvant radiation (OR, 1.917; 95% CI, 1.162-3.162; P = 0.011).

CONCLUSIONS

In a universally insured population, racial differences in the rates of limb-sparing surgery for ESTS are significantly mitigated compared with prior reports. Biologic or disease factors that could not be accounted for in this study may contribute to the increased use of adjuvant radiation among black patients.

Variation in expenditure for common, high cost surgical procedures in a working age population: implications for reimbursement reform

BACKGROUND

In the move toward value-based care, bundled payments are believed to reduce waste and improve coordination. Some commercial insurers have addressed this through the use of bundled payment, the provision of one fee for all care associated with a given index procedure. This system was pioneered by Medicare, using a population generally over 65 years of age, and despite its adoption by mainstream insurers, little is known of bundled payments' ability to reduce variation or cost in a working-age population. This study uses a universally-insured, nationally-representative population of adults aged 18-65 to examine the effect of bundled payments for five high-cost surgical procedures which are known to vary widely in Medicare reimbursement: hip replacement, knee replacement, coronary artery bypass grafting (CABG), lumbar spinal fusion, and colectomy.

METHODS

Five procedures conducted on adults aged 18-65 were identified from the TRICARE database from 2011 to 2014. A 90-day period from index procedure was used to determine episodes of associated post-acute care. Data was sorted by Zip code into hospital referral regions (HRR). Payments were determined from TRICARE reimbursement records, they were subsequently price standardized and adjusted for patient and surgical characteristics. Variation was assessed by stratifying the HRR into quintiles by spending for each index procedure.

RESULTS

After adjusting for case mix, significant inter-quintile variation was observed for all procedures, with knee replacement showing the greatest variation in both index surgery (107%) and total cost of care (75%). Readmission was a driver of variation for colectomy and CABG, with absolute cost variation of $17,257 and $13,289 respectively. Other post-acute care spending was low overall (≤$1606, for CABG).

CONCLUSIONS

This study demonstrates significant regional variation in total spending for these procedures, but much lower spending for post-acute care than previously demonstrated by similar procedures in Medicare. Targeting post-acute care spending, a common approach taken by providers in bundled payment arrangements with Medicare, may be less fruitful in working aged populations.

TRICARE For Children: Between Medicaid And Marketplace Plans For Comprehensiveness And Cost Sharing

TRICARE provides health care benefits to nearly two million children of active duty, retired, National Guard, and reserve service members. Child health advocates and congressional reports have raised questions regarding the adequacy of these benefits, compared with other sources of children's health insurance. To help address these questions, we compared TRICARE benefits with benefits from Medicaid and Marketplace plans because they represent alternative sources of coverage for many of the families enrolled in TRICARE. Overall, we found that TRICARE benefits fell in the middle-between Medicaid plans' more comprehensive benefits with no cost sharing and Marketplace plans' more restrictive benefits with higher cost sharing.

Families With TRICARE Report Lower Health Care Quality And Access Compared To Other Insured And Uninsured Families

Children in military families, who receive health insurance through the TRICARE program, face barriers to care such as frequent relocations, unique behavioral health needs, increased complex health care needs, and lack of accessible specialty care. How TRICARE-insured families perceive health care access and quality for their children compared to their civilian peers' perceptions remains unknown. Using data from the Medical Expenditure Panel Survey, we found that TRICARE-insured families were less likely to report accessible or responsive care compared to civilian peers, whether commercially or publicly insured or uninsured. Military families whose children had complex health or behavioral health care needs reported worse health care access and quality than similar nonmilitary families. Addressing these gaps may require military leaders to examine barriers to achieving acceptable health care access across military treatment facilities and off-base nonmilitary specialty providers, particularly for children with complex health or behavioral health needs.

Provider Acceptance And Beneficiary Access Under TRICARE's PPO Health Plan

TRICARE provides health benefits to more than nine million beneficiaries (active duty and retired military members and their families). Complaints about access to civilian providers in TRICARE's preferred provider organization (PPO) plan led Congress to mandate surveys of beneficiaries and providers to identify the extent of the problem and the reasons for it. The beneficiary survey asked about beneficiaries' perceived access to care, and the provider survey asked about providers' acceptance of TRICARE patients. TRICARE's civilian PPO plans are required to maintain provider networks wherever TRICARE's health maintenance organization option (known as Prime) is offered. For the years 2012-15, we describe beneficiary access and utilization and provider participation in TRICARE's PPO plans in Prime and non-Prime markets. We also compare individual market rankings for access and acceptance. In both market types, most providers reported participating in TRICARE's PPO network, and most PPO users reported using network providers. In areas where Prime is not offered, PPO users reported slightly better access, and providers were more likely to accept new PPO patients. Areas with low access and acceptance, or where multiple access measures indicate problems, may be fruitful for in-depth investigation.

Children of Military Families

There are special considerations when treating depression in the children of military families, due to both unique stressors and unique access to treatment and support resources. This article provides a brief overview of the history of military family care, an understanding of ongoing efforts to provide excellent and timely care for these children, and an understanding of the unique stressors and challenges that the depressed military child faces. The Department of Defense is dedicated to providing for the unique needs of military children and providing robust services to care for these children and their families.

Patient driven care in the management of prostate cancer: analysis of the United States military healthcare system

Background

Patient preferences are assumed to impact healthcare resource utilization, especially treatment options. There is limited data exploring this phenomenon. We sought to identify factors associated with patients transferring care for prostatectomy, from military to civilian facilities, and the receipt of minimally invasive radical prostatectomy (MIRP).

Methods

Retrospective review of 2006-2010 TRICARE data identified men diagnosed with prostate cancer (ICD-9 185) receiving open radical prostatectomy (ORP; ICD-9: 60.5) or MIRP (ICD-9 60.5 + 54.21/17.42). Patients diagnosed at military facilities but underwent surgery at civilian facilities were defined as “transferring care”. Logistic regression models identified predictors of transferring care for patients diagnosed at military facilities. A secondary analysis identified the predictors of MIRP receipt at civilian facilities.

Results

Of 1420 patients, 247 (17.4%) transferred care. These patients were more likely to undergo MIRP (OR = 7.83, p < 0.01), and get diagnosed at low-volume military facilities (OR = 6.10, p < 0.01). Our secondary analysis demonstrated that transferring care was strongly associated with undergoing MIRP (OR = 1.51, p = 0.04).

Conclusions

Patient preferences induced a demand for greater utilization of MIRP and civilian facilities. Further work exploring factors driving these preferences and interventions tailoring them, based on evidence and cost considerations, is required.

Surgery for Otitis Media in a Universal Health Care Model: Socioeconomic Status and Race/Ethnicity Effects

OBJECTIVES

(1) To determine the association between socioeconomic status (SES), race/ethnicity, and other demographic risk factors in surgically managed otitis media within a model of universal health care. 2) To determine quality of life (QOL) outcomes of surgically managed otitis media in this model.

SETTING

Tertiary academic medical center.

STUDY DESIGN

Prospective cohort study.

METHODS

A prospective study was conducted between June 2011 and December 2012 with dependent children of military families. TRICARE provides equal access to care among all beneficiaries regardless of a wide range of annual incomes. Caretakers of children scheduled for bilateral myringotomy and tympanostomy tube (BMT) placement were administered a demographic survey, as well as OM-6 QOL instrument preoperatively and 6 weeks postoperatively. A control group who did not undergo BMT was also administered both the survey and OM-6 for comparison.

RESULTS

Two hundred forty patients were enrolled (120 surgical patients and 120 controls). Logistic regression demonstrated age younger than 6 years old (P < .001), day care attendance (P < .001), and non-Hispanic Caucasian race (P = .022) to be associated with surgery. Surgical QOL outcomes demonstrated a significant improvement in otitis media-6 (OM-6) scores after surgical management from 3.00 (95% confidence interval [CI], 2.79-3.20) to 1.35 (95% CI, 1.22-1.47).

CONCLUSION

In a universal health care model serving more than 2 million children, previously reported proxies of low SES as well as minority race/ethnicity were not associated with surgically managed otitis media contrary to reported literature. Caucasian race, young age, and day care attendance were associated with surgery. Surgery improved QOL outcomes 6 weeks postoperatively.