Reducing TRICARE costs—we all play a part

COLUMBUS AFB, Miss. -- Recently, someone expressed concern that the out-of-pocket costs for TRICARE health insurance were rising. In 2006, the Department of Defense did propose increased TRICARE enrollment fees and deductibles for retirees and dependents under age 65 with the goal to save $9.8 billion over five years. In addition to collecting higher fees, the calculation of savings was based on the assumption that approximately 500,000 retirees and dependents under age 65 would either leave or choose not to enroll in TRICARE because of these higher fees.

Congress rejected the plan because they felt that, although there would be savings, the projected number of people who would opt out of TRICARE was too high. Many beneficiaries in the under 65 retiree and their dependents group, particularly older and sicker individuals, are unlikely to have lower-priced health insurance options available to them and would therefore be likely to stay with TRICARE.

While Congress delayed the increased costs, some changes in the future are inevitable. With the Defense Health Care budget soaring from $17.4 billion in 2000 to a whopping $35.4 billion in 2005, something has to give. There are serious issues with health care costs.

All that sounds a million miles away up in Washington DC and not our problem, but we impact those costs right here at Columbus AFB. It is important that we all understand how our use of health care increases those costs. When first enrolling in TRICARE, each family should have received an explanation of benefits. It is important to read and understand these benefits to decrease the amount of money your family will have to pay for medical bills that aren't paid by TRICARE--your out-of pocket costs.

To help control health care costs, the AF Surgeon General set two business plan goals with the first one being to maintain/increase our enrollment to optimize the resources DoD has already paid for to provide health care at Columbus. The clinic has three Family Practice providers and enough Flight Surgeons to handle Flight Medicine Clinic enrollees and the operational support requirements of the base. So, with that complement of providers and support staff, we are funded for an enrollment of 6000 beneficiaries. This is why we carefully scrutinize all requests to enroll with a downtown primary care provider. As you would expect from a military population, the majority of our beneficiaries are young and healthy. They have the typical colds and illnesses and require annual physicals and follow up care after visiting specialists. If a family member has a chronic illness that requires a lot of specialty care, we will approve that individual to enroll with a specialist practice.

The second business plan goal is to keep as much care "in house" as possible and to control the amount of care that is sent out to specialists. The base clinic isn't funded to provide emergency room level care or a lot of specialty care, so we budget money to pay for those additional costs. One way of controlling those costs is to require a provider referral for all specialty visits. You and your family have the right to go to a specialist on your own, but TRICARE will not pay the charges. So you will end up paying point-of-service fees for that privilege. If you want to control your family's out-of-pocket medical costs, be sure to get a referral from your primary care provider.

A second example of a way to avoid out-of-pocket costs for your family and also decrease DOD health care costs is to reduce Emergency Room visits. You would be surprised at the reasons people from our base visit the emergency room. We get all the bills and have seen people go for anything from diaper rashes and sore throats to car wrecks. We want you to use the Emergency Room for true emergencies but a lot of visits are the result of waiting too long to contact someone for assistance. We have a provider on call whenever the clinic is not open. Just call the appointment line 434-CARE and the answering service will contact our provider on call who can help you determine whether that ER visit is necessary or whether another less expensive option is available. The provider can call in a prescription to a downtown pharmacy or can refer you to an after hours clinic where the wait will be shorter and charges will be less than an ER visit.

When you do have to go to the ER for sutures or some other true emergency, be sure to follow up at the clinic, not at the ER. We recently saw an example of where an individual went to the ER to get a cut finger sewn up. The ER staff gave instructions to follow up in two days. The member returned to the ER without contacting the clinic. All they received at the ER was a dressing change and more instructions to get the stitches removed in two weeks. Again, the member returned to the ER only to get another wound check, dressing change and told to return in another week to get the stitches out--which they did. The final bill for these four ER visits was over $1,400! Over $300 of the bill was for dressing changes that could have been done at the clinic. TRICARE considered the last three visits to be point-of-service charges that must be paid by the enrollee. If the member had contacted the clinic after the first ER visit, all these follow up visits could have been at the clinic with no out of pocket cost to the member.

So, in summary, we want you to go to the Emergency Room for injuries or illnesses that threaten life, limb or eyesight. The cut finger in the example above was certainly appropriate. But to save health care costs for yourself and DOD, always contact the clinic or the clinic provider on call before you return for a follow up visit or go to a specialist. If we send you to a specialist, we are agreeing to pay the bill. If you have a problem that is not an emergency but requires care before the clinic reopens, contact the provider on call to see if you can be seen in an urgent care clinic where the wait is shorter.