DOD Health Care:

Improvements Needed for Tracking Coordination of Specialty Care Referrals for TRICARE Prime Beneficiaries

GAO-19-488: Published: Jun 12, 2019. Publicly Released: Jun 12, 2019.

Additional Materials:

Contact:

Debra A. Draper
(202) 512-7114
DraperD@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

Beneficiaries of DOD's TRICARE Prime health care plan must get referrals for specialty care. They may obtain this care from military or civilian providers. To ensure continuity of care, these providers must communicate with each other.

We found the system DOD uses to track referrals contained incomplete and inaccurate information, which could disrupt patients' care. DOD has begun transitioning to a new system, but we also have concerns about whether staff are adequately trained in it to ensure data accuracy.

We recommended that DOD ensure staff are trained to accurately record information about specialty care referrals in the new system.

Photo of an American flag with dog tags and a stethoscope resting on it

Photo of an American flag with dog tags and a stethoscope resting on it

Additional Materials:

Contact:

Debra A. Draper
(202) 512-7114
DraperD@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

What GAO Found

The Department of Defense's (DOD) Defense Health Agency (DHA) has limited information about the extent to which the referral management process facilitates the coordination of primary and specialty care for beneficiaries enrolled in TRICARE Prime—a managed care option—because information about their specialty care referrals is not always complete or accurate. The coordination of care for these beneficiaries is important because they may move between military treatment facilities (MTF) and civilian providers to obtain needed care. DHA requires specialty care providers to share documentation about the care they provided for referring primary care managers to review. This and other information is to be documented in the Referral Management Suite (RMS), the information technology system used by MTF officials to track and process referrals. However, GAO found that the five MTFs it visited had incomplete and unreliable data in RMS due to lack of training and insufficient staff. For example, GAO found that some MTFs were not tracking referral results in RMS due, in part, to lack of training. Officials with each of the military services told GAO that they are aware of RMS reliability issues and have been working to address them through system updates, training, and hiring staff.

DHA has begun to replace RMS and other existing information technology systems with Military Health System (MHS) Genesis, a new electronic health record system. The implementation of MHS Genesis began in 2017 at four MTFs, which have experienced difficulties with system implementation, including with referral management.

GAO found that the four MTFs using MHS Genesis were not adequately trained on how to use its referral management component prior to the system's deployment. This limited the MTFs' ability to process and track referrals, and led to concerns about the reliability of the system's referral data. While MHS Genesis training on referral management has been redesigned for the next round of MTFs slated for implementation in summer 2019, officials said that it remains unclear whether this training will provide the guidance needed for MTF officials to accurately process and capture information on specialty care referrals. Without adequate training, DHA cannot ensure that the referral data in MHS Genesis accurately reflects the referral experiences of its Prime beneficiaries, potentially impacting the timeliness and quality of care they receive.

DHA and military service officials who are responsible for developing standardized referral management guidance for the department—the Referral Management Working Group—said that they have not been able to obtain reports about referrals for the four MTFs that use MHS Genesis. The system would need to be configured to produce the types of referral reports needed, according to these officials, who told GAO they have been working with the DHA officials responsible for system implementation to develop such reports. Without reliable reports on referrals, DHA will continue to lack the information it needs about the coordination of care for its TRICARE Prime beneficiaries, impeding its ability to manage referrals, as well as ensuring these beneficiaries receive needed care.

Why GAO Did This Study

Specialty care referrals are a key component of care coordination for TRICARE Prime beneficiaries. Each Prime beneficiary is assigned to a primary care manager either at an MTF or within the civilian provider network. Primary care managers are responsible for overseeing all aspects of their patients' care, which includes making referrals for specialty care when needed.

The National Defense Authorization Act for Fiscal Year 2017 included a provision for GAO to examine care coordination within and between the direct and purchased care systems. Among other objectives, this report examines the extent to which the referral management process facilitates the coordination of primary and specialty care for TRICARE Prime beneficiaries. GAO examined relevant policies; analyzed current referral data from five MTFs it visited, selected for variety in military service, geographic location, and numbers of referrals; and interviewed officials with DHA and the military services. GAO also discussed the implementation of MHS Genesis with officials at DOD and the four MTFs where it has been implemented.

What GAO Recommends

GAO recommends that the Secretary of Defense ensure that (1) MTF referral staff are trained to process and accurately document information in MHS Genesis about specially care referrals and (2) MHS Genesis is configured to produce reports with reliable data on the referral process. DOD concurred with both of these recommendations.

For more information, contact Debra A. Draper at (202) 512-7114 or DraperD@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Secretary of Defense should direct DHA to ensure that MTFs' referral management center staff are trained to process and accurately document information in MHS Genesis about specialty care referrals, including the receipt of CLRs, the submission of referral results, and the closure of referrals. (Recommendation 1)

    Agency Affected: Department of Defense

  2. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Secretary of Defense should direct DHA to ensure that MHS Genesis is configured to produce reports that accurately reflect the use and outcomes of specialty care referrals. (Recommendation 2)

    Agency Affected: Department of Defense

 

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