Tricare Philippines Newsletter 14006
Access to Care, Jiving Congress & Hiding Under the Skirts of Contractors
We have three areas to report on in this newsletter.
A new access to care low has been reached
Using the Defense Health Agency’s (DHA) own data we will show that we reached a new all-time low in access to care. This means most of you are paying for your own care or dying because of a lack of care.
To try to make it abundantly clear just how bad it is and to use the latest data, I will do a down and dirty comparison that, while understating the expected per capita cost in the Philippines it still shows a huge chasm between what should be paid and what is paid and which is much worse than our earlier comparison using 2010 data.
In the TRICARE Fiscal Year 2013 Report to Congress DHA reported on page 90 of the report that the average under 65 retiree/survivor and family member on Standard/Extra utilized $8,515 of health care with $7,476 paid by TRICARE per beneficiary. On page 93 of the report the average 65 and over retiree/survivor and family member on Standard/Extra utilized $15,664 of which TRICARE and Medicare paid $15,175 per beneficiary; TRICARE Overseas covers what Medicare would pay in the states.
The DODIG in Report 2014-052 stated that in 2012, $3,610,817 was spent by TRICARE on beneficiary medical care in the Philippines.
Using the DOD Actuary report of retirees and survivors in the Philippines in 2012 and a factor of 1.69 to calculate family members there would have been 11,782 TRICARE beneficiaries in 2012. (DHA claimed there were 11,000 in 2009)
The DHA says the cost of care in the Philippines is 54% of what it costs in the U.S. except that the cost of pharmaceuticals, laboratory and radiology is at 100% and higher cost inpatient care generally involving open heart surgery and cancer treatments are closer to 80% of the cost in the U.S. as well; mostly due to high cost medical supplies.
If we forget the higher cost areas and assume everything costs 54% of what it costs in the states. And if we assume that no Philippines beneficiary is 65 or over and take 54% of $7,476 we find it comes to $4,037. But in 2012 they spent $306 per beneficiary in the Philippines. ($3,610,817 ÷ 11,782)
That works out to 7.6%, ($306 ÷ $4,037) of what is spent on under 65 beneficiaries and a clear indicator that what TMA/DHA told the DODIG, as shown in their report above, is true. Further the information I provided for these calculations are available to anyone on the internet including DHA and the DODIG.
If one was to consider the relative higher cost of care by calculating the percentage that applies to ancillary costs and also used the percentages of 65 and over beneficiaries per the DOD Actuary the percentage would drop considerably and be closer to 4% or less of what would be expected.
Even if you don’t consider those points, it should be clear that even at 7.6% something is dramatically wrong and it should be clear that TMA/DHA and the DODIG are looking the other way to protect their agendas at the expense of beneficiaries in the Philippines.
We all know DHA’s spin doctor’s push out lots of fables, distortions and fabrications, but this is a new low and by a general officer no less
In January 2014 Lt. Gen Robb, Director of DHA appeared before a subcommittee of the House Armed Services Committee. Our Congressman asked that we prepare a question for him regarding issues with TRICARE in the Philippines which he recently answered in writing. We all know how DHA likes to spin the truth when they talk to us or the media. However the spin in the general’s response goes well beyond spin to downright falsification of facts as well as the typical spin.
My Congressman presented the written question asking, among other things, about the status of the long missing employee. His response contained statements that were not true, begged the question or that were misleading and intended to deceive Congress and beneficiaries.
Two paragraphs deal with the promised government employee.
“In 2008, the Deputy Director, TRICARE Management Activity (TMA), visited the Republic of the Philippines. Based on what he saw and heard from the retired beneficiaries, as well as his awareness of significant fraud issues in the Philippines, the Deputy Director directed establishment of a satellite office in the Philippines to enable the TRICARE Area Office- Pacific to better support beneficiaries living there. At that time, office space was identified at the old Clark Air Force Base, and coordination was completed to have a U.S. citizen who would staff the office fall under the protection of the U.S. Embassy. Since that time, the space at the old Clark Air Force Base is no longer available.”
“In 2012, the Deputy Director, TMA reversed the previous decision to establish a satellite office in the Philippines in light of several factors. These factors included the award of the TRICARE Overseas Program (TOP) contract in 2009 to International SOS Assistance (International SOS). This contract requires the operation of a 24/7 Regional Call Center, staffed with customer service representatives trained to assist beneficiaries and host nation providers with questions about claims, locating a provider, benefit determinations, and authorizations for care. Additionally, the agency had decided to implement the Philippine Demonstration Project which is designed to increase access to quality health care, eliminate the need for beneficiaries to file their own claims, and control costs. The Demonstration Project began in January 2013. Nowhere else do we have a TRICARE office specifically to support the retiree population in any other overseas location and establishing one in the Philippines would be potentially precedent-setting, resulting in retirees living in other overseas locations expecting to have a satellite office established specifically to support them. And finally, in this resource constrained environment, establishing a satellite office in the Philippines was not a fiscally sound decision.”
These two paragraphs are fraught with wrong, misleading or manufactured information if not outright lies.
“Due to the absence of TMA resources in the Philippines, TRICARE beneficiaries must rely on phone calls and internet searches for information.Establishing a small TMA presence in the Philippines would provide an opportunity for TMA to educate both providers and beneficiaries. Beneficiaries would have a better outlet for resolving medical claim discrepancies and a direct means for reporting suspected fraudulent claims.”
- The Deputy Director of TMA in 2008 was MG Elder Granger a longtime friend and who I spent many hours discussing the TRICARE issues in the Philippines; he retired in July 2009. He never visited the Philippines contrary to Lt. Gen Robb’s claim above. Not only didn’t he ever visit, his request to visit the Philippines in 2009 was denied. The truth is he decided to place an employee in the Philippines after my and other retiree’s recommendations and to accomplish two goals. The first was to have someone on the ground to monitor the effects of various policies/restrictions imposed by TMA/DHA and provide feedback so adjustments could be made to minimize loss of access to care. Second was to assist beneficiaries with the complex requirements, unique to Philippine TRICARE, in converting claims from local global bills to U.S. itemized and costed bills.
- The lost space at Clark was rented by TMA/DHA and remained vacant for years while TMA/DHA and the Embassy argued over the location. The Embassy refused to allow them to hire someone and place them at Clark due to security concerns. Finally TMA/DHA agreed to move the position to Manila and space was negotiated at the newly built VA clinic. This was three years later, in 2011, and at the same time, as they told the DODIG, they advertised the position for a second time.
- The TOP contract and so called 24/7 Regional Call Center were a known quantity in 2008 when MG Granger agreed to the position and was not designed to duplicate but to compliment it with additional functions. In addition the DODIG addressed this as well in 2011 well after the TOP contract start, implying it was insufficient when they said.
So the claim that this newly discovered information removed the need for the position is felonious. In addition the DODIG made it clear that this was in addition to currently available resources and TMA/DHA responded that they concurred with the reasoning of the DODIG. Obviously TMA/DHA was well aware of the 2009 TOP contract and associated support as was the DODIG in 2011 when the DODIG called for the addition of this position. In addition the DODIG report specifically addressed significant issues with local providers understanding TRICARE policies and well after the TOP contract went into place. So while he said.
“This contract requires the operation of a 24/7 Regional Call Center, staffed with customer service representatives trained to assist beneficiaries and host nation providers with questions about claims, locating a provider, benefit determinations, and authorizations for care.”
He knew full well that the contractor was not meeting those needs that the DODIG was addressing and to which TMA/DHA agreed. This claim is inconsistent with the facts and clearly is begging the question.
“Additionally, the agency had decided to implement the Philippine Demonstration Project which is designed to increase access to quality health care, eliminate the need for beneficiaries to file their own claims, and control costs.”
- He also made this claim.
This is nothing more than a false premise as the Demonstration was on the table and defined well before 2012. In fact it was included in the DODIG report as an acknowledgement that TMA/DHA was in the process of implementing the Demonstration and even listed the processes that were to be included. So both TMA/DHA and the DODIG knew of this project and considered it when the recommendation and concurrence were made. In addition the statement about increasing access to quality health care is totally felonious as the TOP contract does not require quality checks of providers and senior ISOS staff confirmed the only quality check was to use certified providers who they also admitted were not checked for quality. Further the claim that the Demonstration would eliminate the need for beneficiaries to file their own claims is also a false premise since at least 40% of the beneficiaries in the Philippines reside outside the 2% of the Philippines that is covered by the Demonstration. In addition the majority of specialties within the Demonstration areas carry waivers that require beneficiaries in these areas to revert to the alternate and limited Philippine TRICARE Overseas Standard. This is also the case whenever the 60% that are in the Demonstration areas travel. The reality is thousands of claims are still filed by beneficiaries unless, like many, they opt to pay for their own care because they feel that their claims will not be paid anyway.
It is also interesting to see how Lt. Gen Robb begs the questions on certification in his response to the House Armed Services Committee with regard to the issue of national certification of pharmacies, the Philippine Red Cross and major hospitals in the southern Philippines.
In his first paragraph he says;
“All three of the major national pharmacy firms operating in the Republic of the Philippines are TRICARE certified. Mercury Drug was certified in September 2010; Rose Pharmacy in April 2012; and Watsons Pharmacy in July 2013. Certification of these pharmaceutical companies at the corporate level allow TRICARE beneficiaries to access any of these pharmacies’ stores, regardless of where in the country they are located. The Philippine National Red Cross is TRICARE certified effective February 19, 2014. Similar to the certification of the pharmacy companies, certification of the Red Cross at the national level allows TRICARE beneficiaries to access any of the 80 Red Cross Chapters in the Philippines to obtain the necessary testing and blood supplies they may need. Due to the delay in certifying the Philippine National Red Cross, the Defense Health Agency has directed the TRICARE Overseas Program contractor to reprocess all previously submitted claims since September 2010 and provide the appropriate reimbursement to the beneficiaries for their out of pocket expenses for testing and blood supplies obtained from any Philippine Red Cross chapter.”
This is followed with one sentence buried at the end of the last paragraph that states;
“Additionally, throughout the Philippines there are 301 certified institutional facilities that provide inpatient services and 4,335 individual certified providers.”
The original questions were: “Major national pharmacy firms and the Red Cross and all of its field offices have refused to work with the contractor denying beneficiary access to numerous pharmacies and a major source of blood. One of four internationally accredited hospitals and the only one in the southern Philippines cannot be used by beneficiaries for what appears to be nothing more than a paperwork exercise as it is obviously a licensed and legitimate hospital with better quality than many currently certified hospitals.”
- Declaring that all three of the major national pharmacy firms are certified simply begged the question which dealt with why major national pharmacy firms refused to work with the contractor. Two major national pharmacy firms, Manson Drug and South Star Pharmacy have refused to work with ISOS and are no longer available to beneficiaries. That was the issue he should have addressed. He didn’t even get the dates of national certification right but real facts don’t seem to be of concern to TMA/DHA; Mercury Drug was not nationally certified in 2010. It wasn’t until mid-2011 when I brought up the subject yet again while at Tripler in Hawaii that a TMA/DHA employee agree to talk to ISOS again to see if they would agree; we pushed this approach for 5 years before it happened. In the past ISOS turned down the idea as not feasible. But then they were paid by certification plus travel costs where, now the contract had been changed and they were paid a fixed annual fee. My belief is this was the real incentive that finally allowed this process to go forward.
In addition, at the time the question was posed to the director, the Red Cross and all of its field offices had refused to cooperate with ISOS on certification. I was advised we would have to find alternative sources of blood as it would not be certified. External publicity apparently forced TMA/DHA to direct ISOS to certify the Red Cross based on its international certification rather than a local check of the provider since within days of this exposure the denied certification of the Red Cross and all its chapters was reversed. When you consider normal certifications take 90 days or more for a single location, this was a significant event. For as long as certification was required claims from the Red Cross have been denied. Only when I raised the issue of these denied claims and certification with a now deceased WWII Filipino-American retiree and was told of the refusal to cooperate was the issue made public through our blog. Per my recommendation in the blog one or more retirees contacted the Armed Services Blood Program on Facebook asking if they might provide blood to TRICARE beneficiaries in the Philippines because of the certification denial. I know that they brought this to the attention of TMA/DHA and within days the denial was reversed and probably set a record for certification, let alone a national certification with hundreds of chapters spread throughout the country. The comment about the delay in certification prompted a directive to reprocess all previously denied claims shows two things. One, if it is to be believed, ISOS was negligent in certifying the Red Cross for 4 years. Since the relook was really the result of my raising this issue and the denied WWII retirees’ 2010 claim and suggesting that they relook these claims it seems TMA/DHA is trying to mislead the public in the real truth behind this recent certification reversal and retroactive payments.
Why you may get nonsensical answers from Congress if you inquire about TRICARE in the Philippines.
- The second certification issue posed in the question referenced the failure to certify an internationally accredited hospital while certifying others with much lower quality. This question was ignored completely. Instead of answering the question the General bypassed the question by listing statics that were not relevant to the original question. So the question remains unanswered. This was nothing more than begging the question instead of providing a real response to the issue at hand. We know, based on responses from ISOS and TMA/DHA and reviewing the TRICARE Operations Manual (TOM) that quality of providers is not a concern when selecting overseas providers and many of the hospitals that are certified lack facilities that westerners have come to expect. But they may be the only hospital in an area. This video is an example of the kind of hospitals that TMA/DHA accepts for their Demonstration. The real issue still exists and high quality internationally accredited hospitals still remain uncertified due to a paperwork exercise gone bad.
We have two requests for assistance with our Congressman regarding various failures of ISOS to comply with their contract dealing with Demo training and customer service. In a recent email exchange with one of the Congressman’s staff he explained the delay in obtaining responses by indicating that the TRICARE portion of DHA has apparently contracted out Congressional responses to the respective TRICARE contractors. We saw this before from our Senator where ISOS simply disregarded the issues in favor of beating their own drum and more recently with a response another retiree received. In other words if you are overseas and have an issue with TRICARE and write your Congressman or Senator, any inquiry they make will be routed to ISOS to answer; talk about using the fox to guard the henhouse. He said since my issues which are well documented specifically charge ISOS with negligence he felt DHA should respond. He has been trying to contact DHA with little success but was finally told to call “Program Integrations” who may consider responding to the Congressman’s inquiries.
We think this speaks volumes to how DHA hides behind known corrupt contractors and allows beneficiaries to suffer. If any of you have tried to complain to Congress about your treatment here, it may also shed some light on why you never received a response that made one iota of sense.
Bottom line. It seems the former TRICARE Management Activity (TMA) and now DHA have pretty much covered all the bases in their attack on TRICARE beneficiaries in the Philippines.
- We have almost no access to care
- Their spin doctors have convinced Congress and the media that we receive excellent access to care and claims processing is a breeze even while they continue to fight to continue to reduce massive fraud in the Philippines.
- They have successfully isolated themselves completely from those they are well paid to serve. Beneficiaries haven’t had access to DHA for years as all their issues go through a convoluted complaint process that requires they deal directly with the contractor who then reports to DHA how successful they are in doing their job. Now they have done the same with Congress.
As we gather more information from DHA, the contractor and beneficiaries we will continue to send out newsletters but generally not more than once a month.
What we continue to see is rapidly put together policy that sometimes changes within a few days only to be changed again. These in turn raise new issues or other unforeseen problems surface. To keep up with these we will post shorter topic specific updates and notices on our blog, TRICARE Overseas Philippines Blog. Recommend those interested in keeping informed on Philippine TRICARE Standard and the Demonstration check it frequently or alternately add your email address and click “Follow” about midway down the front page and on the right. This will automatically email you a link to each new entry.
Previous Newsletters can be accessed by going to U.S. Military Retirees of the Philippines Group TRICARE Newsletter Archive. If you want to access an older Newsletter that has dropped off the archive list see Links to Old Newsletters
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 The DOD Actuary data for 2012 indicates that 52% of retirees are 65 and over while 72% of survivors are 65 and over.
 Our survey of military retirees living in the Philippines clearly showed that a significant number no longer file claims because of their past experiences where the claims were denied on a technicality or because they were not able to itemize and code their claims.