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New TRICARE contracts shake up fees for some, startle doctors

Dr. Jennifer E. Brooks, a retired Navy commander with a doctorate in clinical psychology, is a TRICARE network healthcare provider in Pensacola, Fla.  She specializes in treating mental health trauma of military patients, including medically disabled retirees suffering from combat-related, post-traumatic stress disorder.

In March, Brooks and behavioral healthcare therapists caring for beneficiaries across TRICARE's 10-state South Region received new "contract packets" inviting them to continue to see their patients but as members of new behavioral healthcare network, this one run directly by Humana Military and with a revised fee deal.

The new "payment arrangement," Brooks was startled to discover, would have her accepting a "30 percent" discount off TRICARE maximum allowable charges.  By law, the TRICARE maximums can't exceed Medicare rates.

Brooks reviewed her current TRICARE contract, signed a few years ago with Humana sub-contractor ValueOptions, and found she already was accepting 10 percent less than Medicare pays.  The new contract, to take effect Jan. 1, would have Brooks accept another 20 percent cut on her therapy services.

"By reducing reimbursement rates so drastically," Brooks warned, "Humana is creating a situation where working for TRICARE becomes an entry-level therapy position.  Yes, all their therapists will have licenses.  But the average length of time they have had those licenses will go down."

For "a trauma therapist working with the military community, trust is a very big issue," Brooks added. "Many of my clients with PTSD have told me that previous therapy was not effective because they were sent to a young person with no military experience whom they could not relate to" and the dropout rate was high.

Providers and beneficiaries might be alarmed by the prospect of falling provider fees for mental health therapy, but they would be wrong to assume TRICARE officials or members of Congress share their concerns, at least right now.

Last year Humana and HealthNet won the next generation TRICARE support contracts to deliver health services for the next five years. Humana is to run the new East Region, formed by merging the current North and South Regions.  Health Net will take over the West Region contract from United Health.

Part of Humana's winning bid included building its own network of mental health providers rather than rely, as it does now in South Region, on subcontractor ValueOptions.  The initial agreements to providers to accept 30 percent off Medicare rates will be, for some therapists, only the start months-long negotiations.

TRICARE officials are monitoring progress by Humana and HealthNet as they build their networks. But they also know the contracts are designed around discounts to hold down costs to the government and secure profits for contractors.

"Our No. 1 concern is that our beneficiaries get the care they need, that it's high quality care and they get it when they need it," said Navy Capt. Edward Simmer, deputy director of the TRICARE Health Plan in Falls Church, Va.

"We hope, to the greatest extent possible, that providers currently providing care to our patients are able to reach agreement with Humana and that they can continue to provide that care so there's no disruption," Simmer said.  "But certainly if some of those providers do choose to leave our network, then we will make absolutely sure the patients they were seeing are immediately referred to another well-qualified provider so their care will continue."

Asked if it is unusual for a contractor to press for a 30-percent rate cut off what Medicare pays, Simmer said discount negotiations are "between the contractor and the providers." TRICARE leaders keep their focus is on whether the contractor provides a large enough network of "high-quality providers."

Congress also sees its role in these contracts as limited to ensuring provider networks are robust and deliver the benefits defined by law. It doesn't tell contractors how to build their networks or what to pay.  That's their business.

Matt Paynter, chief of staff for Humana Military, suggested the confidence shown is justified. His company, he said, has supported TRICARE for 20 years.

"We get great ratings so I can comfortably say we do a good job and have good experience," Paynter said. Company goals for the new contract are to deliver high-quality care, give patients access to care "above and beyond contractual requirements" while "focusing hard on that continuity of care."

To build out behavioral health capacity, he said, "the goal is to negotiate a mutually agreeable reimbursement rate with providers.  Certainly, this is never a take-it or leave-it-you're-going-to-get-kicked-out thing.  We work with providers."

Therapists have more leverage to negotiate depending on where they practice, number of local TRICARE beneficiaries and demand for their specialty.

Dr. Deborah Okon, a clinical psychologist and TRICARE provider in Belen, N.M., said she is one of only two psychologists in a town of 56,000. She specializes in treating eating disorders. New Mexico has too few behavioral health providers.

That's why when Okon got a preliminary contract from HealthNet recently, proposing that she accept reimbursements equal to 85 percent of Medicare rates, she lined out that number and wrote "100 percent" instead.

Okon said she hopes this will be the fourth straight TRICARE contract signed in the last 20 years where she can negotiate fees to match Medicare rates. But she knows that elsewhere in her state the contractor could hang tough on lower fees. As a result, too many therapists will continue to avoid participating in TRICARE.

"Why would [therapists with] PhDs work for the military if they can get 15 percent more by working for Medicare," Okon said.

The reason some give is the steady volume of patients.  Others appreciate the speed of TRICARE payments or the opportunity to care for military patients.

Told that Humana is seeking discounts of 30 percent off Medicare rates for behavioral therapists in southern states, Okon said she was dumbfounded by that approach to securing health services for the military.

"What is the discount thing," she asked.  "Who's getting that money?  Is that administration?  I don't get why they're asking providers to accept so much less."

Paynter for Humana said company profits from discounts "are less than you might think."  The bulk of savings on fees benefit the government through competitive contract awards, he said.  Also, he suggested, the process works. Many behavioral health providers already have signed the deal. Others will "require a more hands-on approach to negotiating and reaching an agreement," he said.

But Humana, he said, already has data showing it has secured a network of behavioral healthcare therapists across the southern states that will surpass access standards demanded by the new contract.

Will that network, as Dr. Brooks contends, be less experienced and thus provide lower quality care for PTSD and mental health challenges?

"Absolutely not," said Paynter.  "We hold our providers and ourselves to very high standards and we have a long history of meeting and exceeding standards."

Brooks is skeptical. More than 90 percent of her patients, she said, have military ties, almost 80 percent of those have PTSD.  Therapists most likely to have succeed in treating them, she said, "have worked with the community long enough to develop a cultural competency.  With time, they become familiar with the unique environment, can speak the language  where acronyms abound  and really understand that 'duty, honor, country' is not just a slogan to these individuals."

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