Karen Welch had plenty of reasons to break out the worry beads last year, even before she dealt with Tricare, her new health insurance provider.
The Zionsville resident was a month pregnant with her first child when she watched her husband, Travis, leave for Afghanistan with his Indiana National Guard unit.
Then she learned she had to find a new primary care physician who would accept Tricare. She also needed an obstetrician/ gynecologist and a pediatrician in the netwowrk for Tricare, the health care coverage the government provides for active-duty soldiers and their families.
"I only interviewed two pediatricians because there were only two or three in the area I didn't have to drive 30 miles away to see," she said.
More than 1,200 Indiana National Guard members have returned from Afghanistan in recent months, and some providers and guard veterans worry they'll encounter frustrations similar to Welch's as they readjust to civilian life.
OrthoIndy surgeon Dr. John Dietz, a West Point graduate and former U.S. Army physician, said he hopes his colleagues consider it a duty to accept returning soldiers and their Tricare coverage. It's a concern shared in Washington and many other corners of the country.
However, providers say dealing with Tricare can mean dealing with payment delays, bureaucratic snarls and reimbursement that yields pennies on the dollar.
The federally funded Tricare covers active-duty service personnel, their families and military retirees. That includes coverage for National Guard and reserve troops after they're activated and during their transition back into civilian life.
The Falls Church, Va.-based program covers 9.2 million people and pays for treatment on and off military bases. It works with regional contractors who administer the plan. California-based Health Net Inc. administers Tricare in Indiana.
The wars in Afghanistan and Iraq and the resulting call-up of military personnel have made thousands of additional families eligible for this coverage. Some need it because their private insurance coverage can be suspended during active-duty service.
In many instances nationally, those families not near a military base have found a cool reception to Tricare. In Arkansas, for instance, only about one of three doctors accepts the coverage, according to U.S. Rep. Vic Snyder, D-Arkansas.
"I'm convinced that it's a national issue that becomes more problematic in those states that call up large numbers of guard and reserve forces," said Snyder, a member of the House Armed Services Committee.
Sorting through the problems
Many say reimbursement is the main problem.
Tricare reimbursement rates vary, but they generally fall slightly below those for Medicare, the federal insurance program for the elderly and the disabled, according to Snyder. Medicare reimburses below the rate provided by private insurance.
Methodist Occupational Health cited low reimbursement as one of the reasons it decided a few months ago to stop accepting Tricare. The Clarian Health Partners subsidiary, which specializes in injury rehabilitation and Worker's Compensation cases, worked primarily with National Guard members or employees who suffered onthe-job injuries locally.
Methodist Occupational Health runs seven clinics in Indianapolis and others in northern Indiana. With $5,800 in claims since May 2004, Tricare represented a small slice of its business, according to its CEO, Tom Brink.
The actual reimbursement made that slice even smaller. Brink said Methodist Occupational received about $800 in reimbursement for that $5,800 Worker's Compensation claim total.
In contrast, a private insurer might pay 98 percent of that total, he said.
In addition, Methodist Occupational had problems with Tricare reimbursement turnaround that sometimes stretched beyond four months. A computer glitch that prevented the practice from getting necessary authorization for further treatment also soured it on Tricare.
Brink said he thought about rejecting Tricare for roughly six months before he followed through.
"I probably held onto it longer than I should have because we wanted to do it," he said. "But at some point, at [a reimbursement rate of] 14 cents on the dollar, it's kind of hard to pay the staff with that," he said.
Brink's complaints reflect Tricare's traditional problem areas: low and slow reimbursement and hassles for things like preauthorization, according to Snyder. However, the insurer has shown signs of improvement.
Snyder said Tricare has become more efficient in recent years. In a letter he sent recently to the American Medical Association, the congressman noted Tricare processes more than 90 percent of its claims in 15 days. Snyder and another congressman used the letter to encourage Tricare acceptance.
Tricare officials describe access to care as "excellent overall," although they acknowledge that beneficiaries in some locations struggle to find providers.
"We are working hard to overcome those challenges and will continue to work with our regional contractors to improve our network," wrote Dr. David Tornberg, acting deputy director of Tricare Management Activity, in an e-mailed response to questions.
The Indiana impact
Greenwood resident Tammy Honeycutt has had to find four new OB/GYNs since 1999 because the first three dropped Tricare shortly after she started seeing them.
She said they all apologize, and they all say "they support the troops." Then they send her thumbing through her provider directory once again.
Honeycutt, whose husband, Charles, returned from Afghanistan last month, managed to find a pediatrician who accepts Tricare for her four children. The only catch: She has to pay higher than normal costs because that doctor is not in Tricare's network.
"We pay out of our pocket trying to find doctors to care for us," she said. "It is so difficult."
Whether Tricare coverage becomes a widespread frustration in Indiana remains to be seen. Tornberg described Tricare's Indiana network as "adequate and meeting the needs of our beneficiaries."
However, Dietz, the OrthoIndy surgeon, said he was alarmed by the lack of specialists Tricare offers in central Indiana. He said the Tricare Web site shows no doctors in orthopedic and vascular surgery, among other specialties.
He also saw only a "smattering" of family practice physicians on the Web site.
Tornberg said the Tricare Indiana network includes 1,142 doctors, and plans to add 436 specialists.
The lack of specialists affected Welch. She said her old insurance coverage gave her dozens of OB/GYNs to chose from.Tricare's network provided about five within a reasonable drive of her home.
Clarian Health Partners, the area's largest hospital network, has contracts to work with 70 managed care plans. Tricare is not among them. The network has more than 1,400 doctors on its staff.
Clarian never signed up for Tricare because it never saw the demand for it, spokesman Jon Mills said. Tricare beneficiaries can still receive treatment from Clarian doctors; they just have to pay out-of-network costs for it.
Travis Welch, who returned this summer, thinks the problem is only beginning to surface here because soldiers are still enjoying their first days back home. He believes some will find the same frustrations his wife encountered when they make their first calls for a doctor's appointment.
Welch, a physician's assistant at OrthoIndy, saw plenty of sprains, strains and joint injuries in Afghanistan, the type of cases that require follow-up care but not inpatient stays at a military hospital.
Dietz, whose practice accepts Tricare, hopes the medical community understands that searching for a new doctor is the last thing returning Indiana National Guard members want to tackle while readjusting to civilian life.
"These guys are going to face a transition that will make combat look easy," Dietz said. "They've done a great service to our country, and we ought to be able to do something to help."