Access to Health Care Among TRICARE-Covered Children

Short abstract

TRICARE-covered children face challenges accessing health care, with the greatest challenges among children who have experienced frequent relocations and children with special health care needs. Analyses of survey data allow a comparison between children with TRICARE and other types of insurance, as well as between children who have changed addresses more and less frequently and between children with special health care needs and those without.

Abstract

TRICARE, the U.S. Department of Defense insurance program for eligible service members and their dependents, provides health care coverage to nearly 2 million children under the age of 18. Survey data and prior evaluations indicate that TRICARE-covered children face challenges in accessing pediatric health care, with the greatest challenges among children who have experienced frequent relocations and children with special health care needs. However, TRICARE has not measured pediatric patient experiences in accessing care since 2010. To fill this gap, RAND researchers analyzed national survey data on the experiences of caregivers of TRICARE-covered children and children with commercial insurance, public insurance, and no insurance to identify differences in access to pediatric care, necessary referrals, care coordination support, ability to pay medical bills, and other factors. Additional analyses highlight variations between children with different TRICARE plans, between children who have changed addresses more and less frequently, and between children with special health care needs and those without. The findings should help inform efforts to increase access to care for children across the Military Health System, as well as improvements to programs designed to support military families during relocations and those with children who have special health care needs.

Military children often face unique stressors that can affect their health care needs and the level of care they receive, including frequent moves, limited pediatric provider options when parents are posted to geographically remote installations, the stresses of deployment, and limited informal support networks to help with special health care needs (SHCN).

TRICARE, the U.S. Department of Defense (DoD) insurance program for eligible service members and their dependents, provides health care coverage to nearly 2 million children under the age of 18 (Defense Health Agency, 2020). These children receive health care either at on-base military treatment facilities (MTFs) or from a network of contracted providers. Prior DoD evaluations have found that TRICARE meets internal standards for access for child beneficiaries (Defense Health Board, 2017; Office of the Secretary of Defense, 2014), but survey results suggest that TRICARE-covered children may have less access to care than children with other sources of insurance and, in some cases, children with no insurance coverage. In response to these findings, DoD asked the RAND Corporation to investigate potential gaps and to identify opportunities to improve health care for military children.

Measures of Health Care Access and Quality for TRICARE-Covered Children

Two DoD surveys monitor TRICARE beneficiaries’ experiences with pediatric providers: the Joint Outpatient Experience Survey (JOES), which includes separate surveys for patients who receive care at MTFs and from contracted providers in the TRICARE network, and the Health Care Survey of DoD Beneficiaries (HCSDB), which solicits feedback from adult TRICARE beneficiaries on access to care in a way that allows comparison with other insurance programs.¹ However, the HCSDB has not included questions about pediatric care experiences since 2010 and the JOES does not collect data on children older than age 10. The Military Health System Data Repository contains information on pediatric health care utilization and quality but does not capture comprehensive data on patient experiences.

To address these data-collection gaps, we analyzed alternative sources of data on access to services for TRICARE-covered children under age 18, including the National Survey of Children's Health (NSCH), which collects data on the physical and emotional health of U.S. children from birth to age 17 (U.S. Census Bureau, undated), and the annual Military Family Lifestyle Survey (MFLS) for 2018, conducted by the nonprofit military family support organization Blue Star Families (undated). We found that the NSCH sample of TRICARE-covered children, as reported by their caregivers, closely matched official DoD data on the sociodemographic characteristics of these children. The MFLS collected data from families via an internet convenience sample and therefore is likely not representative of TRICARE-covered children overall; however, the survey still provides some indication of specific areas of satisfaction and concern for some caregivers of TRICARE-covered children.

We captured perceptions regarding access and quality of care among caregivers of TRICARE-covered children. When possible, we used these measures to compare the experiences of TRICARE-covered children with those of children who had private insurance, public insurance (through Medicaid or another government assistance program), and no insurance. Among TRICARE-covered children, we also explored differences by duty status, service branch, and specific type of TRICARE coverage (e.g., TRICARE Prime, TRICARE Select) to determine whether these differences were associated with differences in caregivers’ perceptions regarding pediatric care access.

Specifically, we used the NSCH data to evaluate pediatric health care access across six domains: usual source of care, specialist care, getting needed care, care coordination, insurance coverage and affordability, and patient-centeredness. Using MFLS data, we examined reported timeliness in seeing a medical provider and obtaining a referral, as well as overall satisfaction with access to care and provider quality.

Key Findings

TRICARE beneficiaries can be enrolled in one of several types of TRICARE plans, depending on eligibility and location. Generally, dependents of service members can be enrolled in either an HMO-type plan known as TRICARE Prime or a PPO-type plan known as TRICARE Select. The primary difference is that dependents enrolled in TRICARE Prime have lower cost-sharing than those in TRICARE Select, but they require a referral for specialty care, and these visits typically need to occur at an MTF. TRICARE Select beneficiaries have higher cost-sharing but more flexibility in providers and do not need referrals to see specialists.

Between 2016 and 2018, caregivers of TRICARE-covered children reported approximately the same level of access to health care as caregivers of children covered by other types of insurance. Both groups reported higher levels of access than uninsured children.

Caregivers of children with any kind of insurance generally reported that coverage was adequate and that providers were responsive to their children's needs. TRICARE-covered children were more likely than commercially insured children to have coverage for mental and behavioral health that met their needs. Their caregivers also reported fewer problems paying for health care (likely due to the lower cost-sharing in TRICARE plans relative to most other insurance) and had greater access to—and need for—care coordination services. However, caregivers of TRICARE-covered and publicly insured children reported more frustration obtaining necessary services than caregivers of commercially insured children.

Compared with children with other types of insurance, TRICARE-covered children were less likely to come from low-income families but relocated more often and were therefore less likely to have a single primary health care provider. They were also more likely to require referrals for various types of specialty care and faced greater difficulty obtaining these referrals.

Access challenges according to several measures were more pronounced for TRICARE-covered children with more-complex health needs. Caregivers of TRICARE-covered children with SHCN had more difficulty getting referrals, were more likely to report that their children did not get needed care, had more frustration getting care, and had a greater desire for more help coordinating care compared with caregivers of TRICARE-covered children without SHCN. However, access experiences were similar among TRICARE-coverage children with SHCN and children with SHCN in other coverage groups.

Service-related relocations among the TRICARE population presented additional challenges for pediatric access. TRICARE-covered children whose families frequently moved reported significantly higher degrees of forgone care, difficulty getting a referral, frustration getting needed services, and a desire for more care coordination than those who had never moved over a child's life.

Among children with TRICARE coverage, those from active-duty families were less likely than children from non–active-duty families to have difficulty obtaining health care (including mental and behavioral health care), and their families were less likely to report trouble paying medical bills. Active-duty families were also less likely to report not getting needed care or having trouble paying health care bills. Caregivers of children with TRICARE Prime with a network primary care manager and those with TRICARE Select were the most likely to agree that these children received timely pediatric care when it was needed and were more satisfied with the overall ease of access and timeliness of their children's health care. These rates were lower for Air Force children, however. Their caregivers also reported greater difficulty obtaining timely referrals and were less satisfied with the quality of providers.

Recommendations

Our findings point to several opportunities for DoD to improve how it tracks and addresses potential gaps in access to care for pediatric TRICARE beneficiaries.

Routinely Collect Pediatric Patient Experience Data

Currently, external data are the only means of comprehensively tracking the health care experiences of the entire population of TRICARE-covered children and assessing those experiences against civilian benchmarks. Legislative changes have made it easier for DoD to collect these data internally, but there is still a need to establish procedures for routine, timely, standardized data collection—such as by resuming fielding of the pediatric survey component of the HCSDB—and to make these data available in a way that facilitates comparison.

Further Streamline Referrals and Monitor Effects on Patient Experiences

Our analysis indicated that the referral process was a source of difficulty for pediatric TRICARE beneficiaries compared with those who had private or public insurance—particularly for children with SHCN. Changes have been underway to streamline and expedite referrals within the Military Health System, but the effects were not yet evident in the data at the time of this research. Going forward, DoD should monitor wait times for referrals and specialty appointments and evaluate the reasons for disparities.

Fully Implement DoD Plans to Monitor the Effects of Permanent Changes of Station and Other Service-Related Relocations

Frequent relocations may exacerbate the challenges that military families face when navigating children's health care options. In response to recent legislation, DoD began monitoring the effects of relocations on children with SHCN. Patient experience data among recently relocated families, combined with administrative data, could be used to determine the effectiveness of programs to mitigate negative effects.

Review the Availability and Use of Care Coordination Services for Children with Complex Health Conditions

Caregivers of TRICARE-covered children with SHCN were more likely than caregivers of other insured children with SHCN to receive care coordination assistance but still reported shortfalls. TRICARE beneficiaries with complex health conditions may be eligible for case management services at no cost. Additionally, primary care managers and 24-hour helplines through Military OneSource and the TRICARE Nurse Advice Line may fulfill limited coordination and assistance roles (TRICARE, 2019). However, our results suggest that a significant degree of demand for such assistance remained unmet in 2016–2018, and administrative data on the use of these services were incomplete. Better access to more-effective care coordination for TRICARE-covered children with SHCN might improve experiences where they lagged behind those of other insurance groups, including difficulty with the referral process and frustration in obtaining needed services. This highlights the need for a broad review of the availability and use of care coordination for children with SHCN to help identify how their needs can be met.