Voice of the Customer: Factors Impacting Beneficiary Choice of Programs in TRICARE

Abstract

Little is known about how a consumer would choose a health plan if cost was not an option such as in the Military Health System. We sought to identify how to recruit TRICARE beneficiaries into new pilot programs challenged by low recruitment. We developed a semistructured interview guide by adapting a framework established by Klinkman to assess factors in choosing a health plan. Using social media platforms, we recruited TRICARE Prime and Select beneficiaries to participate in key informant interviews from October to December 2022. We conducted inductive thematic analysis to determine key areas of concern. We interviewed a total of 20 TRICARE Prime and Select beneficiaries. The majority were women, above age 40, had a master's degree, a sponsor in the US Army and of senior officer rank. Four overarching themes emerged: (I) patient choice; (II) access to care; (III) quality of care; and (IV) cost. This evaluation of TRICARE beneficiaries explores how to motivate high-quality value-based care in a traditionally fee for service system.

Key Points

1. TRICARE provides health insurance to 9.6 million beneficiaries under universal coverage. Recruiting to demonstration projects or other insurance options is poorly understood.

2. When evaluating factors of healthcare TRICARE beneficiaries deemed important, 4 overarching themes emerged including patient choice, access to care, quality of care, and cost.

3. Results can guide recommendations to improve and promote new pilot programs available to TRICARE beneficiaries through new contracts in the private sector.

Introduction

In the United States, continuous health insurance is critical to ensure access to care and positive health outcomes. ¹ Health insurance is usually obtained through employment, government sponsored programs, or the Health Insurance Marketplace established under the Affordable Care Act. However, variability in both cost and quality and between health plans can make it difficult for beneficiaries to make an informed choice when given the opportunity.^2,3 Evidence shows consumers are generally looking for a cost-benefit trade-off, specifically when it comes to premiums, deductibles, and maximum out-of-pocket spending caps. Apart from cost, consumers look for plans with choice of providers and high-quality primary care and specialty physicians.^3,4 As cost is a major component of health insurance in the United States, most of the literature looking at choice of a health plan is linked to cost. Little is known about how a consumer would choose a health plan if cost was not an option such as in the Military Health System (MHS).

The MHS is unique in the United States in that it offers universal health coverage with no or low premium and low or no copayments. The MHS serves approximately 9.6 million beneficiaries, of whom approximately 17% are active-duty service members from every military branch, with the remainder being nonactive-duty dependents and retirees, representative of the US population. ⁵

In addition to care delivered through Military Treatment Facilities (MTFs), the MHS provides care in the private sector using the TRICARE benefit. TRICARE has 2 main types of plans with relatively low and fixed costs, TRICARE Prime, where a beneficiary chooses or is assigned a primary care manager (PCM), and TRICARE Select, where nominally higher costs exist but PCM assignment is not mandatory. A Prime beneficiary can have a PCM at an MTF, in which case they would go to the MTF for care and receive referrals as necessary. In addition, Prime beneficiaries can be assigned a PCM in private sector care. In certain geographic locations, there may be additional choices in plans for care in the private sector.^6,7 For example, the US Family Health Plan is in network with community based, not for profit healthcare systems in 6 areas of the US TRICARE has also initiated a demonstration project for a Prime plan in Atlanta in partnership with Kaiser Permanente. These alternative Prime plans allow beneficiaries to substitute care pathways to the MTF. ⁸

Since cost may not be the main driver of health plan choice in the MHS, a unique environment is created to explore consumer decision making independent of cost. Currently, literature is lacking describing how TRICARE beneficiaries decide between Prime plans. Civilian insurance preference is generally assessed through polls or surveys. ⁹ Klinkman identified a 2-stage analytic framework for the process of choosing a healthcare plan. Stage 1 involves the contract between the employer and the health plan in designing options for employees and stage 2 involves the contract between the employer and the employee and considers the economic and service attributes. ¹⁰ Given evidence showing the importance of patient choice in healthcare.^11‐13 and lack of studies evaluating TRICARE beneficiary preference, we sought to ask beneficiaries what they valued in their healthcare plan in order to inform future decisions impacting beneficiaries. The aim of this study is to evaluate factors driving TRICARE beneficiary values and plan choice in an environment where no or little economic factors exist using the second stage of Klinkman's analytical framework.

Methods

We conducted a qualitative study using key informant interviews to investigate health plan choice among TRICARE Prime and Select beneficiaries. Using the second stage framework established by Klinkman, we developed a semistructured interview guide to assess the questions “What do we need?” and “What would we like?” when choosing a health plan. ¹⁰ The complete interview guide can be found in Supplemental Appendix 1. We recruited participants using a convenience sample and posting to social media platforms, Twitter and Facebook. Recruitment posts were placed on the CHSR USU Twitter profile, and military spouse and veteran Facebook pages. Our target population were TRICARE Prime or Select beneficiaries between ages 18 and 64. Research participants emailed the contact listed in the social media post to schedule their interview. To minimize potential bias, researcher refrained from conducting interviews if they had been previously acquainted with the participant. Virtual interviews were conducted using the Google Meets platform. Informed consent was waived for this study.

Participants were interviewed from October 25 to December 19, 2022. Two researchers conducted interviews. The first researcher guided discussion through the interview guide, and the second took digital notes. Interviews were not recorded. Notes were collated and de-identified to ensure confidentiality. Inductive thematic content analysis was conducted using NVivo software version 20 and open coding techniques. ¹⁴ The research team read through the interview notes and discussed themes identified by the NVivo software. Notes were then coded and codes were synthesized to derive overarching themes. This study was found exempt by the Institutional Review Board (IRB) of the Uniformed Services University of the Health Sciences (USUHS).

Results

We interviewed 20 participants and reached saturation. Most participants were female, in the 51 to 60 age range, held a master's degree, had a sponsor who served in the Army, and a sponsor who was a senior officer. Nearly all participants lived near MTFs and were from the Southern Atlantic region.

Four overarching themes emerged from interviews: (I) patient choice; (II) access to care; (III) quality of care; and (IV) cost. The majority of participants identified their health status as healthy and reported that they accessed care a few times a year or on an as needed basis such as for preventive care and when sick. About half of the participants received care at an MTF, while the other half received care in the private sector. All participants received healthcare benefit information through email and confirmed email as their preferred method of contact. The majority of participants stated that they were satisfied with their healthcare while several participants were moderately satisfied, and 3 reported not being satisfied at all. While the majority were satisfied, areas for improvement emerged from the themes described below.

Theme I: Patient Choice

A resounding theme of the questions asking participants what they would like in their healthcare was patient choice which refers to an individual's ability to choose where they receive their treatment, who administers their care, and to some degree their treatment including the option to refuse treatment altogether. ¹⁵ Participants seek autonomy in choosing providers and where to receive care. Participants prefer to receive care in one location to promote continuity of care, but would be willing to travel if needed for specialty care. Participants also seek choice in ability to receive care and do not want to need referrals for specialist care.

“If I could have the price of Prime but the flexibility of Select,”

“The ability to go outside the MTF you are assigned to if you feel you are not receiving adequate care.”

Theme II: Access to Care

Access to care refers to an individual's ability to see a healthcare provider within a reasonable amount of time. ¹⁶ When asked what would make healthcare access more convenient, the majority of participants mentioned availability of providers accepting TRICARE as well as availability of appointments while others cited distance to facilities as a challenge.

“If there were more providers and specialists that accept Tricare within the area,”

“I would like a satellite campus. This area is growing quite quickly, and it is clear that the MTF cannot handle all of this and depending on where you live it can take 30-45 min to get there.”

Two participants admitted to not accessing care due to difficulties in finding available appointments. Two other participants said nothing could improve their access to care and that they appreciated being able to access civilian Urgent Care Facilities. One participant had a unique response stating they would like a process where the healthcare system reaches out with reminders for care.

Theme III: Quality of Care

Responses from the remaining questions can be grouped into the theme quality of care which refers to the degree in which evidence-based healthcare services for individuals and populations increase the likelihood of desired health outcomes. ¹⁷ Participants want providers with good reputations.

“Reputation and competency are the most important.”

Participants associated quality of care with continuity of care. Continuity of care was deemed important in feeling that the doctors knew who they were and were engaged in their care. When asked how important continuity of care was, one participant responded as below:

“Very, so you don’t have to restate your entire medical history every time you go to the doctor.”

“It is frustrating to have to explain this. It is very difficult to go in every time to explain everything when you are trying to follow up from the last visit.”

One participant suggested an application to be developed where medical records can follow patients with them while they move.

Theme IV: Cost

While cost was not mentioned in the questions, many participants brought up concerns about cost including high copays for services with frequent visits such as physical therapy or allergy shots. When asked about the most important parts of healthcare benefits, the majority of responses reported cost, coverage, and copays as being most important. In the process of reforming TRICARE, copayments were introduced for private sector care ranging from $15 to $35 starting in calendar year 2018. ¹⁸ Cost became more important as participants transferred to retirement from active duty.

“Cost is probably up there as well but it was not something that I had to think about while on active duty. Now that I’m not active duty, cost is starting to factor into my decision-making.”

Other participants feel the cost of TRICARE is one of the most important parts of that coverage.

“Really, it's the price. The ease of someone taking TRICARE and understanding what my copay will be without surprises – that's why I stay on Prime.”

All participants mentioned the importance of keeping costs low and ensuring adequate coverage for providers in their area.

These 4 themes describe responses from the last question asked during the interview “If you receive care at a Military Treatment Facility or at a TRICARE only clinic, would you ever consider switching to a private sector provider or a different network that took TRICARE and did not cost you more?” The participants who were already receiving care in the private sector said they would not wish to receive care again at an MTF.

“I’m never stepping foot in one again.”

The majority of participants currently receiving care at an MTF said they would consider switching with caveats of the same cost, quality care, and access to care.

“It would either have to be the same care for less money or better care for the same money.”

Some participants were worried about the availability of providers who would accept TRICARE near them.

Others were more apprehensive about the success of potential new programs.

“I would but I would really want to research it first. Every time they have something like that it seems to be an insane flaming disaster. With the caveat that you could leave any time during the year, I would try it.”

Two participants did not wish to leave the MTF at which they receive care due to liking their PCM. While one of these participants would not leave themselves, they did want their children to be able to be seen in the private sector.

Discussion

We interviewed 20 TRICARE beneficiaries in the Fall of 2022. This study provides context regarding factors that impact TRICARE beneficiary decision making when choosing a health plan and can aide decision makers in designing future TRICARE demonstration projects as well as add to the rigorous and growing body of literature documenting patient experience in the healthcare setting. While the majority of participants in our study reported being satisfied with their current health plan, most indicated that given the right circumstances, they would be willing to switch to a private sector TRICARE-affiliated health plan, presenting an opportunity for more competitive offerings. Patient choice, access to care, quality of care, and cost all emerged as overarching themes informing TRICARE beneficiaries’ decisions regarding their health plan.

Patient choice was an important factor for our participants, and importance was placed on autonomy in provider choice and location of care. The theme of patient choice in this study aligns with prior research assessing consumer wants in healthcare.^2,4 Evidence has shown that having a choice in selecting a health plan is linked with better satisfaction in meeting healthcare needs. ⁴ However, choice in all facets of healthcare is not necessarily a good thing as the right to choose can be overridden by principles of beneficence, nonmaleficence, and justice. ¹⁹

The desire for a more flexible health plan was also reflected in the second emergent theme: access to care. Participants specifically cited the need for more providers who are willing to take TRICARE insurance and more availability and flexibility in appointment times. Access for some also meant the way that they received information about their healthcare. Nearly all participants preferred receiving information about changes to their healthcare plan by email. Literature shows that integration of patient centered scheduling systems through web-based or interactive voice response systems could lead to better accessibility and availability of care.^20,21 While there are technical solutions to improving appointment availability, lack of providers accepting the TRICARE benefit is a continuing challenge. ²²

In addition to increased choice and flexibility, participants wanted high-quality care. Importance was placed on having access to providers and facilities that had good reputations. Another factor associated with high-quality care was continuity of care. Participants wanted to ensure that they were able to either see the same doctor or a new doctor who was familiar with their medical records so that they did not feel that they were restating their history every visit. Continuity of care has been shown to increase patient satisfaction in healthcare as well as improve quality of care in part through improved health outcomes.^23,24

Despite being told that cost was not a factor for the purpose of this study, many participants still emphasized that cost was the most important consideration when choosing a health plan without prompting. A few participants mentioned specifically how the high copays associated with specialty care, especially physical therapy, was a financial burden. This corresponds with many studies evaluating patient choice in healthcare plans as consumers generally look for a cost-benefit trade-off, specifically when it comes to premiums, deductibles, and maximum out-of-pocket spending caps.^2,4 Our findings are consistent with prior literature from Medicare Advantage (MA) beneficiaries, who face similar circumstances when making health plan choices. ²⁵ Studies suggest that MA beneficiaries seek the highest quality rated health plan with the lowest premiums. ²⁶ However, they are willing to pay more for a higher rated plan to some degree, though this differed among different sociodemographic characteristics. ²⁷

As this study did not explore cost or willingness to pay, further research is needed to determine if this holds true among our population. However, this supports that both groups value quality of care. MA beneficiaries also seek plans that have high degrees of patient choice, with expansive networks and do not prefer plans that require patients to be referred out for care. Access to information was one area where the 2 groups differ, as MA beneficiaries tended to prefer in person contact ²⁷ compared to the email communication TRICARE beneficiaries prefer, but this could be due to the differences in age between the 2 populations, with MA beneficiaries being older on average than TRICARE beneficiaries.

This study allowed us to determine facets of healthcare TRICARE beneficiaries value. Strengths of this study include utilizing a semistructured interview guide in parallel with the analytic framework to encourage 2-way communication. Using this format allowed us to collect open-ended data and explore the participant's thoughts, attitudes, feelings, perceptions, and beliefs about their personal experiences with TRICARE. Our work has implications for TRICARE decision makers. When developing new pilot programs for TRICARE beneficiaries in the civilian networks, consideration should be foremost given to cost. Based on this analysis, participants are willing to take advantage of a civilian network offering given the care is the same or better and does not cost the individual more. Since cost would most likely not change, the biggest concerns for patients expressed in the interviews were access to care, including providers who accept TRICARE as well as appointment availability, continuity of care, and more patient choice. While barriers to care persist in civilian networks, including wait times for appointments and healthcare records not transferring between hospital systems with different electronic medical records, a pilot program has the ability to alleviate these barriers. Recommendations include establishing a robust network of providers from various specialties, creating an application that would allow patients to share their medical records with new providers prior to their appointment, and allowing more flexibility in appointment times. These recommendations would increase choice, continuity of care, and access for beneficiaries.

Limitations

Our study has some limitations. Given the qualitative nature of our study, the results may not be generalizable and should be considered exploratory. Our target population was individuals with either TRICARE Select or Prime. The majority of our respondents were women, had a graduate degree, and had sponsors who served in the US Army or a sponsor rank of senior officer. This older, well-educated group of individuals could have a higher level of health literacy compared to younger less-educated beneficiaries. Additionally, the participants were generally healthy and not chronically ill, however, a few participants did have children with chronic conditions. Although our study's sample does not reflect the entirety of the general population that have these insurance plans, participant contributions were still beneficial in that their responses explained some note-worthy difficulties within TRICARE. Additionally, one of our questions in the interview guide, “Please describe your current health status,” may have benefitted from utilization of the Likert scale. Some participants either hesitated prior to answering this question or asked for clarification. In hindsight, this question may have been stronger if formatted as a 2-part question where participants were first asked to grade their health status on a Likert scale and then prompted for further elaboration. We are fully aware that there may have been inherent bias weaved into some of the questions and deterred respondents, subsequently forcing the respondent to answer in a socially acceptable manner. It is also difficult to investigate causality. For example, some participants reported having unfavorable interactions with their primary care physicians while others have reported no issue and a higher standard of care.

Conclusions

This study identified components of healthcare important to TRICARE beneficiaries and identified recommendations for improvement to promote new pilot options for beneficiaries in private sector care as the Defense Health Agency moves toward the next generation of TRICARE contracts.

Supplemental Material

sj-docx-1-jpx-10.1177_23743735231184762 - Supplemental material for Voice of the Customer: Factors Impacting Beneficiary Choice of Programs in TRICARE

Supplemental material, sj-docx-1-jpx-10.1177_23743735231184762 for Voice of the Customer: Factors Impacting Beneficiary Choice of Programs in TRICARE by Jessica Korona-Bailey, Miranda Lynn Janvrin, Luke Juman and Tracey Perez Koehlmoos in Journal of Patient Experience