Prior to January 1, 2018, TRICARE provided benefits through three main plan options for its non-Medicare-eligible beneficiary population— TRICARE Prime, Standard, and Extra. These options varied by enrollment requirements, choices in civilian and military treatment facility providers, and the amount beneficiaries must contribute toward the cost of their care. (See table 1.) The NDAA for Fiscal Year 2017 terminated the TRICARE Standard and Extra plans beginning on January 1, 2018, and introduced TRICARE Select. Beneficiaries who had used the TRICARE Standard and Extra plans as of December 31, 2017 were automatically enrolled in TRICARE Select for the first year of the new plan, but as of January 1, 2019, beneficiaries were required to actively enroll in TRICARE Select. DOD uses two regional managed care support contractors to develop networks of civilian providers to serve all TRICARE beneficiaries. Within the regions, contractors are required to develop these networks of providers in areas called Prime Service Areas (PSA), which are geographic areas usually within an approximate 40-mile radius of a military inpatient treatment facility, as well as in areas outside of PSA locations, or non-PSAs. To develop the networks, the contractors enter into contracts with some providers—referred to as network providers—to treat TRICARE patients at an agreed upon reimbursement rate. Beneficiaries can also receive care from certified nonnetwork providers. However, beneficiaries visiting a nonnetwork provider may have to pay for the care at the time of the visit and later file a claim for reimbursement, whereas beneficiaries visiting a network provider are only responsible for paying a copayment or cost-sharing amount. The NDAA for Fiscal Year 2017 also mandated that DOD ensure at least 85 percent of the TRICARE Select beneficiary population be covered by the TRICARE network of providers by January 1, 2018, and that DOD determine access standards and ensure the program meets or exceeds access standards of “high-performing health care systems in the United States” for health care appointments. DOD has contracted both of these efforts to the two contractors. Non-Prime beneficiaries’ ratings of TRICARE were generally unchanged during the first year following the transition from TRICARE Standard and Extra to TRICARE Select. Specifically, there was no statistically significant change from the 2017/2018 surveys to the 2019 survey in the percent of beneficiaries who positively rated their health care and their health plans—defined as giving responses of 8 or higher (out of 10) on each survey question. In the 2019 survey, 80 percent of beneficiaries rated their health care positively, and 67 percent rated the TRICARE health plan positively. (See fig. 1.) Non-Prime TRICARE beneficiaries also rated three different types of providers and of the three, ratings of primary care providers decreased from the 2017/2018 to 2019 surveys. The percent of beneficiaries who positively rated their primary care providers decreased from 85 to 80 percent in the 2019 survey. We found no statistically significant differences from the 2017/2018 surveys to the 2019 survey in beneficiaries’ positive ratings of specialty care and mental health care providers, with 83 and 73 percent of beneficiaries reporting positive ratings of their specialty care and mental health care providers, respectively in 2019. (See fig. 2.) In the first year of TRICARE Select, a higher percentage of non-Prime beneficiaries reported experiencing problems finding civilian health care providers who accepted TRICARE than before the transition, particularly for specialty care. We found there was a statistically significant increase in the percentage of beneficiaries who reported problems finding a provider that would accept TRICARE from 27 to 32 percent from the 2017/2018 surveys to the 2019 survey. In particular, there was a statistically significant increase in the percentage of beneficiaries who reported problems finding a specialty care provider in the 2019 survey (24 percent) compared to the 2017/2018 surveys (18 percent). The percent of beneficiaries who reported problems accessing primary care or mental health care remained statistically unchanged with 26 and 31 percent reporting problems, respectively, in the 2019 survey. (See fig. 3.) We also found that a higher percentage of beneficiaries located in PSAs reported experiencing problems finding providers, whereas there was no change for beneficiaries located in non-PSA areas. Specifically, from the 2017/2018 surveys to the 2019 survey, there was a statistically significant increase in the percentage of beneficiaries located in PSAs who reported problems finding any type of civilian provider (27 to 34 percent), primary care providers (21 to 29 percent), and specialty care providers (18 to 25 percent). There was no statistically significant change among beneficiaries in PSAs reporting problems finding mental health care providers or among beneficiaries in non-PSAs for any provider types. (See fig. 4.) To help beneficiaries find providers that accept TRICARE patients, managed care support contractors develop networks of providers in PSAs and some non-PSA locations. Each month, these contractors report to DOD the percent of Select beneficiaries who were covered by the TRICARE network of providers, according to contractor-developed measures of adequate access to care. Although nearly one-third of beneficiaries reported experiencing problems finding a civilian provider, DOD officials told us that nearly 100 percent of beneficiaries in the East have had adequate access to a network provider since January 1, 2018, exceeding the 85 percent requirement. For the West, DOD officials said the contractor reported that more than 85 percent of beneficiaries had adequate access to a network provider as of August 2018. According to DOD officials, the two contractors used different methods to ensure adequate access to a network provider: In the East region, the contractor decided to develop networks of civilian providers in the entire region. In the West region, the spread-out geography of the region made it difficult to develop networks of civilian providers throughout the entire region. Therefore, the contractor used mapping software to determine areas within non-PSAs which had large populations of TRICARE Select beneficiaries. As a result, the contractor identified 12 areas in the West region—which it called Select Areas—to develop additional networks of civilian providers in order to meet the requirement. Contractors also provide resources to beneficiaries to help them identify providers that accept TRICARE patients. Contractors maintain lists of network and other TRICARE-certified providers that accept TRICARE patients, and monitor and report on the accuracy of these lists to DOD monthly. However, contractor representatives noted that providers can decide to accept or not accept TRICARE patients at any time, and these changes are not always reflected in the lists. Contractor representatives explained that if a beneficiary cannot find a provider to accept TRICARE for needed care, the beneficiary can submit a complaint to the contractor. Contractor representatives said that they can address beneficiary complaints by attempting to identify and certify new providers, but noted that some subspecialty providers are not available in all areas. Representatives from one contractor told us that they have identified alternative sources of care when providers are not available. For example, when no civilian psychiatrists were accepting new patients in a remote area, the contractor offered beneficiaries telehealth services from a military treatment facility. There was no statistically significant change after the transition to TRICARE Select in the percent of non-Prime beneficiaries who reported being able to get an appointment as soon as they needed. In the 2019 survey, 88 percent of beneficiaries reported that they could usually or always obtain an appointment for primary care as soon as they needed and 86 percent reported being able to do so for specialty care. (See fig. 5.) Similarly, about 65 percent of beneficiaries reported waiting a week or less between scheduling an appointment for non-urgent care and meeting with their doctor in the 2019 survey, and 83 percent of beneficiaries reported waiting 2 weeks or less. There was no change in the percent of civilian providers nationwide who reported accepting new TRICARE patients if they were also accepting other new patients after the transition to TRICARE Select. Across all provider types, 67 percent of providers in the 2019 survey reported accepting new TRICARE patients if they were also accepting other new patients; this percentage was not statistically significantly different from the 2017/2018 surveys. There was also no statistically significant change among specific provider types—in the 2019 survey, 47 percent of mental health care providers and about 90 percent of primary care and specialty care providers reported accepting new TRICARE patients if they were accepting any new patients. When we analyzed provider responses by network status and specialty, the surveys indicated a decrease in the percentage of network mental health providers who were accepting new TRICARE patients if they were also accepting other new patients. The percent of these network mental health providers decreased a statistically significant amount from 91 percent in the 2017/2018 surveys to 84 percent in the 2019 survey. (See fig. 6.) However, there was no change in the overall percentage of all network or all nonnetwork providers that were accepting new TRICARE patients if they were also accepting any new patients—93 percent of network and 58 percent of nonnetwork providers in the 2019 survey. When we analyzed provider responses by location, we found that provider acceptance of new TRICARE patients decreased by a statistically significant amount in non-PSAs. Specifically, a lower percentage of providers located in non-PSAs reported accepting new TRICARE patients if they were accepting other new patients, decreasing from 72 percent in the 2017/2018 surveys to 68 percent in the 2019 survey. This percentage did not significantly change for providers in PSAs. (See fig. 7.) There were few changes in the reasons providers gave for not accepting TRICARE patients in the first year of TRICARE Select. (See Table 2 for a list of reasons providers offered in the 2019 survey.) Of 14 categories of reasons that providers gave, there was a statistically significant change in two categories between the 2017/2018 surveys to the 2019 survey. Specifically, the percentage of providers who listed reimbursement as a reason for not accepting new TRICARE patients declined from 11 percent to 8 percent, and the percentage of providers who listed that the doctor was not available or too busy increased from 4 percent to 8 percent. DOD provided technical comments on a draft of this report, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees, the Secretary of Defense, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff members have any questions about this report, please contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. James Cosgrove, (202) 512-7114 or cosgrovej@gao.gov. In addition to the contact named above, individuals making key contributions to this report include Tom Conahan (Assistant Director), A. Elizabeth Dobrenz and Jeffrey Mayhew (Analysts-in-Charge), Jennie Apter, Alexander Cattran, Jacquelyn Hamilton, Vikki Porter, and Jeffrey Tamburello. Defense Health Care: TRICARE Surveys Indicate Nonenrolled Beneficiaries’ Access to Care Has Generally Improved, GAO-18-361 (Washington, D.C.: Mar. 29, 2018). Defense Health Care: More-Specific Guidance Needed for Assessing Nonenrolled TRICARE Beneficiaries’ Access to Care, GAO-14-384 (Washington, D.C.: Apr. 28, 2014). Defense Health Care: TRICARE Multiyear Surveys Indicate Problems with Access to Care for Nonenrolled Beneficiaries, GAO-13-364 (Washington, D.C.: Apr. 2, 2013). Defense Health Care: DOD Lacks Assurance That Selected Reserve Members Are Informed About TRICARE Reserve Select, GAO-11-551 (Washington, D.C.: June 3, 2011). Defense Health Care: Access to Civilian Providers under TRICARE Standard and Extra, GAO-11-500 (Washington, D.C.: June 2, 2011). Defense Health Care: 2008 Access to Care Surveys Indicate Some Problems, but Beneficiary Satisfaction Is Similar to Other Health Plans, GAO-10-402 (Washington, D.C.: Mar. 31, 2010).
DOD provided health care to more than 9 million eligible beneficiaries through TRICARE in fiscal year 2018. Most of these beneficiaries were enrolled in TRICARE's managed care plan—TRICARE Prime. However, about 2 million beneficiaries received care primarily from civilian providers through TRICARE's non-Prime options: TRICARE Standard and Extra. Effective January 1, 2018, these two options were eliminated and TRICARE Select was implemented. TRICARE Select has similar benefits for provider choice and obtaining care from civilian providers as TRICARE Standard and Extra, but includes access standards to ensure at least 85 percent of enrollees are covered by TRICARE's network of civilian providers, among other things. The National Defense Authorization Act (NDAA) for Fiscal Year 2008 included a provision for GAO to review results of DOD surveys of non-Prime beneficiaries and civilian providers. Additionally, the NDAA for Fiscal Year 2017 included a provision for GAO to review access to care after implementation of TRICARE Select in 2018. This report addresses both provisions. GAO analyzed DOD's survey results to determine changes after implementation of TRICARE Select in (1) non-Prime beneficiaries' ratings of TRICARE, (2) non-Prime beneficiaries' reported ability to find providers and obtain appointments, and (3) civilian providers' reported acceptance of TRICARE. GAO analyzed the results of the 2017-2019 surveys, and interviewed agency officials and DOD contractors. DOD provided technical comments, which GAO incorporated as appropriate. On January 1, 2018, the Department of Defense (DOD) implemented a new health plan option—TRICARE Select—for beneficiaries who primarily obtain care from civilian providers rather than through TRICARE's managed care plan—TRICARE Prime. DOD surveys indicate few changes in these non-Prime beneficiaries' satisfaction and access to care during the first year following the implementation of TRICARE Select, though GAO cannot directly attribute these differences to implementation due, in part, to other changes in the TRICARE program during the same time frame. Specifically, GAO found the following: There was no change in the percent of beneficiaries reporting positive ratings of their TRICARE health care and health plans—80 percent and 68 percent, respectively—in the first year of TRICARE Select. There was an increase in the percent of beneficiaries reporting problems accessing specialty providers from 18 to 24 percent in the first year of TRICARE Select. However, as the figure shows, there was no statistically significant change in the percent of beneficiaries reporting they received care as soon as needed for primary and specialty care appointments. There was no change in the percent of providers that reported accepting new TRICARE patients if they were also accepting any new patients—about 90 percent of primary care and specialty care providers, and 47 percent of mental health care providers—in the first year of TRICARE Select.