There are two types of authorized civilian providers—network and  nonnetwork providers. Implementation of DOD’s 2008 Beneficiary and Provider Surveys Followed OMB Survey Standards and Generally Addressed Requirements Outlined in the NDAA 2008

In implementing the first year of the beneficiary and provider surveys,  TMA followed the OMB standards for statistical surveys that we reviewed. In addition,  TMA generally addressed the requirements outlined in the NDAA 2008 for  both of its surveys but did not give a high priority to selecting areas with a  high concentration of Selected Reserve servicemembers. TMA plans to cover the entire United States at the end of the 4-year  survey period, which will include any locations with higher concentrations  of Selected Reserve servicemembers. According to a TMA official responsible for implementing the surveys,  TMA did not give a high priority to areas where higher concentrations of  Selected Reserve servicemembers live, as specified in the mandate,  because it decided to randomly select the areas to be surveyed in order to  produce results that can be generalized to the populations from which the  survey samples are selected. 2008 Survey Results Indicate That a Higher Percentage of Nonenrolled Beneficiaries in Prime Service Areas Experienced Problems Accessing Care from Primary Care Physicians or Nurses Than Those in Non-Prime Service Areas

Based on our analysis of the 2008 survey results, we estimated that a  higher percentage of nonenrolled beneficiaries in surveyed Prime Service  Areas experienced problems accessing care from network or nonnetwork  primary care physicians or nurses than nonenrolled beneficiaries in  surveyed non-Prime Service Areas. Nonenrolled Beneficiaries in Prime Service Areas and Non-Prime Service Areas Surveyed in 2008 Rated Satisfaction with Their Health Care Similarly to Each Other and to Beneficiaries of Commercial Health Care Plans

Despite differences in the percentage of beneficiaries in surveyed Prime  and non-Prime Service Areas reporting problems accessing care from  primary care physicians or nurses, our analysis showed that nonenrolled  beneficiaries’ ratings for several categories of health care were similar in  the surveyed Prime Service Areas and non-Prime Service Areas. 2008 Provider Survey Results Are Not Representative of All Providers in Surveyed Areas but Provide Limited Information That Indicates Differences among Respondents’ Awareness and Acceptance of TRICARE

Although the first year’s results of TMA’s 4-year provider survey are not  representative of all providers in the areas surveyed, the results we  analyzed do provide information about access to care based on the  specific views of the respondents. According to a TMA official,  generalizability of provider survey results to the entire country will likely  be possible at the end of the 4-year survey period. Additionally, there were differences between the  responding physicians (primary care physicians and specialists) and  mental health providers (psychiatrists, certified clinical social workers,  clinical psychologists, and others) regarding their awareness and  acceptance of TRICARE. For example, 81 percent of the physicians who responded  reported that they would accept new TRICARE patients, if they were  accepting any new patients at all, compared to 50 percent of the mental  health providers who responded. Agency Comments

We received comments on a draft of this report from DOD. DOD concurred with our overall findings and provided technical  comments, which we incorporated where appropriate. Appendix I: Selected Office of Management and Budget Standards for Statistical Surveys

The National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008)  directed the Department of Defense (DOD) to determine the adequacy of  the number of health care and mental health care providers that currently  accept nonenrolled beneficiaries as patients under TRICARE, DOD’s  health care program. Beneficiary and Provider Survey Content

The NDAA 2008 required that the beneficiary survey include questions to  determine whether TRICARE Standard and Extra beneficiaries have had  difficulties finding physicians and mental health providers willing to  provide services under TRICARE Standard or TRICARE Extra. For the purpose of this report, we refer to  beneficiaries who are not enrolled in TRICARE Prime—that is, those who  use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select—as  nonenrolled beneficiaries.
Why GAO Did This Study

The Department of Defense (DOD) provides health care and mental health care through its TRICARE program. Under TRICARE, beneficiaries may obtain care through TRICARE Prime, an option that includes the use of civilian provider networks and requires enrollment. TRICARE beneficiaries who do not enroll in this option may obtain care from nonnetwork providers through TRICARE Standard, or from network providers through TRICARE Extra. In addition, qualified National Guard and Reserve servicemembers may purchase TRICARE Reserve Select, a plan whose care options are similar to those of TRICARE Standard and TRICARE Extra. We refer to servicemembers who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select as nonenrolled beneficiaries. The National Defense Authorization Act for Fiscal Year 2008 directed GAO to analyze the adequacy of DOD's surveys of TRICARE beneficiaries and providers and report what the surveys' results indicate about access to care for nonenrolled beneficiaries. To do so, GAO evaluated the surveys' methodology by interviewing DOD officials and reviewing relevant documentation, including the Office of Management and Budget's (OMB) survey standards. GAO also assessed the surveys' results by interviewing DOD officials, obtaining relevant documentation, and analyzing the response rates and data for both surveys.

What GAO Found

DOD's implementation of beneficiary and provider surveys for 2008, the first of a 4-year survey effort, followed the OMB survey standards for survey design, data collection, and data accuracy. In addition, DOD generally addressed the survey requirements outlined in the mandate in implementing its 2008 beneficiary and provider surveys but did not give a high priority to selecting geographic areas with a high concentration of Selected Reserve servicemembers. Instead, for both of its surveys, DOD randomly selected areas to produce results that can be generalized to the populations from which the survey samples were drawn. DOD plans to cover the entire United States at the end of the 4-year survey period, which will include any locations with higher concentrations of Selected Reserve servicemembers. In its analysis of the 2008 beneficiary survey data, GAO estimated that a higher percentage of nonenrolled beneficiaries in surveyed areas where TRICARE Prime is offered (Prime Service Areas) experienced problems accessing care from network or nonnetwork primary care providers than beneficiaries in surveyed areas where TRICARE Prime is not offered (non-Prime Service Areas)--30 percent and 24 percent, respectively. GAO also found that beneficiaries in the surveyed areas most often experienced access problems related to providers' willingness to accept TRICARE payments, regardless of whether they lived in a Prime or non-Prime Service Area. Additionally, GAO's comparison of this survey data to related data from a 2008 Department of Health and Human Services' survey showed that beneficiaries in the surveyed Prime and non-Prime Service Areas rated their health care satisfaction similarly to each other and to beneficiaries of commercial health care plans, but slightly lower than Medicare beneficiaries. GAO found that the results for the 2008 provider survey are not representative of all physicians and mental health providers in the geographic areas surveyed, but the results do provide information about access to care based on the specific views of the respondents. According to a DOD official, generalizability of provider survey results to the entire country will likely be possible at the end of the 4-year survey period. GAO's review of the 2008 provider survey results indicates that a lower percentage of respondents in Prime Service Areas reported awareness and acceptance of TRICARE than respondents in non-Prime Service Areas. Additionally, there were differences between responding physicians and responding mental health providers, such as psychiatrists and clinical psychologists, regarding their awareness and acceptance of TRICARE. For example, 81 percent of physicians who responded reported that they would accept new TRICARE patients, if they were accepting any new patients at all, compared to 50 percent of mental health providers who responded. In commenting on a draft of this report, DOD concurred with GAO's overall findings and provided technical comments, which GAO incorporated as appropriate.