	Background

Under TRICARE, beneficiaries have choices among various benefit  options and may obtain care from either military treatment facilities or  civilian providers. The NDAA 2008 directed DOD to conduct surveys  of beneficiaries and civilian providers to assess nonenrolled beneficiaries’  access to care. Nearly One in Three Nonenrolled Beneficiaries Experienced Problems Accessing Care, and They Rated Their Satisfaction with Care Generally Lower than Medicare Fee-for-Service Beneficiaries

		Nearly One in Three Nonenrolled Beneficiaries Experienced Problems Finding Civilian Providers Who Would Accept TRICARE; Those in PSAs Experienced More Problems Finding Primary and Specialty Care than Those in Non-PSAs

Overall, during 2008-2011, an estimated one in three nonenrolled  beneficiaries (about 31 percent) experienced problems finding any type of  civilian provider—primary, specialty, or mental health care provider—who  would accept TRICARE. Civilian Providers’ Acceptance of New TRICARE Patients Has Decreased over Time; Mental Health Providers Report Lower Awareness and Acceptance than Other Provider Types

Nationwide, an estimated 82 percent of civilian providers indicated they  were aware of the TRICARE program, but only an estimated 58 percent  were accepting new TRICARE patients, according to our analysis of the  2008 through 2011 civilian provider survey results. When compared to a  national provider survey, civilian providers’ acceptance of new TRICARE  patients was less than providers’ acceptance of other types of  beneficiaries. According to the TRICARE survey results, when asked the reasons for  not accepting new TRICARE patients, the most-cited category by those  civilian providers who were not accepting any new TRICARE patients was  that the provider “was not aware of the TRICARE program/not  asked/don’t know about TRICARE.” (See fig. Additionally, while nonenrolled beneficiaries cited that providers  were not accepting TRICARE for payment as the top reason why any  providers were unwilling to accept them as patients, the providers cited it  as the third highest reason in addition to “don’t know/no answer.”
When we compared the results of TMA’s 2008-2011 civilian provider  survey (excluding nonphysician mental health providers) to the results of  its 2005-2007 civilian physician survey, we found that although civilian  physicians’ awareness has increased over time, their acceptance of new  TRICARE patients has decreased over time. This was also true whether  they were accepting any new patients or new Medicare patients. Specifically, only an estimated 39 percent of civilian mental health  providers were accepting new TRICARE beneficiaries, compared to an  estimated 67 percent of civilian primary care providers and an estimated  77 percent of civilian specialty care providers. We also found that providers’ awareness and acceptance of TRICARE  differed by type of area. Similar to TMA’s nonenrolled beneficiary survey,  which showed that nonenrolled beneficiaries in PSAs generally  experienced more problems finding providers than their counterparts in  non-PSAs, our analysis of the 2008 through 2011 civilian provider survey  indicated that civilian providers in PSAs were less aware of TRICARE and  less accepting of new TRICARE patients than civilian providers in non- PSAs. Collective Results of TMA’s Beneficiary and Civilian Provider Surveys Indicate Specific Geographic Areas Where Nonenrolled Beneficiaries Have Experienced Access Problems

An analysis of the collective results of the multiyear beneficiary and  civilian provider surveys indicated particular geographic areas where  nonenrolled beneficiaries are experiencing considerable access  problems. Table 6 shows each of  these areas with the estimated percentage of (1) nonenrolled  beneficiaries who experienced problems finding a civilian primary care  provider and (2) civilian primary care providers who were accepting any  new TRICARE patients. Civilian Mental Health Care Providers

Because of the low numbers of survey responses for beneficiaries who  said they needed civilian mental health care, we are unable to report  correlated survey results for access problems to civilian mental health  care providers.of mental health providers and the survey results that only 39 percent of  civilian mental health care providers were accepting new TRICARE  patients, access to mental health care providers is a concern for all  TRICARE beneficiaries, including those who use the TRICARE Standard  and Extra options. Appendix I: TRICARE Management Activity’s Methodology for the 2008-2011 Beneficiary and Civilian Provider 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. Survey Area Selection

The NDAA 2008 specified that DOD survey beneficiaries and providers in  at least 20 TRICARE Prime Service Areas (PSA),areas in which TRICARE Prime is not offered—referred to as non–Prime  Service Areas (non-PSA)—each fiscal year, 2008 through 2011. For the purpose of this report, we use the term  “nonenrolled beneficiaries” for beneficiaries who are not enrolled in  TRICARE Prime and who use the TRICARE Standard or Extra options, or  TRICARE Reserve Select (TRS).
Why GAO Did This Study

DOD provides health and mental health care through its TRICARE program. TRICARE offers three basic options. Beneficiaries who choose TRICARE Prime, an option that uses civilian provider networks, must enroll. Beneficiaries who do not enroll in this option may obtain care from nonnetwork providers under TRICARE Standard or from network providers under 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. GAO refers 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 DOD to conduct annual surveys over fiscal years 2008 through 2011 of both beneficiaries and civilian providers to determine the adequacy of access to health and mental health care providers for nonenrolled beneficiaries. It also directed GAO to review these surveys. This report addresses (1) what the results of the 4-year beneficiary surveys indicate about the adequacy of access to care for nonenrolled beneficiaries; (2) what the results of the 4-year civilian provider surveys indicate about civilian providers' awareness and acceptance of TRICARE, and (3) what the collective results of the surveys indicate about access to care by geographic area. To do so, GAO interviewed DOD officials, obtained relevant documentation, and analyzed the data for both surveys over the 4-year period.

What GAO Found

In its analysis of the 2008-2011 beneficiary survey data, GAO found that nearly one in three nonenrolled beneficiaries experienced problems finding a civilian provider who would accept TRICARE and that nonenrolled beneficiaries' access to civilian primary care and specialty care providers differed by type of location. Specifically, a higher percentage of nonenrolled beneficiaries in Prime Service Areas (PSA), which are areas with civilian provider networks, experienced problems finding a civilian primary care or specialty care provider compared to those in non-Prime Service Areas (non-PSA), which do not have civilian provider networks. GAO found that the top reasons reported by nonenrolled beneficiaries for why they experienced access problems--regardless of type of provider--were that the providers were either not accepting TRICARE payments or new TRICARE patients. Additionally, GAO's comparison of the Department of Defense's (DOD) beneficiary survey data to related data from a Department of Health and Human Services survey showed that nonenrolled beneficiaries' satisfaction ratings for primary and specialty care providers were consistently lower than those of Medicare fee-for-service beneficiaries.
GAO's analysis of the 2008-2011 civilian provider survey data found that about 6 in 10 civilian providers were accepting new TRICARE patients and the most-cited reason for not accepting new TRICARE patients was that the civilian providers were not aware of the TRICARE program. Civilian physicians' acceptance of TRICARE has also decreased over time. Specifically, when compared to DOD's 2005-2007 civilian physician survey results, civilian physicians' acceptance of new TRICARE patients has decreased. This was also true whether they were accepting any new patients or new Medicare patients. Civilian providers' awareness and acceptance of TRICARE also differed by provider type, as fewer civilian mental health care providers were aware of TRICARE or accepting new TRICARE patients than other types of providers. For example, only an estimated 39 percent of civilian mental health care providers were accepting new TRICARE patients, compared to an estimated 67 percent of civilian primary care providers and an estimated 77 percent of civilian specialty care providers. The analysis also showed that civilian providers' awareness and acceptance of TRICARE differ by location type, as civilian providers in PSAs were less aware of TRICARE and less likely to accept new TRICARE patients than those in non-PSAs.
GAO's analysis of the collective results of the beneficiary and civilian provider survey results indicates specific geographic areas, including areas in Texas and California, where nonenrolled beneficiaries have experienced considerable access problems. In each of these areas, although almost all civilian providers were accepting new patients, less than half were accepting new TRICARE patients. In most of these areas, civilian providers most often cited reimbursement concerns as the reasons why they were not accepting any new TRICARE patients.
In commenting on a draft of this report, DOD concurred with GAO's overall findings.