However the  access standards do not apply to beneficiaries using options other than  TRICARE Prime, such as TRICARE Standard or Extra. 2.) Reimbursement Rates and Provider Shortages Hinder Access to Civilian Providers; TMA Can Increase Reimbursement Rates When Needed, but Has Only Limited Means to Address Shortages

Reimbursement rates have been cited as the primary impediment that  hinders beneficiaries’ access to civilian health care and mental health care  providers under TRICARE Standard and Extra. More recent studies by TMA and  others have cited TRICARE’s reimbursement rates as the primary reason  civilian providers may be unwilling to accept these beneficiaries as  patients, for example:    TMA’s first multiyear survey of civilian providers (2005 through 2007)  showed that TRICARE’s reimbursement rates were the primary reason  cited by providers for not accepting TRICARE Standard and Extra  beneficiaries as new patients. Ultimately, the TRICARE  Regional Office director reviews and analyzes the requests. National and Local Shortages of Certain Provider Specialties Impede Beneficiaries’ Access to Civilian Providers, and TMA Is Limited in Its Ability to Address Them

Another main impediment to TRICARE beneficiaries’ access to civilian  providers is a shortage of certain provider specialties, both at the national  and local levels. TMA is Limited in How it Can Address Provider Shortages

TMA has attempted to address civilian provider shortages, but because  these shortages are not specific to the TRICARE program, there are  limitations in what TMA can do. However, in the same report, DOD noted that  TRICARE Standard and Extra beneficiaries reported more problems  finding civilian mental health care providers than beneficiaries who use  other health care coverage, and that psychiatrists have the lowest  acceptance rates of new TRICARE Standard and Extra beneficiaries  compared with other providers. Although TMA Has Typically Used Feedback Mechanisms to Gauge TRICARE Standard and Extra Beneficiaries’ Access to Civilian Providers, It Is Developing a New Method for Monitoring Access

TMA and its contractors have used various feedback mechanisms, such as  surveys, to gauge beneficiaries’ access to care under TRICARE Standard  and Extra. TMA Has Initiated Steps to Establish a Method for Routinely Monitoring Access to Civilian Providers for TRICARE Standard and Extra Beneficiaries

TMA has recently initiated steps to establish an approach to routinely  monitor beneficiaries’ access to both network and nonnetwork providers  under the TRICARE Standard and Extra options. In  recognition that the military health system had no established measures  for determining the adequacy of network and nonnetwork providers for  these beneficiaries, in February 2010, TMA’s Office of Policy and  Operations directed the TRICARE Regional Offices to develop a model to  identify geographic areas where they may experience access problems as  well as areas of provider shortages for the general population. However, because the regional models  were recently developed, it is too early to determine their effectiveness. TMA’s Contractors Educate Civilian Providers about TRICARE and Surveys Indicate That Providers Are Generally Aware of the Program

TMA’s contractors educate civilian providers about TRICARE program  requirements, policies, and procedures. Contractors also conduct outreach  to increase providers’ awareness of TRICARE, and TMA’s provider survey  results indicate providers are generally aware of the program. However,  providers’ awareness of TRICARE does not necessarily signify that they  have an accurate understanding of it. TMA’s Contractors Educate Beneficiaries on All TRICARE Options and Provide Information on Network Providers; New Contracts Will Also Require Information about Nonnetwork Providers

Under the second generation of TRICARE contracts, TMA’s contractors  have beneficiary education programs that contain information on all of the  TRICARE options; contractors also maintain directories of network  providers. Under its third generation of contracts, TMA will also require  contractors to include information on nonnetwork providers in their  directories. Agency Comments

We received comments on a draft of this report from DOD. Defense Health Care: Access to Care for Beneficiaries Who Have Not  Enrolled in TRICARE’s Managed Care Option.
Why GAO Did This Study

The Department of Defense (DOD) provides health care through its TRICARE program, which is managed by the TRICARE Management Activity (TMA). TRICARE offers three basic options. Beneficiaries who choose TRICARE Prime, an option that uses civilian provider networks, must enroll. TRICARE beneficiaries who do not enroll in this option may obtain care from nonnetwork providers under TRICARE Standard or from network providers under TRICARE Extra. The National Defense Authorization Act for Fiscal Year 2008 directed GAO to evaluate various aspects of beneficiaries' access to care under the TRICARE Standard and Extra options. This report examines (1) impediments to TRICARE Standard and Extra beneficiaries' access to civilian health care and mental health care providers and TMA's actions to address the impediments; (2) TMA's efforts to monitor access to civilian providers for TRICARE Standard and Extra beneficiaries; (3) how TMA informs network and nonnetwork civilian providers about TRICARE Standard and Extra; and (4) how TMA informs TRICARE Standard and Extra beneficiaries about their options. To address these objectives, GAO reviewed and analyzed TMA and TRICARE contractor data and documents. GAO also interviewed TMA officials, including those in its regional offices, as well as its contractors.

What GAO Found

Reimbursement rates and provider shortages have been cited as the main impediments that hinder TRICARE Standard and Extra beneficiaries' access to civilian health care and mental health care providers. Providers' concern about TRICARE's reimbursement rates--which are generally set at Medicare rates--has been a long-standing issue and has more recently been cited as the primary reason civilian providers will not accept TRICARE Standard and Extra beneficiaries as patients, according to TMA's surveys of civilian providers. TMA can increase reimbursement rates in certain instances, such as when it determines that access to care is being affected by the level of reimbursement. Shortages of certain provider specialties, such as mental health care providers, at the national and local levels may also impede access, but these shortages are not specific to the TRICARE program and also affect the general population. As a result, there are limitations as to what TMA can do to address them. TMA has primarily used feedback mechanisms, including surveys of beneficiaries and civilian providers, to gauge TRICARE Standard and Extra beneficiaries' access to civilian providers. More recently, in February 2010, in recognition that TRICARE has had no established measures for monitoring the availability of civilian network and nonnetwork providers for these beneficiaries, TMA directed the TRICARE Regional Offices to develop a model to help identify geographic areas where they may experience access problems. GAO's review of the initial models found their methodology to be reasonable. However, because the regional models were recently developed, it is too early to determine their effectiveness. TMA's contractors educate civilian providers about TRICARE program requirements, policies, and procedures. Contractors also conduct outreach to increase providers' awareness of the program, and while TMA's provider survey results indicate that civilian providers are generally aware of the program, this does not necessarily signify that providers have an accurate understanding of the TRICARE program and its options. Similarly, TMA's contractors educate beneficiaries on all of the TRICARE options and maintain directories of network providers to facilitate beneficiaries' access to care. When the new TRICARE contracts are implemented, TMA will also require its contractors to include information on nonnetwork providers in their provider directories. In commenting on a draft of this report, DOD concurred with GAO's overall findings.