MHS Coverage Eligibility for Reservists and Deployed DOD Civilians

Reservists have a general cycle of coverage during which they are  eligible for MHS care through various TRICARE options based on their  duty status – preactivation, active duty, deactivation, and inactive. DOD Makes a Variety of Inpatient and Outpatient Mental Health Care Available Domestically and Overseas

		DOD Offers a Variety of Mental Health Care Services

DOD makes a variety of mental health care services available both  domestically and overseas to active duty servicemembers, ranging from  outpatient services such as psychotherapy and telehealth, to inpatient  services such as acute psychiatric care, as well as emergency services. Consistent with the availability of outpatient mental health services at  MTFs and clinics, about 76 percent of outpatient mental health  encounters for active duty servicemembers were provided through direct  care across all military services in fiscal year 2014 (see table 3). Military Services Also Make Mental Health Care Available through Non- Traditional Methods

To address the mental health needs of servicemembers, the military  services have integrated mental health providers in primary care settings,  embedded mental health providers within units, and used telehealth. DOD Has Increased the Number of Available Mental Health Providers, but DOD Data Show Shortages for Some Provider Types

Our analysis of DOD staffing data for the direct care system from fiscal  years 2009 through 2015 and for the purchased care system from  December 2010 through July 2015 shows that DOD increased the  number of available mental health providers in both delivery systems,  thereby increasing DOD’s mental health capabilities to meet  servicemembers’ mental health care needs. MHS Mental Health Care Available to Inactive Reservists is Generally Limited to Assessments and Referrals or to Care Purchased through TRICARE Reserve Select

Unlike the mental health care made available to active duty  servicemembers, DOD generally does not make mental health care  available to inactive reservists at no cost to them. Air National Guard. While DOD Met Most of Its Mental Health Appointment Access Standards, DOD Lacks a Key Standard, and Its Surveys Suggest Potential Access Problems Recent Data Show That DOD Generally Met Its Access Standards for Most Direct Care Mental Health Appointment Types

Data from DHA’s TRICARE Operation Center for April 2014 through  August 2015 showed that MHS-wide, for appointments by active duty  servicemembers in the direct care system, the mental health access to  care standards were generally met for all domestic and overseas  appointment types except routine appointments. Although the mental health appointment access data suggest that DOD is  not meeting the 7-day standard for routine appointments, officials  suggested that these data are misleading, as some appointments were  coded incorrectly—negatively impacting the routine appointment access  results. DOD Lacks an Access Standard for the Most Common Type of Direct Care Mental Health Appointment

Although DOD has established standards and is monitoring access for  four types of mental health appointments, DOD told us that most mental  health appointments provided in the MHS’s direct care system fall into a  fifth category—follow-up appointments—which generally do not have an  official DOD access to care standard. Limited Data on Mental Health Access in Purchased Care Are Available, but DOD Instead Relies on Beneficiary Surveys and Complaints to Monitor Access

Limited data are available regarding access to care in the MHS’s  purchased care system. For example, fiscal year 2011 through  fiscal year 2014 data from DOD’s Health Care Survey of DOD  Beneficiaries—the principal tool with which DHA monitors the opinions  and experiences of MHS beneficiaries directly—found that about one in  three servicemembers who had a need for treatment or counseling  experienced problems accessing mental health care in the MHS. Data from the  2012 and 2013 TRICARE Standard Survey of Civilian Providers provided  by DOD showed that this percentage had not improved over time, with an  estimated 37 percent of civilian mental health providers accepting new  TRICARE patients during the surveys. It is too  early to determine the extent to which DOD’s ongoing efforts will resolve  all of these concerns. Mental health care is provided to deployed servicemembers and DOD  civilians through various means. Our work also shows that despite federal  internal control standards that call for agencies to have sufficient  information to monitor agency performance, DOD lacks an important  standard for follow-up appointments, which represent nearly two-thirds of  the mental health care provided in the MHS’s direct care system. Recommendation for Executive Action

To enhance oversight of access to mental health care and help ensure  that servicemembers have timely access to mental health care, we  recommend that that Secretary of Defense direct the Assistant Secretary  of Defense for Health Affairs to establish an access standard for mental  health follow-up appointments and regularly monitor data on these  appointments. DOD  did not provide a time frame for implementing this recommendation.
Why GAO Did This Study

DOD reports that between 2005 and 2013, the number of individuals who received mental health care through DOD's MHS grew by 32 percent. MHS mental health care is provided free to active duty servicemembers. Reservists and DOD civilians are eligible for MHS care under certain circumstances.
The National Defense Authorization Act for Fiscal Year 2015 contains a provision for GAO to assess the availability and accessibility of mental health care in DOD's MHS for military servicemembers. This report examines, among other things, (1) the mental health care DOD makes available to servicemembers domestically and overseas and (2) the accessibility of mental health care provided to servicemembers domestically and overseas. GAO analyzed recent, available data on MHS mental health utilization, staffing, and appointment access and compared access data to relevant DOD standards. GAO reviewed mental health data from several DOD surveys as well as documents related to MHS mental health care. GAO also interviewed DOD and service officials and representatives from servicemember and provider associations.

What GAO Found

The Department of Defense's (DOD) Military Health System (MHS) makes a variety of inpatient and outpatient mental health care available to active duty servicemembers and activated National Guard and Reserve servicemembers (reservists) domestically and overseas through its TRICARE health care system. The type of care includes psychological testing and assessment, psychotherapy, medication management, and inpatient psychiatric care. This care is typically available through military treatment facilities and clinics (direct care), and it is supplemented by care provided through networks of civilian providers (purchased care). In fiscal year 2014, DOD provided 76 percent of 2.9 million outpatient mental health encounters through direct care and 69 percent of 0.2 million inpatient mental health bed days through purchased care. To deliver mental health care, the military services use a range of strategies including telehealth, embedding mental health providers within units, and integrating mental health providers in primary care. While DOD has increased the number of available mental health providers in both direct and purchased care in recent years, DOD data indicate that the military services still face shortages for certain providers, such as psychiatrists. Unlike the care available for active duty servicemembers and activated reservists, MHS mental health care for inactive reservists is generally limited to referrals to non-DOD community resources or, if eligible, the reservists can purchase coverage for health care, including mental health care, through TRICARE Reserve Select, a premium-based health plan for reservists.
DOD data on domestic and overseas direct care from April 2014 through August 2015 show that MHS-wide DOD's access to care standards were generally met for three of four mental health appointment types. However, in the case of routine appointments—initial appointments for a new or exacerbated condition—data show that other than the Air Force, MHS routine mental health appointments generally did not meet the 7-day access standard. DOD and service officials attributed this to several factors, including some appointments being incorrectly coded, thus negatively impacting the routine appointment access results. They told GAO that DOD was taking steps to address the coding problem and improve oversight of mental health access. Additionally, the data show that about 59 percent of mental health appointments are follow-up appointments, which generally do not have an official DOD access standard. Federal internal control standards call for agencies to have sufficient information to monitor agency performance. By not establishing and monitoring a follow-up appointment standard, DOD cannot hold the military services accountable for the majority of mental health care provided in the direct care system. For purchased care, limited access data are available, and DOD instead relies on beneficiary surveys and complaints to monitor access—consistent with methods used by civilian health plans. DOD surveys have identified access problems for some servicemembers. For example, a DOD beneficiary survey estimated that about one-third of active duty servicemembers experienced problems accessing mental health care from 2011 through 2014. Additionally, provider surveys from 2012 and 2013 found that only an estimated 37 percent of civilian mental health providers were accepting any new TRICARE patients. DOD's ongoing efforts to improve oversight of mental health access, including implementing a strategic plan, may help address some of these problems, but it is too early to tell.

What GAO Recommends

GAO recommends that DOD establish an access standard for mental health follow-up appointments and regularly monitor data on these appointments. DOD concurred with GAO's recommendation.