TRICARE Select Implementation Plan

In addition to establishing the TRICARE Select option and making other  TRICARE program changes, the NDAA 2017 required DOD to develop an  implementation plan for TRICARE Select that includes seven specific  elements. These elements are, in part, intended to ensure beneficiaries’  access to care under the TRICARE Select option, and they require DOD  to ensure that at least 85 percent of the beneficiary population under  TRICARE Select is covered by the network by January 1, 2018  (Element A); ensure access standards for appointments for health care that meet  or exceed those of high-performing health care systems in the United  States, as determined by the Secretary (Element B); establish mechanisms for monitoring compliance with access  standards (Element C); establish health care provider-to-beneficiary ratios (Element D); monitor on a monthly basis complaints by beneficiaries with respect to  network adequacy and the availability of health care providers  (Element E); establish requirements for mechanisms to monitor the responses to  complaints by beneficiaries (Element F); and establish mechanisms to evaluate the quality metrics of the network  providers established under section 728 (of the NDAA 2017) (Element  G). DOD’s TRICARE Select Implementation Plan Included the Mandated Elements and Addressed Most Leading Planning Practices, but Does Not Reflect Current Approach for Access Standards

		DOD’s Implementation Plan Included the Mandated Elements and Addressed Most Leading Practices for Strategic Management Planning

The TRICARE Select implementation plan DOD submitted to Congress  included the seven specific elements mandated by the NDAA 2017. We also found that the implementation plan reflected most of the leading  practices for sound strategic management planning as identified by our  prior work. These leading practices suggest that strategic  planning documents include the following: (1) a mission statement, (2)  goals, (3) strategies to achieve goals, (4) plans to assess progress, and  (5) identification of challenges and risks. Element G, Evaluation of Quality Metrics, Remains under  Development  We also found that the implementation plan partially addressed or did not  address the leading practices related to strategies or plans to assess  progress for element G—establish mechanisms to evaluate the quality  metrics of the network providers. DOD officials explained that some of the details of their approach to the  mandated elements had not been finalized when they were completing  the implementation plan, including some of the details for element G,  which continues to be a work in progress. DOD officials explained that their approach to the implementation plan  was to create a strategic overview rather than a detailed work plan. Implementation Plan Does Not Reflect Current Approach for Establishing Access Standards

Our review of element B—ensure access standards for appointments for  health care that meet or exceed those of high-performing health care  systems in the United States, as determined by the Secretary—noted that  the approach described in the implementation plan differs from the  approach that DOD intends to use. However, DOD officials told us in interviews that the access  standards for TRICARE Select will be developed by each managed care  support contractor and approved by DOD. DOD officials further stated  that they did not include information about the managed care support  contractors proposing their own access standards because they were still  developing the approach to this element when the implementation plan  was submitted. Because the implementation plan does  not reflect DOD’s current approach, Congress may be lacking important  information, including what responsibilities the contractors have in terms  of providing access to care, impeding its ability to provide oversight. Recommendation for Executive Action

We recommend that the Secretary of Defense direct the Assistant  Secretary of Defense (Health Affairs) to provide written documentation of  DOD’s approach to developing and approving the TRICARE Select  access standards, as well as the final access standards, to Congress. DOD did not provide technical comments.
Why GAO Did This Study

DOD offers health care services to approximately 9.4 million eligible beneficiaries through TRICARE, DOD's regionally structured health care program. In each of its regions, DOD uses contractors to manage health care delivery through civilian provider networks, among other tasks.
The NDAA 2017 made several changes to the TRICARE program, including the establishment of a new preferred provider network health plan option called TRICARE Select. The NDAA 2017 also required DOD to develop an implementation plan for TRICARE Select that addresses seven specific mandated elements on access to care, beneficiary complaints, and quality metrics for network providers.
The NDAA 2017 included a provision for GAO to review the implementation plan. This report examines the extent to which DOD's implementation plan addressed the mandated elements. GAO evaluated DOD's implementation plan using leading planning practices identified in GAO's prior work and standards for internal control. GAO examined program policies, procedures, and contracts and interviewed DOD officials and TRICARE regional contractors.

What GAO Found

The Department of Defense's (DOD) TRICARE Select Implementation Plan addressed the seven specific elements mandated by the National Defense Authorization Act for Fiscal Year 2017 (NDAA 2017). These elements are
Element A: ensuring that at least 85 percent of the TRICARE Select beneficiary population is covered by the network by January 1, 2018;
Element B: ensuring access standards for health care appointments;
Element C: establishing mechanisms for monitoring compliance with standards for access to care;
Element D: establishing health care provider-to-beneficiary ratios;
Element E: monitoring complaints by beneficiaries with respect to network adequacy and health care provider availability;
Element F: establishing requirements for mechanisms to monitor the responses to complaints by beneficiaries; and
Element G: establishing mechanisms to evaluate the quality metrics of the network providers.
GAO also assessed the implementation plan against leading practices for sound strategic management planning and found that it incorporated many of the practices, such as establishing goals, strategies to achieve goals, and plans to assess progress. However, a few of the leading practices were only partially incorporated or not incorporated at all. For example, the implementation plan did not always fully address the leading practice that planning documents include strategies to achieve goals and plans to assess progress. DOD officials explained that some of the details of their approach to the elements had not been finalized when they were completing the implementation plan. These officials added that their approach to the implementation plan was to create a strategic overview, and that some of the details are contained in contract documents and monitored through their oversight responsibilities.
Furthermore, GAO's assessment of the plan's elements found that the approach outlined in the implementation plan for ensuring access standards for health care appointments (Element B) is different from the approach DOD intends to use. The plan noted that DOD will use the access standards for TRICARE Prime—a managed care option—for TRICARE Select. However, DOD officials told GAO that the contractors are responsible for developing their own access standards, which DOD must approve. These officials added that DOD did not include information about the contractors proposing their own access standards because DOD was still developing its approach to this element when the plan was submitted. Because the implementation plan does not reflect DOD's current approach, Congress may not have the information it needs about the contractors' responsibilities for providing access to care, impeding its ability to provide oversight.

What GAO Recommends

GAO recommends that DOD provide written documentation of its approach for developing and approving the TRICARE Select access standards, as well as the final access standards, to Congress. DOD agreed with GAO's recommendation.