Background

Under TRICARE, beneficiaries have choices among various benefit  options and may obtain care from either military treatment facilities or  civilian providers. When nonenrolled beneficiaries receive care from  civilian providers, they have the option of seeing either network or  nonnetwork providers. The NDAA 2008 directed DOD to conduct surveys  of beneficiaries and civilian providers to assess nonenrolled beneficiaries’  access to care.

		TRICARE’s Benefit Options

TRICARE provides benefits through several basic options for its non- Medicare-eligible beneficiary population. These options vary by  enrollment requirements, choices in civilian and military treatment facility  providers, and the amount beneficiaries must contribute toward the cost  of their care. Table 1 provides a summary of some of these benefit  options.
Claims data from fiscal years 2008 to 2011 show that the percentages of  the number of outpatient claims paid for TRICARE Prime and TRS have  gradually increased, while the percentage of claims paid for TRICARE  Standard has declined. (See fig. 1.) The percentage of claims paid for  TRICARE Extra has remained steady over the same period.
Starting on September 30, 2013, the number of PSAs will be reduced,  and as a result, the TRICARE Prime option will be available to fewer  beneficiaries. The targeted PSAs are those that are not in close proximity  to existing MTFs or BRAC locations and will predominantly affect retirees  and their dependents. According to a TMA official, this change is  expected to affect about 171,000 retirees and dependents (37,000 in the  North region, 36,000 in the West region, and 98,000 in the South region), with an estimated savings to DOD of $45 million to $56 million annually.

		Composition of TRICARE’s Nonenrolled Beneficiary Population

In fiscal year 2011, TMA identified about 2 million nonenrolled  beneficiaries (approximately one-fourth of the total eligible TRICARE  population), who fell into three main categories: (1) retirees and their  dependents or survivors, (2) active duty dependents, and (3) National  Guard and Reserve servicemembers and their dependents. (See fig. 2.)

	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. Specifically: an estimated 25 percent of nonenrolled beneficiaries experienced  problems finding a civilian primary care provider; an estimated 25 percent of nonenrolled beneficiaries experienced  problems finding a civilian specialty care provider; and an estimated 28 percent experienced problems accessing a civilian  mental health care provider.
Overall, access to civilian primary care and specialty care providers  differed for nonenrolled beneficiaries located in PSAs compared to those  in non-PSAs. Specifically, we found that more nonenrolled beneficiaries in  PSAs experienced problems finding civilian primary care and specialty  care providers compared to those in non-PSAs. (See fig. 6.) However,  access to civilian mental health care providers did not differ for  nonenrolled beneficiaries in PSAs and non-PSAs.
TMA also surveyed beneficiaries in HSAs in response to access concerns  about these specific areas. We found that more nonenrolled beneficiaries  in HSAs experienced problems accessing civilian specialty care than  those in the areas outside of the surveyed HSAs. (See fig. 7.) However,  there were no statistical differences in the estimated percentages of  nonenrolled beneficiaries who experienced problems finding civilian  primary or mental health care providers between the HSAs and the  locations surveyed outside of these areas.
The top two reasons reported by nonenrolled beneficiaries—regardless of  type of care—for why they believed they experienced problems accessing  a provider included “doctors not accepting TRICARE payments” and  “doctors not accepting new TRICARE patients.” (See fig. 8.)
Our analysis of the 4-year survey data showed that nonenrolled  beneficiaries’ ratings for specific satisfaction measures were similar when  compared between PSAs and non-PSAs, and between surveyed HSAs  and the areas outside of the surveyed HSAs. Specifically, our analysis of  beneficiaries’ ratings for four measures—satisfaction with primary care  providers, specialty care providers, health care, and health plan— indicated no substantial differences between area types. For example,  we found that about 80 percent of nonenrolled beneficiaries in both PSAs  and non-PSAs rated their primary care provider as an 8 or higher on a  scale from 0 to 10.

	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. Specifically, a survey of physicians in 2008 by the Center  for Studying Health System Change found that about 96 percent of  physicians accepted new commercially insured beneficiaries, about   86 percent accepted new Medicare beneficiaries, and about 72 percent  accepted new Medicaid 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. 10 for the top 7 categories  of reasons for why civilian providers were not accepting new TRICARE  patients.) 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. For  example, civilian physicians’ acceptance of any new TRICARE patients  has decreased from about 76 percent in 2005-2007 to an estimated   70 percent in 2008-2011. (See fig. 11.)
When analyzed further by provider type, we found that civilian primary  and specialty care providers had higher awareness and acceptance of  TRICARE than civilian mental health care providers. (See fig. 12.)  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.
The categories of reasons cited for not accepting new TRICARE patients  also differed by provider type. For example, civilian mental health care  providers more often cited “not aware of TRICARE/not asked/don’t know  about TRICARE” than civilian primary or specialty care providers.  Additionally, the top category of reasons cited by civilian primary care  providers was that they were “not accepting patients” while the top  category of reasons cited by specialty providers was “reimbursement.”  (See fig. 13 for the top categories of reasons for civilian providers not  accepting new TRICARE patients, by provider type.)
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. Specifically, an estimated 81 percent of civilian providers in PSAs  were aware of the TRICARE program, compared to an estimated    and an estimated   87 percent of civilian providers in non-PSAs, 56 percent of civilian providers in PSAs were accepting any new  TRICARE patients, compared to an estimated 66 percent of those  providers in non-PSAs. (See fig. 14.)

	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. These locations are defined as areas where (1) the percentage  of nonenrolled beneficiaries who experienced difficulties finding a civilian  provider was at least the national estimate and (2) the percentage of  civilian providers who were accepting any new TRICARE patients was at  or below the national estimate. Using these criteria, we identified a  number of areas where beneficiaries were having access problems,  mostly in Texas. (See app. IV for detailed information about these areas  and how they were determined.)
In determining areas where nonenrolled beneficiaries were experiencing  access problems to any type of civilian provider, we first identified   24 individual areas (out of the 215 individual areas surveyed by the 2008- 2011 beneficiary surveys) where the estimated percentage of nonenrolled beneficiaries who experienced difficulties finding any type of  civilian provider met or exceeded the national estimate (31 percent). Of  these, we identified 2 PSAs where the estimated percentage of civilian  providers who were accepting any new TRICARE patients was at or  below the national estimate (58 percent)—Central/Southern-Central  Coastal California and Northeastern Texas. Additionally, we identified   2 HSAs that also met these criteria, one of which is contained within the  Northeastern Texas PSA. Table 4 shows each of these areas with the  estimated percentage of (1) nonenrolled beneficiaries who experienced  problems finding any type of civilian provider and (2) civilian providers  who were accepting any new TRICARE patients.
For the overlapping PSA and HSA (Northeastern Texas and Dallas/Fort  Worth), we found that although a high percentage of civilian providers  were accepting new patients (between 95 and 97 percent), only about  half of these providers were accepting any new TRICARE patients. (See  table 5.) For the remaining PSA (Central/Southern-Central California) and  HSA (Austin, Texas), between 92 and 98 percent of civilian providers  were accepting new patients, and less than half of those providers were  accepting any new TRICARE patients. Further, of the civilian providers in  all of these areas who were accepting new Medicare patients, between  65 and 70 percent were also accepting any new TRICARE patients.  Reimbursement was the most cited reason for providers not accepting  new TRICARE patients for all of the areas except the PSA in California  for which “not aware of the TRICARE program” was the most cited  reason.
When analyzing this data by type of provider (primary care, specialty, and  mental health), we found four areas where the percentage of civilian  primary care providers who were accepting any new TRICARE patients  was at or below the national estimate, but did not find similarly low- percentage areas for civilian specialty care providers. Because of the low  numbers of survey responses, we are unable to report survey results for  access problems to civilian mental health care providers.

		Civilian Primary Care Providers

In determining areas where nonenrolled beneficiaries experienced access  problems to civilian primary care providers, we first identified 21 individual  areas where the estimated percentage of nonenrolled beneficiaries who  experienced difficulties finding a civilian primary care provider met or  exceeded the national estimate (25 percent). Of these, we identified   2 PSAs where the estimated percentage of civilian primary care providers  who were accepting any new TRICARE patients was at or below the  national estimate (67 percent)—Northeastern Texas and Eastern-Central  Texas. We also identified 2 HSAs that met these criteria, each of which  was contained in one of the PSAs we identified. 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.
As we similarly found in the areas where nonenrolled beneficiaries were  having access problems for any type of civilian provider, we found that  between 94 and 97 percent of civilian primary care providers in the  Northeastern Texas PSA/Dallas/Ft. Worth HSA and the Eastern-Central  Texas PSA/Austin, Texas, HSA were accepting new patients, but only  around half of them were accepting new TRICARE patients. (See  table 7.) Further, of the civilian primary care providers in the two PSAs  who were accepting new Medicare patients, between 59 and 68 percent  were accepting any new TRICARE patients. Reimbursement was the  most cited reason by civilian primary care providers for not accepting any  new TRICARE patients in each of these areas except for the Dallas/Ft.  Worth, Texas, HSA, for which “don’t know/no answer” was the most cited  reason.
In determining areas where nonenrolled beneficiaries are experiencing  access problems to civilian specialty care providers, we first identified  nine individual areas where the estimated percentage of nonenrolled  beneficiaries who experienced difficulties finding a civilian specialty care  provider met or exceeded the national estimate (25 percent). Unlike the  collective results for “any civilian provider” and “civilian primary care  providers,” when we examined civilian specialty care providers’  responses for these areas, we did not identify any geographic areas  where the estimated percentage of civilian specialty care providers who  were accepting any new TRICARE patients was at or below the national  estimate (77 percent) when accounting for the margins of error at the   95 percent confidence limit. For the nine areas where the estimated  percentage of beneficiaries who experienced difficulties finding a civilian  specialty care provider met or exceeded the national estimate, the  percentage of civilian specialty care providers who were accepting new  TRICARE patients ranged from 75 to 86 percent.

		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.

	Agency Comments and Our Evaluation

In reviewing a draft of this report, DOD concurred with our overall findings  and provided technical comments, which we incorporated where  appropriate. (See app. VI.)
We are sending copies of this report to the Secretary of Defense and  appropriate congressional committees. The report is also available at no  charge on GAO’s website at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (202) 512-7114 or draperd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff members who made key  contributions to this report are listed in appendix VII.

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. 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). The NDAA 2008 also included specific  requirements related to the number and priority of areas to be surveyed,  including the populations to be surveyed each year, content for each type  of survey, and the use of benchmarks. Within DOD, the TRICARE  Management Activity (TMA), which oversees the TRICARE program, has  the lead responsibility for designing and implementing the nonenrolled  beneficiary and civilian provider surveys. The following information  describes TMA’s methodology, including its actions to address the  requirements for each of the following: (1) survey area, (2) sample  selection, (3) survey content, and (4) the establishment of benchmarks.

	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. The  NDAA 2008 also required DOD to consult with representatives of  TRICARE beneficiaries and health care and mental health care providers  to identify locations where nonenrolled beneficiaries have experienced  significant access-to-care problems, and give a high priority to surveying  health care and mental health care providers in these areas. Additionally,   and 20 geographic  the NDAA 2008 required DOD to give a high priority to surveying areas in  which a high concentration of Selected Reserve servicemembers live.
In designing the 2008 through 2011 nonenrolled beneficiary and civilian  provider surveys, TMA defined 80 PSAs and 80 non-PSAs that allowed it  to survey the entire country over a 4-year period, and subsequently  develop estimates of access to health care and mental health care at  service area and national levels. TMA identified the 80 PSAs by collecting  zip codes where TRICARE Prime was offered from officials within each of  the three TRICARE Regional Offices. TMA grouped these zip codes into  80 nonoverlapping areas so that each area had roughly the same number  of TRICARE-eligible beneficiaries. Because non-PSAs had not previously  been defined, TMA sought to define them by grouping all zip codes not in  PSAs into one large area using Hospital Referral Regions, which are  groupings of Hospital Service Areas (HSA). TMA divided the large area  into 80 non-PSAs so that each area had roughly the same number of  TRICARE-eligible beneficiaries.
To identify locations where nonenrolled beneficiaries and health care and  mental health care providers have identified significant levels of access- to-care problems under TRICARE Standard and Extra, TMA spoke with  groups representing beneficiaries and health care and mental health care  providers, as well as officials at the TRICARE Regional Offices. These  groups suggested cities and towns where access should be measured (in  addition to the larger PSAs and non-PSAs), and HSAs corresponding to  each city and town were then identified. On the basis of the groups’  recommendations, multiple lists were created and sorted in priority order:  21 HSAs were surveyed in the 2008 surveys; 9 HSAs in the 2009  surveys; 25 HSAs in the 2010 surveys; and 16 HSAs in the 2011 civilian  provider survey. This resulted in a total of 55 HSAs surveyed for the  nonenrolled beneficiary survey, and 71 HSAs surveyed in the civilian  provider survey (the 71 HSAs includes the same 55 HSAs surveyed for  the nonenrolled beneficiary survey and an additional 16 that were  selected for the 2011 fielding). Although the NDAA 2008 required DOD  to give a high priority to surveying areas in which a high concentration of  Selected Reserve servicemembers live, TMA officials decided to  randomly select areas for the surveys in order to produce results that  could be generalized to the populations in the areas surveyed and to  survey the entire United States over the 4-year period—an approach we  deemed acceptable in our previous report.

	Survey Sample Selection

		Nonenrolled Beneficiary Survey Sample Selection

TMA selected its sample of beneficiaries who met its criteria for inclusion  in the beneficiary survey using DOD’s Defense Enrollment Eligibility  Reporting System (DEERS), a database of DOD beneficiaries who may  be eligible for military health benefits. TMA determined a beneficiary’s  eligibility to be included in the nonenrolled beneficiary survey if DEERS  indicated that the individual met five criteria:  1.  eligible for military health care benefits as of the date of the sample  2.  age 18 years old or older;  3.  not an active duty member of the military;  4.  residing in one of the 20 randomly selected PSAs or 20 randomly  selected non-PSAs to be surveyed that year; and  5.  not enrolled in TRICARE Prime, or is enrolled in TRS.
From this database, TMA randomly sampled 1,000 beneficiaries from  each PSA and non-PSA—a sample size that would achieve TMA’s  desired sample error rate. For the 2008, 2009, and 2010 survey  fieldings, TMA used a sample size between approximately 40,000 and  50,000 beneficiaries. Because of budgetary constraints, the sample size  of the 2011 nonenrolled beneficiary survey was decreased to around  34,000. Because of this reduction, the 2011 sample was further  stratified by using claims data to identify beneficiaries who would likely  self-report as TRICARE Standard and Extra users. After receiving the  returned surveys, TMA identified the responses that it considered  complete and eligible on the basis of whether the beneficiary had  answered at least half of TMA’s identified “key” questions. Table 8 shows  the number of nonenrolled beneficiary surveys mailed, by fiscal year.
For each survey fielding, TMA selected the civilian provider sample within  the same 20 PSAs and 20 non-PSAs that had been randomly selected for  that year’s nonenrolled beneficiary survey, as well as civilian providers in  the HSAs identified by beneficiary and provider groups as having  significant levels of access-to-care problems under TRICARE Standard  and Extra. TMA used the American Medical Association Physician  Masterfile to select a sample of physicians who were licensed, office- based civilian medical doctors or licensed civilian doctors of osteopathy  within the specified locations who were engaged in more than 20 hours of  patient care each week. The American Medical Association Physician  Masterfile is a database of physicians in the U.S.—Doctors of Medicine  and Doctors of Osteopathic Medicine—that includes data on all  physicians who have the necessary educational and credentialing  requirements. This “Masterfile” did not differentiate between TRICARE’s  network and nonnetwork civilian providers, which TMA deemed  acceptable to avoid any potential bias in TMA’s sample selection. As  such, TMA selected this file because it is widely recognized as one of the  best commercially available lists of providers in the United States and  contained more than 940,000 physicians along with their addresses,  phone numbers, and information on practice characteristics, such as their  specialty. According to TMA, the American Medical Association updates  physicians’ addresses monthly and other elements through a rotating  census methodology involving approximately one-third of the physician  population each year. Although the Masterfile is considered to contain  most providers, deficiencies in coverage and inaccuracies in detail  remain. Therefore, TMA attempted to update providers’ addresses and  phone numbers and ensure that providers were eligible for the survey by  also using state licensing databases, local commercial lists, and  professional society and association lists.
For its 2008 and 2009 mental health care provider sample selection, TMA  selected a sample of mental health care providers from two sources: the  American Medical Association’s Masterfile of psychiatrists, and LISTS,  Inc.—a list of names with contact information assembled from state  licensing boards. For the 2010 and 2011 mental health care provider  sample selections, TMA also used mental health specialty areas from the  National Plan and Provider Enumeration System database maintained by  the Centers for Medicare & Medicaid Services, in addition to data from  LISTS, Inc., and the psychiatrist data from the American Medical  Association’s Masterfile. According to TMA, it selected these sources for  mental health care providers because they have been identified as the  most comprehensive databases for these health care providers.
From these data sets, TMA planned to randomly sample about   800 providers (400 each of physicians and mental health care providers)  from each PSA, non-PSA, and HSA—a sample size that would achieve   In those instances where there were  TMA’s desired sample error rate.not 800 providers in a single area, TMA selected all of the providers in  that area to receive surveys. As the PSA and non-PSA regions were  formed on the basis of the number of beneficiaries and not the number of  civilian providers, some regions with a large number of civilian providers  were sampled at relatively low rates in 2008, 2009, and 2010. To improve  the precision of national estimates, in 2011 TMA selected six areas to  oversample: (1) Southeastern N.Y. and Northern N.J. (New York City);   (2) Los Angeles, Calif.; (3) Eastern Mass. (Boston); (4) Northeastern/  Central Ohio (Cleveland); (5) Southeastern/Northern Mich. (Detroit); and  (6) Northwestern/Northeastern/Central-Eastern Ill. and Southwestern  Wisc. (Chicago). Therefore, in 2011, a supplemental sample of 4,800  providers was drawn for these 6 PSAs, thereby increasing the numbers of  eligible providers in each area:
1,600 providers from the two 2008 PSAs (Los Angeles, California, and  Southeastern New York/Northern New Jersey);
800 providers from the one 2009 PSA (Eastern Massachusetts); and
2,400 providers from the three 2010 PSAs (Northeastern/Central  Ohio, Southeastern/Northern Michigan, and  Northwestern/Northeastern/Central-Eastern Illinois/Southeastern  Wisconsin).
Upon receipt of the returned surveys, TMA identified the responses that it  considered complete and eligible based on the following criteria for  respondents: (1) if the provider answered “yes” to the questions that  asked whether the provider offers care in an office-based location or  private practice; (2) for the nonphysician mental health survey, if the  provider responded he or she was one of the six TRICARE participating  specialties: certified clinical social worker, certified psychiatric nurse  specialist, clinical psychologist, certified marriage and family therapist,  pastoral counselor, or mental health counselor; and (3) the provider had  to have completed three key questions on the physician survey  instrument, or three key questions on the nonphysician mental health  provider survey instrument. Table 9 shows the number of civilian provider  surveys mailed, by fiscal year.

	Beneficiary and Provider Survey Content

		Nonenrolled Beneficiary 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 care providers willing to  provide services under TRICARE Standard or TRICARE Extra. TMA’s  2008 nonenrolled beneficiary survey included 91 questions that  addressed, among other things, health care plans used; perceived access  to care from a personal doctor, nurse, or specialist; the need for treatment  or counseling; and ratings of health plans. TMA based some of its 2008  nonenrolled beneficiary survey questions on those included in the  Department of Health and Human Services’ Consumer Assessment of  Healthcare Providers and Systems (CAHPS), a national survey of  beneficiaries of commercial health insurance, Medicare, Medicaid, and  the Children’s Health Insurance Program. Over the 4 years of the  nonenrolled beneficiary survey fielding, TMA added three additional  questions to the original 91 questions in the 2008 nonenrolled beneficiary  survey that covered topics about the beneficiaries’ flu-shot history, and  what they liked and disliked about TRICARE Standard and Extra.  Additionally, in 2011, “TRICARE Young Adult” and “TRICARE Retired  Reserve” were added to the response selections for the question that  asked about the health plan the beneficiary used. (See app. II for a copy  of the 2011 beneficiary survey instrument.)
When TMA began mailing the beneficiary survey, it included a combined  cover letter and a questionnaire to all beneficiaries in its sample—with the  option of having beneficiaries complete the survey by mail or Internet.  The cover letter provided information on the options available for  completing the survey, as well as instructions for completing the survey  by Internet. If the beneficiary did not respond to the mailed questionnaire,  TMA mailed a second combined cover letter and questionnaire 4 weeks  later encouraging the beneficiary to complete the survey.

		Civilian Provider Survey Content

For the civilian provider survey, the NDAA 2008 required questions to  determine: (1) whether the provider is aware of TRICARE; (2) the  percentage of the provider’s current patient population that uses any form  of TRICARE; (3) whether the provider accepts Medicare patients for  health care and mental health care; and (4) if the provider accepts  Medicare patients, whether the provider would accept new Medicare  patients. TMA obtained clearance for its provider survey from the Office of  Management and Budget (OMB) as required under the Paperwork  Reduction Act. Subsequent to this review, OMB approved an 11-item  questionnaire for physicians (including psychiatrists) and a 12-item  questionnaire for nonphysician mental health providers. The mental  health care providers’ version of the survey includes an additional  question about what type of mental health care the provider practiced.  Beginning with the 2009 civilian provider survey, an additional follow-up  question was added that asked the provider what type of practice they  practiced in if the provider indicated that they were not in private practice.  Although a civilian provider’s indication that the provider was not in  private practice still made the provider’s responses ineligible for the  survey, the additional information from these nonprivate practice civilian  providers could be used by TMA to glean additional information about  civilian providers. (See app. III for a copy of the 2011 civilian provider  survey instruments.)
When TMA began mailing the provider survey, it included a combined  cover letter and a questionnaire to each provider in the sample. The  providers had the option of completing the survey by mail, fax, or Internet.  The cover letter provided information on the options available for  completing the survey, as well as instructions for completing the survey  by Internet. If the provider did not respond to the mailed questionnaire,  TMA mailed a second combined cover letter and questionnaire about   4 weeks later encouraging the provider to complete the survey.

	Survey Benchmarks

In accordance with the NDAA 2008, TMA identified benchmarks for  analyzing the results of the beneficiary and civilian provider surveys.  Because TMA based some of its 2008 beneficiary survey questions on  those included in the CAHPS surveys, it was able to compare the results  of those questions with its 2008 through 2011 beneficiary survey results.  To benchmark its provider survey, TMA compared the results of its 2008  through 2011 surveys with the results of its 2005, 2006, and 2007  provider surveys. A TMA official noted that TMA was unaware of any  external benchmarks that would be applicable to its surveys of providers.

	Analyses of Survey Results

		Analysis of Nonenrolled Beneficiary Survey Results

In analyzing the results of the nonenrolled beneficiary survey, TMA  representatives conducted yearly nonresponse analyses because the  overall response rate for the surveys was around 38 percent. To  conduct this analysis for the 2008, 2009, and 2010 survey years, TMA did  the following: (1) compared key beneficiary demographic characteristics  of respondents to those of nonrespondents (e.g., beneficiary gender and  age) and (2) interviewed a sample of beneficiaries who did not respond to  the original survey or the follow-up second mailing and compared their  responses with the original survey respondents. Because of budgetary  constraints during the 2011 survey year, TMA only compared key  beneficiary demographic characteristics of respondents to those of the  nonrespondents. The results of TMA’s nonresponse analyses indicated  that respondents to the nonenrolled beneficiary survey differed  substantially from the surveyed population in some demographic  characteristics. For example, the analyses indicated that retirees,  dependents of retirees, and dependents of survivors were  overrepresented in the study, and dependents of active duty  servicemembers, dependents of Guard/Reserve personnel, and  dependents of inactive guard personnel were underrepresented in the  study. Additionally, in each of the years in which TMA representatives  conducted follow-up interviews (2008-2010), they found some response  differences between survey respondents. For example, each year in  follow-up interviews of nonrespondents, they found these beneficiaries  rated their primary care provider and health plans more favorably than  beneficiaries who responded to the survey. According to TMA  representatives, they used a weighting scheme to reflect the survey  population proportions to correct any bias as a result of survey  nonresponse.

		Analysis of Civilian Provider Survey Results

In analyzing the results of the provider survey, TMA conducted a  nonresponse analysis because the overall response rate to the surveys  was about 42 percent. To conduct this analysis for the 2008, 2009, and  2010 surveys, TMA did the following: (1) compared key provider  demographic characteristics of respondents to those of nonrespondents  (for example, provider type and area) and (2) interviewed a sample of  physicians and mental health care providers who did not respond to the  survey, follow-up second mailing, or follow-up telephone calls and  compared their responses with the survey respondents. Because of  budgetary constraints during the 2011 survey year, TMA only compared  key provider demographic characteristics of respondents to those of the  nonrespondents. The results of TMA’s nonresponse analyses indicated  that there are some demographic differences between respondents and  those who did not respond. For example, the analyses indicated that in  some years psychiatrists were underrepresented in the survey samples.  Overall, however, the results were consistent among the nonresponse  analyses and indicated little variation between respondents and  nonrespondents. As TMA used in the weighting scheme for the  nonenrolled beneficiary survey, TMA used a weighting scheme to reflect  the survey population proportions to correct any bias as a result of survey  nonresponse.

Appendix II: Beneficiary Survey Instrument

The National Defense Authorization Act for Fiscal Year 2008 (NDAA  2008) directed the Department of Defense (DOD) to determine the  number of health care and mental health care providers that currently  accept nonenrolled beneficiaries as patients under TRICARE, DOD’s  health care program. 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). Specifically, the NDAA 2008 specified  that DOD conduct surveys of beneficiaries each fiscal year, 2008 through  2011. The NDAA 2008 also required that the beneficiary survey include  questions seeking information from nonenrolled beneficiaries to  determine whether they have had difficulties finding health care and  mental health care providers willing to accept them as patients.
For the 2008 fielding of the beneficiary survey, 91 questions were  included in the survey instrument. Over the next 3 years of the beneficiary  survey’s fielding, TRICARE Management Activity (TMA) used the same  91 questions and added these additional questions:
For the 2009 survey fielding and beyond, TMA added Question #81,  which asked “When did you last have a flu shot?” for a total of 92  questions in 2009;
For the 2010 survey fielding and beyond, TMA added two questions  (Questions #75 and #76) that asked what the beneficiary liked and  disliked about TRICARE Standard and Extra, respectively, for a total  of 94 questions in 2010 and 2011.
In addition, for the 2011 survey instrument, “TRICARE Young Adult” and  “TRICARE Retired Reserve” were added to the response selections for  Question #2, which asked “By which health plan are you currently  covered?”
Following is the actual survey instrument from the 2011 fielding that TMA  used to obtain information from nonenrolled beneficiaries.

Appendix III: Survey Instruments for Civilian Physicians and Nonphysician Mental Health Care Providers

The National Defense Authorization Act for Fiscal Year 2008 (NDAA  2008) directed the Department of Defense (DOD) to determine the  number of health care and mental health care providers that currently  accept nonenrolled beneficiaries as patients under TRICARE, DOD’s  health care program. 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). Specifically, NDAA 2008 directed DOD  to survey providers each fiscal year, 2008 through 2011. The NDAA 2008  also required that the provider survey include questions seeking  information to determine (1) whether the provider is aware of the  TRICARE program, (2) the percentage of the provider’s current patient  population that uses any form of TRICARE, (3) whether the provider  accepts Medicare patients, and (4) if the provider accepts Medicare  patients, whether the provider would accept new Medicare patients. DOD  implemented two versions of its provider survey, one for physicians,  including psychiatrists, and one for nonphysician mental health  providers.
For the 2008 fielding of the civilian provider survey, 11 and 12 questions  were included in the physician and nonphysician mental health provider  survey instruments, respectively. Over the next 3 years of the civilian  provider survey’s fielding, TRICARE Management Activity (TMA)  generally used the same questions, but made the following adjustments  to the survey instruments:
Beginning with the 2009 fielding of both survey instruments and  beyond, TMA adjusted Question #1 which asked the provider whether  they provided health care to patients in an office-based practice (for  physicians) or a private practice (for nonphysician mental health care  providers) so that a “no” response would no longer instruct the  provider to stop answering the survey at that point. Instead, the  revision directed the provider to the newly added Question #1a that  asked the provider what type of practice they were in (if they  answered “no” to Question #1).
For the 2010 and 2011 fieldings of the physician survey instrument,  TMA also adjusted Question #1 from “Does  provide  treatment to patients through an office-based practice?” to “Does [the  provider] provide treatment to patients through private practice?”
Following are the actual survey instruments from the 2011 fielding that  TMA used to obtain information from physicians and nonphysician mental  health care providers.

Appendix IV: Areas Where Nonenrolled Beneficiaries Had Problems Accessing Civilian Providers, 2008-2011

The 2008-2011 beneficiary survey indicated individual areas where  nonenrolled beneficiaries experienced problems finding “any civilian  provider,” civilian primary care providers, and civilian specialty care  providers. We define these locations as areas where the percentage of  nonenrolled beneficiaries who experienced difficulties finding a civilian  provider was at the national estimate or higher.

	Problems Finding Any Provider

We identified 24 individual areas (out of the 215 individual areas surveyed  by the 2008-2011 beneficiary surveys) where the percentage of  nonenrolled beneficiaries who experienced problems finding any type of  provider who would accept TRICARE met or exceeded the national  estimate. We then identified 49 additional areas where the percentage of  nonenrolled beneficiaries who experienced these problems was less than  the national estimate. The remaining 130 areas had estimates that  ranged from 18 to 50 percent, but because of their confidence intervals,  were neither above nor below the 31 percent threshold.the geographic distribution of these three categories of areas.

	Problems Finding Civilian Primary Care Providers

We identified 21 individual areas where the percentage of nonenrolled  beneficiaries who experienced problems finding a civilian primary care  provider who would accept TRICARE patients met or exceeded the  national estimate. We then identified 50 additional areas where the  percentage of nonenrolled beneficiaries who experienced these problems  was less than the national estimate.
The remaining 129 areas had  estimates that ranged from 13 to 44 percent, but because of their  confidence intervals, were neither above nor below the 25 percent  threshold.categories of areas.

	Problems Finding Civilian Specialty Care Providers

We identified nine individual areas where the percentage of nonenrolled  beneficiaries who experienced problems finding a civilian specialty care  provider who would accept TRICARE patients met or exceeded the  national estimate. We then identified 34 additional areas where the  percentage of nonenrolled beneficiaries who experienced these problems  was less than the national estimate. The remaining 144 areas had  estimates that ranged from 14 to 47 percent, but because of their  confidence intervals, were neither above nor below the 25 percent  threshold.categories of areas.

	Problems Finding Civilian Mental Health Care Providers

Because of the low number of nonenrolled beneficiary responses to the  questions about civilian mental health care, we are unable to identify  specific geographic areas where nonenrolled beneficiaries have access  problems to civilian mental health care providers. Of the 215 areas  surveyed in the 4-year beneficiary survey, only 5 areas had 30 or more  respondents—TMA’s threshold for reporting beneficiary survey results— who indicated that they needed mental health care and received it from a  civilian provider. Additionally, for those 5 areas that did have at least   30 nonenrolled beneficiary responses, the margins of error were between  10 and 25 percentage points.

Appendix V: Civilian Provider Acceptance of Any New TRICARE Patients in Hospital Service Areas Surveyed in Fiscal Year 2011

The TRICARE Management Activity (TMA) fielded its provider and  beneficiary surveys to the same Hospital Service Areas (HSA) each year  with one exception. Because of resource constraints, the 2011 fielding of  the beneficiary survey did not include any HSAs. However, 16 HSAs were  included in the 2011 fielding of the provider survey. Because beneficiaries  were not surveyed for these HSAs, they are not included in our collective  analysis of the beneficiary and civilian provider survey results. Table 13  lists the 16 HSAs that were surveyed in the 2011 civilian provider survey  fielding and the estimated percentage of civilian providers who were  accepting any new TRICARE patients.

Appendix VI: Comments from the Department of Defense

Appendix VII: GAO Contact and Staff Acknowledgments

	GAO Contact

	Staff Acknowledgments

In addition to the contact named above, Bonnie Anderson, Assistant  Director; Jennie Apter; Linda Galib; Giselle Hicks; Jeff Mayhew;   Lisa Motley; Dan Ries; and Eric Wedum made key contributions to this  report.

Summary:
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.