GAO 

United States Government Accountability Office

Report to Congressional Committees

DEFENSE HEALTH 

CARE 

2008 Access to Care 

Surveys Indicate Some 

Problems, but 

Beneficiary 

Satisfaction Is Similar 

to Other Health Plans 

March 2010 

GAO-10-402 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

March 2010

DEFENSE HEALTH CARE

2008 Access to Care Surveys Indicate Some 

Problems, but Beneficiary Satisfaction Is Similar to 

Highlights of GAO-10-402, a report to Other Health Plans

congressional committees 

The Department of Defense (DOD) 

provides health care and mental 

health care through its TRICARE 

program. Under TRICARE, 

beneficiaries may obtain care 

through TRICARE Prime, an option 

that includes the use of civilian 

provider networks and requires 

enrollment. TRICARE beneficiaries 

who do not enroll in this option 

may obtain care from nonnetwork 

providers through TRICARE 

Standard, or from network 

providers through 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. We refer 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 GAO to analyze the 

adequacy of DOD’s surveys of 

TRICARE beneficiaries and 

providers and report what the 

surveys’ results indicate about 

access to care for nonenrolled 

beneficiaries. To do so, GAO 

evaluated the surveys’ 

methodology by interviewing DOD 

officials and reviewing relevant 

documentation, including the 

Office of Management and Budget’s 

(OMB) survey standards. GAO also 

assessed the surveys’ results by 

interviewing DOD officials, 

obtaining relevant documentation, 

and analyzing the response rates 

and data for both surveys. 

DOD’s implementation of beneficiary and provider surveys for 2008, the first 

of a 4-year survey effort, followed the OMB survey standards for survey 

design, data collection, and data accuracy. In addition, DOD generally 

addressed the survey requirements outlined in the mandate in implementing 

its 2008 beneficiary and provider surveys but did not give a high priority to 

selecting geographic areas with a high concentration of Selected Reserve 

servicemembers. Instead, for both of its surveys, DOD randomly selected 

areas to produce results that can be generalized to the populations from 

which the survey samples were drawn. DOD plans to cover the entire United 

States at the end of the 4-year survey period, which will include any locations 

with higher concentrations of Selected Reserve servicemembers. 

In its analysis of the 2008 beneficiary survey data, GAO estimated that a higher 

percentage of nonenrolled beneficiaries in surveyed areas where TRICARE 

Prime is offered (Prime Service Areas) experienced problems accessing care 

from network or nonnetwork primary care providers than beneficiaries in 

surveyed areas where TRICARE Prime is not offered (non-Prime Service 

Areas)—30 percent and 24 percent, respectively. GAO also found that 

beneficiaries in the surveyed areas most often experienced access problems 

related to providers’ willingness to accept TRICARE payments, regardless of 

whether they lived in a Prime or non-Prime Service Area. Additionally, GAO’s 

comparison of this survey data to related data from a 2008 Department of 

Health and Human Services’ survey showed that beneficiaries in the surveyed 

Prime and non-Prime Service Areas rated their health care satisfaction 

similarly to each other and to beneficiaries of commercial health care plans, 

but slightly lower than Medicare beneficiaries. 

GAO found that the results for the 2008 provider survey are not representative 

of all physicians and mental health providers in the geographic areas 

surveyed, but the results do provide information about access to care based 

on the specific views of the respondents. According to a DOD official, 

generalizability of provider survey results to the entire country will likely be 

possible at the end of the 4-year survey period. GAO’s review of the 2008 

provider survey results indicates that a lower percentage of respondents in 

Prime Service Areas reported awareness and acceptance of TRICARE than 

respondents in non-Prime Service Areas. Additionally, there were differences 

between responding physicians and responding mental health providers, such 

as psychiatrists and clinical psychologists, regarding their awareness and 

acceptance of TRICARE. For example, 81 percent of physicians who 

responded reported that they would accept new TRICARE patients, if they 

were accepting any new patients at all, compared to 50 percent of mental 

health providers who responded. 

In commenting on a draft of this report, DOD concurred with GAO’s overall 

findings and provided technical comments, which GAO incorporated as 

appropriate. 

View GAO-10-402 or key components.

For more information, contact Randall 

Williamson at (202) 512-7114 or 

williamsonr@gao.gov. 
Page i GAO-10-402 

Contents 

Letter 1

Background 7 

Implementation of DOD’s 2008 Beneficiary and Provider Surveys 

Followed OMB Survey Standards and Generally Addressed 

Requirements Outlined in the NDAA 2008 12 

A Higher Percentage of Nonenrolled Beneficiaries Reported 

Problems Accessing Certain Providers in Prime Service Areas, 

Though in General Beneficiaries Rated Their Satisfaction 

Similarly to Users of Other Health Plans 16 

2008 Provider Survey Results Are Not Representative of All 

Providers in Surveyed Areas but Provide Limited Information 

That Indicates Differences among Respondents’ Awareness and 

Acceptance of TRICARE 23 

Agency Comments 28 

Appendix I Selected Office of Management and Budget 

Standards for Statistical Surveys 29 

Appendix II DOD’s Methodology for the 2008 Beneficiary and 

Provider Surveys 32 

Appendix III Beneficiary Survey Instrument 40 

Appendix IV Survey Instruments for Health Care and Mental 

Health Care Providers 54 

Appendix V Areas Included in the Fiscal Year 2008 Beneficiary 

and Provider Surveys 59 

Appendix VI Comments from the Department of Defense 63 

 DOD's Access to Care Surveys 
Appendix VII GAO Contact and Staff Acknowledgments 64 

Tables 

Table 1: Summary of TRICARE Options 9 

Table 2: Requirements for Beneficiary and Provider Surveys 

Contained in the National Defense Authorization Act for 

Fiscal Year 2008 That Have Been Addressed by the 

Department of Defense 14 

Table 3: Estimated Percentage of Nonenrolled TRICARE 

Beneficiaries Who Experienced Access-to-Care Problems 

with Certain Types of Providers by Types of Areas 

Surveyed in 2008 18 

Table 4: Estimated Top Three Problems TRICARE Nonenrolled 

Beneficiaries Reported in Accessing Certain Types of 

Providers by Types of Areas Surveyed in 2008 20 

Table 5: 2008 Provider Survey Respondents’ Awareness and 

Acceptance of TRICARE by Types of Areas 26 

Table 6: 2008 Provider Survey Respondents’ Awareness and 

Acceptance of TRICARE by Physicians and Mental Health 

Providers 27 

Table 7: Selected OMB Standards Used to Evaluate DOD’s Survey 

Methodology 30 

Table 8: Prime Service Areas Included in the 2008 Beneficiary and 

Provider Surveys 60 

Table 9: Non-Prime Service Areas Included in the 2008 Beneficiary 

and Provider Surveys 61 

Table 10: Hospital Service Areas Included in the 2008 Provider 

Survey 62 

Figures 

Figure 1: TRICARE Beneficiaries in Fiscal Year 2009 8 

Figure 2: Percentage of Claims Paid for TRICARE Prime, TRICARE 

Standard, TRICARE Extra, and TRICARE Reserve Select 

for Fiscal Years 2006 through 2009 10 

Figure 3: 2008 Beneficiary Surveys Mailed, Returned, and 

Completed and Eligible for Analysis 17 

Page ii GAO-10-402 DOD's Access to Care Surveys
Figure 4: 2008 Comparison of Estimated Satisfaction among 

Nonenrolled TRICARE Beneficiaries in Surveyed Prime 

Service Areas and Non-Prime Service Areas with 

Beneficiaries of Medicare and Commercial Health Plans 

on a 0 to 10 Scale, by Rating Category 22 

Figure 5: 2008 Provider Surveys Mailed, Returned, and Completed 

and Eligible for Analysis by Type of Provider 24 

Abbreviations 

BRAC Base Realignment and Closure 

DEERS Defense Enrollment Eligibility Reporting System 

DOD Department of Defense 

HHS Department of Health and Human Services 

NDAA 2008 National Defense Authorization Act for Fiscal Year 2008 

OMB Office of Management and Budget 

TMA TRICARE Management Activity 

VA Department of Veterans Affairs 

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page iii GAO-10-402 DOD's Access to Care Surveys
Page 1 GAO-10-402 

 

United States Government Accountability Office

Washington, DC 20548 

 

March 31, 2010 

The Honorable Carl Levin 

Chairman 

The Honorable John McCain 

Ranking Member 

Committee on Armed Services 

United States Senate 

The Honorable Ike Skelton 

Chairman 

The Honorable Howard P. “Buck” McKeon 

Ranking Member 

Committee on Armed Services 

House of Representatives 

In fiscal year 2009, the Department of Defense (DOD) offered health care 

and mental health care services to over 9 million eligible beneficiaries in 

the United States and abroad through TRICARE, DOD’s regionally 

structured health care program.1

 TRICARE is unique because eligible 

beneficiaries do not have to enroll in the program to use their benefits, and 

therefore DOD does not have complete information on which beneficiaries 

intend to use their benefits. Because of this, DOD cannot accurately 

predict from year to year the health care needs of the eligible population, 

including how to ensure adequate access to health care and mental health 

care. 

Under TRICARE, beneficiaries obtain care either from military hospitals 

and clinics, referred to as military treatment facilities, or from civilian 

providers.2

 DOD’s TRICARE Management Activity (TMA), which oversees 

the program, uses managed care support contractors to develop networks 

of civilian providers and to perform other customer service functions, 

such as processing claims and assisting beneficiaries with finding 

1

Eligible beneficiaries include active duty personnel and their dependents, medically 

eligible National Guard and Reserve servicemembers and their dependents, and retirees 

and their dependents and survivors. Active duty personnel include Reserve component 

members on active duty for at least 30 days. 

2

Through individual agreements between military treatment facilities and the Department 

of Veterans Affairs’ (VA) medical centers, eligible beneficiaries may also receive certain 

types of care from VA medical centers in some locations. 

 DOD's Access to Care Surveys 
 

providers. The contractors are required to establish adequate networks of 

civilian providers—referred to as network providers—to serve all 

TRICARE beneficiaries in geographic areas called Prime Service Areas.3

The contractors use estimates of the number of TRICARE users, among 

other factors, to develop provider networks and ensure adequate access to 

care for beneficiaries. Although some network providers may be located 

outside of Prime Service Areas, contractors are not required to develop 

networks in these areas (which we refer to as non-Prime Service Areas). 

TRICARE has three basic options for its beneficiaries: TRICARE Prime, 

TRICARE Standard, and TRICARE Extra. Beneficiaries who choose 

TRICARE Prime, a managed care option, must enroll and can obtain care 

through the networks of providers established by contractors. 

Beneficiaries do not need to enroll to receive care under TRICARE 

Standard, a fee-for-service option, or TRICARE Extra, a preferred provider 

organization option, and can choose to receive care either through 

nonnetwork providers (under TRICARE Standard) or network providers 

(under TRICARE Extra).4

 All beneficiaries may obtain care at military 

treatment facilities, although priority is first given to active duty personnel 

and then to beneficiaries enrolled in TRICARE Prime. The choices that 

beneficiaries have in selecting TRICARE options and providers can vary 

depending on a beneficiary’s location. Beneficiaries living in Prime Service 

Areas can choose between TRICARE Prime, TRICARE Standard, and 

TRICARE Extra. Beneficiaries living in non-Prime Service Areas can 

choose between TRICARE Standard and TRICARE Extra. According to a 

TMA official, about 18 percent of eligible beneficiaries resided in nonPrime Service Areas in fiscal year 2009. 

Users of TRICARE Standard and Extra in some locations have complained 

about difficulties finding civilian providers who will accept them as 

patients since TRICARE’s inception in 1995. In response to these concerns, 

 

3

Prime Service Areas are geographic areas determined by the Assistant Secretary of 

Defense for Health Affairs that are defined by a set of five-digit zip codes, usually within an 

approximate 40-mile radius of a military inpatient treatment facility. The managed care 

support contracts require the contractor to develop civilian provider networks at all Base 

Realignment and Closure (BRAC) sites, which are military installations that have been 

closed or realigned as a result of decisions made by the Commission on Base Realignment 

and Closure. 

4

DOD’s Defense Enrollment Eligibility Reporting System (DEERS) determines TRICARE 

eligibility. All TRICARE Standard and TRICARE Extra beneficiaries must be properly 

registered in DEERS and have valid identification cards that can be used to show TRICARE 

eligibility. 

Page 2 GAO-10-402 DOD's Access to Care Surveys
 

the National Defense Authorization Act for Fiscal Year 2004 directed DOD 

to monitor access to care for TRICARE beneficiaries who were not 

enrolled in the TRICARE Prime option through a survey of civilian 

providers.5

 The act also directed GAO to review the processes, 

procedures, and analysis used by DOD to determine the adequacy of the 

number of network and nonnetwork civilian providers and the actions

DOD has taken to ensure access to care for beneficiaries who were not 

enrolled in TRICARE Prime. In December 2006, we reported that TM

its contractors used various methods to monitor access to care, including

a provider survey. According to TMA and its contractors, their methods

indicated that access was generally sufficient for users of TRICARE 

Standard and Extra.

A and 

 

6

Nonetheless, concerns about the ability of TRICARE beneficiaries to 

access health care and mental health care from civilian providers 

continue. For example, in the wake of current military operations in 

Afghanistan and Iraq, DOD and others have reported that servicemembers 

and their families are at risk for mental health problems given the stress of 

deployment and exposure to combat. A June 2007 report by DOD’s Task 

Force on Mental Health stated that TRICARE provider networks have 

been tasked with providing an increasing volume and proportion of mental 

health services for families and retirees.7

 In assessing the oversight of the 

mental health network at one location, the task force discovered that out 

of 100 network mental health providers contacted from a list on the 

contractor’s Web site, only 3 would accept new TRICARE patients. 

Additionally, concerns about access to care for National Guard and 

Reserve servicemembers and their families have surfaced in light of DOD’s 

increasing reliance on this population to support military operations, such 

as the conflicts in Afghanistan and Iraq.8

 DOD has reported that as of 

5

See Pub. L. No. 108-136, § 723, 117 Stat. 1392, 1532-34 (2003), and S. Rep. No. 108-46, at 330 

(2003). 

6

GAO, Defense Health Care: Access to Care for Beneficiaries Who Have Not Enrolled in 

TRICARE’s Managed Care Option, GAO-07-48 (Washington, D.C.: Dec. 22, 2006). 

7

Department of Defense, Task Force on Mental Health, An Achievable Vision: Report of the 

Department of Defense Task Force on Mental Health (Falls Church, Va., June 2007). 

8

There are seven reserve components: The Army Reserve, Army National Guard, Air Force 

Reserve, Air National Guard, Navy Reserve, and Marine Corps Reserve, are all part of DOD. 

The seventh component is the Coast Guard Reserve, which is part of the Department of 

Homeland Security but works closely with DOD. 

Page 3 GAO-10-402 DOD's Access to Care Surveys
 

August 31, 2009, over 731,000 National Guard and Reserve servicemembers 

have been deployed in support of conflicts in Afghanistan and Iraq since 

September 11, 2001. DOD has reported that National Guard and Reserve 

servicemembers may not live near military installations like their active 

duty counterparts, and as a result, they may not have access to military 

hospitals and clinics and must instead rely more heavily on civilian 

providers for their care. DOD’s Task Force on Mental Health also reported 

that since a substantial proportion of National Guard and Reserve 

servicemembers reported no civilian health plan coverage before 

deployment and continue to rely on TRICARE thereafter, constraints in 

access to care for this population are a real concern. Qualified members of 

the Selected Reserve—National Guard and Reserve servicemembers who 

are considered essential to wartime missions—who are not activated to 

duty may sign up for TRICARE Reserve Select, a premium-based health 

plan whose care options are similar to those of TRICARE Standard and 

Extra.9

 According to DOD officials, there were approximately 69,000 

members of the Selected Reserve who were eligible and likely to be 

interested in TRICARE Reserve Select, as of September 30, 2009.10 Of 

these, approximately 67 percent had purchased TRICARE Reserve Select. 

For the purpose of this report, we refer to beneficiaries who are not 

enrolled in TRICARE Prime—that is, those who use TRICARE Standard, 

TRICARE Extra, or TRICARE Reserve Select—as nonenrolled 

beneficiaries.11 

In light of continued concerns about access to civilian providers, the 

National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008) 

directed DOD to conduct surveys of beneficiaries and providers to 

determine the adequacy of access to health care and mental health care for 

 

9

To qualify for TRICARE Reserve Select, the beneficiary must not be eligible for or enrolled 

in the Federal Employees Health Benefits Program either under his or her own eligibility or 

through a family member and must be a member of the Selected Reserve component. See 

10 U.S.C. § 1076d. All National Guard and Reserve manpower is assigned to one of three 

Reserve component categories—the Ready Reserve, the Standby Reserve, and the Retired 

Reserve. 10 U.S.C. § 10141(a). The Selected Reserve is a component of the Ready Reserve. 

Once activated to duty, National Guard and Reserve servicemembers are eligible for 

TRICARE Prime. 

10DOD defines Selected Reserve servicemembers likely to be interested in TRICARE 

Reserve Select as those who do not have other health insurance. 

11Although eligible National Guard and Reserve servicemembers are required to purchase 

TRICARE Reserve Select to receive coverage through this plan, we refer to them as 

nonenrolled beneficiaries because their care options are similar to those of TRICARE 

Standard and Extra beneficiaries. 

Page 4 GAO-10-402 DOD's Access to Care Surveys
 

nonenrolled beneficiaries.12 The NDAA 2008 also directed GAO to analyze 

the adequacy of DOD’s beneficiary and provider surveys. This report 

describes (1) how DOD is addressing the NDAA 2008 mandate to 

implement beneficiary and provider surveys to determine the adequacy of 

access to care for nonenrolled beneficiaries, (2) what the results of the 

beneficiary survey indicate about the adequacy of access to care for 

nonenrolled beneficiaries, and (3) what the results of the provider survey 

indicate about the adequacy of access to care for nonenrolled 

beneficiaries. 

To evaluate how DOD is addressing the NDAA 2008 mandate to implement 

beneficiary and provider surveys to determine the adequacy of access to 

care, we reviewed relevant documentation and interviewed officials and 

representatives from TMA’s Health Program Analysis and Evaluation 

Directorate who were responsible for developing, fielding, and analyzing 

the surveys. We evaluated TMA’s beneficiary and provider survey 

methodologies using the Office of Management and Budget’s (OMB) 

standards and guidelines for statistical surveys. We focused our analysis 

on standards specific to designing a survey (e.g., selecting random 

samples), developing a list of eligible survey participants, collecting survey 

data, and ensuring data accuracy. We also evaluated the beneficiary and 

provider surveys to determine whether TMA had complied with all of the 

requirements outlined in the mandate, such as obtaining specific types of 

information and establishing benchmarks for analysis. In addition, we 

spoke with officials representing beneficiary and provider groups to obtain 

their views on access-to-care issues. And finally, we spoke with officials 

from DOD’s Office of Reserve Affairs to obtain their perspectives about 

access-to-care concerns for National Guard and Reserve servicemembers. 

To determine what the results of the beneficiary survey indicate about the 

adequacy of access to care for nonenrolled beneficiaries, we obtained and 

analyzed TMA’s beneficiary survey data for 2008, the first year of a 4-year 

survey effort. We compared the responses of nonenrolled beneficiaries in 

Prime Service Areas to responses of those in non-Prime Service Areas, 

including concerns about access to network or nonnetwork providers.13

 

12See Pub. L. No. 110-181, § 711(a), 122 Stat. 3, 190-191. 

13When asking respondents about access problems, the beneficiary survey instrument did 

not differentiate between network and nonnetwork providers. Therefore, we were unable 

to determine the extent to which beneficiaries’ access problems were linked to network or 

nonnetwork providers. 

Page 5 GAO-10-402 DOD's Access to Care Surveys
 

Where possible, we compared these responses to those of other health 

care consumers surveyed in the Department of Health and Human 

Services’ (HHS) 2008 Consumer Assessment of Healthcare Providers and 

Systems.14 We assessed the reliability of these data by speaking with 

knowledgeable officials and reviewing related documentation, and we 

determined that the beneficiary survey data are sufficiently reliable for the 

purpose of reporting the experiences of nonenrolled beneficiaries in the 

combined Prime Service Areas and combined non-Prime Service Areas 

that TMA surveyed. 

To determine what the results of the provider survey indicate about the 

adequacy of access to care for nonenrolled beneficiaries, we obtained and 

analyzed TMA’s provider survey data for 2008, which is also the first year 

of a 4-year survey effort. We analyzed the survey responses of providers in 

Prime Service Areas, non-Prime Service Areas, and Hospital Service 

Areas15 to determine their awareness of the TRICARE program and 

whether they were accepting nonenrolled TRICARE beneficiaries as new 

patients. We assessed the reliability of these data by speaking with 

knowledgeable officials and reviewing related documentation, and we 

determined that the provider survey data presented in this report are 

sufficiently reliable for the purpose of reporting the information provided 

by the survey respondents in the Prime Service Areas, non-Prime Service 

Areas, and Hospital Service Areas that TMA surveyed. 

We conducted this performance audit from February 2009 through March 

2010 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives. 

 

14All beneficiary and HHS’s Consumer Assessment of Healthcare Providers and Systems 

survey estimates are presented with a sampling error at the 95 percent confidence level, 

and differences in survey estimates are not statistically significant unless otherwise noted. 

15The NDAA 2008 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 access-to-care problems. TMA referred to these locations as 

Hospital Service Areas, which are collections of zip codes organized into over 3,000 

geographic regions in which Medicare beneficiaries seek the majority of their care from 

one hospital or a collection of hospitals. Hospital Service Areas, as defined by a Dartmouth 

University study, have nonoverlapping borders and contain all U.S. zip codes without gaps 

in coverage. 

Page 6 GAO-10-402 DOD's Access to Care Surveys
 

In fiscal year 2009, over 9 million beneficiaries were eligible to receive 

health care and mental health care through DOD’s TRICARE program. 

Under TRICARE, beneficiaries have choices among various benefit 

options and may obtain care from either military treatment facilities or 

civilian providers. 

Background 

Composition of TRICARE’s 

Beneficiary Population 

TRICARE beneficiaries fall into different categories: (1) active duty 

personnel and their dependents, (2) National Guard and Reserve 

servicemembers and their dependents, and (3) retirees and their 

dependents or survivors. Retirees and certain dependents and survivors 

who are entitled to Medicare Part A and enrolled in Part B, and who are 

generally age 65 and older, are eligible to obtain care under a separate 

program called TRICARE for Life.16 As shown in figure 1, active duty 

personnel and their dependents represented 32 percent of the beneficiary 

population, while National Guard and Reserve servicemembers and their 

dependents represented 14 percent. 

 

16TRICARE for Life is a program for Medicare-eligible beneficiaries enrolled in Medicare 

Part B. TRICARE beneficiaries under 65 years of age who are eligible for Medicare Part A 

on the basis of disability or end-stage renal disease are eligible for TRICARE for Life if they 

enroll in Medicare Part B. 

Page 7 GAO-10-402 DOD's Access to Care Surveys
 

Figure 1: TRICARE Beneficiaries in Fiscal Year 2009 

Source: GAO analysis of DOD's DEERS data.

TRICARE for Life retirees and dependents

(generally age 65 and older)a

Active duty personnel and dependents

National Guard and Reserve

servicemembers and dependents

14%

32%

40% 14%

Retirees and their dependents or survivors

(generally under age 65)a

Note: Percentages in the figure are based on DOD data as of September 30, 2009. 

a

TRICARE beneficiaries under 65 years of age who are eligible for Medicare Part A on the basis of 

disability or end-stage renal disease are eligible for TRICARE for Life if they enroll in Medicare 

Part B. 

TRICARE’s Benefit 

Options 

TRICARE provides its benefits through several options for its nonMedicare-eligible beneficiary population. These options vary according to 

TRICARE beneficiary enrollment requirements, the choices TRICARE 

beneficiaries have in selecting civilian and military treatment facility 

providers, and the amount TRICARE beneficiaries must contribute toward 

the cost of their care. Table 1 provides additional information about these 

options. 

Page 8 GAO-10-402 DOD's Access to Care Surveys
 

Table 1: Summary of TRICARE Options 

TRICARE option Description 

TRICARE Prime This managed care option requires beneficiaries to enroll. Active duty servicemembers 

are required to enroll in this option while other TRICARE beneficiaries may choose to 

enroll. TRICARE Prime enrollees receive most of their care from providers at military 

treatment facilities, augmented by network providers who have agreed to meet specific 

standards for appointment wait times among other requirements. TRICARE Prime offers 

lower out-of-pocket costs than the other TRICARE options. 

TRICARE Standard and TRICARE Extra TRICARE beneficiaries who choose not to enroll in TRICARE Prime may obtain health 

care from nonnetwork providers (under TRICARE Standard) or network providers 

(under TRICARE Extra). Under TRICARE Extra, nonenrolled beneficiaries have lower 

co-payments than they would have under the TRICARE Standard option—about 

5 percentage points less for using network providers. 

TRICARE Reserve Select TRICARE Reserve Select is a premium-based health plan that certain National Guard 

and Reserve servicemembers may purchase. Under TRICARE Reserve Select, 

beneficiaries may obtain health care from either nonnetwork or network providers, similar 

to beneficiaries using TRICARE Standard or Extra, respectively, and will pay lower 

co-payments for using network providers. 

Source: GAO summary of DOD TRICARE documentation. 

Note: All beneficiaries may obtain care at military treatment facilities although priority is first given to 

active duty personnel and then to TRICARE Prime enrollees. 

Beneficiaries’ Use of 

TRICARE 

Claims data from fiscal years 2006 to 2009 show that the percentage of 

claims paid for using TRICARE Prime and TRICARE Extra has gradually 

increased, while the percentage of claims paid for using TRICARE 

Standard has declined 2 to 3 percentage points each year. (See fig. 2.) 

Moreover, in 2006 we reported that in fiscal year 2005 about 1.8 million 

beneficiaries who were eligible for TRICARE Standard or Extra17 elected 

not to use their benefits.18 In fiscal year 2009, about 926,000 beneficiaries 

who were eligible for TRICARE Standard, TRICARE Extra, and TRICARE 

Reserve Select elected not to use their benefits.19

 

17This number does not include the beneficiaries who purchased TRICARE Reserve Select. 

TRICARE Reserve Select coverage became available on April 27, 2005, and a very small 

number of beneficiaries purchased this benefit option in fiscal year 2005. 

18GAO-07-48. 

19Does not include beneficiaries who used pharmacy benefits or who received care directly 

from a military treatment facility. 

Page 9 GAO-10-402 DOD's Access to Care Surveys
 

Figure 2: Percentage of Claims Paid for TRICARE Prime, TRICARE Standard, 

TRICARE Extra, and TRICARE Reserve Select for Fiscal Years 2006 through 2009 

0

10

20

30

40

50

60

70

2009a 2008a 2007a 2006a

Percentage of TRICARE claims paid

Fiscal year

Source: GAO analysis of DOD data.

TRICARE Prime

TRICARE Standard

TRICARE Extra

TRICARE Reserve Select

63

22

14

1

65

20

15

1

66

18

15

1

67

15 16

2

Notes: All percentages may not add up to 100 percent because of rounding. Records include 

institutional (e.g., hospital) and noninstitutional (e.g., office-based) locations and medical supplies and 

services, and exclude pharmacy and TRICARE for Life claims. Fiscal year 2009 data are incomplete 

as TMA allows claims to be submitted up to 1 year after receiving care. 

a

Percentages based on 32,685,169 claims in fiscal year 2006; 35,543,975 claims in fiscal year 2007; 

38,486,854 claims in fiscal year 2008; and 37,967,258 claims in fiscal year 2009. 

Network and Nonnetwork 

Providers under TRICARE 

In order for network and nonnetwork civilian providers to be authorized 

to provide care and be reimbursed under TRICARE, they must be licensed 

by their state, accredited by a national organization (if one exists), and 

meet other standards of the medical community. Individual TRICAREauthorized civilian providers can include health care providers, such as 

primary care physicians and specialists, as well as mental health care 

providers, including clinical psychologists. 

Page 10 GAO-10-402 DOD's Access to Care Surveys
 

There are two types of authorized civilian providers—network and 

nonnetwork providers. 

• Network providers are TRICARE-authorized providers who enter a 

contractual agreement with a managed care support contractor to provide 

health care to TRICARE beneficiaries. By law, TRICARE maximum 

allowable reimbursement rates must generally mirror Medicare rates, but 

network providers may agree to accept lower reimbursements as a 

condition of network membership.20 However, network civilian providers 

are not obligated to accept all TRICARE beneficiaries seeking care. For 

example, a network civilian provider may decline to accept TRICARE 

beneficiaries as patients because the provider’s practice does not have 

sufficient capacity.21

• Nonnetwork providers are TRICARE-authorized providers who do not 

have a contractual agreement with a managed care support contractor to 

provide care to TRICARE beneficiaries.22 Nonnetwork civilian providers 

have the option of charging up to 15 percent more than the TRICARE 

reimbursement rate for their services on a case-by-case basis. The 

beneficiary is responsible for paying the extra amount billed in addition to 

required co-payments. 

NDAA 2008 Requirements 

for Beneficiary and 

Provider Surveys to 

Determine Access to Care 

for Nonenrolled TRICARE 

Beneficiaries 

The NDAA 2008 directed 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. Specifically, the 

mandate directed DOD to conduct surveys of beneficiaries and providers 

in at least 20 Prime Service Areas and 20 non-Prime Service Areas in each 

of fiscal years 2008 through 2011. The mandate also directed DOD to give a 

high priority to locations having high concentrations of Selected Reserve 

servicemembers. Additionally, the NDAA 2008 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 to survey health 

care and mental health care providers in these areas. The NDAA 2008 also 

required that specific types of information be requested in the surveys. For 

 

20See 10 U.S.C. §§ 1079(h), 1086(f). 

21A network provider may determine that only a set amount of his or her practice—such as 

10 or 20 percent—will be allocated to TRICARE patients. 

22TRICARE beneficiaries who choose to receive medical care from providers who are not 

TRICARE authorized may be responsible for all billed charges. 

Page 11 GAO-10-402 DOD's Access to Care Surveys
 

example, the mandate stated that the provider survey must include 

questions to determine whether providers are aware of TRICARE. Within 

DOD, TMA has primary responsibility for designing and implementing the 

beneficiary and provider surveys. 

In implementing the first year of the beneficiary and provider surveys, 

TMA followed the OMB standards for statistical surveys that we reviewed. 

However, TMA did identify an error in the geographic categorization of its 

participants for both surveys and has taken steps to correct it. In addition, 

TMA generally addressed the requirements outlined in the NDAA 2008 for 

both of its surveys but did not give a high priority to selecting areas with a 

high concentration of Selected Reserve servicemembers. Instead, for both 

surveys, TMA randomly selected geographic areas to produce results that 

can be generalized to the populations from which the survey samples were 

drawn. TMA plans to cover the entire United States at the end of the 4-year 

survey period, which will include any locations with higher concentrations 

of Selected Reserve servicemembers. 

Implementation of 

DOD’s 2008 

Beneficiary and 

Provider Surveys 

Followed OMB 

Survey Standards and 

Generally Addressed 

Requirements 

Outlined in the NDAA 

2008 

TMA Followed the OMB 

Standards We Reviewed in 

Designing and 

Implementing Its 

Beneficiary and Provider 

Surveys 

In implementing its first round of beneficiary and provider surveys, TMA’s 

methodology for both of the multiyear surveys is consistent with the OMB 

standards for statistical surveys that we reviewed.23 (See app. I for our list 

of selected OMB standards.) These standards document the professional 

principles and practices that federal agencies are required to follow and 

the level of quality and effort expected in statistical activities.24 For 

example, OMB standards recommend that agencies develop a survey 

design that includes a methodology for identifying the target population. 

 

23In general, agency surveys must be approved by OMB. See 44 U.S.C. § 3507. However, 

DOD has authority to conduct surveys of servicemembers and their families to determine 

the effectiveness of federal programs relating to military families and the need for new 

programs without seeking approval from OMB. See 10 U.S.C. § 1782; DOD 8910.1-M, 

Department of Defense Procedures for Management of Information Requirements § C3.7 

(June 1998). Accordingly, DOD sought and obtained OMB approval for the 2008 provider 

survey, but did not do so for the 2008 beneficiary survey. 

24See OMB, Office of Management and Budget Standards and Guidelines for Statistical 

Surveys (Washington, D.C., September 2006). 

Page 12 GAO-10-402 DOD's Access to Care Surveys
 

OMB standards also suggest that federal agencies ensure that the list of 

eligible survey participants representing the target population is evaluated 

for accuracy.25 In conducting its 2008 beneficiary and provider surveys, 

TMA representatives noted that they identified an error in the geographic 

categorization of eligible survey participants for both surveys. Specifically, 

TMA erroneously categorized some beneficiaries and providers as being 

located in 11 non-Prime Service Areas when in fact they were in Prime 

Service Areas. According to a TMA representative, this occurred as a 

result of a computer programming error. TMA identified this error after it 

began fielding the beneficiary survey in June 2008 but prior to fielding the 

provider survey, which began in December 2008. As a result, TMA 

surveyed approximately 9,000 fewer beneficiaries than intended in those 

11 non-Prime Service Areas. TMA plans to correct this error in future years 

by surveying additional beneficiaries in the affected non-Prime Service 

Areas. 

TMA Generally Addressed 

Requirements Outlined in 

the Mandate for Its 

Beneficiary and Provider 

Surveys 

TMA generally addressed the requirements outlined in the mandate during 

the implementation of its 2008 beneficiary and provider surveys, but 

because of methodological considerations TMA used a different approach 

for its selection of survey areas. (See app. II for a more detailed 

description of DOD’s survey methodology.) Overall, the mandate outlined 

specific survey requirements, including the number and priority of areas to 

be surveyed each year, the content for each type of survey, and the use of 

benchmarks, which can be used to assess survey results. (See table 2.) 

 

25The list of eligible survey participants from which a sample is selected is also referred to 

as a sampling frame. 

Page 13 GAO-10-402 DOD's Access to Care Surveys
 

Table 2: Requirements for Beneficiary and Provider Surveys Contained in the National Defense Authorization Act for Fiscal 

Year 2008 That Have Been Addressed by the Department of Defense 

Beneficiary survey Provider survey 

Requirement Requirement description 

DOD met 

requirement? 

DOD met 

requirement? 

Survey goals 1. Determine the number of health care providers in 

TRICARE Prime Service Areas that are accepting 

new patients under TRICARE Standard and Extra 

Yes Yes 

2. Determine the number of health care providers in 

TRICARE non-Prime Service Areas that are accepting 

patients under TRICARE Standard and Extra 

Yes Yes 

3. Determine the availability of mental health care 

providers in TRICARE Prime Service Areas and 

TRICARE non-Prime Service Areas 

Yes Yes 

Survey area selection 4. Survey beneficiaries and providers in at least 20 

TRICARE Prime Service Areas in the United States in 

each fiscal year 2008 through 2011 to determine the 

numbers of health care providers accepting new 

patients under each TRICARE Standard and Extra 

Yes Yes 

5. Survey beneficiaries and providers in 20 non-Prime 

Service Areas, and in which significant numbers of 

beneficiaries who are members of the Selected 

Reserve reside, to determine the availability of health 

care providers accepting new patients under each 

TRICARE Standard and Extra 

Yes Yes 

6. Survey beneficiaries and providers in at least 40 total 

Prime Service Areas and non-Prime Service Areas to 

determine the availability of mental health care 

providers 

Yes Yes 

7. Give a high priority to surveying beneficiaries and 

providers located in geographic areas with high 

concentrations of members of the Selected Reserve 

NoaNoa

8. Consult with representatives of TRICARE 

beneficiaries and health care and mental health care 

providers to identify locations where TRICARE 

Standard beneficiaries are experiencing significant 

levels of access-to-care problems under TRICARE 

Standard or Extra and give a high priority to surveying 

health care and mental health care providers in these 

locations 

N/AbYes 

Page 14 GAO-10-402 DOD's Access to Care Surveys
 

Beneficiary survey Provider survey 

Requirement Requirement description 

DOD met 

requirement? 

DOD met 

requirement? 

Survey content 9. Include questions in provider surveys to determine the 

following: 

• Whether the provider is aware of the TRICARE 

program 

• What percentage of the provider’s current patient 

population uses any form of TRICARE 

• Whether the provider accepts patients for whom 

payment is made under the Medicare program for 

health care and mental health care services 

• If the provider accepts Medicare patients, whether the 

provider would accept new Medicare patients 

N/Ab

Yes 

10. Include questions in beneficiary surveys seeking 

information to determine whether they have difficulties 

in finding health care and mental health care 

providers willing to provide services under TRICARE 

Standard or Extra 

Yes N/Ab

Benchmarks 11. Establish benchmarks to determine the adequacy of 

the availability of health care and mental health care 

providers to beneficiaries eligible for TRICARE 

Yes Yes 

Source: GAO analysis based on review of the National Defense Authorization Act for Fiscal Year 2008 § 711 (a). 

a

While TMA did not give high priority to surveying beneficiaries and providers in locations with high 

concentrations of Selected Reserve servicemembers, TMA’s methodological approach over the 

4-year survey period will meet the intent of the NDAA 2008. 

b

N/A means not applicable. 

According to a TMA official responsible for implementing the surveys, 

TMA did not give a high priority to areas where higher concentrations of 

Selected Reserve servicemembers live, as specified in the mandate, 

because it decided to randomly select the areas to be surveyed in order to 

produce results that can be generalized to the populations from which the 

survey samples are selected. Moreover, at the end of the 4-year survey 

period for the beneficiary and provider surveys, TMA will have surveyed 

all areas of the United States, thereby including any locations with a higher 

concentration of Selected Reserve servicemembers. A TMA official also 

told us that TMA conducted additional analyses of the 2008 beneficiary 

survey results for TRICARE Reserve Select beneficiaries to obtain 

additional information about the Selected Reserve servicemembers, and 

plans to do so in the remaining 3 years of the survey. TMA found that its 

2008 results indicate that TRICARE access is no different for the Selected 

Reserve servicemembers than for other beneficiaries in the surveyed 

areas. 

Page 15 GAO-10-402 DOD's Access to Care Surveys
 

The first year’s results of TMA’s 4-year beneficiary survey are 

representative of the nonenrolled beneficiary population in the combined 

Prime Service Areas and combined non-Prime Service Areas that were 

selected for the 2008 survey. Based on our analysis of these results, we 

estimated that a higher percentage of nonenrolled beneficiaries in 

surveyed Prime Service Areas experienced problems accessing care from 

network or nonnetwork primary care physicians or nurses than 

beneficiaries in surveyed non-Prime Service Areas. However, we could not 

determine whether beneficiary access problems were related to TRICARE 

network providers because the survey did not ask beneficiaries to link 

problems accessing care with network or nonnetwork providers. 

However, we did find that the types of access problems beneficiaries 

experienced, such as providers not accepting TRICARE payments, were 

similar in Prime Service Areas and non-Prime Service Areas. In addition, 

we found that nonenrolled beneficiaries in both the surveyed Prime 

Service Areas and the surveyed non-Prime Service Areas rated their health 

care satisfaction similarly to each other and to beneficiaries of commercial 

health care plans, but slightly lower than Medicare beneficiaries. 

A Higher Percentage 

of Nonenrolled 

Beneficiaries 

Reported Problems 

Accessing Certain 

Providers in Prime 

Service Areas, Though 

in General 

Beneficiaries Rated 

Their Satisfaction 

Similarly to Users of 

Other Health Plans 

Despite a Low Response 

Rate, TMA’s 2008 

Beneficiary Survey Results 

Are Representative of the 

Nonenrolled Beneficiary 

Population for the 

Combined Areas Surveyed 

Despite an overall response rate of about 38 percent, TMA’s 2008 

beneficiary survey results are representative of the nonenrolled 

beneficiary population for the combined Prime Service Areas and 

combined non-Prime Service Areas surveyed. (See fig. 3.) Because of the 

low response rate, TMA conducted a nonresponse analysis to determine 

whether the responses it received were representative of the surveyed 

population.26 The nonresponse analysis indicated that there were no 

differences in demographic characteristics and health coverage between 

beneficiary survey respondents and nonrespondents. As a result, the 

results can be generalized to the combined areas surveyed—that is, the 

survey produced results that are representative of all nonenrolled 

beneficiaries in the 20 surveyed Prime Service Areas and all nonenrolled 

beneficiaries in the 20 surveyed non-Prime Service Areas. 

 

26OMB’s guidelines for ensuring that survey results are representative of the target 

population include conducting a nonresponse analysis for surveys with a response rate 

lower than 80 percent. 

Page 16 GAO-10-402 DOD's Access to Care Surveys
 

Figure 3: 2008 Beneficiary Surveys Mailed, Returned, and Completed and Eligible for Analysis 

Source: GAO analysis of DOD data.

Survey details and response rates

18,447

Surveys

returned

(38 percent)

5,043

Completed

and eligible

responsesa

Composition of the 5,043

beneficiaries with

eligible responses:

Retireesb: 93%, Active dutyc: 6%, TRSd: 1%

93% 6% 1%

48,548

Surveys mailed 

to beneficiaries

Composition of the 

48,548 beneficiaries

who were selected to 

receive these surveys:

Retireesb: 87%, Active dutyc: 12%, TRSd: 1%

87% 12% 1%

a

A complete and eligible response is one in which the beneficiary has answered at least half of the 

TMA-identified “key” questions and has answered that he or she used “TRICARE Extra or Standard” 

or “TRICARE Reserve Select” in response to the following: Which health plan did you use for all or 

most of your health care in the last 12 months? 

b

Retirees under the age of 65 and their dependents or survivors who are not enrolled in TRICARE 

Prime. 

c

Active duty family members who are not enrolled in TRICARE Prime, including family members of 

activated reservists. 

d

TRS refers to beneficiaries who purchased TRICARE Reserve Select. 

Page 17 GAO-10-402 DOD's Access to Care Surveys
 

Based on our analysis of the 2008 survey results, we estimated that a 

higher percentage of nonenrolled beneficiaries in surveyed Prime Service 

Areas experienced problems accessing care from network or nonnetwork 

primary care physicians or nurses than nonenrolled beneficiaries in 

surveyed non-Prime Service Areas. Specifically, about 30 percent of 

beneficiaries in Prime Service Areas experienced problems finding a 

civilian primary care physician or nurse, compared to about 24 percent of 

beneficiaries in non-Prime Service Areas.27 (See table 3.) While we found 

differences in access to care problems between nonenrolled beneficiaries 

in the surveyed Prime Service Areas and non-Prime Service Areas for 

other types of providers, these differences were not statistically significant 

at the 95 percent confidence level.28

2008 Survey Results 

Indicate That a Higher 

Percentage of Nonenrolled 

Beneficiaries in Prime 

Service Areas Experienced 

Problems Accessing Care 

from Primary Care 

Physicians or Nurses Than 

Those in Non-Prime 

Service Areas 

Table 3: Estimated Percentage of Nonenrolled TRICARE Beneficiaries Who Experienced Access-to-Care Problems with 

Certain Types of Providers by Types of Areas Surveyed in 2008

Civilian primary care 

physician or nursea

Civilian specialist 

physicianb

Civilian mental 

health providerc

Prime Service Areasd

Did not have an access problem 70e72 66

Had an access problemf30e28 34

Non-Prime Service Areasg

Did not have an access problem 76e74 71

Had an access problemf 24e 26 29

All service areash

Did not have an access problem 71 73 67

Had an access problemf 29 27 33

Source: GAO analysis of DOD data. 

Notes: All sampling errors are presented at the 95 percent confidence level. Data presented in the 

table are rounded to the nearest whole percentage point. 

a

Based on the following: In the last 12 months, how much of a problem was it to find a personal doctor 

or nurse who would accept TRICARE? Answer choices were “A big problem,” “A small problem,” or 

“Not a problem.” The sampling error for “Civilian primary care physician or nurse” is plus or minus 

2.3 percentage points or less in Prime Service Areas and 3.1 percentage points or less in non-Prime 

Service Areas. 

 

27The sampling error is within plus or minus 3.1 percentage points or less at the 95 percent 

confidence level. 

28Statistical significance is the likelihood that a result is caused by something other than 

just chance. 

Page 18 GAO-10-402 DOD's Access to Care Surveys
 

b

Based on the following: In the last 12 months, how much of a problem was it to find a doctor with this 

specialty who would accept TRICARE? Answer choices were “A big problem,” “A small problem,” 

or “Not a problem.” The sampling error for “Civilian specialist physicians” is plus or minus 

2.7 percentage points or less in Prime Service Areas and 4.4 percentage points or less in non-Prime 

Service Areas. 

c

Based on the following: In the last 12 months, how much of a problem, if any, was it to get the 

treatment or counseling you needed through your health plan? Answer choices were “A big problem,” 

“A small problem,” or “Not a problem.” The sampling error for “Civilian mental health providers” is plus 

or minus 5.5 percentage points or less in Prime Service Areas and 9.1 percentage points or less in 

non-Prime Service Areas. 

d

Prime Service Areas are geographic areas determined by the Assistant Secretary of Defense for 

Health Affairs that are defined by a set of five-digit zip codes, usually within an approximate 40-mile 

radius of a military inpatient treatment facility. Prime Service Area estimates are based on 1,721, 

1,247, and 266 respondents who did not have a problem finding a civilian primary care physician or 

nurse, civilian specialist physician, or civilian mental health provider, respectively, and 711, 442, and 

135 respondents who did have a problem finding a civilian primary care physician or nurse, civilian 

specialist physician, or civilian mental health provider, respectively. 

e

A statistically significant difference exists between the results in Prime Service Areas and non-Prime 

Service Areas for the “Civilian primary care physician or nurse” category at the 95 percent confidence 

level. 

f

”Had an access problem” represents those who responded that they had a big problem or a small 

problem. 

g

Non-Prime Service Areas are geographic areas located outside of Prime Service Areas. Non-Prime 

Service Area estimates are based on 1,606, 901, and 206 respondents who did not have a problem 

finding a civilian primary care physician or nurse, civilian specialist physician, or civilian mental health 

provider, respectively, and 364, 271, and 62 respondents who did have a problem finding a civilian 

primary care physician or nurse, civilian specialist physician, or civilian mental health provider, 

respectively. 

h

All service area estimates based on the summed responses from respondents in Prime Service 

Areas and non-Prime Service Areas. 

We could not determine the extent to which beneficiaries’ access 

problems were related to TRICARE network or nonnetwork providers 

because the 2008 beneficiary survey did not ask beneficiaries to link their 

problems accessing care with network or nonnetwork providers. 

However, in our analysis of the 2008 beneficiary survey results, we found 

that the specific types of access problems experienced by beneficiaries in 

Prime Service Areas and non-Prime Service Areas are similar. (See 

table 4.) For example, we found that the problem most commonly 

reported by nonenrolled beneficiaries in both Prime and non-Prime 

Service Areas, regardless of the type of provider, was that their provider 

was not accepting TRICARE payments. Other commonly reported reasons 

varied by provider type. 

Page 19 GAO-10-402 DOD's Access to Care Surveys
 

Table 4: Estimated Top Three Problems TRICARE Nonenrolled Beneficiaries Reported in Accessing Certain Types of 

Providers by Types of Areas Surveyed in 2008

Prime Service AreasaNon-Prime Service Areasb

Civilian primary care physician or nursec (percentage) 

Doctor not accepting TRICARE payments (54) Doctor not accepting TRICARE payments (48) 

Doctor not taking new TRICARE patients (33) Travel distance too long (33) 

Doctor not taking any new patients (26) Doctor not taking new TRICARE patients (30) 

Civilian specialist physiciand (percentage) 

Doctor not accepting TRICARE payments (46) Doctor not accepting TRICARE payments (45) 

Doctor not taking new TRICARE patients (24) Travel distance too long (34) 

Wait for an appointment was too long (19) Doctor not taking new TRICARE patients (21) 

Civilian mental health providere (percentage) 

Doctor or counselor not accepting TRICARE payments (38) Doctor or counselor not accepting TRICARE payments (32) 

Doctor or counselor not taking new TRICARE patients (21) Wait for an appointment was too long (31) 

Travel distance too long (17) Travel distance too long (24) 

Source: GAO analysis of DOD data. 

Notes: Numbers in parentheses are the percentages of those who responded that they had a 

problem. Percentages do not add to 100 because respondents may select more than one response. 

a

Prime Service Areas are geographic areas determined by the Assistant Secretary of Defense for 

Health Affairs that are defined by a set of five-digit zip codes, usually within an approximate 40-mile 

radius of a military inpatient treatment facility. 

b

Non-Prime Service Areas are geographic areas located outside of Prime Service Areas. 

c

Based on the following: What problems did you encounter in finding a personal doctor who would 

accept TRICARE? All percentage estimates for civilian primary care physician or nurse have 

sampling errors at the 95 percent confidence level of plus or minus 7.0 percentage points or less. 

d

Based on the following: What problems did you encounter in finding a specialist who would accept 

TRICARE? All percentage estimates for civilian specialist physicians have sampling errors at the 95 

percent confidence level of plus or minus 9.4 percentage points or less. 

e

Based on the following: In the last 12 months, what problems did you encounter in finding treatment 

and counseling? All percentage estimates for civilian mental health providers have sampling errors at 

the 95 percent confidence level of plus or minus 18.9 percentage points or less. 

Page 20 GAO-10-402 DOD's Access to Care Surveys
 

Despite differences in the percentage of beneficiaries in surveyed Prime 

and non-Prime Service Areas reporting problems accessing care from 

primary care physicians or nurses, our analysis showed that nonenrolled 

beneficiaries’ ratings for several categories of health care were similar in 

the surveyed Prime Service Areas and non-Prime Service Areas. 

Specifically, our analysis of beneficiaries’ ratings for four categories of 

health care—their satisfaction with providers of primary care and 

specialty care, their health care, and their health plan—indicates no 

statistically significant difference between beneficiaries in surveyed Prime 

Service Areas and non-Prime Service Areas. For example, we estimated 

that 75 percent of beneficiaries in surveyed Prime Service Areas and 

74 percent of beneficiaries in surveyed non-Prime Service Areas rated 

their health plan “7” or higher on a 0 to 10 scale29 (with 0 being the worst 

possible).30

Nonenrolled Beneficiaries 

in Prime Service Areas and 

Non-Prime Service Areas 

Surveyed in 2008 Rated 

Satisfaction with Their 

Health Care Similarly to 

Each Other and to 

Beneficiaries of 

Commercial Health Care 

Plans 

Estimated ratings for nonenrolled beneficiaries in surveyed areas are also 

similar to the estimated ratings of beneficiaries in commercial health 

plans, based on data we analyzed from HHS’s 2008 Consumer Assessment 

of Healthcare Providers and Systems survey. Specifically, in all four 

satisfaction categories there are no statistically significant differences in 

the estimated percentage of beneficiaries who rated their satisfaction “7” 

or higher. (See fig. 4.) However, estimated ratings for nonenrolled 

beneficiaries in surveyed areas were slightly lower than estimated ratings 

of Medicare beneficiaries across three of the satisfaction categories—

primary care physician or nurse, specialist physician, and health plan. 

 

29The sampling error is within plus or minus 3.1 percentage points or less at the 95 percent 

confidence level. 

30The ratings scale is divided into two categories: 0 to 6 and 7 to 10, where 0 is considered 

the worst possible and 10 is the best possible. The ratings scale is based on the one used to 

analyze HHS’s Consumer Assessment of Healthcare Providers and Systems survey, a 

national survey of beneficiaries of commercial health insurance, Medicare, Medicaid, and 

the Children’s Health Insurance Program. 

Page 21 GAO-10-402 DOD's Access to Care Surveys
 

Figure 4: 2008 Comparison of Estimated Satisfaction among Nonenrolled TRICARE Beneficiaries in Surveyed Prime Service 

Areas and Non-Prime Service Areas with Beneficiaries of Medicare and Commercial Health Plans on a 0 to 10 Scale, by Rating 

Category 

0 10 20 30 40 50 60 70 80 90 100

Commercial health plan

Medicare

Non-Prime Service Area

Prime Service Area

0 10 20 30 40 50 60 70 80 90 100

Commercial health plan

Medicare

Non-Prime Service Area

Prime Service Area

0 10 20 30 40 50 60 70 80 90 100

Commercial health plan

Medicare

Non-Prime Service Area

Prime Service Area

Percentage Percentage

Beneficiary rating of primary care physician or nursea Beneficiary rating of specialist physicianb

Percentage Percentage

Beneficiary rating of health cared Beneficiary rating of health plane

12 88

13 87

8c 92c

11 89

12 88

11 89

12 88

13 87

25 75

26 74

19c 81c

23 77

0-6 rating

7-10 rating

Source: GAO analysis of DOD and HHS's Consumer Assessment of Healthcare Providers and Systems data.

0 10 20 30 40 50 60 70 80 90 100

Commercial health plan

Medicare

Non-Prime Service Area

Prime Service Area 11 89

11 89

7c 93c

10 90

a

All percentage estimates for “Beneficiary rating of primary care physician or nurse” have sampling 

errors at the 95 percent confidence level of plus or minus 2.2 percentage points or less. 

b

All percentage estimates for “Beneficiary rating of specialist physician” have sampling errors at the 

95 percent confidence level of plus or minus 3.6 percentage points or less. 

Page 22 GAO-10-402 DOD's Access to Care Surveys
 

c

A statistically significant difference exists between Medicare beneficiaries and nonenrolled 

beneficiaries in both Prime Service Areas and non-Prime Service Areas at the 95 percent confidence 

level. 

d

All percentage estimates for “Beneficiary rating of health care” have sampling errors at the 95 

percent confidence level of plus or minus 2.7 percentage points or less. 

e

All percentage estimates for “Beneficiary rating of health plan” have sampling errors at the 95 

percent confidence level of plus or minus 3.1 percentage points or less. 

Although the first year’s results of TMA’s 4-year provider survey are not 

representative of all providers in the areas surveyed, the results we 

analyzed do provide information about access to care based on the 

specific views of the respondents. According to a TMA official, 

generalizability of provider survey results to the entire country will likely 

be possible at the end of the 4-year survey period. Our analysis of the 2008 

provider survey results indicate that a lower percentage of respondents 

from Prime Service Areas were aware of TRICARE and were accepting 

new TRICARE patients than providers who responded from non-Prime 

Service Areas. The survey results also indicate that respondents from the 

additional areas TMA surveyed reported levels of awareness and 

acceptance of TRICARE that were similar to respondents in non-Prime 

Service Areas. Additionally, there were differences between the 

responding physicians (primary care physicians and specialists) and 

mental health providers (psychiatrists, certified clinical social workers, 

clinical psychologists, and others) regarding their awareness and 

acceptance of TRICARE. 

2008 Provider Survey 

Results Are Not 

Representative of All 

Providers in Surveyed 

Areas but Provide 

Limited Information 

That Indicates 

Differences among 

Respondents’ 

Awareness and 

Acceptance of 

TRICARE 

2008 Provider Survey 

Results Are Not 

Representative of the 

Provider Population in the 

Areas TMA Surveyed 

Unlike the 2008 beneficiary survey, the results of the 2008 provider survey 

are not representative of all physicians and mental health providers in the 

areas TMA surveyed. The 2008 provider survey was administered in the 

same 20 Prime Service Areas and 20 non-Prime Service Areas as the 

beneficiary survey, as well as 21 additional locations that were identified 

as having access-to-care problems, with an overall response rate of about 

45 percent. (See fig. 5.) Because of the low response rate, TMA conducted 

a nonresponse analysis, and the results of this analysis indicated that there 

were differences among those who responded to the provider survey and 

those who did not. Specifically, those who did not respond to the 2008 

provider survey were less likely to be aware of TRICARE and less likely to 

accept TRICARE reimbursement as payment for services. As a result of 

these differences—even though the survey sample was randomly 

selected—the survey results cannot be generalized to all physicians and 

mental health providers in the areas surveyed and can be presented only 

as the specific views of the respondents. Similarly, because the 2008 

Page 23 GAO-10-402 DOD's Access to Care Surveys
 

survey results cannot be generalized, we did not compare them with the 

2008 beneficiary survey results. 

Figure 5: 2008 Provider Surveys Mailed, Returned, and Completed and Eligible for 

Analysis by Type of Provider 

Source: GAO analysis of DOD data.

Completed and eligiblec responses:

Physicians: 7,628 Mental health providers: 3,733d

Surveys mailed:

Physiciansa: 20,030 Mental health providersb: 20,386

Surveys returned (45 percent):

Physicians: 9,010 Mental health providers: 9,229

a

Physicians consist of primary care physicians and specialists. 

b

Mental health providers consist of certified clinical social workers, certified psychiatric nurse 

specialists, clinical psychologists, certified marriage and family therapists, pastoral counselors, mental 

health counselors, and psychiatrists. 

c

TMA considered responses eligible if the respondents were full-time nonfederal providers in patient 

health care (e.g., not retired or in research) working in private practice or an office-based practice, 

and for mental health providers, whether they were in 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. Additionally, 

the respondent had to have completed three key questions on the physician survey instrument, or 

three key questions on the mental health provider survey instrument. 

Page 24 GAO-10-402 DOD's Access to Care Surveys
 

d

There were 9,229 returned mental health provider survey instruments. Of these, TMA considered 

5,398 as ineligible because the providers did not specify that they worked in a private practice. The 

remaining 98 surveys were not eligible for other reasons, including mental health providers who 

indicated that they were not one of the six specific mental health provider types that TMA included in 

the survey. 

A TMA official stated that because more responses will have been 

obtained by the end of the 4-year survey, generalizability of provider 

survey results to the entire country will likely be possible. Moreover, the 

TMA official noted that TMA has decided to redesign the method of 

selecting mental health providers in the 2009 survey to increase the 

number of responses and the likelihood that survey results could be 

generalized. 

2008 Provider Survey 

Results Indicate 

Differences among 

Respondents’ Awareness 

and Acceptance of 

TRICARE 

Our review of the 2008 provider survey results indicated differences in 

awareness and acceptance of TRICARE among respondents in Prime 

Service Areas, non-Prime Service Areas, and the additional Hospital 

Service Areas TMA surveyed. (See table 5.) Specifically, a lower 

percentage of responding providers—physicians and nonphysician mental 

health providers—from Prime Service Areas were aware of the TRICARE 

program and were accepting new TRICARE patients, if they were 

accepting any new patients or any new Medicare patients, than providers 

who responded from non-Prime Service Areas or Hospital Service Areas. 

For example, 64 percent of the respondents in the surveyed Prime Service 

Areas who reported that they are accepting any new patients reported that 

they would accept nonenrolled TRICARE beneficiaries as new patients, 

compared to 76 percent of respondents in the surveyed non-Prime Service 

Areas and 72 percent of respondents in the surveyed Hospital Service 

Areas. Additionally, survey results indicate that in Hospital Service Areas, 

respondents reported awareness and acceptance of TRICARE that was 

similar to that of respondents in non-Prime Service Areas. 

The reason most often cited by respondents in both Prime Service Areas 

and non-Prime Service Areas for not accepting nonenrolled beneficiaries 

as new patients, if they were accepting any new patients at all, was that 

they were not aware of the TRICARE program. Other reasons included 

concerns about low reimbursement rates and that the provider did not 

participate in TRICARE’s provider network. Respondents in Hospital 

Service Areas reported similar reasons, such as concerns about low 

reimbursement rates and not being aware of the TRICARE program, with 

the most cited reason being that they were not participating in TRICARE’s 

provider network. 

Page 25 GAO-10-402 DOD's Access to Care Surveys
 

Table 5: 2008 Provider Survey Respondents’ Awareness and Acceptance of 

TRICARE by Types of Areas 

Percentage 

of respondents

Aware of TRICARE Programa

Prime Service Areasb85

Non-Prime Service Areasc91

Hospital Service Areasd 90

Accepting new TRICARE patients if accepting any new patientse

Prime Service Areas 64

Non-Prime Service Areas 76

Hospital Service Areas 72

Accepting new TRICARE patients if accepting new Medicare patientsf

Prime Service Areas 75

Non-Prime Service Areas 83

Hospital Service Areas 82

Source: GAO analysis of DOD data. 

Notes: The above data represent the responses of physicians and nonphysician mental health 

providers surveyed. These data are presented as unweighted percentages. 

a

Respondents answered yes to the following: “Is the provider aware of the TRICARE health care 

program?” 

b

Prime Service Areas are geographic areas determined by the Assistant Secretary of Defense for 

Health Affairs that are defined by a set of five-digit zip codes, usually within an approximate 40-mile 

radius of a military inpatient treatment facility. 

c

Non-Prime Service Areas are geographic areas located outside of Prime Service Areas. 

d

Hospital Service Areas are collections of zip codes organized into over 3,000 geographic regions in 

which Medicare beneficiaries seek the majority of their care from one hospital or a collection of 

hospitals. Hospital Service Areas have nonoverlapping borders and contain all U.S. zip codes without 

gaps in coverage. 

e

Respondents answered yes to questions that asked the following: “As of today, is the provider 

accepting any new patients?” and “As of today, is the provider accepting new TRICARE Standard 

patients?” The yes response to this question represents the providers’ indication that they were 

accepting new TRICARE Standard patients on either a “claim-by-claim basis” or “for all claims.” 

f

Respondents answered yes to questions that asked the following: “As of today, is the provider 

accepting new Medicare patients?” and “As of today, is the provider accepting new TRICARE 

Standard patients?” The yes response to this question represents the providers’ indication that they 

were accepting new TRICARE Standard patients on either a “claim-by-claim basis” or “for all claims.” 

Page 26 GAO-10-402 DOD's Access to Care Surveys
 

The physicians and mental health providers who responded to the survey 

differed in their awareness and acceptance of TRICARE. Specifically, a 

higher percentage of responding physicians reported awareness and 

acceptance of TRICARE than the mental health providers who responded. 

(See table 6.) For example, 81 percent of the physicians who responded 

reported that they would accept new TRICARE patients, if they were 

accepting any new patients at all, compared to 50 percent of the mental 

health providers who responded. 

Table 6: 2008 Provider Survey Respondents’ Awareness and Acceptance of 

TRICARE by Physicians and Mental Health Providers 

Percentage 

of respondents

Aware of TRICARE programa

Physiciansb 95

Mental health providersc75

Accepting new TRICARE patients if accepting any new patientsd

Physiciansb81

Mental health providersc50

Accepting new TRICARE patients if accepting new Medicare patientse

Physiciansb83

Mental health providersc 67

Source: GAO analysis of DOD data. 

Notes: The above data are presented as unweighted percentages. 

a

Respondents answered yes to the following question: “Is the provider aware of the TRICARE health 

care program?” 

b

Physicians consist of primary care physicians and specialists. 

c

Mental health providers consist of certified clinical social workers, certified psychiatric nurse 

specialists, clinical psychologists, certified marriage and family therapists, pastoral counselors, mental 

health counselors, and psychiatrists. 

d

Respondents answered yes to questions that asked the following: “As of today, is the provider 

accepting any new patients?” and “As of today, is the provider accepting new TRICARE Standard 

patients?” The yes response to this question represents the providers’ indication that they were 

accepting new TRICARE Standard patients on either a “claim-by-claim basis” or “for all claims.” 

e

Respondents answered yes to questions that asked the following: “As of today, is the provider 

accepting new Medicare patients?” and “As of today, is the provider accepting new TRICARE 

Standard patients?” The yes response to this question represents the providers’ indication that they 

were accepting new TRICARE Standard patients on either a “claim-by-claim basis” or “for all claims.” 

Page 27 GAO-10-402 DOD's Access to Care Surveys
 

We received comments on a draft of this report from DOD. (See app. VI.) 

DOD concurred with our overall findings and provided technical 

comments, which we incorporated where appropriate. 

Agency Comments 

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 Web site 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 williamsonr@gao.gov. Contact points for 

our Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. Key contributors to this report are listed in 

Randall B. Wil

appendix VII. 

liamson 

Director, Health Care 

Page 28 GAO-10-402 DOD's Access to Care Surveys
Appendix I: Selected Office of Management Appendix I: Selected Office of Management and Budget Standards for Statistical Surveys 

and Budget Standards for Statistical 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.1

 The NDAA 2008 also directed us to review the 

processes, procedures, and analyses used by DOD to determine the 

adequacy of the number of health care and mental health care providers 

that currently accept nonenrolled beneficiaries as patients. To evaluate the 

methodology DOD used to implement the beneficiary and provider 

surveys, we reviewed the Office of Management and Budget’s (OMB) 

Standards and Guidelines for Statistical Surveys (2006) to identify key 

aspects and best practices of statistical survey methodology that result in 

sound survey design and implementation. We focused our evaluation on 

standards that address, among other things, designing a survey, developing 

sampling frames, collecting survey data, and analyzing survey response 

rates.2

 Table 7 provides a description of these standards. 

 

1

For the purpose of this report, we refer to beneficiaries who are not enrolled in TRICARE 

Prime—that is, those who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve 

Select—as nonenrolled beneficiaries. Although eligible National Guard and Reserve 

servicemembers are required to purchase TRICARE Reserve Select to receive coverage 

through this plan, we refer to them as nonenrolled beneficiaries because their care options 

are similar to those of TRICARE Standard and Extra beneficiaries. 

2

In general, agency surveys must be approved by OMB. See 44 U.S.C. § 3507. However, 

DOD has authority to conduct surveys of servicemembers and their families to determine 

the effectiveness of federal programs relating to military families and the need for new 

programs without seeking approval from OMB. See 10 U.S.C. § 1782; DOD 8910.1-M, 

Department of Defense Procedures for Management of Information Requirements § C3.7 

(June 1998). Accordingly, DOD sought and obtained OMB approval for the 2008 provider 

survey, but did not do so for the 2008 beneficiary survey. 

Page 29 GAO-10-402 DOD's Access to Care Surveys 
Appendix I: Selected Office of Management 

and Budget Standards for Statistical Surveys 

Table 7: Selected OMB Standards Used to Evaluate DOD’s Survey Methodology 

Standard Description 

Survey planning Agencies initiating a new survey or major revision of an existing survey must develop a written 

plan that sets forth a justification, including goals and objectives; potential users; the decisions 

the survey is designed to inform; key survey estimates; the precision required of the estimates; 

the tabulations and analytic results that will inform decisions and other uses; related and 

previous surveys; steps taken to prevent unnecessary duplication with other sources of 

information; when and how frequently users need the data; and the level of detail needed in 

tabulations, confidential microdata, and public-use data files. 

Survey design Agencies must develop a survey design, including defining the target population, designing the 

sampling plan, specifying the data collection instrument and methods, developing a realistic 

timetable and cost estimate, and selecting samples using generally accepted statistical methods 

(e.g., probabilistic methods that can provide estimates of sampling error). Any use of 

nonprobability sampling methods (e.g., cutoff or model-based samples) must be justified 

statistically and be able to measure estimation error. The size and design of the sample must 

reflect the level of detail needed in tabulations and other data products and the precision 

required of key estimates. Documentation of each of these activities and resulting decisions 

must be maintained in the project files for use in documentation. 

Survey response rates Agencies must design the survey to achieve the highest practical rates of response, 

commensurate with the importance of survey uses, respondent burden, and data collection 

costs, to ensure that survey results are representative of the target population so that they can 

be used with confidence to inform decisions. Nonresponse bias analyses must be conducted 

when unit or item response rates or other factors suggest the potential for bias to occur. 

Pretesting survey systems Agencies must ensure that all components of a survey function as intended when implemented 

in the full-scale survey and that measurement error is controlled by conducting a pretest of the 

survey components or by having successfully fielded the survey components on a previous 

occasion. 

Developing sampling frames Agencies must ensure that the frames for the planned sample survey or census are appropriate 

for the study design and are evaluated against the target population for quality. 

Required notifications to potential 

survey respondents 

Agencies must ensure that each data collection instrument clearly states the reasons the 

information is being collected; the way such information is going to be used to further the proper 

performance of the functions of the agency; whether responses to the collection of information 

are voluntary or mandatory (citing authority); the nature and extent of confidentiality to be 

provided, if any, citing authority; an estimate of the average respondent burden together with a 

request that the public direct to the agency any comments concerning the accuracy of this 

burden estimate and any suggestions for reducing this burden; the OMB control number; and a 

statement that an agency may not conduct and a person is not required to respond to an 

information collection request unless it displays a currently valid OMB control number. 

Data collection methodology Agencies must design and administer their data collection instruments and methods in a manner 

that achieves the best balance between maximizing data quality and controlling measurement 

error while minimizing respondent burden and cost. 

Data editing Agencies must edit data appropriately, based on available information, to mitigate or correct 

detectable errors. 

Nonresponse analysis and 

response rate calculation 

Agencies must appropriately measure, adjust for, report, and analyze unit and item nonresponse 

to assess their effects on data quality and to inform users. Response rates must be computed 

using standard formulas to measure the proportion of the eligible sample that is represented by 

the responding units in each study, as an indicator of potential nonresponse bias. 

Page 30 GAO-10-402 DOD's Access to Care Surveys
Appendix I: Selected Office of Management 

and Budget Standards for Statistical Surveys 

Standard Description 

Coding Agencies must add codes to collected data to identify aspects of data quality from the collection 

(e.g., missing data) in order to allow users to appropriately analyze the data. Codes added to 

convert information collected as text into a form that permits immediate analysis must use 

standardized codes, when they are available, to enhance comparability. 

Evaluation Agencies must evaluate the quality of the data and make the evaluation public (through 

technical notes and documentation included in reports of results or through a separate report) to 

allow users to interpret results of analyses and to help designers of recurring surveys focus 

improvement efforts. 

Analysis and report planning Agencies must develop a plan for the analysis of survey data prior to the start of a specific 

analysis to ensure that statistical tests are used appropriately and that adequate resources are 

available to complete the analysis. 

Source: GAO analysis of OMB’s Standards and Guidelines for Statistical Surveys (September 2006). 

Page 31 GAO-10-402 DOD's Access to Care Surveys
Appendix II: D

Beneficiary and

OD’s Methodology for the 2008 

 Provider Surveys 

Page 32 GAO-10-402 

Appendix II: DOD’s Methodology for the 2008 

Beneficiary and Provider Surveys 

The NDAA 2008 directed 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. For the purpose of this report, we refer to beneficiaries who are 

not enrolled in TRICARE Prime—that is, those who use TRICARE 

Standard, TRICARE Extra, or TRICARE Reserve Select1

—as nonenrolled 

beneficiaries.2

 The mandate also included specific requirements related to 

the number and priority of areas to be surveyed, including the populations 

to be surveyed each year, the content for each type of survey, and the use 

of benchmarks. Within DOD, the TRICARE Management Activity (TMA), 

which oversees the TRICARE program, had responsibility for designing 

and implementing the beneficiary and 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. It 

also provides information on TMA’s analyses of its 2008 beneficiary and 

provider surveys. 

Beneficiary and Provider 

Survey Area Selection 

The NDAA 2008 specified that DOD survey beneficiaries and providers in 

at least 20 TRICARE Prime Service Areas,3

 and 20 geographic areas in 

which TRICARE Prime is not offered—referred to as non-Prime Service 

Areas—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, the NDAA 2008 required 

 

1

Qualified members of the Selected Reserve—National Guard and Reserve servicemembers 

who are considered essential to wartime missions—who are not activated to duty may 

purchase TRICARE Reserve Select. 

2

Although eligible National Guard and Reserve servicemembers are required to purchase 

TRICARE Reserve Select to receive coverage through this plan, we refer to them as 

nonenrolled beneficiaries because their care options are similar to those of TRICARE 

Standard and Extra beneficiaries. 

3

Prime Service Areas are geographic areas determined by the Assistant Secretary of 

Defense for Health Affairs that are defined by a set of five-digit zip codes, usually within an 

approximate 40-mile radius of a military inpatient treatment facility. The managed care 

support contracts require the contractor to develop civilian provider networks at all Base 

Realignment and Closure (BRAC) sites, which are military installations that have been 

closed or realigned as a result of decisions made by the Commission on Base Realignment 

and Closure. 

 DOD's Access to Care Surveys 
Appendix II: DOD’s Methodology for the 2008 

Beneficiary and Provider Surveys 

DOD to give a high priority to surveying areas in which higher 

concentrations of Selected Reserve servicemembers live. 

In designing the 2008 beneficiary and provider surveys, TMA defined 80 

Prime Service Areas and 80 non-Prime Service Areas that will allow it to 

survey the entire country over a 4-year period and to develop estimates of 

access to health care and mental health care at service area, state, and 

national levels. TMA identified the 80 Prime Service Areas 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-Prime Service Areas had not 

previously been defined, TMA sought to define them by grouping all zip 

codes not in Prime Service Areas into one large area using Hospital 

Referral Regions,4

 which are groupings of Hospital Service Areas.5 TMA 

divided the large area into 80 non-Prime Service Areas so that each area 

had roughly the same number of TRICARE-eligible beneficiaries. 

To identify locations where 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 TRICARE Regional Offices. These groups suggested 

cities and towns where access should be measured, and Hospital Service 

Areas corresponding to each city and town were then identified. Based on 

the groups’ recommendations, a list was created and sorted in priority 

order, resulting in 21 Hospital Service Areas being included in the 2008 

provider survey. Additionally, TMA plans to include these 21 Hospital 

 

4

The Hospital Referral Region designation is derived from a Dartmouth University study 

that groups Hospital Service Areas into distinct sets by documenting where patients were 

referred for major cardiovascular surgical procedures and for neurosurgery. Each Hospital 

Service Area was examined to determine where most of its residents went for these 

services. The result was the aggregation of the over 3,000 Hospital Service Areas into 306 

Hospital Referral Regions. A TMA official noted that TMA endorsed the Hospital Referral 

Region methodology in part because it is based on the medical observations of Medicare 

beneficiaries, and TRICARE reimbursement rates are based on Medicare reimbursement 

rates. In addition, TMA used this methodology in its survey of civilian providers during 

fiscal years 2005 through 2007. In 2006 we reviewed the methodology TMA used for the 

2005 civilian provider survey. GAO-07-48. 

5

Hospital Service Areas are collections of zip codes organized into over 3,000 geographic 

regions in which Medicare beneficiaries seek the majority of their care from one hospital or 

a collection of hospitals. Hospital Service Areas have nonoverlapping borders and contain 

all U.S. zip codes without gaps in coverage. 

Page 33 GAO-10-402 DOD's Access to Care Surveys
Appendix II: DOD’s Methodology for the 2008 

Beneficiary and Provider Surveys 

Service Areas in its 2009 beneficiary survey along with additional areas 

that are identified for 2009. Although the NDAA 2008 required DOD to give 

a high priority to surveying areas in which higher concentrations of 

Selected Reserve servicemembers live, TMA decided to randomly select 

areas for the surveys in order to produce results that could be generalized 

to the populations in the areas surveyed. 

Selection of Beneficiary 

and Provider Survey 

Sample 

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),6

 a database of DOD beneficiaries who may be 

eligible for military health benefits. TMA determined a beneficiary’s 

eligibility to be included in the 2008 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 file extract; (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 Prime Service Areas or 20 randomly selected 

non-Prime Service Areas; and (5) a user of TRICARE Reserve Select, or 

not enrolled in TRICARE Prime.7

 From this database, TMA randomly 

sampled about 1,000 beneficiaries from each Prime Service Area and nonPrime Service Area—a sample size that would achieve TMA’s desired 

sample error.8

 Specifically, TMA surveyed 48,548 TRICARE beneficiaries 

representing active duty, retired, and Reserve servicemembers, including 

the Selected Reserve. TMA began mailing the beneficiary survey in June 

2008. After receiving the returned surveys, TMA identified the responses 

that it considered complete and eligible based on whether the beneficiary 

had answered at least half of TMA’s identified “key” questions and 

answered that he or she used “TRICARE Extra or Standard” or “TRICARE 

Reserve Select” in response to the following question: “Which health plan 

did you use for all or most of your health care in the last 12 months?” 

 

6

DEERS is a database that contains the service-related and demographic data that are used 

to determine eligibility for military benefits, including health care, for all active duty 

servicemembers, military retirees, and the dependents and survivors of active duty 

servicemembers and military retirees. As individuals join the military, the various agencies 

enter information about them into DEERS and update this information as their status 

changes. The individual servicemember is responsible for providing information to DEERS 

on dependents and for reporting changes concerning dependents. 

7

TMA’s sample included non-Medicare enrolled retirees, dependents of active duty 

personnel, and beneficiaries who purchased TRICARE Reserve Select in fiscal year 2008. 

8

TMA desired a sample error of plus or minus 5 percent at the 95 percent confidence level. 

Page 34 GAO-10-402 DOD's Access to Care Surveys
Appendix II: DOD’s Methodology for the 2008 

Beneficiary and Provider Surveys 

TMA selected the provider sample within the same 20 Prime Service Areas 

and 20 non-Prime Service Areas that had been randomly selected for the 

2008 beneficiary survey. In addition, TMA mailed surveys to physicians 

and mental health providers in the 21 Hospital Service Areas identified by 

beneficiary and provider groups as having significant levels of access-tocare problems under TRICARE Standard and Extra. TMA used the 

American Medical Association Physician Masterfile (Masterfile) to select a 

sample of 20,030 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 Masterfile is a database of physicians in the United 

States—Doctors of Medicine and Doctors of Osteopathic Medicine—that 

includes data on all physicians who have the necessary educational and 

credentialing requirements. The 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 

it contains over 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 to 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 mental health provider sample, TMA 

selected a sample of 20,386 mental health providers from two sources: the 

National Plan and Provider Enumeration System database maintained by 

the Centers for Medicare & Medicaid Services, and from LISTS, Inc., a list 

of names with contact information assembled from state licensing boards. 

According to TMA, it selected these sources for mental health providers 

because they have been identified as the most comprehensive databases 

for these health care providers. TMA did not include all physician 

specialist types, such as epidemiologists and pathologists, in its survey. 

From these data sets, TMA planned to randomly sample about 800 

providers (400 each of physicians and mental health providers) from each 

Page 35 GAO-10-402 DOD's Access to Care Surveys
Appendix II: DOD’s Methodology for the 2008 

Beneficiary and Provider Surveys 

Prime Service Area, non-Prime Service Area, and Hospital Service Area—a 

sample size that would achieve TMA’s desired sample error.9

 In those 

instances where there were not 800 providers in a single area, TMA 

selected all of the providers in that area to receive surveys. TMA began 

mailing the provider survey in December 2008. Upon receipt of the 

returned surveys, TMA identified the responses that it considered 

completed 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 that he 

or she was in 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) if the provider had completed three 

key questions on the physician survey instrument or three key questions 

on the nonphysician mental health provider survey instrument. 

Beneficiary and Provider 

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 providers willing to 

provide services under TRICARE Standard or TRICARE Extra. TMA’s 

beneficiary survey included 91 questions that address, 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 beneficiary survey questions on 

those included in the Department of Health and Human Services’ 2006 

Consumer Assessment of Healthcare Providers and Systems, a national 

survey of beneficiaries of commercial health insurance, Medicare, 

Medicaid, and the Children’s Health Insurance Program. 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. (See app. III for a 

copy of the 2008 beneficiary survey instrument.) 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. 

 

9

TMA desired a sample error of plus or minus 5 percent at a 95 percent confidence level. 

Page 36 GAO-10-402 DOD's Access to Care Surveys
Appendix II: DOD’s Methodology for the 2008 

Beneficiary and Provider Surveys 

For the 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 OMB as required under the 

Paperwork Reduction Act.10 Subsequent to this review, OMB approved an 

11-item questionnaire for physicians (including psychiatrists) and a 

12-item questionnaire for nonphysician mental health providers to be 

administered in fiscal year 2008. (See app. IV for a copy of the 2008 

provider survey instruments.) The mental health providers’ version of the 

survey includes an additional question about what type of mental health 

care the provider practiced. 

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. 

Beneficiary and Provider 

Survey Benchmarks 

In accordance with the NDAA 2008, TMA identified benchmarks for 

analyzing the results of the beneficiary and provider surveys. Because 

TMA based some of its 2008 beneficiary survey questions on those 

included in the Department of Health and Human Services’ 2006 Consumer 

Assessment of Healthcare Providers and Systems survey, it was able to 

compare the results of those questions with its 2008 beneficiary survey 

results. To benchmark its provider survey, TMA compared the results of 

its 2008 survey 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. 

 

10The Paperwork Reduction Act requires that all federal agency activities that involve 

collecting information from the public involving 10 or more people be approved by OMB to 

ensure that collection of this information will have a minimum burden on the public. See 

44 U.S.C. §§ 3507 and 3508. 

Page 37 GAO-10-402 DOD's Access to Care Surveys
Appendix II: DOD’s Methodology for the 2008 

Beneficiary and Provider Surveys 

In analyzing the results of the beneficiary survey, TMA representatives 

conducted a nonresponse analysis because the overall response rate to the 

survey was about 38 percent.11 To conduct this analysis, 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 400 beneficiaries who did not respond to 

the original survey or the follow-up mailing and compared their responses 

with those of the original survey respondents.12 The results of TMA’s 

nonresponse analysis indicated no difference in demographic 

characteristics and health coverage between beneficiary survey 

respondents and nonrespondents within the combined Prime Service 

Areas and combined non-Prime Service Areas surveyed in fiscal year 2008. 

Therefore, TMA concluded that the survey respondents were 

representative of the combined Prime Service Areas and combined nonPrime Service Areas surveyed, and the results of the survey can be 

generalized to the population from which the sample was chosen. TMA 

weighted each response so that the sampled beneficiaries represented the 

population in terms of size for the respective Prime Service Area or nonPrime Service Area from which they were selected. 

Analyses of Beneficiary 

and Provider Survey 

Results 

In analyzing the results of the provider survey, TMA conducted a 

nonresponse analysis because the overall response rate to the survey was 

about 45 percent. To conduct this analysis, TMA did the following: 

(1) compared key provider demographic characteristics of respondents to 

those of nonrespondents (for example, provider type and location) and 

(2) interviewed a sample of 247 providers (140 physicians and 107 mental 

health providers) who did not respond to the original survey, follow-up 

mailing, or follow-up telephone calls and compared their responses with 

 

11OMB’s guidance suggests that if response rates are below 80 percent, an agency should 

conduct a nonresponse analysis. Such an analysis is used to verify that nonrespondents to 

the survey would not answer differently from those who did respond and that the 

respondents are representative of the target population, thus ensuring that the results can 

be generalized to the population from which the sample was chosen. Prior to administering 

the beneficiary and provider surveys, TMA had planned to conduct a nonresponse analysis 

for each survey because of the likelihood that the surveys’ response rates would be less 

than 80 percent. 

12According to a TMA official, TMA chose a sample size of 400 because it would allow it 

determine whether nonrespondents answer the survey differently than respondents and 

whether the respondents are representative of the target population within plus or minus 

5 percent at the 95 percent confidence level. 

Page 38 GAO-10-402 DOD's Access to Care Surveys
Appendix II: DOD’s Methodology for the 2008 

Beneficiary and Provider Surveys 

those of the original survey respondents.13 The results of TMA’s 

nonresponse analysis indicated that there are differences between 

respondents and those who did not respond to the original 2008 provider 

survey. Specifically, among both types of providers (physicians and mental 

health providers), nonrespondents are less likely to be aware of TRICARE 

and less likely to accept TRICARE as a form of payment for services. 

Additionally, nonrespondents are less likely to be accepting new patients. 

Therefore, the survey results cannot be generalized to the population from 

which the sample was chosen and can only be presented in terms of those 

civilian providers who responded to the survey. 

 

13According to a TMA official, a sample size of 247 allows it to determine whether 

nonrespondents answer the survey differently than respondents and whether the 

respondents are representative of the target population within plus or minus 6.2 percent at 

the 95 percent confidence level. 

Page 39 GAO-10-402 DOD's Access to Care Surveys
Appendix III: Beneficiary Survey Instrument Appendix III: Beneficiary Survey Instrument 

The NDAA 2008 directed 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. For the purpose of this 

report, we refer to beneficiaries who are not enrolled in TRICARE Prime—that is, 

those who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select1

—as 

nonenrolled beneficiaries.2

 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. 

Following is the actual survey instrument that DOD used to obtain information from 

nonenrolled beneficiaries. 

 

1

Qualified members of the Selected Reserve—National Guard and Reserve servicemembers who are 

considered essential to wartime missions—who are not activated to duty may purchase TRICARE 

Reserve Select. 

2

Although eligible National Guard and Reserve servicemembers are required to purchase TRICARE 

Reserve Select to receive coverage through this plan, we refer to them as nonenrolled beneficiaries 

because their care options are similar to those of TRICARE Standard and Extra beneficiaries. 

Page 40 GAO-10-402 DOD's Access to Care Surveys 
Appendix III: Beneficiary Survey Instrument 

Page 41 GAO-10-402 DOD's Access to Care Surveys
Appendix III: Beneficiary Survey Instrument 

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Appendix III: Beneficiary Survey Instrument 

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Appendix III: Beneficiary Survey Instrument 

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Appendix III: Beneficiary Survey Instrument 

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Appendix III: Beneficiary Survey Instrument 

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Appendix III: Beneficiary Survey Instrument 

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Appendix III: Beneficiary Survey Instrument 

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Appendix III: Beneficiary Survey Instrument 

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Appendix III: Beneficiary Survey Instrument 

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Appendix III: Beneficiary Survey Instrument 

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Appendix III: Beneficiary Survey Instrument 

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Appendix III: Beneficiary Survey Instrument 

Page 53 GAO-10-402 DOD's Access to Care Surveys
Appendix IV: Survey Instruments for Health Appendix IV: Survey Instruments for Health Care and Mental Health Care Providers 

Care and Mental Health Care Providers 

The NDAA 2008 directed 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. For the purpose of this report, we refer to beneficiaries who are 

not enrolled in TRICARE Prime—that is, those who use TRICARE 

Standard, TRICARE Extra, or TRICARE Reserve Select1

—as nonenrolled 

beneficiaries.2

 Specifically, the 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.3

 Following are the actual survey 

instruments that DOD used to obtain information from physicians and 

nonphysician mental health care providers. 

 

1

Qualified members of the Selected Reserve—National Guard and Reserve servicemembers 

who are considered essential to wartime missions—who are not activated to duty may 

purchase TRICARE Reserve Select. 

2

Although eligible National Guard and Reserve servicemembers are required to purchase 

TRICARE Reserve Select to receive coverage through this plan, we refer to them as 

nonenrolled beneficiaries because their care options are similar to those of TRICARE 

Standard and Extra beneficiaries. 

3

Nonphysician mental health providers are (1) certified marriage and family therapists, 

(2) mental health counselors, (3) pastoral counselors, (4) certified psychiatric nurse 

specialists, (5) clinical psychologists, and (6) certified clinical social workers. 

Page 54 GAO-10-402 DOD's Access to Care Surveys 
Appendix IV: Survey Instruments for Health 

Care and Mental Health Care Providers 

Page 55 GAO-10-402 DOD's Access to Care Surveys
Appendix IV: Survey Instruments for Health 

Care and Mental Health Care Providers 

Page 56 GAO-10-402 DOD's Access to Care Surveys
Appendix IV: Survey Instruments for Health 

Care and Mental Health Care Providers 

Page 57 GAO-10-402 DOD's Access to Care Surveys 
Appendix IV: Survey Instruments for Health 

Care and Mental Health Care Providers 

Page 58 GAO-10-402 DOD's Access to Care Surveys
Appendix V: Areas Included in the Fiscal Year Appendix V: Areas Included in the Fiscal Year 2008 Beneficiary and Provider Surveys 

2008 Beneficiary and Provider Surveys 

The NDAA 2008 directed DOD to determine the adequacy of the number of 

health care providers 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 refer to 

beneficiaries who are not enrolled in TRICARE Prime—that is, those who 

use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select1

—as 

nonenrolled beneficiaries.2

 The NDAA 2008 specified that DOD conduct 

surveys of TRICARE beneficiaries and health care and mental health care 

providers in 20 TRICARE Prime Service Areas3

 and in 20 areas in which 

TRICARE Prime is not offered—referred to as non-Prime Service Areas—

for each fiscal year, 2008 through 2011. Additionally, the NDAA 2008 

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-tocare problems, and give a high priority to surveying health care and mental 

health care providers in these areas. For the 2008 beneficiary and provider 

surveys, DOD selected 20 Prime Service Areas and 20 non-Prime Service 

Areas to determine the adequacy of the number of health care providers 

and mental health care providers who currently accept nonenrolled 

TRICARE beneficiaries as patients. For the 2008 provider survey, DOD 

also surveyed 21 additional areas identified by beneficiary and provider 

groups where nonenrolled beneficiaries are experiencing significant levels 

of access-to care problems—called Hospital Service Areas4

—to determine 

the adequacy of access to care in these areas. DOD’s selected Prime 

 

1

Qualified members of the Selected Reserve—National Guard and Reserve servicemembers 

who are considered essential to wartime missions—who are not activated to duty may 

purchase TRICARE Reserve Select. 

2

Although eligible National Guard and Reserve servicemembers are required to purchase 

TRICARE Reserve Select to receive coverage through this plan, we refer to them as 

nonenrolled beneficiaries because their care options are similar to those of TRICARE 

Standard and Extra beneficiaries. 

3

Prime Service Areas are geographic areas determined by the Assistant Secretary of 

Defense for Health Affairs that are defined by a set of five-digit zip codes, usually within an 

approximate 40-mile radius of a military inpatient treatment facility. The managed care 

support contracts require the contractor to develop civilian provider networks at all Base 

Realignment and Closure (BRAC) sites, which are military installations that have been 

closed or realigned as a result of decisions made by the Commission on Base Realignment 

and Closure. 

4

Hospital Service Areas are collections of zip codes organized into over 3,000 geographic 

regions in which Medicare beneficiaries seek the majority of their care from one hospital or 

a collection of hospitals. Hospital Service Areas have nonoverlapping borders and contain 

all U.S. zip codes without gaps in coverage. 

Page 59 GAO-10-402 DOD's Access to Care Surveys
Appendix V: Areas Included in the Fiscal Year 

2008 Beneficiary and Provider Surveys 

Service Areas and non-Prime Service Areas for 2008 are presented in table 

8 and table 9, respectively. Table 10 lists those locations identified by 

representatives of TRICARE beneficiaries and health care and mental 

health care providers as having significant levels of access-to-care 

problems, which were included in the 2008 provider survey.5

Table 8: Prime Service Areas Included in the 2008 Beneficiary and Provider Surveys 

Prime Service Area 

1. Alabama – Dothan, Montgomery 

2. Arizona – Phoenix 

3. Arizona – Sierra Vista, Tucson, Yuma 

4. California – Los Angeles, Newport Beach 

5. Colorado – Denver, Fort Collins 

6. Delaware – Camden, Dover, Wilmington 

7. Florida – Jacksonville 

8. Florida – Fort Walton Beach, Pensacola 

9. Hawaii – Honolulu , Wailuku 

10. Indiana – Indianapolis, Kokomo, Naperville 

11. Louisiana – Alexandria, New Orleans, Shreveport 

12. Maryland, Virginia, Washington, D.C. – Alexandria, Annapolis, Clinton, Silver Spring, 

Washington 

13. New York – Manhattan, Poughkeepsie 

14. North Carolina – Durham, Elizabeth City, Greenville, Rocky Mount 

15. North Carolina – Fayetteville, Lumberton 

16. Ohio – Cincinnati, Kettering 

17. Pennsylvania – Pittsburgh 

18. Texas – Abilene, Amarillo, Del Rio, Harlington, San Angelo, Wichita Falls 

19. Texas – Austin, Temple 

20. Virginia – Newport News, Suffolk 

Source: DOD. 

 

5

DOD plans to include these areas in its 2009 beneficiary survey in addition to any other 

areas identified. 

Page 60 GAO-10-402 DOD's Access to Care Surveys
Appendix V: Areas Included in the Fiscal Year 

2008 Beneficiary and Provider Surveys 

Table 9: Non-Prime Service Areas Included in the 2008 Beneficiary and Provider 

Surveys 

Non-Prime Service Area 

1. California – Chico, Fresno, Modesto, Napa, Redding, Sacramento, Santa Rosa, 

Stockton 

2. Georgia – Atlanta; North Carolina – Asheville 

3. Illinois – Springfield 

4. Indiana – Evansville 

5. Iowa – Mason City, Sioux City, Waterloo 

6. Kansas – Topeka 

7. Kentucky – Louisville, Owensboro, Paducah 

8. Maine – Bangor, Portland 

9. Minnesota – Duluth, St. Cloud 

10. Missouri – Cape Girardeau, St. Louis 

11. Montana – Billings 

12. New York – Buffalo 

13. North Dakota – Bismarck, Grand Forks, Minot 

14. Oregon – Portland, Salem 

15. Pennsylvania – Altoona, Danville 

16. Pennsylvania – Johnstown, Pittsburgh 

17. Texas – Amarillo, El Paso, Lubbock, Odessa 

18. Washington – Olympia, Seattle, Yakima 

19. West Virgina – Huntington, Morgantown 

20. Wisconsin – La Crosse 

Source: DOD. 

Page 61 GAO-10-402 DOD's Access to Care Surveys
Appendix V: Areas Included in the Fiscal Year 

2008 Beneficiary and Provider Surveys 

Table 10: Hospital Service Areas Included in the 2008 Provider Survey 

Hospital Service Area 

21. Arkansas – Bentonville 

22. California – King City 

23. California – Palm Springs 

24. Colorado – Fort Collins 

25. Florida – Gainesville 

26. Florida – Homestead 

27. Florida – Tampa 

28. Illinois – Peoria 

29. Indiana – Jasper 

30. Indiana – New Albany 

31. Kentucky – Murray 

32. Michigan – Marquette 

33. Mississippi – Columbus 

34. New York – Binghampton 

35. North Carolina – Asheville 

36. North Carolina – Jacksonville 

37. Pennsylvania – Altoona 

38. Utah – Salt Lake City 

39. Virginia – Danville 

40. Virginia – Norfolk 

41. West Virginia – Charleston 

Source: DOD. 

Page 62 GAO-10-402 DOD's Access to Care Surveys
Appendix VI: Comments from the Department Appendix VI: Comments from the of Defense 

Department of Defense 

Page 63 GAO-10-402 DOD's Access to Care Surveys 
Appendix VII: GAO Contact and Staff Appendix VII: GAO Contact and Staff Acknowledgments 

Acknowledgments 

GAO Contact Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov 

In addition to the contact named above, Bonnie Anderson, Assistant 

Director; Martha Kelly, Assistant Director; Susannah Bloch; Peter 

Mangano; Jeff Mayhew; Lisa Motley; Jessica C. Smith; C. Jenna Sondhelm; 

and Suzanne Worth made key contributions to this report. 

Page 64 GAO-10-402 DOD's Access to Care Surveys

Acknowledgments 

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