DEFENSE HEALTH 

CARE

TRICARE Multiyear 

Surveys Indicate 

Problems with Access 

to Care for 

Nonenrolled 

Beneficiaries

Report to Congressional Committees

April 2013

GAO-13-364

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-364, a report to 

congressional committees

April 2013

DEFENSE HEALTH CARE

TRICARE Multiyear Surveys Indicate Problems with 

Access to Care for Nonenrolled Beneficiaries

Why GAO Did This Study

DOD provides health and mental 

health care through its TRICARE 

program. TRICARE offers three basic 

options. Beneficiaries who choose 

TRICARE Prime, an option that uses 

civilian provider networks, must enroll. 

Beneficiaries who do not enroll in this 

option may obtain care from 

nonnetwork providers under TRICARE 

Standard or from network providers 

under TRICARE Extra. In addition, 

qualified National Guard and Reserve 

servicemembers may purchase 

TRICARE Reserve Select, a plan 

whose care options are similar to those 

of TRICARE Standard and TRICARE 

Extra. GAO refers to servicemembers 

who use TRICARE Standard, 

TRICARE Extra, or TRICARE Reserve 

Select as nonenrolled beneficiaries.

The National Defense Authorization 

Act for Fiscal Year 2008 directed DOD 

to conduct annual surveys over fiscal 

years 2008 through 2011 of both 

beneficiaries and civilian providers to 

determine the adequacy of access to 

health and mental health care 

providers for nonenrolled beneficiaries. 

It also directed GAO to review these 

surveys. This report addresses 

(1) what the results of the 4-year 

beneficiary surveys indicate about the 

adequacy of access to care for 

nonenrolled beneficiaries; (2) what the 

results of the 4-year civilian provider 

surveys indicate about civilian 

providers’ awareness and acceptance 

of TRICARE, and (3) what the 

collective results of the surveys 

indicate about access to care by

geographic area. To do so, GAO 

interviewed DOD officials, obtained 

relevant documentation, and analyzed 

the data for both surveys over the

4-year period. 

What GAO Found

In its analysis of the 2008-2011 beneficiary survey data, GAO found that nearly 

one in three nonenrolled beneficiaries experienced problems finding a civilian 

provider who would accept TRICARE and that nonenrolled beneficiaries’ access 

to civilian primary care and specialty care providers differed by type of location. 

Specifically, a higher percentage of nonenrolled beneficiaries in Prime Service 

Areas (PSA), which are areas with civilian provider networks, experienced 

problems finding a civilian primary care or specialty care provider compared to 

those in non–Prime Service Areas (non-PSA), which do not have civilian provider 

networks. GAO found that the top reasons reported by nonenrolled beneficiaries 

for why they experienced access problems—regardless of type of provider—

were that the providers were either not accepting TRICARE payments or new 

TRICARE patients. Additionally, GAO’s comparison of the Department of 

Defense’s (DOD) beneficiary survey data to related data from a Department of 

Health and Human Services survey showed that nonenrolled beneficiaries’ 

satisfaction ratings for primary and specialty care providers were consistently 

lower than those of Medicare fee-for-service beneficiaries.

GAO’s analysis of the 2008-2011 civilian provider survey data found that about 6 

in 10 civilian providers were accepting new TRICARE patients and the most-cited 

reason for not accepting new TRICARE patients was that the civilian providers 

were not aware of the TRICARE program. Civilian physicians’ acceptance of 

TRICARE has also decreased over time. Specifically, when compared to DOD’s 

2005-2007 civilian physician survey results, civilian physicians’ acceptance of 

new TRICARE patients has decreased. This was also true whether they were 

accepting any new patients or new Medicare patients. Civilian providers’ 

awareness and acceptance of TRICARE also differed by provider type, as fewer 

civilian mental health care providers were aware of TRICARE or accepting new 

TRICARE patients than other types of providers. For example, only an estimated 

39 percent of civilian mental health care providers were accepting new TRICARE 

patients, compared to an estimated 67 percent of civilian primary care providers 

and an estimated 77 percent of civilian specialty care providers. The analysis 

also showed that civilian providers’ awareness and acceptance of TRICARE 

differ by location type, as civilian providers in PSAs were less aware of TRICARE 

and less likely to accept new TRICARE patients than those in non-PSAs.

GAO’s analysis of the collective results of the beneficiary and civilian provider 

survey results indicates specific geographic areas, including areas in Texas and 

California, where nonenrolled beneficiaries have experienced considerable 

access problems. In each of these areas, although almost all civilian providers 

were accepting new patients, less than half were accepting new TRICARE 

patients. In most of these areas, civilian providers most often cited 

reimbursement concerns as the reasons why they were not accepting any new 

TRICARE patients.

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

findings.

View GAO-13-364. For more information, 

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov.
Page i GAO-13-364 TRICARE's Access to Care Surveys

Letter 1 

Background 7

Nearly One in Three Nonenrolled Beneficiaries Experienced 

Problems Accessing Care, and They Rated Their Satisfaction 

with Care Generally Lower than Medicare Fee-for-Service 

Beneficiaries 17

Civilian Providers’ Acceptance of New TRICARE Patients Has 

Decreased over Time; Mental Health Providers Report Lower 

Awareness and Acceptance than Other Provider Types 26

Collective Results of TMA’s Beneficiary and Civilian Provider 

Surveys Indicate Specific Geographic Areas Where Nonenrolled 

Beneficiaries Have Experienced Access Problems 36

Agency Comments and Our Evaluation 43

Appendix I TRICARE Management Activity’s Methodology for the 

2008-2011 Beneficiary and Civilian Provider Surveys 44

Appendix II Beneficiary Survey Instrument 56

Appendix III Survey Instruments for Civilian Physicians and 

Nonphysician Mental Health Care Providers 70

Appendix IV Areas Where Nonenrolled Beneficiaries Had Problems 

Accessing Civilian Providers, 2008-2011 76

Appendix V Civilian Provider Acceptance of Any New TRICARE Patients 

in Hospital Service Areas Surveyed in Fiscal Year 2011 87

Appendix VI Comments from the Department of Defense 88

Contents 
Page ii GAO-13-364 TRICARE's Access to Care Surveys

Appendix VII GAO Contact and Staff Acknowledgments 89

Tables

Table 1: Summary of TRICARE Options 8

Table 2: Comparison of TRICARE Network and Nonnetwork 

Civilian Providers 12

Table 3: Requirements for Annual Beneficiary and Provider 

Surveys Contained in the National Defense Authorization 

Act for Fiscal Year 2008 (NDAA 2008) 16

Table 4: Areas Where the Percentage of Nonenrolled Beneficiaries 

Who Experienced Problems Finding a Civilian Provider 

Was at Least the National Estimate and Where the 

Percentage of Civilian Providers Who Were Accepting Any 

New TRICARE Patients Was at or below the National 

Estimate, 2008-2011 37

Table 5: Civilian Providers’ Estimated Percentage of Acceptance of 

New Patients and New TRICARE Patients, by Problem 

Area, 2008-2011 38

Table 6: Areas Where the Percentage of Nonenrolled Beneficiaries 

Who Experienced Problems Finding a Civilian Primary 

Care Provider Was at Least the National Estimate and 

Where the Percentage of Civilian Primary Care Providers 

Who Were Accepting Any New TRICARE Patients Was at 

or below the National Estimate, 2008-2011 40

Table 7: Civilian Primary Care Providers’ Estimated Percentage of 

Acceptance of New Patients and New TRICARE Patients, 

by Problem Area, 2008-2011 41

Table 8: Number of Beneficiary Surveys Mailed, Returned, and 

Complete and Eligible, by Fiscal Year 48

Table 9: Number of Civilian Physician and Nonphysician Mental 

Health Provider Surveys Mailed, Returned, and Complete 

and Eligible, by Fiscal Year 51

Table 10: Prime Service Areas (PSA), Non–Prime Service Areas 

(non-PSA), and Hospital Service Areas (HSA) with 

31 Percent or More of Nonenrolled Beneficiaries 

Experiencing Problems Finding Any Type of Provider, and 

the Willingness of Civilian Providers in the Corresponding 

Areas to Accept New TRICARE Patients, 2008-2011 78
Page iii GAO-13-364 TRICARE's Access to Care Surveys

Table 11: Prime Service Areas (PSA), Non–Prime Service Areas 

(non-PSA), and Hospital Service Areas (HSA) with 

25 Percent or More of Nonenrolled Beneficiaries 

Experiencing Problems Finding a Civilian Primary Care 

Provider, and the Willingness of Civilian Primary Care 

Providers in the Corresponding Areas to Accept New 

TRICARE Patients, 2008-2011 82

Table 12: Prime Service Areas (PSA), Non–Prime Service Areas 

(non-PSA), and Hospital Service Areas (HSA) with 

25 Percent or More of Nonenrolled Beneficiaries 

Experiencing Problems Finding Civilian Specialist 

Providers, and the Willingness of Civilian Specialist 

Providers in the Corresponding Areas to Accept New 

TRICARE Patients, 2008-2011 85

Table 13: Hospital Service Areas (HSA) Surveyed in 2011, and the 

Estimated Percentage of Civilian Providers Who Were 

Accepting Any New TRICARE Patients 87

Figures

Figure 1: Percentage of Outpatient Claims Paid for TRICARE 

Prime, TRICARE Standard, TRICARE Extra, and 

TRICARE Reserve Select for Fiscal Years 2008 through 

2011 9

Figure 2: Types of Nonenrolled TRICARE Beneficiaries 10

Figure 3: Geographic Location of Nonenrolled TRICARE 

Beneficiaries 11

Figure 4: Prime Service Areas (PSA) and Non–Prime Service Areas 

(non-PSA) Surveyed for TRICARE Management Activity’s 

4-Year Beneficiary and Provider Surveys, 2008-2011 13

Figure 5: Hospital Service Areas (HSA) Surveyed for TRICARE 

Management Activity’s (TMA) 4-Year Beneficiary and 

Provider Surveys, 2008-2011 15

Figure 6: Estimated Percentages of Nonenrolled TRICARE 

Beneficiaries Who Experienced Access Problems, by 

Civilian Provider Type, in Prime Service Areas (PSA) and 

Non–Prime Service Areas (non-PSA), 2008-2011 19

Figure 7: Estimated Percentages of Nonenrolled TRICARE 

Beneficiaries Who Experienced Access Problems, by 

Civilian Provider Type, in Hospital Service Areas (HSA) 

and Prime Service Areas (PSA)/non-PSAs Outside of 

Surveyed HSAs, 2008-2011 21
Page iv GAO-13-364 TRICARE's Access to Care Surveys

Figure 8: Top Five Reasons Reported by Nonenrolled Beneficiaries 

Who Experienced Problems Accessing Civilian Primary, 

Specialty, or Mental Health Care, 2008-2011 22

Figure 9: Nonenrolled TRICARE Beneficiaries’ Estimated 

Satisfaction Ratings Compared to Those of Commercially 

Insured, Medicaid, and Medicare Fee-For-Service 

Beneficiaries, 2008-2011 25

Figure 10: Top Seven Categories of Reasons for Not Accepting New 

TRICARE Patients Reported by Civilian Providers That 

Were Not Accepting Any New TRICARE Patients, 2008-

2011 27

Figure 11: Civilian Physicians’ Awareness and Acceptance of 

TRICARE over Time in TRICARE Management Activity’s 

(TMA) Surveys 29

Figure 12: Civilian Providers’ Awareness and Acceptance of 

TRICARE, by Type of Provider, 2008-2011 30

Figure 13: Top Categories of Reasons Reported by Civilian 

Providers for Not Accepting New TRICARE Patients, by 

Provider Type, 2008-2011 32

Figure 14: Civilian Providers’ Awareness and Acceptance of 

TRICARE in Prime Service Areas (PSA) and non–Prime 

Service Areas (non-PSA), 2008-2011 34

Figure 15: Civilian Providers’ Awareness and Acceptance of 

TRICARE, by Hospital Service Areas (HSA) and Prime 

Service Areas/non–Prime Service Areas (PSA/non-PSA) 

outside of the Surveyed HSAs, 2008-2011 35

Figure 16: Estimated Percentage of Nonenrolled Beneficiaries Who 

Experienced Problems Finding a Civilian Primary, 

Specialty, or Mental Health Care Provider, 2008-2011 77

Figure 17: Estimated Percentage of Nonenrolled Beneficiaries Who 

Experienced Problems Finding a Civilian Primary Care 

Provider, 2008-2011 81

Figure 18: Estimated Percentage of Nonenrolled Beneficiaries Who 

Experienced Problems Finding a Civilian Specialty Care 

Provider, 2008-2011 84
Page v GAO-13-364 TRICARE's Access to Care Surveys

Abbreviations

BRAC Base Realignment and Closure

CAHPS Consumer Assessment of Healthcare 

 Providers and Systems

DEERS Defense Enrollment Eligibility Reporting System

DOD Department of Defense

HHS Department of Health and Human Services

HSA Hospital Service Area

NDAA National Defense Authorization Act

NDAA 2008 National Defense Authorization Act for Fiscal 

 Year 2008

non-PSA non–Prime Service Area

OMB Office of Management and Budget

PSA Prime Service Area

TMA TRICARE Management Activity

TRS TRICARE Reserve Select

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Page 1 GAO-13-364 TRICARE's Access to Care Surveys

United States Government Accountability Office

Washington, DC 20548

April 2, 2013

The Honorable Carl Levin

Chairman

The Honorable James Inhofe

Ranking Member

Committee on Armed Services

United States Senate

The Honorable Howard “Buck” McKeon

Chairman

The Honorable Adam Smith

Ranking Member

Committee on Armed Services

House of Representatives

In fiscal year 2012, the Department of Defense (DOD) offered health care 

services, including mental health care services, to about 9.7 million 

eligible beneficiaries in the United States and abroad through TRICARE, 

DOD’s regionally structured health care program.1 Under TRICARE, 

beneficiaries may 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 contractors3

 

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.

to develop networks of 

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

TRICARE beneficiaries in geographic areas called Prime Service Areas 

2

Through individual agreements between military treatment facilities and the Department 

of Veterans Affairs’ medical centers, eligible beneficiaries may also receive certain types 

of care from Department of Veterans Affairs’ medical centers in some locations.

3

TMA uses managed care support contractors in each of the three TRICARE regions 

(North, South, and West) to develop networks of civilian providers and to perform other 

customer-service functions, such as processing claims and assisting beneficiaries with 

finding providers.

 
 

Page 2 GAO-13-364 TRICARE's Access to Care Surveys

(PSA).4

The number and type of civilian providers available to serve TRICARE 

beneficiaries can vary depending on a beneficiary’s location and choice of 

coverage among TRICARE’s three basic plans—TRICARE Prime, 

TRICARE Standard, and TRICARE Extra.

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 PSAs, contractors are not required to develop 

networks in these areas (which we refer to as non-PSAs).

5 Beneficiaries who use 

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

through military treatment facilities or TRICARE’s civilian provider 

network. 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; they can choose to receive care 

through TRICARE Standard when they are seeing nonnetwork civilian 

providers and through TRICARE Extra when they are seeing network 

civilian providers.6 We use the term “nonenrolled beneficiaries” for 

beneficiaries who are not enrolled in TRICARE Prime and who use the 

TRICARE Standard or Extra options, or TRICARE Reserve Select 

(TRS).7

 

4

These geographic areas are determined by the Assistant Secretary of Defense for Health 

Affairs and are defined by a set of five-digit zip codes, usually within an approximate 

40-mile radius of a military treatment facility. In addition to developing networks of civilian 

providers in PSAs, the managed care support contracts also 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.

5

TRICARE offers several other plans, including TRICARE Reserve Select (TRS) for 

certain National Guard and Reserve servicemembers, and TRICARE Young Adult (Prime 

and Standard options) for servicemembers’ dependents up to age 26. TRICARE also 

offers TRICARE for Life to TRICARE beneficiaries who are eligible for Medicare and enroll 

in Part B. Under the TRICARE for Life program, TRICARE processes claims after they 

have been adjudicated by Medicare.

6

All beneficiaries may obtain care at military treatment facilities, although priority is given 

to active duty personnel and then to beneficiaries enrolled in TRICARE Prime.

7

We include TRS beneficiaries in our definition of nonenrolled beneficiaries because, 

although they must enroll in the plan, they can receive care from network or nonnetwork

providers similarly to TRICARE Standard and Extra beneficiaries. We did not include 

TRICARE Young Adult-Standard Option beneficiaries in our analysis because this plan did 

not become available until May 2011. 
 

Page 3 GAO-13-364 TRICARE's Access to Care Surveys

Since TRICARE’s inception in 1995, nonenrolled beneficiaries in some 

locations have complained about difficulties finding civilian providers who 

will accept them as patients. In response to these concerns, the National 

Defense Authorization Act (NDAA) for Fiscal Year 2004 directed DOD to 

monitor access to care for nonenrolled TRICARE beneficiaries through a 

survey of civilian providers.8 The act also directed GAO to review the 

processes, procedures, and analyses 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 TMA and contractor officials used various methods to evaluate 

access to care, including the survey of civilian providers, and according to 

those officials, their methods indicated that access was generally 

sufficient for nonenrolled beneficiaries.

9

Nonetheless, concerns about the ability of TRICARE beneficiaries, 

particularly nonenrolled beneficiaries, to access health care and mental 

health care continued. In light of these continued concerns about access 

to civilian providers, the NDAA for Fiscal Year 2008 (NDAA 2008) 

directed DOD to conduct annual surveys over 4 years of both 

beneficiaries and civilian providers to determine the adequacy of access 

to health care and mental health care providers for nonenrolled 

beneficiaries.10 It also directed GAO to review these surveys along with 

other factors such as DOD’s outreach, marketing, and education efforts, 

and provider reimbursement issues. We have issued several reports that 

address the topics covered in this mandate, including a March 2010 

report on the methodology and results of the first year of DOD’s 4-year 

beneficiary and provider surveys.11

 

8

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

46, at 330 (2003).

In our initial review of the surveys, we 

9

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).

10See Pub. L. No. 110-181, § 711(a), 122 Stat. 3, 190-91, and S. Rep. No. 110-77, at 359-

60 (2007).

11We have previously issued three reports that address the issues covered in this 

mandate. See GAO, Defense Health Care: DOD Lacks Assurance That Selected Reserve 

Members Are Informed about TRICARE Reserve Select, GAO-11-551 (Washington, D.C.: 

June 3, 2011); Defense Health Care: Access to Civilian Providers under TRICARE 

Standard and Extra, GAO-11-500 (Washington, D.C.: June 2, 2011); and Defense Health 

Care: 2008 Access to Care Surveys Indicate Some Problems, but Beneficiary Satisfaction 

Is Similar to Other Health Plans, GAO-10-402 (Washington, D.C.: Mar. 31, 2010). 
 

Page 4 GAO-13-364 TRICARE's Access to Care Surveys

reported that a higher percentage of nonenrolled beneficiaries in the 

surveyed PSAs experienced problems accessing care from civilian 

primary care providers than those in the surveyed non-PSAs. However, 

we could not reach any generalizable conclusions about the civilian 

provider survey because it had not generated sufficient survey responses 

during the first year. The NDAA for Fiscal Year 2012 extended DOD’s 

annual beneficiary and provider surveys for another 4 years, from fiscal 

years 2012 through 2015.12

This report addresses DOD’s beneficiary and civilian provider surveys for 

the first 4-year survey period, covering fiscal years 2008 through 2011. 

Specifically, it addresses (1) what the results of the 4-year beneficiary 

surveys indicate about the adequacy of access to care for nonenrolled 

beneficiaries, (2) what the results of the 4-year civilian provider surveys 

indicate about civilian providers’ awareness and acceptance of TRICARE, 

and (3) what the collective results of the 4-year beneficiary and civilian 

provider surveys indicate about access to care for nonenrolled 

beneficiaries by geographic area.

As of early January 2013, TMA had mailed 

the 2012 beneficiary and civilian provider survey instruments.

To determine what the results of the 4-year beneficiary surveys indicate 

about the adequacy of access to care for nonenrolled beneficiaries, we 

obtained and analyzed survey data on access to civilian primary,13

specialty,14 and mental health care15

 

12See Pub. L. No. 112-81, § 721(a), 125 Stat. 1298, 1479 (2011).

from TMA’s TRICARE Standard 

Surveys of Beneficiaries for 2008 through 2011. For the purposes of our 

analysis, we analyzed survey results for those nonenrolled beneficiaries 

who reported using TRICARE Standard, TRICARE Extra, or TRS the 

most in the last year. Because the overall response rate for the 4 years 

13We use the term “civilian primary care” to refer to instances where respondents 

indicated that their personal doctor or nurse was a civilian. 

14We use the term “civilian specialty care” to refer to instances where respondents 

indicated that they had seen a civilian specialist within the last year. 

15We use the term “civilian mental health care” to refer to instances where respondents 

indicated that they had received treatment or counseling for a personal or family problem 

from a civilian provider within the last year.
 

Page 5 GAO-13-364 TRICARE's Access to Care Surveys

was about 38 percent,16 we verified that TMA’s survey results were 

representative of the areas surveyed by reviewing TMA’s nonresponse 

analyses and interviewing TMA officials.17 We also obtained and analyzed 

the Department of Health and Human Services’ (HHS) Consumer 

Assessment of Healthcare Providers and Systems (CAHPS) survey data 

for the same 2008-2011 period in order to compare nonenrolled 

TRICARE beneficiaries’ satisfaction with their health care, health plan, 

and primary and specialty care providers to that of Medicare fee-forservice, Medicaid, and commercially insured beneficiaries.18

To determine what the results of the 4-year civilian provider surveys 

indicate about civilian providers’ awareness and acceptance of TRICARE, 

we obtained and analyzed the survey data from TMA’s TRICARE 

Standard Surveys of Providers for 2008 through 2011. Because the 

overall response rate was about 42 percent,

We 

assessed the reliability of these data by obtaining information from 

knowledgeable officials and reviewing related documentation, and we 

determined that TMA’s 4-year beneficiary survey data and HHS’s CAHPS 

data were sufficiently reliable for our purposes.

19

 

16For the 4 years of surveys, TMA mailed 176,841 surveys and received 66,590 returned 

surveys that were complete and eligible responses. Complete and eligible responses 

included those TRICARE beneficiaries who answered at least half of the TMA-identified 

“key” questions. 

we verified that TMA’s 

17A nonresponse 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. TMA concluded that the results of 

the beneficiary survey nonresponse analyses suggested that although there were some 

differences in the demographic profile, they were not associated with systematic 

differences in satisfaction with care. TMA officials also told us that the final postsurvey 

weights used in their analysis accounted for the key-characteristic differences in survey 

respondents compared with nonrespondents identified through the nonresponse analyses.

18HHS’s CAHPS survey is a national survey of beneficiaries of commercial health 

insurance, Medicare, Medicaid, and the Children’s Health Insurance Program. We limited 

our CAHPS analysis to Medicare fee-for-service, Medicaid, and commercial CAHPS 

surveys, and pooled the data for each from 2008 through 2011 in order to compare the 

results to TMA’s 4-year beneficiary surveys over the same period. We did not adjust the 

CAHPS survey data for factors that could affect the various beneficiary groups’ ratings, 

such as age or health status. 

19For the 4 years of surveys, TMA mailed 194,774 surveys and received 82,111 returned 

surveys that were complete. A survey was considered complete if the provider answered 

three TMA-identified “key” questions that asked about the providers’ location of practice 

and awareness and acceptance of TRICARE.
 

Page 6 GAO-13-364 TRICARE's Access to Care Surveys

civilian provider survey results were representative of the areas surveyed 

by reviewing TMA’s nonresponse analyses and interviewing TMA 

officials.20 We compared the civilian provider survey results to those of a 

national survey of physicians conducted in 2008 by the Center for 

Studying Health System Change to compare civilian providers’ 

acceptance of any new TRICARE patients to providers’ acceptance of 

any new Medicare (fee-for-service or managed care), Medicaid, and

commercially insured beneficiaries.21 We also compared the results of 

TMA’s 4-year civilian provider survey to those of TMA’s 2005-2007 

civilian physician survey to identify any changes in physicians’ awareness 

and acceptance over time.22

To determine what the results of the collective analysis of the 4-year 

beneficiary and civilian provider surveys indicate about access to care for 

nonenrolled beneficiaries, we compared the results of our analyses of the 

4-year beneficiary and provider survey data by specific geographic 

regions where possible, in order to identify areas with both high 

percentages of nonenrolled beneficiaries who experienced problems 

finding civilian providers and low percentages of civilian providers who 

were accepting new TRICARE patients. Specifically, we identified areas 

where the estimated percentage of nonenrolled beneficiaries that 

We assessed the reliability of these data by 

speaking with knowledgeable officials and reviewing related 

documentation, and we determined that these data were sufficiently 

reliable for our purposes.

 

20From the results of the civilian provider survey nonresponse analyses, TMA concluded 

that although there were some demographic and response differences between 

respondents and nonrespondents, the differences were not large or systematic. TMA 

officials also told us that the final postsurvey weights used in their analysis accounted for 

the key-characteristic differences in survey respondents compared with nonrespondents 

identified through the nonresponse analyses. 

21The Center for Studying Health System Change is a nonpartisan health policy research 

organization that conducts research and analysis focused on the U.S. health care system 

to inform the thinking and decisions of policymakers in government and private industry. 

The 2008 Health Tracking Physician Survey covered a wide variety of physician and 

practice dimensions, from basic physician demographic information, practice organization, 

and career satisfaction, to insurance acceptance, compensation arrangements, 

information-technology use, and charity care provision.

22TMA’s 2005-2007 civilian physician survey was sent to physicians only and did not 

include nonphysician mental health providers. Therefore, when comparing to TMA’s 2005-

2007 civilian physician survey, we show the results of TMA’s 2008-2011 civilian provider 

survey results for civilian physicians only, which consist of civilian primary care and 

specialty care physicians, including psychiatrists.
 

Page 7 GAO-13-364 TRICARE's Access to Care Surveys

experienced problems finding a civilian provider was either at or above 

the national estimate for nonenrolled beneficiaries, using the 95 percent 

confidence limits. For these geographic areas, we then looked at civilian 

provider acceptance of new TRICARE patients and identified areas where 

the percentage of civilian providers that were accepting any new 

TRICARE patients was at or below the national estimate, using the 

95 percent confidence limits.

Our analyses have some limitations. In our analyses of TMA’s beneficiary 

and provider surveys we report survey results for some individual areas, 

but we were unable to compare survey results among all of the individual 

geographic areas surveyed because of low numbers of respondents in 

some areas. Similarly, in our analysis of TMA’s beneficiary survey we 

were unable to identify specific geographic areas in which nonenrolled 

beneficiaries experienced problems finding mental health care providers 

because of the low numbers of respondents who indicated that they 

needed mental health care.

We conducted this performance audit from June 2012 through February 

2013 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.

Under TRICARE, beneficiaries have choices among various benefit 

options and may obtain care from either military treatment facilities or 

civilian providers. When nonenrolled beneficiaries receive care from 

civilian providers, they have the option of seeing either network or 

nonnetwork providers. The NDAA 2008 directed DOD to conduct surveys 

of beneficiaries and civilian providers to assess nonenrolled beneficiaries’ 

access to care.

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

enrollment requirements, choices in civilian and military treatment facility 

providers, and the amount beneficiaries must contribute toward the cost 

of their care. Table 1 provides a summary of some of these benefit 

options.

Background 

TRICARE’s Benefit 

Options 
 

Page 8 GAO-13-364 TRICARE's Access to Care Surveys

Table 1: Summary of TRICARE Options

TRICARE option Description

TRICARE Prime This managed care option requires enrollment, and all active duty servicemembers are 

required to use this option, while other TRICARE beneficiaries have a choice. TRICARE 

Prime enrollees receive most of their care from providers at military treatment facilities 

and also may receive care from network civilian providers. This option has the lowest outof-pocket costs for beneficiaries.

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 civilian providers 

(under TRICARE Extra). The TRICARE Standard option is designed to provide 

beneficiaries with maximum flexibility in selecting providers, but beneficiaries who obtain 

care from a network provider, through TRICARE Extra, pay lower copayments than they 

would under the TRICARE Standard option. TRICARE Standard and Extra beneficiaries 

also may receive care from military treatment facilities, though they have a lower priority 

for receiving care than do TRICARE Prime beneficiaries.

TRICARE Reserve Select (TRS) TRS is a premium-based health plan that certain National Guard and Reserve members 

may purchase.a

Source: GAO summary of DOD TRICARE documentation.

TRS beneficiaries may obtain health care from either nonnetwork or 

network providers, similarly to beneficiaries using TRICARE Standard or Extra, 

respectively, and will pay lower copayments for using network providers.

a

To be eligible for TRS, the beneficiary must be a member of the Selected Reserve of the Ready 

Reserve, and not eligible for or enrolled in the Federal Employees Health Benefits program, either 

under their own eligibility or through a family member who is enrolled in a family plan. 

Claims data from fiscal years 2008 to 2011 show that the percentages of 

the number of outpatient claims paid for TRICARE Prime and TRS have 

gradually increased, while the percentage of claims paid for TRICARE 

Standard has declined. (See fig. 1.) The percentage of claims paid for 

TRICARE Extra has remained steady over the same period.
 

Page 9 GAO-13-364 TRICARE's Access to Care Surveys

Figure 1: Percentage of Outpatient Claims Paid for TRICARE Prime, TRICARE 

Standard, TRICARE Extra, and TRICARE Reserve Select for Fiscal Years 2008 

through 2011

Notes: All percentages may not add up to 100 percent because of rounding. Claims were for 

outpatient services provided in an office or other setting outside of an institution. Claims for services 

rendered at hospitals, military treatment facilities, and other institutions were excluded. TRICARE for 

Life and TRICARE Young Adult claims were excluded, as well as claims for medical supplies and 

from chiropractors and pharmacies.

a

Percentages calculated on the basis of total number of outpatient claims: 23,995,179 claims in fiscal 

year 2008; 26,950,329 claims in fiscal year 2009; 29,857,355 claims in fiscal year 2010; and 

32,012,220 claims in fiscal year 2011.

Starting on September 30, 2013, the number of PSAs will be reduced, 

and as a result, the TRICARE Prime option will be available to fewer 

beneficiaries. The targeted PSAs are those that are not in close proximity 

to existing MTFs or BRAC locations and will predominantly affect retirees 

and their dependents. According to a TMA official, this change is 
 

Page 10 GAO-13-364 TRICARE's Access to Care Surveys

expected to affect about 171,000 retirees and dependents (37,000 in the 

North region, 36,000 in the West region, and 98,000 in the South region), 

with an estimated savings to DOD of $45 million to $56 million annually.23

In fiscal year 2011, TMA identified about 2 million nonenrolled 

beneficiaries (approximately one-fourth of the total eligible TRICARE 

population), who fell into three main categories: (1) retirees and their 

dependents or survivors, (2) active duty dependents, and (3) National 

Guard and Reserve servicemembers and their dependents.24

Figure 2: Types of Nonenrolled TRICARE Beneficiaries

(See fig. 2.)

Notes: Nonenrolled beneficiaries are beneficiaries not enrolled in TRICARE Prime who are eligible for 

TRICARE Standard or Extra, as well as TRICARE Reserve Select enrollees. Data are for nonenrolled 

beneficiaries as of December 31, 2010.

a

 

23TMA officials estimate that the shift from TRICARE Prime to TRICARE Standard will 

increase the out-of-pocket costs of a retiree family of three, for example, by about $700 

per year.

Other nonenrolled beneficiaries include family members of deceased servicemembers and 

secretarial designees.

24Although TMA can identify which beneficiaries have not enrolled, it does not have 

complete information on which beneficiaries intend to use their benefits.

Composition of TRICARE’s 

Nonenrolled Beneficiary 

Population 
 

Page 11 GAO-13-364 TRICARE's Access to Care Surveys

b

Limited to deactivated National Guard or Reserve servicemembers and their dependents. 

Dependents of activated National Guard or Reserve servicemembers are included in the “active duty 

dependents” category.

Most of these nonenrolled beneficiaries lived in PSAs—areas where 

TRICARE managed care support contractors have developed provider 

networks. (See fig. 3.)

Figure 3: Geographic Location of Nonenrolled TRICARE Beneficiaries

Note: Nonenrolled beneficiaries are beneficiaries not enrolled in TRICARE Prime who are eligible for 

TRICARE Standard or Extra, as well as TRICARE Reserve Select enrollees. Data are for nonenrolled 

beneficiaries as of December 31, 2010.

In order for network and nonnetwork civilian providers to be authorized to 

provide care and be reimbursed under TRICARE, they must meet the 

licensing and certification requirements of TRICARE regulations and 

practices for their area of health care. Individual TRICARE-authorized 

civilian providers can include health care providers, such as primary care 

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

including clinical psychologists. Table 2 provides a comparison of network 

and nonnetwork civilian providers.

TRICARE Network and 

Nonnetwork Civilian 

Providers
 

Page 12 GAO-13-364 TRICARE's Access to Care Surveys

Table 2: Comparison of TRICARE Network and Nonnetwork Civilian Providers

Network Civilian Providers: Nonnetwork Civilian Providers:

• Are TRICARE-authorized providers who enter contractual 

agreements with the TRICARE regional managed care 

support contractors in their areas to provide health care and 

mental health care to TRICARE beneficiaries.

• Are TRICARE-authorized providers who do not have 

contractual agreements with regional managed care support 

contractors to provide care to TRICARE beneficiaries.

• Have agreed to accept TRICARE reimbursement rates. By 

law, TRICARE maximum allowable reimbursement rates 

generally must mirror Medicare rates, but network providers 

may agree to accept lower reimbursements as a condition of 

network membership.

• May choose to accept the TRICARE reimbursement rate 

as payment in full for their services, or may charge up to 

15 percent more than the TRICARE reimbursement rate for 

their services on a case-by-case basis (with the difference 

paid by the beneficiary).

• 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.

• May accept TRICARE beneficiaries as patients on a case-bycase basis.

• Have agreed to meet TRICARE Management Activity’s 

access to care standards for TRICARE Prime enrollees. For 

example, these providers are required to offer urgent care 

appointments within 24 hours.

• Are not required to meet TRICARE’s access to care 

standards.

Source: GAO.

The NDAA 2008 directed DOD to conduct surveys of beneficiaries and 

civilian providers in at least 20 PSAs and 20 non-PSAs in each of 4 fiscal 

years, 2008 through 2011.25

 

25In designing the beneficiary and civilian provider surveys, DOD defined 80 distinct PSAs 

and 80 distinct non-PSAs (representing the entire country), and surveyed 20 of each in 

fiscal years 2008 through 2011. This allowed DOD to survey the entire country over a 

4-year period. At the end of the 4-year period, each year’s survey results were combined 

and weighted to develop estimates of access to health care and mental health care at 

individual service area, regional, and national levels.

Fig. 4 shows the 80 PSAs and 80 non-PSAs 

surveyed over the 4-year period of 2008 through 2011.

DOD’s Implementation of 

the NDAA 2008 Beneficiary 

and Civilian Provider 

Survey Requirements
 

Page 13 GAO-13-364 TRICARE's Access to Care Surveys

Figure 4: Prime Service Areas (PSA) and Non–Prime Service Areas (non-PSA) Surveyed for TRICARE Management Activity’s 

4-Year Beneficiary and Provider Surveys, 2008-2011

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—which TMA uses Hospital Service 

Areas (HSA) to define—and to survey health care and mental health care 
 

Page 14 GAO-13-364 TRICARE's Access to Care Surveys

providers in these areas.26 Fig. 5 shows the 71 HSAs identified as 

problem areas by providers and beneficiary groups.27

 

26TMA identified HSAs to include in its survey sampling locations on the basis of the 

recommendations of groups representing TRICARE beneficiaries and civilian providers, 

which identified specific cities and towns in which these groups were aware of 

beneficiaries having problems accessing civilian TRICARE providers. HSAs, as defined by 

a Dartmouth College study, 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, and have nonoverlapping borders and contain all 

U.S. zip codes without gaps in coverage. The HSAs surveyed in the beneficiary and 

civilian provider surveys are within the 80 PSAs or 80 non-PSAs surveyed.

(See app. I for 

TMA’s methodology in implementing the beneficiary and civilian provider 

surveys.)

27Of the 71 HSAs, all were included for the civilian provider survey, but only 55 HSAs 

were included for the beneficiary survey. According to TMA officials, the 16 HSAs that 

were included in the 2011 civilian provider survey were not included in the 2011 

beneficiary survey due to funding issues.
 

Page 15 GAO-13-364 TRICARE's Access to Care Surveys

Figure 5: Hospital Service Areas (HSA) Surveyed for TRICARE Management Activity’s (TMA) 4-Year Beneficiary and Provider 

Surveys, 2008-2011

Note: For the 4-year provider surveys, TMA surveyed a total of 71 HSAs from 2008 to 2011, shown 

above. Fifty-five of these 71 HSAs were also surveyed for the beneficiary survey from 2008 to 2010, 

but according to TMA officials, no HSAs were surveyed for the 2011 beneficiary survey because of 

funding issues.

The NDAA 2008 also required that specific types of information be 

requested in the surveys. For example, the beneficiary survey must 

include questions to determine whether nonenrolled beneficiaries have 

difficulties finding a provider who will accept TRICARE, and the civilian 

provider survey must include questions to determine whether civilian 

providers are aware of TRICARE. (See apps. II and III for the 2011 

beneficiary and civilian provider survey instruments, respectively.) Table 3 
 

Page 16 GAO-13-364 TRICARE's Access to Care Surveys

lists the NDAA 2008 requirements for DOD’s beneficiary and civilian 

provider surveys.

Table 3: Requirements for Annual Beneficiary and Provider Surveys Contained in the National Defense Authorization Act for 

Fiscal Year 2008 (NDAA 2008)

Requirement Requirement description

Survey goals 1. Determine the number of health care providers in TRICARE Prime Service Areas (PSA) that are 

accepting new patients under TRICARE Standard and Extra

2. Determine the number of health care providers in TRICARE non–Prime Service Areas (nonPSA) that are accepting patients under TRICARE Standard and Extra

3. Determine the availability of mental health care providers in TRICARE PSAs and TRICARE nonPSAs 

Survey area selection 4. Survey beneficiaries and providers in at least 20 TRICARE PSAs in each fiscal year to determine 

the availability of health care providers accepting new patients under TRICARE Standard and 

Extra

5. Survey beneficiaries and providers in 20 non-PSAs 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 TRICARE Standard and Extra

6. Survey beneficiaries and providers in at least 40 total PSAs and non-PSAs to determine the 

availability of mental health care providers

7. In prioritizing areas to be surveyed, give a high priority to surveying beneficiaries and providers 

located in geographic areas with high concentrations of members of the Selected Reserve

8. In prioritizing areas to be surveyed, consult with representatives of TRICARE beneficiaries and 

health care and mental health care providers to identify locations where nonenrolled 

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

Beneficiary survey content 9. 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

Provider survey content 10. 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

Benchmarks 11. Establish benchmarks to determine the adequacy of the availability of health care and mental 

health care providers to beneficiaries eligible for TRICARE

Source: GAO analysis of legislation.

Note: Data are based on review of the NDAA 2008 § 711(a).
 

Page 17 GAO-13-364 TRICARE's Access to Care Surveys

We previously reported that TMA generally addressed the requirements 

outlined in the NDAA 2008 during the implementation of its 2008 

beneficiary and provider surveys, but because of methodological 

considerations TMA used a different—but acceptable—approach for its 

selection of survey areas.28 We also found that TMA’s methodology for 

both of the surveys was consistent with the Office of Management and 

Budget (OMB) standards for statistical surveys that we reviewed. Since 

then, TMA has made several minor revisions to the surveys’ 

methodologies for 2009 through 2011, but none of these changes are 

inconsistent with the NDAA 2008 requirements.

 

28We previously reported that, 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 because it decided to randomly select the areas to 

be surveyed in order to produce results that could be generalized to the populations from 

which the survey samples were selected. Since TMA planned to survey the entire United 

States over the 4-year period, its 4-year survey results would include any locations with a 

higher concentration of Selected Reserve servicemembers. See GAO-10-402. 

Nearly One in Three 

Nonenrolled 

Beneficiaries 

Experienced 

Problems Accessing 

Care, and They Rated 

Their Satisfaction 

with Care Generally 

Lower than Medicare 

Fee-for-Service 

Beneficiaries 
 

Page 18 GAO-13-364 TRICARE's Access to Care Surveys

Overall, during 2008-2011, an estimated one in three nonenrolled 

beneficiaries (about 31 percent) experienced problems finding any type of 

civilian provider—primary, specialty, or mental health care provider—who 

would accept TRICARE. Specifically:

• an estimated 25 percent of nonenrolled beneficiaries experienced 

problems finding a civilian primary care provider;

• an estimated 25 percent of nonenrolled beneficiaries experienced 

problems finding a civilian specialty care provider; and

• an estimated 28 percent experienced problems accessing a civilian 

mental health care provider.29

Overall, access to civilian primary care and specialty care providers 

differed for nonenrolled beneficiaries located in PSAs compared to those 

in non-PSAs. Specifically, we found that more nonenrolled beneficiaries in 

PSAs experienced problems finding civilian primary care and specialty 

care providers compared to those in non-PSAs. (See fig. 6.) However, 

access to civilian mental health care providers did not differ for 

nonenrolled beneficiaries in PSAs and non-PSAs.

 

29The margins of error for the estimates of beneficiary problems finding civilian primary, 

specialty, and mental health care providers at the 95 percent confidence level are plus or 

minus 1, 1, and 3 percentage points, respectively. These estimates are not significantly 

different from each other at the 95 percent confidence level.

Nearly One in Three 

Nonenrolled Beneficiaries 

Experienced Problems 

Finding Civilian Providers 

Who Would Accept 

TRICARE; Those in PSAs 

Experienced More 

Problems Finding Primary 

and Specialty Care than 

Those in Non-PSAs 
 

Page 19 GAO-13-364 TRICARE's Access to Care Surveys

Figure 6: Estimated Percentages of Nonenrolled TRICARE Beneficiaries Who 

Experienced Access Problems, by Civilian Provider Type, in Prime Service Areas 

(PSA) and Non–Prime Service Areas (non-PSA), 2008-2011

Notes: Error bars display 95 percent confidence intervals for estimates.

a

Respondents answered “a big problem” or “a small problem” to the question that asked: 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.” 

b

Respondents answered “a big problem” or “a small problem” to the question that asked: “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.” 

c

Respondents answered “a big problem” or “a small problem” to the question that asked: 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.” 

d

Within provider type, the difference in estimates between PSAs and non-PSAs is significantly 

different at the 95 percent confidence level.
 

Page 20 GAO-13-364 TRICARE's Access to Care Surveys

TMA also surveyed beneficiaries in HSAs in response to access concerns 

about these specific areas. We found that more nonenrolled beneficiaries 

in HSAs experienced problems accessing civilian specialty care than 

those in the areas outside of the surveyed HSAs.30

 

30Each surveyed HSA was part of a PSA or non-PSA (depending on the location), and 

because HSAs were not mutually exclusive of the PSAs or non-PSAs, we did not compare 

the results from nonenrolled beneficiaries in HSAs to nonenrolled beneficiaries in PSAs or 

non-PSAs. Instead, we compared the results for the nonenrolled beneficiaries in the 

surveyed HSAs to those nonenrolled beneficiaries in the areas outside the surveyed 

HSAs. 

(See fig. 7.) However, 

there were no statistical differences in the estimated percentages of 

nonenrolled beneficiaries who experienced problems finding civilian 

primary or mental health care providers between the HSAs and the 

locations surveyed outside of these areas.
 

Page 21 GAO-13-364 TRICARE's Access to Care Surveys

Figure 7: Estimated Percentages of Nonenrolled TRICARE Beneficiaries Who 

Experienced Access Problems, by Civilian Provider Type, in Hospital Service Areas 

(HSA) and Prime Service Areas (PSA)/non-PSAs Outside of Surveyed HSAs, 2008-

2011

Notes: Error bars display 95 percent confidence intervals for estimates.

Each surveyed HSA was part of a PSA or non-PSA (depending on the location), and because HSAs 

were not mutually exclusive of the PSAs or non-PSAs, we did not compare the results from 

nonenrolled beneficiaries in HSAs to nonenrolled beneficiaries in PSAs or non-PSAs. Instead, we 

compared the results for the nonenrolled beneficiaries in the surveyed HSAs to those nonenrolled 

beneficiaries in the collective areas outside the surveyed HSAs.

a

Respondents answered “a big problem” or “a small problem” to the question that asked: 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.” 

b

Respondents answered “a big problem” or “a small problem” to the question that asked: 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.” 

c

Respondents answered “a big problem” or “a small problem” to the question that asked: 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.” 

d

The estimates of nonenrolled beneficiaries who experienced problems finding a civilian specialty 

care provider between HSAs and PSAs/non-PSAs outside of the surveyed HSAs are significantly 

different at the 95 percent confidence level.
 

Page 22 GAO-13-364 TRICARE's Access to Care Surveys

The top two reasons reported by nonenrolled beneficiaries—regardless of 

type of care—for why they believed they experienced problems accessing 

a provider included “doctors not accepting TRICARE payments” and 

“doctors not accepting new TRICARE patients.” (See fig. 8.)

Figure 8: Top Five Reasons Reported by Nonenrolled Beneficiaries Who 

Experienced Problems Accessing Civilian Primary, Specialty, or Mental Health 

Care, 2008-2011

Notes: Error bars display 95 percent confidence intervals for estimates.

Estimated percentages are out of the total estimated number of nonenrolled beneficiaries who 

experienced any problems accessing civilian primary, specialty, or mental health care providers.

Percentages across problem types do not add up to 100 percent because respondents were able to 

select more than one response, and only the top five responses for primary and specialty care are 

shown.

In addition to the responses above, the top five responses for mental health care included “Other,” 

with an estimated 21 percent of nonenrolled beneficiaries (plus or minus 5 percentage points) 

indicating “Other” as a reason for having problems finding a provider.
 

Page 23 GAO-13-364 TRICARE's Access to Care Surveys

Unless otherwise noted below, differences in estimates within each problem type are not significantly 

different at the 95 percent confidence level.

a

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

accept TRICARE?” 

b

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

TRICARE?” 

c

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

or counseling?” 

d

The difference in estimates between mental health care and other care types is statistically 

significant at the 95 percent confidence level.

e

The difference in estimates between primary care and other care types is statistically significant at 

the 95 percent confidence level.

Our analysis of the 4-year survey data showed that nonenrolled 

beneficiaries’ ratings for specific satisfaction measures were similar when 

compared between PSAs and non-PSAs, and between surveyed HSAs 

and the areas outside of the surveyed HSAs. Specifically, our analysis of 

beneficiaries’ ratings for four measures—satisfaction with primary care 

providers, specialty care providers, health care, and health plan—

indicated no substantial differences between area types.31 For example, 

we found that about 80 percent of nonenrolled beneficiaries in both PSAs 

and non-PSAs rated their primary care provider as an 8 or higher on a 

scale from 0 to 10.32

Additionally, we found that nonenrolled TRICARE beneficiaries’ 

satisfaction ratings for several of these measures were generally lower 

than those of Medicare fee-for-service beneficiaries and varied compared 

to Medicaid and commercially insured beneficiaries during the same 

 

31In our comparison across location types for all of the satisfaction measures in our 

analysis, there was one statistical difference at the 95 percent confidence level for 

nonenrolled beneficiaries’ 8-10 ratings of their health care in PSAs (about 79 percent) 

compared to those in non-PSAs (about 82 percent). Additionally, there was one statistical 

difference at the 95 percent confidence level for nonenrolled beneficiaries’ 8-10 ratings of 

their health plan in the surveyed HSAs (about 63 percent) compared to those in the areas 

outside of the surveyed HSAs (about 66 percent). However, for the purposes of our 

analyses, we determined that although these were statistical differences, they were not 

substantial differences.

32On the scale of 0 to 10, 0 is the worst possible and 10 is the best possible.

Nonenrolled Beneficiaries’ 

Satisfaction Did Not Differ 

across Types of Areas, but 

Was Generally Lower than 

That of Medicare Fee-forService Beneficiaries
 

Page 24 GAO-13-364 TRICARE's Access to Care Surveys

4-year period,33 according to HHS’s 2008-2011 CAHPS surveys.

34

 

33We divided the rating scale into two categories on the basis of the ratings scale used by 

TMA to analyze the satisfaction measures for TRICARE beneficiaries (0 to 7 and 8 to 10), 

where 0 is considered the worst possible and 10 is the best possible. The CAHPS 

commercial survey asks beneficiaries about their experiences over the last 12 months, 

whereas the Medicare and Medicaid surveys ask about the beneficiaries’ experiences 

over the last 6 months.

(See 

fig. 9.) For example, we found that fewer nonenrolled TRICARE 

beneficiaries rated their primary care provider, specialty care provider, 

and health plan as an 8 or higher compared to Medicare fee-for service 

beneficiaries.

34We found similar results in our analysis of the first year of TMA’s 2008-2011 survey data 

and 2008 CAHPS data for Medicare fee-for-service and commercially insured 

beneficiaries. Specifically, in March 2010, we reported that, although there were no 

statistically significant differences in the estimated ratings for nonenrolled TRICARE 

beneficiaries and other beneficiary types, the estimated ratings for nonenrolled 

beneficiaries in surveyed areas (using categories of 0-6 and 7-10) were slightly lower than 

estimated ratings of Medicare fee-for-service beneficiaries across three of the satisfaction 

measures—primary care provider, specialty care provider, and health plan. See 

GAO-10-402. 
 

Page 25 GAO-13-364 TRICARE's Access to Care Surveys

Figure 9: Nonenrolled TRICARE Beneficiaries’ Estimated Satisfaction Ratings Compared to Those of Commercially Insured, 

Medicaid, and Medicare Fee-For-Service Beneficiaries, 2008-2011

Note: All estimates between nonenrolled TRICARE beneficiaries and other beneficiary groups are 

significantly different at the 95 percent confidence level. We did not adjust the CAHPS survey data for 

factors that could affect the various beneficiary groups’ ratings, such as age or health status. 

a

TRICARE beneficiaries were asked “Using any number from 0 to 10, where 0 is the worst personal 

doctor or nurse possible, and 10 is the best personal doctor or nurse possible, what number would 

you use to rate your personal doctor or nurse?” Commercial, Medicare, and Medicaid beneficiaries 

were asked this question of their personal doctor only. Our analysis is limited to TRICARE 

nonenrolled beneficiaries who indicated that their personal doctor or nurse was a civilian.

b

TRICARE and commercial beneficiaries were asked “We want to know your rating of the specialist 

you saw most often in the last 12 months. Using any number from 0 to 10, where 0 is the worst 

specialist possible, and 10 is the best specialist possible, what number would you use to rate the 

specialist?” Medicare and Medicaid beneficiaries were asked the same question, but only in reference 

to the last 6 months. Our analysis is limited to TRICARE nonenrolled beneficiaries who indicated that 

they had seen a civilian specialist in the last 12 months.
 

Page 26 GAO-13-364 TRICARE's Access to Care Surveys

c

TRICARE and commercial beneficiaries were asked “Using any number from 0 to 10, where 0 is the 

worst health care possible, and 10 is the best health care possible, what number would you use to 

rate all your health care in the last 12 months?” Medicare and Medicaid beneficiaries were asked the 

same question, but only in reference to the last 6 months.

d

TRICARE, commercial, Medicare, and Medicaid beneficiaries were asked “Using any number from 0 

to 10, where 0 is the worst health plan possible, and 10 is the best health plan possible, what number 

would you use to rate your health plan?” 

Nationwide, an estimated 82 percent of civilian providers indicated they 

were aware of the TRICARE program, but only an estimated 58 percent 

were accepting new TRICARE patients, according to our analysis of the 

2008 through 2011 civilian provider survey results.35 When compared to a 

national provider survey, civilian providers’ acceptance of new TRICARE 

patients was less than providers’ acceptance of other types of 

beneficiaries. Specifically, a survey of physicians in 2008 by the Center 

for Studying Health System Change found that about 96 percent of 

physicians accepted new commercially insured beneficiaries, about 

86 percent accepted new Medicare beneficiaries, and about 72 percent 

accepted new Medicaid beneficiaries.36

According to the TRICARE survey results, when asked the reasons for 

not accepting new TRICARE patients, the most-cited category by those 

civilian providers who were not accepting any new TRICARE patients was 

that the provider “was not aware of the TRICARE program/not 

asked/don’t know about TRICARE.” (See fig. 10 for the top 7 categories 

of reasons for why civilian providers were not accepting new TRICARE 

patients.) Additionally, while nonenrolled beneficiaries cited that providers 

were not accepting TRICARE for payment as the top reason why any 

providers were unwilling to accept them as patients, the providers cited it 

as the third highest reason in addition to “don’t know/no answer.” 

 

35The margins of error for civilian providers’ awareness of TRICARE and acceptance of 

new TRICARE patients are both within plus or minus 1 percentage point at the 95 percent 

confidence level.

362008 HSC Health Tracking Physician Survey, Center for Studying Health System 

Change. The survey results were based on a 2008 national survey of 4,720 physicians. 

The margins of error for physicians’ acceptance of new commercially insured 

beneficiaries, new Medicare beneficiaries (fee-for-service and managed care 

beneficiaries), and new Medicaid beneficiaries are all plus or minus 1 percentage point at 

the 95 percent confidence level. The differences in estimates between civilian providers’ 

acceptance of new TRICARE patients and providers’ acceptance of new commercially 

insured, Medicare, and Medicaid beneficiaries are significant at the 95 percent confidence 

level.

Civilian Providers’ 

Acceptance of New 

TRICARE Patients 

Has Decreased over 

Time; Mental Health 

Providers Report 

Lower Awareness and 

Acceptance than 

Other Provider Types
 

Page 27 GAO-13-364 TRICARE's Access to Care Surveys

Figure 10: Top Seven Categories of Reasons for Not Accepting New TRICARE 

Patients Reported by Civilian Providers That Were Not Accepting Any New 

TRICARE Patients, 2008-2011

Notes: Error bars display 95 percent confidence intervals for estimates.

Estimated percentages are out of the total estimated number of civilian providers who were not 

accepting any new TRICARE patients.

Percentages across problem types do not add up to 100 percent because respondents were able to 

select more than one response, and only the top seven responses are shown.

a

For these two categories of reasons, the differences in estimates between them and the other 

categories of reasons, as well as between each other, are statistically significant at the 95 percent 

confidence level.

b

For these two categories of reasons, the differences in estimates between these categories of 

reasons and the others are statistically significant at the 95 percent confidence level. However, the 

differences between the two categories of reasons are not statistically significant at the 95 percent 

confidence level.

c

For the category “insurance image problems/issues with TRICARE in past,” the differences in 

estimates between this category of reasons and all others (except for “specialty not covered”) are 

statistically significant at the 95 percent confidence level.
 

Page 28 GAO-13-364 TRICARE's Access to Care Surveys

d

For the category “specialty not covered,” the differences in estimates between this category of 

reasons and the others (except for “insurance image problems/issues with TRICARE in past” and “not 

accepting patients”) are statistically significant at the 95 percent confidence level.

e

For the category “not accepting patients,” the differences in estimates between this category of 

reasons and all others (except for “specialty not covered”) are statistically significant at the 95 percent 

confidence level.

f

When we compared the results of TMA’s 2008-2011 civilian provider 

survey (excluding nonphysician mental health providers) to the results of 

its 2005-2007 civilian physician survey,

The “miscellaneous” category includes reasons such as “not a provider/signed provider,” and 

“working as locum tenens,” which means that the provider substitutes for the regular provider when 

that regular provider is absent.

37 we found that although civilian 

physicians’ awareness has increased over time, their acceptance of new 

TRICARE patients has decreased over time.38 This was also true whether 

they were accepting any new patients or new Medicare patients. For 

example, civilian physicians’ acceptance of any new TRICARE patients 

has decreased from about 76 percent in 2005-2007 to an estimated 

70 percent in 2008-2011.39

 

37TMA’s 2005-2007 civilian physician survey was sent to physicians only and did not 

include nonphysician mental health providers. Therefore, when comparing to TMA’s 2005-

2007 civilian physician survey, we show the results of TMA’s 2008-2011 civilian provider 

survey for civilian physicians only, which consist of civilian primary care and specialty care 

physicians, including psychiatrists.

(See fig. 11.)

38In accordance with the NDAA 2008, TMA identified benchmarks for analyzing the results 

of the beneficiary and provider surveys. To benchmark its provider survey, TMA compared 

the results of its 2008-2011 surveys with the results of its 2005, 2006, and 2007 physician 

surveys. A TMA official noted that TMA was unaware of any external benchmarks that 

would be applicable to its surveys of providers.

39The margins of error for civilian physicians’ acceptance of any new TRICARE patients 

from the 2008-2011 surveys and the 2005-2007 surveys are both within plus or minus 

1 percentage point at the 95 percent confidence level.
 

Page 29 GAO-13-364 TRICARE's Access to Care Surveys

Figure 11: Civilian Physicians’ Awareness and Acceptance of TRICARE over Time in TRICARE Management Activity’s (TMA) 

Surveys

Notes: Error bars display 95 percent confidence intervals for estimates.

A statistically significant difference exists between civilian physicians from the 2005-2007 surveys and 

those from the 2008-2011 surveys for each of the questions at the 95 percent confidence level.

Civilian physicians consist of civilian primary care and specialty care physicians, including 

psychiatrists.

a

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

care program?” 

b

Respondents answered “for all claims” or on a “claim-by-claim basis” to the following question: “As of 

today, is the provider accepting new TRICARE Standard patients?” 

c

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 providers’ indications that they were 

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

d

When analyzed further by provider type, we found that civilian primary 

and specialty care providers had higher awareness and acceptance of 

TRICARE than civilian mental health care providers. (See fig. 12.)

Specifically, only an estimated 39 percent of civilian mental health 

providers were accepting new TRICARE beneficiaries, compared to an 

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 providers’ indications that they 

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

Page 30 GAO-13-364 TRICARE's Access to Care Surveys

estimated 67 percent of civilian primary care providers and an estimated 

77 percent of civilian specialty care providers.40

Figure 12: Civilian Providers’ Awareness and Acceptance of TRICARE, by Type of Provider, 2008-2011

Notes: Error bars display 95 percent confidence intervals for estimates.

With the exception of primary care providers’ and specialty care providers’ awareness of the 

TRICARE program, a statistically significant difference exists between primary care providers, 

specialty care providers, and mental health care providers for each question at the 95 percent 

confidence level.

a

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

care program?” 

b

Respondents answered “for all claims” or on a “claim-by-claim basis” to the following question: “As of 

today, is the provider accepting new TRICARE Standard patients?” 

c

 

40The margins of error for civilian mental health care, primary care, and specialty care 

providers’ acceptance of new TRICARE patients were each within plus or minus 

1 percentage point at the 95 percent confidence level. For acceptance of new TRICARE 

beneficiaries, the differences in estimates between provider types are significant at the 

95 percent confidence level.

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 
 

Page 31 GAO-13-364 TRICARE's Access to Care Surveys

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.” 

d

The categories of reasons cited for not accepting new TRICARE patients 

also differed by provider type. For example, civilian mental health care 

providers more often cited “not aware of TRICARE/not asked/don’t know 

about TRICARE” than civilian primary or specialty care providers. 

Additionally, the top category of reasons cited by civilian primary care 

providers was that they were “not accepting patients” while the top 

category of reasons cited by specialty providers was “reimbursement.” 

(See fig. 13 for the top categories of reasons for civilian providers not 

accepting new TRICARE patients, by provider type.)

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 32 GAO-13-364 TRICARE's Access to Care Surveys

Figure 13: Top Categories of Reasons Reported by Civilian Providers for Not Accepting New TRICARE Patients, by Provider 

Type, 2008-2011

Notes: Error bars display 95 percent confidence intervals for estimates.

Estimated percentages are out of the estimated number of civilian primary care, specialty care, and 

mental health care providers who were not accepting any new TRICARE patients.

Percentages across problem types do not add up to 100 percent because respondents were able to 

select more than one response, and only the top seven responses are shown (ranked by the overall 

categories of reasons reported by all civilian providers, regardless of area).

Unless otherwise noted below, differences in estimates within each problem type are not significantly 

different at the 95 percent confidence level.

a

For the categories “not aware of TRICARE/not asked/don’t know about TRICARE,” “reimbursement,” 

and “insurance image problems/issues with TRICARE in past,” the differences in estimates between 

mental health care providers and other provider types are statistically significant at the 95 percent 

confidence level.

b

For the category “miscellaneous,” the difference in estimates between mental health care providers 

and primary care providers is statistically significant at the 95 percent confidence level.
 

Page 33 GAO-13-364 TRICARE's Access to Care Surveys

c

For the categories “specialty not covered,” and “not accepting patients,” the differences in estimates 

between primary care and other provider types are statistically significant at the 95 percent 

confidence level.

d

We also found that providers’ awareness and acceptance of TRICARE 

differed by type of area. Similar to TMA’s nonenrolled beneficiary survey, 

which showed that nonenrolled beneficiaries in PSAs generally 

experienced more problems finding providers than their counterparts in 

non-PSAs, our analysis of the 2008 through 2011 civilian provider survey 

indicated that civilian providers in PSAs were less aware of TRICARE and 

less accepting of new TRICARE patients than civilian providers in nonPSAs. Specifically, an estimated 81 percent of civilian providers in PSAs 

were aware of the TRICARE program, compared to an estimated 

87 percent of civilian providers in non-PSAs,

The “miscellaneous” category includes reasons such as “not a provider/signed provider,” and 

“working as locum tenens,” which means that the provider substitutes for the regular provider when 

that regular provider is absent.

41 and an estimated 

56 percent of civilian providers in PSAs were accepting any new 

TRICARE patients, compared to an estimated 66 percent of those 

providers in non-PSAs.42

 

41The margins of error for civilian providers’ awareness of TRICARE in PSAs and nonPSAs are both within plus or minus 1 percentage point at the 95 percent confidence level. 

The differences in estimates are significant at the 95 percent confidence level.

(See fig. 14.)

42The margins of error for civilian providers’ acceptance of new TRICARE patients in 

PSAs and non-PSAs are both within plus or minus 1 percentage point at the 95 percent 

confidence level. The differences in estimates are significant at the 95 percent confidence 

level.
 

Page 34 GAO-13-364 TRICARE's Access to Care Surveys

Figure 14: Civilian Providers’ Awareness and Acceptance of TRICARE in Prime Service Areas (PSA) and non–Prime Service 

Areas (non-PSA), 2008-2011

Notes: Error bars display 95 percent confidence intervals for estimates.

A statistically significant difference exists between civilian providers in PSAs and those in non-PSAs 

for each of the questions at the 95 percent confidence level.

a

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

care program?” 

b

Respondents answered “for all claims” or on a “claim-by-claim basis” to the following question: “As of 

today, is the provider accepting new TRICARE Standard patients?” 

c

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 providers’ indications that they were 

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

d

Civilian providers in HSAs were more frequently aware of TRICARE and 

accepting of new TRICARE beneficiaries than civilian providers in the 

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 providers’ indications that they 

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

Page 35 GAO-13-364 TRICARE's Access to Care Surveys

PSAs and non-PSAs outside of these HSAs.43

Figure 15: Civilian Providers’ Awareness and Acceptance of TRICARE, by Hospital Service Areas (HSA) and Prime Service 

Areas/non–Prime Service Areas (PSA/non-PSA) outside of the Surveyed HSAs, 2008-2011

(See fig. 15.) These HSAs

represented locations that were identified by beneficiary and provider 

groups to TMA as potentially having access problems.

Notes: Error bars display 95 percent confidence intervals for estimates.

Each HSA is part of a PSA or non-PSA (depending on the location); and because HSAs are not 

mutually exclusive of the PSAs or non-PSAs, we did not compare the results from nonenrolled 

beneficiaries in HSAs to nonenrolled beneficiaries in PSAs or non-PSAs. We compared the results for 

the nonenrolled beneficiaries in the surveyed HSAs to those nonenrolled beneficiaries in the areas 

outside of HSAs.

The difference in estimates between HSAs and PSAs/non-PSAs outside of surveyed HSAs for each 

question is statistically significant at the 95 percent confidence level.

a

 

43Each HSA is part of a PSA or non-PSA (depending on the location), and because HSAs 

are not mutually exclusive of the PSAs or non-PSAs, we did not compare the results from 

civilian providers in HSAs to civilian providers in PSAs or non-PSAs. Instead, we 

compared the results for the civilian providers in the surveyed HSAs to those civilian 

providers in the areas outside of HSAs.

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

care program?” 
 

Page 36 GAO-13-364 TRICARE's Access to Care Surveys

b

Respondents answered “for all claims” or on a “claim-by-claim basis” to the following question: “As of 

today, is the provider accepting new TRICARE Standard patients?” 

c

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.” 

d

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.” 

An analysis of the collective results of the multiyear beneficiary and 

civilian provider surveys indicated particular geographic areas where 

nonenrolled beneficiaries are experiencing considerable access 

problems. These locations are defined as areas where (1) the percentage 

of nonenrolled beneficiaries who experienced difficulties finding a civilian 

provider was at least the national estimate and (2) the percentage of 

civilian providers who were accepting any new TRICARE patients was at 

or below the national estimate.44 Using these criteria, we identified a 

number of areas where beneficiaries were having access problems, 

mostly in Texas.45

In determining areas where nonenrolled beneficiaries were experiencing 

access problems to any type of civilian provider, we first identified 

24 individual areas (out of the 215 individual areas surveyed by the 2008-

2011 beneficiary surveys)

(See app. IV for detailed information about these areas 

and how they were determined.)

46

 

44We used the individual area’s estimate and margin of error at the 95 percent confidence 

level to determine whether it was above or below the national estimates. Specifically, for 

nonenrolled beneficiary problems, we used the lower confidence limit of the estimate: If 

the individual area’s lower confidence limit was equal to or greater than the national 

estimate, then we included it as an area. Additionally, for civilian providers’ acceptance of 

TRICARE, we used the upper confidence limit of the estimate: If the upper limit of the 

estimate was equal to or less than the national estimate, then we included it as an area.

where the estimated percentage of 

45A particular geographic area’s exclusion from the lists of problem areas below does not 

necessarily indicate that nonenrolled beneficiaries were not experiencing access problems 

in that area. Because we took a conservative methodological approach and used the 

margins of error at the 95 percent confidence limit to determine whether a geographic 

area met our criteria of a problem area, there may be other areas where nonenrolled 

beneficiaries are experiencing access problems.

46For the 2008-2011 beneficiary survey, 80 PSAs, 80 non-PSAs, and 55 HSAs were 

surveyed. Because the beneficiary survey did not include the 16 HSAs selected to be 

surveyed in 2011, they are not included in this analysis. However, the 2011 civilian 

provider survey did include these 16 HSAs. See app. V to see a list of these 16 HSAs and 

civilian providers’ acceptance of any new TRICARE patients in these areas.

Collective Results of 

TMA’s Beneficiary and 

Civilian Provider 

Surveys Indicate 

Specific Geographic 

Areas Where 

Nonenrolled 

Beneficiaries Have 

Experienced Access 

Problems 
 

Page 37 GAO-13-364 TRICARE's Access to Care Surveys

nonenrolled beneficiaries who experienced difficulties finding any type of 

civilian provider met or exceeded the national estimate (31 percent). Of 

these, we identified 2 PSAs where the estimated percentage of civilian 

providers who were accepting any new TRICARE patients was at or 

below the national estimate (58 percent)—Central/Southern-Central 

Coastal California and Northeastern Texas. Additionally, we identified 

2 HSAs that also met these criteria, one of which is contained within the 

Northeastern Texas PSA. Table 4 shows each of these areas with the 

estimated percentage of (1) nonenrolled beneficiaries who experienced 

problems finding any type of civilian provider and (2) civilian providers 

who were accepting any new TRICARE patients.

Table 4: Areas Where the Percentage of Nonenrolled Beneficiaries Who Experienced Problems Finding a Civilian Provider 

Was at Least the National Estimate and Where the Percentage of Civilian Providers Who Were Accepting Any New TRICARE 

Patients Was at or below the National Estimate, 2008-2011

Area name

Estimated percentage of beneficiaries with 

a problem finding any type of civilian 

provider (margin of error)

Estimated percentage of civilian 

providers accepting new TRICARE 

patients (margin of error) a

Prime Service Areas (PSA)

b

1. Central/Southern-Central Coastal California 48 (12) 45 (8)

2. Northeastern Texas 47 (10) 53 (6)

Hospital Service Areas (HSA)

1. Austin, Texas 58 (18) 46 (6) c

2. Dallas/Ft. Worth, Texas 48 (14) d 50 (6)

Source: GAO analysis of TMA data.

Notes: The margin of error is at the 95 percent confidence level. Areas were considered only if they 

had at least 30 respondents for the beneficiary survey and at least 50 respondents for the civilian 

provider survey.

Areas in this table had an estimated 31 percent or more of nonenrolled beneficiaries who were having 

difficulties finding any type of civilian provider who will accept TRICARE (the national estimate, or 

greater) and equal to or less than an estimated 58 percent of civilian providers who were accepting 

new TRICARE patients (the national estimate or less). Both determinations were made using the 

estimates’ margins of error at the 95 percent confidence level.

Estimated percentages and margins of error have been rounded to the nearest whole number.

a

Estimated percentage is based on the number of nonenrolled beneficiaries who responded “a big 

problem” or “a small problem” to any one of the following three questions: (1) “In the last 12 months, 

how much of a problem was it to find a personal doctor or nurse who would accept TRICARE?”; 

(2) “In the last 12 months, how much of a problem was it to find a doctor with this specialty who would 

accept TRICARE?”; or (3) “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?” We also limited nonenrolled 

beneficiary responses to those who indicated their provider was a civilian provider.

b

Estimated percentage is based on the number of civilian providers who answered “for all claims” or a 

“claim-by-claim basis” to the question that asked “As of today, is the provider accepting new 

TRICARE Standard patients?” 

c

This estimate has a relative margin of error of 30 percent or greater.

d

The Dallas/Ft. Worth, Texas, HSA is part of the Northeastern Texas PSA.
 

Page 38 GAO-13-364 TRICARE's Access to Care Surveys

For the overlapping PSA and HSA (Northeastern Texas and Dallas/Fort 

Worth), we found that although a high percentage of civilian providers 

were accepting new patients (between 95 and 97 percent), only about 

half of these providers were accepting any new TRICARE patients. (See 

table 5.) For the remaining PSA (Central/Southern-Central California) and 

HSA (Austin, Texas), between 92 and 98 percent of civilian providers 

were accepting new patients, and less than half of those providers were 

accepting any new TRICARE patients. Further, of the civilian providers in 

all of these areas who were accepting new Medicare patients, between 

65 and 70 percent were also accepting any new TRICARE patients. 

Reimbursement was the most cited reason for providers not accepting 

new TRICARE patients for all of the areas except the PSA in California 

for which “not aware of the TRICARE program” was the most cited 

reason.

Table 5: Civilian Providers’ Estimated Percentage of Acceptance of New Patients and New TRICARE Patients, by Problem 

Area, 2008-2011

Area name

Estimated percentage 

of civilian providers 

accepting any new 

TRICARE patients 

(margin of error)

Estimated percentage 

of civilian providers 

accepting any 

new patients 

(margin of error) a

Estimated percentage 

of civilian providers 

accepting any new 

TRICARE patients, if

accepting any

new patients 

(margin of error)

Estimated percentage 

of civilian providers 

accepting any new 

TRICARE patients, if 

accepting new 

Medicare patients 

(margin of error) b

Prime Service Areas (PSA)

c

1. Central/Southern-Central 

Coastal California

45 (8) 92 (5) 48 (8) 66 (10)

2. Northeastern Texas 53 (6) 97 (2) 55 (6) 70 (7)

Hospital Service Areas (HSA)

1. Austin, Texas 46 (6) 98 (2) 47 (6) 65 (8)

2. Dallas/Ft. Worth, Texas 50 (6) d 95 (3) 53 (6) 70 (7)

Source: GAO analysis of TMA data.

Notes: The margin of error is at the 95 percent confidence level. Areas were considered only if they 

had at least 30 respondents for the beneficiary survey and at least 50 respondents for the civilian 

provider survey.

Areas in this table had an estimated 31 percent or more of nonenrolled beneficiaries who were having 

difficulties finding any type of civilian provider who will accept TRICARE (the national estimate, or 

greater) and equal to or less than an estimated 58 percent of civilian providers who were accepting 

new TRICARE patients (the national estimate or less). Both determinations were made using the 

estimates’ margins of error at the 95 percent confidence level.

Estimated percentages and margins of error have been rounded to the nearest whole number.

Each surveyed HSA was part of a PSA or non-PSA (depending on the location).

a

Estimated percentage is based on the number of civilian providers who answered “for all claims” or a 

“claim-by-claim basis” to the question that asked “As of today, is the provider accepting new 

TRICARE Standard patients?” 
 

Page 39 GAO-13-364 TRICARE's Access to Care Surveys

b

Estimated percentage is based on the number of civilian providers who 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.” 

c

Estimated percentage is based on the number of civilian providers who 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.” 

d

When analyzing this data by type of provider (primary care, specialty, and 

mental health), we found four areas where the percentage of civilian 

primary care providers who were accepting any new TRICARE patients 

was at or below the national estimate, but did not find similarly lowpercentage areas for civilian specialty care providers. Because of the low 

numbers of survey responses, we are unable to report survey results for 

access problems to civilian mental health care providers.

The Dallas/Ft. Worth, Texas, HSA is part of the Northeastern Texas PSA.

In determining areas where nonenrolled beneficiaries experienced access 

problems to civilian primary care providers, we first identified 21 individual 

areas where the estimated percentage of nonenrolled beneficiaries who 

experienced difficulties finding a civilian primary care provider met or 

exceeded the national estimate (25 percent). Of these, we identified 

2 PSAs where the estimated percentage of civilian primary care providers 

who were accepting any new TRICARE patients was at or below the 

national estimate (67 percent)—Northeastern Texas and Eastern-Central 

Texas. We also identified 2 HSAs that met these criteria, each of which 

was contained in one of the PSAs we identified. Table 6 shows each of 

these areas with the estimated percentage of (1) nonenrolled 

beneficiaries who experienced problems finding a civilian primary care 

provider and (2) civilian primary care providers who were accepting any 

new TRICARE patients.

Civilian Primary Care 

Providers
 

Page 40 GAO-13-364 TRICARE's Access to Care Surveys

Table 6: Areas Where the Percentage of Nonenrolled Beneficiaries Who Experienced Problems Finding a Civilian Primary 

Care Provider Was at Least the National Estimate and Where the Percentage of Civilian Primary Care Providers Who Were 

Accepting Any New TRICARE Patients Was at or below the National Estimate, 2008-2011

Area name

Estimated percent of beneficiaries 

with a problem finding a civilian primary 

care provider (margin of error)

Estimated percent of civilian 

primary care providers accepting new 

TRICARE patients (margin of error) a

Prime Service Areas (PSA)

b

1. Northeastern Texas 40 (10) 48 (10)

2. Eastern-Central Texas 38 (12) 53 (10) c

Hospital Service Areas (HSA)

1. Austin, Texas 56 (18) d 42 (11) c

2. Dallas/Ft. Worth, Texas 40 (14) e 51 (12) c

Source: GAO analysis of TMA data.

Notes: The margin of error is at the 95 percent confidence level. Areas were considered only if they 

had at least 30 respondents for the beneficiary survey and at least 50 respondents for the civilian 

provider survey.

Areas in this table had an estimated 25 percent or more of nonenrolled beneficiaries who were having 

difficulties finding a civilian primary care provider who will accept TRICARE (the national estimate, or 

greater) and equal to or less than an estimated 67 percent of civilian primary care providers who were 

accepting new TRICARE patients (the national estimate or less). Both determinations were made 

using the estimates’ margins of error at the 95 percent confidence level.

Estimated percentages and margins of error have been rounded to the nearest whole number.

a

Estimated percentage is based on the number of beneficiaries who responded that they used 

TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select the most in the last 12 months, 

and of those, the number who responded “a big problem” or “a small problem” to the question that 

asked “In the last 12 months, how much of a problem was it to find a personal doctor or nurse who 

would accept TRICARE?” We also limited nonenrolled beneficiary responses to those who indicated 

their provider was a civilian provider.

b

Estimated percentage is based on the number of civilian primary care providers who answered “for 

all claims” or a “claim-by-claim basis” to the question that asked “As of today, is the provider 

accepting new TRICARE Standard patients?” 

c

These estimates have relative margins of errors that are 30 percent or greater.

d

The Austin, Texas, HSA is part of the Eastern-Central Texas PSA.

e

As we similarly found in the areas where nonenrolled beneficiaries were 

having access problems for any type of civilian provider, we found that 

between 94 and 97 percent of civilian primary care providers in the 

Northeastern Texas PSA/Dallas/Ft. Worth HSA and the Eastern-Central 

Texas PSA/Austin, Texas, HSA were accepting new patients, but only 

around half of them were accepting new TRICARE patients.

The Dallas/Ft. Worth, Texas, HSA is part of the Northeastern Texas PSA.

47

 

47Austin, Texas, HSA is part of the Eastern-Central Texas PSA, and the Dallas/Ft. Worth, 

Texas, HSA is part of the Northeastern Texas PSA.

(See 
 

Page 41 GAO-13-364 TRICARE's Access to Care Surveys

table 7.) Further, of the civilian primary care providers in the two PSAs 

who were accepting new Medicare patients, between 59 and 68 percent 

were accepting any new TRICARE patients.48

Table 7: Civilian Primary Care Providers’ Estimated Percentage of Acceptance of New Patients and New TRICARE Patients, 

by Problem Area, 2008-2011

Reimbursement was the 

most cited reason by civilian primary care providers for not accepting any 

new TRICARE patients in each of these areas except for the Dallas/Ft. 

Worth, Texas, HSA, for which “don’t know/no answer” was the most cited

reason.

Area name

Estimated percentage 

of civilian primary 

care providers 

accepting any new 

TRICARE patients

(margin of error)

Estimated percentage 

of civilian primary care 

providers accepting 

any new patients 

(margin of error) a

Estimated percentage of 

civilian primary care 

providers accepting 

any new TRICARE 

patients, if accepting 

any new patients 

(margin of error)

Estimated percentage of 

civilian primary care 

providers accepting any 

new TRICARE patients, 

if accepting new 

Medicare patients 

(margin of error) b

Prime Service Areas (PSA)

c

1. Northeastern Texas 48 (10) 95 (5) 51 (11) 59 (13)

2. Eastern-Central Texas 53 (10) 96 (4) 55 (10) 68 (15)

Hospital Service Areas (HSA)

1. Austin, Texas 42 (11) d 97 (4) 43 (11) ─

2. Dallas/Ft. Worth, Texas

e

51 (12) f 94 (6) 54 (12) ─

Source: GAO analysis of TMA data.

e

Notes: The margin of error is at the 95 percent confidence level. Areas were considered only if they 

had at least 30 respondents for the beneficiary survey and at least 50 respondents for the civilian 

provider survey.

Areas in this table had an estimated 25 percent or more of nonenrolled beneficiaries who were having 

difficulties finding any type of civilian provider who will accept TRICARE (the national estimate, or 

greater) and equal to or less than an estimated 67 percent of civilian providers who were accepting 

new TRICARE patients (the national estimate or less). Both determinations were made using the 

estimates’ margins of error at the 95 percent confidence level.

Estimated percentages and margins of error have been rounded to the nearest whole number.

a

Estimated percentage is based on the number of civilian primary care providers who answered “for 

all claims” or a “claim-by-claim basis” to the question that asked “As of today, is the provider 

accepting new TRICARE Standard patients?” 

b

 

48We do not present the estimates for the percentage of civilian primary care providers in 

the two HSAs that were accepting any new TRICARE patients, if they were accepting new 

Medicare patients, because the number of responses was below 50.

Estimated percentage is based on the number of civilian primary care providers who 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 
 

Page 42 GAO-13-364 TRICARE's Access to Care Surveys

question represents the providers’ indication that they were accepting new TRICARE Standard 

patients on either a “claim-by-claim basis” or “for all claims.” 

c

Estimated percentage is based on the number of civilian primary care providers who 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.” 

d

The Austin, Texas, HSA is part of the Eastern-Central Texas PSA.

e

Because the number of responses was below 50, we do not present the estimates and margins of 

error for these locations.

f

The Dallas/Ft. Worth, Texas, HSA is part of the Northeastern Texas PSA.

In determining areas where nonenrolled beneficiaries are experiencing 

access problems to civilian specialty care providers, we first identified 

nine individual areas where the estimated percentage of nonenrolled 

beneficiaries who experienced difficulties finding a civilian specialty care 

provider met or exceeded the national estimate (25 percent). Unlike the 

collective results for “any civilian provider” and “civilian primary care 

providers,” when we examined civilian specialty care providers’ 

responses for these areas, we did not identify any geographic areas 

where the estimated percentage of civilian specialty care providers who 

were accepting any new TRICARE patients was at or below the national 

estimate (77 percent) when accounting for the margins of error at the 

95 percent confidence limit. For the nine areas where the estimated 

percentage of beneficiaries who experienced difficulties finding a civilian 

specialty care provider met or exceeded the national estimate, the 

percentage of civilian specialty care providers who were accepting new 

TRICARE patients ranged from 75 to 86 percent.49

Because of the low numbers of survey responses for beneficiaries who 

said they needed civilian mental health care, we are unable to report 

correlated survey results for access problems to civilian mental health 

 

49One of the nine areas, the Alaska non-PSA, had less than 50 civilian specialty care 

provider respondents to the question that asked about acceptance of any new TRICARE 

patients. Therefore, its estimate is not included in this range.

Civilian Specialty Care 

Providers

Civilian Mental Health 

Care Providers
 

Page 43 GAO-13-364 TRICARE's Access to Care Surveys

care providers.50 However, given the nationwide shortage of certain types 

of mental health providers and the survey results that only 39 percent of 

civilian mental health care providers were accepting new TRICARE 

patients, access to mental health care providers is a concern for all 

TRICARE beneficiaries, including those who use the TRICARE Standard 

and Extra options.

In reviewing a draft of this report, DOD concurred with our overall findings 

and provided technical comments, which we incorporated where 

appropriate. (See app. VI.)

We are sending copies of this report to the Secretary of Defense and 

appropriate congressional committees. The report is also available at no 

charge on GAO’s website at http://www.gao.gov. 

If you or your staff members have any questions about this report, please 

contact me at (202) 512-7114 or draperd@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff members who made key 

contributions to this report are listed in appendix VII.

Debra A. Draper

Director, Health Care

 

50In order for nonenrolled beneficiaries to respond to the question that asked “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?,” they needed to have answered “yes” to the question 

that asked “in the last 12 months, did you need any treatment or counseling for a personal 

or family problem?” Additionally, nonenrolled beneficiaries had to have responded that 

their mental health care provider was a civilian provider.

Agency Comments 

and Our Evaluation
Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary and 

Civilian Provider Surveys

Page 44 GAO-13-364 TRICARE's Access to Care Surveys

The National Defense Authorization Act for Fiscal Year 2008 (NDAA 

2008) directed the Department of Defense (DOD) to determine the 

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

that currently accept nonenrolled beneficiaries as patients under 

TRICARE, DOD’s health care program. We use the term “nonenrolled 

beneficiaries” for beneficiaries who are not enrolled in TRICARE Prime 

and who use the TRICARE Standard or Extra options, or TRICARE 

Reserve Select (TRS).1 The NDAA 2008 also included specific 

requirements related to the number and priority of areas to be surveyed, 

including the populations to be surveyed each year, content for each type 

of survey, and the use of benchmarks. Within DOD, the TRICARE 

Management Activity (TMA), which oversees the TRICARE program, has 

the lead responsibility for designing and implementing the nonenrolled 

beneficiary and civilian provider surveys. The following information 

describes TMA’s methodology, including its actions to address the 

requirements for each of the following: (1) survey area, (2) sample 

selection, (3) survey content, and (4) the establishment of benchmarks.

The NDAA 2008 specified that DOD survey beneficiaries and providers in 

at least 20 TRICARE Prime Service Areas (PSA),2

 

1

TRICARE Prime is 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. We included TRS beneficiaries in our definition of nonenrolled 

beneficiaries because, although they must enroll in the plan, they can receive care from 

nonnetwork or network providers similar to TRICARE Standard and Extra beneficiaries. 

We did not include TRICARE Young Adult-Standard Option beneficiaries in our analysis 

because this plan did not become available until May 2011. 

and 20 geographic 

areas in which TRICARE Prime is not offered—referred to as non–Prime 

Service Areas (non-PSA)—each fiscal year, 2008 through 2011. The 

NDAA 2008 also required DOD to consult with representatives of 

TRICARE beneficiaries and health care and mental health care providers 

to identify locations where nonenrolled beneficiaries have experienced 

significant access-to-care problems, and give a high priority to surveying 

health care and mental health care providers in these areas. Additionally, 

2

PSAs are geographic areas determined by the Assistant Secretary of Defense (Health 

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

40 mile radius of a military 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.

Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary

and Civilian Provider Surveys

Survey Area Selection
Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary and 

Civilian Provider Surveys

Page 45 GAO-13-364 TRICARE's Access to Care Surveys

the NDAA 2008 required DOD to give a high priority to surveying areas in 

which a high concentration of Selected Reserve servicemembers live.

In designing the 2008 through 2011 nonenrolled beneficiary and civilian 

provider surveys, TMA defined 80 PSAs and 80 non-PSAs that allowed it 

to survey the entire country over a 4-year period, and subsequently 

develop estimates of access to health care and mental health care at 

service area and national levels. TMA identified the 80 PSAs by collecting 

zip codes where TRICARE Prime was offered from officials within each of 

the three TRICARE Regional Offices. TMA grouped these zip codes into 

80 nonoverlapping areas so that each area had roughly the same number 

of TRICARE-eligible beneficiaries. Because non-PSAs had not previously 

been defined, TMA sought to define them by grouping all zip codes not in 

PSAs into one large area using Hospital Referral Regions,3 which are 

groupings of Hospital Service Areas (HSA).4

To identify locations where nonenrolled beneficiaries and health care and 

mental health care providers have identified significant levels of accessto-care problems under TRICARE Standard and Extra, TMA spoke with 

groups representing beneficiaries and health care and mental health care 

providers, as well as officials at the TRICARE Regional Offices. These 

groups suggested cities and towns where access should be measured (in 

addition to the larger PSAs and non-PSAs), and HSAs corresponding to 

TMA divided the large area 

into 80 non-PSAs so that each area had roughly the same number of 

TRICARE-eligible beneficiaries.

 

3

The Hospital Referral Region designation is derived from a Dartmouth College study that 

groups HSAs into distinct sets by documenting where patients were referred for major 

cardiovascular surgical procedures and for neurosurgery. Each HSA was examined to 

determine where most of its residents went for these services. The result was the 

aggregation of the more than 3,000 HSAs 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 all 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, 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).

4

HSAs 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. HSAs have nonoverlapping borders and contain all U.S. zip codes without gaps 

in coverage.
Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary and 

Civilian Provider Surveys

Page 46 GAO-13-364 TRICARE's Access to Care Surveys

each city and town were then identified. On the basis of the groups’ 

recommendations, multiple lists were created and sorted in priority order: 

21 HSAs were surveyed in the 2008 surveys;5 9 HSAs in the 2009 

surveys; 25 HSAs in the 2010 surveys; and 16 HSAs in the 2011 civilian 

provider survey. This resulted in a total of 55 HSAs surveyed for the 

nonenrolled beneficiary survey, and 71 HSAs surveyed in the civilian 

provider survey (the 71 HSAs includes the same 55 HSAs surveyed for 

the nonenrolled beneficiary survey and an additional 16 that were 

selected for the 2011 fielding).6 Although the NDAA 2008 required DOD 

to give a high priority to surveying areas in which a high concentration of 

Selected Reserve servicemembers live, TMA officials decided to 

randomly select areas for the surveys in order to produce results that 

could be generalized to the populations in the areas surveyed and to 

survey the entire United States over the 4-year period—an approach we 

deemed acceptable in our previous report.7

 

5

Because of timing issues, the 21 HSAs were not identified in time to be included with 

the 2008 fielding of the nonenrolled beneficiary survey. Therefore, TMA surveyed these 

21 HSAs in the 2009 fielding of the nonenrolled beneficiary survey, along with the 9 HSAs 

scheduled to be surveyed during the 2009 fielding. Although the 21 HSAs were not 

actually surveyed during the 2008 fielding, TMA included them when it presented the 

results of the 2008 nonenrolled beneficiary survey. The civilian provider survey was not 

affected by these issues.

6

Of the 71 HSAs, all were included for the civilian provider survey, but only 55 HSAs were 

included for the beneficiary survey. According to TMA officials, the 16 HSAs that were 

included in the 2011 civilian provider survey were not included in the 2011 beneficiary 

survey because of funding issues.

7

See GAO, Defense Health Care: 2008 Access to Care Surveys Indicate Some Problems, 

but Beneficiary Satisfaction Is Similar to Other Health Plans, GAO-10-402 (Washington, 

D.C.: Mar. 31, 2010). 
Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary and 

Civilian Provider Surveys

Page 47 GAO-13-364 TRICARE's Access to Care Surveys

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),8

1. eligible for military health care benefits as of the date of the sample 

file extract;

a database of DOD beneficiaries who may 

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

eligibility to be included in the nonenrolled beneficiary survey if DEERS 

indicated that the individual met five criteria:

2. age 18 years old or older;

3. not an active duty member of the military;

4. residing in one of the 20 randomly selected PSAs or 20 randomly 

selected non-PSAs to be surveyed that year; and

5. not enrolled in TRICARE Prime, or is enrolled in TRS.9

From this database, TMA randomly sampled 1,000 beneficiaries from 

each PSA and non-PSA—a sample size that would achieve TMA’s 

desired sample error rate.10 For the 2008, 2009, and 2010 survey 

fieldings, TMA used a sample size between approximately 40,000 and 

50,000 beneficiaries. Because of budgetary constraints, the sample size 

of the 2011 nonenrolled beneficiary survey was decreased to around 

34,000.11

 

8

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 an individual’s 

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

DEERS on dependents, and for reporting changes concerning dependents.

Because of this reduction, the 2011 sample was further 

9

TMA’s sample included retirees not enrolled in Medicare, dependents of active duty 

personnel, and beneficiaries enrolled in TRS in fiscal year 2008.

10TMA desired a sample error of plus or minus 5 percent at the 95 percent confidence 

level.

11This reduction was achieved by eliminating the HSAs from the 2011 nonenrolled 

beneficiary survey area selection.

Survey Sample 

Selection 

Nonenrolled Beneficiary 

Survey Sample Selection
Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary and 

Civilian Provider Surveys

Page 48 GAO-13-364 TRICARE's Access to Care Surveys

stratified by using claims data to identify beneficiaries who would likely 

self-report as TRICARE Standard and Extra users.12

Table 8: Number of Beneficiary Surveys Mailed, Returned, and Complete and Eligible, by Fiscal Year

After receiving the 

returned surveys, TMA identified the responses that it considered 

complete and eligible on the basis of whether the beneficiary had 

answered at least half of TMA’s identified “key” questions. Table 8 shows 

the number of nonenrolled beneficiary surveys mailed, by fiscal year. 

Fiscal year

Final count mailing 

attributed to this year

Complete and eligible 

surveys returned

Complete and eligible responses 

from nonenrolled beneficiaries who 

used TRICARE Standard, Extra or 

TRICARE Reserve Select a

2008

b

51,568 20,431 6,936

2009 40,996 16,767 5,690

2010 46,063 16,793 6,027

2011 38,214 12,599 5,397

Total 176,841 66,590 24,050

Source: TMA.

a

TRICARE Management Activity (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.

b

Complete and eligible responses from a nonenrolled beneficiary that used TRICARE Standard, 

Extra, or TRICARE Reserve Select are those that were complete and eligible, and the respondent 

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

For each survey fielding, TMA selected the civilian provider sample within 

the same 20 PSAs and 20 non-PSAs that had been randomly selected for 

that year’s nonenrolled beneficiary survey, as well as civilian providers in 

the HSAs identified by beneficiary and provider groups as having 

significant levels of access-to-care problems under TRICARE Standard 

and Extra. TMA used the American Medical Association Physician 

Masterfile to select a sample of physicians who were licensed, officebased civilian medical doctors or licensed civilian doctors of osteopathy 

within the specified locations who were engaged in more than 20 hours of 

patient care each week. The American Medical Association Physician 

 

12According to a TMA official, using TRICARE claims data would help to increase the 

proportion of TRICARE users to those that used other health insurance.

Civilian Provider Survey 

Sample Selection
Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary and 

Civilian Provider Surveys

Page 49 GAO-13-364 TRICARE's Access to Care Surveys

Masterfile is a database of physicians in the U.S.—Doctors of Medicine 

and Doctors of Osteopathic Medicine—that includes data on all 

physicians who have the necessary educational and credentialing 

requirements. This “Masterfile” did not differentiate between TRICARE’s 

network and nonnetwork civilian providers, which TMA deemed 

acceptable to avoid any potential bias in TMA’s sample selection. As 

such, TMA selected this file because it is widely recognized as one of the 

best commercially available lists of providers in the United States and 

contained more than 940,000 physicians along with their addresses, 

phone numbers, and information on practice characteristics, such as their 

specialty.13

For its 2008 and 2009 mental health care provider sample selection, TMA 

selected a sample of mental health care providers from two sources: the 

American Medical Association’s Masterfile of psychiatrists, and LISTS, 

Inc.—a list of names with contact information assembled from state 

licensing boards. For the 2010 and 2011 mental health care provider 

sample selections, TMA also used mental health specialty areas from the 

National Plan and Provider Enumeration System database maintained by 

the Centers for Medicare & Medicaid Services, in addition to data from 

LISTS, Inc., and the psychiatrist data from the American Medical 

Association’s Masterfile. According to TMA, it selected these sources for 

mental health care providers because they have been identified as the 

most comprehensive databases for these health care providers.

According to TMA, the American Medical Association updates 

physicians’ addresses monthly and other elements through a rotating 

census methodology involving approximately one-third of the physician 

population each year. Although the Masterfile is considered to contain

most providers, deficiencies in coverage and inaccuracies in detail 

remain. Therefore, TMA attempted to update providers’ addresses and 

phone numbers and ensure that providers were eligible for the survey by 

also using state licensing databases, local commercial lists, and 

professional society and association lists.

From these data sets, TMA planned to randomly sample about 

800 providers (400 each of physicians and mental health care providers) 

from each PSA, non-PSA, and HSA—a sample size that would achieve 

TMA’s desired sample error rate.14

 

13TMA did not include all physician specialist types, such as epidemiologists and 

pathologists, in its survey. 

In those instances where there were 

14TMA desired a sample error of plus or minus 5 percent at a 95 percent confidence level.
Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary and 

Civilian Provider Surveys

Page 50 GAO-13-364 TRICARE's Access to Care Surveys

not 800 providers in a single area, TMA selected all of the providers in 

that area to receive surveys. As the PSA and non-PSA regions were 

formed on the basis of the number of beneficiaries and not the number of 

civilian providers, some regions with a large number of civilian providers 

were sampled at relatively low rates in 2008, 2009, and 2010. To improve 

the precision of national estimates, in 2011 TMA selected six areas to 

oversample: (1) Southeastern N.Y. and Northern N.J. (New York City); 

(2) Los Angeles, Calif.; (3) Eastern Mass. (Boston); (4) Northeastern/

Central Ohio (Cleveland); (5) Southeastern/Northern Mich. (Detroit); and 

(6) Northwestern/Northeastern/Central-Eastern Ill. and Southwestern 

Wisc. (Chicago). Therefore, in 2011, a supplemental sample of 4,800 

providers was drawn for these 6 PSAs, thereby increasing the numbers of 

eligible providers in each area:

• 1,600 providers from the two 2008 PSAs (Los Angeles, California, and 

Southeastern New York/Northern New Jersey);

• 800 providers from the one 2009 PSA (Eastern Massachusetts); and

• 2,400 providers from the three 2010 PSAs (Northeastern/Central 

Ohio, Southeastern/Northern Michigan, and 

Northwestern/Northeastern/Central-Eastern Illinois/Southeastern 

Wisconsin). 

Upon receipt of the returned surveys, TMA identified the responses that it 

considered complete and eligible based on the following criteria for 

respondents: (1) if the provider answered “yes” to the questions that 

asked whether the provider offers care in an office-based location or 

private practice; (2) for the nonphysician mental health survey, if the 

provider responded he or she was one of the six TRICARE participating 

specialties: certified clinical social worker, certified psychiatric nurse 

specialist, clinical psychologist, certified marriage and family therapist, 

pastoral counselor, or mental health counselor; and (3) the provider had 

to have completed three key questions on the physician survey 

instrument, or three key questions on the nonphysician mental health 

provider survey instrument. Table 9 shows the number of civilian provider 

surveys mailed, by fiscal year.
Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary and 

Civilian Provider Surveys

Page 51 GAO-13-364 TRICARE's Access to Care Surveys

Table 9: Number of Civilian Physician and Nonphysician Mental Health Provider Surveys Mailed, Returned, and Complete and 

Eligible, by Fiscal Year

Final count mailing 

attributed to this year

Completed surveys 

returned

Complete and eligible 

responses a

2008 total

b

40,589 18,557 11,358

Physician 20,193 9,123 7,628

Nonphysician mental health 20,396 9,434 3,730

2009 total 52,234 20,726 14,017

Physician 23,031 9,243 8,036

Nonphysician mental health 29,203 11,483 5,981

2010 total 51,358 22,564 14,822

Physician 25.095 11,278 9,183

Nonphysician mental health 26,263 11,286 5,639

2011 total (supplement total) 50,593 (4,800) b 20,264 (1,649) 13,156 (1,052)

Physician 24,498 (2,400) c 10,279 (829) 8,266 (657)

Nonphysician mental health 26,095 (2,400) c 9,985 (820) 4,890 (395)

Overall total 194,774 82,111 55,019

Source: GAO analysis of TMA data.

a

TRICARE Management Activity (TMA) considered a survey complete if the provider completed three 

key questions on the physician survey instrument, or three key questions on the non-physician mental 

health provider survey instrument that asked about the providers’ location of practice and awareness 

and acceptance of TRICARE.

b

TMA considered a survey complete and eligible if: (1) the provider completed three key questions on 

the physician survey instrument, or three key questions on the non-physician mental health provider 

survey instrument; (2) the provider answered “yes” to the questions that asked whether the provider 

offers care in an office-based location or private practice; and (3) for the non-physician mental health 

survey, if the provider responded they were 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.

c

As the Prime Service Area and non–Prime Service Area regions were formed based on the number 

of beneficiaries and not the number of civilian providers, some regions with a large number of civilian 

providers were sampled at relatively low rates in 2008, 2009, and 2010. To improve the precision of 

national estimates, TMA selected six regions to oversample in 2011. These numbers are not included 

in the 2008, 2009, and 2010 counts.
Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary and 

Civilian Provider Surveys

Page 52 GAO-13-364 TRICARE's Access to Care Surveys

The NDAA 2008 required that the beneficiary survey include questions to 

determine whether TRICARE Standard and Extra beneficiaries have had 

difficulties finding physicians and mental health care providers willing to 

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

2008 nonenrolled beneficiary survey included 91 questions that 

addressed, among other things, health care plans used; perceived access 

to care from a personal doctor, nurse, or specialist; the need for treatment 

or counseling; and ratings of health plans. TMA based some of its 2008 

nonenrolled beneficiary survey questions on those included in the 

Department of Health and Human Services’ Consumer Assessment of 

Healthcare Providers and Systems (CAHPS), a national survey of 

beneficiaries of commercial health insurance, Medicare, Medicaid, and 

the Children’s Health Insurance Program. Over the 4 years of the 

nonenrolled beneficiary survey fielding, TMA added three additional 

questions to the original 91 questions in the 2008 nonenrolled beneficiary 

survey that covered topics about the beneficiaries’ flu-shot history, and 

what they liked and disliked about TRICARE Standard and Extra. 

Additionally, in 2011, “TRICARE Young Adult” and “TRICARE Retired 

Reserve” were added to the response selections for the question that 

asked about the health plan the beneficiary used. (See app. II for a copy 

of the 2011 beneficiary survey instrument.)

When TMA began mailing the beneficiary survey, it included a combined 

cover letter and a questionnaire to all beneficiaries in its sample—with the 

option of having beneficiaries complete the survey by mail or Internet. 

The cover letter provided information on the options available for 

completing the survey, as well as instructions for completing the survey 

by Internet. If the beneficiary did not respond to the mailed questionnaire, 

TMA mailed a second combined cover letter and questionnaire 4 weeks 

later encouraging the beneficiary to complete the survey.

For the civilian provider survey, the NDAA 2008 required questions to 

determine: (1) whether the provider is aware of TRICARE; (2) the 

percentage of the provider’s current patient population that uses any form 

of TRICARE; (3) whether the provider accepts Medicare patients for 

health care and mental health care; and (4) if the provider accepts 

Beneficiary and 

Provider Survey 

Content 

Nonenrolled Beneficiary 

Survey Content

Civilian Provider Survey 

Content 
Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary and 

Civilian Provider Surveys

Page 53 GAO-13-364 TRICARE's Access to Care Surveys

Medicare patients, whether the provider would accept new Medicare 

patients. TMA obtained clearance for its provider survey from the Office of 

Management and Budget (OMB) as required under the Paperwork 

Reduction Act.15

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.

Subsequent to this review, OMB approved an 11-item 

questionnaire for physicians (including psychiatrists) and a 12-item 

questionnaire for nonphysician mental health providers. The mental 

health care providers’ version of the survey includes an additional 

question about what type of mental health care the provider practiced. 

Beginning with the 2009 civilian provider survey, an additional follow-up 

question was added that asked the provider what type of practice they 

practiced in if the provider indicated that they were not in private practice. 

Although a civilian provider’s indication that the provider was not in 

private practice still made the provider’s responses ineligible for the 

survey, the additional information from these nonprivate practice civilian 

providers could be used by TMA to glean additional information about 

civilian providers. (See app. III for a copy of the 2011 civilian provider 

survey instruments.)

In accordance with the NDAA 2008, TMA identified benchmarks for 

analyzing the results of the beneficiary and civilian provider surveys.

Because TMA based some of its 2008 beneficiary survey questions on 

those included in the CAHPS surveys, it was able to compare the results 

of those questions with its 2008 through 2011 beneficiary survey results.

To benchmark its provider survey, TMA compared the results of its 2008 

through 2011 surveys with the results of its 2005, 2006, and 2007 

 

15The 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.

Survey Benchmarks
Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary and 

Civilian Provider Surveys

Page 54 GAO-13-364 TRICARE's Access to Care Surveys

provider surveys. A TMA official noted that TMA was unaware of any 

external benchmarks that would be applicable to its surveys of providers.

In analyzing the results of the nonenrolled beneficiary survey, TMA 

representatives conducted yearly nonresponse analyses because the 

overall response rate for the surveys was around 38 percent.16

 

16OMB’s guidance suggests that if response rates are below 80 percent, agencies 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.

To 

conduct this analysis for the 2008, 2009, and 2010 survey years, TMA did 

the following: (1) compared key beneficiary demographic characteristics 

of respondents to those of nonrespondents (e.g., beneficiary gender and 

age) and (2) interviewed a sample of beneficiaries who did not respond to 

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

responses with the original survey respondents. Because of budgetary 

constraints during the 2011 survey year, TMA only compared key 

beneficiary demographic characteristics of respondents to those of the 

nonrespondents. The results of TMA’s nonresponse analyses indicated 

that respondents to the nonenrolled beneficiary survey differed 

substantially from the surveyed population in some demographic 

characteristics. For example, the analyses indicated that retirees, 

dependents of retirees, and dependents of survivors were 

overrepresented in the study, and dependents of active duty

servicemembers, dependents of Guard/Reserve personnel, and 

dependents of inactive guard personnel were underrepresented in the 

study. Additionally, in each of the years in which TMA representatives 

conducted follow-up interviews (2008-2010), they found some response 

differences between survey respondents. For example, each year in 

follow-up interviews of nonrespondents, they found these beneficiaries 

rated their primary care provider and health plans more favorably than 

beneficiaries who responded to the survey. According to TMA 

representatives, they used a weighting scheme to reflect the survey 

Analyses of Survey 

Results 

Analysis of Nonenrolled 

Beneficiary Survey Results
Appendix I: TRICARE Management Activity’s 

Methodology for the 2008-2011 Beneficiary and 

Civilian Provider Surveys

Page 55 GAO-13-364 TRICARE's Access to Care Surveys

population proportions to correct any bias as a result of survey 

nonresponse.

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

nonresponse analysis because the overall response rate to the surveys 

was about 42 percent. To conduct this analysis for the 2008, 2009, and 

2010 surveys, TMA did the following: (1) compared key provider 

demographic characteristics of respondents to those of nonrespondents 

(for example, provider type and area) and (2) interviewed a sample of 

physicians and mental health care providers who did not respond to the 

survey, follow-up second mailing, or follow-up telephone calls and 

compared their responses with the survey respondents. Because of 

budgetary constraints during the 2011 survey year, TMA only compared 

key provider demographic characteristics of respondents to those of the 

nonrespondents. The results of TMA’s nonresponse analyses indicated 

that there are some demographic differences between respondents and 

those who did not respond. For example, the analyses indicated that in 

some years psychiatrists were underrepresented in the survey samples. 

Overall, however, the results were consistent among the nonresponse 

analyses and indicated little variation between respondents and 

nonrespondents. As TMA used in the weighting scheme for the 

nonenrolled beneficiary survey, TMA used a weighting scheme to reflect 

the survey population proportions to correct any bias as a result of survey 

nonresponse.

Analysis of Civilian 

Provider Survey Results
Appendix II: Beneficiary Survey Instrument

Page 56 GAO-13-364 TRICARE's Access to Care Surveys

The National Defense Authorization Act for Fiscal Year 2008 (NDAA 

2008) directed the Department of Defense (DOD) to determine the 

number of health care and mental health care providers that currently 

accept nonenrolled beneficiaries as patients under TRICARE, DOD’s 

health care program. For the purpose of this report, we use the term 

“nonenrolled beneficiaries” for beneficiaries who are not enrolled in 

TRICARE Prime and who use the TRICARE Standard or Extra options, or 

TRICARE Reserve Select (TRS).1

For the 2008 fielding of the beneficiary survey, 91 questions were 

included in the survey instrument. Over the next 3 years of the beneficiary 

survey’s fielding, TRICARE Management Activity (TMA) used the same 

91 questions and added these additional questions:

Specifically, the NDAA 2008 specified 

that DOD conduct surveys of beneficiaries each fiscal year, 2008 through 

2011. The NDAA 2008 also required that the beneficiary survey include 

questions seeking information from nonenrolled beneficiaries to 

determine whether they have had difficulties finding health care and 

mental health care providers willing to accept them as patients.

• For the 2009 survey fielding and beyond, TMA added Question #81, 

which asked “When did you last have a flu shot?” for a total of 92 

questions in 2009;

• For the 2010 survey fielding and beyond, TMA added two questions 

(Questions #75 and #76) that asked what the beneficiary liked and 

disliked about TRICARE Standard and Extra, respectively, for a total 

of 94 questions in 2010 and 2011.

In addition, for the 2011 survey instrument, “TRICARE Young Adult” and 

“TRICARE Retired Reserve” were added to the response selections for 

Question #2, which asked “By which health plan are you currently 

covered?” 

Following is the actual survey instrument from the 2011 fielding that TMA 

used to obtain information from nonenrolled beneficiaries.

 

1

We include TRS beneficiaries in our definition of nonenrolled beneficiaries because, 

although they must enroll in the plan, they can receive care from network or nonnetwork 

providers similarly to TRICARE Standard and Extra beneficiaries. We did not include 

TRICARE Young Adult-Standard Option beneficiaries in our analysis because this plan did 

not become available until May 2011. 

Appendix II: Beneficiary Survey Instrument
Appendix II: Beneficiary Survey Instrument

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Appendix II: Beneficiary Survey Instrument

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Appendix II: Beneficiary Survey Instrument

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Appendix II: Beneficiary Survey Instrument

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Appendix II: Beneficiary Survey Instrument

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Appendix II: Beneficiary Survey Instrument

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Appendix II: Beneficiary Survey Instrument

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Appendix II: Beneficiary Survey Instrument

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Appendix II: Beneficiary Survey Instrument

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Appendix II: Beneficiary Survey Instrument

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Appendix II: Beneficiary Survey Instrument

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Appendix II: Beneficiary Survey Instrument

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Appendix II: Beneficiary Survey Instrument

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Appendix III: Survey Instruments for Civilian 

Physicians and Nonphysician Mental Health 

Care Providers

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The National Defense Authorization Act for Fiscal Year 2008 (NDAA 

2008) directed the Department of Defense (DOD) to determine the 

number of health care and mental health care providers that currently 

accept nonenrolled beneficiaries as patients under TRICARE, DOD’s 

health care program. For the purpose of this report, we use the term 

“nonenrolled beneficiaries” for beneficiaries who are not enrolled in 

TRICARE Prime and who use the TRICARE Standard or Extra options, or 

TRICARE Reserve Select (TRS).1 Specifically, NDAA 2008 directed DOD 

to survey providers each fiscal year, 2008 through 2011. The NDAA 2008 

also required that the provider survey include questions seeking 

information to determine (1) whether the provider is aware of the 

TRICARE program, (2) the percentage of the provider’s current patient 

population that uses any form of TRICARE, (3) whether the provider 

accepts Medicare patients, and (4) if the provider accepts Medicare 

patients, whether the provider would accept new Medicare patients. DOD 

implemented two versions of its provider survey, one for physicians, 

including psychiatrists, and one for nonphysician mental health 

providers.2

For the 2008 fielding of the civilian provider survey, 11 and 12 questions 

were included in the physician and nonphysician mental health provider 

survey instruments, respectively. Over the next 3 years of the civilian 

provider survey’s fielding, TRICARE Management Activity (TMA) 

generally used the same questions, but made the following adjustments 

to the survey instruments:

• Beginning with the 2009 fielding of both survey instruments and 

beyond, TMA adjusted Question #1 which asked the provider whether 

they provided health care to patients in an office-based practice (for 

physicians) or a private practice (for nonphysician mental health care 

providers) so that a “no” response would no longer instruct the 

provider to stop answering the survey at that point. Instead, the 

 

1

We include TRS beneficiaries in our definition of nonenrolled beneficiaries because, 

although they must enroll in the plan, they can receive care from network or nonnetwork 

providers similarly to TRICARE Standard and Extra beneficiaries. We did not include 

TRICARE Young Adult-Standard Option beneficiaries in our analysis because this plan did 

not become available until May 2011.

2

Nonphysician mental health providers include: (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.

Appendix III: Survey Instruments for Civilian 

Physicians and Nonphysician Mental Health 

Care Providers
Appendix III: Survey Instruments for Civilian 

Physicians and Nonphysician Mental Health 

Care Providers

Page 71 GAO-13-364 TRICARE's Access to Care Surveys

revision directed the provider to the newly added Question #1a that 

asked the provider what type of practice they were in (if they 

answered “no” to Question #1).

• For the 2010 and 2011 fieldings of the physician survey instrument, 

TMA also adjusted Question #1 from “Does [the provider] provide 

treatment to patients through an office-based practice?” to “Does [the 

provider] provide treatment to patients through private practice?” 

Following are the actual survey instruments from the 2011 fielding that 

TMA used to obtain information from physicians and nonphysician mental 

health care providers.
Appendix III: Survey Instruments for Civilian 

Physicians and Nonphysician Mental Health 

Care Providers

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Appendix III: Survey Instruments for Civilian 

Physicians and Nonphysician Mental Health 

Care Providers

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Appendix III: Survey Instruments for Civilian 

Physicians and Nonphysician Mental Health 

Care Providers

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Appendix III: Survey Instruments for Civilian 

Physicians and Nonphysician Mental Health 

Care Providers

Page 75 GAO-13-364 TRICARE's Access to Care Surveys
Appendix IV: Areas Where Nonenrolled 

Beneficiaries Had Problems Accessing Civilian 

Providers, 2008-2011

Page 76 GAO-13-364 TRICARE's Access to Care Surveys

The 2008-2011 beneficiary survey indicated individual areas where 

nonenrolled beneficiaries experienced problems finding “any civilian 

provider,” civilian primary care providers, and civilian specialty care 

providers.1 We define these locations as areas where the percentage of 

nonenrolled beneficiaries who experienced difficulties finding a civilian 

provider was at the national estimate or higher.

We identified 24 individual areas (out of the 215 individual areas surveyed 

by the 2008-2011 beneficiary surveys)2 where the percentage of 

nonenrolled beneficiaries who experienced problems finding any type of 

provider who would accept TRICARE met or exceeded the national 

estimate.3 We then identified 49 additional areas where the percentage of 

nonenrolled beneficiaries who experienced these problems was less than 

the national estimate.4 The remaining 130 areas had estimates that 

ranged from 18 to 50 percent, but because of their confidence intervals, 

were neither above nor below the 31 percent threshold.5

 

1

“Any civilian provider” means the nonenrolled beneficiary had problems finding a civilian 

primary, specialty, or mental health care provider who would accept TRICARE patients.

Figure 16 shows 

the geographic distribution of these three categories of areas.

2

For the beneficiary survey, 80 Prime Service Areas (PSA), 80 non–Prime Service Areas 

(non-PSA), and 55 Hospital Service Areas (HSA) were surveyed. Because the beneficiary 

survey did not include the 16 HSAs selected to be surveyed in 2011, we cannot include 

them in this analysis. However, the 2011 civilian provider survey did include these 

16 HSAs. See app. V to see a list of these 16 HSAs and civilian providers’ acceptance of 

any new TRICARE patients in these areas.

3

An estimated 31 percent of nonenrolled beneficiaries experienced problems finding any 

civilian provider nationally (i.e., a civilian primary, specialty, or mental health care 

provider). To determine whether an area had at least 31 percent of nonenrolled 

beneficiaries who experienced problems finding any type of civilian provider who would 

accept TRICARE, we used the margins of error at the 95 percent confidence level to 

determine the lower limit of the estimate. If the lower limit was 31 percent or above, then 

we included it as an area.

4

To determine whether an area had less than 31 percent of nonenrolled beneficiaries who 

experienced problems finding any type of civilian provider who would accept TRICARE, 

we used the margins of error at the 95 percent confidence level to determine the upper 

limit of the estimate. If the upper limit was below 31 percent, then we included it as an 

area.

5

Twelve areas (all HSAs) were not included because they had less than 30 respondents.

Appendix IV: Areas Where Nonenrolled 

Beneficiaries Had Problems Accessing

Civilian Providers, 2008-2011

Problems Finding Any 

Provider 
Appendix IV: Areas Where Nonenrolled 

Beneficiaries Had Problems Accessing Civilian 

Providers, 2008-2011

Page 77 GAO-13-364 TRICARE's Access to Care Surveys

Figure 16: Estimated Percentage of Nonenrolled Beneficiaries Who Experienced Problems Finding a Civilian Primary, 

Specialty, or Mental Health Care Provider, 2008-2011

Notes: Nationwide, an estimated 31 percent of nonenrolled beneficiaries experienced problems 

finding any civilian provider (i.e., a civilian primary, specialty, or mental health care provider).

We used the lower 95 percent confidence limit to identify areas for which 31 percent or more of 

nonenrolled beneficiaries experienced problems finding any civilian provider. We used the upper 

95 percent confidence limit to identify areas for which fewer than 31 percent of nonenrolled 

beneficiaries experienced problems. Areas depicted in white indicate areas that did not fall into either 

of the above categories due to their 95 percent confidence interval.

We excluded areas from our analysis with fewer than 30 respondents combined for the three survey 

questions that asked if beneficiaries had problems finding a personal doctor or nurse, specialist, or 

treatment and counseling within the last 12 months.
Appendix IV: Areas Where Nonenrolled 

Beneficiaries Had Problems Accessing Civilian 

Providers, 2008-2011

Page 78 GAO-13-364 TRICARE's Access to Care Surveys

TRICARE Management Activity did not identify additional Hospital Service Areas to survey for its 

2011 beneficiary survey.

Table 10 lists the 24 individual areas where at least 31 percent of 

nonenrolled beneficiaries experienced problems finding any type of 

provider who would accept TRICARE patients, and the area’s 

corresponding estimated percentage of civilian providers who would 

accept new TRICARE patients.

Table 10: Prime Service Areas (PSA), Non–Prime Service Areas (non-PSA), and Hospital Service Areas (HSA) with 31 Percent 

or More of Nonenrolled Beneficiaries Experiencing Problems Finding Any Type of Provider, and the Willingness of Civilian 

Providers in the Corresponding Areas to Accept New TRICARE Patients, 2008-2011

Area Area type

Estimated percentage of 

beneficiaries with a problem 

finding any type of provider 

(margin of error)

Estimated percentage of civilian 

providers accepting 

new TRICARE patients 

(margin of error) a

1. Austin, TX

b

HSA c 58 (18) 46 (6) d

2. Anchorage, AK HSA e 56 (20) 68 (4) d

3. AK PSA 51 (17) 75 (4) d

4. AK non-PSA 51 (15) 70 (14)

5. Central-Eastern TX PSA 49 (12) 59 (5)

6. Western-Central WA PSA 48 (15) 52 (8) d

7. Dallas/Ft. Worth, TX HSA f 48 (14) 50 (6)

8. Central/Southern-Central Coastal CA PSA 48 (12) 45 (8)

9. Fredericksburg, VA HSA g 48 (11) 74 (6)

10. Columbia/Sumter, SC HSA 47 (13) 72 (6)

11. Prince William Co., VA HSA h 47 (11) 74 (6)

12. Southern-Central AZ PSA 47 (11) 59 (7)

13. Northeastern TX PSA 47 (10) 53 (6)

14. Central-Northern VA PSA 45 (8) 75 (4)

15. Fairfax Co., VA HSA i 44 (10) 60 (5)

16. Northeastern OK PSA 43 (12) 57 (6)

17. Washington, D.C. PSA 43 (11) 55 (7)

18. Central-Southern MD PSA 43 (9) 53 (6)

19. Southern AZ PSA; Southeastern CA PSA 42 (10) 60 (5)

20. Southeastern FL PSA 42 (9) 58 (6)

21. Southwestern MI non-PSA 41 (11) 66 (7)

22. LA; Southwestern MS PSA 41 (9) 60 (7)

23. Western-Central/ Northern/Southern TX PSA 41 (9) 68 (7)

24. Central-Northern/Central-Eastern FL PSA 40 (9) 71 (6)

Source: GAO analysis of TMA data.
Appendix IV: Areas Where Nonenrolled 

Beneficiaries Had Problems Accessing Civilian 

Providers, 2008-2011

Page 79 GAO-13-364 TRICARE's Access to Care Surveys

Notes: The margins of error are at the 95 percent confidence level. Areas were considered only if 

they had at least 30 respondents for the beneficiary survey and at least 50 respondents for the civilian 

provider survey.

To be included in this table, areas had an estimated 31 percent or more of nonenrolled beneficiaries 

who were having difficulties finding a provider who would accept TRICARE as payment (using the 

estimate’s margin of error at the 95 percent confidence level).

Estimated percentages and margins of error have been rounded to the nearest whole number.

Each surveyed HSA was part of a PSA or non-PSA (depending on the location).

a

Estimated percentage is based on the number of nonenrolled beneficiaries who responded “a big 

problem” or “a small problem” to any one of the following three questions: (1) “In the last 12 months, 

how much of a problem was it to find a personal doctor or nurse who would accept TRICARE?”; 

(2) “In the last 12 months, how much of a problem was it to find a doctor with this specialty who would 

accept TRICARE?”; or (3) “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?” 

b

Estimated percentage is based on the number of civilian providers who answered “for all claims” or a 

“claim-by-claim basis” to the question that asked “As of today, is the provider accepting new 

TRICARE Standard patients?” 

c

Although most of the Austin, Texas, HSA is within the Eastern-Central Texas PSA, one of its zip 

codes is part of the Western-Central/Northern/Southern Texas PSA.

d

These estimates have relative margins of error that are 30 percent or greater.

e

The Anchorage, Alaska, HSA is part of the Alaska PSA and the Alaska non-PSA.

f

The Dallas/Ft. Worth, Texas, HSA is part of the Northeastern Texas PSA.

g

The Fredericksburg, Virginia, HSA is part of the Central-Northern Virginia PSA.

h

The Prince William County, Virginia, HSA is part of the Central-Northern Virginia PSA and the 

Central-Southern Maryland PSA.

i

The Fairfax, Virginia, HSA is part of the Central-Southern Maryland PSA and the Washington, D.C. 

PSA.

We identified 21 individual areas where the percentage of nonenrolled 

beneficiaries who experienced problems finding a civilian primary care 

provider who would accept TRICARE patients met or exceeded the 

national estimate.6 We then identified 50 additional areas where the 

percentage of nonenrolled beneficiaries who experienced these problems 

was less than the national estimate.7

 

6

Nationwide, the estimated percentage of nonenrolled beneficiaries who experienced 

problems finding a civilian primary care provider was 25 percent. To determine whether an 

area had 25 percent or more of nonenrolled beneficiaries who experienced problems 

finding a provider who would accept TRICARE, we used the margins of error at the 

95 percent confidence level to determine the lower limit of the estimate. If the lower limit 

was 25 percent or above, then we included it as an area.

The remaining 129 areas had 

7

To determine whether an area had fewer than 25 percent of nonenrolled beneficiaries 

who experienced problems finding a provider who would accept TRICARE, we used the 

margins of error at the 95 percent confidence level to determine the upper limit of the 

estimate. If the upper limit was below 25 percent, then we included it as an area.

Problems Finding 

Civilian Primary Care 

Providers 
Appendix IV: Areas Where Nonenrolled 

Beneficiaries Had Problems Accessing Civilian 

Providers, 2008-2011

Page 80 GAO-13-364 TRICARE's Access to Care Surveys

estimates that ranged from 13 to 44 percent, but because of their 

confidence intervals, were neither above nor below the 25 percent 

threshold.8

 

8

Fifteen areas (1 PSA and 14 HSAs) were not included because they had less than 30 

respondents.

Figure 17 shows the geographic distribution of these three 

categories of areas.
Appendix IV: Areas Where Nonenrolled 

Beneficiaries Had Problems Accessing Civilian 

Providers, 2008-2011

Page 81 GAO-13-364 TRICARE's Access to Care Surveys

Figure 17: Estimated Percentage of Nonenrolled Beneficiaries Who Experienced Problems Finding a Civilian Primary Care 

Provider, 2008-2011

Notes: Nationwide, an estimated 25 percent of nonenrolled beneficiaries experienced problems 

finding a civilian primary care provider.

We used the lower 95 percent confidence limit to identify areas for which 25 percent or more 

nonenrolled beneficiaries experienced problems finding a civilian primary care provider. We used the 

upper 95 percent confidence limit to identify areas for which fewer than 25 percent of nonenrolled 

beneficiaries experienced problems. Areas depicted in white indicate areas that did not fall into either 

of the above categories.

We excluded areas from our analysis with fewer than 30 respondents to the survey question that 

asked: “In the last 12 months, how much of a problem was it to find a personal doctor or nurse who 

would accept TRICARE?” 
Appendix IV: Areas Where Nonenrolled 

Beneficiaries Had Problems Accessing Civilian 

Providers, 2008-2011

Page 82 GAO-13-364 TRICARE's Access to Care Surveys

TRICARE Management Activity did not identify additional Hospital Service Areas to survey for its 

2011 beneficiary survey.

Table 11 lists the 21 individual areas where at least 25 percent of 

nonenrolled beneficiaries experienced problems finding a civilian primary 

care provider who would accept TRICARE patients, and the areas’ 

corresponding estimated percentage of civilian primary care providers 

who would accept new TRICARE patients.

Table 11: Prime Service Areas (PSA), Non–Prime Service Areas (non-PSA), and Hospital Service Areas (HSA) with 25 Percent 

or More of Nonenrolled Beneficiaries Experiencing Problems Finding a Civilian Primary Care Provider, and the Willingness of 

Civilian Primary Care Providers in the Corresponding Areas to Accept New TRICARE Patients, 2008-2011

Area Area type

Estimated percent of 

beneficiaries with a problem 

finding a primary care 

provider (margin of error)

Estimated percent of 

primary care providers 

accepting new TRICARE 

patients (margin of error) a

1. Austin, TX

b

HSA c 56 (18) 42 (11) d

2. Western-Central WA PSA 47 (16) 60 (13) d

3. Prince William Co., VA HSA e 44 (12) 80 (10)

4. Southern-Central AZ PSA 44 (12) 67 (13)

5. Los Angeles, CA PSA 42 (14) 69 (9) d

6. Columbia/Sumter, SC HSA 42 (13) 84 (8) d

7. Central-Eastern TX PSA 41 (13) 67 (9) d

8. Dallas/Ft. Worth, TX HSA f 40 (14) 51 (12) d

9. Northeastern TX PSA 40 (10) 48 (10)

10. LA; Southwestern MS PSA 39 (10) 71 (11)

11. Asheville, NC HSA 38 (11) 68 (11) d

12. Southwestern MI non-PSA 38 (11) 79 (9) d

13. Central GA PSA 38 (12) 77 (9) d

14. Eastern-Central TX PSA 38 (12) 53 (10) d

15. Washington, D.C. PSA 38 (11) 59 (14)

16. Central/Southern-Central Coastal CA PSA 37 (12) 64 (12) d

17. Western NY non-PSA 37 (12) 64 (13) d

18. Central MS PSA 35 (11) 88 (7) d

19. Central-Northern VA PSA 35 (8) 82 (6)

20. Central-Southern MD PSA 33 (9) 69 (10)

21. Northern/Central/Western NM; 

Northeastern AZ; Southwestern CO

non-PSA 33 (8) 66 (12)

Source: GAO analysis of TMA data.

Notes: The margins of error are at the 95 percent confidence level. Areas were considered only if 

they had at least 30 respondents for the beneficiary survey and at least 50 respondents for the 

provider survey.
Appendix IV: Areas Where Nonenrolled 

Beneficiaries Had Problems Accessing Civilian 

Providers, 2008-2011

Page 83 GAO-13-364 TRICARE's Access to Care Surveys

To be included in this table, areas had an estimated 25 percent or more of nonenrolled beneficiaries 

who were having difficulties finding a civilian primary care provider who would accept TRICARE as 

payment (using the estimate’s margin of error at the 95 percent confidence level).

Estimated percentages and margins of error have been rounded to the nearest whole number.

Each surveyed HSA was part of a PSA or non-PSA (depending on the location).

a

Estimated percentage is based on the number of nonenrolled beneficiaries who responded “a big 

problem” or “a small problem” to the question that asked “In the last 12 months, how much of a 

problem was it to find a personal doctor or nurse who would accept TRICARE?” 

b

Estimated percentage is based on the number of civilian primary care providers who answered “for 

all claims” or a “claim-by-claim basis” to the question that asked “As of today, is the provider 

accepting new TRICARE Standard patients?” 

c

The Austin, Texas, HSA is part of the Eastern-Central Texas PSA.

d

These estimates have relative margins of error that are 30 percent or greater.

e

The Prince William County, Virginia, HSA is part of the Central-Northern Virginia PSA and CentralSouthern Maryland PSA.

f

The Dallas/Ft. Worth, Texas, HSA is part of the Northeastern Texas PSA.

We identified nine individual areas where the percentage of nonenrolled 

beneficiaries who experienced problems finding a civilian specialty care 

provider who would accept TRICARE patients met or exceeded the 

national estimate.9 We then identified 34 additional areas where the 

percentage of nonenrolled beneficiaries who experienced these problems 

was less than the national estimate.10 The remaining 144 areas had 

estimates that ranged from 14 to 47 percent, but because of their 

confidence intervals, were neither above nor below the 25 percent 

threshold.11

 

9

Nationwide, the estimated percentages of nonenrolled beneficiaries who experienced 

problems finding a civilian specialty care provider was 25 percent. To determine whether 

an area had 25 percent or more of nonenrolled beneficiaries who experienced problems 

finding a civilian specialty care provider who would accept TRICARE, we used the 

margins of error at the 95 percent confidence level to determine the lower limit of the 

estimate. If the lower limit was 25 percent or above, then we included it as an area.

Figure 18 shows the geographic distribution of these three 

categories of areas.

10To determine whether an area had fewer than 25 percent of nonenrolled beneficiaries 

who experienced problems finding a civilian specialty care provider who would accept 

TRICARE, we used the margins of error at the 95 percent confidence level to determine 

the upper limit of the estimate. If the upper limit was below 25 percent, then we included it 

as an area.

11Twenty-eight areas (2 PSAs, 2 non-PSAs, and 24 HSAs) were not included because 

they had less than 30 respondents.

Problems Finding 

Civilian Specialty 

Care Providers
Appendix IV: Areas Where Nonenrolled 

Beneficiaries Had Problems Accessing Civilian 

Providers, 2008-2011

Page 84 GAO-13-364 TRICARE's Access to Care Surveys

Figure 18: Estimated Percentage of Nonenrolled Beneficiaries Who Experienced Problems Finding a Civilian Specialty Care 

Provider, 2008-2011

Notes: Nationwide, an estimated 25 percent of nonenrolled beneficiaries experienced problems 

finding a civilian specialty care provider.

We used the lower 95 percent confidence limit to identify areas for which 25 percent or more of 

nonenrolled beneficiaries experienced problems finding a civilian specialty care provider. We used 

the upper 95 percent confidence limit to identify areas for which fewer than 25 percent of nonenrolled 

beneficiaries experienced problems. Areas depicted in white indicate areas that did not fall into either 

of the above categories.

We excluded areas from our analysis with fewer than 30 respondents to the survey question that 

asked: “In the last 12 months, how much of a problem was it to find a doctor with this specialty who 

would accept TRICARE?” 
Appendix IV: Areas Where Nonenrolled 

Beneficiaries Had Problems Accessing Civilian 

Providers, 2008-2011

Page 85 GAO-13-364 TRICARE's Access to Care Surveys

TRICARE Management Activity did not identify additional Hospital Service Areas to survey for its 

2011 beneficiary survey.

Of the nine individual areas where at least 25 percent of nonenrolled 

beneficiaries experienced problems finding a civilian specialty care 

provider who would accept TRICARE patients, one of the areas had less 

than 50 civilian specialty care respondents to the civilian provider 

survey—TMA’s threshold for reporting civilian provider survey results. 

Therefore, we only included eight areas in our collective analysis of 

access to specialty care in the beneficiary and civilian provider survey 

results. Table 12 lists these eight individual areas and the area’s 

corresponding estimated percentage of civilian specialty care providers 

that would accept new TRICARE patients.

Table 12: Prime Service Areas (PSA), Non–Prime Service Areas (non-PSA), and Hospital Service Areas (HSA) with 25 Percent 

or More of Nonenrolled Beneficiaries Experiencing Problems Finding Civilian Specialist Providers, and the Willingness of 

Civilian Specialist Providers in the Corresponding Areas to Accept New TRICARE Patients, 2008-2011

Area Area type

Estimated percent of 

beneficiaries with a problem 

finding a specialty care 

provider (margin of error)

Estimated percent of civilian 

specialty care providers 

accepting new TRICARE 

patients (margin of error) a

1. AK 

b

PSA 49 (17) 83 (6) c

2. Northwestern/Central/Central-Eastern WA PSA 45 (17) 84 (8) c

3. Central-Eastern TX PSA 42 (15) 76 (8) c

4. Central-Northern VA PSA 40 (9) 85 (6)

5. Northeastern TX PSA 39 (13) 75 (7) c

6. Western-Central/ Northern/Southern TX PSA 39 (12) 79 (11) c

7. Prince William Co., VA HSA d 50 (13) 86 (8)

8. Fredericksburg, VA HSA e 38 (12) 78 (9) c

Source: GAO analysis of TMA data.

Notes: The margins of error are at the 95 percent confidence level. Areas were considered only if 

they had at least 30 respondents for the beneficiary survey and at least 50 respondents for the 

provider survey.

To be included in this table, areas had an estimated 25 percent or more of nonenrolled beneficiaries 

who were having difficulties finding a civilian specialty care provider who would accept TRICARE as 

payment (using the estimate’s margin of error at the 95 percent confidence level).

Estimated percentages and margins of error have been rounded to the nearest whole number.

Each surveyed HSA was part of a PSA or non-PSA (depending on the location).

a

Estimated percentage is based on the number of nonenrolled beneficiaries who responded “a big 

problem” or “a small problem” to the question that asked “In the last 12 months, how much of a 

problem was it to find a doctor with this specialty who would accept TRICARE?” 

b

Estimated percentage is based on the number of civilian specialty care providers who answered “for 

all claims” or a “claim-by-claim basis” to the question that asked “As of today, is the provider 

accepting new TRICARE Standard patients?” 

c

These estimates have relative margins of error that are 30 percent or greater.
Appendix IV: Areas Where Nonenrolled 

Beneficiaries Had Problems Accessing Civilian 

Providers, 2008-2011

Page 86 GAO-13-364 TRICARE's Access to Care Surveys

d

The Prince William County, Virginia, HSA is part of the Central-Northern Virginia PSA.

e

The Fredericksburg, Virginia, HSA is part of the Central-Northern Virginia PSA.

Because of the low number of nonenrolled beneficiary responses to the 

questions about civilian mental health care,12

 

12In order for nonenrolled beneficiaries to respond to the question that asked “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?,” they needed to have answered “yes” to the question 

that asked “In the last 12 months, did you need any treatment or counseling for a personal 

or family problem?” Additionally, nonenrolled beneficiaries had to have responded that 

their mental health care provider was a civilian provider.

we are unable to identify 

specific geographic areas where nonenrolled beneficiaries have access 

problems to civilian mental health care providers. Of the 215 areas 

surveyed in the 4-year beneficiary survey, only 5 areas had 30 or more 

respondents—TMA’s threshold for reporting beneficiary survey results—

who indicated that they needed mental health care and received it from a 

civilian provider. Additionally, for those 5 areas that did have at least 

30 nonenrolled beneficiary responses, the margins of error were between 

10 and 25 percentage points.

Problems Finding 

Civilian Mental Health 

Care Providers
Appendix V: Civilian Provider Acceptance of 

Any New TRICARE Patients in Hospital Service 

Areas Surveyed in Fiscal Year 2011

Page 87 GAO-13-364 TRICARE's Access to Care Surveys

The TRICARE Management Activity (TMA) fielded its provider and 

beneficiary surveys to the same Hospital Service Areas (HSA) each year 

with one exception. Because of resource constraints, the 2011 fielding of 

the beneficiary survey did not include any HSAs. However, 16 HSAs were 

included in the 2011 fielding of the provider survey. Because beneficiaries 

were not surveyed for these HSAs, they are not included in our collective 

analysis of the beneficiary and civilian provider survey results. Table 13 

lists the 16 HSAs that were surveyed in the 2011 civilian provider survey 

fielding and the estimated percentage of civilian providers who were 

accepting any new TRICARE patients.

Table 13: Hospital Service Areas (HSA) Surveyed in 2011, and the Estimated 

Percentage of Civilian Providers Who Were Accepting Any New TRICARE Patients 

HSA

Estimated percent of civilian 

providers accepting new TRICARE 

patients (margin of error)

1. Oklahoma City, OK

a

51 (10)

2. Madison, WI 52 (9)

3. Athens, OH 52 (10)

4. Tucson, AZ 56 (5)

5. Tulsa, OK 58 (9)

6. Nashville, TN 65 (7)

7. Lihue/Waimea/Wailuku, HI 66 (7)

8. Birmingham, AL 67 (6)

9. Laramie, WY 71 (14)

10. Hopkinsville, KY 72 (11)

11. Tacoma, WA 75 (8)

12. Augusta, GA 80 (5)

13. Rapid City, SD 81 (6)

14. Columbus, GA 84 (6)

15. Hampton/Newport News, VA 85 (4)

16. Petersburg/Hopewell, VA 91 (6)

Source: GAO analysis of TMA data.

Notes: The margins of error are at the 95 percent confidence level. Areas were considered only if 

they had at least 50 respondents for the civilian provider survey.

a

Appendix V: Civilian Provider Acceptance of 

Any New TRICARE Patients in Hospital 

Service Areas Surveyed in Fiscal Year 2011

Estimated percentage is based on the number of civilian providers who answered “for all claims” or a 

“claim-by-claim basis” to the question that asked “As of today, is the provider accepting new 

TRICARE Standard patients?” 
Appendix VI: Comments from the Department 

of Defense

Page 88 GAO-13-364 TRICARE's Access to Care Surveys

Appendix VI: Comments from the 

Department of Defense
Appendix VII: GAO Contact and Staff 

Acknowledgments

Page 89 GAO-13-364 TRICARE's Access to Care Surveys

Debra A. Draper, (202) 512-7114 or draperd@gao.gov

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

Director; Jennie Apter; Linda Galib; Giselle Hicks; Jeff Mayhew; 

Lisa Motley; Dan Ries; and Eric Wedum made key contributions to this 

report.

Appendix VII: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 

(291045)
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