Defense Health Care: Additional Information Needed about Mental Health Provider Staffing Needs
Published: 2015-01-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Mental health providers are essential to DOD's delivery of health care to servicemembers and other beneficiaries. DOD's need for these providers has grown as increasing numbers of servicemembers experience life-threatening combat situations. This led to congressional attention—such as the NDAA for Fiscal Year 2010, which included provisions to help DOD increase the number of mental health providers it employs.
GAO was asked to review DOD's efforts to increase its mental health provider workforce. Among other objectives, GAO examined (1) how staffing levels changed in response to congressional direction and (2) how DOD and the military services assess current and future needs for mental health providers. GAO reviewed DOD's mental health staffing estimation model and the military services' quarterly mental health provider staffing reports for fiscal years 2009 through 2013, the latest information available. GAO also interviewed DOD and military service officials responsible for assessing mental health staffing needs.
section_title: What GAO Found
paragraphs: In response to the enactment of the National Defense Authorization Act (NDAA) for Fiscal Year 2010, the Department of Defense (DOD) military health system (MHS) increased its mental health provider staffing level by 34 percent. Specifically, DOD increased the number of mental health providers across the MHS from 4,608 providers in fiscal year 2009 to 6,186 providers in fiscal year 2013. Social workers and psychologists were the most frequently added types of mental health providers during this period.
In 2007, DOD created the Psychological Health Risk-Adjusted Model for Staffing (PHRAMS) to assess the MHS's current and future mental health provider staffing needs and DOD annually revises this model. Fiscal year 2014 marked the first time the model was used by the three military services responsible for providing health care—the Army, Air Force, and Navy—for a common purpose, which was the development of DOD's fiscal year 2016 budget request for mental health services. However, GAO found that the military services either were not using PHRAMS as the main basis of their mental health provider staffing needs estimates or were supplementing PHRAMS results with other service-specific methods. The services reported making these adjustments because PHRAMS does not account for factors that are crucial to assess mental health provider staffing needs, such as mental health providers needed for deployments. As a result, the military services' estimates of mental health provider staffing needs may not consistently reflect the beneficiary demand for mental health providers across the military services, and the current version of PHRAMS may not fully capture the military services' needs.
section_title: What GAO Recommends
paragraphs: GAO recommends that the military services report on service-specific or supplemental processes for generating mental health provider staffing estimates and that DOD continue to refine its staffing estimation model. DOD generally concurred with these recommendations, but did not concur with two others related to the use of PHRAMS that are also included in the report. GAO continues to believe these recommendations are valid as discussed further in the report.

section_title: Letter
paragraphs: Mental health providers are essential to maintaining the Department of  Defense’s (DOD) capability to deliver health care services. As part of its  mission, DOD provides a full range of medical care and services,  including mental health services, at no cost to active duty military  servicemembers and at either a reduced cost or no cost to other eligible  beneficiaries–including dependents of servicemembers and some military  retirees. DOD’s ability to deliver this care has been impacted by  increasing numbers of servicemembers who experienced life-threatening  situations in combat and their resulting need for mental health services.
Specifically, DOD faces significant challenges building and maintaining a  mental health provider workforce–including active duty and reserve  military providers and civilian and contract providers working in military  medical facilities–that is capable of providing all the mental health care  servicemembers and their dependents need due to nationwide shortages  of mental health providers. These challenges are exacerbated by the  pressure to control DOD healthcare costs and the need to compete for  mental health providers with other health care delivery systems  throughout the nation which also face increased needs for these  providers.
The increased need for mental health care for servicemembers and their  dependents has led to congressional attention on the recruitment and  retention of qualified mental health providers to work in DOD’s military  health system (MHS). Specifically, the National Defense Authorization Act  (NDAA) for Fiscal Year 2010 included provisions for DOD to increase its  mental health capabilities by increasing the number of active duty mental  health providers and to report on the appropriate number of mental health  providers required to meet the mental health care needs of  servicemembers, retirees, and dependents.
You asked us to review DOD’s efforts to increase its qualified mental  health provider workforce. In this report we examine (1) the staffing levels  of DOD military, civilian, and contracted mental health providers and how  these staffing levels have changed in response to the NDAA for Fiscal  Year 2010; (2) how DOD and the military services assess current and  future needs for mental health providers; and (3) how the military services  report mental health provider staffing levels and future needs to DOD.
To examine the staffing levels of DOD military, civilian, and contract  mental health providers and how these staffing levels changed in  response to the NDAA for Fiscal Year 2010, we analyzed quarterly  mental health staffing reports for fiscal years 2009 through 2013  submitted to DOD from each military service and the National Capital  Region (NCR) Medical Directorate. We analyzed these reports  separately and together to report current mental health provider staffing  levels and compare mental health provider staffing levels from fiscal year  2009, prior to the enactment of the NDAA for Fiscal Year 2010, with such  levels from fiscal year 2013. Fiscal year 2013 was the most recent fiscal  year with complete data available for analysis. To ensure the reliability of  these data, we interviewed Office of the Assistant Secretary of Defense  for Health Affairs (OASD HA) officials responsible for collecting and  analyzing these quarterly staffing reports and reviewed documentation  related to the production of these reports. Based on these actions, we  found information contained in these quarterly staffing reports to be  sufficiently reliable for the purposes of this report.
The Navy provides health care services for the Marine Corps. levels.for Staffing (PHRAMS), DOD’s mental health staffing model used to  project the number and mix of health care providers needed to meet the  mental health care needs of the DOD health care system—including  procedure guides and year-end reports.
We also reviewed the Psychological Health Risk-Adjusted Model  To examine how the military services report mental health provider  staffing levels and future needs to DOD, we interviewed officials from  OASD HA, Army, Air Force, Navy, and the NCR Medical Directorate to  learn about their use of quarterly mental health staffing reports. We also  reviewed the quarterly mental health staffing reports submitted by the  military services and the NCR Medical Directorate for fiscal years 2009  through 2013.
We conducted this performance audit from May 2014 to January 2015 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.
subsections: section_title: Background
paragraphs: The MHS operated by DOD has two missions: (1) supporting wartime and  other deployments and (2) providing peacetime health care. In support  of these two missions, DOD operates a large and complex health care  system that employs more than 150,000 military, civilian, and contract  personnel working in military medical facilities, commonly referred to as  military treatment facilities (MTF).
In terms of the MHS organization and structure, OASD HA serves as the  principal advisor for all DOD health policies and programs. OASD HA has  the authority to issue DOD instructions, publications, and memorandums  that implement policy approved by the Secretary of Defense or the Under  Secretary of Defense for Personnel and Readiness and govern the  management of DOD medical programs. In October 2013, the Defense  Health Agency (DHA) was established to support greater integration of  clinical and business processes across the MHS. The DHA manages the  execution of policies issued by OASD HA, oversees the TRICARE health  plan, and also exercises authority and control over the MTFs and  subordinate clinics assigned to the NCR Medical Directorate.
MTFs and their subordinate clinics are operated by either a military  service or the NCR Medical Directorate. Neither OASD HA nor DHA have  direct command and control of MTFs operated solely by the military  services. medical personnel to administer medical programs and provide medical  services to beneficiaries. The NCR Medical Directorate has direct  authority over civilian providers and personnel working within its facilities;  however, the military services maintain authority over all military providers  and personnel working within NCR Medical Directorate MTFs. See figure  1 for the current organizational and governance structure of the MHS.
The Army and Navy each have a medical command, headed by a surgeon general, who  manages each department’s MTFs and other activities through a regional command  structure. The Navy provides medical services for both Navy and Marine Corps  installations. Unlike the Surgeons General for the Army and Navy, the Air Force Surgeon  General exercises no command authority over Air Force MTFs; instead, Air Force MTF  commanders report to local line commanders.
The Air Force Surgeon General does not have direct authority over Air Force MTFs; however, the Air  Force Surgeon General exercises similar authority to that of the other Surgeons General through his  role as medical advisor to the Air Force Chief of Staff.  The Assistant Secretary of Defense for Health Affairs is the principal advisor for all DOD health  policies and programs. The Office of the Assistant Secretary of Defense for Health Affairs (OASD HA)  also has the authority to issue DOD instructions, publications, and memorandums that implement  policy approved by the Secretary of Defense or the Under Secretary of Defense for Personnel and  Readiness.  DHA was established to support greater integration of clinical and business processes across the  MHS. DHA manages the execution of policies issued by OASD HA, oversees the TRICARE health  plan, and also exercises authority and control over the MTFs and subordinate clinics assigned to the  NCR Medical Directorate.  The NCR Medical Directorate was initially established as a DOD joint task force in September 2007  to operate DOD’s medical facilities in the national capital region—including Walter Reed National  Military Medical Center, Fort Belvoir Community Hospital, and their supporting clinics. The NCR  Medical Directorate reassigned civilian personnel from the military services to the NCR Medical  Directorate, while retaining military health care providers within the appropriate military service’s  command and control.
section_title: DOD and the Military Services Have Increased the Number of Mental Health Providers to About 6,200—an Increase of Over a Third between Fiscal Years 2009 and 2013
paragraphs: The MHS has increased its overall mental health provider staffing level by  34 percent between fiscal years 2009 and 2013. Specifically, DOD  increased the number of providers across the MHS from 4,608 providers  in fiscal year 2009 to 6,186 providers in fiscal year 2013. (See app. I for  more information on fiscal year 2013 mental health provider staffing.) This  increase was in response to a requirement in the NDAA for Fiscal Year  2010 that DOD increase its mental health capabilities. (See app. II for  more information on the recruitment and retention of DOD mental health  providers.)
The type of mental health providers added to the MHS from fiscal year  2009 to fiscal year 2013 varied. (See fig. 2.) Specifically, social workers  and psychologists were the most frequently added types of mental health  providers during this period, while psychiatrists and mental health nurses  were the least frequently added. The Army drove the overall increase in  social workers and psychologists by adding 496 of the 705 social workers  and 421 of the 559 psychologists to the MHS during this period. The Air  Force added more social workers (64) than any other type of provider  during this period, while the Navy added more psychologists (32) and  other licensed providers (32). (See app. III for additional information on  the breakdown of mental health provider staffing level changes for each  military service from fiscal year 2009 to fiscal year 2013.)
During this time frame, the composition of DOD mental health provider  staff by employment category also changed. Across the MHS, the number  of civilian mental health providers increased by 52 percent (1,129) and  military mental health providers increased by 33 percent (479), while the  number of contract mental health providers decreased by 3 percent (30).  (See fig. 3.) The services’ individual changes varied, with the Army driving  this systemic shift to civilian providers. Specifically, the Army added 863  new civilian mental health providers (a 50 percent increase), while  decreasing the number of contract mental health providers by 153 (a   33 percent decrease). The Air Force also increased its civilian mental  health provider staffing by 5 providers (a 2 percent increase) and  increased its contract mental health provider staffing by 72 providers (a  39 percent increase). The Navy increased its number of military mental  health providers by 113 (a 38 percent increase), added 12 civilian mental  health providers (a 5 percent increase), and decreased contract mental  health providers by 37 (an 11 percent decrease).
While all three military services increased their mental health provider  staffing from fiscal year 2009 to fiscal year 2013, the Army’s addition of  1,010 mental health providers represented the largest portion of the DOD- wide increase. The Navy’s increase of 88 mental health providers was the  smallest portion of the DOD-wide increase. (See fig. 4.)
section_title: DOD Created a Model for Developing Mental Health Provider Staffing Needs, but the Military Services Do Not Use It Consistently
paragraphs: DOD created the Psychological Health Risk-Adjusted Model for Staffing  (PHRAMS) to show current and estimate future mental health provider  staffing needs of the MHS. In fiscal year 2014, PHRAMS was used for a  common purpose by the military services for the first time—the  development of the fiscal year 2016 DOD budget request for mental  health programs. However, the military services are either not using  PHRAMS as the primary basis of their estimates of mental health provider  staffing needs or supplementing their PHRAMS results with service- specific staffing methods. This limits DOD’s ability to consistently assess  mental health provider staffing needs throughout the MHS.
subsections: section_title: DOD Created PHRAMS to Estimate Its Current and Future Mental Health Provider Staffing Needs
paragraphs: PHRAMS projects the number and mix of providers needed to meet the  mental health care needs of the MHS. In fiscal year 2007, DOD  contracted with a non-profit research and analysis organization to develop  PHRAMS in response to recommendations from the DOD Task Force on  Mental Health.fund and DOD allocate sufficient staff to provide a full continuum of  mental health services to servicemembers and their dependents and   (2) DOD adopt a risk-adjusted population-based model to calculate  mental health staffing needs. As of September 2014, the contract to  develop and maintain PHRAMS had cost DOD $2 million, according to  DOD officials.
These recommendations included that: (1) Congress  PHRAMS is designed to be a common DOD-wide model that can be used  by the military services to assess current mental health provider staffing  needs and forecast these staffing needs over a 5-year timeframe. DOD  intended PHRAMS to allow the Department to fulfill two goals: (1) assess  whether or not there are enough mental health providers within the MHS  to meet the increased mental health needs of servicemembers and their  dependents that resulted from their experiences in recent conflicts, and  (2) allow the Department to report the mental health provider staffing  needs of the MHS to Congress. DHA and the PHRAMS contractor  engage in an annual model review process to incorporate changes  requested by the military services into the next version of the model.  According to DHA officials, PHRAMS was used for a common purpose for  the first time in fiscal year 2014—the development of the DOD fiscal year  2016 budget request for mental health programs.
To assess current mental health provider staffing needs and determine   5-year forecasts of these needs, PHRAMS places MHS beneficiaries— including servicemembers, dependents, and other beneficiaries—into  40,500 individual risk groups based on unique combinations of eight risk  factors. (See fig. 5.)
PHRAMS uses a number of mental health diagnoses in its calculations, including   those in the following groups: (1) psychoses, (2) non-psychotic depressive disorders,   (3) anxiety-related disorders, (4) neurotic disorders, (5) post-traumatic stress disorder,   (6) adjustment reaction disorders (excluding post-traumatic stress disorder), (7) acute  reaction to stress, (8) substance-induced mental disorders, (9) substance dependence,  (10) non-dependent substance abuse, (11) psychotic disorders of childhood, (12) non- psychotic disorders of childhood, (13) schizophrenic disorder, (14) personality disorders,  (15) disturbance of conduct not elsewhere classified, (16) other psychotic disorders, and  (17) other non-psychotic disorders. PHRAMS also estimates the prevalence of a number  of mental health related events, such as (1) personal or family history of mental or  psychiatric diagnosis, (2) mental or behavioral problem influencing health status,   (3) specific mental health circumstances, (4) mental health examination and observation  with no reported diagnosis, (5) mental health condition in a mother complicating  pregnancy, (6) post-deployment health assessments and post-deployment health  reassessments, and (7) other cases where the diagnosing provider is a mental health  provider. demand for mental health services each risk group will place on the  MHS.
Number of appointments (encounter rate). PHRAMS calculates the  number of appointments that will be needed to treat diagnosed  beneficiaries within each risk group. To do this, the model applies  predetermined encounter rates that specify how many times a  beneficiary with each mental health diagnosis included in the model  will interact with an MTF provider.
Availability of MHS mental health providers. PHRAMS then  determines the number of encounters each MTF-based mental health  provider can supply each year by multiplying the number of  encounters that can be completed each hour (encounter time) by the  total number of annual hours each mental health provider can spend  supplying mental health services to beneficiaries (provider time).
To establish the encounter rates used in PHRAMS, the PHRAMS contractor created   a composite encounter rate for each mental health condition included in the model based  on five inputs: (1) recommendations from a Navy work group, (2) recommendations   from an Air Force work group, (3) information gathered from reviews of clinical literature,   (4) information gathered from reviews of clinical practice guidelines, and (5) other  interviews. Encounter rates are also adjusted based on historical data.
Military and civilian mental health providers have different amounts of hours they can  devote to encounters each year. For example, the default value in PHRAMS version 5 for  military mental health providers’ clinical encounter time was set at 1,190 hours per year,  while the default value for civilian mental health providers’ clinical encounter time was set  at 1,399. This difference accounts for the hours military mental health providers spend  each year performing military-specific duties not related to beneficiary care and  differences in assumed productivity for military and civilian mental health care providers.
section_title: Military Services Mental Health Provider Estimates Are Not Based Mainly on PHRAMS
paragraphs: Despite all military services agreeing to use PHRAMS to generate their  estimates of mental health provider staffing needs for the fiscal year 2016  budget request, the military services either did not use PHRAMS as the  main basis for their mental health provider staffing estimates or  supplemented PHRAMS results using other service-specific methods  prior to submitting their fiscal year 2016 budget requests. Standards for  internal control in the federal government state that agencies’ control  activities should ensure that management’s directives are carried out.The military services reported making these adjustments because  PHRAMS does not account for several factors that are crucial to their  assessment of mental health provider staffing needs, specifically the  following:
Army. Army officials reported that they did not use PHRAMS as the  basis for their fiscal year 2016 budget request and instead determined  their mental health provider staffing needs through their legacy  staffing model and adjusted PHRAMS to ensure it produced similar  results. Unlike PHRAMS, which bases its mental health provider  staffing estimates on beneficiary demand for services, the Army  legacy staffing model uses historical workload data to estimate future  staffing needs in multiple specialties, including mental health. The  Army legacy staffing model uses projected beneficiary population  changes to adjust the historical workload for Army MTFs up or down  as needed. According to the Army official responsible for generating  manpower estimates for Army MTFs, PHRAMS does not currently  meet the needs of the Army. This is because PHRAMS’ assumption  that all military services experience the same encounter rates for  mental health conditions included in the model is an  overgeneralization of mental health service demands. This official  believes that this is particularly problematic for the Army because  deployments are more traumatic for Army servicemembers and may  result in some servicemembers requiring more than the average  number of encounters. As a result, the Army only ran PHRAMS after  the military service had already determined its mental health provider  staffing needs through its legacy staffing model.
Air Force. According to Air Force officials, while the Air Force uses  some aspects of PHRAMS, it did not rely exclusively on PHRAMS to  generate their estimates of mental health staffing needs included in  the fiscal year 2016 budget request. These officials explained that  PHRAMS was the first step in a three-step process used to generate  the Air Force’s fiscal year 2016 budget request for mental health  provider staffing. First, Air Force manpower staff ran PHRAMS and  provided the PHRAMS-generated mental health provider staffing  estimates to Air Force’s mental health consultants for consideration.  Second, the Air Force mental health consultants developed multiple  staffing level proposals by combining the PHRAMS output with their  own expertise and information received during conversations with Air  Force MTF officials. Finally, the Chief of Clinical Operations for the Air  Force Medical Support Agency selected the best staffing proposal  among those submitted for review by the Air Force mental health  consultants. Air Force officials reported that this process was applied  because PHRAMS relies on data that is several years old and does  not take into account all aspects of Air Force mental health provider  staffing, such as mental health providers embedded in operational  units. Air Force officials also explained that they plan to continue  using this process in the future to generate mental health provider  staffing estimates.
Navy. Navy officials reported that they used PHRAMS, but  supplemented PHRAMS estimates of mental health provider staffing  needs with additional information. According to Navy officials, this was  necessary because PHRAMS does not include estimates of mental  health provider staffing needs on Navy vessels and for deployed  Marine Corps units. As a result, Navy officials adjusted their PHRAMS  output to account for these additional needs for mental health  providers. These officials explained that they relied on traditional  methods—such as on-site industrial engineering reviews and industry  standards—to calculate these operational requirements for Navy  mental health providers. According to Navy officials, the fiscal year  2016 budget request submitted by the Navy for mental health provider  staffing is the sum of the estimated staffing levels generated by  PHRAMS and the calculated operational requirements for mental  health providers.
When we shared this information with DHA officials, they told us that they  were unaware of specific supplemental or alternative methods used by  the military services to determine their final mental health provider staffing  estimates. However, these officials did note that the military services do  make modifications to their PHRAMS results through modifying certain  aspects of the model and DHA does not collect information on these  modifications. DHA and the PHRAMS contractor review the model  annually to incorporate changes requested by the military services in the  next version of the model. Standards for internal control in the federal  government state that information should be recorded and communicated  to management and others within the agency that need it in a format and  time frame that enables them to carry out their responsibilities.  However, since DHA did not have access to this information on how the  military services supplemented PHRAMS for their fiscal year 2016 budget  request, this critical information was not included in this annual update  process.
As a result of the military services’ alterations to PHRAMS estimates of  mental health provider staffing needs, DHA cannot consistently determine  how beneficiary demand affects the mental health provider staffing needs  for the MHS. Specifically, due to the Army’s use of a workload-based  staffing estimate, the resulting mental health provider staffing needs  estimates submitted for the fiscal year 2016 budget process may not  consistently reflect the beneficiary demand for mental health services  across military services. In addition, without an accurate picture of the  ways the military services altered or supplemented PHRAMS results,  DHA cannot evaluate the role PHRAMS played in the development of the  fiscal year 2016 budget request for mental health provider staffing and  cannot ensure that it is directing the PHRAMS contractor to make the  most appropriate changes to the model that minimize the need for these  service-specific supplements.
section_title: Military Services Report Mental Health Provider Staffing Levels on Quarterly Reports Submitted to DHA, But Do Not Report Reliable Information on Future Needs
paragraphs: The military services submit quarterly reports to DHA through the OASD  HA human capital office that include information on their current mental  health provider staffing levels and should, as requested, include  information on their future needs for these providers. However, the  military services do not include reliable information about their mental  health provider staffing needs on these quarterly reports, despite having  access to PHRAMS since fiscal year 2010. As a result, DHA does not  have an accurate picture of the mental health provider staffing needs of  the MHS and cannot accurately report this information to Congress.  Standards for internal control in the federal government state that  information should be recorded and communicated to management and  others within the agency that need it in a format and time frame that  enables them to carry out their responsibilities.
DHA requests information each quarter from the military services and the  NCR Medical Directorate on mental health provider staffing in order to  understand the MHS-wide use and need for these providers and report  this information to Congress when requested. Each military service and  the NCR Medical Directorate submits quarterly staffing reports to DHA  through the OASD HA human capital office that include information on  three areas of mental health provider staffing: (1) the number of mental  health providers each military service needs to fulfill the needs of their  beneficiaries, referred to as requirements; (2) the number of authorized  positions each military service has for various types of mental health  providers, referred to as authorizations; and (3) the actual number of  mental health providers each military service has working within their  MTFs and subordinate clinics that quarter, referred to as on-board  providers. However, we found that information reported is unreliable.  Specifically, we found the following:
According to DHA officials, only the Army submits information on the  number of mental health providers its MTFs and subordinate clinics  need to serve Army beneficiaries and it derives these numbers from  the Army workload-based legacy staffing model.
DHA officials told us that the Navy and the Air Force do not track  needs for mental health provider staffing. Instead, they submit the  number of authorized mental health provider positions for both the  requirements and authorizations sections of these quarterly reports.  NCR Medical Directorate officials told us that the requirements section  of their quarterly reports are populated using the staffing needs  identified in the intermediate manpower planning documents that were  created during the formation of the NCR Medical Directorate.  According to DOD officials, the NCR Medical Directorate is currently  reviewing the staffing needs of its MTFs and subordinate clinics and  anticipates completion of this review by December 2014.
Without reliable information from the military services and the NCR  Medical Directorate on the quarterly reports, DHA cannot assess the  need for mental health providers throughout the MHS and cannot ensure  that it is providing assistance to the military services in meeting their  unmet needs. The military services have had access to PHRAMS since  fiscal year 2010 and the model could be used to assess the mental health  provider needs of each military service and the NCR Medical Directorate  on an ongoing basis. Incorporating this information into the requirements  section of the quarterly reports each military service and the NCR Medical  Directorate submit to DHA through the OASD HA human capital office  would provide this important information to DHA. In addition, this  information would also ensure greater consistency in the military services’  and the NCR Medical Directorate’s assessment of this aspect of mental  health provider staffing and ensure greater accuracy in DOD’s reports to  Congress about mental health provider staffing.
section_title: Conclusions
paragraphs: While PHRAMS has been in development since fiscal year 2007, the  military services only recently began using the model for a common  purpose—the fiscal year 2016 DOD budget request. However, PHRAMS  is not meeting its intended goals because the military services are not  using it consistently to assess their mental health provider staffing needs.  Instead, the military services are supplementing PHRAMS mental health  provider staffing estimates with additional information. It is critical that the  military services report how they have supplemented PHRAMS to ensure  (1) that DHA and the PHRAMS contractor can correctly analyze and  interpret the military services’ mental health provider staffing estimates,  and (2) that PHRAMS is updated regularly to meet the needs of the  military services. DHA is also unable to generate accurate reports to  Congress on the staffing needs of the entire MHS, because the military  services are not using PHRAMS to generate consistent mental health  provider staffing needs estimates and are instead reporting unreliable  estimates on their quarterly reports. DHA is therefore unable to assess  and report on current mental health provider staffing needs.
section_title: Recommendations for Executive Action
paragraphs: To ensure DHA can accurately and consistently assess mental health  provider staffing needs across each of the military services, we  recommend that the Secretary of Defense direct the Secretaries of the  Army, Air Force, and Navy to take the following two actions:
Require the medical commands of each military service to report any  additional service-specific methods they use to determine their final  estimates of mental health provider staffing needs; and
Require the medical commands of each military service to include its  estimated mental health provider staffing needs generated through  PHRAMS in the requirements fields of DHA’s quarterly mental health  staffing reports.
We further recommend that the Secretary of Defense direct the Assistant  Secretary of Defense for Health Affairs to take the following two actions:
Ensure DHA, through the PHRAMS contractor, continue to refine  PHRAMS to incorporate the needs of the military services to reduce  the need for additional service-specific methods of determining mental  health provider staffing needs; and
Require the NCR Medical Directorate to include its estimated mental  health provider staffing needs generated through PHRAMS in the  requirements fields of DHA’s quarterly mental health staffing reports.
section_title: Agency Comments and Our Evaluation
paragraphs: DOD provided comments on a draft of this report, which we have  reprinted in appendix IV. In its comments, DOD generally concurred with  two of our four recommendations. DOD also provided technical  comments, which we have incorporated as appropriate.
DOD concurred with our recommendation that the Secretary of Defense  should direct the Secretaries of the Army, the Air Force, and the Navy to  require the medical commands of each military service to report any  additional service-specific methods they use to determine their final  estimates of mental health provider staffing needs. DOD did not provide a  time frame or action plan for implementing this recommendation.
In addition, in response to our recommendation that the Secretary of  Defense ensure DHA, through the PHRAMS contractor, continue to refine  PHRAMS to incorporate the needs of military services to reduce the need  for additional service-specific methods of determining mental health  provider staffing needs, DOD said that DHA continues to serve in an  advisory role to the military services to ensure that the next version of  PHRAMS meets each service’s needs. DOD did not provide a time frame  or action plan for implementing this recommendation.
DOD did not concur with our recommendations to require the medical  commands of each military service and the NCR Medical Directorate to  include their estimated mental health provider staffing needs generated  through PHRAMS in the requirements field of DHA’s quarterly mental  health staffing reports. DOD stated in its comments that using PHRAMS  in the requirements fields of these reports will not add value to the  quarterly mental health staffing reports and noted that the military  services do not use PHRAMS as the sole source of mental health  requirements. We disagree with DOD’s conclusion and maintain that our  recommendations should be implemented. The military services and the  NCR Medical Directorate are not currently providing DHA with consistent  information that it can rely on to: (1) make informed decisions regarding  the MHS-wide usage and need for mental health providers and   (2) develop reports to Congress based on this information.
Specifically, only one military service—the Army—reports the number of  mental health providers that its MTFs need to serve Army beneficiaries in  the requirements field of DHA’s quarterly mental health staffing reports.  The other two military services—the Air Force and the Navy—enter the  number of mental health providers that were authorized by DOD for that  fiscal year in the requirements field because they do not track mental  health provider staffing needs. Additionally, the NCR Medical Directorate  told us that it populates the requirements field of DHA’s quarterly mental  health staffing reports with information that was created during the  formation of the NCR Medical Directorate several years ago and not with  the current needs of its beneficiary population. We believe that to  adequately assess the need for mental health providers throughout the  MHS, DHA needs to have access to consistent and reliable information  on mental health provider staffing needs in the quarterly mental health  staffing reports. By not supplying consistent information on mental health  provider staffing needs generated through PHRAMS—a common staffing  model all military services and the NCR Medical Directorate have access  to—the military services and the NCR Medical Directorate make it difficult  to properly assess relative mental health provider staffing needs across  the services. If our recommendations were implemented, DHA would  have access to consistent information about mental health provider  staffing needs throughout the MHS and would be able to more reliably  report this information to Congress.
We are sending copies of this report to the Secretary of Defense,  appropriate congressional committees, and other interested parties. In  addition, the report is available at no charge on the GAO website at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made major contributions to  this report are listed in appendix V.
section_title: Appendix I: Fiscal Year 2013 Department of Defense Mental Health Provider Staffing
paragraphs: This appendix provides results from our analysis of Department of  Defense (DOD) fiscal year 2013 quarterly mental health staffing reports.  Each military service and the National Capital Region (NCR) Medical  Directorate submit these reports to the Defense Health Agency (DHA)  through the Office of the Assistant Secretary of Defense for Health Affairs  (OASD HA) human capital office each quarter to identify their mental  health staffing levels and needs.
Figure 7 shows the total number of mental health providers working  within the MHS by provider type as of September 2013.
Figure 8 shows the total number of mental health providers working  within the MHS by employment category as of September 2013.
Figure 9 shows the total number of mental health providers working  within the MHS by military service and the NCR Medical Directorate  as of September 2013.
Table 1 shows the mental health provider staffing levels for the Army  as of September 2013.
Table 2 shows the mental health provider staffing levels for the Air  Force as of September 2013.
Table 3 shows the mental health provider staffing levels for the Navy  as of September 2013.
Table 4 shows the mental health provider staffing levels for the NCR  Medical Directorate as of September 2013.
section_title: Appendix II: Recruitment and Retention of Department of Defense Mental Health Providers
paragraphs: This appendix provides information on the recruitment and retention of  Department of Defense (DOD) mental health providers. Specifically, we  discuss (1) the mechanisms the military services use to recruit and retain  mental health providers, and (2) the challenges the military services  experience in recruiting and retaining mental health providers.
To determine the mechanisms the military services use to recruit and  retain mental health providers, we reviewed relevant laws, including each  National Defense Authorization Act (NDAA) from fiscal years 2010  through 2014, to determine the recruitment and retention mechanisms  available to DOD for mental health providers. We also spoke with officials  from Office of the Assistant Secretary of Defense for Health Affairs  (OASD HA), Army, Air Force, and Navy about their use of these  mechanisms.
To determine the challenges the military services experience in recruiting  and retaining mental health providers, we spoke with officials from OASD  HA, Army, Air Force, and Navy. We also reviewed the Health Resources  and Services Administration’s Health Professional Shortage Area  designations to determine whether other health care delivery systems  also experienced challenges in recruiting and retaining certain mental  health providers.
subsections: section_title: Military Services Use Numerous Mechanisms to Recruit and Retain Mental Health Providers
paragraphs: All three military services reported using numerous recruitment and  retention mechanisms, many of which are cited in the NDAA for Fiscal  Year 2010. These mechanisms include the following:
Health Professions Scholarship and Financial Assistance  Program (HPSP). Officials from all three military services reported  using this program to recruit various types of medical providers,  including mental health providers. Through HPSP, the military  services provide scholarships, stipends, and other benefits for  students in advanced health care fields—including physicians,  psychiatric nurse practitioners, and psychologists. The military services reported that HPSP was a particularly important recruitment  tool for physicians, including psychiatrists. However, officials from all  three military services stressed that they cannot predict the exact  number of psychiatrists HPSP will produce annually because it begins  funding medical students’ general training prior to their selection of a  specialty.
Uniformed Services University of the Health Sciences (USUHS).
Generally, USUHS students do not pay tuition and receive full salary and benefits for a  junior officer (second lieutenant or ensign) in exchange for a 7-year active duty military  service commitment. psychology students by service is Army, three students; Air Force, two  to three students; and Navy, five students.
Bonuses for mental health providers. Officials from all three military  services reported using a variety of bonuses for mental health  providers. Specifically, the Army reported using accession,  relocation, and retention bonuses for both military and civilian mental  health providers. The Air Force reported that they provide accession  bonuses to fully-qualified military mental health providers, as well as  bonuses for specialty board certification and a retention bonus after  providers have completed a specified number of years-of-service.  Finally, the Navy reported that all mental health specialties are eligible  for some combination of accession and retention bonuses and board  certification pay.
Direct-hire authority for civilian mental health providers. Both the  Army and Navy reported using direct-hire authority to recruit civilian  mental health providers. The Office of Personnel Management can  grant direct-hire authority to executive branch agencies to fill  vacancies when a critical hiring need or severe shortage of  candidates exists. Direct-hire authorities expedite hiring by eliminating  some competitive hiring procedures, such as rating and ranking  candidates, that would otherwise be required. Agencies may also  pursue agency-specific direct-hire authorities.
Training program for licensed clinical social workers. Both the  Army and Navy reported using the Army’s training program for  licensed clinical social workers. In 2008, the Army created a program  for training licensed clinical social workers with Fayetteville State  University to address a shortage of Army social work military  providers. This program provides participants with a Masters in Social  Work and internship placements. The program annually trains up to  30 Army social work military providers, 5 Army National Guard social  work military providers, and 2 Navy social work military providers.Army officials reported that this program is satisfying all of its need for  social work military providers annually, and Navy officials told us that  this program was an important recruitment tool for their social work  military providers as well.
section_title: Military Services Experience Several Challenges Recruiting and Retaining Mental Health Providers
paragraphs: In the face of nationwide shortages of mental health professionals, the  ability to recruit and retain mental health providers, particularly  psychiatrists, poses a challenge according to officials from all three  military services. The Health Resources and Services Administration has  reported nationwide shortages of psychiatrists and identified 3,900 health  professional shortage areas throughout the nation with a relative scarcity  of psychiatrists. As of January 2014, the Health Resources and Services  Administration reported that it would take approximately 2,600 additional  psychiatrists nationwide to eliminate the current shortages it has  identified.
In addition to nationwide shortages of mental health professionals, there  are other overarching military-specific challenges for all three military  services as they compete for scarce mental health resources. Mental  health provider recruitment and retention challenges specific to military  service include:
Frequent deployments and relocations. Officials from all three  military services reported that both frequent deployments and  relocations made it difficult for them to recruit and retain mental health  military providers. For example, Navy officials told us that they have  received feedback from psychiatrists leaving military service that  requirements to move frequently and deploy were reasons they were  leaving the Navy.
Assignment to work in remote locations. According to officials from  all three military services, the remote locations where many military  treatment facilities are located posed recruitment and retention  challenges for mental health providers. For example, Army officials  explained that many Army bases are located relatively far away from  major metropolitan areas and that mental health military, civilian, and  contract providers are reluctant to be located in what they perceived  to be remote and isolated locations for lengthy periods of time.
Competitive compensation for mental health providers. Officials  from all three military services reported that the inability of DOD to  create compensation packages for civilian mental health providers,  particularly psychiatrists, that were competitive with private sector  compensation affected their ability to recruit and retain these  providers. For example, Army officials stated that both a 3-year long  DOD pay freeze and recent furloughs affected their ability to create  competitive salaries for providers and contributed to the Army’s   15 percent turnover rate in their psychiatrist and psychologist mental  health provider populations in recent years.
section_title: Appendix III: Mental Health Provider Staffing Increases by Military Service
paragraphs: This appendix provides results from our analysis of Department of  Defense (DOD) quarterly mental health staffing reports for fiscal years  2009 and 2013. Each service and the National Capital Region (NCR)  Medical Directorate submits these reports to the Defense Health Agency  (DHA) through the Office of the Assistant Secretary of Defense for Health  Affairs (OASD HA) human capital office each quarter to identify their  mental health staffing levels. The NCR Medical Directorate is not  represented in this appendix because in fiscal year 2009 mental health  provider staffing levels were included in the military service totals and, as  a result, comparisons of NCR Medical Directorate staffing levels from  fiscal year 2009 to fiscal year 2013 are not available.
Table 5 provides results for mental health provider staffing levels for  the Army in fiscal year 2009 and fiscal year 2013.
Table 6 provides results for mental health provider staffing levels for  the Air Force in fiscal year 2009 and fiscal year 2013.
Table 7 provides results for mental health provider staffing levels for  the Navy in fiscal year 2009 and fiscal year 2013.
section_title: Appendix IV: Comments from the Department of Defense
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
paragraphs: Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov.
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Marcia A. Mann, Assistant  Director; A. Elizabeth Dobrenz; Mary Giffin; Cathleen Hamann;   Katherine Nicole Laubacher; Vikki Porter; Dharani Ranganathan;   and Laurie F. Thurber made key contributions to this report.   Jacquelyn Hamilton provided legal support.