Defense Health Care: 2008 Access to Care Surveys Indicate Some Problems, but Beneficiary Satisfaction Is Similar to Other Health Plans
Published: 2010-03-31T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Defense (DOD) provides health care and mental health care through its TRICARE program. Under TRICARE, beneficiaries may obtain care through TRICARE Prime, an option that includes the use of civilian provider networks and requires enrollment. TRICARE beneficiaries who do not enroll in this option may obtain care from nonnetwork providers through TRICARE Standard, or from network providers through TRICARE Extra. In addition, qualified National Guard and Reserve servicemembers may purchase TRICARE Reserve Select, a plan whose care options are similar to those of TRICARE Standard and TRICARE Extra. We refer to servicemembers who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select as nonenrolled beneficiaries. The National Defense Authorization Act for Fiscal Year 2008 directed GAO to analyze the adequacy of DOD's surveys of TRICARE beneficiaries and providers and report what the surveys' results indicate about access to care for nonenrolled beneficiaries. To do so, GAO evaluated the surveys' methodology by interviewing DOD officials and reviewing relevant documentation, including the Office of Management and Budget's (OMB) survey standards. GAO also assessed the surveys' results by interviewing DOD officials, obtaining relevant documentation, and analyzing the response rates and data for both surveys.
section_title: What GAO Found
paragraphs: DOD's implementation of beneficiary and provider surveys for 2008, the first of a 4-year survey effort, followed the OMB survey standards for survey design, data collection, and data accuracy. In addition, DOD generally addressed the survey requirements outlined in the mandate in implementing its 2008 beneficiary and provider surveys but did not give a high priority to selecting geographic areas with a high concentration of Selected Reserve servicemembers. Instead, for both of its surveys, DOD randomly selected areas to produce results that can be generalized to the populations from which the survey samples were drawn. DOD plans to cover the entire United States at the end of the 4-year survey period, which will include any locations with higher concentrations of Selected Reserve servicemembers. In its analysis of the 2008 beneficiary survey data, GAO estimated that a higher percentage of nonenrolled beneficiaries in surveyed areas where TRICARE Prime is offered (Prime Service Areas) experienced problems accessing care from network or nonnetwork primary care providers than beneficiaries in surveyed areas where TRICARE Prime is not offered (non-Prime Service Areas)--30 percent and 24 percent, respectively. GAO also found that beneficiaries in the surveyed areas most often experienced access problems related to providers' willingness to accept TRICARE payments, regardless of whether they lived in a Prime or non-Prime Service Area. Additionally, GAO's comparison of this survey data to related data from a 2008 Department of Health and Human Services' survey showed that beneficiaries in the surveyed Prime and non-Prime Service Areas rated their health care satisfaction similarly to each other and to beneficiaries of commercial health care plans, but slightly lower than Medicare beneficiaries. GAO found that the results for the 2008 provider survey are not representative of all physicians and mental health providers in the geographic areas surveyed, but the results do provide information about access to care based on the specific views of the respondents. According to a DOD official, generalizability of provider survey results to the entire country will likely be possible at the end of the 4-year survey period. GAO's review of the 2008 provider survey results indicates that a lower percentage of respondents in Prime Service Areas reported awareness and acceptance of TRICARE than respondents in non-Prime Service Areas. Additionally, there were differences between responding physicians and responding mental health providers, such as psychiatrists and clinical psychologists, regarding their awareness and acceptance of TRICARE. For example, 81 percent of physicians who responded reported that they would accept new TRICARE patients, if they were accepting any new patients at all, compared to 50 percent of mental health providers who responded. In commenting on a draft of this report, DOD concurred with GAO's overall findings and provided technical comments, which GAO incorporated as appropriate.

section_title: Letter
paragraphs: In fiscal year 2009, the Department of Defense (DOD) offered health care  and mental health care services to over 9 million eligible beneficiaries in  the United States and abroad through TRICARE, DOD’s regionally  structured health care program. TRICARE is unique because eligible  beneficiaries do not have to enroll in the program to use their benefits, and  therefore DOD does not have complete information on which beneficiaries  intend to use their benefits. Because of this, DOD cannot accurately  predict from year to year the health care needs of the eligible population,  including how to ensure adequate access to health care and mental health  care.
Under TRICARE, beneficiaries obtain care either from military hospitals  and clinics, referred to as military treatment facilities, or from civilian  providers. DOD’s TRICARE Management Activity (TMA), which oversees  the program, uses managed care support contractors to develop networks  of civilian providers and to perform other customer service functions,  such as processing claims and assisting beneficiaries with finding  providers. The contractors are required to establish adequate networks of  civilian providers—referred to as network providers—to serve all  TRICARE beneficiaries in geographic areas called Prime Service Areas.  The contractors use estimates of the number of TRICARE users, among  other factors, to develop provider networks and ensure adequate access to  care for beneficiaries. Although some network providers may be located  outside of Prime Service Areas, contractors are not required to develop  networks in these areas (which we refer to as non-Prime Service Areas).
TRICARE has three basic options for its beneficiaries: TRICARE Prime,  TRICARE Standard, and TRICARE Extra. Beneficiaries who choose  TRICARE Prime, a managed care option, must enroll and can obtain care  through the networks of providers established by contractors.  Beneficiaries do not need to enroll to receive care under TRICARE  Standard, a fee-for-service option, or TRICARE Extra, a preferred provider  organization option, and can choose to receive care either through  nonnetwork providers (under TRICARE Standard) or network providers  (under TRICARE Extra).  All beneficiaries may obtain care at military  treatment facilities, although priority is first given to active duty personnel  and then to beneficiaries enrolled in TRICARE Prime. The choices that  beneficiaries have in selecting TRICARE options and providers can vary  depending on a beneficiary’s location. Beneficiaries living in Prime Service  Areas can choose between TRICARE Prime, TRICARE Standard, and  TRICARE Extra. Beneficiaries living in non-Prime Service Areas can  choose between TRICARE Standard and TRICARE Extra. According to a  TMA official, about 18 percent of eligible beneficiaries resided in non- Prime Service Areas in fiscal year 2009.
Users of TRICARE Standard and Extra in some locations have complained  about difficulties finding civilian providers who will accept them as  patients since TRICARE’s inception in 1995. In response to these concerns,  the National Defense Authorization Act for Fiscal Year 2004 directed DOD  to monitor access to care for TRICARE beneficiaries who were not  enrolled in the TRICARE Prime option through a survey of civilian  providers. The act also directed GAO to review the processes,  procedures, and analysis used by DOD to determine the adequacy of the  number of network and nonnetwork civilian providers and the actions  DOD has taken to ensure access to care for beneficiaries who were not  enrolled in TRICARE Prime. In December 2006, we reported that TMA and  its contractors used various methods to monitor access to care, including  a provider survey. According to TMA and its contractors, their methods  indicated that access was generally sufficient for users of TRICARE  Standard and Extra.
Nonetheless, concerns about the ability of TRICARE beneficiaries to  access health care and mental health care from civilian providers  continue. For example, in the wake of current military operations in  Afghanistan and Iraq, DOD and others have reported that servicemembers  and their families are at risk for mental health problems given the stress of  deployment and exposure to combat. A June 2007 report by DOD’s Task  Force on Mental Health stated that TRICARE provider networks have  been tasked with providing an increasing volume and proportion of mental  health services for families and retirees. In assessing the oversight of the  mental health network at one location, the task force discovered that out  of 100 network mental health providers contacted from a list on the  contractor’s Web site, only 3 would accept new TRICARE patients.
Additionally, concerns about access to care for National Guard and  Reserve servicemembers and their families have surfaced in light of DOD’s  increasing reliance on this population to support military operations, such  as the conflicts in Afghanistan and Iraq. DOD has reported that as of  August 31, 2009, over 731,000 National Guard and Reserve servicemembers  have been deployed in support of conflicts in Afghanistan and Iraq since  September 11, 2001. DOD has reported that National Guard and Reserve  servicemembers may not live near military installations like their active  duty counterparts, and as a result, they may not have access to military  hospitals and clinics and must instead rely more heavily on civilian  providers for their care. DOD’s Task Force on Mental Health also reported  that since a substantial proportion of National Guard and Reserve  servicemembers reported no civilian health plan coverage before  deployment and continue to rely on TRICARE thereafter, constraints in  access to care for this population are a real concern. Qualified members of  the Selected Reserve—National Guard and Reserve servicemembers who  are considered essential to wartime missions—who are not activated to  duty may sign up for TRICARE Reserve Select, a premium-based health  plan whose care options are similar to those of TRICARE Standard and  Extra. According to DOD officials, there were approximately 69,000  members of the Selected Reserve who were eligible and likely to be  interested in TRICARE Reserve Select, as of September 30, 2009. Of  these, approximately 67 percent had purchased TRICARE Reserve Select.  For the purpose of this report, we refer to beneficiaries who are not  enrolled in TRICARE Prime—that is, those who use TRICARE Standard,  TRICARE Extra, or TRICARE Reserve Select—as nonenrolled  beneficiaries.
In light of continued concerns about access to civilian providers, the  National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008)  directed DOD to conduct surveys of beneficiaries and providers to  determine the adequacy of access to health care and mental health care for  nonenrolled beneficiaries. The NDAA 2008 also directed GAO to analyze  the adequacy of DOD’s beneficiary and provider surveys. This report  describes (1) how DOD is addressing the NDAA 2008 mandate to  implement beneficiary and provider surveys to determine the adequacy of  access to care for nonenrolled beneficiaries, (2) what the results of the  beneficiary survey indicate about the adequacy of access to care for  nonenrolled beneficiaries, and (3) what the results of the provider survey  indicate about the adequacy of access to care for nonenrolled  beneficiaries.
To evaluate how DOD is addressing the NDAA 2008 mandate to implement  beneficiary and provider surveys to determine the adequacy of access to  care, we reviewed relevant documentation and interviewed officials and  representatives from TMA’s Health Program Analysis and Evaluation  Directorate who were responsible for developing, fielding, and analyzing  the surveys. We evaluated TMA’s beneficiary and provider survey  methodologies using the Office of Management and Budget’s (OMB)  standards and guidelines for statistical surveys. We focused our analysis  on standards specific to designing a survey (e.g., selecting random  samples), developing a list of eligible survey participants, collecting survey  data, and ensuring data accuracy. We also evaluated the beneficiary and  provider surveys to determine whether TMA had complied with all of the  requirements outlined in the mandate, such as obtaining specific types of  information and establishing benchmarks for analysis. In addition, we  spoke with officials representing beneficiary and provider groups to obtain  their views on access-to-care issues. And finally, we spoke with officials  from DOD’s Office of Reserve Affairs to obtain their perspectives about  access-to-care concerns for National Guard and Reserve servicemembers.
To determine what the results of the beneficiary survey indicate about the  adequacy of access to care for nonenrolled beneficiaries, we obtained and  analyzed TMA’s beneficiary survey data for 2008, the first year of a 4-year  survey effort. We compared the responses of nonenrolled beneficiaries in  Prime Service Areas to responses of those in non-Prime Service Areas,  including concerns about access to network or nonnetwork providers.
Where possible, we compared these responses to those of other health  care consumers surveyed in the Department of Health and Human  Services’ (HHS) 2008 Consumer Assessment of Healthcare Providers and  Systems. We assessed the reliability of these data by speaking with  knowledgeable officials and reviewing related documentation, and we  determined that the beneficiary survey data are sufficiently reliable for the  purpose of reporting the experiences of nonenrolled beneficiaries in the  combined Prime Service Areas and combined non-Prime Service Areas  that TMA surveyed.
To determine what the results of the provider survey indicate about the  adequacy of access to care for nonenrolled beneficiaries, we obtained and  analyzed TMA’s provider survey data for 2008, which is also the first year  of a 4-year survey effort. We analyzed the survey responses of providers in  Prime Service Areas, non-Prime Service Areas, and Hospital Service  Areas to determine their awareness of the TRICARE program and  whether they were accepting nonenrolled TRICARE beneficiaries as new  patients. We assessed the reliability of these data by speaking with  knowledgeable officials and reviewing related documentation, and we  determined that the provider survey data presented in this report are  sufficiently reliable for the purpose of reporting the information provided  by the survey respondents in the Prime Service Areas, non-Prime Service  Areas, and Hospital Service Areas that TMA surveyed.
We conducted this performance audit from February 2009 through March  2010 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: In fiscal year 2009, over 9 million beneficiaries were eligible to receive  health care and mental health care through DOD’s TRICARE program.  Under TRICARE, beneficiaries have choices among various benefit  options and may obtain care from either military treatment facilities or  civilian providers.
subsections: section_title: Composition of TRICARE’s Beneficiary Population
paragraphs: TRICARE beneficiaries fall into different categories: (1) active duty  personnel and their dependents, (2) National Guard and Reserve  servicemembers and their dependents, and (3) retirees and their  dependents or survivors. Retirees and certain dependents and survivors  who are entitled to Medicare Part A and enrolled in Part B, and who are  generally age 65 and older, are eligible to obtain care under a separate  program called TRICARE for Life. As shown in figure 1, active duty  personnel and their dependents represented 32 percent of the beneficiary  population, while National Guard and Reserve servicemembers and their  dependents represented 14 percent.
Ntionl Guard nd Reerve ervicememer nd dependentActive dty peronnel nd dependentRetiree nd their dependent or survivor(generlly nder ge 65)
TRICARE beneficiaries under 65 years of age who are eligible for Medicare Part A on the basis of  disability or end-stage renal disease are eligible for TRICARE for Life if they enroll in Medicare   Part B.
section_title: TRICARE’s Benefit Options
paragraphs: TRICARE provides its benefits through several options for its non- Medicare-eligible beneficiary population. These options vary according to  TRICARE beneficiary enrollment requirements, the choices TRICARE  beneficiaries have in selecting civilian and military treatment facility  providers, and the amount TRICARE beneficiaries must contribute toward  the cost of their care. Table 1 provides additional information about these  options.
section_title: Beneficiaries’ Use of TRICARE
paragraphs: Claims data from fiscal years 2006 to 2009 show that the percentage of  claims paid for using TRICARE Prime and TRICARE Extra has gradually  increased, while the percentage of claims paid for using TRICARE  Standard has declined 2 to 3 percentage points each year. (See fig. 2.)  Moreover, in 2006 we reported that in fiscal year 2005 about 1.8 million  beneficiaries who were eligible for TRICARE Standard or Extra elected  not to use their benefits. In fiscal year 2009, about 926,000 beneficiaries  who were eligible for TRICARE Standard, TRICARE Extra, and TRICARE  Reserve Select elected not to use their benefits.
section_title: Network and Nonnetwork Providers under TRICARE
paragraphs: In order for network and nonnetwork civilian providers to be authorized  to provide care and be reimbursed under TRICARE, they must be licensed  by their state, accredited by a national organization (if one exists), and  meet other standards of the medical community. Individual 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.
There are two types of authorized civilian providers—network and  nonnetwork providers.
Network providers are TRICARE-authorized providers who enter a  contractual agreement with a managed care support contractor to provide  health care to TRICARE beneficiaries. By law, TRICARE maximum  allowable reimbursement rates must generally mirror Medicare rates, but  network providers may agree to accept lower reimbursements as a  condition of network membership. However, network civilian providers  are not obligated to accept all TRICARE beneficiaries seeking care. For  example, a network civilian provider may decline to accept TRICARE  beneficiaries as patients because the provider’s practice does not have  sufficient capacity.
Nonnetwork providers are TRICARE-authorized providers who do not  have a contractual agreement with a managed care support contractor to  provide care to TRICARE beneficiaries. Nonnetwork civilian providers  have the option of charging up to 15 percent more than the TRICARE  reimbursement rate for their services on a case-by-case basis. The  beneficiary is responsible for paying the extra amount billed in addition to  required co-payments.
section_title: NDAA 2008 Requirements for Beneficiary and Provider Surveys to Determine Access to Care for Nonenrolled TRICARE Beneficiaries
paragraphs: The NDAA 2008 directed DOD to determine the adequacy of the number of  health care and mental health care providers that currently accept  nonenrolled beneficiaries as patients under TRICARE. Specifically, the  mandate directed DOD to conduct surveys of beneficiaries and providers  in at least 20 Prime Service Areas and 20 non-Prime Service Areas in each  of fiscal years 2008 through 2011. The mandate also directed DOD to give a  high priority to locations having high concentrations of Selected Reserve  servicemembers. Additionally, the NDAA 2008 required DOD to consult  with representatives of TRICARE beneficiaries and health care and mental  health care providers to identify locations where nonenrolled beneficiaries  have experienced significant access-to-care problems, and to survey health  care and mental health care providers in these areas. The NDAA 2008 also  required that specific types of information be requested in the surveys. For  example, the mandate stated that the provider survey must include  questions to determine whether providers are aware of TRICARE. Within  DOD, TMA has primary responsibility for designing and implementing the  beneficiary and provider surveys.
section_title: Implementation of DOD’s 2008 Beneficiary and Provider Surveys Followed OMB Survey Standards and Generally Addressed Requirements Outlined in the NDAA 2008
paragraphs: In implementing the first year of the beneficiary and provider surveys,  TMA followed the OMB standards for statistical surveys that we reviewed.  However, TMA did identify an error in the geographic categorization of its  participants for both surveys and has taken steps to correct it. In addition,  TMA generally addressed the requirements outlined in the NDAA 2008 for  both of its surveys but did not give a high priority to selecting areas with a  high concentration of Selected Reserve servicemembers. Instead, for both  surveys, TMA randomly selected geographic areas to produce results that  can be generalized to the populations from which the survey samples were  drawn. TMA plans to cover the entire United States at the end of the 4-year  survey period, which will include any locations with higher concentrations  of Selected Reserve servicemembers.
subsections: section_title: TMA Followed the OMB Standards We Reviewed in Designing and Implementing Its Beneficiary and Provider Surveys
paragraphs: In implementing its first round of beneficiary and provider surveys, TMA’s  methodology for both of the multiyear surveys is consistent with the OMB  standards for statistical surveys that we reviewed. (See app. I for our list  of selected OMB standards.) These standards document the professional  principles and practices that federal agencies are required to follow and  the level of quality and effort expected in statistical activities. For  example, OMB standards recommend that agencies develop a survey  design that includes a methodology for identifying the target population.
OMB standards also suggest that federal agencies ensure that the list of  eligible survey participants representing the target population is evaluated  for accuracy. In conducting its 2008 beneficiary and provider surveys,  TMA representatives noted that they identified an error in the geographic  categorization of eligible survey participants for both surveys. Specifically,  TMA erroneously categorized some beneficiaries and providers as being  located in 11 non-Prime Service Areas when in fact they were in Prime  Service Areas. According to a TMA representative, this occurred as a  result of a computer programming error. TMA identified this error after it  began fielding the beneficiary survey in June 2008 but prior to fielding the  provider survey, which began in December 2008. As a result, TMA  surveyed approximately 9,000 fewer beneficiaries than intended in those  11 non-Prime Service Areas. TMA plans to correct this error in future years  by surveying additional beneficiaries in the affected non-Prime Service  Areas.
section_title: TMA Generally Addressed Requirements Outlined in the Mandate for Its Beneficiary and Provider Surveys
paragraphs: TMA generally addressed the requirements outlined in the mandate during  the implementation of its 2008 beneficiary and provider surveys, but  because of methodological considerations TMA used a different approach  for its selection of survey areas. (See app. II for a more detailed  description of DOD’s survey methodology.) Overall, the mandate outlined  specific survey requirements, including the number and priority of areas to  be surveyed each year, the content for each type of survey, and the use of  benchmarks, which can be used to assess survey results. (See table 2.)
According to a TMA official responsible for implementing the surveys,  TMA did not give a high priority to areas where higher concentrations of  Selected Reserve servicemembers live, as specified in the mandate,  because it decided to randomly select the areas to be surveyed in order to  produce results that can be generalized to the populations from which the  survey samples are selected. Moreover, at the end of the 4-year survey  period for the beneficiary and provider surveys, TMA will have surveyed  all areas of the United States, thereby including any locations with a higher  concentration of Selected Reserve servicemembers. A TMA official also  told us that TMA conducted additional analyses of the 2008 beneficiary  survey results for TRICARE Reserve Select beneficiaries to obtain  additional information about the Selected Reserve servicemembers, and  plans to do so in the remaining 3 years of the survey. TMA found that its  2008 results indicate that TRICARE access is no different for the Selected  Reserve servicemembers than for other beneficiaries in the surveyed  areas.
section_title: A Higher Percentage of Nonenrolled Beneficiaries Reported Problems Accessing Certain Providers in Prime Service Areas, Though in General Beneficiaries Rated Their Satisfaction Similarly to Users of Other Health Plans
paragraphs: The first year’s results of TMA’s 4-year beneficiary survey are  representative of the nonenrolled beneficiary population in the combined  Prime Service Areas and combined non-Prime Service Areas that were  selected for the 2008 survey. Based on our analysis of these results, we  estimated that a higher percentage of nonenrolled beneficiaries in  surveyed Prime Service Areas experienced problems accessing care from  network or nonnetwork primary care physicians or nurses than  beneficiaries in surveyed non-Prime Service Areas. However, we could not  determine whether beneficiary access problems were related to TRICARE  network providers because the survey did not ask beneficiaries to link  problems accessing care with network or nonnetwork providers.  However, we did find that the types of access problems beneficiaries  experienced, such as providers not accepting TRICARE payments, were  similar in Prime Service Areas and non-Prime Service Areas. In addition,  we found that nonenrolled beneficiaries in both the surveyed Prime  Service Areas and the surveyed non-Prime Service Areas rated their health  care satisfaction similarly to each other and to beneficiaries of commercial  health care plans, but slightly lower than Medicare beneficiaries.
subsections: section_title: Despite a Low Response Rate, TMA’s 2008 Beneficiary Survey Results Are Representative of the Nonenrolled Beneficiary Population for the Combined Areas Surveyed
paragraphs: Despite an overall response rate of about 38 percent, TMA’s 2008  beneficiary survey results are representative of the nonenrolled  beneficiary population for the combined Prime Service Areas and  combined non-Prime Service Areas surveyed. (See fig. 3.) Because of the  low response rate, TMA conducted a nonresponse analysis to determine  whether the responses it received were representative of the surveyed  population. The nonresponse analysis indicated that there were no  differences in demographic characteristics and health coverage between  beneficiary survey respondents and nonrespondents. As a result, the  results can be generalized to the combined areas surveyed—that is, the  survey produced results that are representative of all nonenrolled  beneficiaries in the 20 surveyed Prime Service Areas and all nonenrolled  beneficiaries in the 20 surveyed non-Prime Service Areas.
section_title: 2008 Survey Results Indicate That a Higher Percentage of Nonenrolled Beneficiaries in Prime Service Areas Experienced Problems Accessing Care from Primary Care Physicians or Nurses Than Those in Non-Prime Service Areas
paragraphs: Based on our analysis of the 2008 survey results, we estimated that a  higher percentage of nonenrolled beneficiaries in surveyed Prime Service  Areas experienced problems accessing care from network or nonnetwork  primary care physicians or nurses than nonenrolled beneficiaries in  surveyed non-Prime Service Areas. Specifically, about 30 percent of  beneficiaries in Prime Service Areas experienced problems finding a  civilian primary care physician or nurse, compared to about 24 percent of  beneficiaries in non-Prime Service Areas. (See table 3.) While we found  differences in access to care problems between nonenrolled beneficiaries  in the surveyed Prime Service Areas and non-Prime Service Areas for  other types of providers, these differences were not statistically significant  at the 95 percent confidence level.
We could not determine the extent to which beneficiaries’ access  problems were related to TRICARE network or nonnetwork providers  because the 2008 beneficiary survey did not ask beneficiaries to link their  problems accessing care with network or nonnetwork providers.  However, in our analysis of the 2008 beneficiary survey results, we found  that the specific types of access problems experienced by beneficiaries in  Prime Service Areas and non-Prime Service Areas are similar. (See   table 4.) For example, we found that the problem most commonly  reported by nonenrolled beneficiaries in both Prime and non-Prime  Service Areas, regardless of the type of provider, was that their provider  was not accepting TRICARE payments. Other commonly reported reasons  varied by provider type.
section_title: Nonenrolled Beneficiaries in Prime Service Areas and Non-Prime Service Areas Surveyed in 2008 Rated Satisfaction with Their Health Care Similarly to Each Other and to Beneficiaries of Commercial Health Care Plans
paragraphs: Despite differences in the percentage of beneficiaries in surveyed Prime  and non-Prime Service Areas reporting problems accessing care from  primary care physicians or nurses, our analysis showed that nonenrolled  beneficiaries’ ratings for several categories of health care were similar in  the surveyed Prime Service Areas and non-Prime Service Areas.  Specifically, our analysis of beneficiaries’ ratings for four categories of  health care—their satisfaction with providers of primary care and  specialty care, their health care, and their health plan—indicates no  statistically significant difference between beneficiaries in surveyed Prime  Service Areas and non-Prime Service Areas. For example, we estimated  that 75 percent of beneficiaries in surveyed Prime Service Areas and   74 percent of beneficiaries in surveyed non-Prime Service Areas rated  their health plan “7” or higher on a 0 to 10 scale (with 0 being the worst  possible).
Estimated ratings for nonenrolled beneficiaries in surveyed areas are also  similar to the estimated ratings of beneficiaries in commercial health  plans, based on data we analyzed from HHS’s 2008 Consumer Assessment  of Healthcare Providers and Systems survey. Specifically, in all four  satisfaction categories there are no statistically significant differences in  the estimated percentage of beneficiaries who rated their satisfaction “7”  or higher. (See fig. 4.) However, estimated ratings for nonenrolled  beneficiaries in surveyed areas were slightly lower than estimated ratings  of Medicare beneficiaries across three of the satisfaction categories— primary care physician or nurse, specialist physician, and health plan.
section_title: 2008 Provider Survey Results Are Not Representative of All Providers in Surveyed Areas but Provide Limited Information That Indicates Differences among Respondents’ Awareness and Acceptance of TRICARE
paragraphs: Although the first year’s results of TMA’s 4-year provider survey are not  representative of all providers in the areas surveyed, the results we  analyzed do provide information about access to care based on the  specific views of the respondents. According to a TMA official,  generalizability of provider survey results to the entire country will likely  be possible at the end of the 4-year survey period. Our analysis of the 2008  provider survey results indicate that a lower percentage of respondents  from Prime Service Areas were aware of TRICARE and were accepting  new TRICARE patients than providers who responded from non-Prime  Service Areas. The survey results also indicate that respondents from the  additional areas TMA surveyed reported levels of awareness and  acceptance of TRICARE that were similar to respondents in non-Prime  Service Areas. Additionally, there were differences between the  responding physicians (primary care physicians and specialists) and  mental health providers (psychiatrists, certified clinical social workers,  clinical psychologists, and others) regarding their awareness and  acceptance of TRICARE.
subsections: section_title: 2008 Provider Survey Results Are Not Representative of the Provider Population in the Areas TMA Surveyed
paragraphs: Unlike the 2008 beneficiary survey, the results of the 2008 provider survey  are not representative of all physicians and mental health providers in the  areas TMA surveyed. The 2008 provider survey was administered in the  same 20 Prime Service Areas and 20 non-Prime Service Areas as the  beneficiary survey, as well as 21 additional locations that were identified  as having access-to-care problems, with an overall response rate of about  45 percent. (See fig. 5.) Because of the low response rate, TMA conducted  a nonresponse analysis, and the results of this analysis indicated that there  were differences among those who responded to the provider survey and  those who did not. Specifically, those who did not respond to the 2008  provider survey were less likely to be aware of TRICARE and less likely to  accept TRICARE reimbursement as payment for services. As a result of  these differences—even though the survey sample was randomly  selected—the survey results cannot be generalized to all physicians and  mental health providers in the areas surveyed and can be presented only  as the specific views of the respondents. Similarly, because the 2008  survey results cannot be generalized, we did not compare them with the  2008 beneficiary survey results.
A TMA official stated that because more responses will have been  obtained by the end of the 4-year survey, generalizability of provider  survey results to the entire country will likely be possible. Moreover, the  TMA official noted that TMA has decided to redesign the method of  selecting mental health providers in the 2009 survey to increase the  number of responses and the likelihood that survey results could be  generalized.
section_title: 2008 Provider Survey Results Indicate Differences among Respondents’ Awareness and Acceptance of TRICARE
paragraphs: Our review of the 2008 provider survey results indicated differences in  awareness and acceptance of TRICARE among respondents in Prime  Service Areas, non-Prime Service Areas, and the additional Hospital  Service Areas TMA surveyed. (See table 5.) Specifically, a lower  percentage of responding providers—physicians and nonphysician mental  health providers—from Prime Service Areas were aware of the TRICARE  program and were accepting new TRICARE patients, if they were  accepting any new patients or any new Medicare patients, than providers  who responded from non-Prime Service Areas or Hospital Service Areas.  For example, 64 percent of the respondents in the surveyed Prime Service  Areas who reported that they are accepting any new patients reported that  they would accept nonenrolled TRICARE beneficiaries as new patients,  compared to 76 percent of respondents in the surveyed non-Prime Service  Areas and 72 percent of respondents in the surveyed Hospital Service  Areas. Additionally, survey results indicate that in Hospital Service Areas,  respondents reported awareness and acceptance of TRICARE that was  similar to that of respondents in non-Prime Service Areas.
The reason most often cited by respondents in both Prime Service Areas  and non-Prime Service Areas for not accepting nonenrolled beneficiaries  as new patients, if they were accepting any new patients at all, was that  they were not aware of the TRICARE program. Other reasons included  concerns about low reimbursement rates and that the provider did not  participate in TRICARE’s provider network. Respondents in Hospital  Service Areas reported similar reasons, such as concerns about low  reimbursement rates and not being aware of the TRICARE program, with  the most cited reason being that they were not participating in TRICARE’s  provider network.
The physicians and mental health providers who responded to the survey  differed in their awareness and acceptance of TRICARE. Specifically, a  higher percentage of responding physicians reported awareness and  acceptance of TRICARE than the mental health providers who responded.  (See table 6.) For example, 81 percent of the physicians who responded  reported that they would accept new TRICARE patients, if they were  accepting any new patients at all, compared to 50 percent of the mental  health providers who responded.
section_title: Agency Comments
paragraphs: We received comments on a draft of this report from DOD. (See app. VI.)  DOD concurred with our overall findings and provided technical  comments, which we incorporated where appropriate.
We are sending copies of this report to the Secretary of Defense and  appropriate congressional committees. The report is also available at no  charge on GAO’s Web site at http://www.gao.gov.
section_title: Appendix I: Selected Office of Management and Budget Standards for Statistical Surveys
paragraphs: 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. The NDAA 2008 also directed us to review the  processes, procedures, and analyses used by DOD to determine the  adequacy of the number of health care and mental health care providers  that currently accept nonenrolled beneficiaries as patients. To evaluate the  methodology DOD used to implement the beneficiary and provider  surveys, we reviewed the Office of Management and Budget’s (OMB)  Standards and Guidelines for Statistical Surveys (2006) to identify key  aspects and best practices of statistical survey methodology that result in  sound survey design and implementation. We focused our evaluation on  standards that address, among other things, designing a survey, developing  sampling frames, collecting survey data, and analyzing survey response  rates. Table 7 provides a description of these standards.
section_title: Appendix II: DOD’s Methodology for the 2008 Beneficiary and Provider Surveys
paragraphs: The NDAA 2008 directed DOD to determine the adequacy of the number of  health care and mental health care providers that currently accept  nonenrolled beneficiaries as patients under TRICARE, DOD’s health care  program. For the purpose of this report, we refer to beneficiaries who are  not enrolled in TRICARE Prime—that is, those who use TRICARE  Standard, TRICARE Extra, or TRICARE Reserve Select—as nonenrolled  beneficiaries. The mandate also included specific requirements related to  the number and priority of areas to be surveyed, including the populations  to be surveyed each year, the content for each type of survey, and the use  of benchmarks. Within DOD, the TRICARE Management Activity (TMA),  which oversees the TRICARE program, had responsibility for designing  and implementing the beneficiary and provider surveys. The following  information describes TMA’s methodology, including its actions to address  the requirements for each of the following: (1) survey area, (2) sample  selection, (3) survey content, and (4) the establishment of benchmarks. It  also provides information on TMA’s analyses of its 2008 beneficiary and  provider surveys.
subsections: section_title: Beneficiary and Provider Survey Area Selection
paragraphs: The NDAA 2008 specified that DOD survey beneficiaries and providers in  at least 20 TRICARE Prime Service Areas, and 20 geographic areas in  which TRICARE Prime is not offered—referred to as non-Prime Service  Areas—each fiscal year, 2008 through 2011. The NDAA 2008 also required  DOD to consult with representatives of TRICARE beneficiaries and health  care and mental health care providers to identify locations where  nonenrolled beneficiaries have experienced significant access-to-care  problems, and give a high priority to surveying health care and mental  health care providers in these areas. Additionally, the NDAA 2008 required  DOD to give a high priority to surveying areas in which higher  concentrations of Selected Reserve servicemembers live.
In designing the 2008 beneficiary and provider surveys, TMA defined 80  Prime Service Areas and 80 non-Prime Service Areas that will allow it to  survey the entire country over a 4-year period and to develop estimates of  access to health care and mental health care at service area, state, and  national levels. TMA identified the 80 Prime Service Areas by collecting zip  codes where TRICARE Prime was offered from officials within each of the  three TRICARE Regional Offices. TMA grouped these zip codes into 80  nonoverlapping areas so that each area had roughly the same number of  TRICARE-eligible beneficiaries. Because non-Prime Service Areas had not  previously been defined, TMA sought to define them by grouping all zip  codes not in Prime Service Areas into one large area using Hospital  Referral Regions, which are groupings of Hospital Service Areas. TMA  divided the large area into 80 non-Prime Service Areas so that each area  had roughly the same number of TRICARE-eligible beneficiaries.
To identify locations where beneficiaries and health care and mental  health care providers have identified significant levels of access-to-care  problems under TRICARE Standard and Extra, TMA spoke with groups  representing beneficiaries and health care and mental health care  providers as well as TRICARE Regional Offices. These groups suggested  cities and towns where access should be measured, and Hospital Service  Areas corresponding to each city and town were then identified. Based on  the groups’ recommendations, a list was created and sorted in priority  order, resulting in 21 Hospital Service Areas being included in the 2008  provider survey. Additionally, TMA plans to include these 21 Hospital  Service Areas in its 2009 beneficiary survey along with additional areas  that are identified for 2009. Although the NDAA 2008 required DOD to give  a high priority to surveying areas in which higher concentrations of  Selected Reserve servicemembers live, TMA decided to randomly select  areas for the surveys in order to produce results that could be generalized  to the populations in the areas surveyed.
section_title: Selection of Beneficiary and Provider Survey Sample
paragraphs: TMA selected its sample of beneficiaries who met its criteria for inclusion  in the beneficiary survey using DOD’s Defense Enrollment Eligibility  Reporting System (DEERS), a database of DOD beneficiaries who may be  eligible for military health benefits. TMA determined a beneficiary’s  eligibility to be included in the 2008 beneficiary survey if DEERS indicated  that the individual met five criteria: (1) eligible for military health care  benefits as of the date of the sample file extract; (2) age 18 years old or  older; (3) not an active duty member of the military; (4) residing in one of  the 20 randomly selected Prime Service Areas or 20 randomly selected  non-Prime Service Areas; and (5) a user of TRICARE Reserve Select, or  not enrolled in TRICARE Prime. From this database, TMA randomly  sampled about 1,000 beneficiaries from each Prime Service Area and non- Prime Service Area—a sample size that would achieve TMA’s desired  sample error. Specifically, TMA surveyed 48,548 TRICARE beneficiaries  representing active duty, retired, and Reserve servicemembers, including  the Selected Reserve. TMA began mailing the beneficiary survey in June  2008. After receiving the returned surveys, TMA identified the responses  that it considered complete and eligible based on whether the beneficiary  had answered at least half of TMA’s identified “key” questions and  answered that he or she used “TRICARE Extra or Standard” or “TRICARE  Reserve Select” in response to the following question: “Which health plan  did you use for all or most of your health care in the last 12 months?”
TMA selected the provider sample within the same 20 Prime Service Areas  and 20 non-Prime Service Areas that had been randomly selected for the  2008 beneficiary survey. In addition, TMA mailed surveys to physicians  and mental health providers in the 21 Hospital Service Areas identified by  beneficiary and provider groups as having significant levels of access-to-  care problems under TRICARE Standard and Extra. TMA used the  American Medical Association Physician Masterfile (Masterfile) to select a  sample of 20,030 physicians who were licensed office-based civilian  medical doctors or licensed civilian doctors of osteopathy within the  specified locations who were engaged in more than 20 hours of patient  care each week. The Masterfile is a database of physicians in the United  States—Doctors of Medicine and Doctors of Osteopathic Medicine—that  includes data on all physicians who have the necessary educational and  credentialing requirements. The Masterfile did not differentiate between  TRICARE’s network and nonnetwork civilian providers, which TMA  deemed acceptable to avoid any potential bias in TMA’s sample selection.  As such, TMA selected this file because it is widely recognized as one of  the best commercially available lists of providers in the United States and  it contains over 940,000 physicians along with their addresses; phone  numbers; and information on practice characteristics, such as their  specialty. According to TMA, the American Medical Association updates  physicians’ addresses monthly and other elements through a rotating  census methodology involving approximately one-third of the physician  population each year. Although the Masterfile is considered to contain  most providers, deficiencies in coverage and inaccuracies in detail remain.  Therefore, TMA attempted to update providers’ addresses and phone  numbers and to ensure that providers were eligible for the survey by also  using state licensing databases, local commercial lists, and professional  society and association lists. For its mental health provider sample, TMA  selected a sample of 20,386 mental health providers from two sources: the  National Plan and Provider Enumeration System database maintained by  the Centers for Medicare & Medicaid Services, and from LISTS, Inc., a list  of names with contact information assembled from state licensing boards.  According to TMA, it selected these sources for mental health providers  because they have been identified as the most comprehensive databases  for these health care providers. TMA did not include all physician  specialist types, such as epidemiologists and pathologists, in its survey.  From these data sets, TMA planned to randomly sample about 800  providers (400 each of physicians and mental health providers) from each  Prime Service Area, non-Prime Service Area, and Hospital Service Area—a  sample size that would achieve TMA’s desired sample error. In those  instances where there were not 800 providers in a single area, TMA  selected all of the providers in that area to receive surveys. TMA began  mailing the provider survey in December 2008. Upon receipt of the  returned surveys, TMA identified the responses that it considered  completed and eligible based on the following criteria for respondents:   (1) if the provider answered “yes” to the questions that asked whether the  provider offers care in an office-based location or private practice; (2) for  the nonphysician mental health survey, if the provider responded that he  or she was in one of the six TRICARE participating specialties—certified  clinical social worker, certified psychiatric nurse specialist, clinical  psychologist, certified marriage and family therapist, pastoral counselor,  or mental health counselor; and (3) if the provider had completed three  key questions on the physician survey instrument or three key questions  on the nonphysician mental health provider survey instrument.
section_title: Beneficiary and Provider Survey Content
paragraphs: The NDAA 2008 required that the beneficiary survey include questions to  determine whether TRICARE Standard and Extra beneficiaries have had  difficulties finding physicians and mental health providers willing to  provide services under TRICARE Standard or TRICARE Extra. TMA’s  beneficiary survey included 91 questions that address, among other things,  health care plans used; perceived access to care from a personal doctor,  nurse, or specialist; the need for treatment or counseling; and ratings of  health plans. TMA based some of its 2008 beneficiary survey questions on  those included in the Department of Health and Human Services’ 2006  Consumer Assessment of Healthcare Providers and Systems, a national  survey of beneficiaries of commercial health insurance, Medicare,  Medicaid, and the Children’s Health Insurance Program. When TMA began  mailing the beneficiary survey, it included a combined cover letter and a  questionnaire to all beneficiaries in its sample—with the option of having  beneficiaries complete the survey by mail or Internet. (See app. III for a  copy of the 2008 beneficiary survey instrument.) The cover letter provided  information on the options available for completing the survey, as well as  instructions for completing the survey by Internet. If the beneficiary did  not respond to the mailed questionnaire, TMA mailed a second combined  cover letter and questionnaire 4 weeks later encouraging the beneficiary to  complete the survey.
For the provider survey, the NDAA 2008 required questions to determine  (1) whether the provider is aware of TRICARE; (2) the percentage of the  provider’s current patient population that uses any form of TRICARE;   (3) whether the provider accepts Medicare patients for health care and  mental health care; and (4) if the provider accepts Medicare patients,  whether the provider would accept new Medicare patients. TMA obtained  clearance for its provider survey from OMB as required under the  Paperwork Reduction Act. Subsequent to this review, OMB approved an  11-item questionnaire for physicians (including psychiatrists) and a   12-item questionnaire for nonphysician mental health providers to be  administered in fiscal year 2008. (See app. IV for a copy of the 2008  provider survey instruments.) The mental health providers’ version of the  survey includes an additional question about what type of mental health  care the provider practiced.
When TMA began mailing the provider survey, it included a combined  cover letter and a questionnaire to each provider in the sample. The  providers had the option of completing the survey by mail, fax, or Internet.  The cover letter provided information on the options available for  completing the survey, as well as instructions for completing the survey by  Internet. If the provider did not respond to the mailed questionnaire, TMA  mailed a second combined cover letter and questionnaire about 4 weeks  later encouraging the provider to complete the survey.
section_title: Beneficiary and Provider Survey Benchmarks
paragraphs: In accordance with the NDAA 2008, TMA identified benchmarks for  analyzing the results of the beneficiary and provider surveys. Because  TMA based some of its 2008 beneficiary survey questions on those  included in the Department of Health and Human Services’ 2006 Consumer  Assessment of Healthcare Providers and Systems survey, it was able to  compare the results of those questions with its 2008 beneficiary survey  results. To benchmark its provider survey, TMA compared the results of  its 2008 survey with the results of its 2005, 2006, and 2007 provider  surveys. A TMA official noted that TMA was unaware of any external  benchmarks that would be applicable to its surveys of providers.
section_title: Analyses of Beneficiary and Provider Survey Results
paragraphs: In analyzing the results of the beneficiary survey, TMA representatives  conducted a nonresponse analysis because the overall response rate to the  survey was about 38 percent. To conduct this analysis, TMA did the  following: (1) compared key beneficiary demographic characteristics of  respondents to those of nonrespondents (e.g., beneficiary gender and age)  and (2) interviewed a sample of 400 beneficiaries who did not respond to  the original survey or the follow-up mailing and compared their responses  with those of the original survey respondents. The results of TMA’s  nonresponse analysis indicated no difference in demographic  characteristics and health coverage between beneficiary survey  respondents and nonrespondents within the combined Prime Service  Areas and combined non-Prime Service Areas surveyed in fiscal year 2008.  Therefore, TMA concluded that the survey respondents were  representative of the combined Prime Service Areas and combined non- Prime Service Areas surveyed, and the results of the survey can be  generalized to the population from which the sample was chosen. TMA  weighted each response so that the sampled beneficiaries represented the  population in terms of size for the respective Prime Service Area or non- Prime Service Area from which they were selected.
In analyzing the results of the provider survey, TMA conducted a  nonresponse analysis because the overall response rate to the survey was  about 45 percent. To conduct this analysis, TMA did the following:   (1) compared key provider demographic characteristics of respondents to  those of nonrespondents (for example, provider type and location) and   (2) interviewed a sample of 247 providers (140 physicians and 107 mental  health providers) who did not respond to the original survey, follow-up  mailing, or follow-up telephone calls and compared their responses with  those of the original survey respondents. The results of TMA’s  nonresponse analysis indicated that there are differences between  respondents and those who did not respond to the original 2008 provider  survey. Specifically, among both types of providers (physicians and mental  health providers), nonrespondents are less likely to be aware of TRICARE  and less likely to accept TRICARE as a form of payment for services.  Additionally, nonrespondents are less likely to be accepting new patients.  Therefore, the survey results cannot be generalized to the population from  which the sample was chosen and can only be presented in terms of those  civilian providers who responded to the survey.
section_title: Appendix III: Beneficiary Survey Instrument
paragraphs: The NDAA 2008 directed DOD to determine the adequacy of the number of health  care and mental health care providers that currently accept nonenrolled beneficiaries  as patients under TRICARE, DOD’s health care program. For the purpose of this  report, we refer to beneficiaries who are not enrolled in TRICARE Prime—that is,  those who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select—as  nonenrolled beneficiaries. Specifically, the NDAA 2008 specified that DOD conduct  surveys of beneficiaries each fiscal year, 2008 through 2011. The NDAA 2008 also  required that the beneficiary survey include questions seeking information from  nonenrolled beneficiaries to determine whether they have had difficulties finding  health care and mental health care providers willing to accept them as patients.  Following is the actual survey instrument that DOD used to obtain information from  nonenrolled beneficiaries.
section_title: Appendix IV: Survey Instruments for Health Care and Mental Health Care Providers
paragraphs: The NDAA 2008 directed DOD to determine the adequacy of the number of  health care and mental health care providers that currently accept  nonenrolled beneficiaries as patients under TRICARE, DOD’s health care  program. For the purpose of this report, we refer to beneficiaries who are  not enrolled in TRICARE Prime—that is, those who use TRICARE  Standard, TRICARE Extra, or TRICARE Reserve Select—as nonenrolled  beneficiaries. Specifically, the NDAA 2008 directed DOD to survey  providers each fiscal year, 2008 through 2011. The NDAA 2008 also  required that the provider survey include questions seeking information to  determine (1) whether the provider is aware of the TRICARE program;   (2) the percentage of the provider’s current patient population that uses  any form of TRICARE; (3) whether the provider accepts Medicare patients;  and (4) if the provider accepts Medicare patients, whether the provider  would accept new Medicare patients. DOD implemented two versions of  its provider survey, one for physicians, including psychiatrists, and one for  nonphysician mental health providers. Following are the actual survey  instruments that DOD used to obtain information from physicians and  nonphysician mental health care providers.
section_title: Appendix V: Areas Included in the Fiscal Year 2008 Beneficiary and Provider Surveys
paragraphs: The NDAA 2008 directed DOD to determine the adequacy of the number of  health care providers and mental health care providers that currently  accept nonenrolled beneficiaries as patients under TRICARE, DOD’s  health care program. For the purpose of this report, we refer to  beneficiaries who are not enrolled in TRICARE Prime—that is, those who  use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select—as  nonenrolled beneficiaries. The NDAA 2008 specified that DOD conduct  surveys of TRICARE beneficiaries and health care and mental health care  providers in 20 TRICARE Prime Service Areas and in 20 areas in which  TRICARE Prime is not offered—referred to as non-Prime Service Areas— for each fiscal year, 2008 through 2011. Additionally, the NDAA 2008  required DOD to consult with representatives of TRICARE beneficiaries  and health care and mental health care providers to identify locations  where nonenrolled beneficiaries have experienced significant access-to- care problems, and give a high priority to surveying health care and mental  health care providers in these areas. For the 2008 beneficiary and provider  surveys, DOD selected 20 Prime Service Areas and 20 non-Prime Service  Areas to determine the adequacy of the number of health care providers  and mental health care providers who currently accept nonenrolled  TRICARE beneficiaries as patients. For the 2008 provider survey, DOD  also surveyed 21 additional areas identified by beneficiary and provider  groups where nonenrolled beneficiaries are experiencing significant levels  of access-to care problems—called Hospital Service Areas—to determine  the adequacy of access to care in these areas. DOD’s selected Prime  Service Areas and non-Prime Service Areas for 2008 are presented in table  8 and table 9, respectively. Table 10 lists those locations identified by  representatives of TRICARE beneficiaries and health care and mental  health care providers as having significant levels of access-to-care  problems, which were included in the 2008 provider survey.
section_title: Appendix VI: Comments from the Department of Defense
section_title: Appendix VII: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Bonnie Anderson, Assistant  Director; Martha Kelly, Assistant Director; Susannah Bloch; Peter  Mangano; Jeff Mayhew; Lisa Motley; Jessica C. Smith; C. Jenna Sondhelm;  and Suzanne Worth made key contributions to this report.