Defense Health Care: DOD Lacks Assurance That Selected Reserve Members Are Informed about TRICARE Reserve Select
Published: 2011-06-03T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: TRICARE Reserve Select (TRS) provides certain members of the Selected Reserve--reservists considered essential to wartime missions--with the ability to purchase health care coverage under the Department of Defense's (DOD) TRICARE program after their active duty coverage expires. TRS is similar to TRICARE Standard, a fee-forservice option, and TRICARE Extra, a preferred provider option. The National Defense Authorization Act for Fiscal Year 2008 directed GAO to review TRS education and access to care for TRS beneficiaries. This report examines (1) how DOD ensures that members of the Selected Reserve are informed about TRS and (2) how DOD monitors and evaluates access to civilian providers for TRS beneficiaries. GAO reviewed and analyzed documents and evaluated an analysis of claims conducted by DOD. GAO also interviewed officials with the TRICARE Management Activity (TMA), the DOD entity responsible for managing TRICARE; the regional TRICARE contractors; the Office of Reserve Affairs; and the seven reserve components.
section_title: What GAO Found
paragraphs: DOD does not have reasonable assurance that Selected Reserve members are informed about TRS. A 2007 policy designated the reserve components as having responsibility for providing information about TRS to Selected Reserve members on an annual basis; however, officials from three of the seven components told GAO that they were unaware of this policy. Additionally, only one of the reserve components had a designated official at the headquarters level acting as a central point of contact for TRICARE education, including TRS. Without centralized responsibility for TRS education, the reserve components cannot ensure that all eligible Selected Reserve members are receiving information about the TRS program. Compounding this, the managed care support contractors that manage civilian health care are limited in their ability to educate all reserve component units in their regions as required by their contracts because they do not have access to comprehensive information about these units, and some units choose not to use the contractors to help educate their members about TRS. Nonetheless, DOD officials stated that they were satisfied with the contractors' efforts to educate units upon request and to conduct outreach. Lastly, it is difficult to determine whether Selected Reserve members are knowledgeable about TRS because the results of two DOD surveys that gauged members' awareness of the program may not be representative because of low response rates. Because TRS is the same benefit as the TRICARE Standard and Extra options, DOD monitors access to civilian providers for TRS beneficiaries in conjunction with TRICARE Standard and Extra beneficiaries. DOD has mainly used feedback mechanisms, such as surveys, to gauge access to civilian providers for these beneficiaries in the absence of access standards for these options. GAO found that jointly monitoring access for these two beneficiary groups is reasonable because a claims analysis showed that TRS beneficiaries and TRICARE Standard and Extra beneficiaries had similar health care utilization. Also, during the course of GAO's review, TMA initiated other efforts that specifically evaluated access to civilian providers for the Selected Reserve population and TRS beneficiaries, including mapping the locations of Selected Reserve members in relation to areas with TRICARE provider networks.
section_title: What GAO Recommends
paragraphs: GAO recommends that the Secretary of Defense direct the Assistant Secretary of Defense for Reserve Affairs to develop a policy requiring each reserve component to designate a centralized point of contact for TRS education. DOD partially concurred with this recommendation, citing a concern about regional coordination. GAO modified the recommendation.

section_title: Letter
paragraphs: Since the September 11, 2001, terrorist attacks, the Department of Defense  (DOD) has increasingly relied on reservists to support military operations,  such as the conflicts in Iraq and Afghanistan. This has increased both the  number of Selected Reserve members—reservists who are considered  essential to wartime missions—supporting DOD’s current operations and  the duration of their active duty service. In recognition of this, Congress  has increased the health care benefits available to reservists and their  dependents, which include spouses and dependent children. Specifically,  the National Defense Authorization Acts (NDAA) for Fiscal Years 2004,  2005, 2006, 2007, and 2010 expanded the number of reservists (including  Selected Reserve members) who qualify for TRICARE, the military health  care program, and increased the period of time during which they qualify.  The NDAA for Fiscal Year 2005 also established the program that DOD has  named TRICARE Reserve Select (TRS), under which most members of the  Selected Reserve who are not on active duty may purchase TRICARE  coverage after the coverage associated with active duty expires. TRS is the  same benefit as TRICARE Standard, a fee-for-service option, and  TRICARE Extra, a preferred provider option. All three programs cover  health care provided at military treatment facilities and through civilian  providers, both network (TRICARE Extra) and nonnetwork (TRICARE  Standard). However, unlike TRICARE beneficiaries who use the Standard  and Extra options, TRS enrollees must pay a monthly premium to receive  benefits through the program.
In recent years, members of Congress have raised questions about  whether reservists, including members of the Selected Reserve, and their  dependents have adequate health insurance when they are not on active  duty and whether they have difficulty using TRICARE when they are  eligible for it. In 2007, we reported on several issues related to reservists,  including DOD’s efforts to educate reservists and their dependents about  TRICARE benefits, reservists’ satisfaction with TRICARE, and the types of  problems that reservists and their dependents experienced when using  TRICARE. We found that DOD was challenged by the task of educating  reservists and their dependents about TRICARE, and we recommended  that DOD provide additional briefings to reservists and their dependents at  specific points in time. We also found that although a majority of reservists  reported that they were satisfied with their TRICARE benefits, some  reservists reported experiencing difficulties when using the program,  including difficulties understanding TRICARE and difficulties finding a  health care provider who accepted TRICARE beneficiaries as patients.
Subsequent to our report, the Commission on the National Guard and  Reserves reported to Congress in 2008 that the TRICARE Management  Activity (TMA)—the DOD entity responsible for overseeing TRICARE— and the military services have not undertaken a sufficiently aggressive  educational campaign to help improve reservists’ and their families’  understanding of TRICARE. More recently, groups representing military  beneficiaries told us that they were concerned about low enrollment  within the TRS program, and they questioned whether these enrollment  numbers are the result of inadequate education by DOD. According to  DOD officials, as of December 2010 about 392,000 of the more than  858,000 members of the Selected Reserve were eligible for TRS. Of these,  about 67,000 members (17 percent) had purchased TRS.
Concerns have also been expressed about the ability of reservists,  including members of the Selected Reserve, and their families to access  health care. In June 2007, DOD’s Task Force on Mental Health reported  that because reservists may not live near military installations like their  active duty counterparts, they may not have convenient access to military  hospitals and clinics and must instead rely more heavily on civilian  providers for their care.
The NDAA for Fiscal Year 2008 directed us to review DOD’s efforts to  educate members of the Selected Reserve about TRS and access to care  for TRS beneficiaries. This report examines (1) how DOD ensures that  members of the Selected Reserve are informed about TRS and (2) how  DOD monitors and evaluates access to civilian providers for TRS  beneficiaries.
To examine how DOD ensures that members of the Selected Reserve are  informed about TRS and how DOD monitors and evaluates access to  civilian providers for TRS beneficiaries, we interviewed officials with  TMA, including officials with the Warrior Support Branch, which oversees  TRS, and officials with the Communications and Customer Service  Division, which develops educational materials for TRICARE. We also  interviewed officials from each of the three TRICARE Regional Offices  (North, South, and West) and officials from each of the regional managed  care support contractors (contractors) to discuss their responsibilities for  educating members of the Selected Reserve about TRICARE, including  TRS, and for ensuring beneficiaries’ access to civilian providers. In  addition, we interviewed officials from military coalition groups that  represent reservists to obtain their perspectives on TRS education and  access to civilian providers. To identify TRS education requirements, we  reviewed and analyzed policy guidelines and TRICARE managed care  support contract requirements. We interviewed officials with the Office of  Reserve Affairs as well as officials from each of the seven reserve  components to identify their role in educating the Selected Reserve about  TRICARE. We also reviewed relevant standards for internal control in the  federal government. Additionally, we evaluated two surveys conducted by  DOD that collected information on whether members of the Selected  Reserve were aware of the TRS program—the Status of Forces Survey and  the Focused Survey of TRICARE Reserve Select and Selected Reserve  Military Health System Access and Satisfaction.
To determine how DOD monitors and evaluates access to civilian  providers for TRS, we reviewed TMA’s beneficiary surveys on access to  civilian providers under TRICARE Standard, TRICARE Extra, and TRS. We  also reviewed the TRICARE Regional Offices’ recent efforts to evaluate the  adequacy of access to civilian providers under the TRICARE Standard,  TRICARE Extra, and TRS options. Additionally, we evaluated an analysis  of claims conducted by TMA—at our request—that compared claims filed  by TRICARE Standard and Extra beneficiaries with those filed by TRS  beneficiaries for fiscal years 2008 through 2010 to identify demographic  differences between these populations and to determine whether these  populations used similar types of providers and obtained similar types of  care. We assessed the reliability of these data by speaking with  knowledgeable officials and reviewing related documentation, and we  determined that the claims analyses presented in this report are  sufficiently reliable for our purposes. (See app. I for more detail about the  claims analyses.) We also reviewed efforts by TMA to identify locations of  the Selected Reserve members and analyze whether they resided within an  area that was served by a TRICARE provider network. Finally, we  reviewed TMA’s efforts to repeat its survey that is specific to the TRS  program (Focused Survey of TRICARE Reserve Select and Selected  Reserve Military Health System Access and Satisfaction).
We conducted this performance audit from July 2010 through June 2011 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: Reservists are members of the seven reserve components, which provide  trained and qualified persons available for active duty in the armed forces  in time of war or national emergency. The Selected Reserve is the largest  category of reservists and is designated as essential to wartime missions.  The Selected Reserve is also the only category of reservists that is eligible  for TRS. As of December 31, 2010, the Selected Reserve included 858,997  members dispersed among the seven reserve components with about two- thirds belonging to the Army Reserve and the Army National Guard. See  figure 1 for the number and percentage of Selected Reserve members  within each reserve component.
Additionally, about two-thirds of the Selected Reserve members are   35 years old or younger (64 percent) and about half are single (52 percent).  (See fig. 2.)
subsections: section_title: History of TRS
paragraphs: The NDAA for Fiscal Year 2005 authorized the TRS program and made  TRICARE coverage available to certain members of the Selected Reserve.  The program was subsequently expanded and restructured by the NDAAs  for Fiscal Years 2006 and 2007—although additional program changes  were made in subsequent years.
In fiscal year 2005, to qualify for TRS, members of the Selected Reserve  had to enter into an agreement with their respective reserve components  to continue to serve in the Selected Reserve in exchange for TRS coverage,  and they were given 1 year of TRS eligibility for every 90 days served in  support of a contingency operation.
The NDAA for Fiscal Year 2006, which became effective on October 1,  2006, expanded the program, and almost all members of the Selected  Reserve and their dependents—regardless of their prior active duty  service—had the option of purchasing TRICARE coverage through a  monthly premium. The portion of the premium paid by the members of the  Selected Reserve and their dependents for TRS coverage varied based on  certain qualifying conditions that had to be met, such as whether the  member of the Selected Reserve also had access to an employer- sponsored health plan. The NDAA for Fiscal Year 2006 established two  levels—which DOD called tiers—of qualification for TRS, in addition to  the tier established by the NDAA for Fiscal Year 2005, with enrollees  paying different portions of the premium based on the tier for which they  qualified.
The NDAA for Fiscal Year 2007 significantly restructured the TRS program  by eliminating the three-tiered premium structure and establishing open  enrollment for members of the Selected Reserve provided that they are not  eligible for or currently enrolled in the FEHB Program. The act removed  the requirement that members of the Selected Reserve sign service  agreements to qualify for TRS. Instead, the act established that members  of the Selected Reserve qualify for TRS for the duration of their service in  the Selected Reserve. DOD implemented these changes on October 1,  2007.
section_title: TRICARE Options and Cycle of Coverage for the Selected Reserve
paragraphs: Generally, 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 information about these  options.
Selected Reserve members have a cycle of coverage during which they are  eligible for different TRICARE options based on their duty status— preactivation, active duty, deactivation, and inactive. During preactivation,  when members of the Selected Reserve are notified that they will serve on  active duty in support of a contingency operation in the near future, they  and their families are eligible to enroll in TRICARE Prime, and therefore,  they do not need to purchase TRS coverage. This is commonly referred to  as “early eligibility” and continues uninterrupted once members of the  Selected Reserve begin active duty. While on active duty, members are  required to enroll in TRICARE Prime. Similarly during deactivation, for  180 days after returning from active duty in support of a contingency  operation, members of the Selected Reserve are rendered eligible for the  Transitional Assistance Management Program, a program to transition  back to civilian life in which members and dependents can use the  TRICARE Standard or Extra options. When members of the Selected  Reserve return to inactive status, they can choose to purchase TRS  coverage if eligible.
As a result of the TRICARE coverage cycle and program eligibility  requirements, TMA officials estimate that at any given time, fewer than  half of the members of the Selected Reserve are qualified to purchase TRS.  Currently, to qualify for TRS, a member of the Selected Reserve must not        be eligible for the FEHB Program,    have been notified that he or she will serve on active duty in support of a    be serving on active duty or have recently, that is, within 180 days,  returned from active duty in support of a contingency operation.
Of the more than 390,000 members eligible, about 67,000 members were  enrolled in TRS as of December 31, 2010. (See fig. 3.)
section_title: DOD Entities Involved with TRS
paragraphs: A number of different DOD entities have various responsibilities related to  TRS.
Within the Office of the Under Secretary of Defense for Personnel and  Readiness, the Office of the Assistant Secretary of Defense for Reserve  Affairs works with the seven reserve components to determine whether  members of the Selected Reserve are eligible for TRS and to ensure that  members have information about TRICARE, including TRS.
Within TMA, the Warrior Support Branch is responsible for managing the  TRS option, which includes developing policy and regulations. This office  also works with TMA’s Communication and Customer Service Division to  develop educational materials for this program. The Assistant Secretary of  Defense for Health Affairs oversees TMA and reports to the Under  Secretary of Defense for Personnel and Readiness.
TMA works with contractors to manage civilian health care and other  services in each TRICARE region (North, South, and West). The  contractors are required to establish and maintain sufficient networks of  civilian providers within certain designated areas, called Prime Service  Areas, to ensure access to civilian providers for all TRICARE beneficiaries,  regardless of enrollment status or Medicare eligibility. They are also  responsible for helping TRICARE beneficiaries locate providers and for  informing and educating TRICARE beneficiaries and providers on all  aspects of the TRICARE program, including TRS.
TMA’s TRICARE Regional Offices, located in each of the three TRICARE  regions, are responsible for managing health care delivery for all TRICARE  options in their respective geographic areas and overseeing the  contractors, including monitoring network quality and adequacy,  monitoring customer satisfaction outcomes, and coordinating  appointment and referral management policies.
section_title: DOD Does Not Have Reasonable Assurance That Selected Reserve Members Are Informed about TRS
paragraphs: DOD does not have reasonable assurance that members of the Selected  Reserve are informed about TRS for several reasons. First, the reserve  components do not have a centralized point of contact to ensure that  members are educated about the program. Second, the contractors are  challenged in their ability to educate the reserve component units in their  respective regions because they do not have comprehensive information  about the units in their areas of responsibility. And, finally, DOD cannot  say with certainty whether Selected Reserve members are knowledgeable  about TRS because the results of two surveys that gauged members’  awareness of the program may not be representative of the Selected  Reserve population because of low response rates.
subsections: section_title: Reserve Components Are Responsible for Providing Information about TRS to Selected Reserve Members, but Most Components Have Not Established Centralized Accountability for TRS Education
paragraphs: A 2007 policy from the Under Secretary of Defense for Personnel and  Readiness designated the reserve components as having responsibility for  providing information about TRS to members of the Selected Reserve at  least once a year. When the policy was first issued, officials from the  Office of Reserve Affairs—who have oversight responsibility for the  reserve components—told us that they met with officials from each of the  reserve components to discuss how the components would fulfill this  responsibility. However, according to officials from the Office of Reserve  Affairs, they have not met with the reserve components since 2008 to  discuss how the components are fulfilling their TRS education  responsibilities under the policy. These officials explained that they have  experienced difficulties identifying a representative from each of the  reserve components to attend meetings about TRS education. When we  contacted officials from all seven reserve components to discuss TRS  education, we had similar experiences. Three of the components had  difficulties providing a point of contact. In fact, two of the components  took several months to identify an official whom we could speak with  about TRS education, and the other one had difficulties identifying  someone who could answer our follow-up questions when our original  point of contact was no longer available. Furthermore, officials from three  of the seven components told us that they were not aware of this policy.
Regardless of their knowledge of the 2007 policy, officials from all of the  reserve components told us that education responsibilities are delegated  to their unit commanders. These responsibilities include informing  members about their health options, which would include TRS. All of the  components provide various means of support to their unit commanders  to help fulfill this responsibility. For example, three of the components  provide information about TRICARE directly to their unit commanders or  the commanders’ designees through briefings. The four other components  provide information to their unit commanders through other means, such  as policy documents, Web sites, and newsletters.
Additionally, while most of the components had someone designated to  answer TRICARE benefit questions, only one of the reserve components  had an official at the headquarters level designated as a central point of  contact for TRICARE education, including TRS. This official told us that  he was unaware of the specific 2007 TRS education policy; however, he  said his responsibilities for TRS education include developing annual  communication plans, providing briefings to unit commanders, and  publishing articles in the Air Force magazine about TRS. Designating a  point of contact is important because a key factor in meeting standards for  internal control in federal agencies is defining and assigning key areas of  authority and responsibility—such as a point of contact for a specific  policy. Without a point of contact to ensure that this policy is  implemented, the reserve components are running the risk that some of  their Selected Reserve members may not be receiving information about  the TRS program—especially since some of the reserve component  officials we met with were unaware of the policy.
section_title: TRICARE Contractors Are Challenged in Their Ability to Annually Brief Reserve Component Units about TRS Because They Lack Comprehensive Information about the Units
paragraphs: The TRICARE contractors are required to provide an annual briefing about  TRS to each reserve component unit in their regions, including both  Reserve and National Guard units. All three contractors told us that they  maintain education representatives who are responsible for educating  members of the Selected Reserve on TRS. These representatives conduct  unit outreach and provide information to members of the Selected Reserve  at any time during predeployment and demobilization, at family events,  and during drill weekends. The contractors use briefing materials  maintained by TMA and posted on the TRICARE Web site. In addition to  conducting briefings, the three contractors have increased their outreach  efforts in various ways, including creating an online tutorial that explains  TRS, mailing TRS information to Selected Reserve members, and working  closely with Family Program coordinators to provide TRS information to  family members.
However, the contractors are challenged in their ability to meet their  requirement for briefing all units annually. First, they typically provide  briefings to units upon request because this approach is practical based  upon units’ schedules and availability. For example, officials from one  contractor told us that even though they know when geographically  dispersed units will be gathering in one location, these units have busy  schedules and may not have time for the contractor to provide a briefing.  Each contractor records the briefings that are requested, when the briefing  requests were fulfilled and by whom, and any questions or concerns that  resulted from the briefings. However, some unit commanders do not  request briefings from the contractors. For example, officials with one  reserve component told us that they do not rely on the contractor to brief  units because they were unaware that the contractors provided this  service. In addition, these officials as well as officials from another reserve  component told us that they did not know if their unit commanders were  aware that they could request briefings from the contractors. All of the  contractors told us that they conduct outreach to offer information to  some of the units that have not requested a briefing, including both calling  units to offer a briefing and providing materials. They added that more  outreach is conducted to National Guard units because they are able to  obtain information about these units from state officials. The TRICARE  Regional Offices also told us that they conduct outreach to units to let  them know that the contractor is available to brief the units about TRS.  However, even though the contractor and the TRICARE Regional Offices  conduct outreach to a unit, it does not necessarily mean that the unit will  request a briefing.
Furthermore, while contractors are aware of some units in their regions,  they do not have access to comprehensive lists of all reserve component  units in their regions because the Web site links containing unit  information that TMA originally provided to the contractors have become  inactive. As a result, the contractors are not able to verify whether all units  in their regions have received briefings. Officials from the Office of  Reserve Affairs told us that reserve components report unit information to  the Defense Manpower Data Center (DMDC), which maintains personnel  information about all members of the military. However, these officials  raised concerns about the accuracy of this information because it could be  about 3 to 6 months old and may not be comprehensive. Officials at the  Office of Reserve Affairs told us that the reserve components would likely  have more up-to-date information about their units as they are responsible  for reporting this information to DMDC. However, officials from TMA, the  TRICARE Regional Offices, and contractors also told us that a  comprehensive list of units would be difficult to maintain because the unit  structure changes frequently.
Despite the challenges contractors face, officials with TMA’s Warrior  Support Branch told us that they are satisfied with the contractors’ efforts  to provide TRS briefings to the reserve component units in their regions.  However, because officials do not know which units have been briefed on  the program, there is a risk that some reserve component members are not  receiving sufficient information on TRS and may not be taking advantage  of coverage available to them.
section_title: DOD Has Conducted Surveys That Gauge TRS Awareness, but the Results May Not Be Representative
paragraphs: DOD has conducted two surveys that gauge whether members of the  Selected Reserve are aware of TRS, among other issues. In 2008, TMA  conducted the Focused Survey of TRICARE Reserve Select and Selected  Reserve Military Health System Access and Satisfaction to better  understand reserve component members’ motivation for enrolling in TRS  and to compare TRS enrollees’ satisfaction with and access to health care  services with that of other beneficiary groups. In reporting the results of  this survey to Congress in February 2009, TMA stated that lack of  awareness was an important factor in why eligible members of the  Selected Reserve did not enroll in TRS. TMA also reported that less than  half of the eligible Selected Reserve members who were not enrolled in  TRS were aware of the program. However, the survey’s response rate  was almost 18 percent, and such a low response rate decreases the  likelihood that the survey results were representative of the views and  characteristics of the Selected Reserve population. According to the Office  of Management and Budget’s standards for statistical surveys, a  nonresponse analysis is recommended for surveys with response rates  lower than 80 percent to determine whether the responses are  representative of the surveyed population. Accordingly, TMA conducted a  nonresponse analysis to determine whether the survey responses it  received were representative of the surveyed population, and the analysis  identified substantial differences between the original respondents and the  follow-up respondents. As a result of the differences found in the  nonresponse analysis, TMA adjusted the statistical weighting techniques  for nonresponse bias and applied the weights to the data before drawing  conclusions and reporting the results.
DMDC conducts a quarterly survey, called the Status of Forces Survey,  which is directed to all members of the military services. DMDC conducts  several versions of this survey, including a version for members of the  reserve components. This survey focuses on different issues at different  points in time. For example, every other year the survey includes  questions on health benefits, including questions on whether members of  the reserve components are aware of TRICARE, including TRS. In July  2010, we issued a report raising concerns about the reliability of DOD’s  Status of Forces Surveys because they generally have a 25 to 42 percent  response rate, and DMDC has not been conducting nonresponse analyses  to determine whether the surveys’ results are representative of the target  population. We recommended that DMDC develop and implement  guidance both for conducting a nonresponse analysis and using the results  of this analysis to inform DMDC’s statistical weighting techniques, as part  of the collection and analysis of the Status of Forces Survey results. DOD  concurred with this recommendation, but as of January 2011, had not  implemented it.
section_title: DOD Monitors Access to Civilian Providers under TRS in Conjunction with Other TRICARE Options and Has Taken Steps to Evaluate Access Specifically for TRS
paragraphs: DOD monitors access to civilian providers under TRS in conjunction with  monitoring efforts related to the TRICARE Standard and Extra options. In  addition, during the course of our review, TMA initiated additional efforts  that specifically examine access to civilian providers for TRS beneficiaries  and the Selected Reserve population, including mapping the locations of  Selected Reserve members in relation to areas with TRICARE provider  networks.
subsections: section_title: DOD Monitors Access to Civilian Providers for TRS Beneficiaries along with TRICARE Standard and Extra Beneficiaries
paragraphs: Because TRS is the same benefit as the TRICARE Standard and Extra  options, DOD monitors TRS beneficiaries’ access to civilian providers as a  part of monitoring access to civilian providers for beneficiaries who use  TRICARE Standard and Extra. As we have recently reported, in the  absence of access-to-care standards for these options, TMA has mainly  used feedback mechanisms to gauge access to civilian providers for these  beneficiaries. For example, in response to a mandate included in the  NDAA for Fiscal Year 2008, DOD has completed 2 years of a multiyear  survey of beneficiaries who use the TRICARE Standard, TRICARE Extra,  and TRS options and 2 years of its second multiyear survey of civilian  providers. Congress required that these surveys obtain information on  access to care and that DOD give a high priority to locations having high  concentrations of Selected Reserve members. In March 2010, we reported  that TMA generally addressed the methodological requirements outlined in  the mandate during the implementation of the first year of the multiyear  surveys. While TMA did not give a high priority to locations with high  concentrations of Selected Reserve members, TMA’s methodological  approach over the 4-year survey period will cover the entire United States,  including areas with high concentrations of Selected Reserve members.
In February 2010, TMA directed the TRICARE Regional Offices to monitor  access to civilian providers for TRICARE Standard, TRICARE Extra, and  TRS beneficiaries through the development of a model that can be used to  identify geographic areas where beneficiaries may experience access  problems. As of May 2010, each of the TRICARE Regional Offices had  implemented an initial model appropriate to its region. These models  include, for example, data on area populations, provider types, and  potential provider shortages for the general population. Officials at each  regional office said that their models are useful but noted that they are  evolving and will be updated.
To determine whether jointly monitoring access to civilian providers for  TRS beneficiaries along with TRICARE Standard and Extra beneficiaries  was reasonable, we asked TMA to perform an analysis of claims (for fiscal  years 2008, 2009, and 2010) to identify differences in age demographics  and health care utilization between these beneficiary groups. This analysis  found that although the age demographics for these populations were  different—more than half of the TRS beneficiaries were age 29 and under,  while more than half of the TRICARE Standard and Extra beneficiaries  were over 45—both groups otherwise shared similarities with their health  care utilization. Specifically, both beneficiary groups had similar  diagnoses, used the same types of specialty providers, and used similar  proportions of mental health care, primary care, and specialty care. (See  fig. 4.) Specifically:    Seven of the top 10 diagnoses for both TRS and TRICARE Standard and  Extra beneficiaries were the same. Three of these diagnoses—allergic  rhinitis, joint disorder, and back disorder—made up more than 20  percent of claims for both beneficiary groups.
The five provider specialties that filed the most claims for both beneficiary  groups were the same—family practice, physical therapy, allergy, internal  medicine, and pediatrics. Furthermore, the majority of claims filed for  both beneficiary groups were filed by family practice providers.
Both beneficiary groups had the same percentage of claims filed for  mental health care and similar percentages for primary care and other  specialty care. (See app. II for additional details on the results of this  claims analysis.)
Based on this analysis, jointly monitoring access for TRS beneficiaries and  TRICARE Standard and Extra beneficiaries appears to be a reasonable  approach.
section_title: DOD Has Taken Steps to Separately Evaluate Access to Civilian Providers for the Selected Reserve Population and TRS Beneficiaries
paragraphs: DOD has taken steps to evaluate access to civilian providers for the  Selected Reserve population and TRS beneficiaries separately from other  TRICARE beneficiaries. Specifically, during the course of our review, TMA  initiated the following efforts:    During the fall of 2010, TMA officials analyzed the locations of Selected  Reserve members and their families, including TRS beneficiaries, to  determine what percentage of them live within TRICARE’s Prime Service  Areas (areas in which the managed care contractors are required to  establish and maintain sufficient networks of civilian providers).  According to these data, as of August 31, 2010, over 80 percent of Selected  Reserve members and their families lived in Prime Service Areas: 100  percent in the South region, which is all Prime Service Areas, and over 70  percent in the North and West regions.
TMA officials told us that they are repeating the Focused Survey of  TRICARE Reserve Select and Select Reserve Military Health System  Access and Satisfaction, which had first been conducted in 2008. Using  results from its first survey, TMA reported to Congress in February 2009  that members of the Selected Reserve who were enrolled in TRS were  pleased with access and quality of care under their plan. However, as we  have noted, the response rate for this survey was almost 18 percent,  although TMA took steps to adjust the data prior to reporting the results.  Officials told us that the follow-up survey will focus on whether access to  care for TRS beneficiaries has changed. Officials sent the survey  instrument to participants in January 2011. Officials told us that they  anticipate results will be available during the summer of 2011.
section_title: Conclusions
paragraphs: TRS is an important option for members of the Selected Reserve.  However, educating this population about TRS has been challenging, and  despite efforts by the reserve components and the contractors, some  members of the Selected Reserve are likely still unaware of this option.  Most of the reserve components lack centralized accountability for TRS  education, making it unclear if all members are getting information about  the program—a concern that is further exacerbated by the lack of  awareness about the TRS education policy among officials from some of  the reserve components. Additionally, the contractors’ limitations in  briefing all of the units in their regions about TRS make each component’s  need for a central point of contact more evident. Without centralized  accountability, the reserve components do not have assurance that all  members of the Selected Reserve who may need TRS have the information  they need to take advantage of the health care options available to them.
section_title: Recommendation for Executive Action
paragraphs: We recommend that the Secretary of Defense direct the Assistant  Secretary of Defense for Reserve Affairs to develop a policy that requires  each reserve component to designate a centralized point of contact for  TRS education, who will be accountable for ensuring that the reserve  components are providing information about TRS to their Selected  Reserve members annually. In establishing responsibilities for the  centralized points of contact, DOD should explicitly task them with  coordinating with their respective TRICARE Regional Offices to ensure  that contractors are provided information on the number and location of  reserve component units in their regions.
section_title: Agency Comments and Our Evaluation
paragraphs: In commenting on a draft of this report, DOD partially concurred with our  recommendation. (DOD’s comments are reprinted in app. III.) Specifically,  DOD agreed that the Assistant Secretary of Defense for Reserve Affairs  should develop a policy that requires each of the seven reserve  components to designate a central point of contact for TRS education that  will be accountable for providing information about TRS to their Selected  Reserve members annually. However, DOD countered that each designee  should coordinate the provision of reserve unit information through the  TRICARE Regional Offices rather than communicating directly with the  TRICARE contractors, noting that the TRICARE Regional Offices have  oversight responsibility for the contractors in their respective regions. We  understand the department’s concern about coordinating contractor  communications through the TRICARE Regional Offices, and we have  modified our recommendation accordingly. DOD also provided technical  comments, which we incorporated where appropriate.
We are sending copies of this report to the Secretary of Defense and other  interested parties. The report also is available at no charge on the GAO  Web site at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. Key contributors to this report are listed in  appendix IV.
section_title: Appendix I: TRICARE Management Activity Analysis of Claims
paragraphs: We asked the TRICARE Management Activity (TMA) to conduct an  analysis of claims filed for TRICARE Reserve Select (TRS) beneficiaries  and TRICARE Standard and Extra beneficiaries. We requested claims data  for the most recent three complete fiscal years—2008, 2009, and 2010— based on the fact that the program last experienced changes with  eligibility and premiums in fiscal year 2007. For the purpose of this  analysis, claims consist of all services provided by a professional in an  office or other setting outside of an institution. Records of services  rendered at a hospital or other institution were excluded from this  analysis. In addition, records for medical supplies and from chiropractors  and pharmacies were also excluded. We asked TMA to conduct the  following comparative analyses for TRS beneficiaries and TRICARE  Standard and Extra beneficiaries:  1.  Demographics, including age for each year and averaged over 3 years  2.  Percentage of claims filed for primary care, mental health, and other  specialists each year for 3 years  3.  The top 10 procedures in ranking order made each year and the  4.  The top 10 primary diagnoses in ranking order made each year and the  5.  The top five provider specialties in ranking order visited each year and  the average over 3 years  6.  Percentage of claims filed for the top five provider specialties and the  To ensure that TMA’s data were sufficiently reliable, we conducted data  reliability assessments of the data sets that we used to assess their quality  and methodological soundness. Our review consisted of (1) examining  documents that described the respective data, (2) interviewing TMA  officials about the data collection and analysis processes, and   (3) interviewing TMA officials about internal controls in place to ensure  that data are complete and accurate. We found that all of the data sets  used in this report were sufficiently reliable for our purposes. However,  we did not independently verify TMA’s calculations.
section_title: Appendix II: Claims Filed for TRICARE Reserve Select and TRICARE Standard and Extra Beneficiaries
paragraphs: Tables 2 through 5 contain information on claims filed for TRICARE  Reserve Select and TRICARE Standard and Extra beneficiaries.
section_title: Appendix III: Comments from the Department of Defense
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Bonnie Anderson, Assistant  Director; Danielle Bernstein; Susannah Bloch; Ashley Dean; Lisa Motley;  Jessica Smith; and Suzanne Worth made key contributions to this report.