Defense Health Care: DOD Is Meeting Most Mental Health Care Access Standards, but It Needs a Standard for Follow-up Appointments
Released: 2016-04-28T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: DOD reports that between 2005 and 2013, the number of individuals who received mental health care through DOD's MHS grew by 32 percent. MHS mental health care is provided free to active duty servicemembers. Reservists and DOD civilians are eligible for MHS care under certain circumstances.

The National Defense Authorization Act for Fiscal Year 2015 contains a provision for GAO to assess the availability and accessibility of mental health care in DOD's MHS for military servicemembers. This report examines, among other things, (1) the mental health care DOD makes available to servicemembers domestically and overseas and (2) the accessibility of mental health care provided to servicemembers domestically and overseas. GAO analyzed recent, available data on MHS mental health utilization, staffing, and appointment access and compared access data to relevant DOD standards. GAO reviewed mental health data from several DOD surveys as well as documents related to MHS mental health care. GAO also interviewed DOD and service officials and representatives from servicemember and provider associations.

section_title: What GAO Found
paragraphs: The Department of Defense's (DOD) Military Health System (MHS) makes a variety of inpatient and outpatient mental health care available to active duty servicemembers and activated National Guard and Reserve servicemembers (reservists) domestically and overseas through its TRICARE health care system. The type of care includes psychological testing and assessment, psychotherapy, medication management, and inpatient psychiatric care. This care is typically available through military treatment facilities and clinics (direct care), and it is supplemented by care provided through networks of civilian providers (purchased care). In fiscal year 2014, DOD provided 76 percent of 2.9 million outpatient mental health encounters through direct care and 69 percent of 0.2 million inpatient mental health bed days through purchased care. To deliver mental health care, the military services use a range of strategies including telehealth, embedding mental health providers within units, and integrating mental health providers in primary care. While DOD has increased the number of available mental health providers in both direct and purchased care in recent years, DOD data indicate that the military services still face shortages for certain providers, such as psychiatrists. Unlike the care available for active duty servicemembers and activated reservists, MHS mental health care for inactive reservists is generally limited to referrals to non-DOD community resources or, if eligible, the reservists can purchase coverage for health care, including mental health care, through TRICARE Reserve Select, a premium-based health plan for reservists.

DOD data on domestic and overseas direct care from April 2014 through August 2015 show that MHS-wide DOD's access to care standards were generally met for three of four mental health appointment types. However, in the case of routine appointments—initial appointments for a new or exacerbated condition—data show that other than the Air Force, MHS routine mental health appointments generally did not meet the 7-day access standard. DOD and service officials attributed this to several factors, including some appointments being incorrectly coded, thus negatively impacting the routine appointment access results. They told GAO that DOD was taking steps to address the coding problem and improve oversight of mental health access. Additionally, the data show that about 59 percent of mental health appointments are follow-up appointments, which generally do not have an official DOD access standard. Federal internal control standards call for agencies to have sufficient information to monitor agency performance. By not establishing and monitoring a follow-up appointment standard, DOD cannot hold the military services accountable for the majority of mental health care provided in the direct care system. For purchased care, limited access data are available, and DOD instead relies on beneficiary surveys and complaints to monitor access—consistent with methods used by civilian health plans. DOD surveys have identified access problems for some servicemembers. For example, a DOD beneficiary survey estimated that about one-third of active duty servicemembers experienced problems accessing mental health care from 2011 through 2014. Additionally, provider surveys from 2012 and 2013 found that only an estimated 37 percent of civilian mental health providers were accepting any new TRICARE patients. DOD's ongoing efforts to improve oversight of mental health access, including implementing a strategic plan, may help address some of these problems, but it is too early to tell.

section_title: What GAO Recommends
paragraphs: GAO recommends that DOD establish an access standard for mental health follow-up appointments and regularly monitor data on these appointments. DOD concurred with GAO's recommendation.

section_title: Letter
paragraphs: As part of its mission, the Department of Defense’s (DOD) Military Health  System (MHS) provides a full range of medical care and services,  including mental health care, to eligible individuals in the United States,  overseas, and in deployed settings, such as Iraq and Afghanistan. DOD  reports that between 2005 and 2013, the number of individuals who  received mental health care through DOD’s MHS grew by 32 percent.  This growth has been attributed to multiple factors, including more  referrals to care from mental health screenings and increasing numbers  of servicemembers who experienced life-threatening situations while  deployed in combat since September 11, 2001 and their resulting need  for mental health treatment. Since 2001, DOD has also expanded the use  of its civilian workforce to perform combat support functions traditionally  performed by military personnel, thereby increasing these civilians’ risk  for developing post-traumatic stress disorder and other mental health  conditions. DOD has experienced challenges in providing mental health  care to meet the needs of its servicemembers, and these challenges have  been exacerbated by issues such as nationwide shortages of mental  health providers and the pressure to control DOD healthcare costs. In the  MHS, care is provided through TRICARE, DOD’s regionally structured  health care system. Under TRICARE, active duty servicemembers  typically receive most of their care in what is known as the direct care  component—that is, in military hospitals and clinics referred to as military  treatment facilities (MTF). The care provided in MTFs is supplemented by  services offered through TRICARE’s purchased care networks of civilian  providers.

The National Defense Authorization Act (NDAA) for Fiscal Year 2015  contains a provision for us to assess the availability and accessibility of  mental health care for servicemembers and deployed DOD civilian  employees. This report examines  1.  the mental health care DOD makes available to military  servicemembers domestically and overseas,  2.  the accessibility of the mental health care provided through DOD’s  MHS to military servicemembers domestically and overseas, and  3.  the availability and accessibility of mental health care for military  servicemembers and DOD civilians in deployed settings.

In this report, we are focusing on services available to active duty  servicemembers, National Guard and Reserve servicemembers, and  deployed DOD civilians. Unless otherwise specified, our use of the term  “servicemembers” throughout this report is generally meant to include  active duty servicemembers and National Guard and Reserve  servicemembers. We consider overseas to be those areas in which the  MHS provides health care services in Eurasia-Africa, Latin America and  Canada, and the Pacific, and we consider deployed settings to be areas  to which servicemembers are deployed in support of contingency  operations, such as Iraq or Afghanistan. Additionally, in this report, we  use the term “mental health provider” to describe a licensed or certified  clinical provider—those that have met the minimum requirements needed  to obtain and maintain a license or certification—including psychiatrists,  psychologists, mental health nurse practitioners, licensed social workers,  and other licensed providers. We did not review other types of mental  health personnel, such as administrative staff and technicians. Therefore,  in this report, we consider mental health care to be care delivered by  licensed or certified clinical providers, and do not include other services  such as non-medical counseling provided by individuals such as  chaplains.

To examine what mental health care DOD makes available to military  servicemembers domestically and overseas, we reviewed relevant DOD  and service documentation on mental health care provided in the MHS’s  direct and purchased care systems. We also reviewed data on utilization  of mental health treatment services in both the direct and purchased care  systems by active duty servicemembers, including activated reservists,  from fiscal years 2009 to 2014. To determine the reliability of the  utilization data, we reviewed relevant documentation, discussed this  information with the contractor officials that prepared the data, and  reviewed the data for reasonableness, outliers, and consistency; as a  result, we determined that the data were sufficiently reliable for the  objectives of our review.

To examine the availability of mental health providers in the direct care  system, we analyzed quarterly mental health staffing reports for fiscal  years 2009 through 2015 submitted to DOD from each military service  and the National Capital Region (NCR) Medical Directorate. We  analyzed these reports separately and together to examine staffing level  changes from fiscal years 2009 to 2015 and identify any staffing  shortages of DOD mental health providers in the direct care system in  fiscal year 2015, the most recent fiscal year with complete data available  for analysis. To examine mental health provider staffing levels and  shortages in the purchased care system, we analyzed provider network  adequacy reports from the month of December of each year for 2010  through 2014, and the report for the month of July for 2015, which was  the most recent month with complete data available for analysis. To  ensure the reliability of the data in the mental health staffing reports and  the provider network adequacy reports, we interviewed officials from the  Office of the Assistant Secretary of Defense for Health Affairs responsible  for collecting and analyzing the quarterly staffing reports, and TRICARE  Regional Office officials responsible for collecting and analyzing the  monthly network adequacy reports. In addition, we reviewed  documentation related to the production of these reports, performed data  checks on the network adequacy reports and examined the data for  missing values. On the basis of these steps as well as our prior review of  the quarterly staffing reports, we found the data to be sufficiently reliable  for the purposes of this report.

To further examine the availability of MHS mental health care, we also  interviewed officials from the DOD and the military services, specifically  the Army, Army Reserve, Navy, Navy Reserve, Air Force, Air Force  Reserve, Marine Corps, Marine Corps Reserve, National Guard Bureau,  NCR Medical Directorate, Defense Health Agency (DHA), and TRICARE  Regional Offices, to learn about the mental health care available to  servicemembers and reservists. Because DOD civilians are generally not  entitled to MHS health care except when deployed or if they have a health  condition determined to be related to their deployment, we did not include  DOD civilians in our review of what mental health care DOD makes  available domestically and overseas.

To examine the accessibility of mental health care provided through  DOD’s MHS to military servicemembers domestically and overseas, we  reviewed direct care mental health appointment access data from monthly  Access to Care Mental Health Summary reports produced by DHA’s  TRICARE Operations Center. We examined mental health appointment  access data from April 2014 through August 2015, the most recent data  that were readily available as of the date of our request. We also  reviewed available purchased care mental health appointment access  data for the same time period. We compared the direct and purchased  care mental health appointment data to access to care standards set in  DOD policy. We assessed the reliability of the mental health appointment  data for the MHS’s direct and purchased care systems by interviewing  knowledgeable DOD and military service officials, reviewing supporting  documentation, and reviewing the data for obvious errors or outliers; as a  result, we determined that they were sufficiently reliable for the objectives  of this report. We also examined whether the data and access to care  standards used by DOD to assess mental health access are consistent  with federal standards for internal control.

To further examine the accessibility of MHS mental health care, we also  obtained results for questions relevant to access to MHS mental health  care from four recent surveys: (1) the fiscal year 2011-2014 Health Care  Survey of DOD Beneficiaries; (2) the TRICARE Standard Survey of  Civilian Providers for 2012 and 2013; (3) the TRICARE Standard Survey  of Beneficiaries for 2012 and 2013; and (4) the 2013 Air Force  Community Assessment survey. Through reviews of survey-related  documentation and interviews with relevant officials, and on the basis of  our prior reviews of the two TRICARE Standard surveys, we assessed  the reliability of the data from each of the four surveys and determined  that they were sufficiently reliable for the purposes of this report. We also  reviewed DOD and service documents, interviewed DOD and military  service officials, and interviewed representatives from associations  representing servicemembers and mental health providers. Additionally,  we reviewed relevant published literature related to MHS mental health  access. For those studies included in this report, we reviewed the  methods used in the studies and found them to be reasonable. Because  DOD civilians are generally not entitled to MHS health care except when  deployed or if they have a health condition determined to be related to  their deployment, we did not include DOD civilians in our review of how  accessible MHS mental health care is domestically and overseas.

To examine the availability and accessibility of mental health care for  military servicemembers and DOD civilians in deployed settings, we  interviewed DOD and military service officials and reviewed Mental Health  Advisory Team (MHAT) reports that provide insight into the types of  mental health care available in deployed settings such as Afghanistan.  MHATs are small teams who deploy to combat environments and conduct  surveys and focus groups of both servicemembers and providers. From  2003 to 2013, MHATs conducted studies on a mostly annual basis that  examined the mental health care provided in Afghanistan and Iraq,  including the types of mental health care available in the deployed  environment.

We conducted this performance audit from July 2015 to April 2016 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
subsections: section_title: MHS Overview
paragraphs: The MHS operated by DOD has two missions: (1) supporting wartime and  other deployments and (2) providing peacetime health care. In support of  these two missions, DOD operates a large and complex health care  system that employs more than 150,000 military, civilian, and contract  personnel working in MTFs. DHA oversees the TRICARE health plan,  and also exercises authority and control over the MTFs and subordinate  clinics assigned to the NCR Medical Directorate. Outside of the NCR  Medical Directorate, each military service operates its own MTFs and  their subordinate clinics. Each military service recruits, trains, and funds  its own medical personnel to administer medical programs and provide  medical services to servicemembers. DHA does not have direct  command and control of MTFs operated by the military services.

In the MHS, health care is provided at no cost to active duty military  servicemembers through the TRICARE Prime health care option.  Reservists called or ordered to active service for more than 30 days have  the same coverage as active duty servicemembers under TRICARE  Prime, while inactive reservists may qualify to purchase TRICARE  Reserve Select (TRS) coverage. The health care services covered by  TRICARE Prime and TRS are generally the same, although the options  vary by factors such as enrollment requirements, choices between civilian  and MTF providers, required contribution from servicemembers toward  the cost of care, and referral and prior authorization requirements. Data  from the end of fiscal year 2014 showed that there were 1,587,987 active  duty servicemembers enrolled in TRICARE Prime and 121,912 reservists  with TRS.

Within the United States, TRICARE is organized into three main  regions—North, South, and West. (See fig. 1 for a map of the three  regions.) DHA and TRICARE Regional Offices are responsible for  managing purchased care through contractors in each of these regions.  In each region, the contractor develops a network of civilian providers— referred to as network providers—to serve all the TRICARE beneficiaries  in geographic areas called Prime Service Areas. The TRICARE  Regional Offices, in particular, are responsible for monitoring the quality  and adequacy of contractors’ provider networks and customer-satisfaction  outcomes. Overseas, TRICARE is divided into three areas: Eurasia- Africa, Latin America and Canada, and Pacific. One contractor serves  these areas, which is overseen by the TRICARE Overseas Office.

section_title: MHS Coverage Eligibility for Reservists and Deployed DOD Civilians
paragraphs: Reservists have a general cycle of coverage during which they are  eligible for MHS care through various TRICARE options based on their  duty status – preactivation, active duty, deactivation, and inactive. During  preactivation, when reservists are notified that they will serve on active  duty in support of a contingency operation for more than 30 days in the  near future, they are eligible for TRICARE benefits as an active duty  servicemember. While on active duty for more than 30 days, reservists  are required to enroll in TRICARE Prime and are eligible to receive the  same medical services accorded to active-duty servicemembers. During  deactivation, reservists returning from more than 30 days of active duty in  support of a contingency operation may be eligible for 180 days of  transitional health care through various TRICARE options. Inactive  reservists can choose to purchase TRS coverage, if eligible, or use any  other health coverage for which they may be eligible, such as employer- sponsored insurance. For reservists who are injured, become ill, or incur  a disease while in a duty status, a line of duty determination is required  and must be approved in order to determine eligibility for any MHS  medical care associated with the specific injury, illness, or disease. If this  determination is positive, the reservist is eligible to receive medical  treatment for the specific injury, illness, or disease described in the line of  duty determination through MTFs or civilian providers.

DOD’s policies also entitle all deployed DOD civilian employees to  medical treatment and services, including mental health services, at the  same level and scope of those services provided to military personnel  while in that deployed setting. Upon returning from deployment, DOD  civilians are eligible to receive care in an MTF for any mental health  conditions determined to be related to their deployment. This care is  provided at no cost. Formerly deployed DOD civilians with mental health  conditions related to their deployment can also elect to get treatment  outside an MTF and get their care reimbursed, or seek care through their  regular health insurance if the health plan will cover the treatment.

section_title: DOD Access to Care Standards
paragraphs: DOD has established, in regulation and policy, TRICARE Prime access  standards related to various aspects of DOD mental health care, including  appointment wait times. The standards include appointment wait time  standards for four types of mental health appointments—acute, routine,  wellness, and specialty (see table 1). DOD measures its compliance with  these wait time standards in several ways, including monitoring the  average number of days to be seen for each appointment type, as well as  the average percentage of appointments that meet the relevant access  standard. The MHS goal is for 90 percent of appointments of each type  to meet the relevant access standard. The standards apply to care  delivered to TRICARE Prime beneficiaries in either direct care or  purchased care. The policy notes that it applies to overseas locations to  the extent practicable, but overseas locations often present unique  circumstances. The access standards, however, do not apply to care  delivered in deployed settings.

Within the MHS’s direct care system, compliance with the access  standards is monitored using appointment data available from DOD’s  Composite Health Care System, the electronic system through which  patient appointments are booked. Appointments are scheduled in the  system, which is programmed to count the actual waiting time between  the date of the appointment request and the scheduled appointment date.  These metrics are readily available at each MTF and at higher  organizational levels, including service headquarters. DOD reports that  oversight of appointment wait times and the availability of care for all  clinics under the command of an MTF is a key responsibility of the  leadership team at that facility and that ultimately, the MTF Commander is  accountable for performance related to delays in care for all medical care,  including mental health.

In the purchased care system, detailed data about compliance with  DOD’s access to care standards are not available; instead, patient  satisfaction with the length of time to an appointment, as measured  through TRICARE beneficiary surveys, is used as a surrogate measure of  access. While the TRICARE regional contractors submit appointment  data to DHA, the contractors do not collect and report the same level of  detail on access to care as is available in the direct care system, and the  contractors do not use the same information systems. Moreover, the  overseas contractor does not collect the same data as the U.S.  contractors.

section_title: Utilization of MHS Mental Health Care
paragraphs: Use of MHS mental health care has generally increased among active  duty servicemembers. From fiscal year 2009 through fiscal year 2013, the  percentage of active duty servicemembers who used either outpatient or  inpatient mental health care provided through DOD’s MHS increased  across all four services. Across all services, utilization began to decline in  fiscal year 2014 (see fig. 2).

section_title: DOD Makes a Variety of Inpatient and Outpatient Mental Health Care Available Domestically and Overseas
subsections: section_title: DOD Offers a Variety of Mental Health Care Services
paragraphs: DOD makes a variety of mental health care services available both  domestically and overseas to active duty servicemembers, ranging from  outpatient services such as psychotherapy and telehealth, to inpatient  services such as acute psychiatric care, as well as emergency services.  Table 2 lists the covered outpatient and inpatient mental health services  available to servicemembers through the various TRICARE options. Army  and Air Force officials stated the same mental health care is generally  available domestically and overseas. While a TRICARE fact sheet notes  that when overseas, limitations on mental health care services may apply,  the Air Force reported that servicemembers are screened prior to  overseas tours to minimize the likelihood of needing care that is not  available. Army officials added that the availability of specific mental  health services to be provided through direct care in a particular MTF or  clinic depends on multiple factors, including the MTF’s size and the  mental health needs of the beneficiary population it serves. For example,  not all MTFs offer inpatient mental health services. In such cases, an  active duty servicemember requiring inpatient mental health services  would either be referred to purchased care or travel to an MTF that offers  such services.

section_title: DOD Provides Most Outpatient Services through Direct Care and Most Inpatient Services through Purchased Care
paragraphs: In fiscal year 2014, DOD provided most of its outpatient mental health  services through the direct care system, while providing most of its  inpatient mental health services through the purchased care system.  Among all of DOD’s military services, outpatient mental health care is  provided at nearly all MTFs and clinics, while inpatient mental health care  is less widespread. For example, the Army reported that in fiscal year  2014, all of its 56 MTFs and clinics provided outpatient mental health  care, whereas only 13, or 23 percent, of the Army’s MTFs and clinics  provided inpatient mental health care. For the same year, the Air Force  reported all of its 75 MTFs with mental health clinics provided outpatient  mental health services, but only 2 MTFs, or approximately 3 percent,  provided inpatient mental health care. The Navy, which also provides  health care services for the Marine Corps, reported that in fiscal year  2014, there were 67 MTFs and clinics that provided outpatient mental  health care, whereas only 4 MTFs provided inpatient mental health care.

Consistent with the availability of outpatient mental health services at  MTFs and clinics, about 76 percent of outpatient mental health  encounters for active duty servicemembers were provided through direct  care across all military services in fiscal year 2014 (see table 3). In  contrast, inpatient mental health care was provided mostly through  purchased care in that year for all the military services except the Navy,  which divided its provision of inpatient mental health care equally through  direct care and purchased care. DOD and Army officials reported that  they have increasingly focused on providing mental health care through  the direct care system—citing reasons such as a need for DOD and the  services to be aware of active duty servicemembers’ mental well-being to  assess both their fitness for duty and whether they pose any risk to  themselves or others.

section_title: Military Services Also Make Mental Health Care Available through Non- Traditional Methods
paragraphs: To address the mental health needs of servicemembers, the military  services have integrated mental health providers in primary care settings,  embedded mental health providers within units, and used telehealth.  Each military service has established a program to integrate mental  health providers into primary care settings to decrease overall health care  costs and improve patient access to mental health services. A DOD  official stated that these mental health providers, officially termed internal  behavioral health consultants, are typically psychologists and social  workers who help primary care providers with any mental health concerns  that servicemembers have. As needed, the consultants also help  servicemembers adhere to their treatment regimens. According to DOD,  internal behavioral health consultants typically see patients one to four  times for a 30-minute appointment per episode of care and refer them to  specialty mental health care for a more intensive level of services if they  show no improvement.

The number of behavioral health consultants varies across DOD’s military  services. Army officials stated that in fiscal year 2014, the Army had  internal behavioral health consultants in 38 of its 56 MTFs and clinics.  The officials reported that integrating internal behavioral health  consultants into primary care settings has been an effective method to  provide behavioral health care. The Air Force reported that as of fiscal  year 2014, 71 of its 75 MTFs had internal behavioral health consultants.  The Navy reported that as of fiscal year 2014, the service had placed  internal behavioral health consultants in 71 clinics throughout the 27  domestic and overseas Naval MTFs, and has plans to eventually have  them in 80 clinics.

DOD’s military services have also co-located mental health providers with  units to provide an easy point of access to mental health care and to help  destigmatize these services. For example, the Army uses Embedded  Behavioral Health (EBH) teams, which are multidisciplinary teams of  approximately 13 mental health providers and support staff who are  stationed near servicemembers’ units and barracks. In fiscal year 2014,  the Army had 58 functional EBH teams that supported all of its combat  brigade teams. Air Force officials reported that the Air Force embeds  mental health providers in units that remotely pilot aircraft, Special  Operations units, and at one Air Force base. In fiscal year 2014, the Air  Force had 23 embedded mental health providers. The Navy uses both the  Army’s and the Air Force’s approach, with embedded mental health  teams stationed near servicemembers’ units, as well as mental health  providers co-located with units. The Navy embeds active duty mental  health providers in all of its large seagoing platforms, in all Marine Corps  infantry regiments, and in all Navy and Marine Corps Special Operations  Commands. In fiscal year 2014, the Navy had 19 locations with  embedded mental health teams located near units and an additional 11  mental health providers stationed aboard its ships.

The military services have also implemented telehealth programs with  varying degrees of complexity to leverage the services’ existing resources  and increase the availability of mental health care in areas with provider  shortages.

The Army has a global multidisciplinary telehealth program, consisting  of psychiatrists, psychologists, and other mental health providers, who  provide mental health care to servicemembers in regionally-remote  settings as well as in deployed settings. An Army official stated that  the Army uses telehealth when an MTF reaches capacity,  supplementing that MTF’s delivery of care with telehealth services  instead of using the purchased care or requiring the servicemember to  wait to receive care. The same official noted that the Army is looking  to use its telehealth program to support administrative evaluations in  addition to providing mental health treatment.

The Air Force uses telehealth to provide psychiatry services to smaller  isolated bases. Air Force officials reported that their telehealth  program consists of 9 staff, including 5 psychiatrists who use video  teleconferencing to support MTFs that do not have an on-site  psychiatrist and 2 psychologists who primarily assist with completing  administrative evaluations.

The Navy Medicine telehealth program office has begun telehealth  services at several Navy health care facilities and is developing plans  for its systematic use. Navy officials reported that the Navy used  telehealth on an ad hoc basis in the past to provide mental health care  at installations that did not have access to mental health providers.

section_title: DOD Has Increased the Number of Available Mental Health Providers, but DOD Data Show Shortages for Some Provider Types
paragraphs: Our analysis of DOD staffing data for the direct care system from fiscal  years 2009 through 2015 and for the purchased care system from  December 2010 through July 2015 shows that DOD increased the  number of available mental health providers in both delivery systems,  thereby increasing DOD’s mental health capabilities to meet  servicemembers’ mental health care needs. In its direct care system,  DOD increased the number of mental health providers by 15 percent— from 4,608 providers to 5,276 providers—from fiscal year 2009 through  fiscal year 2015. This increase was in response to the NDAA for Fiscal  Year 2010, which required the Secretary of each military service to  increase the number of active duty mental health personnel authorized for  the service. Of the three military services, the Army and Air Force  increased their mental health provider staffing from fiscal year 2009  through fiscal year 2015. The Army’s addition of 467 mental health  providers, from 2,721 in fiscal year 2009 to 3,188 in fiscal year 2015, was  the largest increase among the military services. In contrast, the Navy  decreased its staffing by 51 mental health providers, from 883 in fiscal  year 2009 to 832 in fiscal year 2015 (see fig. 3).

Despite the general increase in the available MHS mental health  providers, shortages for certain types of mental health providers, such as  psychiatrists and social workers, have persisted (see fig. 4). For  example, DOD staffing data show that by the end of fiscal year 2015, all  of the military services had a shortage of psychiatrists, with 127 positions  authorized but not filled. In addition, both the Navy and the Air Force had  more authorized positions for every type of mental health provider, except  mental health nurse practitioners, than were filled. (See app. 1 for more  information on service-level staffing shortages in fiscal year 2015.) We  previously found that the military services believed that a nationwide  shortage of mental health professionals, as well as overarching military- specific challenges such as frequent deployments and relocations and  competitive compensation, have adversely affected DOD’s ability to  recruit and retain mental health providers.

In the purchased care system, two of the three domestic TRICARE  managed care contractors increased the number of available network  mental health providers in Prime Service Areas, which are geographic  areas usually within an approximate 40-mile radius of an MTF. Network  providers are those civilian providers who have a contractual relationship  with the TRICARE managed care contractor to provide care at a  negotiated rate. From December 2010 to July 2015, the total number of  network mental health providers increased by 7,887 providers (52 percent  increase), from 15,216 in December 2010 to 23,103 in July 2015, in the  TRICARE North region. During the same time period, the total number of  network mental health providers increased by 39,025 providers (190  percent increase), from 20,515 in December 2010 to 59,540 in July 2015,  in the TRICARE West region. In contrast, from December 2011 to July  2015, the total number of network mental health providers in the  TRICARE South region decreased by 2,149 providers (17 percent  decrease), from 12,505 in December 2011 to 10,356 in July 2015 (see fig.  5). An official from the TRICARE South contractor stated that while the  number of network mental health providers in Prime Service Areas  showed a decrease, the South region over this time period had an overall  increase in mental health providers (if providers outside Prime Service  Areas are also included). The official added that despite the decrease, the  number of providers contracted was more than sufficient to meet the  demand in the vast majority of areas throughout the South region.

Despite the general increase in mental health providers in the purchased  care system, DOD data show that from December 2010 to July 2015  provider shortages, particularly for psychiatrists, persisted for certain  Prime Service Areas in all three regions (e.g., Fort Riley, KS; Ft Polk, LA;  Traverse City, MI). The provider shortages were more prevalent in the  TRICARE West Region, with up to 15 percent of Prime Service Areas  contracting fewer psychiatrists than targeted and up to 11 percent of  Prime Service Areas contracting fewer behavioral health providers than  targeted for the network in certain years. In spite of the general  decrease in contracted network mental health providers from December  2011 to July 2015 in the TRICARE South Region, the region had the  fewest psychiatrist and behavioral health provider shortages, with no  more than 6 percent of Prime Service Areas experiencing psychiatrist  shortages, and no more than 2 percent of Prime Service Areas  experiencing behavioral health provider shortages during this time period.  Officials from the TRICARE South contractor told us that these shortages  were possibly due to shortages of psychiatrists, particularly child  psychiatrists, both at the national and local levels. TRICARE Regional  Office officials told us that the contractors were limited in their ability to  address these provider shortages because the provider shortages affect  the entire health system and are not specific to the TRICARE program.

section_title: MHS Mental Health Care Available to Inactive Reservists is Generally Limited to Assessments and Referrals or to Care Purchased through TRICARE Reserve Select
paragraphs: Unlike the mental health care made available to active duty  servicemembers, DOD generally does not make mental health care  available to inactive reservists at no cost to them. While active duty  servicemembers have access to a range of mental health care services  provided at no cost to the servicemembers through TRICARE Prime,  officials from the various Guard and Reserve components of DOD’s  military services told us that DOD generally does not make such mental  health care available to inactive reservists—with the exception of  conducting mental health assessments and referring reservists to  community resources. Reservists who purchase TRS have access to the  list of covered inpatient and outpatient services available through  TRICARE. However, National Guard officials stated that the premiums,  co-pays, and deductibles associated with seeking treatment would not be  affordable for some reservists, particularly those of lower ranks and for  whom the Reserve or Guard is the sole source of employment. DOD  reports that as of June 2014, about 25 percent of the reservists eligible to  participate in TRS were enrolled.

Regarding the assessment and referral services available to inactive  reservists, service officials reported that these services are provided  through Directors of Psychological Health (DPH), who are typically  licensed mental health providers, and who are responsible for developing  community resource guides and cultivating community contacts that can  provide either free or discounted mental health care to inactive  reservists. The Air and Army National Guard DPH programs are  different in certain respects.

Air National Guard. An Air National Guard official stated that as of  July 2015, the Air National Guard had 93 DPHs who were embedded  in 89 Air Force wings, with another 8 national staff who supported the  DPHs in individual states. The official stated that Air National Guard  servicemembers have more in-person, face-to-face interactions with  their DPHs by virtue of the DPHs being embedded with the units.

Army National Guard. A National Guard Bureau official stated that  as of July 2015, the Army National Guard had 157 DPHs. An Air  National Guard official reported that unlike Air National Guard DPHs,  Army National Guard DPHs may have dual status (for example, as a  guardsman on the weekend and a clinical psychologist during the  week), and those DPHs can therefore be deployed along with their  units, leaving the Army National Guard with the challenge of finding a  replacement to serve reservists remaining in their state.

In addition to the general DPH role to assess and refer reservists to  community mental health resources, Air Force Reserve DPHs can also  provide some clinical services, according to an Air Force Reserve official.  The official told us that the Air Force Reserve DPHs are clinical social  workers who are licensed, credentialed, and privileged to work in military  hospitals and clinics. The same official stated that while these DPHs  provide referrals and are mostly engaged in prevention efforts, the DPHs  can provide some clinical services for reservists, which are then  documented as such in the reservists’ electronic medical records. An Air  Force Reserve official noted that as of August 2015, there were 30 DPHs  embedded in wings where the Air Force Reserve saw the greatest need,  and the official said that the Air Force Reserve is likely to get additional  DPHs in the future.

A Navy official stated that the Navy and Marine Corps Reserve  Psychological Health Outreach Program teams, in their roles as DPHs,  have instituted a Resiliency Check-In program that provides Navy and  Marine Corps reservists with check-in screenings with a mental health  provider, information on local community mental health resources, and  case management as needed following the screening. The official, who is  responsible for the psychological health of Navy and Marine Reserve  Forces, credited the program with helping destigmatize mental health  care. According to the official, these 12 regionally embedded  Psychological Health Outreach Program teams are composed of 4-5  licensed mental health professionals led by regional DPHs who service all  of the Navy and Marine Corps Reserve sites using various forms of  communication and annual site visits. For each Resiliency Check-In  event, the teams typically schedule a minimum 15-minute appointment  with each reservist to screen for psychological health and other needs. If  a reservist is found to be in need of mental health care or have other  needs that can impact the reservist’s psychological health or unit, the  teams provide the reservist with information detailing local health care  resources; the teams also follow-up with the reservist for as long as  needed.

section_title: While DOD Met Most of Its Mental Health Appointment Access Standards, DOD Lacks a Key Standard, and Its Surveys Suggest Potential Access Problems Recent Data Show That DOD Generally Met Its Access Standards for Most Direct Care Mental Health Appointment Types
paragraphs: Data from DHA’s TRICARE Operation Center for April 2014 through  August 2015 showed that MHS-wide, for appointments by active duty  servicemembers in the direct care system, the mental health access to  care standards were generally met for all domestic and overseas  appointment types except routine appointments. The data come from  Access to Care Mental Health Summary reports, which measure access  both in terms of the average percentage of appointments that met the  relevant access standard and the average number of days to be seen.  The data show that in terms of the percentage of domestic and overseas  mental health appointments that met the access standard each month  between April 2014 and August 2015, on average 96 percent or more of  specialty and wellness appointments met the 28-day standard, exceeding  the MHS goal of 90 percent (see table 4). For acute appointments, more  than 90 percent of all three services’ appointments met the 1-day  standard on average; however, only 79 percent of NCR Medical  Directorate acute appointments met the standard. For routine  appointments, only the Air Force exceeded the 90 percent goal. Less  than half of the Army routine appointments on average met the 7-day  standard.

In terms of average days to be seen, MHS-wide specialty and wellness  appointments met the 28-day standard by a wide margin, averaging about  11 and 10 days to be seen, respectively (see table 5). There was more  variability in terms of meeting the 1-day standard for acute appointments.  Specifically, the Air Force and the Army met the standard from April 2014  through August 2015, but the Navy and the NCR Medical Directorate did  not meet the standard—averaging 1.67 and 1.79 days to be seen,  respectively. For routine appointments, only the Air Force met the 7-day  standard in terms of average days to be seen, and both the Army and the  NCR Medical Directorate more than doubled the desired days to a routine  appointment.

We also examined routine appointment access in terms of the average  days to the third next available appointment, another measure of access  that is prospective rather than retrospective, and which DOD officials  suggested may be a more accurate representation of appointment  availability. Data for the average number of days to the third next  available routine appointment showed that the military services also did  not meet the 7-day routine appointment access standard from April 2014  through August 2015 using this measure, with an MHS average of about  11 days to the third next available routine appointment. (See table 6.)

Although the mental health appointment access data suggest that DOD is  not meeting the 7-day standard for routine appointments, officials  suggested that these data are misleading, as some appointments were  coded incorrectly—negatively impacting the routine appointment access  results. For example, DOD, Navy and NCR Medical Directorate officials  attributed the large numbers of days to routine appointments, in part, to a  known technical problem in DOD’s Composite Health Care System, which  is used to book appointments. Officials said that this resulted in non- routine mental health appointments that were averaging about 15 days to  be seen being mistakenly booked as routine—driving up the average  days to routine appointments. In February 2016, DOD officials reported  that a fix to this technical problem in the appointment booking system was  underway and that the services had developed and disseminated specific  guidance for booking clerks on the issue of incorrect appointment type  categorization.

Additionally, Army officials said that a particular type of mental health  treatment might be negatively impacting the Army’s performance against  the access standard for routine appointments; about one-third of routine  appointments were for an intensive outpatient program which has  scheduled start dates, such as the first Monday of the month. An Army  official noted that while these appointments were booked as routine, the  planned start date for the program may not occur for two weeks after  booking. Another Army official noted that categorizing these appointments  as routine may be a misapplication of the routine appointment category.  An Army official said that as of December 2015 Army officials had begun  discussions internally about standardizing the coding for these  appointments.

Nonetheless, a DOD official also said that the routine appointment data  suggested that there may not be enough routine appointments available  to meet demand, and that to resolve the access performance issue  mental health clinics might need to make more routine appointments  available on their schedules. The official suggested that because access  data show that other types of mental health appointments, such as  specialty appointments, are being scheduled well within the MHS  standard timeframe of 28 days, mental health clinic appointment  schedules should possibly be revised to allocate more routine  appointments. However, in February 2016 DOD officials reported that  until the issue of incorrectly coded appointments in the Composite Health  Care System was resolved, the officials were limited in their ability to  determine the extent to which a shortage of mental health appointments  exists.

In addition to the factors mentioned above, NCR Medical Directorate  officials also reported that difficulty recruiting and hiring qualified clinicians  had affected their ability to deliver timely care to their patient population,  but they were taking steps to improve access. Officials reported that  ongoing enhancements to their staffing, referral, and appointing  processes, as well as care delivery options, such as telehealth, were  intended to improve access performance. NCR Medical Directorate  officials said that MTF directors and commanders meet at least monthly  to review progress in this area.
subsections: section_title: DOD Lacks an Access Standard for the Most Common Type of Direct Care Mental Health Appointment
paragraphs: Although DOD has established standards and is monitoring access for  four types of mental health appointments, DOD told us that most mental  health appointments provided in the MHS’s direct care system fall into a  fifth category—follow-up appointments—which generally do not have an  official DOD access to care standard. A DOD official said that acute,  routine, wellness, and specialty appointment categories are generally to  be used only for a patient’s initial referral or assessment for mental health  care and that additional follow-up appointments for counseling, for  instance, would fall into this fifth appointment category, which are coded  as ‘future’ appointments. Of the more than 2.6 million direct care mental  health appointments that were scheduled from April 2014 through August  2015, about 59 percent were follow-up appointments (see fig. 6).

Regarding the lack of an access standard for follow-up appointments, a  DOD official said that unlike the other appointment types, an access  standard for follow-up appointments was not established in regulation,  and that follow-up appointments generally do not have an official access  standard against which they are measured. However, data are available  from the Composite Health Care System through which DOD could  monitor follow-up appointment access. Federal standards for internal  control note that control activities need to be established and reviewed to  monitor performance measures and indicators, and that these controls  could call for comparisons and assessments relating different sets of data  to one another so that analyses of the relationships can be made and  appropriate actions taken. By not establishing, reviewing, and  monitoring an official performance standard for follow-up appointments— the most common mental health appointment type—DOD is missing  performance information for the majority of the mental health care it  provides.

Unlike DOD, some health care systems have established access  standards and measurement strategies for follow-up mental health care.  For example, the Veterans Health Administration’s policy is that follow-up  care for established veterans should be provided within 30 days of the  clinically indicated date. In addition, a 2012 report from the Department of  Veterans Affairs Office of Inspector General noted that the private sector  health care organizations they studied measured follow-up appointments  by establishing a pre-determined average number of visits (e.g., four)  within the first 45–60 days of an initial new patient appointment, and they  also measured the length of time between subsequent visits (e.g., the  amount of time until the second, third, and fourth visits).

DOD officials said that DHA is in the process of improving its oversight  and monitoring of access to mental health care, although it did not report  plans to develop an access standard for follow-up appointments. A DOD  official noted that while there is not currently a DHA-led governance  structure to conduct monthly assessments of access to care in specialty  care (including mental health), there will be one in the future that mirrors  the already established primary care monitoring structure. The official  noted that a newly formed advisory board had been established to  optimize specialty care, evaluate performance, and make  recommendations for continuous process improvement, and another  official noted that under this advisory board, a Mental Health Working  Group had been chartered. That group has developed a mental health  strategic plan—slated for implementation by the end of fiscal year 2016— which contains goals and initiatives related to improving access  performance, including the standardization of business processes across  all three services and the NCR. As part of its effort to standardize  business processes, the Mental Health Working Group is proposing a  revision to current coding practices, which it hopes will allow for greater  surveillance and the ability to intervene and incentivize compliance with  access standards. Additionally, the strategic plan contains an initiative  related to identifying benchmarks for access, which is scheduled to be  completed by the third quarter of fiscal year 2016. Nonetheless, DOD  officials did not indicate that developing an official access standard for  follow-up appointments would be part of the strategic planning process.

section_title: Limited Data on Mental Health Access in Purchased Care Are Available, but DOD Instead Relies on Beneficiary Surveys and Complaints to Monitor Access
paragraphs: Limited data are available regarding access to care in the MHS’s  purchased care system. As previously mentioned, in lieu of detailed  access to care compliance data, patient satisfaction with length of time to  appointment, as measured through beneficiary surveys described later in  this report, is used as a surrogate measure of access. In addition to  beneficiary surveys, TRICARE Regional Office officials told us that they  generally rely on beneficiary reports of access concerns, rather than on  appointment wait time data. The officials said that all such reports are  investigated and researched, and corrective action is taken when  possible. A consultant that reviewed access in the MHS’s purchased care  system noted that these methods of monitoring compliance with access  standards—beneficiary surveys and monitoring of beneficiary  complaints—were consistent with the primary methods used by civilian  health plans, even though the methods are not consistent with the direct- care system’s focus on appointment wait time data. The consultant also  found that developing automated systems to better monitor wait times in  purchased care was neither practical nor feasible, given the dispersed  networks of providers that make up the purchased care system.

Nonetheless, in all three domestic TRICARE regions the 28-day mental  health appointment access standard for specialty appointments is  monitored for a servicemember’s first mental health appointment that is  referred to purchased care. The wait time is measured as the time  between a referral authorization and the first specialty service date  reported on associated claims. While this measure may overstate the  time to care because it does not account for factors such as the time a  servicemember may take after receiving a referral authorization before  calling for an appointment, the measure appears to be the best available  proxy for monitoring compliance with this standard, according to the  consultant that reviewed access in the MHS’s purchased care system.  Data provided by each TRICARE Regional Office showed that the three  regions did not meet the MHS goal of having 90 percent of appointments  meet the access standard. For specialty mental health appointments with  behavioral health providers, more than three-fourths of appointments met  the access standard, and for psychiatry appointments, about two-thirds of  appointments met the access standard (see table 7). However, as noted  previously, this measurement may overstate the amount of time  servicemembers must wait before receiving care.

section_title: DOD Surveys and Other Sources of Access Information Show That Some Servicemembers Have Experienced Mental Health Access Problems
paragraphs: Various DOD and Air Force surveys have found that some  servicemembers experienced problems or have concerns about  accessing mental health care. For example, fiscal year 2011 through  fiscal year 2014 data from DOD’s Health Care Survey of DOD  Beneficiaries—the principal tool with which DHA monitors the opinions  and experiences of MHS beneficiaries directly—found that about one in  three servicemembers who had a need for treatment or counseling  experienced problems accessing mental health care in the MHS. (See  app. II, table 13.) Service-specific results were generally similar to the  overall results, although fewer active duty Air Force servicemembers  experienced access problems compared to the other services, with an  estimated 23 to 29 percent of Air Force servicemembers experiencing  problems over the four-year period. Similar to the results for active duty  servicemembers, about an estimated one-third of reservists experienced  problems accessing mental health treatment over the four years.

Results from the Air Force’s 2013 Community Assessment survey found  that the majority of Air Force servicemembers did not feel that various  mental health access barriers related to logistics and appointment  scheduling were applicable to them. (See app. II, table 14.) However, it  is unknown what percentage of Air Force servicemembers responding to  the 2013 Community Assessment actually sought counseling or other  mental health care. In response to various questions related to potential  access barriers, the 2013 survey results estimate that the listed access  barriers did not affect the majority of Air Force servicemembers’ ability to  seek counseling or other mental health care services. For example, in  response to the statement “It would be difficult to schedule an  appointment,” 81 percent of active duty Air Force servicemembers  reported that this statement “does not describe me at all.”

Additional DOD surveys specific to purchased care have also identified  some potential problems regarding access to civilian mental health  providers. For example, DOD’s nationwide TRICARE Standard Surveys  of Civilian Providers have found that less than half of civilian mental  health providers were accepting new TRICARE patients. (See app. II,  table 15.) As we have previously reported, surveys from 2008 through  2011 estimated that only about 39 percent of civilian mental health  providers were accepting any new TRICARE patients. Data from the  2012 and 2013 TRICARE Standard Survey of Civilian Providers provided  by DOD showed that this percentage had not improved over time, with an  estimated 37 percent of civilian mental health providers accepting new  TRICARE patients during the surveys. A TRICARE Regional Office  official suggested that the challenge of finding a civilian mental health  provider who is accepting new TRICARE patients should be less of a  concern for Prime beneficiaries, because they would typically be seeking  care from TRICARE network providers. The Regional Office official also  said that they would assist any Prime beneficiary who reported  challenges in finding a mental health provider, and a DOD official  explained that if a mental health specialist is not available, the contractor  (domestic or overseas) is contractually responsible for locating a non- network provider for Prime beneficiaries.

Additionally, DOD’s TRICARE Standard Survey of Beneficiaries, which  surveyed beneficiaries not enrolled in TRICARE Prime (that is,  nonenrolled beneficiaries), including reservists with TRS, have also found  that these beneficiaries experienced problems accessing a civilian mental  health care provider. (See app. II, table 16.) As we previously reported,  surveys from 2008 through 2011 show that an estimated 28 percent of  these nonenrolled beneficiaries experienced problems accessing civilian  mental health care providers. The 2012 and 2013 survey data show  similar results, with an estimated 30 percent of nonenrolled beneficiaries  experiencing problems accessing services provided by a civilian mental  health care provider.

In addition to surveys, recent research related to access to DOD mental  health has also identified potential problems with access to care for some  types of servicemembers. For example, a 2015 RAND Corporation study  about access to behavioral health care found that active duty  servicemembers classified as living in geographically remote areas made  up to 20 percent fewer visits to behavioral health care providers than  those living closer to facilities. The RAND study also found that remote  servicemembers needing or wanting behavioral health care face  challenges similar to those faced by the rural population generally,  including a shortage of appropriate service providers, long travel times to  facilities, and few travel options. Additionally, the study found that gaps in  broadband service in rural and remote areas impede the use of telehealth  services. However, despite the high representation of reservists who live  in geographically remote areas, RAND’s analyses did not find the  remoteness associated with less utilization of behavioral health care in  that population.

Two Army-specific studies also identified some concerns with access to  mental health care. A 2010 survey of Army mental health care providers  and their patients found that while the majority of the providers reported  being able to spend sufficient time with patients (92 percent) and  schedule encounters to meet patients’ needs (82 percent), the providers  also identified services for which access to treatment was more limited  and patient subgroups with an unmet need for additional clinical care or  services. For example, the providers’ patients with more severe  symptoms and diagnostic and clinical complexity reported higher rates of  access problems. Additionally, a study of three samples of Army National  Guard soldiers at three time points found that while stigma was the most  frequently cited barrier to care (34 percent of soldiers overall), 31 percent  of the soldiers reported at least one significant barrier to care related to  logistics (where to get help, inadequate transport, difficult to schedule,  getting time off work, care costs too much money, no providers available,  long distances to care). One logistical barrier—mental health treatment  costing too much—was the most commonly reported, with 16 percent of  soldiers overall noting this barrier.

We also learned about mental health access challenges in our interviews  with service officials representing reservists and with representatives from  an association representing Reserve officers. Both groups identified  mental health access challenges experienced by reservists. However,  service officials reported that they typically hear about these types of  access challenges anecdotally and do not systematically collect  information about access challenges faced by reservists. For example,  while activated reservists or those with line of duty mental health  conditions may have a right to DOD health care, Army National Guard  and Army Reserve officials and representatives from the Reserve Officers  Association reported that reservists’ access may be limited by their  distance from an MTF or from other resources available in their area,  particularly if they live in a geographically remote area. An Army National  Guard official and a Navy and Marine Corps Reserve official noted that in  some communities reservists face challenges finding providers that will  accept TRICARE or providers that are accepting new patients. National  Guard officials and a Navy and Marine Corps Reserve official also noted  that the TRS premiums and other costs are another access barrier for  some reservists, particularly for lower ranking servicemembers or those  who are otherwise unemployed. Additionally, representatives from the  Reserve Officers Association and the Army National Guard reported  challenges associated with putting reservists on orders to receive care  related to a line of duty condition. An Army National Guard official noted,  for example, that the minimum time for orders is an 8-hour day or a 4- hour drill period, which means servicemembers would have to be put on  active duty for that day, precluding them from doing anything else,  including working their civilian jobs.

While access problems were identified in surveys, studies, and our  interviews, DOD’s current work to establish a governance structure for  mental health access oversight, which includes the implementation of the  department’s mental health strategic plan, may address some of these  concerns. For example, the governance structure may improve  accountability when access standards are not being met. However, some  problems such as finding available mental health providers may remain  because, as noted previously, provider shortages affect the entire health  system and are not specific to DOD or the TRICARE program. It is too  early to determine the extent to which DOD’s ongoing efforts will resolve  all of these concerns.

section_title: Mental Health Care Available in Deployed Settings Varies Depending on the Environment, and Access Data Are Generally Not Available
subsections: section_title: Mental Health Care Available in Deployed Settings Varies by Environment, Is Delivered Through Various Means, and Has Decreased Along with Deployments
paragraphs: Officials from the Army, Navy, and Marine Corps reported that the  availability of mental health care varies depending on the deployed  environment. They noted that such care is more variable than the  services available domestically and that in general, deployed reservists  and DOD civilians have access to the same mental health care available  to active duty servicemembers in that deployed environment. This is  consistent with findings from our prior work. For example, in 2013 we  reported that the health care services that are available aboard Navy  vessels largely depend on the type and class of vessel. Larger vessels  generally offer a wider range of services—including specialized  services—than do smaller vessels, due largely to their more robust crew  levels and capabilities.

Additionally, MHAT studies about the mental health care available in  Afghanistan, where a significant number of deployed servicemembers  have been located in recent years, have found that the mental health  resources available there were robust but unevenly distributed. The Joint  Mental Health Advisory Team 8 (J-MHAT 8) study, conducted in 2012,  noted that the range of mental health care provided in Afghanistan  included emergency psychiatric care and medical evacuations,  psychotherapy, medication management, traumatic event management,  outreach, education, awareness training, and medical evaluations.  However, the study also found that the providers and clinics that deliver  these services were unevenly distributed, resulting in a small number of  clinics providing the bulk of the services.

Navy and Marine Corps officials told us that the availability of mental  health care in deployed settings varies depending on a number of factors.  For example, a Navy official cited factors including the type of deployed  setting, the number of deployed personnel, and the assessed needs of a  particular unit. A Marine Corps official noted some additional factors, such  as the deployment purpose and the expected stress from the deployment.  This official stated that Navy and Marine commanders, after consulting  with psychological health advisors and considering a variety of factors,  generally determine what, if any, mental health resources deploy with  particular units.

Mental health care is provided to deployed servicemembers and DOD  civilians through various means. Army officials told us, for example, that  mental health care in deployed settings is provided to servicemembers  through behavioral health officers assigned to brigade combat teams, as  well as through combat operational stress control teams. An Army  official stated that each brigade deploys with two different behavioral  health officers—frequently psychologists and social workers—and staff  that support these officers with providing care. The official said that the  combat operational stress control teams comprise up to 30 individuals  that assist with prevention initiatives and provide support for mental  health issues for each brigade combat team. The official added that the  division would also have a psychiatrist who helps coordinate care. Navy  and Air Force officials similarly stated that in certain deployed settings  mental health providers may be co-located or embedded with deployed  personnel. The Marine Corps’ combat operational stress control program  includes teams of Marine leaders, religious ministry personnel, and  mental health providers assigned to battalion-sized units that have been  trained in identifying, managing, and preventing combat stress issues.

Clinic settings and telehealth are also used to deliver mental health care  in certain deployed settings. For example, the report for J-MHAT 8  described clinic settings in Afghanistan through which servicemembers  received care. That study found, for example, that the majority of mental  health services provided in Afghanistan were provided at combat stress  clinics and behavioral health clinics, which are outpatient clinics that  provide mental health care to any walk-in patients. Mental health care in  Afghanistan was also provided in restoration clinics—residential treatment  facilities designed to maximize restoration and return-to-duty for  servicemembers. J-MHAT 8 also found that telehealth was used in  Afghanistan, although most providers surveyed reported that they  preferred in-person counseling as a method of care delivery for  servicemembers. Army officials noted that over the past several years,  the Army has increasingly leveraged telehealth to increase access to  care, particularly in remote locations.

Data on the number of deployed mental health providers in Afghanistan  show that the number of providers available to offer mental health care  services increased from 2005 through 2010, before decreasing as the  United States scaled back its military operations (see fig. 7). Army  officials told us that there are generally more behavioral health providers  deployed to areas of combat operations, such as Afghanistan, compared  to other non-combat missions.

Data provided by the military services and DOD regarding the total  number of mental health providers deployed to any location since fiscal  year 2014 suggest that deployed mental health provider availability has  continued to decrease since the last MHAT study in Afghanistan—MHAT  9 in 2013—when there were 129 mental health providers in Afghanistan,  consistent with the overall drawdown in deployed forces. For fiscal year  2014, the services reported a total of 114 mental health providers in any  deployed setting (of these, the Army reported 64, the Air Force reported  29, the Navy reported 21, and the Marine Corps reported none). As of  February 2016, DOD reported that there were a total of 36 mental health  providers in deployed settings, of which 10 were located in Afghanistan.  Army officials confirmed that the number of deployed mental health  providers has decreased since 2013 in accordance with the overall force  drawdown in Afghanistan. Army and DOD officials also reported some  additional factors that have affected the total number of deployed mental  health providers in recent years, such as troops no longer performing  combat patrols and the behavioral health providers’ non-combat missions,  which include providing local support to Allied missions and supporting  redeployment operations.

section_title: Mental Health Access Data for Deployed Settings Are Generally Not Available, Although Afghanistan Studies Show Some Access Improvement since 2009
paragraphs: According to DOD, data on access to mental health care in deployed  settings are generally not available, and DOD’s access to care standards  do not apply in these environments. For example, an Army official noted  that the Army’s access to data on mental health encounters in deployed  settings is fairly limited. He stated that data availability depends on factors  such as commanders’ preferences regarding what data to record and  internet connectivity at the deployed site. In lieu of data on access, a  DOD official noted that DOD has reviewed the staffing ratios in the MHAT  reports in order to monitor access in the deployed environment. In recent  years MHAT data has indicated that the number of mental health  providers in Afghanistan was sufficient to meet mental health needs of  deployed servicemembers, according to the 2013 MHAT 9 report.

The MHAT studies conducted in Afghanistan from 2009 through 2013  showed some improvement in active duty servicemembers’ opinions  about access to mental health care. As part of the studies,  servicemembers were surveyed about various logistical barriers to  accessing mental health care, and the responses were separated by  those servicemembers who screened positive for mental health problems  and those who did not (see table 8). The MHAT studies found that the  percentage of servicemembers agreeing with the statements “mental  health services aren’t available” and “it is too difficult to get to the location  where the mental health specialist is” decreased significantly since 2009.

However, as table 8 shows, the MHAT studies from 2009 through 2013  also found that some servicemembers continued to experience barriers  accessing mental health services. For example, the MHAT studies  consistently found that a higher percentage of Army servicemembers who  screened positive for mental health problems experienced barriers to  mental health care compared with those who did not screen positive. The  studies also found that the percentage of servicemembers who  experienced some access barriers remained fairly stable from 2009  through 2013. For example, during this period the percentage of  servicemembers reporting that they would experience difficulty getting  time off work for treatment remained the highest compared to the other  access barrier questions. In addition, the MHAT studies also identified  stigma as a strong potential barrier to seeking mental health care, with  servicemembers that screened positive for mental health conditions  reporting high levels of stigma-related concerns. For example, in the 2013  study, 49 percent of Army servicemembers that screened positive for a  mental health condition reported that they agreed or strongly agreed that  they would be seen as weak if they were to seek mental health care.

Although the MHAT studies showed that some servicemembers  continued to experience barriers accessing mental health services over  time, as noted previously, the number of servicemembers deployed to  Afghanistan has declined in recent years. Additionally, DOD reported in  February 2016 that it was working to expand its telehealth efforts there  and that efforts such as circulating providers throughout the battlefield  and organizing providers in teams had improved the utilization and  efficiency of deployed mental health providers since the last MHAT report  in 2013.

section_title: Conclusions
paragraphs: Providing our nation’s military servicemembers with timely access to  mental health care is a crucial responsibility of DHA and the military  services. Recent data show that DOD is generally meeting three of its  four appointment wait time access standards in its direct care system— where the majority of outpatient mental health care is delivered. However,  recent DOD surveys also show that about a third of servicemembers  reported that they experienced problems accessing care—indicating that  servicemember perceptions of access and DOD’s access to care  standards may not be aligned. Our work also shows that despite federal  internal control standards that call for agencies to have sufficient  information to monitor agency performance, DOD lacks an important  standard for follow-up appointments, which represent nearly two-thirds of  the mental health care provided in the MHS’s direct care system. Without  such a standard, DOD does not have a mechanism for holding MTFs or  the services accountable for providing timely access to the most common  mental health care provided in the direct care system.

Nonetheless, DOD has efforts underway to expand the mental health  care available to its servicemembers and to improve access to that care.  For example, DOD’s current work to establish a governance structure for  the oversight of mental health access, which includes the department’s  mental health strategic plan, could help DOD and the military services  identify, monitor, and improve the performance of those military services  or MTFs not performing up to standards and help ensure that  servicemembers have timely access to necessary mental health care.  However, it is too soon to determine what the impact of DOD’s efforts will  be on improving access. Additionally, some factors outside of DOD’s  control, such as the nationwide shortage of mental health providers, may  continue to limit DOD’s ability to address all identified access problems.

section_title: Recommendation for Executive Action
paragraphs: To enhance oversight of access to mental health care and help ensure  that servicemembers have timely access to mental health care, we  recommend that that Secretary of Defense direct the Assistant Secretary  of Defense for Health Affairs to establish an access standard for mental  health follow-up appointments and regularly monitor data on these  appointments.

section_title: Agency Comments
paragraphs: We provided a draft of this report to DOD for comment. DOD provided  written comments, which are reproduced in appendix III. DOD also  provided technical comments that were incorporated, as appropriate.

In its written comments, DOD concurred with our recommendation, but  noted that developing a standard for follow-up mental health  appointments would be difficult. Nonetheless, the agency reported that it  would review appropriate methods to develop follow-up standards. DOD  did not provide a time frame for implementing this recommendation.

We are sending copies of this report to the Secretary of Defense,  appropriate congressional committees, and other interested parties. In  addition, the report is available at no charge on the GAO website at  http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made major contributions to  this report are listed in appendix III.

section_title: Appendix I: Fiscal Year 2015 Department of Defense (DOD) Mental Health Provider Staffing Shortages
paragraphs: This appendix provides results from our analysis of DOD fiscal year 2015  quarterly mental health staffing reports by military service and the  National Capital Region (NCR) Medical Directorate. These reports are  submitted by the services and the NCR Medical Directorate to the Office  of the Assistant Secretary of Defense for Health Affairs human capital  office each quarter to provide status updates on mental health care  provider staffing levels.

section_title: Appendix II: Department of Defense (DOD) and Air Force Survey Data Related to Mental Health Access
paragraphs: Tables 13 through 16 contain results for questions relevant to access to  mental health care in DOD’s Military Health System from four recent  surveys. The four surveys are: (1) the fiscal year 2011-2014 Health Care  Survey of DOD Beneficiaries; (2) the 2013 Air Force Community  Assessment survey, (3) the TRICARE Standard Survey of Civilian  Providers for 2012 and 2013; and (4) the TRICARE Standard Survey of  Beneficiaries for 2012 and 2013.

section_title: Appendix III: Comments from the Department of Defense

section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
paragraphs: Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov.

section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Lori Achman, Assistant Director;  Muriel Brown; Krister Friday; Jacquelyn Hamilton; Dharani Ranganathan;  Christina Ritchie; and Helen Sauer made key contributions to this report.


Question-summary annotations: questions: question: What does DOD data on domestic and overseas direct care show?
answer: DOD data on domestic and overseas direct care from April 2014 through August 2015 show that MHS-wide DOD's access to care standards were generally met for three of four mental health appointment types.
child_questions: question: What is the case with routine appointments?
answer: However, in the case of routine appointments—initial appointments for a new or exacerbated condition—data show that other than the Air Force, MHS routine mental health appointments generally did not meet the 7-day access standard.

question: What factors did DOD and service officials attribute this to?
answer: DOD and service officials attributed this to several factors, including some appointments being incorrectly coded, thus negatively impacting the routine appointment access results.

question: What did they tell GAO?
answer: They told GAO that DOD was taking steps to address the coding problem and improve oversight of mental health access.

question: What else did the data show?
answer: Additionally, the data show that about 59 percent of mental health appointments are follow-up appointments, which generally do not have an official DOD access standard.

question: What do federal internal control standards call for?
answer: Federal internal control standards call for agencies to have sufficient information to monitor agency performance.

question: What can DOD not do by not establishing and monitoring a follow-up appointment standard?
answer: By not establishing and monitoring a follow-up appointment standard, DOD cannot hold the military services accountable for the majority of mental health care provided in the direct care system.

question: What is the case for purchased care?
answer: For purchased care, limited access data are available, and DOD instead relies on beneficiary surveys and complaints to monitor access—consistent with methods used by civilian health plans.

question: What have DOD surveys identified?
answer: DOD surveys have identified access problems for some servicemembers.
child_questions: question: What is an example of this?
answer: For example, a DOD beneficiary survey estimated that about one-third of active duty servicemembers experienced problems accessing mental health care from 2011 through 2014.

question: What did provider surveys from 2012 to 2013 find?
answer: Additionally, provider surveys from 2012 and 2013 found that only an estimated 37 percent of civilian mental health providers were accepting any new TRICARE patients.

question: How might DOD's ongoing efforts implement change?
answer: DOD's ongoing efforts to improve oversight of mental health access, including implementing a strategic plan, may help address some of these problems, but it is too early to tell.

questions: question: What does the National Defense Authorization Act for FY2015 contain?
answer: The National Defense Authorization Act for Fiscal Year 2015 contains a provision for GAO to assess the availability and accessibility of mental health care in DOD's MHS for military servicemembers.

question: What does this report examine?
answer: This report examines, among other things, (1) the mental health care DOD makes available to servicemembers domestically and overseas and (2) the accessibility of mental health care provided to servicemembers domestically and overseas.
child_questions: question: What did GAO recently analyze?
answer: GAO analyzed recent, available data on MHS mental health utilization, staffing, and appointment access and compared access data to relevant DOD standards.

question: What data did GAO review?
answer: GAO reviewed mental health data from several DOD surveys as well as documents related to MHS mental health care. GAO also interviewed DOD and service officials and representatives from servicemember and provider associations.