Under TRICARE, beneficiaries have choices among various benefit options and may obtain care from either military treatment facilities or civilian providers. When nonenrolled beneficiaries receive care from civilian providers, they have the option of seeing either network or nonnetwork providers. The NDAA 2008 directed DOD to conduct surveys of beneficiaries and civilian providers to assess nonenrolled beneficiaries’ access to care. TRICARE provides benefits through several basic options for its non- Medicare-eligible beneficiary population. These options vary by enrollment requirements, choices in civilian and military treatment facility providers, and the amount beneficiaries must contribute toward the cost of their care. Table 1 provides a summary of some of these benefit options. Claims data from fiscal years 2008 to 2011 show that the percentages of the number of outpatient claims paid for TRICARE Prime and TRS have gradually increased, while the percentage of claims paid for TRICARE Standard has declined. (See fig. 1.) The percentage of claims paid for TRICARE Extra has remained steady over the same period. Starting on September 30, 2013, the number of PSAs will be reduced, and as a result, the TRICARE Prime option will be available to fewer beneficiaries. The targeted PSAs are those that are not in close proximity to existing MTFs or BRAC locations and will predominantly affect retirees and their dependents. According to a TMA official, this change is expected to affect about 171,000 retirees and dependents (37,000 in the North region, 36,000 in the West region, and 98,000 in the South region), with an estimated savings to DOD of $45 million to $56 million annually. In fiscal year 2011, TMA identified about 2 million nonenrolled beneficiaries (approximately one-fourth of the total eligible TRICARE population), who fell into three main categories: (1) retirees and their dependents or survivors, (2) active duty dependents, and (3) National Guard and Reserve servicemembers and their dependents. (See fig. 2.) Overall, during 2008-2011, an estimated one in three nonenrolled beneficiaries (about 31 percent) experienced problems finding any type of civilian provider—primary, specialty, or mental health care provider—who would accept TRICARE. Specifically: an estimated 25 percent of nonenrolled beneficiaries experienced problems finding a civilian primary care provider; an estimated 25 percent of nonenrolled beneficiaries experienced problems finding a civilian specialty care provider; and an estimated 28 percent experienced problems accessing a civilian mental health care provider. Overall, access to civilian primary care and specialty care providers differed for nonenrolled beneficiaries located in PSAs compared to those in non-PSAs. Specifically, we found that more nonenrolled beneficiaries in PSAs experienced problems finding civilian primary care and specialty care providers compared to those in non-PSAs. (See fig. 6.) However, access to civilian mental health care providers did not differ for nonenrolled beneficiaries in PSAs and non-PSAs. TMA also surveyed beneficiaries in HSAs in response to access concerns about these specific areas. We found that more nonenrolled beneficiaries in HSAs experienced problems accessing civilian specialty care than those in the areas outside of the surveyed HSAs. (See fig. 7.) However, there were no statistical differences in the estimated percentages of nonenrolled beneficiaries who experienced problems finding civilian primary or mental health care providers between the HSAs and the locations surveyed outside of these areas. The top two reasons reported by nonenrolled beneficiaries—regardless of type of care—for why they believed they experienced problems accessing a provider included “doctors not accepting TRICARE payments” and “doctors not accepting new TRICARE patients.” (See fig. 8.) Our analysis of the 4-year survey data showed that nonenrolled beneficiaries’ ratings for specific satisfaction measures were similar when compared between PSAs and non-PSAs, and between surveyed HSAs and the areas outside of the surveyed HSAs. Specifically, our analysis of beneficiaries’ ratings for four measures—satisfaction with primary care providers, specialty care providers, health care, and health plan— indicated no substantial differences between area types. For example, we found that about 80 percent of nonenrolled beneficiaries in both PSAs and non-PSAs rated their primary care provider as an 8 or higher on a scale from 0 to 10. Nationwide, an estimated 82 percent of civilian providers indicated they were aware of the TRICARE program, but only an estimated 58 percent were accepting new TRICARE patients, according to our analysis of the 2008 through 2011 civilian provider survey results. When compared to a national provider survey, civilian providers’ acceptance of new TRICARE patients was less than providers’ acceptance of other types of beneficiaries. Specifically, a survey of physicians in 2008 by the Center for Studying Health System Change found that about 96 percent of physicians accepted new commercially insured beneficiaries, about 86 percent accepted new Medicare beneficiaries, and about 72 percent accepted new Medicaid beneficiaries. According to the TRICARE survey results, when asked the reasons for not accepting new TRICARE patients, the most-cited category by those civilian providers who were not accepting any new TRICARE patients was that the provider “was not aware of the TRICARE program/not asked/don’t know about TRICARE.” (See fig. 10 for the top 7 categories of reasons for why civilian providers were not accepting new TRICARE patients.) Additionally, while nonenrolled beneficiaries cited that providers were not accepting TRICARE for payment as the top reason why any providers were unwilling to accept them as patients, the providers cited it as the third highest reason in addition to “don’t know/no answer.” When we compared the results of TMA’s 2008-2011 civilian provider survey (excluding nonphysician mental health providers) to the results of its 2005-2007 civilian physician survey, we found that although civilian physicians’ awareness has increased over time, their acceptance of new TRICARE patients has decreased over time. This was also true whether they were accepting any new patients or new Medicare patients. For example, civilian physicians’ acceptance of any new TRICARE patients has decreased from about 76 percent in 2005-2007 to an estimated 70 percent in 2008-2011. (See fig. 11.) When analyzed further by provider type, we found that civilian primary and specialty care providers had higher awareness and acceptance of TRICARE than civilian mental health care providers. (See fig. 12.) Specifically, only an estimated 39 percent of civilian mental health providers were accepting new TRICARE beneficiaries, compared to an estimated 67 percent of civilian primary care providers and an estimated 77 percent of civilian specialty care providers. The categories of reasons cited for not accepting new TRICARE patients also differed by provider type. For example, civilian mental health care providers more often cited “not aware of TRICARE/not asked/don’t know about TRICARE” than civilian primary or specialty care providers. Additionally, the top category of reasons cited by civilian primary care providers was that they were “not accepting patients” while the top category of reasons cited by specialty providers was “reimbursement.” (See fig. 13 for the top categories of reasons for civilian providers not accepting new TRICARE patients, by provider type.) We also found that providers’ awareness and acceptance of TRICARE differed by type of area. Similar to TMA’s nonenrolled beneficiary survey, which showed that nonenrolled beneficiaries in PSAs generally experienced more problems finding providers than their counterparts in non-PSAs, our analysis of the 2008 through 2011 civilian provider survey indicated that civilian providers in PSAs were less aware of TRICARE and less accepting of new TRICARE patients than civilian providers in non- PSAs. Specifically, an estimated 81 percent of civilian providers in PSAs were aware of the TRICARE program, compared to an estimated and an estimated 87 percent of civilian providers in non-PSAs, 56 percent of civilian providers in PSAs were accepting any new TRICARE patients, compared to an estimated 66 percent of those providers in non-PSAs. (See fig. 14.) An analysis of the collective results of the multiyear beneficiary and civilian provider surveys indicated particular geographic areas where nonenrolled beneficiaries are experiencing considerable access problems. These locations are defined as areas where (1) the percentage of nonenrolled beneficiaries who experienced difficulties finding a civilian provider was at least the national estimate and (2) the percentage of civilian providers who were accepting any new TRICARE patients was at or below the national estimate. Using these criteria, we identified a number of areas where beneficiaries were having access problems, mostly in Texas. (See app. IV for detailed information about these areas and how they were determined.) In determining areas where nonenrolled beneficiaries were experiencing access problems to any type of civilian provider, we first identified 24 individual areas (out of the 215 individual areas surveyed by the 2008- 2011 beneficiary surveys) where the estimated percentage of nonenrolled beneficiaries who experienced difficulties finding any type of civilian provider met or exceeded the national estimate (31 percent). Of these, we identified 2 PSAs where the estimated percentage of civilian providers who were accepting any new TRICARE patients was at or below the national estimate (58 percent)—Central/Southern-Central Coastal California and Northeastern Texas. Additionally, we identified 2 HSAs that also met these criteria, one of which is contained within the Northeastern Texas PSA. Table 4 shows each of these areas with the estimated percentage of (1) nonenrolled beneficiaries who experienced problems finding any type of civilian provider and (2) civilian providers who were accepting any new TRICARE patients. For the overlapping PSA and HSA (Northeastern Texas and Dallas/Fort Worth), we found that although a high percentage of civilian providers were accepting new patients (between 95 and 97 percent), only about half of these providers were accepting any new TRICARE patients. (See table 5.) For the remaining PSA (Central/Southern-Central California) and HSA (Austin, Texas), between 92 and 98 percent of civilian providers were accepting new patients, and less than half of those providers were accepting any new TRICARE patients. Further, of the civilian providers in all of these areas who were accepting new Medicare patients, between 65 and 70 percent were also accepting any new TRICARE patients. Reimbursement was the most cited reason for providers not accepting new TRICARE patients for all of the areas except the PSA in California for which “not aware of the TRICARE program” was the most cited reason. When analyzing this data by type of provider (primary care, specialty, and mental health), we found four areas where the percentage of civilian primary care providers who were accepting any new TRICARE patients was at or below the national estimate, but did not find similarly low- percentage areas for civilian specialty care providers. Because of the low numbers of survey responses, we are unable to report survey results for access problems to civilian mental health care providers. In determining areas where nonenrolled beneficiaries experienced access problems to civilian primary care providers, we first identified 21 individual areas where the estimated percentage of nonenrolled beneficiaries who experienced difficulties finding a civilian primary care provider met or exceeded the national estimate (25 percent). Of these, we identified 2 PSAs where the estimated percentage of civilian primary care providers who were accepting any new TRICARE patients was at or below the national estimate (67 percent)—Northeastern Texas and Eastern-Central Texas. We also identified 2 HSAs that met these criteria, each of which was contained in one of the PSAs we identified. Table 6 shows each of these areas with the estimated percentage of (1) nonenrolled beneficiaries who experienced problems finding a civilian primary care provider and (2) civilian primary care providers who were accepting any new TRICARE patients. As we similarly found in the areas where nonenrolled beneficiaries were having access problems for any type of civilian provider, we found that between 94 and 97 percent of civilian primary care providers in the Northeastern Texas PSA/Dallas/Ft. Worth HSA and the Eastern-Central Texas PSA/Austin, Texas, HSA were accepting new patients, but only around half of them were accepting new TRICARE patients. (See table 7.) Further, of the civilian primary care providers in the two PSAs who were accepting new Medicare patients, between 59 and 68 percent were accepting any new TRICARE patients. Reimbursement was the most cited reason by civilian primary care providers for not accepting any new TRICARE patients in each of these areas except for the Dallas/Ft. Worth, Texas, HSA, for which “don’t know/no answer” was the most cited reason. In determining areas where nonenrolled beneficiaries are experiencing access problems to civilian specialty care providers, we first identified nine individual areas where the estimated percentage of nonenrolled beneficiaries who experienced difficulties finding a civilian specialty care provider met or exceeded the national estimate (25 percent). Unlike the collective results for “any civilian provider” and “civilian primary care providers,” when we examined civilian specialty care providers’ responses for these areas, we did not identify any geographic areas where the estimated percentage of civilian specialty care providers who were accepting any new TRICARE patients was at or below the national estimate (77 percent) when accounting for the margins of error at the 95 percent confidence limit. For the nine areas where the estimated percentage of beneficiaries who experienced difficulties finding a civilian specialty care provider met or exceeded the national estimate, the percentage of civilian specialty care providers who were accepting new TRICARE patients ranged from 75 to 86 percent. Because of the low numbers of survey responses for beneficiaries who said they needed civilian mental health care, we are unable to report correlated survey results for access problems to civilian mental health care providers.of mental health providers and the survey results that only 39 percent of civilian mental health care providers were accepting new TRICARE patients, access to mental health care providers is a concern for all TRICARE beneficiaries, including those who use the TRICARE Standard and Extra options. In reviewing a draft of this report, DOD concurred with our overall findings and provided technical comments, which we incorporated where appropriate. (See app. VI.) We are sending copies of this report to the Secretary of Defense and appropriate congressional committees. The report is also available at no charge on GAO’s website at http://www.gao.gov. If you or your staff members have any questions about this report, please contact me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff members who made key contributions to this report are listed in appendix VII. The National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008) directed the Department of Defense (DOD) to determine the adequacy of the number of health care and mental health care providers that currently accept nonenrolled beneficiaries as patients under TRICARE, DOD’s health care program. We use the term “nonenrolled beneficiaries” for beneficiaries who are not enrolled in TRICARE Prime and who use the TRICARE Standard or Extra options, or TRICARE Reserve Select (TRS). The NDAA 2008 also included specific requirements related to the number and priority of areas to be surveyed, including the populations to be surveyed each year, content for each type of survey, and the use of benchmarks. Within DOD, the TRICARE Management Activity (TMA), which oversees the TRICARE program, has the lead responsibility for designing and implementing the nonenrolled beneficiary and civilian provider surveys. The following information describes TMA’s methodology, including its actions to address the requirements for each of the following: (1) survey area, (2) sample selection, (3) survey content, and (4) the establishment of benchmarks. The NDAA 2008 specified that DOD survey beneficiaries and providers in at least 20 TRICARE Prime Service Areas (PSA),areas in which TRICARE Prime is not offered—referred to as non–Prime Service Areas (non-PSA)—each fiscal year, 2008 through 2011. The NDAA 2008 also required DOD to consult with representatives of TRICARE beneficiaries and health care and mental health care providers to identify locations where nonenrolled beneficiaries have experienced significant access-to-care problems, and give a high priority to surveying health care and mental health care providers in these areas. Additionally, and 20 geographic the NDAA 2008 required DOD to give a high priority to surveying areas in which a high concentration of Selected Reserve servicemembers live. In designing the 2008 through 2011 nonenrolled beneficiary and civilian provider surveys, TMA defined 80 PSAs and 80 non-PSAs that allowed it to survey the entire country over a 4-year period, and subsequently develop estimates of access to health care and mental health care at service area and national levels. TMA identified the 80 PSAs by collecting zip codes where TRICARE Prime was offered from officials within each of the three TRICARE Regional Offices. TMA grouped these zip codes into 80 nonoverlapping areas so that each area had roughly the same number of TRICARE-eligible beneficiaries. Because non-PSAs had not previously been defined, TMA sought to define them by grouping all zip codes not in PSAs into one large area using Hospital Referral Regions, which are groupings of Hospital Service Areas (HSA). TMA divided the large area into 80 non-PSAs so that each area had roughly the same number of TRICARE-eligible beneficiaries. To identify locations where nonenrolled beneficiaries and health care and mental health care providers have identified significant levels of access- to-care problems under TRICARE Standard and Extra, TMA spoke with groups representing beneficiaries and health care and mental health care providers, as well as officials at the TRICARE Regional Offices. These groups suggested cities and towns where access should be measured (in addition to the larger PSAs and non-PSAs), and HSAs corresponding to each city and town were then identified. On the basis of the groups’ recommendations, multiple lists were created and sorted in priority order: 21 HSAs were surveyed in the 2008 surveys; 9 HSAs in the 2009 surveys; 25 HSAs in the 2010 surveys; and 16 HSAs in the 2011 civilian provider survey. This resulted in a total of 55 HSAs surveyed for the nonenrolled beneficiary survey, and 71 HSAs surveyed in the civilian provider survey (the 71 HSAs includes the same 55 HSAs surveyed for the nonenrolled beneficiary survey and an additional 16 that were selected for the 2011 fielding). Although the NDAA 2008 required DOD to give a high priority to surveying areas in which a high concentration of Selected Reserve servicemembers live, TMA officials decided to randomly select areas for the surveys in order to produce results that could be generalized to the populations in the areas surveyed and to survey the entire United States over the 4-year period—an approach we deemed acceptable in our previous report. TMA selected its sample of beneficiaries who met its criteria for inclusion in the beneficiary survey using DOD’s Defense Enrollment Eligibility Reporting System (DEERS), a database of DOD beneficiaries who may be eligible for military health benefits. TMA determined a beneficiary’s eligibility to be included in the nonenrolled beneficiary survey if DEERS indicated that the individual met five criteria: 1. eligible for military health care benefits as of the date of the sample 2. age 18 years old or older; 3. not an active duty member of the military; 4. residing in one of the 20 randomly selected PSAs or 20 randomly selected non-PSAs to be surveyed that year; and 5. not enrolled in TRICARE Prime, or is enrolled in TRS. From this database, TMA randomly sampled 1,000 beneficiaries from each PSA and non-PSA—a sample size that would achieve TMA’s desired sample error rate. For the 2008, 2009, and 2010 survey fieldings, TMA used a sample size between approximately 40,000 and 50,000 beneficiaries. Because of budgetary constraints, the sample size of the 2011 nonenrolled beneficiary survey was decreased to around 34,000. Because of this reduction, the 2011 sample was further stratified by using claims data to identify beneficiaries who would likely self-report as TRICARE Standard and Extra users. After receiving the returned surveys, TMA identified the responses that it considered complete and eligible on the basis of whether the beneficiary had answered at least half of TMA’s identified “key” questions. Table 8 shows the number of nonenrolled beneficiary surveys mailed, by fiscal year. For each survey fielding, TMA selected the civilian provider sample within the same 20 PSAs and 20 non-PSAs that had been randomly selected for that year’s nonenrolled beneficiary survey, as well as civilian providers in the HSAs identified by beneficiary and provider groups as having significant levels of access-to-care problems under TRICARE Standard and Extra. TMA used the American Medical Association Physician Masterfile to select a sample of physicians who were licensed, office- based civilian medical doctors or licensed civilian doctors of osteopathy within the specified locations who were engaged in more than 20 hours of patient care each week. The American Medical Association Physician Masterfile is a database of physicians in the U.S.—Doctors of Medicine and Doctors of Osteopathic Medicine—that includes data on all physicians who have the necessary educational and credentialing requirements. This “Masterfile” did not differentiate between TRICARE’s network and nonnetwork civilian providers, which TMA deemed acceptable to avoid any potential bias in TMA’s sample selection. As such, TMA selected this file because it is widely recognized as one of the best commercially available lists of providers in the United States and contained more than 940,000 physicians along with their addresses, phone numbers, and information on practice characteristics, such as their specialty. According to TMA, the American Medical Association updates physicians’ addresses monthly and other elements through a rotating census methodology involving approximately one-third of the physician population each year. Although the Masterfile is considered to contain most providers, deficiencies in coverage and inaccuracies in detail remain. Therefore, TMA attempted to update providers’ addresses and phone numbers and ensure that providers were eligible for the survey by also using state licensing databases, local commercial lists, and professional society and association lists. For its 2008 and 2009 mental health care provider sample selection, TMA selected a sample of mental health care providers from two sources: the American Medical Association’s Masterfile of psychiatrists, and LISTS, Inc.—a list of names with contact information assembled from state licensing boards. For the 2010 and 2011 mental health care provider sample selections, TMA also used mental health specialty areas from the National Plan and Provider Enumeration System database maintained by the Centers for Medicare & Medicaid Services, in addition to data from LISTS, Inc., and the psychiatrist data from the American Medical Association’s Masterfile. According to TMA, it selected these sources for mental health care providers because they have been identified as the most comprehensive databases for these health care providers. From these data sets, TMA planned to randomly sample about 800 providers (400 each of physicians and mental health care providers) from each PSA, non-PSA, and HSA—a sample size that would achieve In those instances where there were TMA’s desired sample error rate.not 800 providers in a single area, TMA selected all of the providers in that area to receive surveys. As the PSA and non-PSA regions were formed on the basis of the number of beneficiaries and not the number of civilian providers, some regions with a large number of civilian providers were sampled at relatively low rates in 2008, 2009, and 2010. To improve the precision of national estimates, in 2011 TMA selected six areas to oversample: (1) Southeastern N.Y. and Northern N.J. (New York City); (2) Los Angeles, Calif.; (3) Eastern Mass. (Boston); (4) Northeastern/ Central Ohio (Cleveland); (5) Southeastern/Northern Mich. (Detroit); and (6) Northwestern/Northeastern/Central-Eastern Ill. and Southwestern Wisc. (Chicago). Therefore, in 2011, a supplemental sample of 4,800 providers was drawn for these 6 PSAs, thereby increasing the numbers of eligible providers in each area: 1,600 providers from the two 2008 PSAs (Los Angeles, California, and Southeastern New York/Northern New Jersey); 800 providers from the one 2009 PSA (Eastern Massachusetts); and 2,400 providers from the three 2010 PSAs (Northeastern/Central Ohio, Southeastern/Northern Michigan, and Northwestern/Northeastern/Central-Eastern Illinois/Southeastern Wisconsin). Upon receipt of the returned surveys, TMA identified the responses that it considered complete and eligible based on the following criteria for respondents: (1) if the provider answered “yes” to the questions that asked whether the provider offers care in an office-based location or private practice; (2) for the nonphysician mental health survey, if the provider responded he or she was one of the six TRICARE participating specialties: certified clinical social worker, certified psychiatric nurse specialist, clinical psychologist, certified marriage and family therapist, pastoral counselor, or mental health counselor; and (3) the provider had to have completed three key questions on the physician survey instrument, or three key questions on the nonphysician mental health provider survey instrument. Table 9 shows the number of civilian provider surveys mailed, by fiscal year. The NDAA 2008 required that the beneficiary survey include questions to determine whether TRICARE Standard and Extra beneficiaries have had difficulties finding physicians and mental health care providers willing to provide services under TRICARE Standard or TRICARE Extra. TMA’s 2008 nonenrolled beneficiary survey included 91 questions that addressed, among other things, health care plans used; perceived access to care from a personal doctor, nurse, or specialist; the need for treatment or counseling; and ratings of health plans. TMA based some of its 2008 nonenrolled beneficiary survey questions on those included in the Department of Health and Human Services’ Consumer Assessment of Healthcare Providers and Systems (CAHPS), a national survey of beneficiaries of commercial health insurance, Medicare, Medicaid, and the Children’s Health Insurance Program. Over the 4 years of the nonenrolled beneficiary survey fielding, TMA added three additional questions to the original 91 questions in the 2008 nonenrolled beneficiary survey that covered topics about the beneficiaries’ flu-shot history, and what they liked and disliked about TRICARE Standard and Extra. Additionally, in 2011, “TRICARE Young Adult” and “TRICARE Retired Reserve” were added to the response selections for the question that asked about the health plan the beneficiary used. (See app. II for a copy of the 2011 beneficiary survey instrument.) When TMA began mailing the beneficiary survey, it included a combined cover letter and a questionnaire to all beneficiaries in its sample—with the option of having beneficiaries complete the survey by mail or Internet. The cover letter provided information on the options available for completing the survey, as well as instructions for completing the survey by Internet. If the beneficiary did not respond to the mailed questionnaire, TMA mailed a second combined cover letter and questionnaire 4 weeks later encouraging the beneficiary to complete the survey. For the civilian provider survey, the NDAA 2008 required questions to determine: (1) whether the provider is aware of TRICARE; (2) the percentage of the provider’s current patient population that uses any form of TRICARE; (3) whether the provider accepts Medicare patients for health care and mental health care; and (4) if the provider accepts Medicare patients, whether the provider would accept new Medicare patients. TMA obtained clearance for its provider survey from the Office of Management and Budget (OMB) as required under the Paperwork Reduction Act. Subsequent to this review, OMB approved an 11-item questionnaire for physicians (including psychiatrists) and a 12-item questionnaire for nonphysician mental health providers. The mental health care providers’ version of the survey includes an additional question about what type of mental health care the provider practiced. Beginning with the 2009 civilian provider survey, an additional follow-up question was added that asked the provider what type of practice they practiced in if the provider indicated that they were not in private practice. Although a civilian provider’s indication that the provider was not in private practice still made the provider’s responses ineligible for the survey, the additional information from these nonprivate practice civilian providers could be used by TMA to glean additional information about civilian providers. (See app. III for a copy of the 2011 civilian provider survey instruments.) When TMA began mailing the provider survey, it included a combined cover letter and a questionnaire to each provider in the sample. The providers had the option of completing the survey by mail, fax, or Internet. The cover letter provided information on the options available for completing the survey, as well as instructions for completing the survey by Internet. If the provider did not respond to the mailed questionnaire, TMA mailed a second combined cover letter and questionnaire about 4 weeks later encouraging the provider to complete the survey. In accordance with the NDAA 2008, TMA identified benchmarks for analyzing the results of the beneficiary and civilian provider surveys. Because TMA based some of its 2008 beneficiary survey questions on those included in the CAHPS surveys, it was able to compare the results of those questions with its 2008 through 2011 beneficiary survey results. To benchmark its provider survey, TMA compared the results of its 2008 through 2011 surveys with the results of its 2005, 2006, and 2007 provider surveys. A TMA official noted that TMA was unaware of any external benchmarks that would be applicable to its surveys of providers. In analyzing the results of the nonenrolled beneficiary survey, TMA representatives conducted yearly nonresponse analyses because the overall response rate for the surveys was around 38 percent. To conduct this analysis for the 2008, 2009, and 2010 survey years, TMA did the following: (1) compared key beneficiary demographic characteristics of respondents to those of nonrespondents (e.g., beneficiary gender and age) and (2) interviewed a sample of beneficiaries who did not respond to the original survey or the follow-up second mailing and compared their responses with the original survey respondents. Because of budgetary constraints during the 2011 survey year, TMA only compared key beneficiary demographic characteristics of respondents to those of the nonrespondents. The results of TMA’s nonresponse analyses indicated that respondents to the nonenrolled beneficiary survey differed substantially from the surveyed population in some demographic characteristics. For example, the analyses indicated that retirees, dependents of retirees, and dependents of survivors were overrepresented in the study, and dependents of active duty servicemembers, dependents of Guard/Reserve personnel, and dependents of inactive guard personnel were underrepresented in the study. Additionally, in each of the years in which TMA representatives conducted follow-up interviews (2008-2010), they found some response differences between survey respondents. For example, each year in follow-up interviews of nonrespondents, they found these beneficiaries rated their primary care provider and health plans more favorably than beneficiaries who responded to the survey. According to TMA representatives, they used a weighting scheme to reflect the survey population proportions to correct any bias as a result of survey nonresponse. In analyzing the results of the provider survey, TMA conducted a nonresponse analysis because the overall response rate to the surveys was about 42 percent. To conduct this analysis for the 2008, 2009, and 2010 surveys, TMA did the following: (1) compared key provider demographic characteristics of respondents to those of nonrespondents (for example, provider type and area) and (2) interviewed a sample of physicians and mental health care providers who did not respond to the survey, follow-up second mailing, or follow-up telephone calls and compared their responses with the survey respondents. Because of budgetary constraints during the 2011 survey year, TMA only compared key provider demographic characteristics of respondents to those of the nonrespondents. The results of TMA’s nonresponse analyses indicated that there are some demographic differences between respondents and those who did not respond. For example, the analyses indicated that in some years psychiatrists were underrepresented in the survey samples. Overall, however, the results were consistent among the nonresponse analyses and indicated little variation between respondents and nonrespondents. As TMA used in the weighting scheme for the nonenrolled beneficiary survey, TMA used a weighting scheme to reflect the survey population proportions to correct any bias as a result of survey nonresponse. The National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008) directed the Department of Defense (DOD) to determine the number of health care and mental health care providers that currently accept nonenrolled beneficiaries as patients under TRICARE, DOD’s health care program. For the purpose of this report, we use the term “nonenrolled beneficiaries” for beneficiaries who are not enrolled in TRICARE Prime and who use the TRICARE Standard or Extra options, or TRICARE Reserve Select (TRS). Specifically, the NDAA 2008 specified that DOD conduct surveys of beneficiaries each fiscal year, 2008 through 2011. The NDAA 2008 also required that the beneficiary survey include questions seeking information from nonenrolled beneficiaries to determine whether they have had difficulties finding health care and mental health care providers willing to accept them as patients. For the 2008 fielding of the beneficiary survey, 91 questions were included in the survey instrument. Over the next 3 years of the beneficiary survey’s fielding, TRICARE Management Activity (TMA) used the same 91 questions and added these additional questions: For the 2009 survey fielding and beyond, TMA added Question #81, which asked “When did you last have a flu shot?” for a total of 92 questions in 2009; For the 2010 survey fielding and beyond, TMA added two questions (Questions #75 and #76) that asked what the beneficiary liked and disliked about TRICARE Standard and Extra, respectively, for a total of 94 questions in 2010 and 2011. In addition, for the 2011 survey instrument, “TRICARE Young Adult” and “TRICARE Retired Reserve” were added to the response selections for Question #2, which asked “By which health plan are you currently covered?” Following is the actual survey instrument from the 2011 fielding that TMA used to obtain information from nonenrolled beneficiaries. The National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008) directed the Department of Defense (DOD) to determine the number of health care and mental health care providers that currently accept nonenrolled beneficiaries as patients under TRICARE, DOD’s health care program. For the purpose of this report, we use the term “nonenrolled beneficiaries” for beneficiaries who are not enrolled in TRICARE Prime and who use the TRICARE Standard or Extra options, or TRICARE Reserve Select (TRS). Specifically, NDAA 2008 directed DOD to survey providers each fiscal year, 2008 through 2011. The NDAA 2008 also required that the provider survey include questions seeking information to determine (1) whether the provider is aware of the TRICARE program, (2) the percentage of the provider’s current patient population that uses any form of TRICARE, (3) whether the provider accepts Medicare patients, and (4) if the provider accepts Medicare patients, whether the provider would accept new Medicare patients. DOD implemented two versions of its provider survey, one for physicians, including psychiatrists, and one for nonphysician mental health providers. For the 2008 fielding of the civilian provider survey, 11 and 12 questions were included in the physician and nonphysician mental health provider survey instruments, respectively. Over the next 3 years of the civilian provider survey’s fielding, TRICARE Management Activity (TMA) generally used the same questions, but made the following adjustments to the survey instruments: Beginning with the 2009 fielding of both survey instruments and beyond, TMA adjusted Question #1 which asked the provider whether they provided health care to patients in an office-based practice (for physicians) or a private practice (for nonphysician mental health care providers) so that a “no” response would no longer instruct the provider to stop answering the survey at that point. Instead, the revision directed the provider to the newly added Question #1a that asked the provider what type of practice they were in (if they answered “no” to Question #1). For the 2010 and 2011 fieldings of the physician survey instrument, TMA also adjusted Question #1 from “Does provide treatment to patients through an office-based practice?” to “Does [the provider] provide treatment to patients through private practice?” Following are the actual survey instruments from the 2011 fielding that TMA used to obtain information from physicians and nonphysician mental health care providers. The 2008-2011 beneficiary survey indicated individual areas where nonenrolled beneficiaries experienced problems finding “any civilian provider,” civilian primary care providers, and civilian specialty care providers. We define these locations as areas where the percentage of nonenrolled beneficiaries who experienced difficulties finding a civilian provider was at the national estimate or higher. We identified 24 individual areas (out of the 215 individual areas surveyed by the 2008-2011 beneficiary surveys) where the percentage of nonenrolled beneficiaries who experienced problems finding any type of provider who would accept TRICARE met or exceeded the national estimate. We then identified 49 additional areas where the percentage of nonenrolled beneficiaries who experienced these problems was less than the national estimate. The remaining 130 areas had estimates that ranged from 18 to 50 percent, but because of their confidence intervals, were neither above nor below the 31 percent threshold.the geographic distribution of these three categories of areas. We identified 21 individual areas where the percentage of nonenrolled beneficiaries who experienced problems finding a civilian primary care provider who would accept TRICARE patients met or exceeded the national estimate. We then identified 50 additional areas where the percentage of nonenrolled beneficiaries who experienced these problems was less than the national estimate. The remaining 129 areas had estimates that ranged from 13 to 44 percent, but because of their confidence intervals, were neither above nor below the 25 percent threshold.categories of areas. We identified nine individual areas where the percentage of nonenrolled beneficiaries who experienced problems finding a civilian specialty care provider who would accept TRICARE patients met or exceeded the national estimate. We then identified 34 additional areas where the percentage of nonenrolled beneficiaries who experienced these problems was less than the national estimate. The remaining 144 areas had estimates that ranged from 14 to 47 percent, but because of their confidence intervals, were neither above nor below the 25 percent threshold.categories of areas. Because of the low number of nonenrolled beneficiary responses to the questions about civilian mental health care, we are unable to identify specific geographic areas where nonenrolled beneficiaries have access problems to civilian mental health care providers. Of the 215 areas surveyed in the 4-year beneficiary survey, only 5 areas had 30 or more respondents—TMA’s threshold for reporting beneficiary survey results— who indicated that they needed mental health care and received it from a civilian provider. Additionally, for those 5 areas that did have at least 30 nonenrolled beneficiary responses, the margins of error were between 10 and 25 percentage points. The TRICARE Management Activity (TMA) fielded its provider and beneficiary surveys to the same Hospital Service Areas (HSA) each year with one exception. Because of resource constraints, the 2011 fielding of the beneficiary survey did not include any HSAs. However, 16 HSAs were included in the 2011 fielding of the provider survey. Because beneficiaries were not surveyed for these HSAs, they are not included in our collective analysis of the beneficiary and civilian provider survey results. Table 13 lists the 16 HSAs that were surveyed in the 2011 civilian provider survey fielding and the estimated percentage of civilian providers who were accepting any new TRICARE patients. In addition to the contact named above, Bonnie Anderson, Assistant Director; Jennie Apter; Linda Galib; Giselle Hicks; Jeff Mayhew; Lisa Motley; Dan Ries; and Eric Wedum made key contributions to this report.

Summary: DOD provides health and mental health care through its TRICARE program. TRICARE offers three basic options. Beneficiaries who choose TRICARE Prime, an option that uses civilian provider networks, must enroll. Beneficiaries who do not enroll in this option may obtain care from nonnetwork providers under TRICARE Standard or from network providers under TRICARE Extra. In addition, qualified National Guard and Reserve servicemembers may purchase TRICARE Reserve Select, a plan whose care options are similar to those of TRICARE Standard and TRICARE Extra. GAO refers to servicemembers who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select as nonenrolled beneficiaries. The National Defense Authorization Act for Fiscal Year 2008 directed DOD to conduct annual surveys over fiscal years 2008 through 2011 of both beneficiaries and civilian providers to determine the adequacy of access to health and mental health care providers for nonenrolled beneficiaries. It also directed GAO to review these surveys. This report addresses (1) what the results of the 4-year beneficiary surveys indicate about the adequacy of access to care for nonenrolled beneficiaries; (2) what the results of the 4-year civilian provider surveys indicate about civilian providers' awareness and acceptance of TRICARE, and (3) what the collective results of the surveys indicate about access to care by geographic area. To do so, GAO interviewed DOD officials, obtained relevant documentation, and analyzed the data for both surveys over the 4-year period. In its analysis of the 2008-2011 beneficiary survey data, GAO found that nearly one in three nonenrolled beneficiaries experienced problems finding a civilian provider who would accept TRICARE and that nonenrolled beneficiaries' access to civilian primary care and specialty care providers differed by type of location. Specifically, a higher percentage of nonenrolled beneficiaries in Prime Service Areas (PSA), which are areas with civilian provider networks, experienced problems finding a civilian primary care or specialty care provider compared to those in non-Prime Service Areas (non-PSA), which do not have civilian provider networks. GAO found that the top reasons reported by nonenrolled beneficiaries for why they experienced access problems--regardless of type of provider--were that the providers were either not accepting TRICARE payments or new TRICARE patients. Additionally, GAO's comparison of the Department of Defense's (DOD) beneficiary survey data to related data from a Department of Health and Human Services survey showed that nonenrolled beneficiaries' satisfaction ratings for primary and specialty care providers were consistently lower than those of Medicare fee-for-service beneficiaries. GAO's analysis of the 2008-2011 civilian provider survey data found that about 6 in 10 civilian providers were accepting new TRICARE patients and the most-cited reason for not accepting new TRICARE patients was that the civilian providers were not aware of the TRICARE program. Civilian physicians' acceptance of TRICARE has also decreased over time. Specifically, when compared to DOD's 2005-2007 civilian physician survey results, civilian physicians' acceptance of new TRICARE patients has decreased. This was also true whether they were accepting any new patients or new Medicare patients. Civilian providers' awareness and acceptance of TRICARE also differed by provider type, as fewer civilian mental health care providers were aware of TRICARE or accepting new TRICARE patients than other types of providers. For example, only an estimated 39 percent of civilian mental health care providers were accepting new TRICARE patients, compared to an estimated 67 percent of civilian primary care providers and an estimated 77 percent of civilian specialty care providers. The analysis also showed that civilian providers' awareness and acceptance of TRICARE differ by location type, as civilian providers in PSAs were less aware of TRICARE and less likely to accept new TRICARE patients than those in non-PSAs. GAO's analysis of the collective results of the beneficiary and civilian provider survey results indicates specific geographic areas, including areas in Texas and California, where nonenrolled beneficiaries have experienced considerable access problems. In each of these areas, although almost all civilian providers were accepting new patients, less than half were accepting new TRICARE patients. In most of these areas, civilian providers most often cited reimbursement concerns as the reasons why they were not accepting any new TRICARE patients. In commenting on a draft of this report, DOD concurred with GAO's overall findings.