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. 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. 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. 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). 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov. 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.

Summary: 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. 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. 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.