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 military medical facilities, commonly referred to as military treatment facilities (MTF). In terms of the MHS organization and structure, OASD HA serves as the principal advisor for all DOD health policies and programs. OASD HA has the authority to issue DOD instructions, publications, and memorandums that implement policy approved by the Secretary of Defense or the Under Secretary of Defense for Personnel and Readiness and govern the management of DOD medical programs. In October 2013, the Defense Health Agency (DHA) was established to support greater integration of clinical and business processes across the MHS. The DHA manages the execution of policies issued by OASD HA, oversees the TRICARE health plan, and also exercises authority and control over the MTFs and subordinate clinics assigned to the NCR Medical Directorate. MTFs and their subordinate clinics are operated by either a military service or the NCR Medical Directorate. Neither OASD HA nor DHA have direct command and control of MTFs operated solely by the military services. medical personnel to administer medical programs and provide medical services to beneficiaries. The NCR Medical Directorate has direct authority over civilian providers and personnel working within its facilities; however, the military services maintain authority over all military providers and personnel working within NCR Medical Directorate MTFs. See figure 1 for the current organizational and governance structure of the MHS. The Army and Navy each have a medical command, headed by a surgeon general, who manages each department’s MTFs and other activities through a regional command structure. The Navy provides medical services for both Navy and Marine Corps installations. Unlike the Surgeons General for the Army and Navy, the Air Force Surgeon General exercises no command authority over Air Force MTFs; instead, Air Force MTF commanders report to local line commanders. The Air Force Surgeon General does not have direct authority over Air Force MTFs; however, the Air Force Surgeon General exercises similar authority to that of the other Surgeons General through his role as medical advisor to the Air Force Chief of Staff. The Assistant Secretary of Defense for Health Affairs is the principal advisor for all DOD health policies and programs. The Office of the Assistant Secretary of Defense for Health Affairs (OASD HA) also has the authority to issue DOD instructions, publications, and memorandums that implement policy approved by the Secretary of Defense or the Under Secretary of Defense for Personnel and Readiness. DHA was established to support greater integration of clinical and business processes across the MHS. DHA manages the execution of policies issued by OASD HA, oversees the TRICARE health plan, and also exercises authority and control over the MTFs and subordinate clinics assigned to the NCR Medical Directorate. The NCR Medical Directorate was initially established as a DOD joint task force in September 2007 to operate DOD’s medical facilities in the national capital region—including Walter Reed National Military Medical Center, Fort Belvoir Community Hospital, and their supporting clinics. The NCR Medical Directorate reassigned civilian personnel from the military services to the NCR Medical Directorate, while retaining military health care providers within the appropriate military service’s command and control. The MHS has increased its overall mental health provider staffing level by 34 percent between fiscal years 2009 and 2013. Specifically, DOD increased the number of providers across the MHS from 4,608 providers in fiscal year 2009 to 6,186 providers in fiscal year 2013. (See app. I for more information on fiscal year 2013 mental health provider staffing.) This increase was in response to a requirement in the NDAA for Fiscal Year 2010 that DOD increase its mental health capabilities. (See app. II for more information on the recruitment and retention of DOD mental health providers.) The type of mental health providers added to the MHS from fiscal year 2009 to fiscal year 2013 varied. (See fig. 2.) Specifically, social workers and psychologists were the most frequently added types of mental health providers during this period, while psychiatrists and mental health nurses were the least frequently added. The Army drove the overall increase in social workers and psychologists by adding 496 of the 705 social workers and 421 of the 559 psychologists to the MHS during this period. The Air Force added more social workers (64) than any other type of provider during this period, while the Navy added more psychologists (32) and other licensed providers (32). (See app. III for additional information on the breakdown of mental health provider staffing level changes for each military service from fiscal year 2009 to fiscal year 2013.) During this time frame, the composition of DOD mental health provider staff by employment category also changed. Across the MHS, the number of civilian mental health providers increased by 52 percent (1,129) and military mental health providers increased by 33 percent (479), while the number of contract mental health providers decreased by 3 percent (30). (See fig. 3.) The services’ individual changes varied, with the Army driving this systemic shift to civilian providers. Specifically, the Army added 863 new civilian mental health providers (a 50 percent increase), while decreasing the number of contract mental health providers by 153 (a 33 percent decrease). The Air Force also increased its civilian mental health provider staffing by 5 providers (a 2 percent increase) and increased its contract mental health provider staffing by 72 providers (a 39 percent increase). The Navy increased its number of military mental health providers by 113 (a 38 percent increase), added 12 civilian mental health providers (a 5 percent increase), and decreased contract mental health providers by 37 (an 11 percent decrease). While all three military services increased their mental health provider staffing from fiscal year 2009 to fiscal year 2013, the Army’s addition of 1,010 mental health providers represented the largest portion of the DOD- wide increase. The Navy’s increase of 88 mental health providers was the smallest portion of the DOD-wide increase. (See fig. 4.) DOD created the Psychological Health Risk-Adjusted Model for Staffing (PHRAMS) to show current and estimate future mental health provider staffing needs of the MHS. In fiscal year 2014, PHRAMS was used for a common purpose by the military services for the first time—the development of the fiscal year 2016 DOD budget request for mental health programs. However, the military services are either not using PHRAMS as the primary basis of their estimates of mental health provider staffing needs or supplementing their PHRAMS results with service- specific staffing methods. This limits DOD’s ability to consistently assess mental health provider staffing needs throughout the MHS. PHRAMS projects the number and mix of providers needed to meet the mental health care needs of the MHS. In fiscal year 2007, DOD contracted with a non-profit research and analysis organization to develop PHRAMS in response to recommendations from the DOD Task Force on Mental Health.fund and DOD allocate sufficient staff to provide a full continuum of mental health services to servicemembers and their dependents and (2) DOD adopt a risk-adjusted population-based model to calculate mental health staffing needs. As of September 2014, the contract to develop and maintain PHRAMS had cost DOD $2 million, according to DOD officials. These recommendations included that: (1) Congress PHRAMS is designed to be a common DOD-wide model that can be used by the military services to assess current mental health provider staffing needs and forecast these staffing needs over a 5-year timeframe. DOD intended PHRAMS to allow the Department to fulfill two goals: (1) assess whether or not there are enough mental health providers within the MHS to meet the increased mental health needs of servicemembers and their dependents that resulted from their experiences in recent conflicts, and (2) allow the Department to report the mental health provider staffing needs of the MHS to Congress. DHA and the PHRAMS contractor engage in an annual model review process to incorporate changes requested by the military services into the next version of the model. According to DHA officials, PHRAMS was used for a common purpose for the first time in fiscal year 2014—the development of the DOD fiscal year 2016 budget request for mental health programs. To assess current mental health provider staffing needs and determine 5-year forecasts of these needs, PHRAMS places MHS beneficiaries— including servicemembers, dependents, and other beneficiaries—into 40,500 individual risk groups based on unique combinations of eight risk factors. (See fig. 5.) PHRAMS uses a number of mental health diagnoses in its calculations, including those in the following groups: (1) psychoses, (2) non-psychotic depressive disorders, (3) anxiety-related disorders, (4) neurotic disorders, (5) post-traumatic stress disorder, (6) adjustment reaction disorders (excluding post-traumatic stress disorder), (7) acute reaction to stress, (8) substance-induced mental disorders, (9) substance dependence, (10) non-dependent substance abuse, (11) psychotic disorders of childhood, (12) non- psychotic disorders of childhood, (13) schizophrenic disorder, (14) personality disorders, (15) disturbance of conduct not elsewhere classified, (16) other psychotic disorders, and (17) other non-psychotic disorders.