This is the accessible text file for GAO report number GAO-10-402 entitled 'Defense Health Care: 2008 Access to Care Surveys Indicate Some Problems, but Beneficiary Satisfaction Is Similar to Other Health Plans' which was released on March 31, 2010. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Report to Congressional Committees: United States Government Accountability Office: GAO: March 2010: Defense Health Care: 2008 Access to Care Surveys Indicate Some Problems, but Beneficiary Satisfaction Is Similar to Other Health Plans: GAO-10-402: GAO Highlights: Highlights of GAO-10-402, a report to congressional committees. Why GAO Did This Study: The Department of Defense (DOD) provides health care and mental health care through its TRICARE program. Under TRICARE, beneficiaries may obtain care through TRICARE Prime, an option that includes the use of civilian provider networks and requires enrollment. TRICARE beneficiaries who do not enroll in this option may obtain care from non-network providers through TRICARE Standard, or from network providers through 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. We refer 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 GAO to analyze the adequacy of DOD’s surveys of TRICARE beneficiaries and providers and report what the surveys’ results indicate about access to care for nonenrolled beneficiaries. To do so, GAO evaluated the surveys’ methodology by interviewing DOD officials and reviewing relevant documentation, including the Office of Management and Budget’s (OMB) survey standards. GAO also assessed the surveys’ results by interviewing DOD officials, obtaining relevant documentation, and analyzing the response rates and data for both surveys. What GAO Found: DOD’s implementation of beneficiary and provider surveys for 2008, the first of a 4-year survey effort, followed the OMB survey standards for survey design, data collection, and data accuracy. In addition, DOD generally addressed the survey requirements outlined in the mandate in implementing its 2008 beneficiary and provider surveys but did not give a high priority to selecting geographic areas with a high concentration of Selected Reserve servicemembers. Instead, for both of its surveys, DOD randomly selected areas to produce results that can be generalized to the populations from which the survey samples were drawn. DOD plans to cover the entire United States at the end of the 4- year survey period, which will include any locations with higher concentrations of Selected Reserve servicemembers. In its analysis of the 2008 beneficiary survey data, GAO estimated that a higher percentage of nonenrolled beneficiaries in surveyed areas where TRICARE Prime is offered (Prime Service Areas) experienced problems accessing care from network or non-network primary care providers than beneficiaries in surveyed areas where TRICARE Prime is not offered (non-Prime Service Areas)—30 percent and 24 percent, respectively. GAO also found that beneficiaries in the surveyed areas most often experienced access problems related to providers’ willingness to accept TRICARE payments, regardless of whether they lived in a Prime or non-Prime Service Area. Additionally, GAO’s comparison of this survey data to related data from a 2008 Department of Health and Human Services’ survey showed that beneficiaries in the surveyed Prime and non-Prime Service Areas rated their health care satisfaction similarly to each other and to beneficiaries of commercial health care plans, but slightly lower than Medicare beneficiaries. GAO found that the results for the 2008 provider survey are not representative of all physicians and mental health providers in the geographic areas surveyed, but the results do provide information about access to care based on the specific views of the respondents. According to a DOD official, generalizability of provider survey results to the entire country will likely be possible at the end of the 4-year survey period. GAO’s review of the 2008 provider survey results indicates that a lower percentage of respondents in Prime Service Areas reported awareness and acceptance of TRICARE than respondents in non-Prime Service Areas. Additionally, there were differences between responding physicians and responding mental health providers, such as psychiatrists and clinical psychologists, regarding their awareness and acceptance of TRICARE. For example, 81 percent of physicians who responded reported that they would accept new TRICARE patients, if they were accepting any new patients at all, compared to 50 percent of mental health providers who responded. In commenting on a draft of this report, DOD concurred with GAO’s overall findings and provided technical comments, which GAO incorporated as appropriate. View [hyperlink, http://www.gao.gov/products/GAO-10-402] or key components. For more information, contact Randall Williamson at (202) 512-7114 or williamsonr@gao.gov. [End of section] Contents: Letter: Background: Implementation of DOD's 2008 Beneficiary and Provider Surveys Followed OMB Survey Standards and Generally Addressed Requirements Outlined in the NDAA 2008: A Higher Percentage of Nonenrolled Beneficiaries Reported Problems Accessing Certain Providers in Prime Service Areas, Though in General Beneficiaries Rated Their Satisfaction Similarly to Users of Other Health Plans: 2008 Provider Survey Results Are Not Representative of All Providers in Surveyed Areas but Provide Limited Information That Indicates Differences among Respondents' Awareness and Acceptance of TRICARE: Agency Comments: Appendix I: Selected Office of Management and Budget Standards for Statistical Surveys: Appendix II: DOD's Methodology for the 2008 Beneficiary and Provider Surveys: Appendix III: Beneficiary Survey Instrument: Appendix IV: Survey Instruments for Health Care and Mental Health Care Providers: Appendix V: Areas Included in the Fiscal Year 2008 Beneficiary and Provider Surveys: Appendix VI: Comments from the Department of Defense: Appendix VII: GAO Contact and Staff Acknowledgments: Tables: Table 1: Summary of TRICARE Options: Table 2: Requirements for Beneficiary and Provider Surveys Contained in the National Defense Authorization Act for Fiscal Year 2008 That Have Been Addressed by the Department of Defense: Table 3: Estimated Percentage of Nonenrolled TRICARE Beneficiaries Who Experienced Access-to-Care Problems with Certain Types of Providers by Types of Areas Surveyed in 2008: Table 4: Estimated Top Three Problems TRICARE Nonenrolled Beneficiaries Reported in Accessing Certain Types of Providers by Types of Areas Surveyed in 2008: Table 5: 2008 Provider Survey Respondents' Awareness and Acceptance of TRICARE by Types of Areas: Table 6: 2008 Provider Survey Respondents' Awareness and Acceptance of TRICARE by Physicians and Mental Health Providers: Table 7: Selected OMB Standards Used to Evaluate DOD's Survey Methodology: Table 8: Prime Service Areas Included in the 2008 Beneficiary and Provider Surveys: Table 9: Non-Prime Service Areas Included in the 2008 Beneficiary and Provider Surveys: Table 10: Hospital Service Areas Included in the 2008 Provider Survey: Figures: Figure 1: TRICARE Beneficiaries in Fiscal Year 2009: Figure 2: Percentage of Claims Paid for TRICARE Prime, TRICARE Standard, TRICARE Extra, and TRICARE Reserve Select for Fiscal Years 2006 through 2009: Figure 3: 2008 Beneficiary Surveys Mailed, Returned, and Completed and Eligible for Analysis: Figure 4: 2008 Comparison of Estimated Satisfaction among Nonenrolled TRICARE Beneficiaries in Surveyed Prime Service Areas and Non-Prime Service Areas with Beneficiaries of Medicare and Commercial Health Plans on a 0 to 10 Scale, by Rating Category: Figure 5: 2008 Provider Surveys Mailed, Returned, and Completed and Eligible for Analysis by Type of Provider: Abbreviations: BRAC: Base Realignment and Closure: DEERS: Defense Enrollment Eligibility Reporting System: DOD: Department of Defense: HHS: Department of Health and Human Services: NDAA 2008: National Defense Authorization Act for Fiscal Year 2008: OMB: Office of Management and Budget: TMA: TRICARE Management Activity: VA: Department of Veterans Affairs: [End of section] United States Government Accountability Office: Washington, DC 20548: March 31, 2010: The Honorable Carl Levin: Chairman: The Honorable John McCain: Ranking Member: Committee on Armed Services: United States Senate: The Honorable Ike Skelton: Chairman: The Honorable Howard P. "Buck" McKeon: Ranking Member: Committee on Armed Services: House of Representatives: In fiscal year 2009, the Department of Defense (DOD) offered health care and mental health care services to over 9 million eligible beneficiaries in the United States and abroad through TRICARE, DOD's regionally structured health care program.[Footnote 1] TRICARE is unique because eligible beneficiaries do not have to enroll in the program to use their benefits, and therefore DOD does not have complete information on which beneficiaries intend to use their benefits. Because of this, DOD cannot accurately predict from year to year the health care needs of the eligible population, including how to ensure adequate access to health care and mental health care. Under TRICARE, beneficiaries obtain care either from military hospitals and clinics, referred to as military treatment facilities, or from civilian providers.[Footnote 2] DOD's TRICARE Management Activity (TMA), which oversees the program, uses managed care support contractors to develop networks of civilian providers and to perform other customer service functions, such as processing claims and assisting beneficiaries with finding providers. The contractors are required to establish adequate networks of civilian providers-- referred to as network providers--to serve all TRICARE beneficiaries in geographic areas called Prime Service Areas.[Footnote 3] The contractors use estimates of the number of TRICARE users, among other factors, to develop provider networks and ensure adequate access to care for beneficiaries. Although some network providers may be located outside of Prime Service Areas, contractors are not required to develop networks in these areas (which we refer to as non-Prime Service Areas). TRICARE has three basic options for its beneficiaries: TRICARE Prime, TRICARE Standard, and TRICARE Extra. Beneficiaries who choose TRICARE Prime, a managed care option, must enroll and can obtain care through the networks of providers established by contractors. Beneficiaries do not need to enroll to receive care under TRICARE Standard, a fee-for- service option, or TRICARE Extra, a preferred provider organization option, and can choose to receive care either through non-network providers (under TRICARE Standard) or network providers (under TRICARE Extra).[Footnote 4] All beneficiaries may obtain care at military treatment facilities, although priority is first given to active duty personnel and then to beneficiaries enrolled in TRICARE Prime. The choices that beneficiaries have in selecting TRICARE options and providers can vary depending on a beneficiary's location. Beneficiaries living in Prime Service Areas can choose between TRICARE Prime, TRICARE Standard, and TRICARE Extra. Beneficiaries living in non-Prime Service Areas can choose between TRICARE Standard and TRICARE Extra. According to a TMA official, about 18 percent of eligible beneficiaries resided in non-Prime Service Areas in fiscal year 2009. Users of TRICARE Standard and Extra in some locations have complained about difficulties finding civilian providers who will accept them as patients since TRICARE's inception in 1995. In response to these concerns, the National Defense Authorization Act for Fiscal Year 2004 directed DOD to monitor access to care for TRICARE beneficiaries who were not enrolled in the TRICARE Prime option through a survey of civilian providers.[Footnote 5] The act also directed GAO to review the processes, procedures, and analysis used by DOD to determine the adequacy of the number of network and non-network civilian providers and the actions DOD has taken to ensure access to care for beneficiaries who were not enrolled in TRICARE Prime. In December 2006, we reported that TMA and its contractors used various methods to monitor access to care, including a provider survey. According to TMA and its contractors, their methods indicated that access was generally sufficient for users of TRICARE Standard and Extra.[Footnote 6] Nonetheless, concerns about the ability of TRICARE beneficiaries to access health care and mental health care from civilian providers continue. For example, in the wake of current military operations in Afghanistan and Iraq, DOD and others have reported that servicemembers and their families are at risk for mental health problems given the stress of deployment and exposure to combat. A June 2007 report by DOD's Task Force on Mental Health stated that TRICARE provider networks have been tasked with providing an increasing volume and proportion of mental health services for families and retirees. [Footnote 7] In assessing the oversight of the mental health network at one location, the task force discovered that out of 100 network mental health providers contacted from a list on the contractor's Web site, only 3 would accept new TRICARE patients. Additionally, concerns about access to care for National Guard and Reserve servicemembers and their families have surfaced in light of DOD's increasing reliance on this population to support military operations, such as the conflicts in Afghanistan and Iraq.[Footnote 8] DOD has reported that as of August 31, 2009, over 731,000 National Guard and Reserve servicemembers have been deployed in support of conflicts in Afghanistan and Iraq since September 11, 2001. DOD has reported that National Guard and Reserve servicemembers may not live near military installations like their active duty counterparts, and as a result, they may not have access to military hospitals and clinics and must instead rely more heavily on civilian providers for their care. DOD's Task Force on Mental Health also reported that since a substantial proportion of National Guard and Reserve servicemembers reported no civilian health plan coverage before deployment and continue to rely on TRICARE thereafter, constraints in access to care for this population are a real concern. Qualified members of the Selected Reserve--National Guard and Reserve servicemembers who are considered essential to wartime missions--who are not activated to duty may sign up for TRICARE Reserve Select, a premium-based health plan whose care options are similar to those of TRICARE Standard and Extra.[Footnote 9] According to DOD officials, there were approximately 69,000 members of the Selected Reserve who were eligible and likely to be interested in TRICARE Reserve Select, as of September 30, 2009.[Footnote 10] Of these, approximately 67 percent had purchased TRICARE Reserve Select. For the purpose of this report, we refer to beneficiaries who are not enrolled in TRICARE Prime--that is, those who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select--as nonenrolled beneficiaries.[Footnote 11] In light of continued concerns about access to civilian providers, the National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008) directed DOD to conduct surveys of beneficiaries and providers to determine the adequacy of access to health care and mental health care for nonenrolled beneficiaries.[Footnote 12] The NDAA 2008 also directed GAO to analyze the adequacy of DOD's beneficiary and provider surveys. This report describes (1) how DOD is addressing the NDAA 2008 mandate to implement beneficiary and provider surveys to determine the adequacy of access to care for nonenrolled beneficiaries, (2) what the results of the beneficiary survey indicate about the adequacy of access to care for nonenrolled beneficiaries, and (3) what the results of the provider survey indicate about the adequacy of access to care for nonenrolled beneficiaries. To evaluate how DOD is addressing the NDAA 2008 mandate to implement beneficiary and provider surveys to determine the adequacy of access to care, we reviewed relevant documentation and interviewed officials and representatives from TMA's Health Program Analysis and Evaluation Directorate who were responsible for developing, fielding, and analyzing the surveys. We evaluated TMA's beneficiary and provider survey methodologies using the Office of Management and Budget's (OMB) standards and guidelines for statistical surveys. We focused our analysis on standards specific to designing a survey (e.g., selecting random samples), developing a list of eligible survey participants, collecting survey data, and ensuring data accuracy. We also evaluated the beneficiary and provider surveys to determine whether TMA had complied with all of the requirements outlined in the mandate, such as obtaining specific types of information and establishing benchmarks for analysis. In addition, we spoke with officials representing beneficiary and provider groups to obtain their views on access-to- care issues. And finally, we spoke with officials from DOD's Office of Reserve Affairs to obtain their perspectives about access-to-care concerns for National Guard and Reserve servicemembers. To determine what the results of the beneficiary survey indicate about the adequacy of access to care for nonenrolled beneficiaries, we obtained and analyzed TMA's beneficiary survey data for 2008, the first year of a 4-year survey effort. We compared the responses of nonenrolled beneficiaries in Prime Service Areas to responses of those in non-Prime Service Areas, including concerns about access to network or non-network providers.[Footnote 13] Where possible, we compared these responses to those of other health care consumers surveyed in the Department of Health and Human Services' (HHS) 2008 Consumer Assessment of Healthcare Providers and Systems.[Footnote 14] We assessed the reliability of these data by speaking with knowledgeable officials and reviewing related documentation, and we determined that the beneficiary survey data are sufficiently reliable for the purpose of reporting the experiences of nonenrolled beneficiaries in the combined Prime Service Areas and combined non-Prime Service Areas that TMA surveyed. To determine what the results of the provider survey indicate about the adequacy of access to care for nonenrolled beneficiaries, we obtained and analyzed TMA's provider survey data for 2008, which is also the first year of a 4-year survey effort. We analyzed the survey responses of providers in Prime Service Areas, non-Prime Service Areas, and Hospital Service Areas[Footnote 15] to determine their awareness of the TRICARE program and whether they were accepting nonenrolled TRICARE beneficiaries as new patients. We assessed the reliability of these data by speaking with knowledgeable officials and reviewing related documentation, and we determined that the provider survey data presented in this report are sufficiently reliable for the purpose of reporting the information provided by the survey respondents in the Prime Service Areas, non-Prime Service Areas, and Hospital Service Areas that TMA surveyed. We conducted this performance audit from February 2009 through March 2010 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Background: In fiscal year 2009, over 9 million beneficiaries were eligible to receive health care and mental health care through DOD's TRICARE program. Under TRICARE, beneficiaries have choices among various benefit options and may obtain care from either military treatment facilities or civilian providers. Composition of TRICARE's Beneficiary Population: TRICARE beneficiaries fall into different categories: (1) active duty personnel and their dependents, (2) National Guard and Reserve servicemembers and their dependents, and (3) retirees and their dependents or survivors. Retirees and certain dependents and survivors who are entitled to Medicare Part A and enrolled in Part B, and who are generally age 65 and older, are eligible to obtain care under a separate program called TRICARE for Life.[Footnote 16] As shown in figure 1, active duty personnel and their dependents represented 32 percent of the beneficiary population, while National Guard and Reserve servicemembers and their dependents represented 14 percent. Figure 1: TRICARE Beneficiaries in Fiscal Year 2009: [Refer to PDF for image: pie-chart] Retirees and their dependents or survivors (generally under age 65)[A]: 40%; Active duty personnel and dependents: 32%; National Guard and Reserve servicemembers and dependents: 14%; TRICARE for Life retirees and dependents (generally age 65 and older)[A]: 14%. Source: GAO analysis of DOD's DEERS data. Note: Percentages in the figure are based on DOD data as of September 30, 2009. [A] TRICARE beneficiaries under 65 years of age who are eligible for Medicare Part A on the basis of disability or end-stage renal disease are eligible for TRICARE for Life if they enroll in Medicare Part B. [End of figure] TRICARE's Benefit Options: TRICARE provides its benefits through several options for its non- Medicare-eligible beneficiary population. These options vary according to TRICARE beneficiary enrollment requirements, the choices TRICARE beneficiaries have in selecting civilian and military treatment facility providers, and the amount TRICARE beneficiaries must contribute toward the cost of their care. Table 1 provides additional information about these options. Table 1: Summary of TRICARE Options: TRICARE option: TRICARE Prime; Description: This managed care option requires beneficiaries to enroll. Active duty servicemembers are required to enroll in this option while other TRICARE beneficiaries may choose to enroll. TRICARE Prime enrollees receive most of their care from providers at military treatment facilities, augmented by network providers who have agreed to meet specific standards for appointment wait times among other requirements. TRICARE Prime offers lower out-of-pocket costs than the other TRICARE options. TRICARE option: TRICARE Standard and TRICARE Extra; Description: TRICARE beneficiaries who choose not to enroll in TRICARE Prime may obtain health care from non-network providers (under TRICARE Standard) or network providers (under TRICARE Extra). Under TRICARE Extra, nonenrolled beneficiaries have lower co-payments than they would have under the TRICARE Standard option--about 5 percentage points less for using network providers. TRICARE option: TRICARE Reserve Select; Description: TRICARE Reserve Select is a premium-based health plan that certain National Guard and Reserve servicemembers may purchase. Under TRICARE Reserve Select, beneficiaries may obtain health care from either non-network or network providers, similar to beneficiaries using TRICARE Standard or Extra, respectively, and will pay lower co- payments for using network providers. Source: GAO summary of DOD TRICARE documentation. Note: All beneficiaries may obtain care at military treatment facilities although priority is first given to active duty personnel and then to TRICARE Prime enrollees. [End of table] Beneficiaries' Use of TRICARE: Claims data from fiscal years 2006 to 2009 show that the percentage of claims paid for using TRICARE Prime and TRICARE Extra has gradually increased, while the percentage of claims paid for using TRICARE Standard has declined 2 to 3 percentage points each year. (See figure 2.) Moreover, in 2006 we reported that in fiscal year 2005 about 1.8 million beneficiaries who were eligible for TRICARE Standard or Extra[Footnote 17] elected not to use their benefits.[Footnote 18] In fiscal year 2009, about 926,000 beneficiaries who were eligible for TRICARE Standard, TRICARE Extra, and TRICARE Reserve Select elected not to use their benefits.[Footnote 19] Figure 2: Percentage of Claims Paid for TRICARE Prime, TRICARE Standard, TRICARE Extra, and TRICARE Reserve Select for Fiscal Years 2006 through 2009: [Refer to PDF for image: multiple vertical bar graph] Fiscal year: 2006[A]; TRICARE Prime: 63%; TRICARE Standard: 22%; TRICARE Extra: 14%; TRICARE Reserve Select: 1%. Fiscal year: 2007[A]; TRICARE Prime: 65%; TRICARE Standard: 20%; TRICARE Extra: 15%; TRICARE Reserve Select: 1%. Fiscal year: 2008[A]; TRICARE Prime: 66%; TRICARE Standard: 18%; TRICARE Extra: 15%; TRICARE Reserve Select: 1%. Fiscal year: 2009[A]; TRICARE Prime: 67%; TRICARE Standard: 15%; TRICARE Extra: 16%; TRICARE Reserve Select: 2%. Source: GAO analysis of DOD data. Notes: All percentages may not add up to 100 percent because of rounding. Records include institutional (e.g., hospital) and noninstitutional (e.g., office-based) locations and medical supplies and services, and exclude pharmacy and TRICARE for Life claims. Fiscal year 2009 data are incomplete as TMA allows claims to be submitted up to 1 year after receiving care. [A] Percentages based on 32,685,169 claims in fiscal year 2006; 35,543,975 claims in fiscal year 2007; 38,486,854 claims in fiscal year 2008; and 37,967,258 claims in fiscal year 2009. [End of figure] Network and Non-network Providers under TRICARE: In order for network and non-network civilian providers to be authorized to provide care and be reimbursed under TRICARE, they must be licensed by their state, accredited by a national organization (if one exists), and meet other standards of the medical community. Individual TRICARE-authorized civilian providers can include health care providers, such as primary care physicians and specialists, as well as mental health care providers, including clinical psychologists. There are two types of authorized civilian providers--network and non- network providers. * Network providers are TRICARE-authorized providers who enter a contractual agreement with a managed care support contractor to provide health care to TRICARE beneficiaries. By law, TRICARE maximum allowable reimbursement rates must generally mirror Medicare rates, but network providers may agree to accept lower reimbursements as a condition of network membership.[Footnote 20] However, network civilian providers are not obligated to accept all TRICARE beneficiaries seeking care. For example, a network civilian provider may decline to accept TRICARE beneficiaries as patients because the provider's practice does not have sufficient capacity.[Footnote 21] * Non-network providers are TRICARE-authorized providers who do not have a contractual agreement with a managed care support contractor to provide care to TRICARE beneficiaries.[Footnote 22] Non-network civilian providers have the option of charging up to 15 percent more than the TRICARE reimbursement rate for their services on a case-by- case basis. The beneficiary is responsible for paying the extra amount billed in addition to required co-payments. NDAA 2008 Requirements for Beneficiary and Provider Surveys to Determine Access to Care for Nonenrolled TRICARE Beneficiaries: The NDAA 2008 directed 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. Specifically, the mandate directed DOD to conduct surveys of beneficiaries and providers in at least 20 Prime Service Areas and 20 non-Prime Service Areas in each of fiscal years 2008 through 2011. The mandate also directed DOD to give a high priority to locations having high concentrations of Selected Reserve servicemembers. Additionally, the NDAA 2008 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 to survey health care and mental health care providers in these areas. The NDAA 2008 also required that specific types of information be requested in the surveys. For example, the mandate stated that the provider survey must include questions to determine whether providers are aware of TRICARE. Within DOD, TMA has primary responsibility for designing and implementing the beneficiary and provider surveys. Implementation of DOD's 2008 Beneficiary and Provider Surveys Followed OMB Survey Standards and Generally Addressed Requirements Outlined in the NDAA 2008: In implementing the first year of the beneficiary and provider surveys, TMA followed the OMB standards for statistical surveys that we reviewed. However, TMA did identify an error in the geographic categorization of its participants for both surveys and has taken steps to correct it. In addition, TMA generally addressed the requirements outlined in the NDAA 2008 for both of its surveys but did not give a high priority to selecting areas with a high concentration of Selected Reserve servicemembers. Instead, for both surveys, TMA randomly selected geographic areas to produce results that can be generalized to the populations from which the survey samples were drawn. TMA plans to cover the entire United States at the end of the 4- year survey period, which will include any locations with higher concentrations of Selected Reserve servicemembers. TMA Followed the OMB Standards We Reviewed in Designing and Implementing Its Beneficiary and Provider Surveys: In implementing its first round of beneficiary and provider surveys, TMA's methodology for both of the multiyear surveys is consistent with the OMB standards for statistical surveys that we reviewed.[Footnote 23] (See appendix I for our list of selected OMB standards.) These standards document the professional principles and practices that federal agencies are required to follow and the level of quality and effort expected in statistical activities.[Footnote 24] For example, OMB standards recommend that agencies develop a survey design that includes a methodology for identifying the target population. OMB standards also suggest that federal agencies ensure that the list of eligible survey participants representing the target population is evaluated for accuracy.[Footnote 25] In conducting its 2008 beneficiary and provider surveys, TMA representatives noted that they identified an error in the geographic categorization of eligible survey participants for both surveys. Specifically, TMA erroneously categorized some beneficiaries and providers as being located in 11 non-Prime Service Areas when in fact they were in Prime Service Areas. According to a TMA representative, this occurred as a result of a computer programming error. TMA identified this error after it began fielding the beneficiary survey in June 2008 but prior to fielding the provider survey, which began in December 2008. As a result, TMA surveyed approximately 9,000 fewer beneficiaries than intended in those 11 non-Prime Service Areas. TMA plans to correct this error in future years by surveying additional beneficiaries in the affected non- Prime Service Areas. TMA Generally Addressed Requirements Outlined in the Mandate for Its Beneficiary and Provider Surveys: TMA generally addressed the requirements outlined in the mandate during the implementation of its 2008 beneficiary and provider surveys, but because of methodological considerations TMA used a different approach for its selection of survey areas. (See appendix II for a more detailed description of DOD's survey methodology.) Overall, the mandate outlined specific survey requirements, including the number and priority of areas to be surveyed each year, the content for each type of survey, and the use of benchmarks, which can be used to assess survey results. (See table 2.) Table 2: Requirements for Beneficiary and Provider Surveys Contained in the National Defense Authorization Act for Fiscal Year 2008 That Have Been Addressed by the Department of Defense: Requirement: Survey goals; Requirement description: 1. Determine the number of health care providers in TRICARE Prime Service Areas that are accepting new patients under TRICARE Standard and Extra; Beneficiary survey: DOD met requirement? Yes; Provider survey: DOD met requirement? Yes. Requirement: Survey goals; Requirement description: 2. Determine the number of health care providers in TRICARE non-Prime Service Areas that are accepting patients under TRICARE Standard and Extra; Beneficiary survey: DOD met requirement? Yes; Provider survey: DOD met requirement? Yes. Requirement: Survey goals; Requirement description: 3. Determine the availability of mental health care providers in TRICARE Prime Service Areas and TRICARE non- Prime Service Areas; Beneficiary survey: DOD met requirement? Yes; Provider survey: DOD met requirement? Yes. Requirement: Survey area selection; Requirement description: 4. Survey beneficiaries and providers in at least 20 TRICARE Prime Service Areas in the United States in each fiscal year 2008 through 2011 to determine the numbers of health care providers accepting new patients under each TRICARE Standard and Extra; Beneficiary survey: DOD met requirement? Yes; Provider survey: DOD met requirement? Yes. Requirement: Survey area selection; Requirement description: 5. Survey beneficiaries and providers in 20 non-Prime Service Areas, and in which significant numbers of beneficiaries who are members of the Selected Reserve reside, to determine the availability of health care providers accepting new patients under each TRICARE Standard and Extra; Beneficiary survey: DOD met requirement? Yes; Provider survey: DOD met requirement? Yes. Requirement: Survey area selection; Requirement description: 6. Survey beneficiaries and providers in at least 40 total Prime Service Areas and non-Prime Service Areas to determine the availability of mental health care providers; Beneficiary survey: DOD met requirement? Yes; Provider survey: DOD met requirement? Yes. Requirement: Survey area selection; Requirement description: 7. Give a high priority to surveying beneficiaries and providers located in geographic areas with high concentrations of members of the Selected Reserve; Beneficiary survey: DOD met requirement? No[A]; Provider survey: DOD met requirement? No[A]. Requirement: Survey area selection; Requirement description: 8. Consult with representatives of TRICARE beneficiaries and health care and mental health care providers to identify locations where TRICARE Standard beneficiaries are experiencing significant levels of access-to-care problems under TRICARE Standard or Extra and give a high priority to surveying health care and mental health care providers in these locations; Beneficiary survey: DOD met requirement? N/A[B]; Provider survey: DOD met requirement? Yes. Requirement: Survey content; Requirement description: 9. Include questions in provider surveys to determine the following: * Whether the provider is aware of the TRICARE program; * What percentage of the provider's current patient population uses any form of TRICARE; * Whether the provider accepts patients for whom payment is made under the Medicare program for health care and mental health care services; * If the provider accepts Medicare patients, whether the provider would accept new Medicare patients; Beneficiary survey: DOD met requirement? N/A[B]; Provider survey: DOD met requirement? Yes. Requirement: Survey content; Requirement description: 10. Include questions in beneficiary surveys seeking information to determine whether they have difficulties in finding health care and mental health care providers willing to provide services under TRICARE Standard or Extra; Beneficiary survey: DOD met requirement? Yes; Provider survey: DOD met requirement? N/A[B]. Requirement: Benchmarks; Requirement description: 11. Establish benchmarks to determine the adequacy of the availability of health care and mental health care providers to beneficiaries eligible for TRICARE; Beneficiary survey: DOD met requirement? Yes; Provider survey: DOD met requirement? Yes. Source: GAO analysis based on review of the National Defense Authorization Act for Fiscal Year 2008 § 711 (a). [A] While TMA did not give high priority to surveying beneficiaries and providers in locations with high concentrations of Selected Reserve servicemembers, TMA's methodological approach over the 4-year survey period will meet the intent of the NDAA 2008. [B] N/A means not applicable. [End of table] According to a TMA official responsible for implementing the surveys, TMA did not give a high priority to areas where higher concentrations of Selected Reserve servicemembers live, as specified in the mandate, because it decided to randomly select the areas to be surveyed in order to produce results that can be generalized to the populations from which the survey samples are selected. Moreover, at the end of the 4-year survey period for the beneficiary and provider surveys, TMA will have surveyed all areas of the United States, thereby including any locations with a higher concentration of Selected Reserve servicemembers. A TMA official also told us that TMA conducted additional analyses of the 2008 beneficiary survey results for TRICARE Reserve Select beneficiaries to obtain additional information about the Selected Reserve servicemembers, and plans to do so in the remaining 3 years of the survey. TMA found that its 2008 results indicate that TRICARE access is no different for the Selected Reserve servicemembers than for other beneficiaries in the surveyed areas. A Higher Percentage of Nonenrolled Beneficiaries Reported Problems Accessing Certain Providers in Prime Service Areas, Though in General Beneficiaries Rated Their Satisfaction Similarly to Users of Other Health Plans: The first year's results of TMA's 4-year beneficiary survey are representative of the nonenrolled beneficiary population in the combined Prime Service Areas and combined non-Prime Service Areas that were selected for the 2008 survey. Based on our analysis of these results, we estimated that a higher percentage of nonenrolled beneficiaries in surveyed Prime Service Areas experienced problems accessing care from network or non-network primary care physicians or nurses than beneficiaries in surveyed non-Prime Service Areas. However, we could not determine whether beneficiary access problems were related to TRICARE network providers because the survey did not ask beneficiaries to link problems accessing care with network or non- network providers. However, we did find that the types of access problems beneficiaries experienced, such as providers not accepting TRICARE payments, were similar in Prime Service Areas and non-Prime Service Areas. In addition, we found that nonenrolled beneficiaries in both the surveyed Prime Service Areas and the surveyed non-Prime Service Areas rated their health care satisfaction similarly to each other and to beneficiaries of commercial health care plans, but slightly lower than Medicare beneficiaries. Despite a Low Response Rate, TMA's 2008 Beneficiary Survey Results Are Representative of the Nonenrolled Beneficiary Population for the Combined Areas Surveyed: Despite an overall response rate of about 38 percent, TMA's 2008 beneficiary survey results are representative of the nonenrolled beneficiary population for the combined Prime Service Areas and combined non-Prime Service Areas surveyed. (See figure 3.) Because of the low response rate, TMA conducted a nonresponse analysis to determine whether the responses it received were representative of the surveyed population.[Footnote 26] The nonresponse analysis indicated that there were no differences in demographic characteristics and health coverage between beneficiary survey respondents and nonrespondents. As a result, the results can be generalized to the combined areas surveyed--that is, the survey produced results that are representative of all nonenrolled beneficiaries in the 20 surveyed Prime Service Areas and all nonenrolled beneficiaries in the 20 surveyed non-Prime Service Areas. Figure 3: 2008 Beneficiary Surveys Mailed, Returned, and Completed and Eligible for Analysis: [Refer to PDF for image: illustration] Survey details and response rates: Surveys mailed to beneficiaries: 48,548; Composition of the 48,548 beneficiaries who were selected to receive these surveys: Retirees[B]: 87%; Active duty[C]: 12%; TRS[D]: 1%. Surveys returned: 18,447 (38 percent). Completed and eligible responses[A]: 5,043; Composition of the 5,043 beneficiaries with eligible responses: Retirees[B]: 93%; Active duty[C]: 6%; TRS[D]: 1%. Source: GAO analysis of DOD data. [A] A complete and eligible response is one in which the beneficiary has answered at least half of the TMA-identified "key" questions and has answered that he or she used "TRICARE Extra or Standard" or "TRICARE Reserve Select" in response to the following: Which health plan did you use for all or most of your health care in the last 12 months? [B] Retirees under the age of 65 and their dependents or survivors who are not enrolled in TRICARE Prime. [C] Active duty family members who are not enrolled in TRICARE Prime, including family members of activated reservists. [D] TRS refers to beneficiaries who purchased TRICARE Reserve Select. [End of figure] 2008 Survey Results Indicate That a Higher Percentage of Nonenrolled Beneficiaries in Prime Service Areas Experienced Problems Accessing Care from Primary Care Physicians or Nurses Than Those in Non-Prime Service Areas: Based on our analysis of the 2008 survey results, we estimated that a higher percentage of nonenrolled beneficiaries in surveyed Prime Service Areas experienced problems accessing care from network or non- network primary care physicians or nurses than nonenrolled beneficiaries in surveyed non-Prime Service Areas. Specifically, about 30 percent of beneficiaries in Prime Service Areas experienced problems finding a civilian primary care physician or nurse, compared to about 24 percent of beneficiaries in non-Prime Service Areas. [Footnote 27] (See table 3.) While we found differences in access to care problems between nonenrolled beneficiaries in the surveyed Prime Service Areas and non-Prime Service Areas for other types of providers, these differences were not statistically significant at the 95 percent confidence level.[Footnote 28] Table 3: Estimated Percentage of Nonenrolled TRICARE Beneficiaries Who Experienced Access-to-Care Problems with Certain Types of Providers by Types of Areas Surveyed in 2008: Prime Service Areas[D]: Did not have an access problem; Civilian primary care physician or nurse[A]: 70%[E]; Civilian specialist physician[B]: 72%; Civilian mental health provider[C]: 66%. Prime Service Areas[D]: Had an access problem[F]; Civilian primary care physician or nurse[A]: 30%[E]; Civilian specialist physician[B]: 28%; Civilian mental health provider[C]: 34%. Non-Prime Service Areas[G]: Did not have an access problem; Civilian primary care physician or nurse[A]: 76%[E]; Civilian specialist physician[B]: 74%; Civilian mental health provider[C]: 71%. Non-Prime Service Areas[G]: Had an access problem[F]; Civilian primary care physician or nurse[A]: 24%[E]; Civilian specialist physician[B]: 26%; Civilian mental health provider[C]: 29%. All service areas[H]: Did not have an access problem; Civilian primary care physician or nurse[A]: 71%; Civilian specialist physician[B]: 73%; Civilian mental health provider[C]: 67%. All service areas[H]: Had an access problem[F]; Civilian primary care physician or nurse[A]: 29%; Civilian specialist physician[B]: 27%; Civilian mental health provider[C]: 33%. Source: GAO analysis of DOD data. Notes: All sampling errors are presented at the 95 percent confidence level. Data presented in the table are rounded to the nearest whole percentage point. [A] Based on the following: In the last 12 months, how much of a problem was it to find a personal doctor or nurse who would accept TRICARE? Answer choices were "A big problem," "A small problem," or "Not a problem." The sampling error for "Civilian primary care physician or nurse" is plus or minus 2.3 percentage points or less in Prime Service Areas and 3.1 percentage points or less in non-Prime Service Areas. [B] Based on the following: In the last 12 months, how much of a problem was it to find a doctor with this specialty who would accept TRICARE? Answer choices were "A big problem," "A small problem," or "Not a problem." The sampling error for "Civilian specialist physicians" is plus or minus 2.7 percentage points or less in Prime Service Areas and 4.4 percentage points or less in non-Prime Service Areas. [C] Based on the following: In the last 12 months, how much of a problem, if any, was it to get the treatment or counseling you needed through your health plan? Answer choices were "A big problem," "A small problem," or "Not a problem." The sampling error for "Civilian mental health providers" is plus or minus 5.5 percentage points or less in Prime Service Areas and 9.1 percentage points or less in non- Prime Service Areas. [D] Prime Service Areas are geographic areas determined by the Assistant Secretary of Defense for Health Affairs that are defined by a set of five-digit zip codes, usually within an approximate 40-mile radius of a military inpatient treatment facility. Prime Service Area estimates are based on 1,721, 1,247, and 266 respondents who did not have a problem finding a civilian primary care physician or nurse, civilian specialist physician, or civilian mental health provider, respectively, and 711, 442, and 135 respondents who did have a problem finding a civilian primary care physician or nurse, civilian specialist physician, or civilian mental health provider, respectively. [E] A statistically significant difference exists between the results in Prime Service Areas and non-Prime Service Areas for the "Civilian primary care physician or nurse" category at the 95 percent confidence level. [F] "Had an access problem" represents those who responded that they had a big problem or a small problem. [G] Non-Prime Service Areas are geographic areas located outside of Prime Service Areas. Non-Prime Service Area estimates are based on 1,606, 901, and 206 respondents who did not have a problem finding a civilian primary care physician or nurse, civilian specialist physician, or civilian mental health provider, respectively, and 364, 271, and 62 respondents who did have a problem finding a civilian primary care physician or nurse, civilian specialist physician, or civilian mental health provider, respectively. [H] All service area estimates based on the summed responses from respondents in Prime Service Areas and non-Prime Service Areas. [End of table] We could not determine the extent to which beneficiaries' access problems were related to TRICARE network or non-network providers because the 2008 beneficiary survey did not ask beneficiaries to link their problems accessing care with network or non-network providers. However, in our analysis of the 2008 beneficiary survey results, we found that the specific types of access problems experienced by beneficiaries in Prime Service Areas and non-Prime Service Areas are similar. (See table 4.) For example, we found that the problem most commonly reported by nonenrolled beneficiaries in both Prime and non- Prime Service Areas, regardless of the type of provider, was that their provider was not accepting TRICARE payments. Other commonly reported reasons varied by provider type. Table 4: Estimated Top Three Problems TRICARE Nonenrolled Beneficiaries Reported in Accessing Certain Types of Providers by Types of Areas Surveyed in 2008: Prime Service Areas[A]: Civilian primary care physician or nurse[C]: Doctor not accepting TRICARE payments (54%); Non-Prime Service Areas[B]: Doctor not accepting TRICARE payments (48%). Prime Service Areas[A]: Civilian primary care physician or nurse[C]: Doctor not taking new TRICARE patients (33%); Non-Prime Service Areas[B]: Travel distance too long (33%). Prime Service Areas[A]: Civilian primary care physician or nurse[C]: Doctor not taking any new patients (26%); Non-Prime Service Areas[B]: Doctor not taking new TRICARE patients (30%). Prime Service Areas[A]: Civilian specialist physician[D]: Doctor not accepting TRICARE payments (46%); Non-Prime Service Areas[B]: Doctor not accepting TRICARE payments (45%). Prime Service Areas[A]: Civilian specialist physician[D]: Doctor not taking new TRICARE patients (24%); Non-Prime Service Areas[B]: Travel distance too long (34%). Prime Service Areas[A]: Civilian specialist physician[D]: Wait for an appointment was too long (19%); Non-Prime Service Areas[B]: Doctor not taking new TRICARE patients (21%). Prime Service Areas[A]: Civilian mental health provider[E]: Doctor or counselor not accepting TRICARE payments (38%); Non-Prime Service Areas[B]: Doctor or counselor not accepting TRICARE payments (32%). Prime Service Areas[A]: Civilian mental health provider[E]: Doctor or counselor not taking new TRICARE patients (21%); Non-Prime Service Areas[B]: Wait for an appointment was too long (31%). Prime Service Areas[A]: Civilian mental health provider[E]: Travel distance too long (17%); Non-Prime Service Areas[B]: Travel distance too long (24%). Source: GAO analysis of DOD data. Notes: Numbers in parentheses are the percentages of those who responded that they had a problem. Percentages do not add to 100 because respondents may select more than one response. [A] Prime Service Areas are geographic areas determined by the Assistant Secretary of Defense for Health Affairs that are defined by a set of five-digit zip codes, usually within an approximate 40-mile radius of a military inpatient treatment facility. [B] Non-Prime Service Areas are geographic areas located outside of Prime Service Areas. [C] Based on the following: What problems did you encounter in finding a personal doctor who would accept TRICARE? All percentage estimates for civilian primary care physician or nurse have sampling errors at the 95 percent confidence level of plus or minus 7.0 percentage points or less. [D] Based on the following: What problems did you encounter in finding a specialist who would accept TRICARE? All percentage estimates for civilian specialist physicians have sampling errors at the 95 percent confidence level of plus or minus 9.4 percentage points or less. [E] Based on the following: In the last 12 months, what problems did you encounter in finding treatment and counseling? All percentage estimates for civilian mental health providers have sampling errors at the 95 percent confidence level of plus or minus 18.9 percentage points or less. [End of table] Nonenrolled Beneficiaries in Prime Service Areas and Non-Prime Service Areas Surveyed in 2008 Rated Satisfaction with Their Health Care Similarly to Each Other and to Beneficiaries of Commercial Health Care Plans: Despite differences in the percentage of beneficiaries in surveyed Prime and non-Prime Service Areas reporting problems accessing care from primary care physicians or nurses, our analysis showed that nonenrolled beneficiaries' ratings for several categories of health care were similar in the surveyed Prime Service Areas and non-Prime Service Areas. Specifically, our analysis of beneficiaries' ratings for four categories of health care--their satisfaction with providers of primary care and specialty care, their health care, and their health plan--indicates no statistically significant difference between beneficiaries in surveyed Prime Service Areas and non-Prime Service Areas. For example, we estimated that 75 percent of beneficiaries in surveyed Prime Service Areas and 74 percent of beneficiaries in surveyed non-Prime Service Areas rated their health plan "7" or higher on a 0 to 10 scale[Footnote 29] (with 0 being the worst possible). [Footnote 30] Estimated ratings for nonenrolled beneficiaries in surveyed areas are also similar to the estimated ratings of beneficiaries in commercial health plans, based on data we analyzed from HHS's 2008 Consumer Assessment of Healthcare Providers and Systems survey. Specifically, in all four satisfaction categories there are no statistically significant differences in the estimated percentage of beneficiaries who rated their satisfaction "7" or higher. (See figure 4.) However, estimated ratings for nonenrolled beneficiaries in surveyed areas were slightly lower than estimated ratings of Medicare beneficiaries across three of the satisfaction categories--primary care physician or nurse, specialist physician, and health plan. Figure 4: 2008 Comparison of Estimated Satisfaction among Nonenrolled TRICARE Beneficiaries in Surveyed Prime Service Areas and Non-Prime Service Areas with Beneficiaries of Medicare and Commercial Health Plans on a 0 to 10 Scale, by Rating Category: [Refer to PDF for image: 4 horizontal bar graphs] Beneficiary rating of primary care physician or nurse[A]: Prime Service Area, 0-6 rating: 11%; Prime Service Area, 7-10 rating: 89%; Non-Prime Service Area, 0-6 rating: 11%; Non-Prime Service Area, 7-10 rating: 89%; Medicare, 0-6 rating: 7%[C]; Medicare, 7-10 rating: 93%[C]; Commercial Health Plan, 0-6 rating: 10%; Commercial Health Plan, 7-10 rating: 90%. Beneficiary rating of specialist physician[B]: Prime Service Area, 0-6 rating: 12%; Prime Service Area, 7-10 rating: 88%; Non-Prime Service Area, 0-6 rating: 13%; Non-Prime Service Area, 7-10 rating: 87%; Medicare, 0-6 rating: 8%[C]; Medicare, 7-10 rating: 92%[C]; Commercial Health Plan, 0-6 rating: 11%; Commercial Health Plan, 7-10 rating: 89%. Beneficiary rating of health care[D]: Prime Service Area, 0-6 rating: 12%; Prime Service Area, 7-10 rating: 88%; Non-Prime Service Area, 0-6 rating: 11%; Non-Prime Service Area, 7-10 rating: 89%; Medicare, 0-6 rating: 12%; Medicare, 7-10 rating: 88%; Commercial Health Plan, 0-6 rating: 13%; Commercial Health Plan, 7-10 rating: 87%. Beneficiary rating of health plan[E]: Prime Service Area, 0-6 rating: 25%; Prime Service Area, 7-10 rating: 75%; Non-Prime Service Area, 0-6 rating: 26%; Non-Prime Service Area, 7-10 rating: 74%; Medicare, 0-6 rating: 19%[C]; Medicare, 7-10 rating: 81%[C]; Commercial Health Plan, 0-6 rating: 23%; Commercial Health Plan, 7-10 rating: 77%. Source: GAO analysis of DOD and HHS's Consumer Assessment of Healthcare Providers and Systems data. [A] All percentage estimates for "Beneficiary rating of primary care physician or nurse" have sampling errors at the 95 percent confidence level of plus or minus 2.2 percentage points or less. [B] All percentage estimates for "Beneficiary rating of specialist physician" have sampling errors at the 95 percent confidence level of plus or minus 3.6 percentage points or less. [C] A statistically significant difference exists between Medicare beneficiaries and nonenrolled beneficiaries in both Prime Service Areas and non-Prime Service Areas at the 95 percent confidence level. [D] All percentage estimates for "Beneficiary rating of health care" have sampling errors at the 95 percent confidence level of plus or minus 2.7 percentage points or less. [E] All percentage estimates for "Beneficiary rating of health plan" have sampling errors at the 95 percent confidence level of plus or minus 3.1 percentage points or less. [End of figure] 2008 Provider Survey Results Are Not Representative of All Providers in Surveyed Areas but Provide Limited Information That Indicates Differences among Respondents' Awareness and Acceptance of TRICARE: Although the first year's results of TMA's 4-year provider survey are not representative of all providers in the areas surveyed, the results we analyzed do provide information about access to care based on the specific views of the respondents. According to a TMA official, generalizability of provider survey results to the entire country will likely be possible at the end of the 4-year survey period. Our analysis of the 2008 provider survey results indicate that a lower percentage of respondents from Prime Service Areas were aware of TRICARE and were accepting new TRICARE patients than providers who responded from non-Prime Service Areas. The survey results also indicate that respondents from the additional areas TMA surveyed reported levels of awareness and acceptance of TRICARE that were similar to respondents in non-Prime Service Areas. Additionally, there were differences between the responding physicians (primary care physicians and specialists) and mental health providers (psychiatrists, certified clinical social workers, clinical psychologists, and others) regarding their awareness and acceptance of TRICARE. 2008 Provider Survey Results Are Not Representative of the Provider Population in the Areas TMA Surveyed: Unlike the 2008 beneficiary survey, the results of the 2008 provider survey are not representative of all physicians and mental health providers in the areas TMA surveyed. The 2008 provider survey was administered in the same 20 Prime Service Areas and 20 non-Prime Service Areas as the beneficiary survey, as well as 21 additional locations that were identified as having access-to-care problems, with an overall response rate of about 45 percent. (See figure 5.) Because of the low response rate, TMA conducted a nonresponse analysis, and the results of this analysis indicated that there were differences among those who responded to the provider survey and those who did not. Specifically, those who did not respond to the 2008 provider survey were less likely to be aware of TRICARE and less likely to accept TRICARE reimbursement as payment for services. As a result of these differences--even though the survey sample was randomly selected--the survey results cannot be generalized to all physicians and mental health providers in the areas surveyed and can be presented only as the specific views of the respondents. Similarly, because the 2008 survey results cannot be generalized, we did not compare them with the 2008 beneficiary survey results. Figure 5: 2008 Provider Surveys Mailed, Returned, and Completed and Eligible for Analysis by Type of Provider: [Refer to PDF for image: illustrated table] Surveys mailed: Physicians[A]: 20,030; Mental health providers[B]: 20,386. Surveys returned (45 percent): Physicians: 9,010; Mental health providers: 9,229. Completed and eligible[C] responses: Physicians: 7,628; Mental health providers: 3,733[D]. Source: GAO analysis of DOD data. [A] Physicians consist of primary care physicians and specialists. [B] Mental health providers consist of certified clinical social workers, certified psychiatric nurse specialists, clinical psychologists, certified marriage and family therapists, pastoral counselors, mental health counselors, and psychiatrists. [C] TMA considered responses eligible if the respondents were full- time nonfederal providers in patient health care (e.g., not retired or in research) working in private practice or an office-based practice, and for mental health providers, whether they were in 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. Additionally, the respondent had to have completed three key questions on the physician survey instrument, or three key questions on the mental health provider survey instrument. [D] There were 9,229 returned mental health provider survey instruments. Of these, TMA considered 5,398 as ineligible because the providers did not specify that they worked in a private practice. The remaining 98 surveys were not eligible for other reasons, including mental health providers who indicated that they were not one of the six specific mental health provider types that TMA included in the survey. [End of figure] A TMA official stated that because more responses will have been obtained by the end of the 4-year survey, generalizability of provider survey results to the entire country will likely be possible. Moreover, the TMA official noted that TMA has decided to redesign the method of selecting mental health providers in the 2009 survey to increase the number of responses and the likelihood that survey results could be generalized. 2008 Provider Survey Results Indicate Differences among Respondents' Awareness and Acceptance of TRICARE: Our review of the 2008 provider survey results indicated differences in awareness and acceptance of TRICARE among respondents in Prime Service Areas, non-Prime Service Areas, and the additional Hospital Service Areas TMA surveyed. (See table 5.) Specifically, a lower percentage of responding providers--physicians and nonphysician mental health providers--from Prime Service Areas were aware of the TRICARE program and were accepting new TRICARE patients, if they were accepting any new patients or any new Medicare patients, than providers who responded from non-Prime Service Areas or Hospital Service Areas. For example, 64 percent of the respondents in the surveyed Prime Service Areas who reported that they are accepting any new patients reported that they would accept nonenrolled TRICARE beneficiaries as new patients, compared to 76 percent of respondents in the surveyed non-Prime Service Areas and 72 percent of respondents in the surveyed Hospital Service Areas. Additionally, survey results indicate that in Hospital Service Areas, respondents reported awareness and acceptance of TRICARE that was similar to that of respondents in non-Prime Service Areas. The reason most often cited by respondents in both Prime Service Areas and non-Prime Service Areas for not accepting nonenrolled beneficiaries as new patients, if they were accepting any new patients at all, was that they were not aware of the TRICARE program. Other reasons included concerns about low reimbursement rates and that the provider did not participate in TRICARE's provider network. Respondents in Hospital Service Areas reported similar reasons, such as concerns about low reimbursement rates and not being aware of the TRICARE program, with the most cited reason being that they were not participating in TRICARE's provider network. Table 5: 2008 Provider Survey Respondents' Awareness and Acceptance of TRICARE by Types of Areas: Aware of TRICARE Program[A]: Prime Service Areas[B]; Percentage of respondents: 85%. Aware of TRICARE Program[A]: Non-Prime Service Areas[C]; Percentage of respondents: 91%. Aware of TRICARE Program[A]: Hospital Service Areas[D]; Percentage of respondents: 90%. Accepting new TRICARE patients if accepting any new patients[E]: Prime Service Areas; Percentage of respondents: 64%. Accepting new TRICARE patients if accepting any new patients[E]: Non- Prime Service Areas; Percentage of respondents: 76%. Accepting new TRICARE patients if accepting any new patients[E]: Hospital Service Areas; Percentage of respondents: 72%. Accepting new TRICARE patients if accepting new Medicare patients[F]: Prime Service Areas; Percentage of respondents: 75%. Accepting new TRICARE patients if accepting new Medicare patients[F]: Non-Prime Service Areas; Percentage of respondents: 83%. Accepting new TRICARE patients if accepting new Medicare patients[F]: Hospital Service Areas; Percentage of respondents: 82%. Source: GAO analysis of DOD data. Notes: The above data represent the responses of physicians and nonphysician mental health providers surveyed. These data are presented as unweighted percentages. [A] Respondents answered yes to the following: "Is the provider aware of the TRICARE health care program?" [B] Prime Service Areas are geographic areas determined by the Assistant Secretary of Defense for Health Affairs that are defined by a set of five-digit zip codes, usually within an approximate 40-mile radius of a military inpatient treatment facility. [C] Non-Prime Service Areas are geographic areas located outside of Prime Service Areas. [D] Hospital Service Areas are collections of zip codes organized into over 3,000 geographic regions in which Medicare beneficiaries seek the majority of their care from one hospital or a collection of hospitals. Hospital Service Areas have nonoverlapping borders and contain all U.S. zip codes without gaps in coverage. [E] Respondents answered yes to questions that asked the following: "As of today, is the provider accepting any new patients?" and "As of today, is the provider accepting new TRICARE Standard patients?" The yes response to this question represents the providers' indication that they were accepting new TRICARE Standard patients on either a "claim-by-claim basis" or "for all claims." [F] Respondents answered yes to questions that asked the following: "As of today, is the provider accepting new Medicare patients?" and "As of today, is the provider accepting new TRICARE Standard patients?" The yes response to this question represents the providers' indication that they were accepting new TRICARE Standard patients on either a "claim-by-claim basis" or "for all claims." [End of table] The physicians and mental health providers who responded to the survey differed in their awareness and acceptance of TRICARE. Specifically, a higher percentage of responding physicians reported awareness and acceptance of TRICARE than the mental health providers who responded. (See table 6.) For example, 81 percent of the physicians who responded reported that they would accept new TRICARE patients, if they were accepting any new patients at all, compared to 50 percent of the mental health providers who responded. Table 6: 2008 Provider Survey Respondents' Awareness and Acceptance of TRICARE by Physicians and Mental Health Providers: Aware of TRICARE program[A]: Physicians[B]; Percentage of respondents: Aware of TRICARE program[A]: 95%. Aware of TRICARE program[A]: Mental health providers[C]; Percentage of respondents: Aware of TRICARE program[A]: 75%. Accepting new TRICARE patients if accepting any new patients[D]: Physicians[B]; Percentage of respondents: Aware of TRICARE program[A]: 81%. Accepting new TRICARE patients if accepting any new patients[D]: Mental health providers[C]; Percentage of respondents: Aware of TRICARE program[A]: 50%. Accepting new TRICARE patients if accepting new Medicare patients[E]: Physicians[B]; Percentage of respondents: Aware of TRICARE program[A]: 83%. Accepting new TRICARE patients if accepting new Medicare patients[E]: Mental health providers[C]; Percentage of respondents: Aware of TRICARE program[A]: 67%. Source: GAO analysis of DOD data. Notes: The above data are presented as unweighted percentages. [A] Respondents answered yes to the following question: "Is the provider aware of the TRICARE health care program?" [B] Physicians consist of primary care physicians and specialists. [C] Mental health providers consist of certified clinical social workers, certified psychiatric nurse specialists, clinical psychologists, certified marriage and family therapists, pastoral counselors, mental health counselors, and psychiatrists. [D] Respondents answered yes to questions that asked the following: "As of today, is the provider accepting any new patients?" and "As of today, is the provider accepting new TRICARE Standard patients?" The yes response to this question represents the providers' indication that they were accepting new TRICARE Standard patients on either a "claim-by-claim basis" or "for all claims." [E] Respondents answered yes to questions that asked the following: "As of today, is the provider accepting new Medicare patients?" and "As of today, is the provider accepting new TRICARE Standard patients?" The yes response to this question represents the providers' indication that they were accepting new TRICARE Standard patients on either a "claim-by-claim basis" or "for all claims." [End of table] Agency Comments: We received comments on a draft of this report from DOD. (See appendix VI.) DOD concurred with our overall findings and provided technical comments, which we incorporated where appropriate. 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 Web site at [hyperlink, http://www.gao.gov]. If you or your staff members have any questions about this report, please contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Key contributors to this report are listed in appendix VII. Signed by: Randall B. Williamson: Director, Health Care: [End of section] Appendix I: Selected Office of Management and Budget Standards for Statistical Surveys: 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.[Footnote 31] The NDAA 2008 also directed us to review the processes, procedures, and analyses used by DOD to determine the adequacy of the number of health care and mental health care providers that currently accept nonenrolled beneficiaries as patients. To evaluate the methodology DOD used to implement the beneficiary and provider surveys, we reviewed the Office of Management and Budget's (OMB) Standards and Guidelines for Statistical Surveys (2006) to identify key aspects and best practices of statistical survey methodology that result in sound survey design and implementation. We focused our evaluation on standards that address, among other things, designing a survey, developing sampling frames, collecting survey data, and analyzing survey response rates.[Footnote 32] Table 7 provides a description of these standards. Table 7: Selected OMB Standards Used to Evaluate DOD's Survey Methodology: Standard: Survey planning; Description: Agencies initiating a new survey or major revision of an existing survey must develop a written plan that sets forth a justification, including goals and objectives; potential users; the decisions the survey is designed to inform; key survey estimates; the precision required of the estimates; the tabulations and analytic results that will inform decisions and other uses; related and previous surveys; steps taken to prevent unnecessary duplication with other sources of information; when and how frequently users need the data; and the level of detail needed in tabulations, confidential microdata, and public-use data files. Standard: Survey design; Description: Agencies must develop a survey design, including defining the target population, designing the sampling plan, specifying the data collection instrument and methods, developing a realistic timetable and cost estimate, and selecting samples using generally accepted statistical methods (e.g., probabilistic methods that can provide estimates of sampling error). Any use of nonprobability sampling methods (e.g., cutoff or model-based samples) must be justified statistically and be able to measure estimation error. The size and design of the sample must reflect the level of detail needed in tabulations and other data products and the precision required of key estimates. Documentation of each of these activities and resulting decisions must be maintained in the project files for use in documentation. Standard: Survey response rates; Description: Agencies must design the survey to achieve the highest practical rates of response, commensurate with the importance of survey uses, respondent burden, and data collection costs, to ensure that survey results are representative of the target population so that they can be used with confidence to inform decisions. Nonresponse bias analyses must be conducted when unit or item response rates or other factors suggest the potential for bias to occur. Standard: Pretesting survey systems; Description: Agencies must ensure that all components of a survey function as intended when implemented in the full-scale survey and that measurement error is controlled by conducting a pretest of the survey components or by having successfully fielded the survey components on a previous occasion. Standard: Developing sampling frames; Description: Agencies must ensure that the frames for the planned sample survey or census are appropriate for the study design and are evaluated against the target population for quality. Standard: Required notifications to potential survey respondents; Description: Agencies must ensure that each data collection instrument clearly states the reasons the information is being collected; the way such information is going to be used to further the proper performance of the functions of the agency; whether responses to the collection of information are voluntary or mandatory (citing authority); the nature and extent of confidentiality to be provided, if any, citing authority; an estimate of the average respondent burden together with a request that the public direct to the agency any comments concerning the accuracy of this burden estimate and any suggestions for reducing this burden; the OMB control number; and a statement that an agency may not conduct and a person is not required to respond to an information collection request unless it displays a currently valid OMB control number. Standard: Data collection methodology; Description: Agencies must design and administer their data collection instruments and methods in a manner that achieves the best balance between maximizing data quality and controlling measurement error while minimizing respondent burden and cost. Standard: Data editing; Description: Agencies must edit data appropriately, based on available information, to mitigate or correct detectable errors. Standard: Nonresponse analysis and response rate calculation; Description: Agencies must appropriately measure, adjust for, report, and analyze unit and item nonresponse to assess their effects on data quality and to inform users. Response rates must be computed using standard formulas to measure the proportion of the eligible sample that is represented by the responding units in each study, as an indicator of potential nonresponse bias. Standard: Coding; Description: Agencies must add codes to collected data to identify aspects of data quality from the collection (e.g., missing data) in order to allow users to appropriately analyze the data. Codes added to convert information collected as text into a form that permits immediate analysis must use standardized codes, when they are available, to enhance comparability. Standard: Evaluation; Description: Agencies must evaluate the quality of the data and make the evaluation public (through technical notes and documentation included in reports of results or through a separate report) to allow users to interpret results of analyses and to help designers of recurring surveys focus improvement efforts. Standard: Analysis and report planning; Description: Agencies must develop a plan for the analysis of survey data prior to the start of a specific analysis to ensure that statistical tests are used appropriately and that adequate resources are available to complete the analysis. Source: GAO analysis of OMB's Standards and Guidelines for Statistical Surveys (September 2006). [End of table] [End of section] Appendix II: DOD's Methodology for the 2008 Beneficiary and Provider Surveys: The NDAA 2008 directed 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. For the purpose of this report, we refer to beneficiaries who are not enrolled in TRICARE Prime--that is, those who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select[Footnote 33]--as nonenrolled beneficiaries.[Footnote 34] The mandate also included specific requirements related to the number and priority of areas to be surveyed, including the populations to be surveyed each year, the content for each type of survey, and the use of benchmarks. Within DOD, the TRICARE Management Activity (TMA), which oversees the TRICARE program, had responsibility for designing and implementing the beneficiary and 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. It also provides information on TMA's analyses of its 2008 beneficiary and provider surveys. Beneficiary and Provider Survey Area Selection: The NDAA 2008 specified that DOD survey beneficiaries and providers in at least 20 TRICARE Prime Service Areas,[Footnote 35] and 20 geographic areas in which TRICARE Prime is not offered--referred to as non-Prime Service Areas--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, the NDAA 2008 required DOD to give a high priority to surveying areas in which higher concentrations of Selected Reserve servicemembers live. In designing the 2008 beneficiary and provider surveys, TMA defined 80 Prime Service Areas and 80 non-Prime Service Areas that will allow it to survey the entire country over a 4-year period and to develop estimates of access to health care and mental health care at service area, state, and national levels. TMA identified the 80 Prime Service Areas 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-Prime Service Areas had not previously been defined, TMA sought to define them by grouping all zip codes not in Prime Service Areas into one large area using Hospital Referral Regions,[Footnote 36] which are groupings of Hospital Service Areas.[Footnote 37] TMA divided the large area into 80 non-Prime Service Areas so that each area had roughly the same number of TRICARE-eligible beneficiaries. To identify locations where 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 TRICARE Regional Offices. These groups suggested cities and towns where access should be measured, and Hospital Service Areas corresponding to each city and town were then identified. Based on the groups' recommendations, a list was created and sorted in priority order, resulting in 21 Hospital Service Areas being included in the 2008 provider survey. Additionally, TMA plans to include these 21 Hospital Service Areas in its 2009 beneficiary survey along with additional areas that are identified for 2009. Although the NDAA 2008 required DOD to give a high priority to surveying areas in which higher concentrations of Selected Reserve servicemembers live, TMA decided to randomly select areas for the surveys in order to produce results that could be generalized to the populations in the areas surveyed. Selection of Beneficiary and Provider Survey Sample: 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),[Footnote 38] a database of DOD beneficiaries who may be eligible for military health benefits. TMA determined a beneficiary's eligibility to be included in the 2008 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 file extract; (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 Prime Service Areas or 20 randomly selected non- Prime Service Areas; and (5) a user of TRICARE Reserve Select, or not enrolled in TRICARE Prime.[Footnote 39] From this database, TMA randomly sampled about 1,000 beneficiaries from each Prime Service Area and non-Prime Service Area--a sample size that would achieve TMA's desired sample error.[Footnote 40] Specifically, TMA surveyed 48,548 TRICARE beneficiaries representing active duty, retired, and Reserve servicemembers, including the Selected Reserve. TMA began mailing the beneficiary survey in June 2008. After receiving the returned surveys, TMA identified the responses that it considered complete and eligible based on whether the beneficiary had answered at least half of TMA's identified "key" questions and answered that he or she used "TRICARE Extra or Standard" or "TRICARE Reserve Select" in response to the following question: "Which health plan did you use for all or most of your health care in the last 12 months?" TMA selected the provider sample within the same 20 Prime Service Areas and 20 non-Prime Service Areas that had been randomly selected for the 2008 beneficiary survey. In addition, TMA mailed surveys to physicians and mental health providers in the 21 Hospital Service Areas 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 (Masterfile) to select a sample of 20,030 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 Masterfile is a database of physicians in the United States--Doctors of Medicine and Doctors of Osteopathic Medicine--that includes data on all physicians who have the necessary educational and credentialing requirements. The Masterfile did not differentiate between TRICARE's network and non-network 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 it contains over 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 to 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 mental health provider sample, TMA selected a sample of 20,386 mental health providers from two sources: the National Plan and Provider Enumeration System database maintained by the Centers for Medicare & Medicaid Services, and from LISTS, Inc., a list of names with contact information assembled from state licensing boards. According to TMA, it selected these sources for mental health providers because they have been identified as the most comprehensive databases for these health care providers. TMA did not include all physician specialist types, such as epidemiologists and pathologists, in its survey. From these data sets, TMA planned to randomly sample about 800 providers (400 each of physicians and mental health providers) from each Prime Service Area, non-Prime Service Area, and Hospital Service Area--a sample size that would achieve TMA's desired sample error.[Footnote 41] In those instances where there were not 800 providers in a single area, TMA selected all of the providers in that area to receive surveys. TMA began mailing the provider survey in December 2008. Upon receipt of the returned surveys, TMA identified the responses that it considered completed 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 that he or she was in 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) if the provider had completed three key questions on the physician survey instrument or three key questions on the nonphysician mental health provider survey instrument. Beneficiary and Provider Survey Content: 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 providers willing to provide services under TRICARE Standard or TRICARE Extra. TMA's beneficiary survey included 91 questions that address, 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 beneficiary survey questions on those included in the Department of Health and Human Services' 2006 Consumer Assessment of Healthcare Providers and Systems, a national survey of beneficiaries of commercial health insurance, Medicare, Medicaid, and the Children's Health Insurance Program. 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. (See appendix III for a copy of the 2008 beneficiary survey instrument.) 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 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 OMB as required under the Paperwork Reduction Act.[Footnote 42] Subsequent to this review, OMB approved an 11-item questionnaire for physicians (including psychiatrists) and a 12-item questionnaire for nonphysician mental health providers to be administered in fiscal year 2008. (See appendix IV for a copy of the 2008 provider survey instruments.) The mental health providers' version of the survey includes an additional question about what type of mental health care the provider practiced. 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. Beneficiary and Provider Survey Benchmarks: In accordance with the NDAA 2008, TMA identified benchmarks for analyzing the results of the beneficiary and provider surveys. Because TMA based some of its 2008 beneficiary survey questions on those included in the Department of Health and Human Services' 2006 Consumer Assessment of Healthcare Providers and Systems survey, it was able to compare the results of those questions with its 2008 beneficiary survey results. To benchmark its provider survey, TMA compared the results of its 2008 survey 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. Analyses of Beneficiary and Provider Survey Results: In analyzing the results of the beneficiary survey, TMA representatives conducted a nonresponse analysis because the overall response rate to the survey was about 38 percent.[Footnote 43] To conduct this analysis, 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 400 beneficiaries who did not respond to the original survey or the follow-up mailing and compared their responses with those of the original survey respondents.[Footnote 44] The results of TMA's nonresponse analysis indicated no difference in demographic characteristics and health coverage between beneficiary survey respondents and nonrespondents within the combined Prime Service Areas and combined non-Prime Service Areas surveyed in fiscal year 2008. Therefore, TMA concluded that the survey respondents were representative of the combined Prime Service Areas and combined non- Prime Service Areas surveyed, and the results of the survey can be generalized to the population from which the sample was chosen. TMA weighted each response so that the sampled beneficiaries represented the population in terms of size for the respective Prime Service Area or non-Prime Service Area from which they were selected. In analyzing the results of the provider survey, TMA conducted a nonresponse analysis because the overall response rate to the survey was about 45 percent. To conduct this analysis, TMA did the following: (1) compared key provider demographic characteristics of respondents to those of nonrespondents (for example, provider type and location) and (2) interviewed a sample of 247 providers (140 physicians and 107 mental health providers) who did not respond to the original survey, follow-up mailing, or follow-up telephone calls and compared their responses with those of the original survey respondents.[Footnote 45] The results of TMA's nonresponse analysis indicated that there are differences between respondents and those who did not respond to the original 2008 provider survey. Specifically, among both types of providers (physicians and mental health providers), nonrespondents are less likely to be aware of TRICARE and less likely to accept TRICARE as a form of payment for services. Additionally, nonrespondents are less likely to be accepting new patients. Therefore, the survey results cannot be generalized to the population from which the sample was chosen and can only be presented in terms of those civilian providers who responded to the survey. [End of section] Appendix III: Beneficiary Survey Instrument: The NDAA 2008 directed 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. For the purpose of this report, we refer to beneficiaries who are not enrolled in TRICARE Prime--that is, those who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select[Footnote 46]--as nonenrolled beneficiaries.[Footnote 47] 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. Following is the actual survey instrument that DOD used to obtain information from nonenrolled beneficiaries. Office Of The Assistant Secretary Of Defense: Health Affairs: Tricare Management Activity: Health Program Analysis And Evaluation Directorate: June 25, 2008: [Insert beneficiary name] Street Address: City, State Zip: Dear [Insert beneficiary name]: We need your help. In support of U.S. military men and women, Congress has directed the Department of Defense to conduct a study on whether military service members and their families have access to the health care and the mental health care they need. This survey, the June 2008 Health Care Survey of Don Beneficiaries, asks for your comments on your health, your experience with the availability of health care, and your satisfaction with health care services, whether in our military treatment facilities or through private sector care paid for by the DoD or through your own insurance plan. Even if you did not receive any of your health care from a military facility, we still ask that you complete the survey. Your views are important to us and your opinions count. I urge you to share your perspective on these important issues. This is your opportunity to impact directly the formulation of Department of Defense health care policies. Your answers will be held in the strictest confidence, and you will not be personally identified in any reports or release of survey data. While your participation is really needed, it is entirely voluntary. Please take the time today to complete and return the enclosed survey. Or, if you wish, you may access the survey at the following website using the 8-digit survey ID and 6-digit password assigned to you. http://www.synovatemet/healthsurvey08: ID: 34000018: Password: 727052: If your address on this letter is incorrect, if you cannot access the Web site, or if you have questions pertaining to the survey, please contact the Survey Processing Center. You can reach them by email at dod.survey@synovate.net; by calling 1-800-235-7878; or sending a fax to 1-800-409-7681. If you do not wish to participate or to receive reminders about this survey, you may remove yourself from the mailing list by contacting the Survey Processing Center. Be sure to include the 8-digit number above your address on this letter in all communications. Thank you for your time and assistance in this very important effort. For more information about the Health Care Survey of Department of Defense Beneficiaries, please go to the TRICARE Web site at http://tricare.mil. Sincerely, Signed by: Thomas V. Williams, Ph.D. Director, Health Program Analysis and Evaluation Directorate: Office of the Assistant Secretary of Defense (Health Affairs)/TRICARE Management Activity: [End of letter] Health Care Survey of DoD Beneficiaries: 7P34-04: JUNE, 2008: Department Of Defense Health Care Survey Of DoD Beneficiaries: Privacy Act Statement: In accordance with the Privacy Act of 1974 (Public Law 93-579), the Department of Defense is required to inform you of the purposes and use of this survey. Please read it carefully. Authority: Title 10 U.S.C., Chapter 55; Section 706, Public Law 102- 484; E.O. 9397. Purpose: This survey helps health policy makers gauge beneficiary satisfaction with the current military health care system and provides valuable input from beneficiaries that will be used to improve the Military Health System. Routine Uses: None. Disclosure: Voluntary. There is no penalty if you choose not to respond. However, maximum participation is encouraged so that the data will be as complete and representative as possible. As an eligible TRICARE beneficiary, please complete this survey even if you did not receive your health care from a military facility. Please recognize that some specific questions about TRICARE benefits may not apply to you, depending on your entitlement and particular TRICARE program. Survey Instructions: This survey is about the health care of the person whose name appears on the envelope. The questionnaire should be completed by that person. If you are not the addressee, please give this survey to that person. Answer all of the questions by checking the box to the left of your answer. You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this: Yes [arrow]: Go To Question 21; No. Please return the completed questionnaire in the enclosed postage-paid envelope within seven days. If the envelope is missing, please send to: Office of the Assistant Secretary of Defense (Health Affairs): TMA/HPAE: c/o Synovate Survey Processing Center: PO Box 5030: Chicago, IL 60680-4138: Survey Starts Here: 1. Are you the person whose name appears on the cover letter? Yes [arrow]: Go To Question 2; No: Please give this questionnaire to the person addressed on the cover letter. 2. By which of the following health plans are you currently covered? Mark All That Apply. Military Health Plans: TRICARE Prime (including TRICARE Prime Remote and TRICARE Overseas); TRICARE Extra or Standard (CHAMPUS); TRICARE Plus; TRICARE for Life; TRICARE Supplemental Insurance; TRICARE Reserve Select; Other Health Plans: Medicare; Federal Employees Health Benefit Program (FEHBP); Medicaid or other stale health insurance; A civilian HMO (such as Kaiser); Other civilian health insurance (such as Blue Cross); Uniformed Services Family Health Plan (USFHP); The Veterans Administration (VA); Government health insurance from a country other than the US; Not sure; 3. Which health plan did you use for all or most of your health care in the last 12 months? Mark Only One Answer. TRICARE Prime; TRICARE Extra or Standard (CHAMPUS); TRICARE Plus; TRICARE Reserve Select; Medicare (may include TRICARE for Life); Federal Employees Health Benefit Program (FEHBP); Medicaid or other state health insurance; A civilian HMO (such as Kaiser); Other civilian health insurance (such as Blue Cross); Uniformed Services Family Health Plan (USFHP); The Veterans Administration (VA); Government health insurance from a country other than the US; Not sure; Did not use any health plan in the last 12 months; [Arrow] Go To Question 5. For the remainder of this questionnaire, the term health plan refers to the plan you indicated in Question 3. 4. How many months or years in a row have you been in this health plan? Less than 6 months; 6 up to 12 months; 12 up to 24 months; 2 up to 5 years; 5 up to 10 years; 10 or more years. 5. Many beneficiaries who are eligible for TRICARE also have the opportunity to obtain other civilian health insurance through their job or a family member's job, through COBRA, or through retirement coverage from a previous job, or from some other group. COBRA lets beneficiaries pay to keep their coverage temporarily when they leave their job. Do you have the opportunity to obtain civilian health insurance for yourself through some civilian group? Yes; No; [arrow] Go To Question 9 6. What options do you have for obtaining civilian coverage? Mark All That Apply. Through my current employer; Through COBRA from my previous employer; Through retirement coverage from my previous employer; Through a family member's current employer; Through COBRA from a family member's previous employer; Through retirement coverage from a family member's previous employer; Through another organization; Through a government program; Don't know. 7. Are you now covered by a civilian health insurance policy? Yes; No; [arrow] Go To Question 9. 8. Are you alone covered or are you and others in your household covered by the civilian health insurance policy? I alone am covered; I and at least one other person in my household are covered. 9. Have you used TRICARE for any health care (not including for prescription drugs) in the past 12 months? Yes; [arrow] Go To Question 11; No. 10. Why haven't you used TRICARE? Mark All That Apply. I have a greater choice of doctors with my civilian plan; My personal doctor is not available to me through TRICARE; My TRICARE regular doctor is no longer available to me; My TRICARE specialist is no longer available to me; My preferred doctors do not accept TRICARE; I prefer civilian hospitals; There are no military facilities near me; I have to travel too far to see my TRICARE doctor; I get better customer service with civilian plans; TRICARE benefits are poor compared to my civilian plan; It is easier for me to get care through my civilian plan; I do not want to pay the premium for TRICARE; I pay less for civilian care than I would for TRICARE; I have not needed health care; Another reason. Your Personal Doctor Or Nurse: The next questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits. 11. A personal doctor or nurse is the health provider who knows you best. This can be a general doctor, a specialist doctor, a nurse practitioner, or a physician assistant. Do you have one person you think of as your personal doctor or nurse? Yes; No; [Arrow] Go To Question 15. 12. Using any number from 0 to 10 where 0 is the worst personal doctor or nurse possible, and 10 is the best personal doctor or nurse possible, what number would you use to rate your personal doctor or nurse? 0; Worst personal doctor or nurse possible; 1; 2; 3; 4; 5; 6; 7; 8; 9; 10; Best personal doctor or nurse possible; I don't have a personal doctor or nurse; 13. How long does it take you to travel to your personal doctor or nurse? Less than 15 minutes; 15 to 30 minutes; 31 minutes to 60 minutes (1 hour); 61 minutes to 90 minutes; 91 minutes to 120 minutes (2 hours); More than 120 minutes (2 hours). 14. Did you have the same personal doctor or nurse before you joined this health plan? Yes; [arrow] Go To Question 16; No. 15. Since you joined your health plan, how much of a problem, if any, was it to get a personal doctor or nurse you are happy with? A big problem; A small problem; Not a problem. 16. Where is your personal doctor or nurse located? Mark Only One Answer. A military facility — This includes: Military clinic, Military Hospital, PRIMUS clinic, NAVCARE clinic; [arrow] Go To Question 18; A civilian facility —This includes: Doctor's office, Clinic, Hospital, Civilian TRICARE contractor; Uniformed Services Family Health Plan facility (USFHP) Veterans Affairs (VA) clinic or hospital; I do not have a personal doctor or nurse. 17. In the last 12 months, did you try to find a personal doctor or nurse who was located at a military treatment facility? Yes No; [arrow] Go To Question 20. 18. How much of a problem, if any, was it to find an available personal doctor or nurse at a military treatment facility? A big problem; A small problem; Not a problem; [arrow] Go To Question 20. 19. What is the biggest problem you encountered trying to find a personal doctor or nurse at a military treatment facility? Mark Only One Answer. The military facilities near me have downsized or closed; The wait for an appointment at the military treatment facilities near me is too long; The waiting rooms at the military facilities near me are crowded or uncomfortable; The staff at the military treatment facilities near me are not helpful or courteous; I have had problems communicating with doctor(s) at the military treatment facilities; Another reason. 20. Is your personal doctor or nurse a civilian? Yes; No; [arrow] Go To Question 25; I do not have a personal doctor or nurse; [arrow] Go To Question 25. 21. The TRICARE civilian provider network is made up of the doctors, clinics, hospitals and other health care providers who are part of DoD's preferred provider pool. Is your personal doctor or nurse part of the TRICARE civilian provider network? Yes; No. 22. What is the specialty of your personal doctor or nurse? Mark Only One Answer. Family Medicine or General Practitioner; Internist; Pediatrician; OB-GYN; Geriatrician or Geriatric Nurse; Preventive Medicine; Nurse Practitioner or Physician's Assistant; Other specialty. 23. In the last 12 months, how much of a problem was it to find a personal doctor or nurse who would accept TRICARE? A big problem; A small problem; Not a problem; [arrow] Go To Question 25. 24. What problems did you encounter in finding a personal doctor who would accept TRICARE? Mark All That Apply. Travel distance too long; Problems communicating with doctor; Doctor(s) not taking any new patients; Doctor(s) not taking new TRICARE patients; Doctor(s) not accepting TRICARE payments; Could not find the specialty I wanted; Did not like doctor(s); Wait for an appointment was too long; Could not find information about doctors; Other. Getting Health Care From A Specialist: When you answer the next questions do not include dental visits. 25. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and others who specialize in one area of health care. In the last 12 months, did you or your doctor think you needed to see a specialist? Yes No 4; [arrow] Go To Question 27. 26. In the last 12 months, how much of a problem, if any, was it to see a specialist that you needed to see? A big problem; A small problem; Not a problem; I didn't need a specialist in the last 12 months. 27. In the last 12 months, did you see a specialist? Yes No; [arrow] Go To Question 36. 28. We want to know your rating of the specialist you saw most often in the last 12 months. Using any number from 0 to 10 where 0 is the worst specialist possible, and 10 is the best specialist possible, what number would you use to rate the specialist? 0; Worst specialist possible; 1; 2; 3; 4; 5; 6; 7; 8; 9; 10; Best specialist possible; I didn't see a specialist in the last 12 months. 29. How long does it take you to travel to the specialist you saw most in the past 12 months? Less than 15 minutes; 15 to 30 minutes; 31 minutes to 60 minutes (1 hour); 61 minutes to 90 minutes; 91 minutes to 120 minutes (2 hours); More than 120 minutes (2 hours). 30. In the last 12 months, did you see a civilian specialist? Yes No; [arrow] Go To Question 36. 31. In the last 12 months, was the civilian specialist you saw most the same doctor as your personal doctor? Yes; No. 32. In the last 12 months, was the civilian specialist you saw most part of the TRICARE civilian provider network? Yes; No. 33. In the last 12 months, what was the specialty of the civilian specialist you saw most? Mark Only One Answer. Surgeon; Cardiologist (heart doctor); Allergist; Dermatologist (skin doctor); Rheumatologist (specialist of the joints); Endocrinologist (thyroid, hormone and diabetes specialist); Urologist (specialist of the urinary tract and male reproductive system); Oncologist (cancer specialist); Orthopedist (specialist of the bones, muscles and their connected tissues); Ear, nose and throat specialist; Obstetrician/Gynecologist; Ophthalmologist; Other. 34. In the last 12 months, how much of a problem was it to find a doctor with this specialty who would accept TRICARE? A big problem A small problem Not a problem; [arrow] Go To Question 36. 35. What problems did you encounter in finding a specialist who would accept TRICARE? Mark All That Apply. Travel distance too long; Problems communicating with doctor; Doctor(s) not taking any new patients; Doctor(s) not taking new TRICARE patients; Doctor(s) not accepting TRICARE payments; Could not find the specialty I wanted; Did not like doctor(s); Wait for an appointment was too long; Could not find information about doctors; Other. Calling Doctors' Offices: 36. In the last 12 months, did you call a doctor's office or clinic during regular office hours to get help or advice for yourself? Yes No; [arrow] Go To Question 38. 37. In the last 12 months, when you called during regular office hours, how often did you gel the help or advice you needed? Never; Sometimes; Usually; Always; I didn't call for help or advice during regular office hours in the last 12 months. Your Health Care In The Last 12 Months: 38. In the last 12 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor's office? Yes; No; [arrow] Go To Question 41. 39. In the last 12 months, when you needed care right away for an illness, injury, or condition, how often did you get care as soon as you wanted? Never; Sometimes; Usually; Always; I didn't need care right away for an illness, injury or condition in the last 12 months. 40. In the last 12 months, when you needed care right away for an illness, injury, or condition, how long did you usually have to wait between trying to get care and actually seeing a provider? Same day; 1 day; 2 days; 3 days; 4-7 days; 8-14 days; 15 days or longer; I didn't need care right away for an illness, injury or condition in the last 12 months. 41. A health provider could be a general doctor, a specialist doctor, a nurse practitioner, a physician assistant, a nurse, or anyone else you would see for health care. In the last 12 months, not counting the times you needed health care right away, did you make any appointments with a doctor or other health provider for health care? Yes; No; [arrow] Go To Question 44. 42. In the last 12 months, not counting times you needed health care right away, how often did you get an appointment for health care as soon as you wanted? Never; Sometimes; Usually; Always; I had no appointments in the last 12 months. 43. In the last 12 months, not counting the times you needed health care right away, how many days did you usually have to wait between making an appointment and actually seeing a provider? Same day; 1 day; 2-3 days; 4-7 days; 8-14 days; 15-30 days; 31 days or longer; I had no appointments in the last 12 months. 44. In the last 12 months, how many times did you go to an emergency room to get care for yourself? None; 1; 2; 3; 4; 5 to 9; 10 or more. 45. In the last 12 months, (not counting times you went to an emergency room), how many times did you go to a doctor's office or clinic to get care for yourself? None; [arrow] Go To Question 58; 1; 2; 3; 4; 5 to 9; 10 or more. 46. In the last 12 months, did you or a doctor believe you needed any care, tests, or treatment? Yes; No; [arrow] Go To Question 48. 47. In the last 12 months, how much of a problem, if any, was it to get the care, tests or treatment you or a doctor believed necessary? A big problem; A small problem; Not a problem; I had no visits in the last 12 months. 48. In the last 12 months, did you need approval from your health plan for any care, tests, or treatment? Yes; No; [arrow] Go To Question 50. 49. In the last 12 months, how much of a problem, if any, were delays in health care while you waited for approval from your health plan? A big problem; A small problem; Not a problem; I had no visits in the last 12 months. 50. In the last 12 months, how often were you taken to the exam room within 15 minutes of your appointment? Never; Sometimes; Usually; Always; I had no visits in the last 12 months. 51. In the last 12 months, how often did office staff at a doctor's office or clinic treat you with courtesy and respect? Never; Sometimes; Usually; Always; I had no visits in the last 12 months. 52. In the last 12 months, how often were office staff at a doctor's office or clinic as helpful as you thought they should be? Never; Sometimes; Usually; Always; I had no visits in the last 12 months; 53. In the last 12 months, how often did doctors or other health providers listen carefully to you? Never; Sometimes; Usually; Always; I had no visits in the last 12 months. 54. In the last 12 months, how often did doctors or other health providers explain things In a way you could understand? Never; Sometimes; Usually; Always; I had no visits in the last 12 months. 55. In the last 12 months, how often did doctors or other health providers show respect for what you had to say? Never; Sometimes; Usually; Always; I had no visits in the last 12 months. 56. In the last 12 months, how often did doctors or other health providers spend enough time with you? Never; Sometimes; Usually; Always; I had no visits in the last 12 months. 57. Using any number from 0 to 10, where 0 is the worst health care possible, and 10 is the best health care possible, what number would you use to rate all your health care in the last 12 months? 0; Worst health care possible; 1; 2; 3; 4; 5; 6; 7; 8; 9; 10; Best health care possible; I had no visits in the last 12 months. 58. In the last 12 months, where did you go most often for your health care? Mark Only One Answer. A military facility — This includes: Military clinic, Military hospital, PRIMUS clinic, NAVCARE clinic; A civilian facility —This includes: Doctor's office, Clinic, Hospital, Civilian TRICARE contractor; Uniformed Services Family Health Plan facility (USFHP); Veterans Affairs (VA) clinic or hospital; I went to none of the listed types of facilities in the last 12 months. Treatment Or Counseling: 59. In the last 12 months, did you need any treatment or counseling for a personal or family problem? Yes No; [arrow] Go To Question 74. 60. In the last 12 months, what type of provider did you want to see most for this treatment or counseling? Mark Only One Answer. Psychologist; Psychiatrist; Psychotherapist; Social worker; Mental health counselor; Marriage or family therapist; Your personal doctor or nurse; Other; Don't know. 61. In the last 12 months, did you receive treatment or counseling for a personal or family problem? Yes; No; [arrow] Go To Question 65. 62. In the last 12 months, did you receive this treatment or counseling from a civilian provider? Yes No; [arrow] Go To Question 64. 63. In the last 12 months, did you receive this treatment or counseling from a provider in TRICARE's civilian network? Yes; No. 64. In the last 12 months, what type of provider did you see most often for this treatment or counseling? Mark Only One Answer. Psychologist; Psychiatrist; Psychotherapist; Social worker; Mental health counselor; Marriage or family therapist; Your personal doctor or nurse; Other; Don't know. 65. In the last 12 months, how much of a problem, if any, was it to get the treatment or counseling you needed through your health plan? A big problem; A small problem; Not a problem; [arrow] Go To Question 67. 66. In the last 12 months, what problems did you encounter in finding treatment or counseling? Mark All That Apply. Travel distance too long; Problems communicating with doctor; Doctor(s) or counselor(s) not taking new patients; Doctor(s) or counselor(s) not taking new TRICARE patients; Doctor(s) or counselor(s) not accepting TRICARE payments; Could not find the specialty I wanted; Did not like doctor(s) or counselor(s); Wait for an appointment was too long; Could not find information about doctors or counselors; Other. 67. In the last 12 months, did you need treatment or counseling right away? Yes No; [arrow] Go To Question 69. 68. In the last 12 months, when you needed treatment or counseling right away, how often did you see someone as soon as you wanted? Never; Sometimes; Usually; Always. 69. In the last 12 months, did you need approval for any treatment or counseling? Yes; No; [arrow] Go To Question 71. 70. In the last 12 months, how much of a problem, if any, were delays in treatment or counseling while you waited for approval? A big problem; A small problem; Not a problem. 71. In the last 12 months, did you call customer service to get information or help about treatment or counseling? Yes No; [arrow] Go To Question 73. 72. In the last 12 months, how much of a problem, if any, was it to get the help you needed when you called customer service? A big problem; A small problem; Not a problem. 73. Using any number from 0 to 10, where 0 is the worst treatment or counseling possible, and 10 is the best treatment or counseling possible, what number would you use to rate all your treatment or counseling in the last 12 months? 0; Worst treatment or counseling possible; 1; 2; 3; 4; 5; 6; 7; 8; 9; 10; Best treatment or counseling possible; I didn't receive treatment or counseling in the last 12 months. Your Health Plan: The next question asks about your experience with your health plan. By your health plan, we mean the health plan you marked in Question 3. 74. Using any number from 0 to 10 where 0 is the worst health plan possible, and 10 is the best health plan possible, what number would you use to rate your health plan? 0; Worst health plan possible; 1; 2; 3; 4; 5; 6; 7; 8; 9; 10; Best health plan possible. Preventive Care: Preventive care is medical care you receive that is intended to maintain your good health or prevent a future medical problem. A physical or blood pressure screening are examples of preventive care. 75. When did you last have a blood pressure reading? Less than 12 months ago; 1 to 2 years ago; More than 2 years ago. 76. Do you know if your blood pressure is too high? Yes, it is too high; No, it is not too high; Don't know. 77. Have you ever smoked at least 100 cigarettes in your entire life? Yes; No; [arrow] Go To Question 80; Don't know; [arrow] Go To Question 80. 78. Do you now smoke every day, some days or not at all? Every day; Some days; Not at all; [arrow] Go To Question 80; Don't know; [arrow] Go To Question 80. 79. In the last 12 months, on how many visits were you advised to quit smoking by a doctor or other health provider in your plan? None; 1 visit; 2 to 4 visits; 5 to 9 visits; 10 or more visits; I had no visits in the last 12 months. 80. When did you last have a cholesterol screening, that is, a test to determine the level of cholesterol in your blood? Less than 12 months ago; 1 to 2 years ago; More than 2 but less than 5 years ago; 5 or more years ago; Never had a cholesterol screening. 81. Are you male or female? Male 4; [arrow] Go To Question 85; Female. 82. When did you last have a Pap smear test? Within the last 12 months; 1 to 3 years ago; More than 3 but less than 5 years ago; 5 or more years ago; Never had a Pap smear test. 83. Are you under age 40? Yes 4; [arrow] Go To Question 85; No. 84. When was the last time your breasts were checked by mammography? Within the last 12 months; 1 to 2 years ago; More than 2 but less than 5 years ago; 5 or more years ago; Never had a mammogram. About You: 85. In general, how would you rate your overall health now? Excellent; Very good; Good; Fair; Poor. 86. Are you limited in any way in any activities because of any impairment or health problem? Yes; No. 87. What is the highest grade or level of school that you have completed? 8th grade or less; Some high school, but did not graduate; High school graduate or GED; Some college or 2-year degree; 4-year college graduate; More than 4-year college degree. 88. Are you of Hispanic or Latino origin or descent? Mark "No" if not Spanish /Hispanic/Latino. No, not Spanish. Hispanic, or Latino; Yes, Mexican, Mexican American, Chicano; Yes, Puerto Rican; Yes, Cuban; Yes, other Spanish, Hispanic, or Latino. 89. What is your race? Mark One Or More races to indicate what you consider yourself to be, White; Black or African American; American Indian or Alaska Native; Asian (e.g., Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese); Native Hawaiian or other Pacific Islander (e.g., Samoan, Guamanian, or Chamorro). 90. What is your age now? 18 to 24; 25 to 34; 35 to 44; 45 to 54; 55 to 64; 65 to 74; 75 or older. 91. Which of the following income ranges is closest to your family's (2007) total income from all sources? Your best estimate would be fine. Less than $10,000; $10,000 to $24,999; $25,000 to $49,999; $50,000 to $74,999; $75,000 to $99,999; $100,000 to $124,999; $125,000 to $149,999; $150,000 and above; Don't know. Thank You For Taking The Time To Complete The Survey! Your generous contribution will greatly aid efforts to improve the health of our military community. Return your survey in the postage-paid envelope. If the envelope is missing, please send to: Office of the Assistant Secretary of Defense (HA): TMA/HPAE: c/o Synovate Survey Processing Center: PO Box 5030: Chicago, IL 60680-4138: Questions about the survey? Email: dod.survey@synovate.net: Toll-free phone (in the US, Puerto Rico and Canada): 1-800-235-7878, available 24 hours a day. Toll-free fax (in the US and Canada): 1-800-409-7681. When calling or writing, please provide your name, address, and the 8- digit number above your address on the envelope. Questions about your TRICARE coverage? For additional information on TRICARE, or if you are not sure about your benefits, or if you don't have a primary care manager; contact the TRICARE Service Center in your region: North: 1-877-874-2273: South: 1-800-444-5445: West: 1-888-874-9378: Outside the US: 1-888-777-8343: The website is: www.tricare.osd.mil/tricareservicecenters. Veterans: Contact the US Department of Veterans Affairs at 1-877-222-VETS; or go to www.va.gov. [End of section] Appendix IV: Survey Instruments for Health Care and Mental Health Care Providers: The NDAA 2008 directed 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. For the purpose of this report, we refer to beneficiaries who are not enrolled in TRICARE Prime--that is, those who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select[Footnote 48]--as nonenrolled beneficiaries.[Footnote 49] Specifically, the 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.[Footnote 50] Following are the actual survey instruments that DOD used to obtain information from physicians and nonphysician mental health care providers. Office Of The Assistant Secretary Of Defense: Health Affairs: Tricare Management Activity: Health Program Analysis And Evaluation Directorate: 21025002 Attn: Billing Manager For: Dr. John Doe 1234 E North St: Ste 123: Anytown, US 12345-6789: February 6, 2009: Dear DR. John Doe, Hello! The physician named above has been selected to participate in a very important survey effort. In support of U.S. military men and women, Congress has directed the Department of Defense to survey civilian physicians across the U.S. to determine whether military service members and their families have access to the health care they need. A substantial amount of health care to service members and their families is delivered by private, civilian physicians like DR. JOHN DOE, and we need your help. We are asking you to please answer the questions on the back of this letter on behalf of the physician above and return it within five days. There are several ways to complete this survey, which should only take five minutes of your time: * Complete the survey on the reverse side of this letter and return it via postal mail in the enclosed postage paid envelope; * Complete the survey on the reverse side of this letter and fax it to 1-800-585-9446; * Complete the survey on the internet at the following URL: https://www.dodcv08.com. Your unique login name: 21025002: Your unique password: 17562128: We recognize that there may be more than one provider in your office and ask that you complete the survey for the provider listed above. Since we may survey more than one provider in your office, please complete each survey for the appropriate provider named above. If you are not the appropriate person to answer these questions, please pass this on to the person in your office most familiar with DR. JOHN DOE's billing and insurance. Thank you in advance for your cooperation and help as we examine this important issue that impacts our American service men and women. If you have questions about this survey, please call Synovate between the hours of 8AM and 5PM Eastern Time at 1-800-228-6764. Sincerely yours, Signed by: Thomas V. Williams, Ph.D. Director, Health Program Analysis and Evaluation Directorate: Office of the Assistant Secretary of Defense (Health Affairs) TRICARE Management Activity: Survey Questions On Reverse Side: We estimate this survey will take an average five (5) minutes to complete inducing the time for reviewing instructions, getting the needed data, and completing and reviewing the survey. Please return your completed survey in the provided envelope or by the fax number above, however, you may send comments regarding our estimate or any other aspect of this survey, inducing suggestions for reducing the completion time, to Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division (OMB Number 0720-0031). The OMB number above is currently valid, and you are not required to respond, unless this number is dsplayed. Q1. Does DR. John Doe provide health care to patients through an office-based practice? Yes; [arrow] Go To Q2; No. Thank you, please return the questionnaire. Q2. Is DR. John Doe aware of the TRICARE health care program? Yes; No; I Don't Know; Q3. As of today, is DR. John Doe a contracted member of the TRICARE health care program? Yes; No; I Don't Know. Q4. As of today, is DR. John Doe accepting new TRICARE Standard patients? No; [arrow] Go To Q5; Yes, on a claim by claim basis only; [arrow] Go To Q6; Yes, for all claims; [arrow] Go To Q6; I Don't know; [arrow] Go To Q6. Q5. If you answered "no" to Q4 above, why is DR. John Doe not accepting new TRICARE Standard patients? Please list all the reasons. If you need additional space, please include a separate sheet of paper. Q6. What percentage of patients seen by DR. John Doe use any form of TRICARE? If unsure, please write down your best guess. None: DR. John Doe has no TRICARE patients; __ percent use some form of TRICARE; I Don't Know. Q7. Does DR. John Doe accept any Medicare patients? Yes; No; I Don't Know. Q8. As of today, is DR. John Doe accepting new Medicare patients? Yes; [arrow] Thank you, please return the questionnaire; No; [arrow] Go To Q9; I Don't Know; [arrow] Go To Q10. Q9. If you answered "no" to Q8 above, why is DR. John Doe not accepting new Medicare patients? Please list all the reasons. If you need additional space, please include a separate sheet of paper. Q10. Does DR. John Doe accept any insurance plans? Yes; No. Q11. As of today, is DR. John Doe accepting any new patients? Yes; No; I Don't Know. Thank you for taking the time to complete this survey. Please put this in the enclosed postage-paid envelope and return it to the Survey Processing Center or fax the survey to Synovate at 1-800-585-9446. If you have any questions about TRICARE, its specific health plans, or the benefits it provides, please visit the TRICARE web site at www.tricare.osd.mil for assistance. Privacy Act Statement: According to the Privacy Act of 1974 (Public law 93579], the Department. of Defense is required to inform you of the purposes and use of this survey. Please read carefully, Authority: Section 711 of the National Defense Authorization Act for Fiscal Year 2008 (Public Law (P.L.) 110-181. Purpose: Mandated by Congress, this confidential survey of civilian providers helps TR:CARE health policy makers gauge civilian provider awareness and acceptance of the TRICARE Standard health care benefit option, and will provide valuable aggregated input to help improve the Military Health System. Routine Uses: Those disclosures generally permitted under 5.9.S.C. 552a(b) of the Privacy Act. Disclosure: Providing information in this questionnaire is voluntary. There is no penalty if you choose not to respond However, maximum participation is encouraged so that data will be as complete and representative as possible. You may notice a number on this survey: this number is used only to let us know if you returned the survey to minimize sending you reminders. [End of survey] Office Of The Assistant Secretary Of Defense: Health Affairs: Tricare Management Activity: Health Program Analysis And Evaluation Directorate: 22025001: For: John Doe: PO Box 1234: Anywhere, US 77777-7777: February 6, 2009: Dear John Doe, Hello! You have been selected to participate in a very important survey effort. In support of U.S. military men and women, Congress has directed the Department of Defense to survey civilian mental and behavioral health care providers across the U.S. to determine whether military service members and their families have access to the care they need. A substantial amount of mental and behavioral health care provided to our military and their families is delivered by private, civilian providers like yourself. The DoD has contracted Synovate to conduct this survey. We are asking you to please answer the questions on the back of this letter and return it within five days. We suggest that the survey be completed by the person in your office who is most knowledgeable about billing and insurance. We recognize that there may be more than one provider in your office and ask that this survey be completed for the provider listed above. There are several ways to complete this survey, which should only take five minutes of your time: * Complete the survey on the reverse side of this letter and return it via postal mail in the enclosed postage paid envelope; * Complete the survey on the reverse side of this letter and fax it to 1-800-585-9446; * Complete the survey on the internet at the following URL: https://www.dodcv08.com. Your unique login name: 22025001: Your unique password: 08094946: Thank you in advance for your cooperation and help as we examine this important issue that impacts our American service men and women. If you have questions about this survey, please call Synovate between the hours of 8AM and 5PM Eastern Time at 1-800-228-6764. Sincerely yours, Signed by: Thomas V. Williams, Ph.D. Director, Health Program Analysis and Evaluation Directorate: Office of the Assistant Secretary of Defense (Health Affairs) TRICARE Management Activity: Survey Questions On Reverse Side: We estimate this survey will take an average five (5) minutes to complete inducing the time for reviewing instructions, getting the needed data, and completing and reviewing the survey. Please return your completed survey in the provided envelope or by the fax number above, however, you may send comments regarding our estimate or any other aspect of this survey, inducing suggestions for reducing the completion time, to Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division (OMB Number 0720-0031). The OMB number above is currently valid, and you are not required to respond, unless this number is displayed. Q1. Does JOHN DOE provide treatment or counseling to patients through private practice? Yes; [arrow] Go To Q2; No; Thank you, please return the questionnaire. Q2. What type of health care provider is John Doe? Mark All That Apply. Certified Clinical Social Worker; Certified Psychiatric Nurse Specialist; Clinical Psychologist; Certified Marriage and Family Therapist; Pastoral Counselor; Mental Health Counselor; Other. Q3. Is John Doe aware of the TRICARE health care program? Yes; No; I Don't Know. Q4. Is John Doe a contracted member of the TRICARE network of health care providers? Yes; No; I Don't Know. Q5. As of today, is John Doe accepting new TRICARE Standard patients? No; [arrow] Go To Q6; Yes, on a claim by claim basis only; [arrow] Go To Q7; Yes, for all claims; [arrow] Go To Q7; I Don't know; [arrow] Go To Q7. Q6. You answered "no" to the question above. Why is John Doe not accepting new TRICARE Standard patients? Please list all the reasons. If you need additional space, please include a separate sheet of paper. Q7. What percentage of patients seen by John Doe use some form of TRICARE? If unsure, please write down your best guess. None JOHN DOE has no TRICARE patients; __ percent use some form of TRICARE; I Don't Know. Q8. Does John Doe accept any Medicare patients? Yes; No; I Don't Know. Q9. As of today, is John Doe accepting new Medicare patients? Yes; [arrow] Thank you, please return the questionnaire; No; [arrow] Go To Q11; I Don't Know; [arrow] Go To Q11; 10. You answered "no" to the question above. Why is John Doe not accepting new Medicare patients? Please list all the reasons. If you need additional space, please include a separate sheet of paper. 11. Does John Doe accept any insurance plans? Yes; No; Q12. As of today, is John Doe accepting any new patients? Yes; No; I Don't Know. Thank you for taking the time to complete this survey. Please put this in the enclosed postage-paid envelope and return it to the Survey Processing Center or fax the survey to Synovate at 1-800-585-9446. If you have any questions about TRICARE, its specific health plans, or the benefits it provides, please visit the TRICARE web site at www.tricare.osd.mil for assistance. Please list all the reasons. If you need additional space, please include a separate sheet of paper. Privacy Act Statement: According to the Privacy Act of 1974 (Public law 93-579), the Department of Defense is required to inform you of the purposed and use of this survey. Please read carefully. Authority Section 711 of the National Defense Authorization Act for Fiscal Year 2008 (Public Law (P.L.) 110-181. Purpose: Mandated by Congress, this confidential survey of civilian providers helps TRICARE health policy makers gauge civilian provider awareness and acceptance of the TRICARE Standard health owe benefit option, and will provide valuable aggregated input to help improve the Military Health System. Routine Uses: Those disclosures generally permitted under 5.U.S.C. 552a(b) of the Privacy Act. Disclosure: Providing information in this questionnaire involuntary. There is no penally it you chaise not to respond. However, maximum participation is encouraged so that data will be as complete and representative as possible. You may notice a number on this survey: this number is used only to let us know if you returned the survey to minimize sending you reminders. [End of section] Appendix V: Areas Included in the Fiscal Year 2008 Beneficiary and Provider Surveys: The NDAA 2008 directed DOD to determine the adequacy of the number of health care providers 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 refer to beneficiaries who are not enrolled in TRICARE Prime--that is, those who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select [Footnote 51]--as nonenrolled beneficiaries.[Footnote 52] The NDAA 2008 specified that DOD conduct surveys of TRICARE beneficiaries and health care and mental health care providers in 20 TRICARE Prime Service Areas[Footnote 53] and in 20 areas in which TRICARE Prime is not offered--referred to as non-Prime Service Areas--for each fiscal year, 2008 through 2011. Additionally, the NDAA 2008 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. For the 2008 beneficiary and provider surveys, DOD selected 20 Prime Service Areas and 20 non-Prime Service Areas to determine the adequacy of the number of health care providers and mental health care providers who currently accept nonenrolled TRICARE beneficiaries as patients. For the 2008 provider survey, DOD also surveyed 21 additional areas identified by beneficiary and provider groups where nonenrolled beneficiaries are experiencing significant levels of access-to care problems--called Hospital Service Areas[Footnote 54]--to determine the adequacy of access to care in these areas. DOD's selected Prime Service Areas and non-Prime Service Areas for 2008 are presented in table 8 and table 9, respectively. Table 10 lists those locations identified by representatives of TRICARE beneficiaries and health care and mental health care providers as having significant levels of access-to-care problems, which were included in the 2008 provider survey.[Footnote 55] Table 8: Prime Service Areas Included in the 2008 Beneficiary and Provider Surveys: Prime Service Areas: 1. Alabama - Dothan, Montgomery. 2. Arizona - Phoenix. 3. Arizona - Sierra Vista, Tucson, Yuma. 4. California - Los Angeles, Newport Beach. 5. Colorado - Denver, Fort Collins. 6. Delaware - Camden, Dover, Wilmington. 7. Florida - Jacksonville. 8. Florida - Fort Walton Beach, Pensacola. 9. Hawaii - Honolulu , Wailuku. 10. Indiana - Indianapolis, Kokomo, Naperville. 11. Louisiana - Alexandria, New Orleans, Shreveport. 12. Maryland, Virginia, Washington, D.C. - Alexandria, Annapolis, Clinton, Silver Spring, Washington. 13. New York - Manhattan, Poughkeepsie. 14. North Carolina - Durham, Elizabeth City, Greenville, Rocky Mount. 15. North Carolina - Fayetteville, Lumberton. 16. Ohio - Cincinnati, Kettering. 17. Pennsylvania - Pittsburgh. 18. Texas - Abilene, Amarillo, Del Rio, Harlington, San Angelo, Wichita Falls. 19. Texas - Austin, Temple. 20. Virginia - Newport News, Suffolk. Source: DOD. [End of table] Table 9: Non-Prime Service Areas Included in the 2008 Beneficiary and Provider Surveys: Non-Prime Service Area: 1. California - Chico, Fresno, Modesto, Napa, Redding, Sacramento, Santa Rosa, Stockton. 2. Georgia - Atlanta; North Carolina - Asheville. 3. Illinois - Springfield. 4. Indiana - Evansville. 5. Iowa - Mason City, Sioux City, Waterloo. 6. Kansas - Topeka. 7. Kentucky - Louisville, Owensboro, Paducah. 8. Maine - Bangor, Portland. 9. Minnesota - Duluth, St. Cloud. 10. Missouri - Cape Girardeau, St. Louis. 11. Montana - Billings. 12. New York - Buffalo. 13. North Dakota - Bismarck, Grand Forks, Minot. 14. Oregon - Portland, Salem. 15. Pennsylvania - Altoona, Danville. 16. Pennsylvania - Johnstown, Pittsburgh. 17. Texas - Amarillo, El Paso, Lubbock, Odessa. 18. Washington - Olympia, Seattle, Yakima. 19. West Virgina - Huntington, Morgantown. 20. Wisconsin - La Crosse. Source: DOD. [End of table] Table 10: Hospital Service Areas Included in the 2008 Provider Survey: Hospital Service Area: 21. Arkansas - Bentonville. 22. California - King City. 23. California - Palm Springs. 24. Colorado - Fort Collins. 25. Florida - Gainesville. 26. Florida - Homestead. 27. Florida - Tampa. 28. Illinois - Peoria. 29. Indiana - Jasper. 30. Indiana - New Albany. 31. Kentucky - Murray. 42. Michigan - Marquette. 33. Mississippi - Columbus. 34. New York - Binghampton. 35. North Carolina - Asheville. 36. North Carolina - Jacksonville. 37. Pennsylvania - Altoona. 38. Utah - Salt Lake City. 39. Virginia - Danville. 40. Virginia - Norfolk. 41. West Virginia - Charleston. Source: DOD. [End of table] [End of section] Appendix VI: Comments from the Department of Defense: Office Of The Assistant Secretary Of Defense: Health Affairs: Washington, DC 20301-t200: March 18 2010: Mr. Randall Williamson: Director, Health Care: U.S. Government Accountability Office: 441 G. Street, NW: Washington, DC 20548: Dear Mr. Williamson: This is the Department of Defense (DoD) response to the General Accountability Office (GAO) Draft Report GA0-10-402, "Defense Health Care: 2008 Access to Care Surveys Indicate Some Problems, but Beneficiary Satisfaction Is Similar to Other Health Plans," dated February 25, 2010 (GAO Code 290762)." DoD acknowledges receipt of the draft audit report and concurs with the overall findings. We have provided suggested technical corrections in the enclosed formal response. Thank you for the opportunity to review and comment on the draft report. The points of contact for additional information are Mr. Mark Ellis (Functional) at (703) 681-0039, and Mr. Gunther Zimmerman (Audit Liaison) at (703) 681-4360. Sincerely, Signed by: Charles L. Rice, M.D. President, Uniformed Services University of the Health Sciences: Performing the Duties of the Assistant Secretary of Defense (Health Affairs): Attachments: As stated: [End of section] Appendix VII: GAO Contact and Staff Acknowledgments: GAO Contact: Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov: Acknowledgments: In addition to the contact named above, Bonnie Anderson, Assistant Director; Martha Kelly, Assistant Director; Susannah Bloch; Peter Mangano; Jeff Mayhew; Lisa Motley; Jessica C. Smith; C. Jenna Sondhelm; and Suzanne Worth made key contributions to this report. [End of section] Footnotes: [1] Eligible beneficiaries include active duty personnel and their dependents, medically eligible National Guard and Reserve servicemembers and their dependents, and retirees and their dependents and survivors. Active duty personnel include Reserve component members on active duty for at least 30 days. [2] Through individual agreements between military treatment facilities and the Department of Veterans Affairs' (VA) medical centers, eligible beneficiaries may also receive certain types of care from VA medical centers in some locations. [3] Prime Service Areas are geographic areas determined by the Assistant Secretary of Defense for Health Affairs that are defined by a set of five-digit zip codes, usually within an approximate 40-mile radius of a military inpatient treatment facility. The managed care support contracts require the contractor to develop civilian provider networks at all Base Realignment and Closure (BRAC) sites, which are military installations that have been closed or realigned as a result of decisions made by the Commission on Base Realignment and Closure. [4] DOD's Defense Enrollment Eligibility Reporting System (DEERS) determines TRICARE eligibility. All TRICARE Standard and TRICARE Extra beneficiaries must be properly registered in DEERS and have valid identification cards that can be used to show TRICARE eligibility. [5] See Pub. L. No. 108-136, § 723, 117 Stat. 1392, 1532-34 (2003), and S. Rep. No. 108-46, at 330 (2003). [6] GAO, Defense Health Care: Access to Care for Beneficiaries Who Have Not Enrolled in TRICARE's Managed Care Option, [hyperlink, http://www.gao.gov/products/GAO-07-48] (Washington, D.C.: Dec. 22, 2006). [7] Department of Defense, Task Force on Mental Health, An Achievable Vision: Report of the Department of Defense Task Force on Mental Health (Falls Church, Va., June 2007). [8] There are seven reserve components: The Army Reserve, Army National Guard, Air Force Reserve, Air National Guard, Navy Reserve, and Marine Corps Reserve, are all part of DOD. The seventh component is the Coast Guard Reserve, which is part of the Department of Homeland Security but works closely with DOD. [9] To qualify for TRICARE Reserve Select, the beneficiary must not be eligible for or enrolled in the Federal Employees Health Benefits Program either under his or her own eligibility or through a family member and must be a member of the Selected Reserve component. See 10 U.S.C. § 1076d. All National Guard and Reserve manpower is assigned to one of three Reserve component categories--the Ready Reserve, the Standby Reserve, and the Retired Reserve. 10 U.S.C. § 10141(a). The Selected Reserve is a component of the Ready Reserve. Once activated to duty, National Guard and Reserve servicemembers are eligible for TRICARE Prime. [10] DOD defines Selected Reserve servicemembers likely to be interested in TRICARE Reserve Select as those who do not have other health insurance. [11] Although eligible National Guard and Reserve servicemembers are required to purchase TRICARE Reserve Select to receive coverage through this plan, we refer to them as nonenrolled beneficiaries because their care options are similar to those of TRICARE Standard and Extra beneficiaries. [12] See Pub. L. No. 110-181, § 711(a), 122 Stat. 3, 190-191. [13] When asking respondents about access problems, the beneficiary survey instrument did not differentiate between network and non- network providers. Therefore, we were unable to determine the extent to which beneficiaries' access problems were linked to network or non- network providers. [14] All beneficiary and HHS's Consumer Assessment of Healthcare Providers and Systems survey estimates are presented with a sampling error at the 95 percent confidence level, and differences in survey estimates are not statistically significant unless otherwise noted. [15] The NDAA 2008 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 access-to-care problems. TMA referred to these locations as Hospital Service Areas, which are collections of zip codes organized into over 3,000 geographic regions in which Medicare beneficiaries seek the majority of their care from one hospital or a collection of hospitals. Hospital Service Areas, as defined by a Dartmouth University study, have nonoverlapping borders and contain all U.S. zip codes without gaps in coverage. [16] TRICARE for Life is a program for Medicare-eligible beneficiaries enrolled in Medicare Part B. TRICARE beneficiaries under 65 years of age who are eligible for Medicare Part A on the basis of disability or end-stage renal disease are eligible for TRICARE for Life if they enroll in Medicare Part B. [17] This number does not include the beneficiaries who purchased TRICARE Reserve Select. TRICARE Reserve Select coverage became available on April 27, 2005, and a very small number of beneficiaries purchased this benefit option in fiscal year 2005. [18] [hyperlink, http://www.gao.gov/products/GAO-07-48]. [19] Does not include beneficiaries who used pharmacy benefits or who received care directly from a military treatment facility. [20] See 10 U.S.C. §§ 1079(h), 1086(f). [21] A network provider may determine that only a set amount of his or her practice--such as 10 or 20 percent--will be allocated to TRICARE patients. [22] TRICARE beneficiaries who choose to receive medical care from providers who are not TRICARE authorized may be responsible for all billed charges. [23] In general, agency surveys must be approved by OMB. See 44 U.S.C. § 3507. However, DOD has authority to conduct surveys of servicemembers and their families to determine the effectiveness of federal programs relating to military families and the need for new programs without seeking approval from OMB. See 10 U.S.C. § 1782; DOD 8910.1-M, Department of Defense Procedures for Management of Information Requirements § C3.7 (June 1998). Accordingly, DOD sought and obtained OMB approval for the 2008 provider survey, but did not do so for the 2008 beneficiary survey. [24] See OMB, Office of Management and Budget Standards and Guidelines for Statistical Surveys (Washington, D.C., September 2006). [25] The list of eligible survey participants from which a sample is selected is also referred to as a sampling frame. [26] OMB's guidelines for ensuring that survey results are representative of the target population include conducting a nonresponse analysis for surveys with a response rate lower than 80 percent. [27] The sampling error is within plus or minus 3.1 percentage points or less at the 95 percent confidence level. [28] Statistical significance is the likelihood that a result is caused by something other than just chance. [29] The sampling error is within plus or minus 3.1 percentage points or less at the 95 percent confidence level. [30] The ratings scale is divided into two categories: 0 to 6 and 7 to 10, where 0 is considered the worst possible and 10 is the best possible. The ratings scale is based on the one used to analyze HHS's Consumer Assessment of Healthcare Providers and Systems survey, a national survey of beneficiaries of commercial health insurance, Medicare, Medicaid, and the Children's Health Insurance Program. [31] For the purpose of this report, we refer to beneficiaries who are not enrolled in TRICARE Prime--that is, those who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select--as nonenrolled beneficiaries. Although eligible National Guard and Reserve servicemembers are required to purchase TRICARE Reserve Select to receive coverage through this plan, we refer to them as nonenrolled beneficiaries because their care options are similar to those of TRICARE Standard and Extra beneficiaries. [32] In general, agency surveys must be approved by OMB. See 44 U.S.C. § 3507. However, DOD has authority to conduct surveys of servicemembers and their families to determine the effectiveness of federal programs relating to military families and the need for new programs without seeking approval from OMB. See 10 U.S.C. § 1782; DOD 8910.1-M, Department of Defense Procedures for Management of Information Requirements § C3.7 (June 1998). Accordingly, DOD sought and obtained OMB approval for the 2008 provider survey, but did not do so for the 2008 beneficiary survey. [33] Qualified members of the Selected Reserve--National Guard and Reserve servicemembers who are considered essential to wartime missions--who are not activated to duty may purchase TRICARE Reserve Select. [34] Although eligible National Guard and Reserve servicemembers are required to purchase TRICARE Reserve Select to receive coverage through this plan, we refer to them as nonenrolled beneficiaries because their care options are similar to those of TRICARE Standard and Extra beneficiaries. [35] Prime Service Areas are geographic areas determined by the Assistant Secretary of Defense for Health Affairs that are defined by a set of five-digit zip codes, usually within an approximate 40-mile radius of a military inpatient treatment facility. The managed care support contracts require the contractor to develop civilian provider networks at all Base Realignment and Closure (BRAC) sites, which are military installations that have been closed or realigned as a result of decisions made by the Commission on Base Realignment and Closure. [36] The Hospital Referral Region designation is derived from a Dartmouth University study that groups Hospital Service Areas into distinct sets by documenting where patients were referred for major cardiovascular surgical procedures and for neurosurgery. Each Hospital Service Area was examined to determine where most of its residents went for these services. The result was the aggregation of the over 3,000 Hospital Service Areas into 306 Hospital Referral Regions. A TMA official noted that TMA endorsed the Hospital Referral Region methodology in part because it is based on the medical observations of Medicare beneficiaries, and TRICARE reimbursement rates are based on Medicare reimbursement rates. In addition, TMA used this methodology in its survey of civilian providers during fiscal years 2005 through 2007. In 2006 we reviewed the methodology TMA used for the 2005 civilian provider survey. [hyperlink, http://www.gao.gov/products/GAO-07-48]. [37] Hospital Service Areas are collections of zip codes organized into over 3,000 geographic regions in which Medicare beneficiaries seek the majority of their care from one hospital or a collection of hospitals. Hospital Service Areas have nonoverlapping borders and contain all U.S. zip codes without gaps in coverage. [38] DEERS is a database that contains the service-related and demographic data that are used to determine eligibility for military benefits, including health care, for all active duty servicemembers, military retirees, and the dependents and survivors of active duty servicemembers and military retirees. As individuals join the military, the various agencies enter information about them into DEERS and update this information as their status changes. The individual servicemember is responsible for providing information to DEERS on dependents and for reporting changes concerning dependents. [39] TMA's sample included non-Medicare enrolled retirees, dependents of active duty personnel, and beneficiaries who purchased TRICARE Reserve Select in fiscal year 2008. [40] TMA desired a sample error of plus or minus 5 percent at the 95 percent confidence level. [41] TMA desired a sample error of plus or minus 5 percent at a 95 percent confidence level. [42] The Paperwork Reduction Act requires that all federal agency activities that involve collecting information from the public involving 10 or more people be approved by OMB to ensure that collection of this information will have a minimum burden on the public. See 44 U.S.C. §§ 3507 and 3508. [43] OMB's guidance suggests that if response rates are below 80 percent, an agency should conduct a nonresponse analysis. Such an analysis is used to verify that nonrespondents to the survey would not answer differently from those who did respond and that the respondents are representative of the target population, thus ensuring that the results can be generalized to the population from which the sample was chosen. Prior to administering the beneficiary and provider surveys, TMA had planned to conduct a nonresponse analysis for each survey because of the likelihood that the surveys' response rates would be less than 80 percent. [44] According to a TMA official, TMA chose a sample size of 400 because it would allow it determine whether nonrespondents answer the survey differently than respondents and whether the respondents are representative of the target population within plus or minus 5 percent at the 95 percent confidence level. [45] According to a TMA official, a sample size of 247 allows it to determine whether nonrespondents answer the survey differently than respondents and whether the respondents are representative of the target population within plus or minus 6.2 percent at the 95 percent confidence level. [46] Qualified members of the Selected Reserve--National Guard and Reserve servicemembers who are considered essential to wartime missions--who are not activated to duty may purchase TRICARE Reserve Select. [47] Although eligible National Guard and Reserve servicemembers are required to purchase TRICARE Reserve Select to receive coverage through this plan, we refer to them as nonenrolled beneficiaries because their care options are similar to those of TRICARE Standard and Extra beneficiaries. [48] Qualified members of the Selected Reserve--National Guard and Reserve servicemembers who are considered essential to wartime missions--who are not activated to duty may purchase TRICARE Reserve Select. [49] Although eligible National Guard and Reserve servicemembers are required to purchase TRICARE Reserve Select to receive coverage through this plan, we refer to them as nonenrolled beneficiaries because their care options are similar to those of TRICARE Standard and Extra beneficiaries. [50] Nonphysician mental health providers are (1) certified marriage and family therapists, (2) mental health counselors, (3) pastoral counselors, (4) certified psychiatric nurse specialists, (5) clinical psychologists, and (6) certified clinical social workers. [51] Qualified members of the Selected Reserve--National Guard and Reserve servicemembers who are considered essential to wartime missions--who are not activated to duty may purchase TRICARE Reserve Select. [52] Although eligible National Guard and Reserve servicemembers are required to purchase TRICARE Reserve Select to receive coverage through this plan, we refer to them as nonenrolled beneficiaries because their care options are similar to those of TRICARE Standard and Extra beneficiaries. [53] Prime Service Areas are geographic areas determined by the Assistant Secretary of Defense for Health Affairs that are defined by a set of five-digit zip codes, usually within an approximate 40-mile radius of a military inpatient treatment facility. The managed care support contracts require the contractor to develop civilian provider networks at all Base Realignment and Closure (BRAC) sites, which are military installations that have been closed or realigned as a result of decisions made by the Commission on Base Realignment and Closure. [54] Hospital Service Areas are collections of zip codes organized into over 3,000 geographic regions in which Medicare beneficiaries seek the majority of their care from one hospital or a collection of hospitals. Hospital Service Areas have nonoverlapping borders and contain all U.S. zip codes without gaps in coverage. [55] DOD plans to include these areas in its 2009 beneficiary survey in addition to any other areas identified. 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