Defense Health Care:

2008 Access to Care Surveys Indicate Some Problems, but Beneficiary Satisfaction Is Similar to Other Health Plans

GAO-10-402: Published: Mar 31, 2010. Publicly Released: Mar 31, 2010.

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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 nonnetwork 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.

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 nonnetwork 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.