Defense Health Care: More-Specific Guidance Needed for Assessing Nonenrolled TRICARE Beneficiaries' Access to Care

What GAO Found

The Department of Defense (DOD) has devoted significant resources over the past decade—largely through national surveys of beneficiaries and civilian providers—in determining whether nonenrolled beneficiaries (those not enrolled in TRICARE Prime) have adequate access to health care. However, the lack of access standards for this population has significantly limited the department's ability to make these determinations. In 2010, the Deputy Chief of TRICARE Policy and Operations issued an action memo that outlined a series of recommendations for how the TRICARE Regional Offices (TRO) should gauge nonenrolled beneficiaries' access to care. Two of the memo's recommendations—analyzing the results of DOD's national surveys and using beneficiary-to-provider population models—provide a strategy for monitoring and assessing nonenrolled beneficiaries' access to care. However, GAO found that these recommendations do not include sufficient guidance that specifies what process to follow in determining whether nonenrolled beneficiaries' access to care is adequate. According to federal internal control standards, having a monitoring strategy that includes specific guidance is important for leadership to ensure that ongoing monitoring is effective and will trigger separate evaluations when problems are identified.

In the absence of more-specific guidance, GAO found that the TROs' efforts to implement the action memo's recommendations have resulted in limited and inconsistent methods for identifying and addressing areas with potential access problems, which in some instances have included the use of judgment in place of clear criteria for making these determinations. For example:

One recommendation advises the TROs to report on the results of the access questions from the nonenrolled beneficiary survey for their region, and to include any subsequent action plans to address the potential access problems they identify. GAO found that the TROs varied in the extent to which they used the survey data to identify potential problem areas, and none of them had a clearly documented methodology for how they used these data, including a rationale for when further actions should be taken.

Another recommendation advises the TROs to establish a working group to adapt and standardize a beneficiary population-to-provider model to determine whether there are sufficient numbers of civilian providers to provide reasonable access to care. However, GAO found that only one of the TROs applied criteria to its population-to-provider ratios, and while this TRO identified areas with potential access problems, officials told GAO that they ultimately used their judgment to determine that no access problems existed because they had not received beneficiary complaints from these areas.

Without more-specific guidance, DOD does not have reasonable assurance that the TROs' efforts to assess access to care for nonenrolled beneficiaries are effective or that its own efforts to field and analyze large, costly, national surveys are providing useful data.

Why GAO Did This Study

DOD provides health care through TRICARE, its regionally structured health care program. In each of its regions (North, South, West), DOD has a TRO that oversees health care delivery. Beneficiaries who choose the TRICARE Prime option must enroll. Beneficiaries who do not enroll may obtain care under the TRICARE Standard, Extra, or Reserve Select options—referred to as nonenrolled beneficiaries. Since TRICARE's inception in 1995, nonenrolled beneficiaries have complained about difficulties finding civilian providers who will accept them as patients.

The National Defense Authorization Act for Fiscal Year 2008 mandated that GAO evaluate the processes, procedures, and analyses used by DOD to determine the adequacy of access to care for these beneficiaries. This report addresses the extent to which the TROs have assessed nonenrolled beneficiaries' access to care. To conduct this work, GAO reviewed and analyzed relevant documentation and interviewed DOD officials, including officials in each of the TROs. In addition, GAO reviewed federal internal control standards for monitoring performance. GAO also interviewed officials from organizations representing military beneficiaries to discuss their perspectives on the TROs' efforts.