Defense Health Care: DOD Is Meeting Most Mental Health Care Access Standards, but It Needs a Standard for Follow-up Appointments

GAO-16-416 Published: Apr 28, 2016. Publicly Released: Apr 28, 2016.
Jump To:
Skip to Highlights

What GAO Found

The Department of Defense's (DOD) Military Health System (MHS) makes a variety of inpatient and outpatient mental health care available to active duty servicemembers and activated National Guard and Reserve servicemembers (reservists) domestically and overseas through its TRICARE health care system. The type of care includes psychological testing and assessment, psychotherapy, medication management, and inpatient psychiatric care. This care is typically available through military treatment facilities and clinics (direct care), and it is supplemented by care provided through networks of civilian providers (purchased care). In fiscal year 2014, DOD provided 76 percent of 2.9 million outpatient mental health encounters through direct care and 69 percent of 0.2 million inpatient mental health bed days through purchased care. To deliver mental health care, the military services use a range of strategies including telehealth, embedding mental health providers within units, and integrating mental health providers in primary care. While DOD has increased the number of available mental health providers in both direct and purchased care in recent years, DOD data indicate that the military services still face shortages for certain providers, such as psychiatrists. Unlike the care available for active duty servicemembers and activated reservists, MHS mental health care for inactive reservists is generally limited to referrals to non-DOD community resources or, if eligible, the reservists can purchase coverage for health care, including mental health care, through TRICARE Reserve Select, a premium-based health plan for reservists.

DOD data on domestic and overseas direct care from April 2014 through August 2015 show that MHS-wide DOD's access to care standards were generally met for three of four mental health appointment types. However, in the case of routine appointments—initial appointments for a new or exacerbated condition—data show that other than the Air Force, MHS routine mental health appointments generally did not meet the 7-day access standard. DOD and service officials attributed this to several factors, including some appointments being incorrectly coded, thus negatively impacting the routine appointment access results. They told GAO that DOD was taking steps to address the coding problem and improve oversight of mental health access. Additionally, the data show that about 59 percent of mental health appointments are follow-up appointments, which generally do not have an official DOD access standard. Federal internal control standards call for agencies to have sufficient information to monitor agency performance. By not establishing and monitoring a follow-up appointment standard, DOD cannot hold the military services accountable for the majority of mental health care provided in the direct care system. For purchased care, limited access data are available, and DOD instead relies on beneficiary surveys and complaints to monitor access—consistent with methods used by civilian health plans. DOD surveys have identified access problems for some servicemembers. For example, a DOD beneficiary survey estimated that about one-third of active duty servicemembers experienced problems accessing mental health care from 2011 through 2014. Additionally, provider surveys from 2012 and 2013 found that only an estimated 37 percent of civilian mental health providers were accepting any new TRICARE patients. DOD's ongoing efforts to improve oversight of mental health access, including implementing a strategic plan, may help address some of these problems, but it is too early to tell.

Why GAO Did This Study

DOD reports that between 2005 and 2013, the number of individuals who received mental health care through DOD's MHS grew by 32 percent. MHS mental health care is provided free to active duty servicemembers. Reservists and DOD civilians are eligible for MHS care under certain circumstances.

The National Defense Authorization Act for Fiscal Year 2015 contains a provision for GAO to assess the availability and accessibility of mental health care in DOD's MHS for military servicemembers. This report examines, among other things, (1) the mental health care DOD makes available to servicemembers domestically and overseas and (2) the accessibility of mental health care provided to servicemembers domestically and overseas. GAO analyzed recent, available data on MHS mental health utilization, staffing, and appointment access and compared access data to relevant DOD standards. GAO reviewed mental health data from several DOD surveys as well as documents related to MHS mental health care. GAO also interviewed DOD and service officials and representatives from servicemember and provider associations.

Skip to Recommendations


GAO recommends that DOD establish an access standard for mental health follow-up appointments and regularly monitor data on these appointments. DOD concurred with GAO's recommendation.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Defense To enhance oversight of access to mental health care and help ensure that servicemembers have timely access to mental health care, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to establish an access standard for mental health follow-up appointments and regularly monitor data on these appointments.
Closed – Implemented
The Department of Defense (DOD) concurred with this recommendation. In August 2018, DOD provided documentation showing that in January 2018, the Defense Health Agency issued a memorandum establishing a standard for follow-up, or future, mental health appointments. The standard requires that Medical Treatment Facilities (MTFs) ensure at least three future appointments in each clinic are available within 7 days. DOD also reported in August 2018 that MTFs can monitor their own compliance with this standard through the Military Health System Dashboard website, and that DOD monitors MTFs compliance through a report on the TRICARE Operations Center's website. Additionally, DOD noted that assignment for monitoring compliance with this, and other appointment standards, had been assigned to the Director of the Healthcare Operations Directorate via the Tri-Service Patient Centered Care Operations Board to the Medical Operations Group. As such, we are closing this recommendation as implemented.

Full Report

GAO Contacts