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United States Government Accountability Office: 
GAO: 

Report to the Subcommittee on Defense, Committee on Appropriations, 
U.S. Senate: 

January 2015: 

Defense Health Care: 

Additional Information Needed about Mental Health Provider Staffing 
Needs: 

GAO-15-184: 

GAO Highlights: 

Highlights of GAO-15-184, a report to the Subcommittee on Defense, 
Committee on Appropriations, U.S. Senate. 

Why GAO Did This Study: 

Mental health providers are essential to DOD’s delivery of health care 
to servicemembers and other beneficiaries. DOD’s need for these 
providers has grown as increasing numbers of servicemembers experience 
life-threatening combat situations. This led to congressional 
attention—-such as the NDAA for Fiscal Year 2010, which included 
provisions to help DOD increase the number of mental health providers 
it employs.

GAO was asked to review DOD’s efforts to increase its mental health
provider workforce. Among other objectives, GAO examined (1) how
staffing levels changed in response to congressional direction and (2) 
how DOD and the military services assess current and future needs for 
mental health providers. GAO reviewed DOD’s mental health staffing 
estimation model and the military services’ quarterly mental health 
provider staffing reports for fiscal years 2009 through 2013, the
latest information available. GAO also interviewed DOD and military 
service officials responsible for assessing mental health staffing 
needs.

What GAO Found: 

In response to the enactment of the National Defense Authorization Act 
(NDAA) for Fiscal Year 2010, the Department of Defense (DOD) military 
health system (MHS) increased its mental health provider staffing 
level by 34 percent. Specifically, DOD increased the number of mental 
health providers across the MHS from 4,608 providers in fiscal year 
2009 to 6,186 providers in fiscal year 2013. Social workers and 
psychologists were the most frequently added types of mental health 
providers during this period. 

Figure: Total Department of Defense (DOD) Mental Health Providers by 
Provider Type, September 2009 Compared to September 2013: 

[Refer to PDF for image: horizontal bar graph] 

Number of providers by type: 

Type: Other licensed provider; 
FY 2013: 80; 
FY 2009: 97. 

Type: Social worker; 
FY 2013: 2,494; 
FY 2009: 1,789. 

Type: Mental health nurse; 
FY 2013: 725; 
FY 2009: 570. 

Type: Psychologist; 
FY 2013: 2,079; 
FY 2009: 1,520. 

Type: Psychiatrist; 
FY 2013: 808; 
FY 2009: 652. 

Source: GAO analysis of DOD data. GAO-15-184. 

[End of figure] 

In 2007, DOD created the Psychological Health Risk-Adjusted Model for 
Staffing (PHRAMS) to assess the MHS's current and future mental health 
provider staffing needs and DOD annually revises this model. Fiscal 
year 2014 marked the first time the model was used by the three 
military services responsible for providing health care—-the Army, Air 
Force, and Navy-—for a common purpose, which was the development of 
DOD's fiscal year 2016 budget request for mental health services. 
However, GAO found that the military services either were not using 
PHRAMS as the main basis of their mental health provider staffing needs 
estimates or were supplementing PHRAMS results with other service-
specific methods. The services reported making these adjustments 
because PHRAMS does not account for factors that are crucial to assess 
mental health provider staffing needs, such as mental health providers 
needed for deployments. As a result, the military services' estimates 
of mental health provider staffing needs may not consistently reflect 
the beneficiary demand for mental health providers across the military 
services, and the current version of PHRAMS may not fully capture the 
military services' needs. 

What GAO Recommends: 

GAO recommends that the military services report on service-specific 
or supplemental processes for generating mental health provider 
staffing estimates and that DOD continue to refine its staffing 
estimation model. DOD generally concurred with these recommendations, 
but did not concur with two others related to the use of PHRAMS that 
are also included in the report. GAO continues to believe these 
recommendations are valid as discussed further in the report.

View GAO-15-184. For more information, contact Randall B. Williamson 
at (202) 512-7114 or williamsonr@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

DOD and the Military Services Have Increased the Number of Mental 
Health Providers to About 6,100--an Increase of Over a Third between 
Fiscal Years 2009 and 2013: 

DOD Created a Model for Developing Mental Health Provider Staffing 
Needs, but the Military Services Do Not Use It Consistently: 

Military Services Report Mental Health Provider Staffing Levels on 
Quarterly Reports Submitted to DHA, But Do Not Report Reliable 
Information on Future Needs: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Fiscal Year 2013 Department of Defense Mental Health 
Provider Staffing: 

Appendix II: Recruitment and Retention of Department of Defense Mental 
Health Providers: 

Appendix III: Mental Health Provider Staffing Increases by Military 
Service: 

Appendix IV: Comments from the Department of Defense: 

Appendix V: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Total Number of Army Mental Health Providers as of September 
2013: 

Table 2: Total Number of Air Force Mental Health Providers as of 
September 2013: 

Table 3: Total Number of Navy Mental Health Providers as of September 
2013: 

Table 4: Total Number of National Capital Region (NCR) Medical 
Directorate Mental Health Providers as of September 2013: 

Table 5: Total Number of Army Mental Health Providers, Fiscal Year 
2009 Compared to Fiscal Year 2013: 

Table 6: Total Number of Air Force Mental Health Providers, Fiscal 
Year 2009 Compared to Fiscal Year 2013: 

Table 7: Total Number of Navy Mental Health Providers, Fiscal Year 
2009 Compared to Fiscal Year 2013: 

Figures: 

Figure 1: Governance Structure of the Department of Defense (DOD) 
Military Health System (MHS): 

Figure 2: Total Department of Defense (DOD) Mental Health Providers by 
Provider Type, September 2009 Compared to September 2013: 

Figure 3: Total Department of Defense (DOD) Mental Health Providers by 
Employment Category, September 2009 Compared to September 2013: 

Figure 4: Total Department of Defense (DOD) Mental Health Providers by 
Military Service and the National Capital Region (NCR) Medical 
Directorate, September 2009 Compared to September 2013: 

Figure 5: Risk Factors Included in the Department of Defense (DOD) 
Psychological Health Risk-Adjusted Model for Staffing (PHRAMS): 

Figure 6: Department of Defense (DOD) Psychological Health Risk-
Adjusted Model for Staffing (PHRAMS) Military Treatment Facility (MTF)-
Based Mental Health Provider Needs Calculation: 

Figure 7: Total Department of Defense (DOD) Mental Health Providers by 
Provider Type, September 2013: 

Figure 8: Total Department of Defense (DOD) Mental Health Providers by 
Employment Category, September 2013: 

Figure 9: Total Department of Defense (DOD) Mental Health Providers by 
Military Service and the National Capital Region (NCR) Medical 
Directorate, September 2013: 

Abbreviations: 

DHA: Defense Health Agency: 

DOD: Department of Defense: 

HPSP: Health Professions Scholarship and Financial Assistance Program: 

MHS: military health system: 

MTF: military treatment facility: 

NCR: National Capital Region: 

NDAA: National Defense Authorization Act: 

OASD HA: Office of the Assistant Secretary of Defense for Health 
Affairs: 

PHRAMS: Psychological Health Risk-Adjusted Model for Staffing: 

USUHS: Uniformed Services University of the Health Sciences: 

[End of section] 

United States Government Accountability Office: 
GAO:
441 G St. N.W. 
Washington, DC 20548: 

January 30, 2015: 

The Honorable Thad Cochran: 
Chairman: 
The Honorable Richard J. Durbin: 
Vice Chairman: 
Subcommittee on Defense: 
Committee on Appropriations United States Senate: 

Mental health providers are essential to maintaining the Department of 
Defense's (DOD) capability to deliver health care services.[Footnote 
1] As part of its mission, DOD provides a full range of medical care 
and services, including mental health services, at no cost to active 
duty military servicemembers and at either a reduced cost or no cost 
to other eligible beneficiaries-including dependents of servicemembers 
and some military retirees.[Footnote 2] DOD's ability to deliver this 
care has been impacted by increasing numbers of servicemembers who 
experienced life-threatening situations in combat and their resulting 
need for mental health services.[Footnote 3] Specifically, DOD faces 
significant challenges building and maintaining a mental health 
provider workforce-including active duty and reserve military 
providers and civilian and contract providers working in military 
medical facilities-that is capable of providing all the mental health 
care servicemembers and their dependents need due to nationwide 
shortages of mental health providers.[Footnote 4] These challenges are 
exacerbated by the pressure to control DOD healthcare costs and the 
need to compete for mental health providers with other health care 
delivery systems throughout the nation which also face increased needs 
for these providers.[Footnote 5] 

The increased need for mental health care for servicemembers and their 
dependents has led to congressional attention on the recruitment and 
retention of qualified mental health providers to work in DOD's 
military health system (MHS). Specifically, the National Defense 
Authorization Act (NDAA) for Fiscal Year 2010 included provisions for 
DOD to increase its mental health capabilities by increasing the 
number of active duty mental health providers and to report on the 
appropriate number of mental health providers required to meet the 
mental health care needs of servicemembers, retirees, and dependents. 
[Footnote 6] 

You asked us to review DOD's efforts to increase its qualified mental 
health provider workforce. In this report we examine (1) the staffing 
levels of DOD military, civilian, and contracted mental health 
providers and how these staffing levels have changed in response to 
the NDAA for Fiscal Year 2010; (2) how DOD and the military services 
assess current and future needs for mental health providers; and (3) 
how the military services report mental health provider staffing 
levels and future needs to DOD. 

To examine the staffing levels of DOD military, civilian, and contract 
mental health providers and how these staffing levels changed in 
response to the NDAA for Fiscal Year 2010, we analyzed quarterly 
mental health staffing reports for fiscal years 2009 through 2013 
submitted to DOD from each military service and the National Capital 
Region (NCR) Medical Directorate.[Footnote 7] We analyzed these 
reports separately and together to report current mental health 
provider staffing levels and compare mental health provider staffing 
levels from fiscal year 2009, prior to the enactment of the NDAA for 
Fiscal Year 2010, with such levels from fiscal year 2013. Fiscal year 
2013 was the most recent fiscal year with complete data available for 
analysis. To ensure the reliability of these data, we interviewed 
Office of the Assistant Secretary of Defense for Health Affairs (OASD 
HA) officials responsible for collecting and analyzing these quarterly 
staffing reports and reviewed documentation related to the production 
of these reports. Based on these actions, we found information 
contained in these quarterly staffing reports to be sufficiently 
reliable for the purposes of this report. 

To examine how DOD and the military services assess current and future 
needs for mental health providers, we interviewed officials from OASD 
HA, Army, Air Force, Navy,[Footnote 8] the DOD Task Force on Mental 
Health, and the Interagency Task Force on Military and Veterans Mental 
Health to learn about actions taken to assess mental health provider 
staffing levels.[Footnote 9] We also reviewed the Psychological Health 
Risk-Adjusted Model for Staffing (PHRAMS), DOD's mental health 
staffing model used to project the number and mix of health care 
providers needed to meet the day-to-day mental health care needs of 
the DOD health care system--including procedure guides and year-end 
reports. 

To examine how the military services report mental health provider 
staffing levels and future needs to DOD, we interviewed officials from 
OASD HA, Army, Air Force, Navy, and the NCR Medical Directorate to 
learn about their use of quarterly mental health staffing reports. We 
also reviewed the quarterly mental health staffing reports submitted 
by the military services and the NCR Medical Directorate for fiscal 
years 2009 through 2013. 

We conducted this performance audit from May 2014 to January 2015 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: 

The MHS operated by DOD has two missions: (1) supporting wartime and 
other deployments and (2) providing peacetime health care.[Footnote 
10] In support of these two missions, DOD operates a large and complex 
health care system that employs more than 150,000 military, civilian, 
and contract personnel working in military medical facilities, 
commonly referred to as military treatment facilities (MTF). 

In terms of the MHS organization and structure, OASD HA serves as the 
principal advisor for all DOD health policies and programs. OASD HA 
has the authority to issue DOD instructions, publications, and 
memorandums that implement policy approved by the Secretary of Defense 
or the Under Secretary of Defense for Personnel and Readiness and 
govern the management of DOD medical programs. In October 2013, the 
Defense Health Agency (DHA) was established to support greater 
integration of clinical and business processes across the MHS. The DHA 
manages the execution of policies issued by OASD HA, oversees the 
TRICARE health plan, and also exercises authority and control over the 
MTFs and subordinate clinics assigned to the NCR Medical Directorate. 
[Footnote 11] 

MTFs and their subordinate clinics are operated by either a military 
service or the NCR Medical Directorate. Neither OASD HA nor DHA have 
direct command and control of MTFs operated solely by the military 
services.[Footnote 12] Each military service recruits, trains, and 
funds its own medical personnel to administer medical programs and 
provide medical services to beneficiaries. The NCR Medical Directorate 
has direct authority over civilian providers and personnel working 
within its facilities; however, the military services maintain 
authority over all military providers and personnel working within NCR 
Medical Directorate MTFs. See figure 1 for the current organizational 
and governance structure of the MHS. 

Figure 1: Governance Structure of the Department of Defense (DOD) 
Military Health System (MHS): 

[Refer to PDF for image: organizational chart] 

Top level: 
Secretary of Defense: 

Second level: 

Secretary of the Navy: 
* Navy Surgeon General: 
- Navy Bureau of Medicine and Surgery; 
-- Navy military facilities (MTF). 

Secretary of Army: 
* Army Surgeon General: 
- Army Medical Command; 
-- Army MTFs. 

Secretary of the Air Force: 
* Air Force Surgeon General[A]; 
* Air Force Major Commands: 
- Air Force MTFs. 

Undersecretary of Defense for Personnel and Readiness: 
* Assistant Secretary of Defense for Health Affairs[B]: 
- Defense Health Agency (DHA)[C]; 
-- National Capital Region (NCR) Medical Directorate[D]; NCR Medical 
Directorate MTFs. 

Source: GAO. GAO-15-184. 

[A] The Air Force Surgeon General does not have direct authority over 
Air Force MTFs; however, the Air Force Surgeon General exercises 
similar authority to that of the other Surgeons General through his 
role as medical advisor to the Air Force Chief of Staff. 

[B] The Assistant Secretary of Defense for Health Affairs is the 
principal advisor for all DOD health policies and programs. The Office 
of the Assistant Secretary of Defense for Health Affairs (OASD HA) 
also has the authority to issue DOD instructions, publications, and 
memorandums that implement policy approved by the Secretary of Defense 
or the Under Secretary of Defense for Personnel and Readiness. 

[C] DHA was established to support greater integration of clinical and 
business processes across the MHS. DHA manages the execution of 
policies issued by OASD HA, oversees the TRICARE health plan, and also 
exercises authority and control over the MTFs and subordinate clinics 
assigned to the NCR Medical Directorate. 

[D] The NCR Medical Directorate was initially established as a DOD 
joint task force in September 2007 to operate DOD's medical facilities 
in the national capital region--including Walter Reed National 
Military Medical Center, Fort Belvoir Community Hospital, and their 
supporting clinics. The NCR Medical Directorate reassigned civilian 
personnel from the military services to the NCR Medical Directorate, 
while retaining military health care providers within the appropriate 
military service's command and control. 

[End of figure] 

DOD and the Military Services Have Increased the Number of Mental 
Health Providers to About 6,100--an Increase of Over a Third between 
Fiscal Years 2009 and 2013: 

The MHS has increased its overall mental health provider staffing 
level by 34 percent between fiscal years 2009 and 2013. Specifically, 
DOD increased the number of providers across the MHS from 4,608 
providers in fiscal year 2009 to 6,186 providers in fiscal year 2013. 
[Footnote 13] (See appendix I for more information on fiscal year 2013 
mental health provider staffing.) This increase was in response to a 
requirement in the NDAA for Fiscal Year 2010 that DOD increase its 
mental health capabilities.[Footnote 14] (See appendix II for more 
information on the recruitment and retention of DOD mental health 
providers.) 

The type of mental health providers added to the MHS from fiscal year 
2009 to fiscal year 2013 varied. (See figure 2.) Specifically, social 
workers and psychologists were the most frequently added types of 
mental health providers during this period, while psychiatrists and 
mental health nurses were the least frequently added. The Army drove 
the overall increase in social workers and psychologists by adding 496 
of the 705 social workers and 421 of the 559 psychologists to the MHS 
during this period. The Air Force added more social workers (64) than 
any other type of provider during this period, while the Navy added 
more psychologists (32) and other licensed providers (32). (See 
appendix III for additional information on the breakdown of mental 
health provider staffing level changes for each military service from 
fiscal year 2009 to fiscal year 2013.) 

Figure 2: Total Department of Defense (DOD) Mental Health Providers by 
Provider Type, September 2009 Compared to September 2013: 

[Refer to PDF for image: horizontal bar graph] 

Number of providers by type: 

Type: Other licensed provider; 
FY 2013: 80; 
FY 2009: 97. 

Type: Social worker; 
FY 2013: 2,494; 
FY 2009: 1,789. 

Type: Mental health nurse[A]; 
FY 2013: 725; 
FY 2009: 570. 

Type: Psychologist; 
FY 2013: 2,079; 
FY 2009: 1,520. 

Type: Psychiatrist; 
FY 2013: 808; 
FY 2009: 652. 

Source: GAO analysis of DOD data. GAO-15-184. 

Notes: The total number of DOD mental health providers in fiscal year 
2013 was 6,186. The total number of DOD mental health providers in 
fiscal year 2009 was 4,608. Mental health provider totals in this 
figure have been rounded to the nearest full-time equivalent. 

[A] The mental health nurse category includes both mental health nurse 
practitioners and mental health registered nurses. In fiscal year 
2009, DOD did not report separate employment information on these two 
types of mental health providers. 

[End of figure] 

During this time frame, the composition of DOD mental health provider 
staff by employment category also changed. Across the MHS, the number 
of civilian mental health providers increased by 52 percent (1,129) 
and military mental health providers increased by 33 percent (479), 
while the number of contract mental health providers decreased by 3 
percent (30). (See figure 3.) The services' individual changes varied, 
with the Army driving this systemic shift to civilian providers. 
Specifically, the Army added 863 new civilian mental health providers 
(a 50 percent increase), while decreasing the number of contract 
mental health providers by 153 (a 33 percent decrease). The Air Force 
also increased its civilian mental health provider staffing 
by 5 providers (a 2 percent increase) and increased its contract 
mental health provider staffing by 72 providers (a 39 percent 
increase). The Navy increased its number of military mental health 
providers by 113 (a 38 percent increase), added 12 civilian mental 
health providers (a 5 percent increase), and decreased contract mental 
health providers by 37 (an 11 percent decrease). 

Figure 3: Total Department of Defense (DOD) Mental Health Providers by 
Employment Category, September 2009 Compared to September 2013: 

Figure 3: Total Department of Defense (DOD) Mental Health Providers by 
Employment Category, September 2009 Compared to September 2013: 

[Refer to PDF for image: horizontal bar graph] 

Number of providers by employment category: 

Category: Contract; 
FY 2013: 950; 
FY 2009: 980. 

Category: Civilian; 
FY 2013: 3,315; 
FY 2009: 2,186. 

Category: Military; 
FY 2013: 1,921; 
FY 2009: 1,462. 

Source: GAO analysis of DOD data. GAO-15-184. 

Notes: The total number of DOD mental health providers for fiscal year 
2013 was 6,186. The total number of DOD mental health providers for 
fiscal year 2009 was 4,608. Mental health provider totals in this 
figure have been rounded to the nearest full-time equivalent. 

[End of figure] 

While all three military services increased their mental health 
provider staffing from fiscal year 2009 to fiscal year 2013, the 
Army's addition of 1,010 mental health providers represented the 
largest portion of the DOD-wide increase. The Navy's increase of 88 
mental health providers was the smallest portion of the DOD-wide 
increase. (See figure 4.) 

Figure 4: Total Department of Defense (DOD) Mental Health Providers by 
Military Service and the National Capital Region (NCR) Medical 
Directorate, September 2009 Compared to September 2013: 

[Refer to PDF for image: horizontal bar graph] 

Number of providers by military service: 

Military service: NCR Medical Directorate[A]; 
FY 2013: 338; 
FY 2009: 0. 

Military service: Navy; 
FY 2013: 971; 
FY 2009: 883. 

Military service: Air Force; 
FY 2013: 1,147; 
FY 2009: 1,003. 

Military service: Army; 
FY 2013: 3,731; 
FY 2009: 2,721. 

Source: GAO analysis of DOD data. GAO-15-184. 

Notes: The total number of DOD mental health providers in fiscal year 
2013 was 6,186. The total number of DOD mental health providers in 
fiscal year 2009 was 4,608. Mental health provider totals in this 
figure have been rounded to the nearest full-time equivalent. 

[A] In fiscal year 2009, all civilian and contract mental health 
providers assigned to the military treatment facilities (MTF) and 
subordinate clinics that are now within the NCR Medical Directorate 
were included in the military service totals, because at that time all 
MTFs within the NCR Medical Directorate were managed by multiple 
military services. In fiscal year 2013, the NCR Medical Directorate 
reported its own civilian and contract mental health provider totals 
while retaining military mental health providers within the 
appropriate military services' figures. 

[End of figure] 

DOD Created a Model for Developing Mental Health Provider Staffing 
Needs, but the Military Services Do Not Use It Consistently: 

DOD created the Psychological Health Risk-Adjusted Model for Staffing 
(PHRAMS) to show current and estimate future mental health provider 
staffing needs of the MHS. In fiscal year 2014, PHRAMS was used for a 
common purpose by the military services for the first time--the 
development of the fiscal year 2016 DOD budget request for mental 
health programs.[Footnote 15] However, the military services are 
either not using PHRAMS as the primary basis of their estimates of 
mental health provider staffing needs or supplementing their PHRAMS 
results with service-specific staffing methods. This limits DOD's 
ability to consistently assess mental health provider staffing needs 
throughout the MHS. 

DOD Created PHRAMS to Estimate Its Current and Future Mental Health 
Provider Staffing Needs: 

PHRAMS projects the number and mix of providers needed to meet the 
mental health care needs of the MHS. In fiscal year 2007, DOD 
contracted with a non-profit research and analysis organization to 
develop PHRAMS in response to recommendations from the DOD Task Force 
on Mental Health.[Footnote 16] These recommendations included that: 
(1) Congress fund and DOD allocate sufficient staff to provide a full 
continuum of mental health services to servicemembers and their 
dependents and (2) DOD adopt a risk-adjusted population-based model to 
calculate mental health staffing needs. As of September 2014, the 
contract to develop and maintain PHRAMS had cost DOD $2 million, 
according to DOD officials. 

PHRAMS is designed to be a common DOD-wide model that can be used by 
the military services to assess current mental health provider 
staffing needs and forecast these staffing needs over a 5-year 
timeframe.[Footnote 17] DOD intended PHRAMS to allow the Department to 
fulfill two goals: (1) assess whether or not there are enough mental 
health providers within the MHS to meet the increased mental health 
needs of servicemembers and their dependents that resulted from their 
experiences in recent conflicts, and (2) allow the Department to 
report the mental health provider staffing needs of the MHS to 
Congress. DHA and the PHRAMS contractor engage in an annual model 
review process to incorporate changes requested by the military 
services into the next version of the model. According to DHA 
officials, PHRAMS was used for a common purpose for the first time in 
fiscal year 2014--the development of the DOD fiscal year 2016 budget 
request for mental health programs. 

To assess current mental health provider staffing needs and determine 
5-year forecasts of these needs, PHRAMS places MHS beneficiaries--
including servicemembers, dependents, and other beneficiaries--into 
40,500 individual risk groups based on unique combinations of eight 
risk factors.[Footnote 18] (See figure 5.) 

Figure 5: Risk Factors Included in the Department of Defense (DOD) 
Psychological Health Risk-Adjusted Model for Staffing (PHRAMS): 

[Refer to PDF for image: illustration] 

Risk Groups (40,500 groups): 

Component (3 options): 
* Active duty; 
* Guard/reserve-active; 
* Guard/reserve-inactive. 

Service (5 options): 
Army; 
Air Force; 
Navy; 
Marine Corps; 
Unknown[D]. 

Deployment experience[B] (6 options): 
* Never deployed; 
* Moderate-not recent; 
* Moderate-recent; 
* High-not recent; 
* High-recent; 
* Currently deployed. 

Rank group[C] (5 options): 
* Junior enlisted; 
* Senior enlisted; 
* Junior officer; 
* Senior officer; 
* Unknown[D]. 

Beneficiary category (3 options): 
* Servicemember; 
* Family member[E]; 
* All others. 

Gender (2 options): 
* Female; 
* Male. 

Enrollment in military health care (3 options): 
* Enrolled to a military treatment facility; 
* Enrolled to a TRICARE network provider[F]; 
* Not enrolled. 

Age: 
* Under 18; 
* 18-24	
* 25-44
* 45-64
* 65 and over 

Source: GAO analysis of DOD documents. GAO-15-184. 

Notes: This figure includes all risk factors included in version 5 of 
PHRAMS. 

[A] Deployment experience is a combination of how recently 
servicemembers have been deployed and the degree of their deployments. 
PHRAMS considers servicemembers to be recently deployed if they 
deployed within the past year. The degree of deployment is a 
combination of the number of deployments and the cumulative number of 
months a servicemember has been deployed between September 2001 and 
the end of fiscal year 2012. Servicemembers will have high degrees of 
deployment if one of two conditions occur: (1) they have been 
cumulatively deployed for 12 months or more or (2) they have been 
cumulatively deployed for 6 to 12 months with fewer than 3 
deployments. Servicemembers have moderate degrees of deployment if 
they have ever deployed and do not meet the criteria for a high degree 
of deployment. 

[B] Rank groups are divided into junior and senior categories. For 
enlisted servicemembers, the first four ranks in each military service 
are considered junior and the next five ranks are considered senior. 
For officers, the first three ranks in each military service are 
considered junior and the next seven ranks are considered senior. 
Warrant Officers are categorized as senior enlisted. 

[C] A small percentage of the beneficiary population has missing 
information for one or more risk factor data elements. PHRAMS assigns 
these individuals to an "unknown" group. 

[D] Risk factor values for component, service, deployment experience, 
and rank group for family members are populated using the sponsoring 
servicemember's information. 

[E] In addition to operating its own health care facilities, DOD also 
provides health care to servicemembers, dependents, and military 
retirees through its TRICARE purchased care network. TRICARE 
supplements the health care resources of DOD with networks of civilian 
health care providers. 

[End of figure] 

To determine MTF-based mental health provider staffing needs,[Footnote 
19] PHRAMS calculates three key aspects of mental health services in 
the MHS--(1) the beneficiary demand for mental health services; (2) 
the number of appointments needed to treat these conditions, referred 
to as encounters; and (3) the availability of MHS mental health 
providers to supply these encounters. (See figure 6.) 

* Beneficiary demand for mental health services. PHRAMS uses 
historical data to determine the prevalence of certain mental health 
diagnoses within each of the 40,500 risk groups included in the model. 
[Footnote 20] These prevalence rates are then combined with 
projections of the number of beneficiaries in each risk group to 
estimate the demand for mental health services each risk group will 
place on the MHS.[Footnote 21] 

* Number of appointments (encounter rate). PHRAMS calculates the 
number of appointments that will be needed to treat diagnosed 
beneficiaries within each risk group. To do this, the model applies 
predetermined encounter rates that specify how many times a 
beneficiary with each mental health diagnosis included in the model 
will interact with an MTF provider.[Footnote 22] 

* Availability of MHS mental health providers. PHRAMS then determines 
the number of encounters each MTF-based mental health provider can 
supply each year by multiplying the number of encounters that can be 
completed each hour (encounter time) by the total number of annual 
hours each mental health provider can spend supplying mental health 
services to beneficiaries (provider time).[Footnote 23] 

Figure 6: Department of Defense (DOD) Psychological Health Risk-
Adjusted Model for Staffing (PHRAMS) Military Treatment Facility (MTF)-
Based Mental Health Provider Needs Calculation: 

[Refer to PDF for image: illustration] 

Prevalence, times Risk group, times Encounter rate, divided by 
[Encounter time times Provider time] equals Number of MTF providers 
needed to meet future need? 

Prevalence (Rate of mental health diagnoses in risk group): How many 
people in each risk group are likely to receive a mental health 
diagnosis? 

Risk group (Projected number of beneficiaries): How many people are 
expected to be in each risk group in the future. 

Encounter rate[A] (Number of MTF-based encounters per mental health 
diagnosis): How many times will someone with a mental health diagnosis 
interact with am MTF provider? 

Encounter time (Encounters per hours): How much time does each 
interaction with a provider take? 

Provider time[B] (Number of hours each provider can devote to 
encounters): How much time does each provider have available to 
interact with patients? 

Source: GAO analysis of DOD documents. GAO-15-184. 

Notes: This figure includes information from version 5 of PHRAMS. 
PHRAMS is also used to estimate the number of TRICARE providers that 
will be needed to provide mental health services to beneficiaries 
enrolled in the TRICARE network. 

[A] To establish the encounter rates used in PHRAMS, the PHRAMS 
contractor created a composite encounter rate for each mental health 
condition included in the model based on five inputs: (1) 
recommendations from a Navy work group, (2) recommendations from an 
Air Force work group, (3) information gathered from reviews of 
clinical literature, (4) information gathered from reviews of clinical 
practice guidelines, and (5) other interviews. Encounter rates are 
also adjusted based on historical data. PHRAMS assigns all predicted 
encounters to either MTFs or the TRICARE network. Within the model, 
military service users can modify the percentage of encounters that 
are assigned to MTFs and the TRICARE network. 

[B] Military and civilian mental health providers have different 
amounts of hours they can devote to encounters each year. For example, 
the default value in PHRAMS version 5 for military mental health 
providers' clinical encounter time was set at 1,190 hours per year, 
while the default value for civilian mental health providers' clinical 
encounter time was set at 1,399. This difference accounts for the 
hours military mental health providers spend each year performing 
military-specific duties not related to beneficiary care and 
differences in assumed productivity for military and civilian mental 
health care providers. 

[End of figure] 

Military Services Mental Health Provider Estimates Are Not Based 
Mainly on PHRAMS: 

Despite all military services agreeing to use PHRAMS to generate their 
estimates of mental health provider staffing needs for the fiscal year 
2016 budget request, the military services either did not use PHRAMS 
as the main basis for their mental health provider staffing estimates 
or supplemented PHRAMS results using other service-specific methods 
prior to submitting their fiscal year 2016 budget requests.[Footnote 
24] Standards for internal control in the federal government state 
that agencies' control activities should ensure that management's 
directives are carried out.[Footnote 25] The military services reported 
making these adjustments because PHRAMS does not account for several 
factors that are crucial to their assessment of mental health provider 
staffing needs, specifically the following: 

* Army. Army officials reported that they did not use PHRAMS as the 
basis for their fiscal year 2016 budget request and instead determined 
their mental health provider staffing needs through their legacy 
staffing model and adjusted PHRAMS to ensure it produced similar 
results. Unlike PHRAMS, which bases its mental health provider 
staffing estimates on beneficiary demand for services, the Army legacy 
staffing model uses historical workload data to estimate future 
staffing needs in multiple specialties, including mental health. 
[Footnote 26] The Army legacy staffing model uses projected 
beneficiary population changes to adjust the historical workload for 
Army MTFs up or down as needed. According to the Army official 
responsible for generating manpower estimates for Army MTFs, PHRAMS 
does not currently meet the needs of the Army. This is because PHRAMS' 
assumption that all military services experience the same encounter 
rates for mental health conditions included in the model is an 
overgeneralization of mental health service demands. This official 
believes that this is particularly problematic for the Army because 
deployments are more traumatic for Army servicemembers and may result 
in some servicemembers requiring more than the average number of 
encounters. As a result, the Army only ran PHRAMS after the military 
service had already determined its mental health provider staffing 
needs through its legacy staffing model. 

* Air Force. According to Air Force officials, while the Air Force 
uses some aspects of PHRAMS, it did not rely exclusively on PHRAMS to 
generate their estimates of mental health staffing needs included in 
the fiscal year 2016 budget request. These officials explained that 
PHRAMS was the first step in a three-step process used to generate the 
Air Force's fiscal year 2016 budget request for mental health provider 
staffing. First, Air Force manpower staff ran PHRAMS and provided the 
PHRAMS-generated mental health provider staffing estimates to Air 
Force's mental health consultants for consideration.[Footnote 27] 
Second, the Air Force mental health consultants developed multiple 
staffing level proposals by combining the PHRAMS output with their own 
expertise and information received during conversations with Air Force 
MTF officials. Finally, the Chief of Clinical Operations for the Air 
Force Medical Support Agency selected the best staffing proposal among 
those submitted for review by the Air Force mental health consultants. 
Air Force officials reported that this process was applied because 
PHRAMS relies on data that is several years old and does not take into 
account all aspects of Air Force mental health provider staffing, such 
as mental health providers embedded in operational units. Air Force 
officials also explained that they plan to continue using this process 
in the future to generate mental health provider staffing estimates. 

* Navy. Navy officials reported that they used PHRAMS, but 
supplemented PHRAMS estimates of mental health provider staffing needs 
with additional information. According to Navy officials, this was 
necessary because PHRAMS does not include estimates of mental health 
provider staffing needs on Navy vessels and for deployed Marine Corps 
units. As a result, Navy officials adjusted their PHRAMS output to 
account for these additional needs for mental health providers. These 
officials explained that they relied on traditional methods--such as 
on-site industrial engineering reviews and industry standards--to 
calculate these operational requirements for Navy mental health 
providers. According to Navy officials, the fiscal year 2016 budget 
request submitted by the Navy for mental health provider staffing is 
the sum of the estimated staffing levels generated by PHRAMS and the 
calculated operational requirements for mental health providers. 

When we shared this information with DHA officials, they told us that 
they were unaware of specific supplemental or alternative methods used 
by the military services to determine their final mental health 
provider staffing estimates. However, these officials did note that 
the military services do make modifications to their PHRAMS results 
through modifying certain aspects of the model and DHA does not 
collect information on these modifications. DHA and the PHRAMS 
contractor review the model annually to incorporate changes requested 
by the military services in the next version of the model. Standards 
for internal control in the federal government state that information 
should be recorded and communicated to management and others within 
the agency that need it in a format and time frame that enables them 
to carry out their responsibilities.[Footnote 28] However, since DHA 
did not have access to this information on how the military services 
supplemented PHRAMS for their fiscal year 2016 budget request, this 
critical information was not included in this annual update process. 

As a result of the military services' alterations to PHRAMS estimates 
of mental health provider staffing needs, DHA cannot consistently 
determine how beneficiary demand affects the mental health provider 
staffing needs for the MHS. Specifically, due to the Army's use of a 
workload-based staffing estimate, the resulting mental health provider 
staffing needs estimates submitted for the fiscal year 2016 budget 
process may not consistently reflect the beneficiary demand for mental 
health services across military services. In addition, without an 
accurate picture of the ways the military services altered or 
supplemented PHRAMS results, DHA cannot evaluate the role PHRAMS 
played in the development of the fiscal year 2016 budget request for 
mental health provider staffing and cannot ensure that it is directing 
the PHRAMS contractor to make the most appropriate changes to the 
model that minimize the need for these service-specific supplements. 

Military Services Report Mental Health Provider Staffing Levels on 
Quarterly Reports Submitted to DHA, But Do Not Report Reliable 
Information on Future Needs: 

The military services submit quarterly reports to DHA through the OASD 
HA human capital office that include information on their current 
mental health provider staffing levels and should, as requested, 
include information on their future needs for these providers. 
However, the military services do not include reliable information 
about their mental health provider staffing needs on these quarterly 
reports, despite having access to PHRAMS since fiscal year 2010. 
[Footnote 29] As a result, DHA does not have an accurate picture 
of the mental health provider staffing needs of the MHS and cannot 
accurately report this information to Congress. Standards for internal 
control in the federal government state that information should be 
recorded and communicated to management and others within the agency 
that need it in a format and time frame that enables them to carry out 
their responsibilities.[Footnote 30] 

DHA requests information each quarter from the military services and 
the NCR Medical Directorate on mental health provider staffing in 
order to understand the MHS-wide use and need for these providers and 
report this information to Congress when requested. Each military 
service and the NCR Medical Directorate submits quarterly staffing 
reports to DHA through the OASD HA human capital office that include 
information on three areas of mental health provider staffing: (1) the 
number of mental health providers each military service needs to 
fulfill the needs of their beneficiaries, referred to as requirements; 
(2) the number of authorized positions each military service has for 
various types of mental health providers, referred to as 
authorizations; and (3) the actual number of mental health providers 
each military service has working within their MTFs and subordinate 
clinics that quarter, referred to as on-board providers. However, we 
found that information reported is unreliable. Specifically, we found 
the following: 

* According to DHA officials, only the Army submits information on the 
number of mental health providers its MTFs and subordinate clinics 
need to serve Army beneficiaries and it derives these numbers from the 
Army workload-based legacy staffing model. 

* DHA officials told us that the Navy and the Air Force do not track 
needs for mental health provider staffing. Instead, they submit the 
number of authorized mental health provider positions for both the 
requirements and authorizations sections of these quarterly reports. 
NCR Medical Directorate officials told us that the requirements 
section of their quarterly reports are populated using the staffing 
needs identified in the intermediate manpower planning documents that 
were created during the formation of the NCR Medical Directorate. 
According to DOD officials, the NCR Medical Directorate is currently 
reviewing the staffing needs of its MTFs and subordinate clinics and 
anticipates completion of this review by December 2014. 

Without reliable information from the military services and the NCR 
Medical Directorate on the quarterly reports, DHA cannot assess the 
need for mental health providers throughout the MHS and cannot ensure 
that it is providing assistance to the military services in meeting 
their unmet needs. The military services have had access to PHRAMS 
since fiscal year 2010 and the model could be used to assess the 
mental health provider needs of each military service and the NCR 
Medical Directorate on an ongoing basis. Incorporating this 
information into the requirements section of the quarterly reports 
each military service and the NCR Medical Directorate submit to DHA 
through the OASDHA human capital office would provide this important 
information to DHA. In addition, this information would also ensure 
greater consistency in the military services' and the NCR Medical 
Directorate's assessment of this aspect of mental health provider 
staffing and ensure greater accuracy in DOD's reports to Congress 
about mental health provider staffing. 

Conclusions: 

While PHRAMS has been in development since fiscal year 2007, the 
military services only recently began using the model for a common 
purpose--the fiscal year 2016 DOD budget request. However, PHRAMS is 
not meeting its intended goals because the military services are not 
using it consistently to assess their mental health provider staffing 
needs. Instead, the military services are supplementing PHRAMS mental 
health provider staffing estimates with additional information. It is 
critical that the military services report how they have supplemented 
PHRAMS to ensure (1) that DHA and the PHRAMS contractor can correctly 
analyze and interpret the military services' mental health provider 
staffing estimates, and (2) that PHRAMS is updated regularly to meet 
the needs of the military services. DHA is also unable to generate 
accurate reports to Congress on the staffing needs of the entire MHS, 
because the military services are not using PHRAMS to generate 
consistent mental health provider staffing needs estimates and are 
instead reporting unreliable estimates on their quarterly reports. DHA 
is therefore unable to assess and report on current mental health 
provider staffing needs. 

Recommendations for Executive Action: 

To ensure DHA can accurately and consistently assess mental health 
provider staffing needs across each of the military services, we 
recommend that the Secretary of Defense direct the Secretaries of the 
Army, Air Force, and Navy to take the following two actions: 

* Require the medical commands of each military service to report any 
additional service-specific methods they use to determine their final 
estimates of mental health provider staffing needs; and: 

* Require the medical commands of each military service to include 
its estimated mental health provider staffing needs generated 
through PHRAMS in the requirements fields of DHA's quarterly mental 
health staffing reports. 

We further recommend that the Secretary of Defense direct the 
Assistant Secretary of Defense for Health Affairs to take the 
following two actions: 

* Ensure DHA, through the PHRAMS contractor, continue to refine PHRAMS 
to incorporate the needs of the military services to reduce the need 
for additional service-specific methods of determining mental health 
provider staffing needs; and: 

* Require the NCR Medical Directorate to include its estimated 
mental health provider staffing needs generated through PHRAMS in the 
requirements fields of DHA's quarterly mental health staffing reports. 

Agency Comments and Our Evaluation: 

DOD provided comments on a draft of this report, which we have 
reprinted in appendix IV. In its comments, DOD generally concurred 
with two of our four recommendations. DOD also provided technical 
comments, which we have incorporated as appropriate. 

DOD concurred with our recommendation that the Secretary of Defense 
should direct the Secretaries of the Army, the Air Force, and the Navy 
to require the medical commands of each military service to report any 
additional service-specific methods they use to determine their final 
estimates of mental health provider staffing needs. DOD did not 
provide a time frame or action plan for implementing this 
recommendation. 

In addition, in response to our recommendation that the Secretary 
of Defense ensure DHA, through the PHRAMS contractor, continue to 
refine PHRAMS to incorporate the needs of military services to reduce 
the need for additional service-specific methods of determining mental 
health provider staffing needs, DOD said that DHA continues to serve 
in an advisory role to the military services to ensure that the next 
version of PHRAMS meets each service's needs. DOD did not provide a 
time frame or action plan for implementing this recommendation. 

DOD did not concur with our recommendations to require the medical 
commands of each military service and the NCR Medical Directorate to 
include their estimated mental health provider staffing needs 
generated through PHRAMS in the requirements field of DHA's quarterly 
mental health staffing reports. DOD stated in its comments that 
using PHRAMS in the requirements fields of these reports will not add 
value to the quarterly mental health staffing reports and noted that 
the military services do not use PHRAMS as the sole source of mental 
health requirements. We disagree with DOD's conclusion and maintain 
that our recommendations should be implemented. The military services 
and the NCR Medical Directorate are not currently providing DHA with 
consistent information that it can rely on to: (1) make informed 
decisions regarding the MHS-wide usage and need for mental health 
providers and (2) develop reports to Congress based on this 
information. 

Specifically, only one military service--the Army--reports the number 
of mental health providers that its MTFs need to serve Army 
beneficiaries in the requirements field of DHA's quarterly mental 
health staffing reports. The other two military services--the Air 
Force and the Navy--enter the number of mental health providers that 
were authorized by DOD for that fiscal year in the requirements field 
because they do not track mental health provider staffing needs. 
Additionally, the NCR Medical Directorate told us that it populates 
the requirements field of DHA's quarterly mental health staffing 
reports with information that was created during the formation of the 
NCR Medical Directorate several years ago and not with the current 
needs of its beneficiary population. We believe that to adequately 
assess the need for mental health providers throughout the MHS, DHA 
needs to have access to consistent and reliable information on mental 
health provider staffing needs in the quarterly mental health staffing 
reports. By not supplying consistent information on mental health 
provider staffing needs generated through PHRAMS--a common staffing 
model all military services and the NCR Medical Directorate have 
access to--the military services and the NCR Medical Directorate make 
it difficult to properly assess relative mental health provider 
staffing needs across the services. If our recommendations were 
implemented, DHA would have access to consistent information about 
mental health provider staffing needs throughout the MHS and would be 
able to more reliably report this information to Congress. 

We are sending copies of this report to the Secretary of Defense, 
appropriate congressional committees, and other interested parties. In 
addition, the report is available at no charge on the GAO website at 
[hyperlink, http://www.gao.gov]. 

If you or your staff 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. GAO staff who made major 
contributions to this report are listed in appendix V. 

Signed by: 

Randall B. Williamson: 
Director, Health Care: 

[End of section] 

Appendix I: Fiscal Year 2013 Department of Defense Mental Health 
Provider Staffing: 

This appendix provides results from our analysis of Department of
Defense (DOD) fiscal year 2013 quarterly mental health staffing reports.
Each military service and the National Capital Region (NCR) Medical
Directorate submit these reports to the Defense Health Agency (DHA)
through the Office of the Assistant Secretary of Defense for Health 
Affairs (OASD HA) human capital office each quarter to identify their 
mental health staffing levels and needs.

* Figure 7 shows the total number of mental health providers working 
within the MHS by provider type as of September 2013. 

* Figure 8 shows the total number of mental health providers working 
within the MHS by employment category as of September 2013.[Footnote 
30] 

* Figure 9 shows the total number of mental health providers working 
within the MHS by military service and the NCR Medical Directorate as 
of September 2013. 

* Table 1 shows the mental health provider staffing levels for the 
Army as of September 2013. 

* Table 2 shows the mental health provider staffing levels for the Air 
Force as of September 2013. 

* Table 3 shows the mental health provider staffing levels for the 
Navy as of September 2013. 

* Table 4 shows the mental health provider staffing levels for the NCR 
Medical Directorate as of September 2013. 

Figure 7: Total Department of Defense (DOD) Mental Health Providers by 
Provider Type, September 2013: 

[Refer to PDF for image: pie-chart] 

Social worker: 40% (2,484 social workers); 
Psychologist: 34% (2,079 psychologists); 
Psychiatrist: 13% (808 psychiatrists); 
Mental health registered nurse (RN): 9% (552 mental health RNs); 
Mental health nurse practitioner (NP): 3% (173 mental health NPs); 
Other licensed provider: 1% (80 other licensed practitioners). 

Source: GAO analysis of DOD data. GAO-15-184. 

Note: The total number of DOD mental health providers in fiscal year 
2013 was 6,186. Mental health provider totals and percentages in this 
figure have been rounded to the nearest full-time equivalent. 

[End of figure] 

Figure 8: Total Department of Defense (DOD) Mental Health Providers by 
Employment Category, September 2013: 

[Refer to PDF for image: pie-chart] 

Contract provider[A]: 15% (950 contract providers); 
Military provider: 31% (1,921 military providers); 
Civilian provider[A]: 54% (3,315 civilian providers). 

Source: GAO analysis of DOD data. GAO-15-184. 

Note: The total number of DOD mental health providers in fiscal year 
2013 was 6,186. Mental health provider totals and percentages in this 
figure have been rounded to the nearest full-time equivalent. 

[A] Civilian and contract providers are represented as full-time 
employee equivalent positions. 

[End of figure] 

Figure 9: Total Department of Defense (DOD) Mental Health Providers by 
Military Service and the National Capital Region (NCR) Medical 
Directorate, September 2013: 

[Refer to PDF for image: pie-chart] 

NCR Medical Directorate: 5% (338 NCR Medical Directorate providers); 
Navy: 16% (971 Navy providers); 
Air Force: 19% (1,147 Air Force providers); 
Army: 60% (3,731 Army providers). 

Source: GAO analysis of DOD data. GAO-15-184. 

Note: The total number of DOD mental health providers in fiscal year 
2013 was 6,186. Mental health provider totals and percentages in this 
figure have been rounded to the nearest full-time equivalent. 

[End of figure] 

Table 1: Total Number of Army Mental Health Providers as of September 
2013: 

Provider type: Psychiatrist; 
Employment category: 
Military: 199; 
Civilian: 140; Contract: 91; 
Total: 430. 

Provider type: Psychologist; 
Employment category: 
Military: 239; 
Civilian: 980; 
Contract: 78; 
Total: 1,297. 

Provider type: Mental health nurse practitioner; 
Employment category: 
Military: 37; 
Civilian: 47; 
Contract: 20; 
Total: 104. 

Provider type: Mental health registered nurse; 
Employment category: 
Military: 91; 
Civilian: 117; 
Contract: 13; 
Total: 221. 

Provider type: Social worker; 
Employment category: 
Military: 273; 
Civilian: 1,298; 
Contract: 107; 
Total: 1,678. 

Provider type: Other licensed provider; 
Employment category: 
Military: 0; 
Civilian: 0; 
Contract: 0; 
Total: 0. 

Provider type: Total; 
Employment category: 
Military: 839; 
Civilian: 2,582; 
Contract: 310[A]; 
Total: 3,731[A]. 

Source: GAO analysis of DOD Department of Defense data. GAO-15-184. 

[A] Numbers do not total due to rounding to the nearest number of full-
time equivalent positions. 

[End of table] 

Table 2: Total Number of Air Force Mental Health Providers as of 
September 2013: 

Provider type: Psychiatrist; 
Employment category: 
Military: 132; 
Civilian: 5; 
Contract: 9; 
Total: 146. 

Provider type: Psychologist; 
Employment category: 
Military: 247; 
Civilian: 14; 
Contract: 103; 
Total: 364. 

Provider type: Mental health nurse practitioner; 
Employment category: 
Military: 26; 
Civilian: 0; 
Contract: 0; 
Total: 26. 

Provider type: Mental health registered nurse; 
Employment category: 
Military: 39; 
Civilian: 53; 
Contract: 28; 
Total: 120. 

Provider type: Social worker; 
Employment category: 
Military: 231; 
Civilian: 143; Contract: 117; 
Total: 491. 

Provider type: Other licensed provider; 
Employment category: 
Military: 0; 
Civilian: 0; 
Contract: 0; 
Total: 0. 

Provider type: Total; 
Employment category: 
Military: 675; 
Civilian: 215; 
Contract: 257; 
Total: 1,147. 

Source: GAO analysis of DOD Department of Defense data. GAO-15-184. 

[End of table] 

Table 3: Total Number of Navy Mental Health Providers as of September 
2013: 

Provider type: Psychiatrist; 
Employment category: 
Military: 109; 
Civilian: 38; 
Contract: 28; 
Total: 175. 

Provider type: Psychologist; 
Employment category: 
Military: 144; 
Civilian: 103; 
Contract: 93; 
Total: 340. 

Provider type: Mental health nurse practitioner; 
Employment category: 
Military: 32; 
Civilian: 2; 
Contract: 9; 
Total: 43. 

Provider type: Mental health registered nurse; 
Employment category: 
Military: 71; 
Civilian: 14; 
Contract: 68; 
Total: 153. 

Provider type: Social worker; 
Employment category: 
Military: 51; 
Civilian: 89; 
Contract: 66; 
Total: 206. 

Provider type: Other licensed provider; 
Employment category: 
Military: 0; 
Civilian: 23; 
Contract: 31; 
Total: 54. 

Provider type: Total; 
Employment category: 
Military: 407; 
Civilian: 269; 
Contract: 295; 
Total: 971. 

Source: GAO analysis of DOD Department of Defense data. GAO-15-184. 

[End of table] 

Table 4: Total Number of National Capital Region (NCR) Medical 
Directorate Mental Health Providers as of September 2013: 

Provider type: Psychiatrist; 
Employment category: 
Military[A]: 0; 
Civilian: 51; 
Contract: 6; 
Total: 57. 

Provider type: Psychologist; 
Employment category: 
Military[A]: 0; 
Civilian: 56; 
Contract: 22; 
Total: 78. 

Provider type: Mental health nurse practitioner; 
Employment category: 
Military[A]: 0; 
Civilian: 0; 
Contract: 0; 
Total: 0. 

Provider type: Mental health registered nurse; 
Employment category: 
Military[A]: 0; 
Civilian: 40; 
Contract: 18; 
Total: 58. 

Provider type: Social worker; 
Employment category: 
Military[A]: 0; 
Civilian: 86; 
Contract: 33; 
Total: 119. 

Provider type: Other licensed provider; 
Employment category: 
Military[A]: 0; 
Civilian: 16; 
Contract: 10; 
Total: 26. 

Provider type: Total; 
Employment category: 
Military[A]: 0; 
Civilian: 249; 
Contract: 89; 
Total: 338. 

Source: GAO analysis of DOD Department of Defense (DOD) data. 
GAO-15-184. 

[A] The NCR Medical Directorate was initially established as a DOD 
joint task force in September 2007 to operate DOD's medical facilities 
in the national capital region--including Walter Reed National 
Military Medical Center, Fort Belvoir Community Hospital, and 
supporting clinics. The NCR Medical Directorate reassigned civilian 
and contract personnel from the military services to the NCR Medical 
Directorate while retaining military mental health providers within 
the appropriate military services' figures. 

[End of table] 

[End of section] 

Appendix II: Recruitment and Retention of Department of Defense Mental 
Health Providers: 

This appendix provides information on the recruitment and retention of 
Department of Defense (DOD) mental health providers. Specifically, we 
discuss (1) the mechanisms the military services use to recruit and 
retain mental health providers, and (2) the challenges the military 
services experience in recruiting and retaining mental health 
providers. 

To determine the mechanisms the military services use to recruit and 
retain mental health providers, we reviewed relevant laws, including 
each National Defense Authorization Act (NDAA) from fiscal years 2010 
through 2014, to determine the recruitment and retention mechanisms 
available to DOD for mental health providers. We also spoke with 
officials from Office of the Assistant Secretary of Defense for Health 
Affairs (OASD HA), Army, Air Force, and Navy about their use of these 
mechanisms. 

To determine the challenges the military services experience in 
recruiting and retaining mental health providers, we spoke with 
officials from OASD HA, Army, Air Force, and Navy. We also reviewed 
the Health Resources and Services Administration's Health Professional 
Shortage Area designations to determine whether other health care 
delivery systems also experienced challenges in recruiting and 
retaining certain mental health providers.[Footnote 31] 

Military Services Use Numerous Mechanisms to Recruit and Retain Mental 
Health Providers: 

All three military services reported using numerous recruitment and 
retention mechanisms, many of which are cited in the NDAA for Fiscal 
Year 2010. These mechanisms include the following: [Footnote 32] 

* Health Professions Scholarship and Financial Assistance Program 
(HPSP). Officials from all three military services reported using this 
program to recruit various types of medical providers, including 
mental health providers. Through HPSP, the military services provide 
scholarships, stipends, and other benefits for students in advanced 
health care fields--including physicians, psychiatric nurse 
practitioners, and psychologists.[Footnote 33] The military services 
reported that HPSP was a particularly important recruitment tool for 
physicians, including psychiatrists. However, officials from all three 
military services stressed that they cannot predict the exact number 
of psychiatrists HPSP will produce annually because it begins funding 
medical students' general training prior to their selection of a 
specialty. 

* Uniformed Services University of the Health Sciences (USUHS). All 
three military services reported that USUHS was a mechanism for 
recruiting and training clinical psychologists. USUHS trains, 
educates, and prepares military health providers, including clinical 
psychologists, to work in the military health system (MHS).[Footnote 
34] Officials from the military services reported that the annual 
enrollment in USUHS for clinical psychology students by service is 
Army, three students; Air Force, two to three students; and Navy, five 
students. 

* Bonuses for mental health providers. Officials from all three 
military services reported using a variety of bonuses for mental 
health providers.[Footnote 35] Specifically, the Army reported using 
accession, relocation, and retention bonuses for both military and 
civilian mental health providers. The Air Force reported that they 
provide accession bonuses to fully-qualified military mental health 
providers, as well as bonuses for specialty board certification and a 
retention bonus after providers have completed a specified number of 
years-of-service. Finally, the Navy reported that all mental health 
specialties are eligible for some combination of accession and 
retention bonuses and board certification pay. 

* Direct-hire authority for civilian mental health providers. Both the 
Army and Navy reported using direct-hire authority to recruit civilian 
mental health providers. The Office of Personnel Management can grant 
direct-hire authority to executive branch agencies to fill vacancies 
when a critical hiring need or severe shortage of candidates exists. 
Direct-hire authorities expedite hiring by eliminating some 
competitive hiring procedures, such as rating and ranking candidates, 
that would otherwise be required. Agencies may also pursue agency-
specific direct-hire authorities. 

* Training program for licensed clinical social workers. Both the Army 
and Navy reported using the Army's training program for licensed 
clinical social workers. In 2008, the Army created a program for 
training licensed clinical social workers with Fayetteville State 
University to address a shortage of Army social work military 
providers. This program provides participants with a Masters in Social 
Work and internship placements. The program annually trains up to 30 
Army social work military providers, 5 Army National Guard social work 
military providers, and 2 Navy social work military 
providers.[Footnote 36] Army officials reported that this program is 
satisfying all of its need for social work military providers 
annually, and Navy officials told us that this program was an 
important recruitment tool for their social work military providers as 
well. 

Military Services Experience Several Challenges Recruiting and 
Retaining Mental Health Providers: 

In the face of nationwide shortages of mental health professionals, 
the ability to recruit and retain mental health providers, 
particularly psychiatrists, poses a challenge according to officials 
from all three military services. The Health Resources and Services 
Administration has reported nationwide shortages of psychiatrists and 
identified 3,900 health professional shortage areas throughout the 
nation with a relative scarcity of psychiatrists.[Footnote 37] As of 
January 2014, the Health Resources and Services Administration 
reported that it would take approximately 2,600 additional 
psychiatrists nationwide to eliminate the current shortages it has 
identified. 

In addition to nationwide shortages of mental health professionals, 
there are other overarching military-specific challenges for all three 
military services as they compete for scarce mental health resources. 
Mental health provider recruitment and retention challenges specific 
to military service include: 

* Frequent deployments and relocations. Officials from all three 
military services reported that both frequent deployments and 
relocations made it difficult for them to recruit and retain mental 
health military providers. For example, Navy officials told us that 
they have received feedback from psychiatrists leaving military 
service that requirements to move frequently and deploy were reasons 
they were leaving the Navy. 

* Assignment to work in remote locations. According to officials from 
all three military services, the remote locations where many military 
treatment facilities are located posed recruitment and retention 
challenges for mental health providers. For example, Army officials 
explained that many Army bases are located relatively far away from 
major metropolitan areas and that mental health military, civilian, 
and contract providers are reluctant to be located in what they 
perceived to be remote and isolated locations for lengthy periods of 
time. 

* Competitive compensation for mental health providers. Officials from 
all three military services reported that the inability of DOD to 
create compensation packages for civilian mental health providers, 
particularly psychiatrists, that were competitive with private sector 
compensation affected their ability to recruit and retain these 
providers. For example, Army officials stated that both a 3-year long 
DOD pay freeze and recent furloughs affected their ability to create 
competitive salaries for providers and contributed to the Army's 15 
percent turnover rate in their psychiatrist and psychologist mental 
health provider populations in recent years. 

[End of section] 

Appendix III: Mental Health Provider Staffing Increases by Military 
Service: 

This appendix provides results from our analysis of Department of
Defense (DOD) quarterly mental health staffing reports for fiscal years
2009 and 2013. Each service and the National Capital Region (NCR)
Medical Directorate submits these reports to the Defense Health Agency
(DHA) through the Office of the Assistant Secretary of Defense for 
Health Affairs (OASD HA) human capital office each quarter to identify 
their mental health staffing levels. The NCR Medical Directorate is not
represented in this appendix because in fiscal year 2009 mental health
provider staffing levels were included in the military service totals 
and, as a result, comparisons of NCR Medical Directorate staffing 
levels from fiscal year 2009 to fiscal year 2013 are not available.

* Table 5 provides results for mental health provider staffing levels 
for the Army in fiscal year 2009 and fiscal year 2013. 

* Table 6 provides results for mental health provider staffing levels 
for the Air Force in fiscal year 2009 and fiscal year 2013. 

* Table 7 provides results for mental health provider staffing levels 
for the Navy in fiscal year 2009 and fiscal year 2013. 

Table 5: Total Number of Army Mental Health Providers, Fiscal Year 
2009 Compared to Fiscal Year 2013: 

Provider type: Psychiatrist; 
Employment category: Military: 
Fiscal year: 2009: 126; 
Fiscal year: 2013[A]: 199; 
Employment category: Civilian: 
Fiscal year: 2009: 118; 
Fiscal year: 2013[A]: 140; 
Employment category: Contract: 
Fiscal year: 2009: 92; 
Fiscal year: 2013[A]: 91; 
Total: 
Fiscal year: 2009: 336; 
Fiscal year: 2013[A]: 430. 

Provider type: Psychologist; 
Employment category: Military: 
Fiscal year: 2009: 187; 
Fiscal year: 2013[A]: 239; 
Employment category: Civilian: 
Fiscal year: 2009: 579; 
Fiscal year: 2013[A]: 980; 
Employment category: Contract: 
Fiscal year: 2009: 110; 
Fiscal year: 2013[A]: 78; 
Total: 
Fiscal year: 2009: 876; 
Fiscal year: 2013[A]: 1,297. 

Provider type: Mental health nurse[B]; 
Employment category: Military: 
Fiscal year: 2009: 102; 
Fiscal year: 2013[A]: 128; 
Employment category: Civilian: 
Fiscal year: 2009: 140; 
Fiscal year: 2013[A]: 164; 
Employment category: 
Contract: Fiscal year: 2009: 31; 
Fiscal year: 2013[A]: 33; 
Total: 
Fiscal year: 2009: 273; 
Fiscal year: 2013[A]: 325. 

Provider type: Social worker; 
Employment category: Military: 
Fiscal year: 2009: 125; 
Fiscal year: 2013[A]: 273; 
Employment category: Civilian: 
Fiscal year: 2009: 882; 
Fiscal year: 2013[A]: 1,298; 
Employment category: Contract: 
Fiscal year: 2009: 175; 
Fiscal year: 2013[A]: 107; 
Total: 
Fiscal year: 2009: 1,182; 
Fiscal year: 2013[A]: 1,678. 

Provider type: Other licensed provider; 
Employment category: Military: 
Fiscal year: 2009: 0; 
Fiscal year: 2013[A]: 0; 
Employment category: Civilian: 
Fiscal year: 2009: 0; 
Fiscal year: 2013[A]: 0; 
Employment category: Contract: 
Fiscal year: 2009: 55; 
Fiscal year: 2013[A]: 0; 
Total: 
Fiscal year: 2009: 55; 
Fiscal year: 2013[A]: 0. 

Provider type: Total; 
Employment category: Military: 
Fiscal year: 2009: 540; 
Fiscal year: 2013[A]: 839; 
Employment category: Civilian: 
Fiscal year: 2009: 1,719; 
Fiscal year: 2013[A]: 2,582; 
Employment category: Contract: 
Fiscal year: 2009: 463; 
Fiscal year: 2013[A]: 310[C]; 
Total: 
Fiscal year: 2009: 2,721[C]; 
Fiscal year: 2013[A]: 3,731[C]. 

Source: GAO analysis of Department of Defense (DOD) data. GAO-15-184. 

[A] Fiscal year 2013 values do not include civilian and contract 
providers assigned to military treatment facilities and subordinate 
clinics within the National Capital Region Medical Directorate because 
beginning in fiscal year 2011 this command began reporting as a 
separate entity. 

[B] The mental health nurse category includes both mental health nurse 
practitioners and mental health registered nurses. In fiscal year 
2009, DOD did not report separate employment information on these two 
types of mental health providers. 

[C] Numbers do not total due to rounding to the nearest number of full-
time equivalent positions. 

[End of table] 

Table 6: Total Number of Air Force Mental Health Providers, Fiscal 
Year 2009 Compared to Fiscal Year 2013: 

Provider type: Psychiatrist; 
Employment category: Military: 
Fiscal year: 2009: 136; 
Fiscal year: 2013[A]: 132; 
Employment category: Civilian: 
Fiscal year: 2009: 2; 
Fiscal year: 2013[A]: 5; 
Employment category: Contract: 
Fiscal year: 2009: 5; 
Fiscal year: 2013[A]: 9; 
Total: 
Fiscal year: 2009: 143; 
Fiscal year: 2013[A]: 146. 

Provider type: Psychologist; 
Employment category: Military: 
Fiscal year: 2009: 214; 
Fiscal year: 2013[A]: 247; 
Employment category: Civilian: 
Fiscal year: 2009: 10; 
Fiscal year: 2013[A]: 14; 
Employment category: Contract: 
Fiscal year: 2009: 112; 
Fiscal year: 2013[A]: 103; 
Total: 
Fiscal year: 2009: 336; 
Fiscal year: 2013[A]: 364. 

Provider type: Mental health nurse[B]; 
Employment category: Military: 
Fiscal year: 2009: 38; 
Fiscal year: 2013[A]: 65; 
Employment category: Civilian: 
Fiscal year: 2009: 57; 
Fiscal year: 2013[A]: 53; 
Employment category: Contract: 
Fiscal year: 2009: 2; 
Fiscal year: 2013[A]: 28; 
Total: 
Fiscal year: 2009: 97; 
Fiscal year: 2013[A]: 146. 

Provider type: Social worker; 
Employment category: Military: 
Fiscal year: 2009: 220; 
Fiscal year: 2013[A]: 231; 
Employment category: Civilian: 
Fiscal year: 2009: 141; 
Fiscal year: 2013[A]: 143; 
Employment category: Contract: 
Fiscal year: 2009: 66; 
Fiscal year: 2013[A]: 117; 
Total: 
Fiscal year: 2009: 427; 
Fiscal year: 2013[A]: 491. 

Provider type: Other licensed provider; 
Employment category: Military: 
Fiscal year: 2009: 0; 
Fiscal year: 2013[A]: 0; 
Employment category: Civilian: 
Fiscal year: 2009: 0; 
Fiscal year: 2013[A]: 0; 
Employment category: Contract: 
Fiscal year: 2009: 0; 
Fiscal year: 2013[A]: 0; 
Total: 
Fiscal year: 2009: 0; 
Fiscal year: 2013[A]: 0. 

Provider type: Total; 
Employment category: Military: 
Fiscal year: 2009: 608; 
Fiscal year: 2013[A]: 675; 
Employment category: Civilian: 
Fiscal year: 2009: 210; 
Fiscal year: 2013[A]: 215; 
Employment category: Contract: 
Fiscal year: 2009: 185; 
Fiscal year: 2013[A]: 257; 
Total: 
Fiscal year: 2009: 1,003; 
Fiscal year: 2013[A]: 1,147. 

Source: GAO analysis of Department of Defense (DOD) data. GAO-15-184. 

[A] Fiscal year 2013 values do not include civilian and contract 
providers assigned to military treatment facilities and subordinate 
clinics within the National Capital Region Medical Directorate 
because beginning in fiscal year 2011 this command began reporting as 
a separate entity. 

[B] The mental health nurse category includes both mental health nurse 
practitioners and mental health registered nurses. In fiscal year 
2009, DOD did not report separate employment information on these two 
types of mental health providers. 

[End of table] 

Table 7: Total Number of Navy Mental Health Providers, Fiscal Year 
2009 Compared to Fiscal Year 2013: 

Provider type: Psychiatrist; 
Employment Category: Military: 
Fiscal year: 2009: 97; 
Fiscal year: 2013[A]: 109; 
Employment Category: Civilian: 
Fiscal year: 2009: 27; 
Fiscal year: 2013[A]: 38; 
Employment Category: Contract: 
Fiscal year: 2009: 49; 
Fiscal year: 2013[A]: 28; 
Total: 
Fiscal year: 2009: 173; 
Fiscal year: 2013[A]: 175. 

Provider type: Psychologist; 
Employment Category: Military: 
Fiscal year: 2009: 106; 
Fiscal year: 2013[A]: 144; 
Employment Category: Civilian: 
Fiscal year: 2009: 100; 
Fiscal year: 2013[A]: 103; 
Employment Category: 
Contract: Fiscal year: 2009: 102; 
Fiscal year: 2013[A]: 93; 
Total: 
Fiscal year: 2009: 308; 
Fiscal year: 2013[A]: 340. 

Provider type: Mental health nurse[B]; 
Employment Category: Military: 
Fiscal year: 2009: 69; 
Fiscal year: 2013[A]: 103; 
Employment Category: Civilian: 
Fiscal year: 2009: 13; 
Fiscal year: 2013[A]: 16; 
Employment Category: Contract: 
Fiscal year: 2009: 118; 
Fiscal year: 2013[A]: 77; 
Total: 
Fiscal year: 2009: 200; 
Fiscal year: 2013[A]: 196. 

Provider type: Social worker; 
Employment Category: Military: 
Fiscal year: 2009: 22; 
Fiscal year: 2013[A]: 51; 
Employment Category: Civilian: 
Fiscal year: 2009: 99; 
Fiscal year: 2013[A]: 89; 
Employment Category: Contract: 
Fiscal year: 2009: 59; 
Fiscal year: 2013[A]: 66; 
Total: 
Fiscal year: 2009: 180; 
Fiscal year: 2013[A]: 206. 

Provider type: Other licensed provider; 
Employment Category: Military: 
Fiscal year: 2009: 20; 
Fiscal year: 2013[A]: 0; 
Employment Category: Civilian: 
Fiscal year: 2009: 18; 
Fiscal year: 2013[A]: 23; 
Employment Category: Contract: 
Fiscal year: 2009: 4; 
Fiscal year: 2013[A]: 31; 
Total: 
Fiscal year: 2009: 42; 
Fiscal year: 2013[A]: 54. 

Provider type: Total; 
Employment Category: Military: 
Fiscal year: 2009: 314; 
Fiscal year: 2013[A]: 407; 
Employment Category: Civilian: 
Fiscal year: 2009: 257; 
Fiscal year: 2013[A]: 269; 
Employment Category: Contract: 
Fiscal year: 2009: 332; 
Fiscal year: 2013[A]: 295; 
Total: 
Fiscal year: 2009: 903; 
Fiscal year: 2013[A]: 971. 

Source: GAO analysis of Department of Defense (DOD) data. GAO-15-184. 

[A] Fiscal year 2013 values do not include civilian and contract 
providers assigned to military treatment facilities and subordinate 
clinics within the National Capital Region Medical Directorate because 
beginning in fiscal year 2011 this command began reporting as a 
separate entity. 

[B] The mental health nurse category includes both mental health nurse 
practitioners and mental health registered nurses. In fiscal year 
2009, DOD did not report separate employment information on these two 
types of mental health providers. 

[End of table] 

[End of section] 

Appendix IV: Comments from the Department of Defense: 

The Assistant Secretary Of Defense: 
Health Affairs: 
1200 Defense Pentagon: 
Washington, DC 29301-1200: 

December 12, 2014: 

Mr. Randy Williamson: 
Director, Health Care: 
U.S. Govermment Accountability Office: 
441 G Street, N.W. 
Washington, DC 20548: 

Dear Mr. Williamson, 

This is the Department of Defense response to the Government 
Accountability Office (GAO) Draft Report, GAO-I5-184, "Defense Health 
Care: Additional Information Needed About Mental Health Provider 
Staffing Needs," dated November 10, 2014 (GAO Code 291218). 

Thank you for the opportunity to review and provide continents on the 
draft report. We sent the draft to the Services for their comments and 
have included those comments to the response (enclosed). We have 
reviewed the report for technical accuracy and do not agree with the 
findings and some of the recommendations (enclosure). 

Of the four recommendations, we non-concur with any recommendation to 
require the Services to include PHRAMS in the requirements field of 
the quarterly reports. We have collected these reports since 2009 and 
since the Services do not use PHRAMS as the sole source of mental 
health requirements, it will not add value to require that data 
element in the quarterly report. 

My points of contact are Ms. Rebecca Russell (Functional) who may be 
reached at (703) 681-8805, or rebecca.russell@ha.osd.mil and Mr. 
Gunther Zimmerman (Audit Liaison) who may he reached at (703) 681-
3492, or gunther.zimmerman@dha.mil. 

Sincerely, 

Signed by: 

Jonathan Woodson, M.D. 

Enclosures: As stated. 

GAO Draft Report Dated November 7, 2014: 
GAO-15-184 (GAO CODE 291218): 

"Defense Health Care: Additional Information Needed About Mental 
Health Provider Staffing Needs" 

Department Of Defense Comments: 

Recommendation #1: 

To ensure DHA can accurately and consistently assess mental health 
provider stalling needs across each of the military services, we 
recommend that the Secretary of Defense direct the Secretaries of the 
Army, Air Force. and Navy to take the following two actions: 

* Require the medical commands °Teach military service to report any 
additional service-specific methods they use to determine their final 
estimates of mental health provider staffing needs; and 

* Require the medical commands of each military service to include 
their estimated mental health provider staffing needs generated 
through PHRAMS in the requirements fields of DNA's quarterly mental 
health staffing reports. 

DoD Response: 

* We concur with the recommendation. that the medical commands of each 
military service include any additional Service-specific methods they 
use to determine final estimates of mental health provider staffing 
needs. 

* We do not concur with this recommendation, Using PHRAMS in the 
requirements fields will not add value to the quarterly mental health 
stalling reports. 

Recommendation #2: 

We further recommend that the Secretary of Defense direct the 
Assistant Secretary of Defense For Health Affairs to take the 
following two actions: 

* Ensure DHA, through the PHRAMS contractor, continue to refine 
PFIRAMS to incorporate the needs of the military services to reduce 
the need for additional service-specific methods of determining mental 
health provider staffing needs; and; 

* Require the NCR Medical Directorate to include their estimated 
mental health provider stalling needs generated through PHRAMS in the 
requirements fields of DHA's quarterly mental health sidling reports. 

DoD Response: 

* The DHA continues to serve in an advisory role to the Services to 
ensure the nest version of PHRAMS meets the needs of the each Service. 
Service leaders and DHA leadership will provide guidance and 
milestones to ensure timely metrics are met. 

* We do not concur with this recommendation. Using PHRAMS in the 
requirements fields will not add value to the quarterly mental health 
staffing reports. 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov. 

Staff Acknowledgments: 

In addition to the contact named above, Marcia A. Mann, Assistant 
Director; A. Elizabeth Dobrenz; Mary Giffin; Cathleen Hamann; 
Katherine Nicole Laubacher; Vikki Porter; Dharani Ranganathan; and 
Laurie F. Thurber made key contributions to this report. Jacquelyn 
Hamilton provided legal support. 

[End of section] 

Footnotes: 

[1] See GAO, Military Personnel: Enhanced Collaboration and Process 
Improvements Needed for Determining Military Treatment Facility 
Medical Personnel Requirements, [hyperlink, 
http://www.gao.gov/products/GAO-10-696] (Washington, D.C.: July 29, 
2010). 

[2] Within DOD's health care system, servicemembers, dependents, and 
other beneficiaries can receive care both in DOD's own military 
treatment facilities (MTF) or through its TRICARE purchased care 
system of civilian providers. The TRICARE purchased care network is 
used to supplement the care provided by MTFs and MTFs may review all 
requests for specialty care, such as mental health care, to determine 
if they have the capability and capacity to provide the care. 

[3] See Executive Order 13625, Improving Access to Mental Health 
Services for Veterans, Service Members, and Military Families (Aug. 
31, 2012). 

[4] In this report, we use the term mental health provider to describe 
a licensed or certified clinical provider--those that have met the 
minimum requirements needed to obtain and maintain a license or 
certification--including psychiatrists, psychologists, mental health 
nurse practitioners, mental health registered nurses, licensed social 
workers, and other licensed providers. We did not review other types 
of mental health personnel, such as administrative staff and 
technicians, who may not be licensed or certified but may be included 
in the population referred to by applicable laws. In this report we 
use the term mental health provider and mental health personnel 
interchangeably. 

[5] See Congressional Budget Office, Approaches to Reducing Federal 
Spending on Military Health Care: Actual and Projected Costs for 
Military Health Care as a Share of DOD's Base Budget, 2000 to 2028, 
Pub. No. 4282 (January 2014). 

[6] See Pub. L. No. 111-84, § 714, 123 Stat. 2190, 2381 (Oct. 28, 
2009). The NDAA for Fiscal Year 2010 required DOD to increase the 
number of active duty mental health personnel. We discuss the status 
of these personnel increases in this report. The NDAA for Fiscal Year 
2010 also required DOD to submit to Congress no later than one year 
after the enactment of the Act a report on the appropriate number of 
mental health personnel required to meet the mental health care needs 
of servicemembers, military retirees, and dependents. DOD issued this 
report to appropriate congressional committees in February 2011 and 
defined staffing levels for each service. 

[7] NCR Medical Directorate manages DOD medical facilities within the 
national capital region. Military mental health providers working 
within NCR Medical Directorate facilities are accounted for in their 
military services' quarterly mental health staffing reports. However, 
the NCR Medical Directorate manages its own civilian and contract 
provider workforce and, as a result, reports its staffing levels 
separately from the military services for these two types of mental 
health providers. 

[8] The Navy provides health care services for the Marine Corps. 

[9] Section 723 of the NDAA for Fiscal Year 2006 directed the 
Secretary of Defense to establish a task force to examine Armed Forces 
mental health issues and produce a report containing an assessment of, 
and recommendations for, improving the efficacy of mental health 
services provided to servicemembers by DOD. The DOD Task Force on
Mental Health was comprised of seven military and seven civilian 
professionals with mental health experience and issued its final 
report in June 2007. In August 2012, the President signed an executive 
order establishing an Interagency Task Force on Military and Veterans 
Mental Health, co-chaired by the Secretaries of Defense, Veterans 
Affairs, and Health and Human Services. This task force coordinates 
and reviews agency efforts to enhance veteran and military mental 
health and substance abuse services and develops recommendations on 
strategies to improve these services. See Executive Order 13625, 
Improving Access to Mental Health Services for Veterans, Service 
Members, and Military Families (August 31, 2012). 

[10] See GAO, Defense Health Care: Department of Defense Needs a 
Strategic Approach to Contracting for Health Care Professionals, GAO-
13-322 (Washington, D.C.: May 28, 2013). According to DOD, the MHS 
mission is to provide optimal health services in support of our 
nation's military mission—anytime, anywhere. 

[11] In addition to operating its own health care facilities, DOD also 
provides health care to military servicemembers, dependents, and 
military retirees through its TRICARE purchased care network. TRICARE 
supplements the health care resources of DOD with networks of civilian 
health care providers. 

[12] The Army and Navy each have a medical command, headed by a 
surgeon general, who manages each department's MTFs and other 
activities through a regional command structure. The Navy provides 
medical services for both Navy and Marine Corps installations. Unlike 
the Surgeons General for the Army and Navy, the Air Force Surgeon 
General exercises no command authority over Air Force MTFs; instead, 
Air Force MTF commanders report to local line commanders. 

[13] Mental health provider totals in this report have been rounded to 
the nearest full-time equivalent. Information on mental health 
provider staffing levels contained in this report was obtained from 
quarterly mental health staffing reports submitted by the military 
services to DHA through the OASD HA human capital office. 

[14] See Pub. L. No. 111-84, § 714, 123 Stat. 2190, 2381 (Oct. 28, 
2009). 

[15] This was in response to a September 2013 memorandum from the 
Assistant Secretary of Defense for Health Affairs that requested that 
the military services nominate their choice of mental health provider 
staffing model that would meet the following three criteria: (1) 
demonstrate adaptability to the Army, the Air Force, and the Navy; (2) 
demonstrate clinical validity to be used for the budget request to 
predict staffing; and (3) be ready for use for the fiscal year 2016 
budget request. PHRAMS was the selected model for this process, which 
began in fiscal year 2014. 

[16] DOD contracted with the CNA Corporation for the development and 
maintenance of PHRAMS. 

[17] In addition to mental health providers, PHRAMS also includes 
estimates for the number of full-time equivalent primary care and 
other providers, including chaplains, needed by the MHS to administer 
mental health services. Primary care and other provider estimates are 
generated by PHRAMS because these providers deliver some mental health 
services to MHS beneficiaries. 

[18] Some risk factors for dependents of servicemembers are populated 
based on their sponsoring servicemember's information. 

[19] See L.M. Pikulin and D.M. Harris, The Psychological Health Risk-
Adjusted Model for Staffing (PHRAMS): Update for Version 5.0, a 
special report prepared at the request of the Department of Defense, 
December 2013. PHRAMS is also used to estimate the number of TRICARE 
providers that will be needed to provide mental health services to 
beneficiaries enrolled in the TRICARE network. 

[20] PHRAMS uses a number of mental health diagnoses in its 
calculations, including those in the following groups: (1) psychoses, 
(2) non-psychotic depressive disorders, (3) anxiety-related disorders, 
(4) neurotic disorders, (5) post-traumatic stress disorder, (6) 
adjustment reaction disorders (excluding post-traumatic stress 
disorder), (7) acute reaction to stress, (8) substance-induced mental 
disorders, (9) substance dependence, (10) non-dependent substance 
abuse, (11) psychotic disorders of childhood, (12) non-psychotic 
disorders of childhood, (13) schizophrenic disorder, (14) personality 
disorders, (15) disturbance of conduct not elsewhere classified, (16) 
other psychotic disorders, and (17) other non-psychotic disorders. 
PHRAMS also estimates the prevalence of a number of mental health 
related events, such as (1) personal or family history of mental or 
psychiatric diagnosis, (2) mental or behavioral problem influencing 
health status, (3) specific mental health circumstances, (4) mental 
health examination and observation with no reported diagnosis, (5) 
mental health condition in a mother complicating pregnancy, (6) post-
deployment health assessments and post-deployment health 
reassessments, and (7) other cases where the diagnosing provider is a 
mental health provider. 

[21] The model includes a small upward adjustment to each risk group's 
prevalence rate to account for untreated mental health conditions in 
the beneficiary population. 

[22] To establish the encounter rates used in PHRAMS, the PHRAMS 
contractor created a composite encounter rate for each mental health 
condition included in the model based on five inputs: (1) 
recommendations from a Navy work group, (2) recommendations from an 
Air Force work group, (3) information gathered from reviews of 
clinical literature, (4) information gathered from reviews of clinical 
practice guidelines, and (5) other interviews. Encounter rates are 
also adjusted based on historical data. 

[23] Military and civilian mental health providers have different 
amounts of hours they can devote to encounters each year. For example, 
the default value in PHRAMS version 5 for military mental health 
providers' clinical encounter time was set at 1,190 hours per year, 
while the default value for civilian mental health providers' clinical 
encounter time was set at 1,399. This difference accounts for the 
hours military mental health providers spend each year performing 
military-specific duties not related to beneficiary care and 
differences in assumed productivity for military and civilian mental 
health care providers. 

[24] While the NCR Medical Directorate was required to use PHRAMS for 
its fiscal year 2016 budget request, we focused our analysis in this 
section on only the military services. 

[25] See GAO, Standards for Internal Control in the Federal 
Government, [hyperlink, 
http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.: 
November 1999). 

[26] The Army legacy staffing model calculates mental health provider 
staffing needs for each Army MTF by determining the number of relative 
value units for each MTF and projects the number of providers that are 
necessary to produce the desired level of productivity for the 
following year. Relative value units measure the amount of time and 
effort it takes to treat a beneficiary. 

[27] An Air Force official told us that Air Force mental health 
consultants are senior clinicians from a variety of specialties 
assigned as consultants to the Air Force Surgeon General to assist in 
staffing and other necessary operations. 

[28] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]. 

[29] DOD refers to staffing needs as requirements. 

[30] See [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]. 

[31] Mental health providers working within the MHS fall within three 
employment categories: (1) military providers, who can be either 
active duty or reserve servicemembers; (2) civilian providers; or (3) 
contract providers. 

[32] The Health Resources and Services Administration is an agency of 
the Department of Health and Human Services and is the primary federal 
agency charged with improving access to health care by strengthening 
the health care workforce, building healthy communities, and achieving 
health equity. The Health Resources and Services Administration 
designates certain areas of the nation as Health Professional Shortage 
Areas. 

[33] The NDAA for Fiscal Year 2010 also included a number of other 
recruitment and retention mechanisms not highlighted in this report. 
These additional mechanisms included the expansion of DOD's capacity 
to train masters-level clinical psychologists and social workers with 
expertise in deployment-related mental health disorders, detailing 
commissioned officers to accredited schools of psychology for training 
leading to a doctoral degree in clinical psychology or social work, 
and reassigning military mental health providers from administrative 
to clinical positions. 

[34] Qualifying HPSP students receive (1) full tuition for any 
accredited medical, psychiatric nurse practitioner, or psychology 
program; (2) a monthly stipend during the period of academic 
instruction; (3) officer's pay during academic breaks while training 
in DOD facilities; and (4) credit for time spent in educational 
training and placement in the appropriate rank as though this time was 
spent in active duty military service. Scholarship recipients incur a 
1-year active duty military service obligation for each year they 
receive HPSP scholarship payments, and minimum service obligations 
differ by health care field. Additional active duty service 
obligations may be incurred for residency and fellowship training. 

[35] Generally, USUHS students do not pay tuition and receive full 
salary and benefits for a junior officer (second lieutenant or ensign) 
in exchange for a 7-year active duty military service commitment. 

[36] Accession bonuses may be offered to certain new military 
servicemembers, including mental health providers. Retention bonuses, 
referred to in applicable laws and regulations as allowances, may be 
offered to existing military servicemembers and to current civilians, 
including mental health providers, if DOD determines that they have 
high or unique qualifications or DOD has a special need for the 
providers' services that makes it essential to retain them and the 
providers would be likely to leave federal service if a retention 
incentive was not offered. Relocation bonuses may be offered to 
current civilians, including mental health providers, who must 
relocate to accept positions in a different geographic area if the 
agency determines that their positions are likely to be difficult to 
fill in the absence of incentives. 

[37] An Army official told us that the Army has begun discussions with 
the Air Force to train a small number of Air Force social work 
military providers through this program as well. 

[38] The Health Resources and Services Administration designates 
certain areas of the nation as Health Professional Shortage Areas. 
Health Professional Shortage Areas may be urban or rural areas, 
population groups, or medical or other public facilities. In order for 
an area to be designated as a mental health Health Professional 
Shortage Area, there must be a psychiatrist to population ratio of at 
least 1: 30,000. In other words, when there are 30,000 or more people 
per psychiatrist, an area is eligible to be designated as a mental 
health Health Professional Shortage Area. 

[End of section] 

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