Defense Health Care: TRICARE Multiyear Surveys Indicate Problems with Access to Care for Nonenrolled Beneficiaries

What GAO Found

In its analysis of the 2008-2011 beneficiary survey data, GAO found that nearly one in three nonenrolled beneficiaries experienced problems finding a civilian provider who would accept TRICARE and that nonenrolled beneficiaries' access to civilian primary care and specialty care providers differed by type of location. Specifically, a higher percentage of nonenrolled beneficiaries in Prime Service Areas (PSA), which are areas with civilian provider networks, experienced problems finding a civilian primary care or specialty care provider compared to those in non-Prime Service Areas (non-PSA), which do not have civilian provider networks. GAO found that the top reasons reported by nonenrolled beneficiaries for why they experienced access problems--regardless of type of provider--were that the providers were either not accepting TRICARE payments or new TRICARE patients. Additionally, GAO's comparison of the Department of Defense's (DOD) beneficiary survey data to related data from a Department of Health and Human Services survey showed that nonenrolled beneficiaries' satisfaction ratings for primary and specialty care providers were consistently lower than those of Medicare fee-for-service beneficiaries.

GAO's analysis of the 2008-2011 civilian provider survey data found that about 6 in 10 civilian providers were accepting new TRICARE patients and the most-cited reason for not accepting new TRICARE patients was that the civilian providers were not aware of the TRICARE program. Civilian physicians' acceptance of TRICARE has also decreased over time. Specifically, when compared to DOD's 2005-2007 civilian physician survey results, civilian physicians' acceptance of new TRICARE patients has decreased. This was also true whether they were accepting any new patients or new Medicare patients. Civilian providers' awareness and acceptance of TRICARE also differed by provider type, as fewer civilian mental health care providers were aware of TRICARE or accepting new TRICARE patients than other types of providers. For example, only an estimated 39 percent of civilian mental health care providers were accepting new TRICARE patients, compared to an estimated 67 percent of civilian primary care providers and an estimated 77 percent of civilian specialty care providers. The analysis also showed that civilian providers' awareness and acceptance of TRICARE differ by location type, as civilian providers in PSAs were less aware of TRICARE and less likely to accept new TRICARE patients than those in non-PSAs.

GAO's analysis of the collective results of the beneficiary and civilian provider survey results indicates specific geographic areas, including areas in Texas and California, where nonenrolled beneficiaries have experienced considerable access problems. In each of these areas, although almost all civilian providers were accepting new patients, less than half were accepting new TRICARE patients. In most of these areas, civilian providers most often cited reimbursement concerns as the reasons why they were not accepting any new TRICARE patients.

In commenting on a draft of this report, DOD concurred with GAO's overall findings.

Why GAO Did This Study

DOD provides health and mental health care through its TRICARE program. TRICARE offers three basic options. Beneficiaries who choose TRICARE Prime, an option that uses civilian provider networks, must enroll. Beneficiaries who do not enroll in this option may obtain care from nonnetwork providers under TRICARE Standard or from network providers under TRICARE Extra. In addition, qualified National Guard and Reserve servicemembers may purchase TRICARE Reserve Select, a plan whose care options are similar to those of TRICARE Standard and TRICARE Extra. GAO refers to servicemembers who use TRICARE Standard, TRICARE Extra, or TRICARE Reserve Select as nonenrolled beneficiaries.

The National Defense Authorization Act for Fiscal Year 2008 directed DOD to conduct annual surveys over fiscal years 2008 through 2011 of both beneficiaries and civilian providers to determine the adequacy of access to health and mental health care providers for nonenrolled beneficiaries. It also directed GAO to review these surveys. This report addresses (1) what the results of the 4-year beneficiary surveys indicate about the adequacy of access to care for nonenrolled beneficiaries; (2) what the results of the 4-year civilian provider surveys indicate about civilian providers' awareness and acceptance of TRICARE, and (3) what the collective results of the surveys indicate about access to care by geographic area. To do so, GAO interviewed DOD officials, obtained relevant documentation, and analyzed the data for both surveys over the 4-year period.

For more information, contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov.