Defense Health Care: TRICARE Select Implementation Plan Included Mandated Elements, but Access Standards Should Be Clarified
Fast Facts
DOD offers health care services to over 9 million people through its TRICARE program. The National Defense Authorization Act of 2017 made several changes to TRICARE, including establishing a new preferred provider network option called TRICARE Select. The act also required DOD to develop an implementation plan for Select that addresses specific issues, such as access to care and beneficiary complaints.
We found that while DOD's implementation plan addressed all required issues, it doesn't reflect DOD's current approach for establishing access standards. We recommended that DOD provide written documentation of its current approach to Congress.
Aerial photo of the Pentagon building.
Highlights
What GAO Found
The Department of Defense's (DOD) TRICARE Select Implementation Plan addressed the seven specific elements mandated by the National Defense Authorization Act for Fiscal Year 2017 (NDAA 2017). These elements are
Element A: ensuring that at least 85 percent of the TRICARE Select beneficiary population is covered by the network by January 1, 2018;
Element B: ensuring access standards for health care appointments;
Element C: establishing mechanisms for monitoring compliance with standards for access to care;
Element D: establishing health care provider-to-beneficiary ratios;
Element E: monitoring complaints by beneficiaries with respect to network adequacy and health care provider availability;
Element F: establishing requirements for mechanisms to monitor the responses to complaints by beneficiaries; and
Element G: establishing mechanisms to evaluate the quality metrics of the network providers.
GAO also assessed the implementation plan against leading practices for sound strategic management planning and found that it incorporated many of the practices, such as establishing goals, strategies to achieve goals, and plans to assess progress. However, a few of the leading practices were only partially incorporated or not incorporated at all. For example, the implementation plan did not always fully address the leading practice that planning documents include strategies to achieve goals and plans to assess progress. DOD officials explained that some of the details of their approach to the elements had not been finalized when they were completing the implementation plan. These officials added that their approach to the implementation plan was to create a strategic overview, and that some of the details are contained in contract documents and monitored through their oversight responsibilities.
Furthermore, GAO's assessment of the plan's elements found that the approach outlined in the implementation plan for ensuring access standards for health care appointments (Element B) is different from the approach DOD intends to use. The plan noted that DOD will use the access standards for TRICARE Prime—a managed care option—for TRICARE Select. However, DOD officials told GAO that the contractors are responsible for developing their own access standards, which DOD must approve. These officials added that DOD did not include information about the contractors proposing their own access standards because DOD was still developing its approach to this element when the plan was submitted. Because the implementation plan does not reflect DOD's current approach, Congress may not have the information it needs about the contractors' responsibilities for providing access to care, impeding its ability to provide oversight.
Why GAO Did This Study
DOD offers health care services to approximately 9.4 million eligible beneficiaries through TRICARE, DOD's regionally structured health care program. In each of its regions, DOD uses contractors to manage health care delivery through civilian provider networks, among other tasks.
The NDAA 2017 made several changes to the TRICARE program, including the establishment of a new preferred provider network health plan option called TRICARE Select. The NDAA 2017 also required DOD to develop an implementation plan for TRICARE Select that addresses seven specific mandated elements on access to care, beneficiary complaints, and quality metrics for network providers.
The NDAA 2017 included a provision for GAO to review the implementation plan. This report examines the extent to which DOD's implementation plan addressed the mandated elements. GAO evaluated DOD's implementation plan using leading planning practices identified in GAO's prior work and standards for internal control. GAO examined program policies, procedures, and contracts and interviewed DOD officials and TRICARE regional contractors.
Recommendations
GAO recommends that DOD provide written documentation of its approach for developing and approving the TRICARE Select access standards, as well as the final access standards, to Congress. DOD agreed with GAO's recommendation.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Defense | The Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to provide written documentation of DOD's approach to developing and approving the TRICARE Select access standards, as well as the final access standards, to Congress. (Recommendation 1) |
In April 2018, we reported that DOD's implementation plan for TRICARE Select did not adequately address access to care standards-one of the seven elements required for the plan as outlined in the National Defense Authorization Act for Fiscal Year 2017-so we recommended that the department report its plans for this element to Congress. In August 2023, DOD provided us with a copy of the document it prepared for Congress that outlines its approach to developing and approving access standards for TRICARE Select. In the document, DOD notes that it is the department's position that the current TRICARE access to care standards are not developed for a particular plan option (i.e., Prime or Select); rather, it is DOD's position that the standards apply to all enrollees seeking care from the TRICARE network. Thus, to the extent that TRICARE Select enrollees seek care from a TRICARE network provider, the appointment timeliness and drive time standards, which have typically been associated with the TRICARE Prime option, also apply to TRICARE Select enrollees. However, the department also acknowledged that these access standards can't be tracked for Select enrollees due to the structure of the benefit and beneficiaries' ability to self-refer. As a result, we found DOD's explanation of access standards for TRICARE Select and their regulations, website, and access to care policy to be limiting, unclear, and contradictory. Nonetheless, this document also identifies additional ways that DOD plans to monitor TRICARE Select enrollees' access to care. Such efforts include an annual survey of TRICARE Select enrollees and increases in the size of TRICARE networks to allow for more TRICARE Select enrollees to access care from network providers, should they so choose. Based on our review of the document provided to Congress and supporting materials provided by DOD, we consider this recommendation to be partially implemented until DOD updates its regulations, website, and policy to consistently represent the department's position that the TRICARE access to care standards apply to all enrollees seeking care from the networks, irrespective of their option plans.
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