Publicly Released: August 12, 2020
Objective
The objective of this evaluation was to determine whether the DoD meets outpatient mental health access to care standards for active duty service members and their families, in accordance with law and applicable DoD policies.
Background
Military service, especially combat, can carry a psychological cost for the DoD military members and their families who support them. The DoD has the responsibility to effectively identify and treat mental health conditions through a consistent standard of care. The DoD Military Health System (MHS) is one of the largest integrated health care systems in the United States. Integrated health care is offered to active duty service members and their families through military medical treatment facilities (MTFs), known as the direct care system, and through networks of civilian providers operated by civilian managed care support contractors, known as the purchased care system. Active duty service members and their families enrolled to an MTF use the purchased care system if the MTF does not have an available appointment due to lack of capability or capacity.
Federal Regulations establish access to care standards that apply to both the direct and purchased care systems and establish that the wait time for an urgent care visit must generally not exceed 24 hours, a routine visit must not exceed 1 week (7 days), and a specialty care referral must not exceed 4 weeks (28 days).
Finding
The DoD did not consistently meet outpatient mental health access to care standards for active duty service members and their families, in accordance with law and applicable DoD policies. Specifically, for the December 2018 to June 2019 time period, we found that:
• 7 of 13 MTFs (direct care system) or their supporting TRICARE network (purchased care system) did not meet the specialty mental health access to care standard each month; and
• An average of 53 percent (4,415 of 8,328 per month) of all active duty service members and their families, identified as needing mental health care and referred to the purchased care system, did not receive care and the MHS did not know why.
Additionally, during our site visits between August and October 2019, 9 of 13 MTFs reported the inability to meet evidence-based treatment (treatment proven successful in controlled studies) or monitor the prescribed behavioral health treatment dosage (including visit frequency) in accordance with DHA-PI 6490.02, which means the patient’s follow-up treatment may have been delayed or did not occur.
The DoD did not consistently meet outpatient mental health access to care standards because the DHA:
• lacked an MHS-wide model to identify appropriate levels of staffing in direct and purchased care;
• published inconsistent and unclear access to mental health care policies;
• did not have visibility of patients who attempted, but were unable, to obtain mental health appointments in the purchased care system; and
• measured the 28-day specialty access to care standard differently between the direct and purchased care systems, both of which included only those patients who were able to get an appointment, excluded patients who self-referred, and considered only the patients’ first appointment.
As a result, thousands of active duty service members and their families may have experienced delays in obtaining mental health care. The delays may have involved numerous members not being able to: (1) see the right provider at the right time, (2) obtain mental health care at all, or (3) receive timely follow-up treatment. All of these types of delays in mental health care increase the risk of jeopardizing patient safety and affecting the readiness of the force. For example, in June 2019, active duty service members and their families referred to the TRICARE network waited 57 days for behavioral health counseling and therapy intake, and 79 days for psychiatry, on average, at Naval Health Clinic Oak Harbor.
Recommendations
We made a total of 14 recommendations to the Assistant Secretary of Defense for Health Affairs (ASD[HA]) and the Defense Health Agency (DHA) Director to improve access to mental health care in the DoD. We recommended the ASD(HA) update the ASD(HA) Memorandum, “TRICARE Policy for Access to Care”, February 23, 2011, to remove the eight-visit limitation for outpatient mental health care.
We also made recommendations for the DHA Director to develop a single MHS-wide model to identify appropriate staffing levels, update and clarify DoD and DHA policies, develop a method to book patient appointments in the purchased care system, and develop standardized mental health access to care measures.
Management Comments
The Defense Health Agency (DHA) Director, responding for the Assistant Secretary of Defense for Health Affairs (ASD[HA]), agreed to update the ASD(HA) Memorandum, “TRICARE Policy for Access to Care”, February 23, 2011, to remove the eight-visit limitation for outpatient mental health care. The DHA Director also responded to the recommendations directed towards DHA. The DHA Director agreed with 9, partially agreed with 3, and disagreed with 1, of the 13 subordinate recommendations for the DHA.
The DHA Director stated that although the DHA is adopting a consistent approach to determine which beneficiaries receive mental health care at an MTF, mental health care will vary by MTF mission and capabilities. The DHA Director further stated that the 7-day access standard will be applied to mental health providers in primary care clinics; however, the 28-day access standard, which applies to all specialty care, will continue to be applied to mental health specialty care clinics in both direct and private sector care. The DHA Director also stated that a standard process will be established for mental health appointments, but the elements of the mental health assessment will be tailored to each beneficiary’s needs.
The DHA Director disagreed with the recommendation to develop standardized mental health access to care measures for direct and purchased care for both active duty service members and their families, including tracking the reasons referrals are not used. The DHA Director stated that this recommendation would require invasive questioning of beneficiaries, which could increase stigma and reluctance to seek needed care.
Our Response
Based on the responses from the DHA Director, we consider seven recommendations resolved, but open, and seven unresolved. Seven recommendations are unresolved because we either disagreed with the DHA Director’s response or the response did not fully address the recommendation. We also modified three recommendations to be more specific based on management comments received.
This report is the result of Proj. No. D2019-DEV0PB-0178.000