Defense Health Care
DOD Lacks Assurance That Selected Reserve Members Are Informed about TRICARE Reserve Select Gao ID: GAO-11-551 June 3, 2011TRICARE Reserve Select (TRS) provides certain members of the Selected Reserve--reservists considered essential to wartime missions--with the ability to purchase health care coverage under the Department of Defense's (DOD) TRICARE program after their active duty coverage expires. TRS is similar to TRICARE Standard, a fee-forservice option, and TRICARE Extra, a preferred provider option. The National Defense Authorization Act for Fiscal Year 2008 directed GAO to review TRS education and access to care for TRS beneficiaries. This report examines (1) how DOD ensures that members of the Selected Reserve are informed about TRS and (2) how DOD monitors and evaluates access to civilian providers for TRS beneficiaries. GAO reviewed and analyzed documents and evaluated an analysis of claims conducted by DOD. GAO also interviewed officials with the TRICARE Management Activity (TMA), the DOD entity responsible for managing TRICARE; the regional TRICARE contractors; the Office of Reserve Affairs; and the seven reserve components.
DOD does not have reasonable assurance that Selected Reserve members are informed about TRS. A 2007 policy designated the reserve components as having responsibility for providing information about TRS to Selected Reserve members on an annual basis; however, officials from three of the seven components told GAO that they were unaware of this policy. Additionally, only one of the reserve components had a designated official at the headquarters level acting as a central point of contact for TRICARE education, including TRS. Without centralized responsibility for TRS education, the reserve components cannot ensure that all eligible Selected Reserve members are receiving information about the TRS program. Compounding this, the managed care support contractors that manage civilian health care are limited in their ability to educate all reserve component units in their regions as required by their contracts because they do not have access to comprehensive information about these units, and some units choose not to use the contractors to help educate their members about TRS. Nonetheless, DOD officials stated that they were satisfied with the contractors' efforts to educate units upon request and to conduct outreach. Lastly, it is difficult to determine whether Selected Reserve members are knowledgeable about TRS because the results of two DOD surveys that gauged members' awareness of the program may not be representative because of low response rates. Because TRS is the same benefit as the TRICARE Standard and Extra options, DOD monitors access to civilian providers for TRS beneficiaries in conjunction with TRICARE Standard and Extra beneficiaries. DOD has mainly used feedback mechanisms, such as surveys, to gauge access to civilian providers for these beneficiaries in the absence of access standards for these options. GAO found that jointly monitoring access for these two beneficiary groups is reasonable because a claims analysis showed that TRS beneficiaries and TRICARE Standard and Extra beneficiaries had similar health care utilization. Also, during the course of GAO's review, TMA initiated other efforts that specifically evaluated access to civilian providers for the Selected Reserve population and TRS beneficiaries, including mapping the locations of Selected Reserve members in relation to areas with TRICARE provider networks. GAO recommends that the Secretary of Defense direct the Assistant Secretary of Defense for Reserve Affairs to develop a policy requiring each reserve component to designate a centralized point of contact for TRS education. DOD partially concurred with this recommendation, citing a concern about regional coordination. GAO modified the recommendation.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Randall B. Williamson Team: Government Accountability Office: Health Care Phone: (206) 287-4860GAO-11-551, Defense Health Care: DOD Lacks Assurance That Selected Reserve Members Are Informed about TRICARE Reserve Select
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
June 2011:
Defense Health Care:
DOD Lacks Assurance That Selected Reserve Members Are Informed about
TRICARE Reserve Select:
GAO-11-551:
GAO Highlights:
Highlights of GAO-11-551, a report to congressional committees.
Why GAO Did This Study:
TRICARE Reserve Select (TRS) provides certain members of the Selected
Reserve”reservists considered essential to wartime missions”with the
ability to purchase health care coverage under the Department of
Defense‘s (DOD) TRICARE program after their active duty coverage
expires. TRS is similar to TRICARE Standard, a fee-for-service option,
and TRICARE Extra, a preferred provider option.
The National Defense Authorization Act for Fiscal Year 2008 directed
GAO to review TRS education and access to care for TRS beneficiaries.
This report examines (1) how DOD ensures that members of the Selected
Reserve are informed about TRS and (2) how DOD monitors and evaluates
access to civilian providers for TRS beneficiaries. GAO reviewed and
analyzed documents and evaluated an analysis of claims conducted by
DOD. GAO also interviewed officials with the TRICARE Management
Activity (TMA), the DOD entity responsible for managing TRICARE; the
regional TRICARE contractors; the Office of Reserve Affairs; and the
seven reserve components.
What GAO Found:
DOD does not have reasonable assurance that Selected Reserve members
are informed about TRS. A 2007 policy designated the reserve
components as having responsibility for providing information about
TRS to Selected Reserve members on an annual basis; however, officials
from three of the seven components told GAO that they were unaware of
this policy. Additionally, only one of the reserve components had a
designated official at the headquarters level acting as a central
point of contact for TRICARE education, including TRS. Without
centralized responsibility for TRS education, the reserve components
cannot ensure that all eligible Selected Reserve members are receiving
information about the TRS program. Compounding this, the managed care
support contractors that manage civilian health care are limited in
their ability to educate all reserve component units in their regions
as required by their contracts because they do not have access to
comprehensive information about these units, and some units choose not
to use the contractors to help educate their members about TRS.
Nonetheless, DOD officials stated that they were satisfied with the
contractors‘ efforts to educate units upon request and to conduct
outreach. Lastly, it is difficult to determine whether Selected
Reserve members are knowledgeable about TRS because the results of two
DOD surveys that gauged members‘ awareness of the program may not be
representative because of low response rates.
Because TRS is the same benefit as the TRICARE Standard and Extra
options, DOD monitors access to civilian providers for TRS
beneficiaries in conjunction with TRICARE Standard and Extra
beneficiaries. DOD has mainly used feedback mechanisms, such as
surveys, to gauge access to civilian providers for these beneficiaries
in the absence of access standards for these options. GAO found that
jointly monitoring access for these two beneficiary groups is
reasonable because a claims analysis showed that TRS beneficiaries and
TRICARE Standard and Extra beneficiaries had similar health care
utilization. Also, during the course of GAO‘s review, TMA initiated
other efforts that specifically evaluated access to civilian providers
for the Selected Reserve population and TRS beneficiaries, including
mapping the locations of Selected Reserve members in relation to areas
with TRICARE provider networks.
What GAO Recommends:
GAO recommends that the Secretary of Defense direct the Assistant
Secretary of Defense for Reserve Affairs to develop a policy requiring
each reserve component to designate a centralized point of contact for
TRS education. DOD partially concurred with this recommendation,
citing a concern about regional coordination. GAO modified the
recommendation.
View [hyperlink, http://www.gao.gov/products/GAO-11-551] or key
components. For more information, contact Randall B. Williamson at
(202) 512-7114 or williamsonr@gao.gov.
[End of section]
Contents:
Letter:
Background:
DOD Does Not Have Reasonable Assurance That Selected Reserve Members
Are Informed about TRS:
DOD Monitors Access to Civilian Providers under TRS in Conjunction
with Other TRICARE Options and Has Taken Steps to Evaluate Access
Specifically for TRS:
Conclusions:
Recommendation for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: TRICARE Management Activity Analysis of Claims:
Appendix II: Claims Filed for TRICARE Reserve Select and TRICARE
Standard and Extra Beneficiaries:
Appendix III: Comments from the Department of Defense:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Summary of TRICARE Options:
Table 2: Percentage of Claims Filed for TRICARE Reserve Select (TRS)
and TRICARE Standard and Extra Beneficiaries by Age of Beneficiary,
Fiscal Years 2008 through 2010:
Table 3: Percentage of Claims Filed for TRICARE Reserve Select (TRS)
and TRICARE Standard and Extra Beneficiaries by Mental Health Care,
Primary Health Care, and Other Types of Specialty Care, Fiscal Years
2008 through 2010:
Table 4: Percentage of Claims Filed for TRICARE Reserve Select (TRS)
and TRICARE Standard and Extra Beneficiaries by Top 10 Diagnoses in
Ranking Order, Fiscal Years 2008 through 2010:
Table 5: Percentage of Claims Filed for TRICARE Reserve Select (TRS)
and TRICARE Standard and Extra Beneficiaries by Top Five Provider
Specialties, Fiscal Years 2008 through 2010:
Figures:
Figure 1: Number of Selected Reserve Members by Component as a
Percentage of All Selected Reserve Members, December 31, 2010:
Figure 2: Age and Marital Status of Selected Reserve Members, December
31, 2010:
Figure 3: Cycle of TRICARE Coverage and Eligibility as of December 31,
2010:
Figure 4: Proportion of Claims Filed by TRICARE Reserve Select and
TRICARE Standard and Extra Beneficiaries for Mental Health, Primary,
and Other Specialty Care, Fiscal Years 2008 through 2010:
Abbreviations:
DMDC: Defense Manpower Data Center:
DOD: Department of Defense:
FEHB: Federal Employees Health Benefits:
NDAA: National Defense Authorization Act:
TAMP: Transitional Assistance Management Program:
TMA: TRICARE Management Activity:
TRS: TRICARE Reserve Select:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
June 3, 2011:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Member:
Committee on Armed Services:
United States Senate:
The Honorable Howard P. "Buck" McKeon:
Chairman:
The Honorable Adam Smith:
Ranking Member:
Committee on Armed Services:
House of Representatives:
Since the September 11, 2001, terrorist attacks, the Department of
Defense (DOD) has increasingly relied on reservists to support
military operations, such as the conflicts in Iraq and Afghanistan.
This has increased both the number of Selected Reserve members--
reservists who are considered essential to wartime missions--
supporting DOD's current operations and the duration of their active
duty service.[Footnote 1] In recognition of this, Congress has
increased the health care benefits available to reservists and their
dependents, which include spouses and dependent children.
Specifically, the National Defense Authorization Acts (NDAA) for
Fiscal Years 2004, 2005, 2006, 2007, and 2010 expanded the number of
reservists (including Selected Reserve members) who qualify for
TRICARE, the military health care program, and increased the period of
time during which they qualify.[Footnote 2] The NDAA for Fiscal Year
2005 also established the program that DOD has named TRICARE Reserve
Select (TRS), under which most members of the Selected Reserve who are
not on active duty may purchase TRICARE coverage after the coverage
associated with active duty expires. TRS is the same benefit as
TRICARE Standard, a fee-for-service option, and TRICARE Extra, a
preferred provider option. All three programs cover health care
provided at military treatment facilities and through civilian
providers, both network (TRICARE Extra) and nonnetwork (TRICARE
Standard).[Footnote 3] However, unlike TRICARE beneficiaries who use
the Standard and Extra options, TRS enrollees must pay a monthly
premium to receive benefits through the program.
In recent years, members of Congress have raised questions about
whether reservists, including members of the Selected Reserve, and
their dependents have adequate health insurance when they are not on
active duty and whether they have difficulty using TRICARE when they
are eligible for it. In 2007, we reported on several issues related to
reservists, including DOD's efforts to educate reservists and their
dependents about TRICARE benefits, reservists' satisfaction with
TRICARE, and the types of problems that reservists and their
dependents experienced when using TRICARE.[Footnote 4] We found that
DOD was challenged by the task of educating reservists and their
dependents about TRICARE, and we recommended that DOD provide
additional briefings to reservists and their dependents at specific
points in time. We also found that although a majority of reservists
reported that they were satisfied with their TRICARE benefits, some
reservists reported experiencing difficulties when using the program,
including difficulties understanding TRICARE and difficulties finding
a health care provider who accepted TRICARE beneficiaries as patients.
Subsequent to our report, the Commission on the National Guard and
Reserves reported to Congress in 2008 that the TRICARE Management
Activity (TMA)--the DOD entity responsible for overseeing TRICARE--and
the military services have not undertaken a sufficiently aggressive
educational campaign to help improve reservists' and their families'
understanding of TRICARE.[Footnote 5] More recently, groups
representing military beneficiaries told us that they were concerned
about low enrollment within the TRS program, and they questioned
whether these enrollment numbers are the result of inadequate
education by DOD. According to DOD officials, as of December 2010
about 392,000 of the more than 858,000 members of the Selected Reserve
were eligible for TRS.[Footnote 6] Of these, about 67,000 members (17
percent) had purchased TRS.
Concerns have also been expressed about the ability of reservists,
including members of the Selected Reserve, and their families to
access health care. In June 2007, DOD's Task Force on Mental Health
reported that because reservists may not live near military
installations like their active duty counterparts, they may not have
convenient access to military hospitals and clinics and must instead
rely more heavily on civilian providers for their care.[Footnote 7]
The NDAA for Fiscal Year 2008 directed us to review DOD's efforts to
educate members of the Selected Reserve about TRS and access to care
for TRS beneficiaries.[Footnote 8] This report examines (1) how DOD
ensures that members of the Selected Reserve are informed about TRS
and (2) how DOD monitors and evaluates access to civilian providers
for TRS beneficiaries.
To examine how DOD ensures that members of the Selected Reserve are
informed about TRS and how DOD monitors and evaluates access to
civilian providers for TRS beneficiaries, we interviewed officials
with TMA, including officials with the Warrior Support Branch, which
oversees TRS, and officials with the Communications and Customer
Service Division, which develops educational materials for TRICARE. We
also interviewed officials from each of the three TRICARE Regional
Offices (North, South, and West) and officials from each of the
regional managed care support contractors (contractors) to discuss
their responsibilities for educating members of the Selected Reserve
about TRICARE, including TRS, and for ensuring beneficiaries' access
to civilian providers. In addition, we interviewed officials from
military coalition groups that represent reservists to obtain their
perspectives on TRS education and access to civilian providers. To
identify TRS education requirements, we reviewed and analyzed policy
guidelines and TRICARE managed care support contract requirements. We
interviewed officials with the Office of Reserve Affairs as well as
officials from each of the seven reserve components to identify their
role in educating the Selected Reserve about TRICARE. We also reviewed
relevant standards for internal control in the federal government.
[Footnote 9] Additionally, we evaluated two surveys conducted by DOD
that collected information on whether members of the Selected Reserve
were aware of the TRS program--the Status of Forces Survey and the
Focused Survey of TRICARE Reserve Select and Selected Reserve Military
Health System Access and Satisfaction.
To determine how DOD monitors and evaluates access to civilian
providers for TRS, we reviewed TMA's beneficiary surveys on access to
civilian providers under TRICARE Standard, TRICARE Extra, and TRS. We
also reviewed the TRICARE Regional Offices' recent efforts to evaluate
the adequacy of access to civilian providers under the TRICARE
Standard, TRICARE Extra, and TRS options. Additionally, we evaluated
an analysis of claims conducted by TMA--at our request--that compared
claims filed by TRICARE Standard and Extra beneficiaries with those
filed by TRS beneficiaries for fiscal years 2008 through 2010 to
identify demographic differences between these populations and to
determine whether these populations used similar types of providers
and obtained similar types of care. We assessed the reliability of
these data by speaking with knowledgeable officials and reviewing
related documentation, and we determined that the claims analyses
presented in this report are sufficiently reliable for our purposes.
(See appendix I for more detail about the claims analyses.) We also
reviewed efforts by TMA to identify locations of the Selected Reserve
members and analyze whether they resided within an area that was
served by a TRICARE provider network. Finally, we reviewed TMA's
efforts to repeat its survey that is specific to the TRS program
(Focused Survey of TRICARE Reserve Select and Selected Reserve
Military Health System Access and Satisfaction).
We conducted this performance audit from July 2010 through June 2011
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:
Reservists are members of the seven reserve components, which provide
trained and qualified persons available for active duty in the armed
forces in time of war or national emergency. The Selected Reserve is
the largest category of reservists and is designated as essential to
wartime missions.[Footnote 10] The Selected Reserve is also the only
category of reservists that is eligible for TRS. As of December 31,
2010, the Selected Reserve included 858,997 members dispersed among
the seven reserve components with about two-thirds belonging to the
Army Reserve and the Army National Guard.[Footnote 11] See figure 1
for the number and percentage of Selected Reserve members within each
reserve component.
Figure 1: Number of Selected Reserve Members by Component as a
Percentage of All Selected Reserve Members, December 31, 2010:
[Refer to PDF for image: vertical bar graph]
Reserve Component: Army National Guard;
Number of Selected Reserve Members: 364,111 (42%).
Reserve Component: Army Reserve;
Number of Selected Reserve Members: 205,525 (24%).
Total Army: 569,636 (66%).
Reserve Component: Navy Reserve;
Number of Selected Reserve Members: 64,649 (8%).
Reserve Component: Marine Corps Reserve;
Number of Selected Reserve Members: 39,676 (5%).
Reserve Component: Air National Guard;
Number of Selected Reserve Members: 106,816 (12%).
Reserve Component: Air Force Reserve;
Number of Selected Reserve Members: 70,278 (8%).
Reserve Component: Coast Guard;
Number of Selected Reserve Members: 7,942 (1%).
Source: GAO analysis of Department of Defense data.
[End of figure]
Additionally, about two-thirds of the Selected Reserve members are 35
years old or younger (64 percent) and about half are single (52
percent). (See figure 2.)
Figure 2: Age and Marital Status of Selected Reserve Members, December
31, 2010:
[Refer to PDF for image: 2 vertical bar graphs]
Age range: 18-24;
Percentage: 29%.
Age range: 25-29;
Percentage: 20%.
Age range: 30-35;
Percentage: 15%.
Age range: 36-40;
Percentage: 12%.
Age range: 41-45;
Percentage: 11%.
Age range: Over 45;
Percentage: 13%.
Marital/dependent category: Married with dependents;
Percentage: 46%.
Marital/dependent category: Married without dependents;
Percentage: 2%.
Marital/dependent category: Single with dependents;
Percentage: 9%.
Marital/dependent category: Single without dependents;
Percentage: 43%.
Source: GAO analysis of Department of Defense data.
[End of figure]
History of TRS:
The NDAA for Fiscal Year 2005 authorized the TRS program and made
TRICARE coverage available to certain members of the Selected
Reserve.[Footnote 12] The program was subsequently expanded and
restructured by the NDAAs for Fiscal Years 2006 and 2007[Footnote 13]--
although additional program changes were made in subsequent years.
[Footnote 14]
* In fiscal year 2005, to qualify for TRS, members of the Selected
Reserve had to enter into an agreement with their respective reserve
components to continue to serve in the Selected Reserve in exchange
for TRS coverage, and they were given 1 year of TRS eligibility for
every 90 days served in support of a contingency operation.[Footnote
15]
* The NDAA for Fiscal Year 2006, which became effective on October 1,
2006, expanded the program, and almost all members of the Selected
Reserve and their dependents--regardless of their prior active duty
service--had the option of purchasing TRICARE coverage through a
monthly premium. The portion of the premium paid by the members of the
Selected Reserve and their dependents for TRS coverage varied based on
certain qualifying conditions that had to be met, such as whether the
member of the Selected Reserve also had access to an employer-
sponsored health plan. The NDAA for Fiscal Year 2006 established two
levels--which DOD called tiers--of qualification for TRS, in addition
to the tier established by the NDAA for Fiscal Year 2005, with
enrollees paying different portions of the premium based on the tier
for which they qualified.[Footnote 16]
* The NDAA for Fiscal Year 2007 significantly restructured the TRS
program by eliminating the three-tiered premium structure and
establishing open enrollment for members of the Selected Reserve
provided that they are not eligible for or currently enrolled in the
FEHB Program.[Footnote 17] The act removed the requirement that
members of the Selected Reserve sign service agreements to qualify for
TRS. Instead, the act established that members of the Selected Reserve
qualify for TRS for the duration of their service in the Selected
Reserve. DOD implemented these changes on October 1, 2007.
TRICARE Options and Cycle of Coverage for the Selected Reserve:
Generally, TRICARE provides its benefits through several options for
its non-Medicare-eligible beneficiary population.[Footnote 18] These
options vary according to TRICARE beneficiary enrollment requirements,
the choices TRICARE beneficiaries have in selecting civilian and
military treatment facility providers, and the amount TRICARE
beneficiaries must contribute toward the cost of their care. Table 1
provides information about these options.
Table 1: Summary of TRICARE Options:
TRICARE option: TRICARE Prime;
Description: Active duty servicemembers are required to enroll in this
managed care option while other TRICARE beneficiaries may choose to
enroll in this option. TRICARE Prime enrollees receive most of their
care from providers at military treatment facilities, augmented by
network civilian providers. TRICARE Prime offers lower out-of-pocket
costs than the other TRICARE options. It is also the only option with
access standards, which include appointment wait times and travel
times.
TRICARE option: TRICARE Standard and TRICARE Extra;
Description: TRICARE beneficiaries, who are not on active duty, who
choose not to enroll in TRICARE Prime may obtain health care from
nonnetwork civilian providers (under TRICARE Standard) or network
civilian providers (under TRICARE Extra). Under TRICARE Extra,
beneficiaries have lower cost-shares than they would have under the
TRICARE Standard option--about 5 percentage points less for using
network providers.
TRICARE option: TRICARE Reserve Select (TRS);
Description: TRS is a premium-based health plan that certain members
of the Selected Reserve, who are not on active duty, may purchase.
Under TRS, beneficiaries may obtain health care from either nonnetwork
or network civilian providers, similar to beneficiaries using TRICARE
Standard or Extra, respectively, and will pay lower cost-shares for
using network providers.
Source: GAO summary of Department of Defense TRICARE documentation.
Note: All beneficiaries may obtain care at military treatment
facilities although priority is first given to active duty personnel
and then TRICARE Prime enrollees.
[End of table]
Selected Reserve members have a cycle of coverage during which they
are eligible for different TRICARE options based on their duty status--
preactivation, active duty, deactivation, and inactive. During
preactivation, when members of the Selected Reserve are notified that
they will serve on active duty in support of a contingency operation
in the near future, they and their families are eligible to enroll in
TRICARE Prime, and therefore, they do not need to purchase TRS
coverage.[Footnote 19] This is commonly referred to as "early
eligibility" and continues uninterrupted once members of the Selected
Reserve begin active duty. While on active duty, members are required
to enroll in TRICARE Prime. Similarly during deactivation, for 180
days after returning from active duty in support of a contingency
operation, members of the Selected Reserve are rendered eligible for
the Transitional Assistance Management Program, a program to
transition back to civilian life in which members and dependents can
use the TRICARE Standard or Extra options.[Footnote 20] When members
of the Selected Reserve return to inactive status, they can choose to
purchase TRS coverage if eligible.
As a result of the TRICARE coverage cycle and program eligibility
requirements, TMA officials estimate that at any given time, fewer
than half of the members of the Selected Reserve are qualified to
purchase TRS. Currently, to qualify for TRS, a member of the Selected
Reserve must not:
* be eligible for the FEHB Program,
* have been notified that he or she will serve on active duty in
support of a contingency operation, and:
* be serving on active duty or have recently, that is, within 180
days, returned from active duty in support of a contingency operation.
Of the more than 390,000 members eligible, about 67,000 members were
enrolled in TRS as of December 31, 2010. (See figure 3.)
Figure 3: Cycle of TRICARE Coverage and Eligibility as of December 31,
2010:
[Refer to PDF for image: illustrated vertical bar graph]
Total:
There are 858,997 total members of the Selected Reserve.
FEHB:
About 103,080 (12%) were eligible for the Federal Employees Health
Benefits (FEHB) Program, which makes them ineligible for TRS.
Cycle of TRICARE coverage:
1. Preactivation (Up to 180 days early eligibility):
Member is eligible to enroll in TRICARE Prime[A].
About 40,000 (5%) were enrolled in early eligibility prior to active
duty.
2. Activation (Active duty):
Member is required to enroll in TRICARE Prime[B].
About 284,000 (33%) have been called to active duty.
3. Deactivation (Leaving active duty):
Member is enrolled in Transitional Assistance Management Program
(TAMP) and members can use TRICARE Standard and Extra[C].
About 40,000 (5%) were enrolled in the TAMP, which is for a period of
180 days.
4. Inactive status (Continued coverage);
Member can enroll in TRICARE Reserve Select (TRS), if they qualify and
elect to purchase coverage[D].
Of the 391,917 remaining, who are eligible for TRS, about 67,000
enrolled.
Source: GAO analysis of Department of Defense data.
[A] If a Selected Reserve member was enrolled in TRS prior to
preactivation, the member is automatically disenrolled at this time.
Even if a member does not enroll, the member will receive TRICARE
benefits. In addition, at this time, members and their families begin
receiving the same care as active duty servicemembers and their
families. This is applicable when a member of the Selected Reserve is
called to active duty for more than 30 days and is serving in support
of a contingency operation.
[B] Even if a member does not enroll he or she will still receive
TRICARE Prime benefits.
[C] TAMP is applicable when a member of the Selected Reserve is called
to active duty for more than 30 days and is serving in support of a
contingency operation. TRICARE Prime is available in specific
locations.
[D] If a member was enrolled in TRS prior to serving on active duty,
the member must reenroll after returning to inactive status. Members
are not automatically reenrolled in TRS; they must requalify and
purchase TRS again. In addition, the cycle repeats once a Selected
Reserve member is called to active duty.
[End of figure]
DOD Entities Involved with TRS:
A number of different DOD entities have various responsibilities
related to TRS.
* Within the Office of the Under Secretary of Defense for Personnel
and Readiness, the Office of the Assistant Secretary of Defense for
Reserve Affairs works with the seven reserve components to determine
whether members of the Selected Reserve are eligible for TRS and to
ensure that members have information about TRICARE, including TRS.
* Within TMA, the Warrior Support Branch is responsible for managing
the TRS option, which includes developing policy and regulations. This
office also works with TMA's Communication and Customer Service
Division to develop educational materials for this program. The
Assistant Secretary of Defense for Health Affairs oversees TMA and
reports to the Under Secretary of Defense for Personnel and Readiness.
* TMA works with contractors to manage civilian health care and other
services in each TRICARE region (North, South, and West).[Footnote 21]
The contractors are required to establish and maintain sufficient
networks of civilian providers within certain designated areas, called
Prime Service Areas, to ensure access to civilian providers for all
TRICARE beneficiaries, regardless of enrollment status or Medicare
eligibility.[Footnote 22] They are also responsible for helping
TRICARE beneficiaries locate providers and for informing and educating
TRICARE beneficiaries and providers on all aspects of the TRICARE
program, including TRS.
* TMA's TRICARE Regional Offices, located in each of the three TRICARE
regions, are responsible for managing health care delivery for all
TRICARE options in their respective geographic areas and overseeing
the contractors, including monitoring network quality and adequacy,
monitoring customer satisfaction outcomes, and coordinating
appointment and referral management policies.
DOD Does Not Have Reasonable Assurance That Selected Reserve Members
Are Informed about TRS:
DOD does not have reasonable assurance that members of the Selected
Reserve are informed about TRS for several reasons. First, the reserve
components do not have a centralized point of contact to ensure that
members are educated about the program. Second, the contractors are
challenged in their ability to educate the reserve component units in
their respective regions because they do not have comprehensive
information about the units in their areas of responsibility. And,
finally, DOD cannot say with certainty whether Selected Reserve
members are knowledgeable about TRS because the results of two surveys
that gauged members' awareness of the program may not be
representative of the Selected Reserve population because of low
response rates.
Reserve Components Are Responsible for Providing Information about TRS
to Selected Reserve Members, but Most Components Have Not Established
Centralized Accountability for TRS Education:
A 2007 policy from the Under Secretary of Defense for Personnel and
Readiness designated the reserve components as having responsibility
for providing information about TRS to members of the Selected Reserve
at least once a year. When the policy was first issued, officials from
the Office of Reserve Affairs--who have oversight responsibility for
the reserve components--told us that they met with officials from each
of the reserve components to discuss how the components would fulfill
this responsibility. However, according to officials from the Office
of Reserve Affairs, they have not met with the reserve components
since 2008 to discuss how the components are fulfilling their TRS
education responsibilities under the policy. These officials explained
that they have experienced difficulties identifying a representative
from each of the reserve components to attend meetings about TRS
education. When we contacted officials from all seven reserve
components to discuss TRS education, we had similar experiences. Three
of the components had difficulties providing a point of contact. In
fact, two of the components took several months to identify an
official whom we could speak with about TRS education, and the other
one had difficulties identifying someone who could answer our follow-
up questions when our original point of contact was no longer
available. Furthermore, officials from three of the seven components
told us that they were not aware of this policy.
Regardless of their knowledge of the 2007 policy, officials from all
of the reserve components told us that education responsibilities are
delegated to their unit commanders. These responsibilities include
informing members about their health options, which would include TRS.
All of the components provide various means of support to their unit
commanders to help fulfill this responsibility.[Footnote 23] For
example, three of the components provide information about TRICARE
directly to their unit commanders or the commanders' designees through
briefings. The four other components provide information to their unit
commanders through other means, such as policy documents, Web sites,
and newsletters.
Additionally, while most of the components had someone designated to
answer TRICARE benefit questions, only one of the reserve components
had an official at the headquarters level designated as a central
point of contact for TRICARE education, including TRS.[Footnote 24]
This official told us that he was unaware of the specific 2007 TRS
education policy; however, he said his responsibilities for TRS
education include developing annual communication plans, providing
briefings to unit commanders, and publishing articles in the Air Force
magazine about TRS. Designating a point of contact is important
because a key factor in meeting standards for internal control in
federal agencies is defining and assigning key areas of authority and
responsibility--such as a point of contact for a specific policy.
Without a point of contact to ensure that this policy is implemented,
the reserve components are running the risk that some of their
Selected Reserve members may not be receiving information about the
TRS program--especially since some of the reserve component officials
we met with were unaware of the policy.
TRICARE Contractors Are Challenged in Their Ability to Annually Brief
Reserve Component Units about TRS Because They Lack Comprehensive
Information about the Units:
The TRICARE contractors are required to provide an annual briefing
about TRS to each reserve component unit in their regions, including
both Reserve and National Guard units. All three contractors told us
that they maintain education representatives who are responsible for
educating members of the Selected Reserve on TRS. These
representatives conduct unit outreach and provide information to
members of the Selected Reserve at any time during predeployment and
demobilization, at family events, and during drill weekends. The
contractors use briefing materials maintained by TMA and posted on the
TRICARE Web site. In addition to conducting briefings, the three
contractors have increased their outreach efforts in various ways,
including creating an online tutorial that explains TRS, mailing TRS
information to Selected Reserve members, and working closely with
Family Program coordinators to provide TRS information to family
members.
However, the contractors are challenged in their ability to meet their
requirement for briefing all units annually. First, they typically
provide briefings to units upon request because this approach is
practical based upon units' schedules and availability. For example,
officials from one contractor told us that even though they know when
geographically dispersed units will be gathering in one location,
these units have busy schedules and may not have time for the
contractor to provide a briefing. Each contractor records the
briefings that are requested, when the briefing requests were
fulfilled and by whom, and any questions or concerns that resulted
from the briefings. However, some unit commanders do not request
briefings from the contractors. For example, officials with one
reserve component told us that they do not rely on the contractor to
brief units because they were unaware that the contractors provided
this service. In addition, these officials as well as officials from
another reserve component told us that they did not know if their unit
commanders were aware that they could request briefings from the
contractors. All of the contractors told us that they conduct outreach
to offer information to some of the units that have not requested a
briefing, including both calling units to offer a briefing and
providing materials. They added that more outreach is conducted to
National Guard units because they are able to obtain information about
these units from state officials. The TRICARE Regional Offices also
told us that they conduct outreach to units to let them know that the
contractor is available to brief the units about TRS. However, even
though the contractor and the TRICARE Regional Offices conduct
outreach to a unit, it does not necessarily mean that the unit will
request a briefing.
Furthermore, while contractors are aware of some units in their
regions, they do not have access to comprehensive lists of all reserve
component units in their regions because the Web site links containing
unit information that TMA originally provided to the contractors have
become inactive. As a result, the contractors are not able to verify
whether all units in their regions have received briefings. Officials
from the Office of Reserve Affairs told us that reserve components
report unit information to the Defense Manpower Data Center (DMDC),
which maintains personnel information about all members of the
military. However, these officials raised concerns about the accuracy
of this information because it could be about 3 to 6 months old and
may not be comprehensive. Officials at the Office of Reserve Affairs
told us that the reserve components would likely have more up-to-date
information about their units as they are responsible for reporting
this information to DMDC. However, officials from TMA, the TRICARE
Regional Offices, and contractors also told us that a comprehensive
list of units would be difficult to maintain because the unit
structure changes frequently.
Despite the challenges contractors face, officials with TMA's Warrior
Support Branch told us that they are satisfied with the contractors'
efforts to provide TRS briefings to the reserve component units in
their regions. However, because officials do not know which units have
been briefed on the program, there is a risk that some reserve
component members are not receiving sufficient information on TRS and
may not be taking advantage of coverage available to them.
DOD Has Conducted Surveys That Gauge TRS Awareness, but the Results
May Not Be Representative:
DOD has conducted two surveys that gauge whether members of the
Selected Reserve are aware of TRS, among other issues. In 2008, TMA
conducted the Focused Survey of TRICARE Reserve Select and Selected
Reserve Military Health System Access and Satisfaction to better
understand reserve component members' motivation for enrolling in TRS
and to compare TRS enrollees' satisfaction with and access to health
care services with that of other beneficiary groups.[Footnote 25] In
reporting the results of this survey to Congress in February 2009, TMA
stated that lack of awareness was an important factor in why eligible
members of the Selected Reserve did not enroll in TRS.[Footnote 26]
TMA also reported that less than half of the eligible Selected Reserve
members who were not enrolled in TRS were aware of the program.
[Footnote 27] However, the survey's response rate was almost 18
percent, and such a low response rate decreases the likelihood that
the survey results were representative of the views and
characteristics of the Selected Reserve population. According to the
Office of Management and Budget's standards for statistical surveys, a
nonresponse analysis is recommended for surveys with response rates
lower than 80 percent to determine whether the responses are
representative of the surveyed population. Accordingly, TMA conducted
a nonresponse analysis to determine whether the survey responses it
received were representative of the surveyed population, and the
analysis identified substantial differences between the original
respondents and the follow-up respondents. As a result of the
differences found in the nonresponse analysis, TMA adjusted the
statistical weighting techniques for nonresponse bias and applied the
weights to the data before drawing conclusions and reporting the
results.
DMDC conducts a quarterly survey, called the Status of Forces Survey,
which is directed to all members of the military services. DMDC
conducts several versions of this survey, including a version for
members of the reserve components. This survey focuses on different
issues at different points in time. For example, every other year the
survey includes questions on health benefits, including questions on
whether members of the reserve components are aware of TRICARE,
including TRS. In July 2010, we issued a report raising concerns about
the reliability of DOD's Status of Forces Surveys because they
generally have a 25 to 42 percent response rate, and DMDC has not been
conducting nonresponse analyses to determine whether the surveys'
results are representative of the target population.[Footnote 28] We
recommended that DMDC develop and implement guidance both for
conducting a nonresponse analysis and using the results of this
analysis to inform DMDC's statistical weighting techniques, as part of
the collection and analysis of the Status of Forces Survey results.
DOD concurred with this recommendation, but as of January 2011, had
not implemented it.
DOD Monitors Access to Civilian Providers under TRS in Conjunction
with Other TRICARE Options and Has Taken Steps to Evaluate Access
Specifically for TRS:
DOD monitors access to civilian providers under TRS in conjunction
with monitoring efforts related to the TRICARE Standard and Extra
options. In addition, during the course of our review, TMA initiated
additional efforts that specifically examine access to civilian
providers for TRS beneficiaries and the Selected Reserve population,
including mapping the locations of Selected Reserve members in
relation to areas with TRICARE provider networks.
DOD Monitors Access to Civilian Providers for TRS Beneficiaries along
with TRICARE Standard and Extra Beneficiaries:
Because TRS is the same benefit as the TRICARE Standard and Extra
options, DOD monitors TRS beneficiaries' access to civilian providers
as a part of monitoring access to civilian providers for beneficiaries
who use TRICARE Standard and Extra. As we have recently reported, in
the absence of access-to-care standards for these options, TMA has
mainly used feedback mechanisms to gauge access to civilian providers
for these beneficiaries.[Footnote 29] For example, in response to a
mandate included in the NDAA for Fiscal Year 2008, DOD has completed 2
years of a multiyear survey of beneficiaries who use the TRICARE
Standard, TRICARE Extra, and TRS options and 2 years of its second
multiyear survey of civilian providers. Congress required that these
surveys obtain information on access to care and that DOD give a high
priority to locations having high concentrations of Selected Reserve
members. In March 2010, we reported that TMA generally addressed the
methodological requirements outlined in the mandate during the
implementation of the first year of the multiyear surveys.[Footnote
30] While TMA did not give a high priority to locations with high
concentrations of Selected Reserve members, TMA's methodological
approach over the 4-year survey period will cover the entire United
States, including areas with high concentrations of Selected Reserve
members.
In February 2010, TMA directed the TRICARE Regional Offices to monitor
access to civilian providers for TRICARE Standard, TRICARE Extra, and
TRS beneficiaries through the development of a model that can be used
to identify geographic areas where beneficiaries may experience access
problems. As of May 2010, each of the TRICARE Regional Offices had
implemented an initial model appropriate to its region. These models
include, for example, data on area populations, provider types, and
potential provider shortages for the general population. Officials at
each regional office said that their models are useful but noted that
they are evolving and will be updated.
To determine whether jointly monitoring access to civilian providers
for TRS beneficiaries along with TRICARE Standard and Extra
beneficiaries was reasonable, we asked TMA to perform an analysis of
claims (for fiscal years 2008, 2009, and 2010) to identify differences
in age demographics and health care utilization between these
beneficiary groups. This analysis found that although the age
demographics for these populations were different--more than half of
the TRS beneficiaries were age 29 and under, while more than half of
the TRICARE Standard and Extra beneficiaries were over 45--both groups
otherwise shared similarities with their health care utilization.
[Footnote 31] Specifically, both beneficiary groups had similar
diagnoses, used the same types of specialty providers, and used
similar proportions of mental health care, primary care, and specialty
care. (See figure 4.) Specifically:
* Seven of the top 10 diagnoses for both TRS and TRICARE Standard and
Extra beneficiaries were the same. Three of these diagnoses--allergic
rhinitis,[Footnote 32] joint disorder, and back disorder--made up more
than 20 percent of claims for both beneficiary groups.
* The five provider specialties that filed the most claims for both
beneficiary groups were the same--family practice, physical therapy,
allergy, internal medicine, and pediatrics. Furthermore, the majority
of claims filed for both beneficiary groups were filed by family
practice providers.
* Both beneficiary groups had the same percentage of claims filed for
mental health care and similar percentages for primary care and other
specialty care. (See appendix II for additional details on the results
of this claims analysis.)
Based on this analysis, jointly monitoring access for TRS
beneficiaries and TRICARE Standard and Extra beneficiaries appears to
be a reasonable approach.
Figure 4: Proportion of Claims Filed by TRICARE Reserve Select and
TRICARE Standard and Extra Beneficiaries for Mental Health, Primary,
and Other Specialty Care, Fiscal Years 2008 through 2010:
[Refer to PDF for image: 2 pie-charts]
TRS beneficiaries:
Mental health care: 6.7%;
Primary health care: 43.8%;
Other specialty care: 49.5%.
TRICARE standard and extra beneficiaries:
Mental health care: 6.7%;
Primary health care: 38.6%;
Other specialty care: 54.7%.
Source: GAO analysis of TRICARE Management Activity data.
[End of figure]
DOD Has Taken Steps to Separately Evaluate Access to Civilian
Providers for the Selected Reserve Population and TRS Beneficiaries:
DOD has taken steps to evaluate access to civilian providers for the
Selected Reserve population and TRS beneficiaries separately from
other TRICARE beneficiaries. Specifically, during the course of our
review, TMA initiated the following efforts:
* During the fall of 2010, TMA officials analyzed the locations of
Selected Reserve members and their families, including TRS
beneficiaries, to determine what percentage of them live within
TRICARE's Prime Service Areas (areas in which the managed care
contractors are required to establish and maintain sufficient networks
of civilian providers). According to these data, as of August 31,
2010, over 80 percent of Selected Reserve members and their families
lived in Prime Service Areas: 100 percent in the South region, which
is all Prime Service Areas, and over 70 percent in the North and West
regions.[Footnote 33]
* TMA officials told us that they are repeating the Focused Survey of
TRICARE Reserve Select and Select Reserve Military Health System
Access and Satisfaction, which had first been conducted in 2008. Using
results from its first survey, TMA reported to Congress in February
2009 that members of the Selected Reserve who were enrolled in TRS
were pleased with access and quality of care under their plan.
However, as we have noted, the response rate for this survey was
almost 18 percent, although TMA took steps to adjust the data prior to
reporting the results. Officials told us that the follow-up survey
will focus on whether access to care for TRS beneficiaries has
changed. Officials sent the survey instrument to participants in
January 2011. Officials told us that they anticipate results will be
available during the summer of 2011.
Conclusions:
TRS is an important option for members of the Selected Reserve.
However, educating this population about TRS has been challenging, and
despite efforts by the reserve components and the contractors, some
members of the Selected Reserve are likely still unaware of this
option. Most of the reserve components lack centralized accountability
for TRS education, making it unclear if all members are getting
information about the program--a concern that is further exacerbated
by the lack of awareness about the TRS education policy among
officials from some of the reserve components. Additionally, the
contractors' limitations in briefing all of the units in their regions
about TRS make each component's need for a central point of contact
more evident. Without centralized accountability, the reserve
components do not have assurance that all members of the Selected
Reserve who may need TRS have the information they need to take
advantage of the health care options available to them.
Recommendation for Executive Action:
We recommend that the Secretary of Defense direct the Assistant
Secretary of Defense for Reserve Affairs to develop a policy that
requires each reserve component to designate a centralized point of
contact for TRS education, who will be accountable for ensuring that
the reserve components are providing information about TRS to their
Selected Reserve members annually. In establishing responsibilities
for the centralized points of contact, DOD should explicitly task them
with coordinating with their respective TRICARE Regional Offices to
ensure that contractors are provided information on the number and
location of reserve component units in their regions.
Agency Comments and Our Evaluation:
In commenting on a draft of this report, DOD partially concurred with
our recommendation. (DOD's comments are reprinted in appendix III.)
Specifically, DOD agreed that the Assistant Secretary of Defense for
Reserve Affairs should develop a policy that requires each of the
seven reserve components to designate a central point of contact for
TRS education that will be accountable for providing information about
TRS to their Selected Reserve members annually. However, DOD countered
that each designee should coordinate the provision of reserve unit
information through the TRICARE Regional Offices rather than
communicating directly with the TRICARE contractors, noting that the
TRICARE Regional Offices have oversight responsibility for the
contractors in their respective regions. We understand the
department's concern about coordinating contractor communications
through the TRICARE Regional Offices, and we have modified our
recommendation accordingly. DOD also provided technical comments,
which we incorporated where appropriate.
We are sending copies of this report to the Secretary of Defense and
other interested parties. The report also is available at no charge on
the GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staff members 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. Key contributors to this
report are listed in appendix IV.
Signed by:
Randall B. Williamson:
Director, Health Care:
[End of section]
Appendix I: TRICARE Management Activity Analysis of Claims:
We asked the TRICARE Management Activity (TMA) to conduct an analysis
of claims filed for TRICARE Reserve Select (TRS) beneficiaries and
TRICARE Standard and Extra beneficiaries. We requested claims data for
the most recent three complete fiscal years--2008, 2009, and 2010--
based on the fact that the program last experienced changes with
eligibility and premiums in fiscal year 2007.[Footnote 34] For the
purpose of this analysis, claims consist of all services provided by a
professional in an office or other setting outside of an institution.
Records of services rendered at a hospital or other institution were
excluded from this analysis. In addition, records for medical supplies
and from chiropractors and pharmacies were also excluded. We asked TMA
to conduct the following comparative analyses for TRS beneficiaries
and TRICARE Standard and Extra beneficiaries:
1. Demographics, including age for each year and averaged over 3 years:
2. Percentage of claims filed for primary care, mental health, and
other specialists each year for 3 years:
3. The top 10 procedures in ranking order made each year and the
average over 3 years:
4. The top 10 primary diagnoses in ranking order made each year and
the average over 3 years:
5. The top five provider specialties in ranking order visited each
year and the average over 3 years:
6. Percentage of claims filed for the top five provider specialties
and the average over 3 years:
To ensure that TMA's data were sufficiently reliable, we conducted
data reliability assessments of the data sets that we used to assess
their quality and methodological soundness. Our review consisted of
(1) examining documents that described the respective data, (2)
interviewing TMA officials about the data collection and analysis
processes, and (3) interviewing TMA officials about internal controls
in place to ensure that data are complete and accurate. We found that
all of the data sets used in this report were sufficiently reliable
for our purposes. However, we did not independently verify TMA's
calculations.
[End of section]
Appendix II: Claims Filed for TRICARE Reserve Select and TRICARE
Standard and Extra Beneficiaries:
Tables 2 through 5 contain information on claims filed for TRICARE
Reserve Select and TRICARE Standard and Extra beneficiaries.
Table 2: Percentage of Claims Filed for TRICARE Reserve Select (TRS)
and TRICARE Standard and Extra Beneficiaries by Age of Beneficiary,
Fiscal Years 2008 through 2010:
Age: Under 18;
Sex: Female;
TRICARE Standard and Extra: FY 2008: 9.3%;
TRICARE Standard and Extra: FY 2009: 9.4%;
TRICARE Standard and Extra: FY 2010: 9.8%;
TRICARE Standard and Extra: Total: 9.5%;
TRS: FY 2008: 16.8%;
TRS: FY 2009: 16.4%;
TRS: FY 2010: 16.0%;
TRS: Total: 16.3%.
Age: Under 18;
Sex: Male;
TRICARE Standard and Extra: FY 2008: 18-24: 10.0%;
TRICARE Standard and Extra: FY 2009: 18-24: 10.3%;
TRICARE Standard and Extra: FY 2010: 18-24: 10.9%;
TRICARE Standard and Extra: Total: 18-24: 10.4%;
TRS: FY 2008: 18-24: 20.6%;
TRS: FY 2009: 18-24: 20.0%;
TRS: FY 2010: 18-24: 19.8%;
TRS: Total: 18-24: 20.0%.
Age: 18-24;
Sex: Female;
TRICARE Standard and Extra: FY 2008: 4.4%;
TRICARE Standard and Extra: FY 2009: 4.7%;
TRICARE Standard and Extra: FY 2010: 5.0%;
TRICARE Standard and Extra: Total: 4.7%;
TRS: FY 2008: 6.3%;
TRS: FY 2009: 6.7%;
TRS: FY 2010: 7.0%;
TRS: Total: 6.8%.
Age: 18-24;
Sex: Male;
TRICARE Standard and Extra: FY 2008: 25-29: 1.8%;
TRICARE Standard and Extra: FY 2009: 25-29: 1.9%;
TRICARE Standard and Extra: FY 2010: 25-29: 2.0%;
TRICARE Standard and Extra: Total: 25-29: 1.9%;
TRS: FY 2008: 25-29: 4.0%;
TRS: FY 2009: 25-29: 4.1%;
TRS: FY 2010: 25-29: 4.5%;
TRS: Total: 25-29: 4.3%.
Age: 25-29;
Sex: Female;
TRICARE Standard and Extra: FY 2008: 1.7%;
TRICARE Standard and Extra: FY 2009: 2.0%;
TRICARE Standard and Extra: FY 2010: 2.3%;
TRICARE Standard and Extra: Total: 2.0%;
TRS: FY 2008: 5.9%;
TRS: FY 2009: 7.3%;
TRS: FY 2010: 7.8%;
TRS: Total: 7.3%.
Age: 25-29;
Sex: Male;
TRICARE Standard and Extra: FY 2008: 30-35: 0.3%;
TRICARE Standard and Extra: FY 2009: 30-35: 0.3%;
TRICARE Standard and Extra: FY 2010: 30-35: 0.4%;
TRICARE Standard and Extra: Total: 30-35: 0.3%;
TRS: FY 2008: 30-35: 4.1%;
TRS: FY 2009: 30-35: 4.9%;
TRS: FY 2010: 30-35: 5.4%;
TRS: Total: 30-35: 5.0%.
Age: 30-35;
Sex: Female;
TRICARE Standard and Extra: FY 2008: 2.2%;
TRICARE Standard and Extra: FY 2009: 2.3%;
TRICARE Standard and Extra: FY 2010: 2.6%;
TRICARE Standard and Extra: Total: 2.4%;
TRS: FY 2008: 7.4%;
TRS: FY 2009: 7.7%;
TRS: FY 2010: 7.8%;
TRS: Total: 7.7%.
Age: 30-35;
Sex: Male;
TRICARE Standard and Extra: FY 2008: 36-40: 0.3%;
TRICARE Standard and Extra: FY 2009: 36-40: 0.3%;
TRICARE Standard and Extra: FY 2010: 36-40: 0.3%;
TRICARE Standard and Extra: Total: 36-40: 0.3%;
TRS: FY 2008: 36-40: 4.0%;
TRS: FY 2009: 36-40: 4.5%;
TRS: FY 2010: 36-40: 4.7%;
TRS: Total: 36-40: 4.5%.
Age: 36-40;
Sex: Female;
TRICARE Standard and Extra: FY 2008: 2.8%;
TRICARE Standard and Extra: FY 2009: 2.8%;
TRICARE Standard and Extra: FY 2010: 2.8%;
TRICARE Standard and Extra: Total: 2.8%;
TRS: FY 2008: 6.6%;
TRS: FY 2009: 6.1%;
TRS: FY 2010: 5.5%;
TRS: Total: 5.9%.
Age: 36-40;
Sex: Male;
TRICARE Standard and Extra: FY 2008: 41-45: 0.4%;
TRICARE Standard and Extra: FY 2009: 41-45: 0.3%;
TRICARE Standard and Extra: FY 2010: 41-45: 0.4%;
TRICARE Standard and Extra: Total: 41-45: 0.4%;
TRS: FY 2008: 41-45: 4.1%;
TRS: FY 2009: 41-45: 3.8%;
TRS: FY 2010: 41-45: 4.2%;
TRS: Total: 41-45: 4.0%.
Age: 41-45;
Sex: Female;
TRICARE Standard and Extra: FY 2008: 4.4%;
TRICARE Standard and Extra: FY 2009: 4.1%;
TRICARE Standard and Extra: FY 2010: 3.9%;
TRICARE Standard and Extra: Total: 4.2%;
TRS: FY 2008: 5.4%;
TRS: FY 2009: 5.1%;
TRS: FY 2010: 4.8%;
TRS: Total: 5.0%.
Age: 41-45;
Sex: Male;
TRICARE Standard and Extra: FY 2008: Over 45: 1.2%;
TRICARE Standard and Extra: FY 2009: Over 45: 1.1%;
TRICARE Standard and Extra: FY 2010: Over 45: 1.0%;
TRICARE Standard and Extra: Total: Over 45: 1.1%;
TRS: FY 2008: Over 45: 3.7%;
TRS: FY 2009: Over 45: 3.2%;
TRS: FY 2010: Over 45: 3.1%;
TRS: Total: Over 45: 3.2%.
Age: Over 45;
Sex: Female;
TRICARE Standard and Extra: FY 2008: 41.2%;
TRICARE Standard and Extra: FY 2009: 40.3%;
TRICARE Standard and Extra: FY 2010: 39.0%;
TRICARE Standard and Extra: Total: 40.1%;
TRS: FY 2008: 6.7%;
TRS: FY 2009: 5.9%;
TRS: FY 2010: 5.5%;
TRS: Total: 5.9%.
Age: Over 45;
Sex: Male;
TRICARE Standard and Extra: FY 2008: Total: 20.2%;
TRICARE Standard and Extra: FY 2009: Total: 20.1%;
TRICARE Standard and Extra: FY 2010: Total: 19.7%;
TRICARE Standard and Extra: Total: Total: 20.0%;
TRS: FY 2008: Total: 4.5%;
TRS: FY 2009: Total: 4.4%;
TRS: FY 2010: Total: 4.0%;
TRS: Total: Total: 4.2%.
Total:
TRICARE Standard and Extra: FY 2008: 100.0%;
TRICARE Standard and Extra: FY 2009: 100.0%;
TRICARE Standard and Extra: FY 2010: 100.0%;
TRICARE Standard and Extra: Total: 100.0%;
TRS: FY 2008: 100.0%;
TRS: FY 2009: 100.0%;
TRS: FY 2010: 100.0%;
TRS: Total: 100.0%.
Source: GAO analysis of TRICARE Management Activity data.
[End of table]
Table 3: Percentage of Claims Filed for TRICARE Reserve Select (TRS)
and TRICARE Standard and Extra Beneficiaries by Mental Health Care,
Primary Health Care, and Other Types of Specialty Care, Fiscal Years
2008 through 2010:
Mental health care;
TRICARE Standard and Extra: FY 2008: 6.8%;
TRICARE Standard and Extra: FY 2009: 6.6%;
TRICARE Standard and Extra: FY 2010: 6.7%;
TRICARE Standard and Extra: Total: 6.7%;
TRS: FY 2008: 7.1%;
TRS: FY 2009: 6.6%;
TRS: FY 2010: 6.7%;
TRS: Total: 6.7%.
Other specialty care;
TRICARE Standard and Extra: FY 2008: 54.5%;
TRICARE Standard and Extra: FY 2009: 54.8%;
TRICARE Standard and Extra: FY 2010: 54.8%;
TRICARE Standard and Extra: Total: 54.7%;
TRS: FY 2008: 49.9%;
TRS: FY 2009: 49.4%;
TRS: FY 2010: 49.4%;
TRS: Total: 49.5%.
Primary health care;
TRICARE Standard and Extra: FY 2008: 38.7%;
TRICARE Standard and Extra: FY 2009: 38.6%;
TRICARE Standard and Extra: FY 2010: 38.5%;
TRICARE Standard and Extra: Total: 38.6%;
TRS: FY 2008: 43.0%;
TRS: FY 2009: 44.1%;
TRS: FY 2010: 43.9%;
TRS: Total: 43.8%.
Total;
TRICARE Standard and Extra: FY 2008: 100.0%;
TRICARE Standard and Extra: FY 2009: 100.0%;
TRICARE Standard and Extra: FY 2010: 100.0%;
TRICARE Standard and Extra: Total: 100.0%;
TRS: FY 2008: 100.0%;
TRS: FY 2009: 100.0%;
TRS: FY 2010: 100.0%;
TRS: Total: 100.0%.
Source: GAO analysis of TRICARE Management Activity data.
[End of table]
Table 4: Percentage of Claims Filed for TRICARE Reserve Select (TRS)
and TRICARE Standard and Extra Beneficiaries by Top 10 Diagnoses in
Ranking Order, Fiscal Years 2008 through 2010:
Rank: 1;
TRICARE Standard and Extra: Diagnoses: Allergic rhinitis[A];
TRICARE Standard and Extra: Percentage of services: 12.1%;
TRS: Diagnoses: Allergic rhinitis;
TRS: Percentage of services: 14.2%.
Rank: 2;
TRICARE Standard and Extra: Diagnoses: Joint disorder neck and nose;
TRICARE Standard and Extra: Percentage of services: 4.8%;
TRS: Diagnoses: Health supervision child[B];
TRS: Percentage of services: 5.5%.
Rank: 3;
TRICARE Standard and Extra: Diagnoses: Back disorder neck and nose;
TRICARE Standard and Extra: Percentage of services: 3.5%;
TRS: Diagnoses: Joint disorder neck and nose;
TRS: Percentage of services: 4.5%.
Rank: 4;
TRICARE Standard and Extra: Diagnoses: Essential hypertension[C];
TRICARE Standard and Extra: Percentage of services: 2.3%;
TRS: Diagnoses: Back disorder neck and nose;
TRS: Percentage of services: 3.0%.
Rank: 5;
TRICARE Standard and Extra: Diagnoses: Affective psychoses[D];
TRICARE Standard and Extra: Percentage of services: 2.2%;
TRS: Diagnoses: Adjustment reaction[E];
TRS: Percentage of services: 2.3%.
Rank: 6;
TRICARE Standard and Extra: Diagnoses: Peripheral Enthesopathies[F];
TRICARE Standard and Extra: Percentage of services: 2.1%;
TRS: Diagnoses: Special examinations[G];
TRS: Percentage of services: 2.1%.
Rank: 7;
TRICARE Standard and Extra: Diagnoses: Health supervision child;
TRICARE Standard and Extra: Percentage of services: 2.1%;
TRS: Diagnoses: Affective psychoses;
TRS: Percentage of services: 1.8%.
Rank: 8;
TRICARE Standard and Extra: Diagnoses: Diabetes mellitus[H];
TRICARE Standard and Extra: Percentage of services: 1.7%;
TRS: Diagnoses: Asthma[I];
TRS: Percentage of services: 1.8%.
Rank: 9;
TRICARE Standard and Extra: Diagnoses: Adjustment reaction;
TRICARE Standard and Extra: Percentage of services: 1.7%;
TRS: Diagnoses: Acute upper respiratory infections of multiple or
unspecified sites;
TRS: Percentage of services: 1.6%.
Rank: 10;
TRICARE Standard and Extra: Diagnoses: Special examinations;
TRICARE Standard and Extra: Percentage of services: 1.7%;
TRS: Diagnoses: Suppurative and unspecified otitis media[J];
TRS: Percentage of services: 1.5%.
TRICARE Standard and Extra: Diagnoses: Diagnoses: Other diagnoses[K];
TRICARE Standard and Extra: Percentage of services: 65.7%;
TRS: Diagnoses: Diagnoses: Other diagnoses;
TRS: Percentage of services: Percentage of services: 61.7%.
Source: GAO analysis of TRICARE Management Activity data.
[A] Allergic rhinitis is a collection of symptoms, mostly in the nose
and eyes, which occur when inhaling an allergen, such as dust, dander,
or pollen.
[B] Health supervision of a child refers to the routine medical
examination of an infant or child.
[C] Essential hypertension refers to high blood pressure with no
identifiable cause.
[D] Affective psychoses is a group of mental disorders, usually
recurrent, in which a severe disturbance of mood is accompanied by one
or more of the following: delusions, perplexity, disturbed attitude to
self, or disorder of perception and behavior.
[E] Adjustment reaction refers to the reaction to chronic stress,
including grief and prolonged depression.
[F] Peripheral Enthesopathies refers to a group of disorders of
muscles and tendons and their attachments, such as rotator cuff
syndrome.
[G] Special examinations refers to routine exams, such as examinations
related to vision care, dental care, and pregnancy tests or other
gynecological examinations:
[H] Diabetes mellitus comprises a group of heterogeneous disorders
that have an increase in blood glucose concentrations. The current
classifications for diabetes mellitus Types 1 through 4.
[I] Asthma is an inflammatory disorder of the airways, which causes
attacks of wheezing, shortness of breath, chest tightness, and
coughing.
[J] Suppurative and unspecified otitis media refers to a group of
disorders related to the ear, such as the rupturing of the ear drum.
[K] Other diagnoses include any claims filed for medical diagnoses not
outlined as top 10 diagnoses above.
[End of table]
Table 5: Percentage of Claims Filed for TRICARE Reserve Select (TRS)
and TRICARE Standard and Extra Beneficiaries by Top Five Provider
Specialties, Fiscal Years 2008 through 2010:
Provider specialty: Family practice;
TRICARE Standard and Extra: 15.7%;
TRS: 16.0%.
Provider specialty: Physical therapist;
TRICARE Standard and Extra: 11.6%;
TRS: 10.8%.
Provider specialty: Allergy;
TRICARE Standard and Extra: 9.8%;
TRS: 13.6%.
Provider specialty: Internal medicine;
TRICARE Standard and Extra: 8.9%;
TRS: 5.1%.
Provider specialty: Pediatrics;
TRICARE Standard and Extra: 6.8%;
TRS: 14.7%.
Provider specialty: Other specialties;
TRICARE Standard and Extra: 47.2%;
TRS: 39.9%.
Source: GAO analysis of TRICARE Management Activity data.
[End of table]
[End of section]
Appendix III: Comments from the Department of Defense:
The Assistant Secretary Of Defense:
Health Affairs:
1200 Defense Pentagon:
Washington, DC 20301-1200:
May 18, 2011:
Mr. Randall B. Williamson:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Williamson:
This is the Department of Defense response to the Government
Accountability Office (GAO) draft report, "Defense Health Care: DoD
Lacks Assurance That Selected Reserve Members Are Informed About
TRICARE Reserve Select," dated April 21, 2011 (GAO Code #290870/GA0-11-
551). The response is provided in two sections: 1) Response to the
GAO's recommendation, and 2) Technical Comments.
The points of contact are Mr. Brian Smith (Primary Action Officer) and
Mr. Gunther Zimmerman (TRICARE Management Activity Audit Liaison). Mr.
Smith may be reached at (703) 681-7842, or Brian.Smith@tma.osd.mil.
Mr. Zimmerman may be reached at (703) 681-4365, or
Gunther.Zimmerman@tma.osd.mil.
Sincerely,
Signed by:
Jonathan Woodson, M.D.
Attachment: As stated.
[End of letter]
Government Accountability Office Draft Report:
Dated April 21, 2011:
GAO Code # 290870/GAO-11551:
"Defense Health Care: DOD Lacks Assurance That Selected Reserve
Members Are Informed About TRICARE Reserve Select"
Department Of Defense Comments To The Government Accountability Office
Recommendations:
Recommendation: The Government Accountability Office recommends that the
Secretary of Defense direct the Assistant Secretary of Defense for
Reserve Affairs to develop a policy that requires each reserve
component to designate a centralized point of contact for TRICARE
Reserve Select (TRS) education, who will be accountable for ensuring
that the reserve components are providing information about TRS to
their selected Reserve members annually. In establishing
responsibilities for the centralized points of contact, the Department
of Defense (DoD) should explicitly task them with coordinating with
the respective contractors to provide information on the number and
location of reserve component units in their regions.
DOD Response: The DoD partially concurs with this recommendation. The
DoD agrees that the Assistant Secretary of Defense for Reserve Affairs
should develop a policy that requires each of the seven Reserve
components to designate a central point of contact for TRS education,
who will be accountable for providing information about TRS to their
selected Reserve members annually. However, each designee should
coordinate with the TRICARE Regional Office (TRO) to provide
information on the number and location of reserve component units in
their region, rather than contacting TRICARE contractors directly.
TROs are responsible for oversight of their respective contractors and
can ensure the contractors are performing requirements as specified in
their respective contracts.
[End of section]
Appendix IV: 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, Bonnie Anderson, Assistant
Director; Danielle Bernstein; Susannah Bloch; Ashley Dean; Lisa
Motley; Jessica Smith; and Suzanne Worth made key contributions to
this report.
[End of section]
Footnotes:
[1] For the purposes of this report, the term reservist includes all
members of the seven reserve components, which include the Army
National Guard, Army Reserve, Navy Reserve, Marine Corps Reserve, Air
National Guard, Air Force Reserve, and Coast Guard. There are
different categories of reservists within the seven reserve
components. The Selected Reserve is the largest category of reservists
among the components and has priority over all other categories of
reservists.
[2] Prior to these expansions, a reservist and his or her dependents
were eligible for TRICARE only while the reservist was serving on
active duty for more than 30 days.
[3] Network providers are TRICARE-authorized providers who enter a
contractual agreement to provide health care to TRICARE beneficiaries.
Nonnetwork providers are TRICARE-authorized providers who do not have
a contractual agreement to provide care to TRICARE beneficiaries. All
beneficiaries may obtain care at military treatment facilities
although priority is first given to any active duty personnel and then
to beneficiaries using TRICARE Prime, another TRICARE option, which
requires the beneficiary to enroll.
[4] GAO, Military Health: Increased TRICARE Eligibility for Reservists
Presents Educational Challenges, [hyperlink,
http://www.gao.gov/products/GAO-07-195] (Washington, D.C.: Feb. 12,
2007).
[5] Commission on the National Guard and Reserves, Transforming the
National Guard and Reserves into a 21st-Century Operational Force:
Final Report to Congress and the Secretary of Defense (Washington
D.C., 2008).
[6] To qualify for TRS, a member of the Selected Reserve of a reserve
component must not be eligible for or enrolled in the Federal
Employees Health Benefits (FEHB) Program either under his or her own
eligibility or through a family member. See 10 U.S.C. § 1076d. All
National Guard and Reserve manpower is assigned to one of three
reserve component categories--the Ready Reserve, the Standby Reserve,
and the Retired Reserve. 10 U.S.C. § 10141(a). The Selected Reserve is
a component of the Ready Reserve. Once activated to duty, National
Guard and Reserve servicemembers are eligible for TRICARE Prime.
[7] Department of Defense, Task Force on Mental Health, An Achievable
Vision: Report of the Department of Defense Task Force on Mental
Health (Falls Church, Va., June 2007).
[8] Pub. L. No. 110-181, § 711(b)(2)(G), (H), 122 Stat. 3, 192 (2008).
[9] Standards for internal control in the federal government state
that agency management is responsible for establishing and maintaining
a control environment that sets a positive attitude toward internal
control and conscientious management, including an organizational
structure with clearly defined areas of authority and responsibility.
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), and Internal Control Management and
Evaluation Tool, [hyperlink, http://www.gao.gov/products/GAO-01-1008G]
(Washington, D.C.: August 2001).
[10] The other reserve categories are the Individual Ready Reserve,
Standby Reserve, and Retired Reserve.
[11] According to officials, this number is not the official strength
of the Selected Reserve.
[12] See Pub. L. No. 108-375, § 701, 118 Stat. 1811, 1980-82 (2004).
[13] See Pub. L. No. 109-163, §§ 701-702, 119 Stat. 3136, 3339-42
(2006); Pub. L. No. 109-364, § 706, 120 Stat. 2083, 2282 (2006).
[14] For example, the NDAA for Fiscal Year 2009 specified that the
appropriate actuarial basis for calculating TRS premiums should
utilize the actual cost of providing benefits to TRS members and their
dependents in preceding calendar years beginning with calendar year
2010.
[15] A contingency operation is a military operation that is
designated by the Secretary of Defense as an operation in which
members of the Armed Forces are or may become involved in military
actions, operations, or hostilities against an enemy of the United
States or against an opposing force or a military operation that
results in the call-up to (or retention on) active duty of members of
the uniformed Services under certain statutes during war or a national
emergency declared by the President or Congress.
[16] For tier one, a reservist must have had qualifying active duty
service in support of a contingency operation on or after September
11, 2001, for at least 90 days and must have agreed to serve in the
Selected Reserve for the entire period of TRS coverage. The reservist
must have executed this service agreement within 90 days after release
from active duty. The reservist was responsible for paying 28 percent
of the premium. For tier two a reservist who did not qualify for tier
one must not have been eligible for employer-sponsored health
insurance, or must have been eligible for unemployment compensation,
or must have been self-employed, and must have executed a service
agreement to serve in the Selected Reserve for the entire period of
TRS coverage. The reservist must have qualified during open season or
submitted documentation establishing a qualifying life event. The
reservist was responsible for paying 50 percent of the premium. For
tier three, a reservist who did not qualify for tier one or two may
have been eligible for employer-sponsored insurance, but must have
executed a service agreement to serve in the Selected Reserve for the
entire period of TRS coverage. The reservist must have qualified
during open season or submitted documentation establishing a
qualifying life event. The reservist was responsible for paying 85
percent of the premium.
[17] The NDAA for Fiscal Year 2008, provided that certain members of
the Selected Reserve, who were eligible for the FEHB Program, could
continue to receive benefits under their previous tier 1 TRS agreement
despite FEHB eligibility.
[18] Retirees and certain dependents and survivors who are entitled to
Medicare Part A and enrolled in Part B, and who are generally age 65
and older, are eligible to obtain care under a separate program called
TRICARE for Life. TRICARE for Life is a program that supplements
Medicare coverage for Medicare-eligible beneficiaries enrolled in
Medicare Part B. TRICARE beneficiaries under 65 years of age who are
eligible for Medicare Part A on the basis of disability or end-stage
renal disease are eligible for TRICARE for Life if they enroll in
Medicare Part B.
[19] For members activated not in support of a contingency operation,
TRICARE coverage becomes effective when active duty starts.
[20] Members activated not in support of a contingency operation are
not eligible for the Transitional Assistance Management Program and
return to inactive status immediately after returning from active duty.
[21] The current managed care support contracts are the second
generation of TRICARE contracts and the implementation period for
these contracts was set to end on March 31, 2010, with the third
generation of contracts to begin on April 1, 2010. However, this
timeline was delayed because of to bid protests on two of the three
contracts.
[22] Prime Service Areas are determined by the Assistant Secretary of
Defense for Health Affairs and are defined by a set of five-digit zip
codes, usually within an approximate 40-mile radius of a military
inpatient treatment facility. However, the contractors were allowed to
offer expanded or additional Prime Service Areas beyond the 40-mile
radius.
[23] A unit commander exercises authority over subordinates within a
unit by virtue of rank or assignment. A commander has the authority
and responsibility for effectively using available resources and for
planning the employment of, organizing, directing, coordinating, and
controlling military forces for the accomplishment of assigned
missions. Within the reserve components, the unit under the control of
the commander can consist of any number of servicemembers organized
hierarchically into groups of various sizes for functional, tactical,
and administrative purposes.
[24] Officials from a second reserve component stated that they have a
staff member who maintains information on a Web site about TRICARE;
however, this person does not serve as a central point of contact for
TRS education.
[25] This survey was based on the Health Care Survey of Department of
Defense Beneficiaries, which was designed to provide a comprehensive
look at beneficiary opinions about their DOD health care benefits.
Members of the Selected Reserve are included in this survey. Officials
told us that over time they have analyzed responses from members of
the Selected Reserve and these responses were the impetus behind
conducting this focused survey in 2008. TMA officials are currently
repeating the Focused Survey of TRICARE Reserve Select and Selected
Reserve Military Health System Access and Satisfaction.
[26] Department of Defense, TRICARE Management Activity, Evaluation of
the TRICARE Program: Fiscal Year 2009 Report to Congress (Washington
D.C., 2009).
[27] Access to more affordable civilian options and opportunities to
obtain civilian health insurance also affected the decision not to
enroll.
[28] GAO, Human Capital: Quality of DOD Status of Forces Surveys Could
Be Improved by Performing Nonresponse Analysis of the Results,
[hyperlink, http://www.gao.gov/products/GAO-10-751R] (Washington,
D.C.: July 12, 2010).
[29] GAO, Defense Health Care: Access to Civilian Providers under
TRICARE Standard and Extra, [hyperlink,
http://www.gao.gov/products/GAO-11-500] (Washington, D.C.: June 2,
2011).
[30] For additional information on how TMA generally addressed the
methodological requirements, see GAO, Defense Health Care: 2008 Access
to Care Surveys Indicate Some Problems, but Beneficiary Satisfaction
Is Similar to Other Health Plans, [hyperlink,
http://www.gao.gov/products/GAO-10-402] (Washington, D.C.: Mar. 31,
2010).
[31] For the purpose of this analysis, claims consist of all services
provided by a professional, including a doctor or nurse, and do not
include services submitted by an institution. In addition, these
claims do not include inpatient care, medical supplies, or pharmacy
claims.
[32] Allergic rhinitis is a collection of symptoms, mostly in the nose
and eyes, which occur when a person breathes in something the person
is allergic to, such as dust, dander, or pollen.
[33] These percentages include members of the Selected Reserve and
their dependents. Selected Reserve members living overseas, in unknown
locations, and in Puerto Rico and Guam were not included in this
analysis.
[34] Claims filed for fiscal year 2010 may not be complete because
individuals have up to 1 year to file a claim.
[End of section]
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