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Mental health providers are essential to maintaining the Department of Defense s (DOD) capability to deliver health care services.1 As part of its mission, DOD provides a full range of medical care and services, including mental health services, at no cost to active duty military servicemembers and at either a reduced cost or no cost to other eligible beneficiaries including dependents of servicemembers and some military retirees.2 DOD s ability to deliver this care has been impacted by increasing numbers of servicemembers who experienced life-threatening situations in combat and their resulting need for mental health services. Specifically, DOD faces significant challenges building and maintaining a mental health provider workforce including active duty and reserve military providers and civilian and contract providers working in military medical facilities that is capable of providing all the mental health care servicemembers and their dependents need due to nationwide shortages of mental health providers.4 These challenges are exacerbated by the pressure to control DOD healthcare costs and the need to compete for mental health providers with other health care delivery systems throughout the nation which also face increased needs for these providers.5 The increased need for mental health care for servicemembers and their dependents has led to congressional attention on the recruitment and retention of qualified mental health providers to work in DOD s military health system (MHS). Specifically, the National Defense Authorization Act (NDAA) for Fiscal Year 2010 included provisions for DOD to increase its mental health capabilities by increasing the number of active duty mental health providers and to report on the appropriate number of mental health providers required to meet the mental health care needs of servicemembers, retirees, and dependents.6 You asked us to review DOD s efforts to increase its qualified mental health provider workforce., Report to the Subcommittee on Defense, Committee on Appropriations, U.S. Senate.

Why GAO Did This Study. Non-disability mental conditions, such as personality disorders, can render a servicemember unsuitable for military service and can lead to an administrative separation. GAO was mandated to report on non-disability mental condition separations. This report examines the extent to which (1) DOD and the military services are able to identify the number of enlisted servicemembers separated for nondisability mental conditions, and (2) the military services are complying with DOD requirements when separating enlisted servicemembers for non-disability mental conditions, including personality disorders, and how DOD and the military services oversee such separations. GAO analyzed DOD and the military services separation policies, policies related to tracking separations, reports the military services submitted to DOD regarding compliance with separation requirements, and interviewed DOD and military service officials. What GAO Recommends. GAO recommends that DOD and the military services develop a method to identify the number of servicemembers separated for non-disability mental conditions and take a number of actions to ensure that their policies and processes can ensure that servicemembers are appropriately separated for non-disability mental conditions in accordance with DOD s separation requirements. DOD generally concurred with GAO s recommendations, but did not provide information on how or when it plans to implement the recommendations., Report to Congressional Committees.

VHA s Family Caregiver Program is designed to provide support and services to family caregivers of post-9/11 veterans who have a serious injury incurred or aggravated in the line of duty. The program provides approved primary family caregivers with a monthly financial stipend as well as training and other support services, such as counseling and respite care., Report to Congressional Requesters

GAO s May 2013 report on the oversight and management of the Non-VA Medical Care Program found that the Department of Veterans Affairs (VA) does not collect data on wait times veterans face in obtaining care from non-VA providers. The lack of data on wait times limits VA s efforts to effectively oversee the Non-VA Medical Care Program because it is not possible for VA to determine if veterans who receive care from non-VA providers are receiving that care sooner than they would in VA facilities. In addition, GAO found that VA cannot assess the cost-effectiveness of non-VA medical care because it cannot analyze data on all services and charges for an episode of care, which is a combined total of all care provided to a veteran during a single office visit or inpatient stay. As a result, VA cannot determine whether delivering care through non-VA providers is more cost-effective than augmenting its own capacity in areas with high utilization of non-VA medical care.

Female servicemembers are serving in more complex occupational specialties and are being deployed to combat operations, potentially leading to increased health risks. Similar to their male counterparts, female servicemembers must maintain their medical readiness; however, they have unique health care needs that require access to gender-specific services. The National Defense Authorization Act for Fiscal Year 2012 directed GAO to review a variety of issues related to health care for female servicemembers. This report describes (1) the extent that DOD s policies for assessing individual medical readiness include unique health care issues of female servicemembers; (2) the availability of health care services to meet the unique needs of female servicemembers at domestic Army installations; and (3) the extent that DOD s research organizations have identified a need for research on the specific health care needs of female servicemembers who have served in combat. GAO reviewed DOD and military service policies on individual medical readiness and surveyed senior health care officials about the availability of specific health services at the 27 domestic Army installations with MTFs that report directly to the domestic regional medical commands. GAO focused on the Army because it has more female servicemembers than the other military services. GAO also visited six Army installations two from each of the Army s three domestic regional medical commands and interviewed DOD officials who conduct research on health issues for servicemembers., Report to Congressional Addressees.

Following a series of high-profile sexual assault cases involving servicemembers, in 2004 Congress directed the Secretary of Defense to develop a comprehensive policy for the Department of Defense (DoD) on the prevention of, and response to, sexual assaults involving servicemembers. Among other things, the legislation required DoD to establish a standardized department-wide definition of sexual assault and procedures for confidentially reporting sexual assault incidents. DoD established the Sexual Assault Prevention and Response (SAPR) program in 2005 to promote prevention, encourage increased reporting of the crime, and improve response capabilities for victims. You asked us the following: (1) How are cases of acute sexual assault reported, documented, and investigated, when victims are treated at a military treatment facility (MTF)?; (2) What training is provided to health care professionals working in MTFs on the treatment of victims of sexual assault?; (3) How do MTFs provide acute treatment and care to victims of sexual assault, including forensic medical-legal exams and mental health counseling, as well as preventative treatment for the human immunodeficiency virus (HIV), sexually transmitted diseases, and pregnancy?; and (4) What types of long-term services, support, and follow-up, including mental health services, do MTFs provide to victims of sexual assault? This briefing includes information on the following topics from our body of work, which correspond with the questions asked in the request letter: DoD's approach for reporting, documenting, and investigating alleged sexual assault incidents; DoD training of servicemembers related to sexual assault; DoD care and treatment provided to victims of sexual assault, including mental health counseling and medical care.

I am pleased to be here today as you discuss the challenges facing the Federal Recovery Coordination Program (FRCP)--a program that was jointly developed by the Departments of Defense (DOD) and Veterans Affairs (VA) following critical media reports of deficiencies in the provision of outpatient services at Walter Reed Army Medical Center. This program was established to assist "severely wounded, ill, and injured" Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) servicemembers, veterans, and their families with access to care, services, and benefits. Specifically, the program's population was to include individuals who had suffered traumatic brain injuries, amputations, burns, spinal cord injuries, visual impairment, and post-traumatic stress disorder. From January 2008--when FRCP enrollment began--to May 2011, the FRCP has provided services to a total of 1,665 servicemembers and veterans; of these, 734 are currently active enrollees. As the first care coordination program developed collaboratively by DOD and VA, the FRCP is more comprehensive in scope than clinical or nonclinical case management programs. It uses Federal Recovery Coordinators (FRC) who are either senior-level registered nurses or licensed social workers to monitor and coordinate both the clinical and nonclinical services needed by program enrollees by serving as a link between case managers of multiple programs. Unlike case managers, FRCs have planning, coordination, monitoring, and problem-resolution responsibilities that encompass both health services and benefits provided through DOD, VA, other federal agencies, states, and the private sector., Testimony before the Subcommittee on Health, Committee on Veterans' Affairs, House of Representatives.

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.

Reimbursement rates and provider shortages have been cited as the main impediments that hinder TRICARE Standard and Extra beneficiaries' access to civilian health care and mental health care providers. Providers' concern about TRICARE's reimbursement rates--which are generally set at Medicare rates--has been a long-standing issue and has more recently been cited as the primary reason civilian providers will not accept TRICARE Standard and Extra beneficiaries as patients, according to TMA's surveys of civilian providers. TMA can increase reimbursement rates in certain instances, such as when it determines that access to care is being affected by the level of reimbursement. Shortages of certain provider specialties, such as mental health care providers, at the national and local levels may also impede access, but these shortages are not specific to the TRICARE program and also affect the general population. As a result, there are limitations as to what TMA can do to address them. TMA has primarily used feedback mechanisms, including surveys of beneficiaries and civilian providers, to gauge TRICARE Standard and Extra beneficiaries' access to civilian providers. More recently, in February 2010, in recognition that TRICARE has had no established measures for monitoring the availability of civilian network and non-network providers for these beneficiaries, TMA directed the TRICARE Regional Offices to develop a model to help identify geographic areas where they may experience access problems. GAO's review of the initial models found their methodology to be reasonable. However, because the regional models were recently developed, it is too early to determine their effectiveness. TMA's contractors educate civilian providers about TRICARE program requirements, policies, and procedures.

Servicemembers wounded in recent conflicts are surviving injuries that would have been fatal in past conflicts, in part because of advanced protective equipment and medical treatment. However, the severity of their injuries can result in a lengthy transition from patient status back to active duty or to veteran status. Most severely wounded servicemembers from the conflicts in Iraq and Afghanistan initially are evacuated to Landstuhl Regional Medical Center in Germany for treatment. From there, they are usually transported to military treatment facilities in the United States, with most of the severely wounded admitted to Walter Reed Army Medical Center, the National Naval Medical Center, or Brooke Army Medical Center. Background Acute medical treatment and stabilization is the first of three phases in the 'continuum of care' experienced by severely wounded servicemembers. The second phase of the continuum is rehabilitation at a DOD, VA, or civilian facility. (The recovery needs of some servicemembers receiving rehabilitation may require their return to a medical center for acute medical care, such as surgical procedures.) The third phase of the continuum is reintegration-either return to active duty or to the civilian community as a veteran, where they may receive health care from DOD, VA, or civilian providers.

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCOE) was established to lead DOD's effort to develop excellence in DOD prevention, outreach, and care for those with psychological health and traumatic brain injury conditions. GAO was asked to report on (1) challenges DCOE has faced in its development; (2) the extent to which DCOE's strategic plan aligns with key practices used by leading public sector organizations; and (3) the extent to which internal controls provide reasonable assurance that DCOE information on financial obligations is reliable for management decision making. GAO reviewed documentation and interviewed DCOE officials about DCOE development challenges, evaluated DCOE's strategic plan against practices used by leading public-sector organizations, assessed the design of internal controls for recording obligations, and tested fiscal year 2009 DCOE obligations to supporting documentation to determine if the obligations were properly classified., Report to Congressional Requesters.

In addition to providing health care to veterans, the Department of Veterans Affairs (VA) funds research that focuses on health conditions veterans may experience. According to VA, experts estimate that up to 20 percent of Operation Enduring Freedom and Operation Iraqi Freedom veterans have experienced post-traumatic stress disorder (PTSD) and demand for PTSD treatment is increasing. Because of the importance of research in improving the services that veterans receive, GAO was asked to report on VA's funding of PTSD research, and its processes for funding PTSD research proposals, reviewing and incorporating research outcomes into clinical practice guidelines (CPG)--tools that offer clinicians recommendations for clinical services but do not require clinicians to provide one service over another--and determining which PTSD services are required to be made available at VA facilities. To do this work, GAO obtained and summarized VA data on the funding of PTSD research from its medical and prosthetic research appropriation through its intramural research program. GAO also reviewed relevant VA documents, such as those for developing CPGs and those related to VA's 2008 Uniform Mental Health Services in VA Medical Centers and Clinics handbook (Handbook), which defines certain mental health services that must be made available at VA facilities. GAO also interviewed VA officials., Report to the Ranking Member, Subcommittee on Health, Committee on Veterans' Affairs, House of Representatives.

In fiscal year 2009, over 9 million beneficiaries were eligible to receive health care and mental health care through DOD's TRICARE program. Under TRICARE, beneficiaries have choices among various benefit options and may obtain care from either military treatment facilities or civilian providers

The National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008) requires the Departments of Defense (DOD) and Veterans Affairs (VA) to jointly develop and implement comprehensive policies on the care, management, and transition of recovering servicemembers. The Senior Oversight Committee (SOC)-jointly chaired by DOD and VA leadership-has assumed responsibility for these policies. The NDAA 2008 also requires GAO to report on the progress DOD and VA make in developing and implementing the policies., Testimony before the Personnel Subommittee of the Committee on Armed Services, U.S. Senate.

Over the past 8 years, DOD has designated over 34,000 servicemembers involved in OEF and OIF as wounded in action. The severity of injuries can result in a lengthy process for a patient to either return to duty or to transition to veteran status. The most seriously injured servicemembers from these conflicts usually receive care at Walter Reed Army Medical Center or the National Naval Medical Center. According to DOD officials, once they are stabilized and discharged from the hospital, servicemembers may relocate closer to their homes or military bases and be treated as outpatients by the closest military or VA facility. Recovering servicemembers potentially navigate two different disability evaluation systems that serve different purposes. DOD's system serves a personnel management purpose by identifying servicemembers who are no longer medically fit for duty. If a servicemember is found unfit because of medical conditions incurred in the line of duty, the servicemember is assigned a disability rating and can be discharged from duty. This disability rating, along with years of service and other factors, determines subsequent disability and health care benefits from DOD. Under VA's system, disability ratings help determine the level of disability compensation a veteran receives and priority status for enrollment for health care benefits. To determine eligibility for disability compensation, VA evaluates all claimed medical conditions, whether they were evaluated previously by the military service's evaluation process or not. If VA finds that a veteran has one or more service-connected disabilities that together result in a final rating of at least 10 percent, VA will pay monthly compensation and the veteran will be eligible to receive a higher priority status for health care benefits enrollment.

At the Department of Defense (DoD), a personality disorder can render a service member unsuitable for service. GAO was required to report on personality disorder separations with regard to the following: (1) the extent to which selected military installations complied with DoD's separation requirements, and (2) how DoD ensures compliance with these requirements. GAO reviewed a sample of 312 service members' records from four installations, representing the Army, Air Force, and Marine Corps, that had the highest or second highest number of Operation Enduring Freedom or Operation Iraqi Freedom service members separated because of a personality disorder. The review is generalizable to the installations, but not to the services. GAO also reviewed 59 Navy service members' records, but this review is not generalizable to the installation or the Navy because parts of the separation process could have been completed at multiple locations. GAO recommends that DoD do the following: (1) ensure that the services' personality disorder separations comply with DoD's requirements, and (2) monitor the services' compliance. DoD concurred with GAO's first recommendation and partially concurred with the other. DoD stated that it will strengthen policy guidance for the services' compliance reporting, but stated that it is the responsibility of the services to ensure compliance., Report to Congressional Addressees.

PDHRA (post-deployment health reassessment) is a screening tool for military servicemembers; it is designed to identify and address their health concerns including mental health concerns 90 to 180 days after return from deployment. Although DOD established PDHRA requirements and policies, it gave the military services discretion to implement them to meet their unique needs as long as the services adhere to the requirements and policies. DOD oversees the military services compliance with PDHRA requirements through its deployment health assessment quality assurance program and is required to report on the quality assurance program annually to the Armed Services Committees of the House of Representatives and Senate. The Senate Committee on Armed Services directed us to review DOD's oversight of PDHRA, and the House Committee on Armed Services and 11 senators also expressed. In this report, we focus on how DOD ensures that servicemembers complete the PDHRA. Specifically, we discuss how well DOD's quality assurance program oversees the military services' compliance with the requirement that they ensure that servicemembers complete the PDHRA., Report to the Committee on Armed Services, United States Senate and the Committee on Armed Services, House of Representatives.

Armed Forces Institute of Pathology (AFIP) pathologists perform three key services -- diagnostic consultations, education, and research -- primarily for physicians from DoD, the Department of Veterans Affairs (VA), and civilian institutions. The 2005 Base Realignment and Closure (BRAC) provision required the Department of Defense (DoD) to close the AFIP). GAO was asked to address the status and potential impact of implementing this BRAC provision. This report discusses the following: (1) key services AFIP provides to the military and civilian communities; (2) DoD's plans to terminate, relocate, or outsource services currently provided by AFIP; and (3) the potential impacts of disestablishing AFIP on military and civilian communities. New legislation requires DoD to consider this GAO report as it develops its plan for the reorganization of AFIP. GAO reviewed DoD's plans, analysis, and other relevant information, and interviewed officials from the public and private sectors. GAO recommends DoD report to Congress on the following: (1) its strategies for organizing consultation services, (2) AFIP's tissue specimen repository's assets and their potential use, and (3) its strategies for using the repository. DoD generally concurred with GAO's findings and conclusions. GAO has modified its recommendations to reflect concerns DoD raised about additional steps it needs to take before it can report on its strategies for using the repository. The Department of Veterans Affairs (VA) stated that GAO's report was factually accurate, but believed that it did not sufficiently describe the impact of closing AFIP. GAO believes that this report provides a balanced assessment of AFIP's services and the impact of its closing., Report to the Committee on Health, Education, Labor, and Pensions, U.S. Senate.