United States Government Accountability Office Report to Congressional Committees COAST GUARD April 2023 HEALTH CARE Additional Actions Could Help Ensure Beneficiaries' Access GAO-23-105574 April 2023 COAST GUARD HEALTH CARE Additional Actions Could Help Ensure Beneficiaries' Access Highlights of GAO-23-105574, a report to congressional committees Why GAO Did This Study What GAO Found In support of its missions, the Coast GAO found that the location of Coast Guard units may contribute to challenges Guard is tasked with providing health accessing medical and dental care through TRICARE-the Department of care to its active duty personnel and Defense's health plan, administered by the Defense Health Agency (DHA). For ensuring the availability of health care instance, Coast Guard active duty personnel and their dependents are more than for their dependents. Coast Guard twice as likely as the personnel and dependents from the other military services personnel have access to limited to be enrolled in TRICARE Prime Remote (see figure). Such enrollment means outpatient care at Coast Guard clinics. they are stationed in an area that is more than 50 miles away from a military These personnel and their dependents medical treatment facility. Almost 40 percent of Coast Guard clinics (17 of 43 may also obtain medical care and clinics) are located in medically underserved areas, which indicate a shortage of dental care from military facilities and primary care services. Additionally, 25 percent (11 of 43 clinics) are located in civilian providers through TRICARE. areas with at least one type of health provider shortage (primary care, mental The William M. (Mac) Thornberry health, or dental). National Defense Authorization Act for Fiscal Year 2021 included a provision Percent of U.S. Coast Guard Beneficiaries Enrolled in TRICARE Prime Remote Compared to for GAO to review the Coast Guard Beneficiaries of Other Military Services, as of October 2022 health care system. This report examines, among other objectives, challenges Coast Guard beneficiaries face accessing medical and dental care through TRICARE, the extent to which the Coast Guard monitors TRICARE access, and what data show about beneficiaries' TRICARE access. GAO reviewed relevant Coast Guard and TRICARE documents and analyzed access-to-care data for Coast Guard beneficiaries for 2018 through GAO found that the Coast Guard conducts ad hoc monitoring of its beneficiaries' 2021 (most recent available). GAO access to TRICARE, but it does not routinely analyze data from DHA and its also interviewed Coast Guard and contractors to monitor access. No formal agreement exists between the Coast DHA officials as well as officials from Guard and DHA to facilitate the sharing of data for care provided at DHA medical six Coast Guard clinics selected for facilities. Obtaining and routinely monitoring TRICARE access data would better variation in geographic location and position the Coast Guard to identify and address potential access concerns to number of medical staff. help ensure that its beneficiaries are receiving timely care. What GAO Recommends GAO analyzed DHA and contractor data on Coast Guard beneficiaries' access to care through TRICARE, and found that their access to primary and dental care GAO is making seven generally met DHA's access standards. However, access to specialty care varied recommendations, including that the by source and type of care. Specifically, beneficiaries accessed routine specialty Coast Guard and DHA agree to share care from DHA medical facilities within its standard of 28 days, but access to access data and that the Coast Guard such care from civilian providers sometimes took longer. For example, the monitor access to TRICARE for Coast average days to care for obstetrics and gynecology services ranged from 27 to Guard beneficiaries. The Department 40 days, and the average for dermatology ranged from 31 to 41 days. Similarly, of Homeland Security concurred with our recommendations. The Coast Guard beneficiaries' accessed mental health care at DHA medical facilities Department of Defense did not provide within 28 days, but it took on average up to 41 days to be seen by a civilian comments. psychiatrist for routine care. When referred for urgent psychiatric care, where View GAO-23-105574. For more information, care is expected to be received within 3 days, average days to care ranged contact Alyssa M. Hundrup at (202) 512-7114 between 18 and 32 days. TRICARE contractors told GAO access may exceed or hundrupa@gao.gov standards for reasons such as provider availability and beneficiary preference. United States Government Accountability Office Contents Letter 1 Background 7 Various Staffing Challenges May Affect Coast Guard Clinic Access; Tools such as Telehealth Have Helped Facilitate Access 16 Remote Locations and Other Challenges May Affect Beneficiaries' Access to TRICARE, but the Coast Guard Has Programs to Address Some of These Issues 23 Coast Guard Does Not Routinely Monitor TRICARE Medical and Dental Access for Its Beneficiaries 36 Beneficiaries' Access to Medical Care under TRICARE Varied by Type and Source of Care; Access to Dental Care Was Generally within Requirements 41 Conclusions 49 Recommendations for Executive Action 50 Agency Comments 51 Appendix I Methodology for Examining Coast Guard Beneficiaries' Access to Medical and Dental Care through TRICARE 53 Appendix II Supplemental Site Visit Information on Selected U.S. Coast Guard Clinics 56 Appendix III TRICARE Access Standards and Available Data for U.S. Coast Guard Beneficiaries 70 Appendix IV Comments from the Department of Homeland Security 73 Appendix V GAO Contact and Staff Acknowledgments 77 Page i GAO-23-105574 Coast Guard Health Care Tables Table 1: Selected U.S. Coast Guard Clinics Included in GAO's Review 6 Table 2: U.S. Coast Guard Clinics Located in Medically Underserved Areas and Health Provider Shortage Areas as Designated by the Health Resources and Services Administration, as of May 2022 26 Table 3: Access-to-Care Data Available for U.S. Coast Guard Active Duty Personnel and Dependents enrolled in TRICARE, by Type and Source of Care 71 Figures Figure 1: Sources of Medical and Dental Care for U.S. Coast Guard Beneficiaries under the Coast Guard's Health Services Program and the Department of Defense's TRICARE Health Plan, by Type of Care 9 Figure 2: Locations of U.S. Coast Guard Clinics within the Department of Defense's TRICARE Regions in the United States, as of November 2022 11 Figure 3: Enrollment of U.S. Coast Guard Personnel and Their Dependents in Specific TRICARE Benefit Options, as of October 2022 14 Figure 4: Percent of U.S. Coast Guard Beneficiaries Enrolled in TRICARE Prime Remote Compared to Beneficiaries of Other Military Services, as of October 2022 24 Figure 5: Timeliness to Routine Mental Health Care from Civilian Providers for U.S. Coast Guard TRICARE Prime Beneficiaries in the TRICARE West and East Regions 30 Figure 6: Timeliness to Urgent Mental Health Care from Civilian Providers for U.S. Coast Guard TRICARE Prime Beneficiaries in the TRICARE West and East Regions 31 Figure 7: Timeliness of Routine Specialty Care for U.S. Coast Guard TRICARE Prime Beneficiaries at DHA Medical Facilities, as shown by Its Legacy and New Electronic Health Record Systems 44 Figure 8: Timeliness to Selected Routine Specialty Care for U.S. Coast Guard TRICARE Prime Beneficiaries Accessing Care from Civilian Providers in the TRICARE West Region, Jan. 2018 - Dec. 2021 46 Page ii GAO-23-105574 Coast Guard Health Care Figure 9: Timeliness to Selected Routine Specialty Care for U.S. Coast Guard TRICARE Prime Beneficiaries Accessing Care from Civilian Providers in the TRICARE East Region, Jan. 2018 - Dec. 2021 47 Figure 10: Locations and Number of Active Duty Personnel Served by Selected U.S. Coast Guard Clinics Included in GAO's Review 57 Abbreviations DHA Defense Health Agency DOD Department of Defense USPHS U.S. Public Health Service This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page iii GAO-23-105574 Coast Guard Health Care Letter 441 G St. N.W. Washington, DC 20548 April 4, 2023 The Honorable Maria Cantwell Chair The Honorable Ted Cruz Ranking Member Committee on Commerce, Science, and Transportation United States Senate The Honorable Sam Graves Chairman The Honorable Rick Larsen Ranking Member Committee on Transportation and Infrastructure House of Representatives The U.S. Coast Guard, a multi-mission military service within the Department of Homeland Security, is the principal federal service responsible for maritime safety, security, and environmental stewardship in U.S. ports and waterways. As part of its mission, the Coast Guard serves as a first responder and humanitarian service provider through surge operations, which are high-intensity efforts involving personnel, aircraft, and vessels that are launched in response to emergency situations, such as hurricanes. Many of its operating locations are along the East and West coasts and Great Lakes, including in remote areas, such as Kodiak, Alaska, and other locations outside of the continental United States. The Coast Guard also deploys its personnel worldwide in support of national defense. In support of its missions, the Coast Guard is responsible for providing medical and dental care to its active duty personnel and their dependents, among others. 1 Active duty personnel can access a limited range of 1The scope of our review includes Coast Guard active duty personnel and their dependents, which we refer to jointly as beneficiaries as appropriate. Coast Guard reserve personnel, retirees, and their dependents are also eligible for health services through the Coast Guard and the Department of Defense, but were outside the scope of our review. Page 1 GAO-23-105574 Coast Guard Health Care outpatient medical and dental services at Coast Guard clinics. 2 In February 2022, we reported on how the Coast Guard staffs these clinics and monitors whether they are meeting its access-to-care standards. 3 Coast Guard personnel and their dependents may also obtain medical and dental care through the Department of Defense (DOD). Specifically, they may obtain care through DOD's regional health plan called TRICARE, which is administered by the Defense Health Agency (DHA). Through TRICARE, Coast Guard beneficiaries can obtain medical care either directly from DHA's hospitals and clinics, referred to as military medical treatment facilities (medical facilities) or through regional networks (East and West) of civilian health care providers who participate in TRICARE. These regional networks are administered by two private sector companies-referred to as managed care support contractors. 4 As of October 2022, approximately 37,000 Coast Guard active duty personnel and about 51,000 Coast Guard dependents were enrolled in TRICARE. 5 For dental care, Coast Guard active duty personnel can go to DHA dental treatment facilities (dental facilities) on military installations or to civilian dentists through DHA's Active Duty Dental Program, which is 2Clinicsprovide primary care and other outpatient services and are staffed by at least one physician. Additionally, the Coast Guard health services program operates sickbays, which are small facilities normally staffed by a health service technician and located on shore or on board Coast Guard vessels. For the purposes of this review, we excluded sickbays because they typically provide limited services and active duty personnel are not assigned to providers at them for their routine care. 3GAO, Coast Guard Health Care: Improvements Needed for Determining Staffing Needs and Monitoring Access to Care. GAO-22-105152 (Washington D.C.: Feb. 4, 2022). We found that the Coast Guard did not have staffing standards for its health services program, nor a reliable approach for monitoring access to care in its clinics and sickbays. We recommended that the agency (1) implement health care staffing standards, and (2) improve its process for collecting more reliable data to monitor access to care at clinics and sickbays. The Coast Guard concurred with our recommendations. As of December 2022, the Coast Guard had not yet implemented these recommendations. 4The TRICARE health plan also includes an overseas contractor that, like the TRICARE East and West managed care support contractors, is responsible for administering a network of civilian health care providers and serving military beneficiaries, including Coast Guard active duty personnel and dependents, in locations such as Puerto Rico and Guam. We did not include overseas health care in the scope of our work. 5These numbers are based on data obtained from the TRICARE managed care support contractors regarding Coast Guard beneficiary TRICARE enrollment in the East and West regions. Page 2 GAO-23-105574 Coast Guard Health Care administered by a contractor. Coast Guard dependents may enroll in DHA's TRICARE Dental Program, which is also administered by a contractor, to obtain dental care through a national network of civilian dentists. In fiscal year 2022, the Coast Guard reported spending about $360 million for TRICARE medical and dental care. While these various health care options are available, Coast Guard personnel and their dependents have reported some access-to-care challenges. For example, we previously reported that the increasing numbers of surge operations, in which the Coast Guard deploys its health care personnel, have decreased the number of staff available in its clinics. 6 This could potentially reduce the number of available appointments for active duty personnel at Coast Guard clinics. Furthermore, some Coast Guard personnel and dependents serve and live in remote areas that may have few community medical and dental providers. The William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021 included provisions for us to examine aspects of Coast Guard health care. 7 This report examines: 1. challenges the Coast Guard faces in ensuring its active duty personnel have access to medical and dental care at Coast Guard clinics, and how it addresses such challenges; 2. challenges Coast Guard beneficiaries face accessing medical and dental care through TRICARE, and how the Coast Guard addresses such challenges; 3. the extent to which the Coast Guard monitors access to care for Coast Guard beneficiaries who obtain medical and dental care through TRICARE; and 4. what available data show about Coast Guard beneficiaries' access to TRICARE medical and dental care. To examine the challenges the Coast Guard faces in ensuring its active duty personnel have access to medical and dental care at its clinics and how it addresses such challenges, we reviewed Coast Guard policies and 6GAO-22-105152. 7Pub. L. No. 116-283, § 8259, 134 Stat. 3388, 4679 (2021). This is our second report, following GAO-22-105152, in response to these provisions. Page 3 GAO-23-105574 Coast Guard Health Care procedures for its clinics, such as the Coast Guard's medical manual. 8 We also reviewed the Department of Health and Human Services' U.S. Public Health Service (USPHS) policies and procedures for its officers, who can be detailed to work in Coast Guard clinics, and its memorandum of agreement with the Department of Homeland Security. 9 Additionally, we interviewed Coast Guard and USPHS officials about access-to-care challenges at Coast Guard clinics. To obtain beneficiary perspectives on any such challenges, we selected and interviewed representatives from two organizations representing Coast Guard beneficiaries and an organization representing uniformed services officers, including Coast Guard officers. 10 Finally, we assessed the Coast Guard's actions to address access-to-care challenges against recommended processes included in the Department of Homeland Security's workforce planning model. 11 To examine the challenges Coast Guard beneficiaries face accessing medical and dental care through TRICARE and how the Coast Guard addresses such challenges, we reviewed relevant documentation from DHA and its contractors, such as policies and procedures for ensuring access to care. We also reviewed Coast Guard documentation about the actions taken to address access-to-care challenges under TRICARE. Additionally, we obtained and reviewed TRICARE enrollment data as of October 2022 for Coast Guard beneficiaries to compare with beneficiaries of the other military services. We also obtained Coast Guard clinic locations to determine the extent to which they are located in medically underserved areas and geographic health provider shortage areas. 12 8Departmentof Homeland Security United States Coast Guard, Coast Guard Medical Manual, COMDTINST M6000.1F, June 2018. 9Department of Homeland Security; Department of Health and Human Services, Office of the Assistant Secretary for Health, Commissioned Corps of the U.S. Public Health Service, Memorandum of Agreement (2019). 10Specifically, we interviewed representatives from the Coast Guard Enlisted Association, Coast Guard Spectrum, and the Military Officers Association of America. 11Department of Homeland Security, DHS Workforce Planning Guide (Washington, D.C.: July 2015). 12The Department of Health and Human Services' Health Resources and Services Administration designates geographic areas lacking access to primary care services as medically underserved areas. It also designates areas having a shortage of primary, dental, or mental health care providers as geographic health professional shortage areas. We used publicly available data from https://data.hrsa.gov/tools/shortage-area/by-address (accessed May 17, 2022) to conduct analyses on these designations. Page 4 GAO-23-105574 Coast Guard Health Care Finally, we interviewed Coast Guard and DHA officials, and representatives from the two TRICARE managed care support contractors, the TRICARE dental contractor, and the selected organizations representing Coast Guard beneficiaries about any challenges faced by Coast Guard beneficiaries accessing care through TRICARE. To examine the extent to which the Coast Guard monitors access to care for Coast Guard beneficiaries who obtain medical and dental care through TRICARE, we reviewed relevant Coast Guard policies and procedures. 13 We also reviewed the TRICARE policy on access to care, the TRICARE Operations Manual, and DHA's contracts with the two managed care support contractors and the dental contractor. 14 We interviewed Coast Guard officials about the extent to which they monitor Coast Guard beneficiaries' access to TRICARE, and spoke with officials from DHA and the military services, and representatives from the TRICARE contractors about the availability of data for monitoring Coast Guard beneficiaries' access to such care. We assessed Coast Guard's monitoring efforts against relevant criteria in the Coast Guard medical manual and Coast Guard technical directives. To examine what available data show about Coast Guard beneficiaries' access to TRICARE medical and dental care, we obtained data from DHA and its contractors for the period from January 1, 2018, through December 31, 2021, the most recent years available. 15 We analyzed access to primary care, specialty care, and dental care for Coast Guard personnel and their dependents, including by whether care was accessed at DHA's medical facilities or through the private sector care system of 13See, for example, Department of Homeland Security United States Coast Guard, Coast Guard Medical Manual; Health, Safety and Work-Life Service Center Technical Directive 2021-003, "TRICARE Medical Referrals Procedures;" and Health, Safety and Work-Life Service Center Technical Directive 2021-004, "MHS GENESIS Procedural Guidance." 14See Defense Health Agency, TRICARE Operations Manual, 6010.56-M, April 1, 2015. The TRICARE Operations Manual is incorporated by reference into the managed care support contracts and is the primary vehicle for operational guidelines and instructions to the contractor. 15We selected this time frame to capture the four most recent and complete years of data from when health care delivery began under the current managed care support contracts. As a result, our analyses include data both before and during the COVID-19 pandemic. Page 5 GAO-23-105574 Coast Guard Health Care TRICARE civilian medical and dental providers. 16 To assess the reliability of these data, we interviewed officials with DHA and its contractors and reviewed related documentation. We found these data sufficiently reliable for our reporting purposes. See appendix I for more details on the scope and methodology of our access-to-care data analyses. To obtain clinic-level perspectives for all four objectives, we conducted site visits with six Coast Guard clinics. We selected these clinics for variation by geographic location, number of staff, and relative population density where the clinic was located. At the clinics, we interviewed administrators, health care providers, and referral management coordinators, as well as leadership officials from the clinics' locations, including commanding and executive officers. We spoke with these officials about any challenges Coast Guard personnel faced accessing medical and dental care at Coast Guard clinics and through TRICARE, as well as their processes for monitoring access. Additionally, we interviewed the ombudsmen assigned to each location to obtain the perspectives of Coast Guard dependents. 17 Information obtained from these site visits cannot be generalized to other Coast Guard clinics. See table 1 for the Coast Guard clinics we selected. (See appendix II for additional information on the six selected clinics.) Table 1: Selected U.S. Coast Guard Clinics Included in GAO's Review Coast Guard clinic Location Base Cape Cod Kaehler Memorial Clinic Buzzards Bay, Massachusetts Air Station Detroit Clinic Selfridge, Michigan Sector Key West Clinic Key West, Florida Base Kodiak Rockmore-King Clinic Kodiak, Alaska Sector Humboldt Bay Clinic McKinleyville, California Base Portsmouth Clinic Portsmouth, Virginia Source: GAO. | GAO-23-105574 16We were unable to examine Coast Guard beneficiaries' access to dental care from the military services' dental facilities. According to officials from the Army, Navy, and Air Force, they do not monitor access to care by individual branch of service (e.g. for Coast Guard beneficiaries). 17The Coast Guard Ombudsman Program is a program that seeks to improve communication between command and Coast Guard dependents. The ombudsmen act as communication links and advocates for dependents, as well as provide dependents with information and resources. Page 6 GAO-23-105574 Coast Guard Health Care We conducted this performance audit from December 2021 to April 2023 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 Coast Guard Health Care In 2020, the Congressional Research Service reported that approximately Services 60 percent of Coast Guard active duty personnel obtained their health care primarily from the Coast Guard health services program, which is administered by the Health, Safety and Work-Life Directorate. 18 Through this program, the Coast Guard offers a limited range of outpatient medical and dental services to personnel at its clinics. 19 All other health care, including referrals for any specialty care, is provided through TRICARE. The Coast Guard has 43 outpatient clinics in the 50 states, the District of Columbia, and Puerto Rico. 20 These clinics are staffed by: • Coast Guard personnel, including enlisted members and officers, primarily serving as physician assistants and health services 18Congressional Research Service, Defense Health Primer: U.S. Coast Guard Health Services (Washington, D.C.: December 15, 2020). The Health, Safety and Work-Life Directorate includes two organizations – the Office of Health Services, which is responsible for the provision of health care to Coast Guard personnel and ensuring availability of health care to their dependents, and the Health, Safety and Work-Life Service Center, which implements policies set by the Directorate, among other things. For the purposes of this report, we refer to officials from these organizations as "Coast Guard health officials." 19Outpatient services provided at Coast Guard clinics include primary care, occupational health, flight medicine, optometry, mental health, physical therapy, dentistry, and basic laboratory, radiology, and pharmacy services. Available services vary by clinic. The Coast Guard does not provide inpatient services. 20As of November 2022, Coast Guard health officials reported they are in the process of opening an additional clinic in Charleston, South Carolina. Page 7 GAO-23-105574 Coast Guard Health Care technicians, who provide routine and emergency care as well as administrative support. 21 • USPHS officers who are detailed to the Coast Guard by the Department of Health and Human Services to serve as physicians, dentists, and other types of providers, such as pharmacists or mental health providers. 22 • Staff contracted by the Coast Guard to fill some of its vacancies and augment other health care staff roles, including positions for which the Coast Guard does not train its own personnel, such as dental hygienists. As of September 2022, the Coast Guard reported that there were 771 Coast Guard personnel, 152 USPHS officers, and 191 contracted health care staff serving in its clinics and sickbays. Coast Guard personnel and USPHS officers may also have other mission-related duties. For example, Coast Guard health services technicians may be required to temporarily leave their clinics in response to a surge deployment, such as to provide medical services in the aftermath of a natural disaster. USPHS officers may be deployed by the Department of Health and Human Services to respond to public health emergencies. TRICARE For any medical or dental care that is not available through the Coast Guard health services program, Coast Guard active duty personnel and their dependents are eligible for DOD's TRICARE health plan. See figure 1 for an overview of the sources of care for Coast Guard beneficiaries. 21Health services technicians are Coast Guard enlisted personnel with both clinical and administrative duties that support the clinic providers. For example, health services technicians are responsible for rendering first aid, performing tentative diagnosis and emergency treatment, and, if they meet certain training requirements, providing nursing care. These technicians also manage the administrative responsibilities of the clinics, such as staffing the front desk, managing referrals, and administering special programs, such as medical screening programs. 22USPHS officers are not Coast Guard employees. They are detailed to the Coast Guard according to the terms set forth in a memorandum of agreement between the Department of Health and Human Services and the Department of Homeland Security. Page 8 GAO-23-105574 Coast Guard Health Care Figure 1: Sources of Medical and Dental Care for U.S. Coast Guard Beneficiaries under the Coast Guard's Health Services Program and the Department of Defense's TRICARE Health Plan, by Type of Care a The Active Duty Dental Program provides dental care to active duty service members that are referred by or live or work more than 50 miles from a military dental treatment facility. Dental care is provided by a network of civilian dental providers. b The TRICARE Dental Program is a voluntary dental plan available to dependents of active duty service members, among others. Beneficiaries must enroll for a period of 1 year followed by month- to-month enrollment and must pay applicable premiums and cost-shares. Page 9 GAO-23-105574 Coast Guard Health Care Medical Care. Under TRICARE, Coast Guard personnel can obtain medical care through DHA's medical facilities when they are not located near a Coast Guard clinic, or when they have a referral for specialty care. 23 Coast Guard dependents can also access care at these facilities, although they have a lower priority for appointments. 24 As of October 2019, DHA had assumed responsibility for the administration and management of the military services' medical facilities within the United States. 25 DHA's managed care support contractors are responsible for developing networks of civilian providers in the TRICARE East and West regions. Their responsibilities also include customer service functions, assisting beneficiaries with finding providers, processing claims, and authorizing referrals. They must comply with performance standards outlined in their contracts, such as maintaining accurate online directories of their network providers and submitting monthly access-to-care reports to DHA. DHA is responsible for overseeing the TRICARE contracts, including the extent to which the managed care support contractors meet their performance standards. The managed care support contracts in effect at the time of our review began health care delivery on January 1, 2018. See figure 2 for a map of the TRICARE regions and the locations of Coast Guard clinics within each region. 23A few select specialty services, such as behavioral health, physical therapy, and optometry, may be available at Coast Guard clinics. 24Active duty service members have first priority for appointments at DHA medical facilities, followed by active duty family members enrolled in TRICARE Prime and retirees, then followed by other priority groups. 25The National Defense Authorization Act of 2017, as amended, transferred administrative and management responsibilities of DHA medical facilities, including budgetary matters, information technology, health care administration and management, administrative policy and procedure, and military medical construction, among other things, from the individual military services to DHA. DHA began assuming these responsibilities in October 2018, and according to DHA, the transition process was completed for all medical facilities within the United States in October 2019. Pub. L. No. 114-328, § 702, 130 Stat. 2000, 2193 (2016) (codified at 10 U.S.C. § 1073c). Page 10 GAO-23-105574 Coast Guard Health Care Figure 2: Locations of U.S. Coast Guard Clinics within the Department of Defense's TRICARE Regions in the United States, as of November 2022 TRICARE offers several medical benefit options for Coast Guard personnel and their dependents, including • TRICARE Prime. TRICARE Prime is a managed care plan. Beneficiaries who enroll in this option are assigned to a primary care manager, who is responsible for their routine primary care and for making referrals for specialty care. Beneficiaries are eligible to enroll in TRICARE Prime if they either (1) work or live inside a Prime Service Area, which is generally within 40 miles of a DHA medical Page 11 GAO-23-105574 Coast Guard Health Care facility, or (2) live within 100 miles of a primary care manager. 26 Active duty service members are automatically enrolled in TRICARE Prime. This includes Coast Guard personnel, who may be assigned to and served by a Coast Guard clinic. Coast Guard dependents, like other military service dependents, may choose to enroll in Prime or another TRICARE benefit option. DHA uses access standards to monitor TRICARE Prime beneficiaries' timely access to appointments and drive times for care obtained at DHA medical facilities and from the network of civilian providers. For example, specialty care appointments are to be provided within 28 days, and within a 1-hour drive-time. Coast Guard personnel are generally assigned to primary care managers at a Coast Guard clinic or a DHA medical facility, while their dependents may have a DHA or civilian primary care manager. DHA's medical facilities have the right of first refusal to see TRICARE Prime beneficiaries residing in Prime Service Areas who are referred for specialty care. 27 If a DHA medical facility cannot provide the referred specialty care, then the referral is sent to the managed care support contractor for the TRICARE network of civilian providers. • TRICARE Prime Remote. Beneficiaries with a sponsor who lives and works more than 50 miles, or more than a 1-hour driving time, from a DHA medical facility may be eligible for the benefits of TRICARE Prime if they enroll in TRICARE Prime Remote, available in designated locations. This includes the right to timely access to care in accordance with DHA's defined timeliness standards, though beneficiaries must waive the drive-time access standards. For this option, beneficiaries may be enrolled with a civilian primary care manager. However, if a civilian primary care manager is not available, 26Prime Service Areas are geographic areas usually within an approximate 40-mile radius of a DHA medical facility in which the managed care support contractors offer enrollment in TRICARE Prime and develop networks of civilian providers. Network primary care managers are located within Prime Service Areas. 27About a third (15) of the 43 Coast Guard clinics represent Coast Guard "standalone" Prime Service Areas, meaning there are no other DHA medical facilities in the service area. According to the TRICARE West region managed care contractor, six of the Coast Guard clinics in its region each represent their own Prime Service Area. According to the TRICARE East region managed care support contractor, nine of the 24 Coast Guard clinics in its region are in their own Coast Guard Prime Service Area. The remaining clinics are located within another military installation's Prime Service Area, located outside of a Prime Service Area, or are part of TRICARE Overseas Page 12 GAO-23-105574 Coast Guard Health Care then beneficiaries may access primary care from a TRICARE- authorized provider in the community. 28 • TRICARE Select. TRICARE Select is a self-managed, preferred provider organization option available to dependents. Beneficiaries enrolled in Select can obtain health care from any network or non- network TRICARE-authorized provider. 29 These beneficiaries are not required to have a primary care manager and do not require referrals for specialty care appointments. Because beneficiaries enrolled in TRICARE Select self-manage their appointments, the time and distance metrics used to monitor access for TRICARE Prime beneficiaries can not be used for TRICARE Select beneficiaries, according to DHA officials. Over 80 percent of Coast Guard personnel and 64 percent of their dependents were enrolled in TRICARE Prime as of October 2022, while others were enrolled in TRICARE Prime Remote or TRICARE Select, if eligible. See figure 3 for information on Coast Guard beneficiary enrollment in TRICARE benefit options. 28Beneficiaries without an assigned civilian primary care manager are given the status of "primary care manager – unassigned," which allows them to access care from any TRICARE-authorized provider. A TRICARE-authorized provider is licensed by a state, accredited by a national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE. There are two types of TRICARE- authorized providers: those who participate in the TRICARE network (network provider) and those who do not (non-network provider). 29TRICARE also offers other TRICARE options, such as TRICARE for Life, which is available for beneficiaries who are eligible for Medicare and enrolled in Part B. However, because the scope of our review includes Coast Guard active duty personnel and their dependents, we did not include such options in our reporting. Page 13 GAO-23-105574 Coast Guard Health Care Figure 3: Enrollment of U.S. Coast Guard Personnel and Their Dependents in Specific TRICARE Benefit Options, as of October 2022 Note: Beneficiaries may be eligible to enroll in TRICARE Prime if they live in a Prime Service Area, a geographic area usually within an approximate 40-mile radius of a Defense Health Agency military medical treatment facility (medical facility), or within 100 miles of a primary care manager. TRICARE Prime Remote extends the TRICARE Prime benefits to those beneficiaries who live more than 50 miles, or more than a 1-hour driving time, from a Defense Health Agency medical facility in designated locations. TRICARE Select is a self-managed, preferred provider plan. Dental Care. Under TRICARE, active duty personnel can obtain dental care at DHA dental facilities, or from civilian dentists through DHA's Active Duty Dental Program. If there is no DHA dental facility within 50 miles of their unit, or if the local DHA dental facility has reached capacity, Coast Guard personnel may obtain care from a civilian network dentist in the Active Duty Dental Program, which is administered through a national contract. More than three-quarters of Coast Guard personnel who did not Page 14 GAO-23-105574 Coast Guard Health Care receive dental care in their Coast Guard clinic used the Active Duty Dental program. 30 Coast Guard dependents are eligible to enroll in DHA's TRICARE Dental Program, which is a premium-based program that covers certain dental services. Similar to the Active Duty Dental Program, this program is administered through a national contract that requires the establishment of a network of civilian dentists. Both dental programs have appointment timeliness and drive time access standards. For example, routine dental care must be provided within 21 days. If care is provided through the Active Duty Dental Program, beneficiaries should not have to drive more than 40 miles from their place of residence for such care; if provided through the TRICARE Dental Program, then no more than 35 miles. The most recent contract for the Active Duty Dental Program went into effect on May 1, 2022, and the TRICARE Dental Program, on May 1, 2017. The same contractor administers both dental plans. MHS GENESIS As of November 2021, Coast Guard officials reported that its clinics had transitioned from a paper health record system to an electronic health record system called MHS GENESIS. 31 MHS GENESIS is DHA's commercial electronic health record system. DHA began incrementally 30Specifically, between August 2018 and July 2021, 76 percent of Coast Guard personnel that received dental care outside of a Coast Guard clinic leveraged the Active Duty Dental Program for periodic dental evaluations or for appointments to address specific dental concerns. Comparatively, 57 percent of active duty service members from the other military services received care outside of DHA dental facilities, according to DHA data. 31As of November 2022, Coast Guard officials reported that the Coast Guard clinic in Borinquen, Puerto Rico, was in the process of implementing MHS GENESIS. Officials said they expect the clinic to be fully using MHS GENESIS in early 2023. The Coast Guard previously had an electronic health record system prior to its procurement of MHS GENESIS that it attempted to update between 2010 and 2015. However, the service ultimately canceled the project in 2015 and reverted to a paper health record. See GAO, Coast Guard Health Records: Timely Acquisition of New System Is Critical to Overcoming Challenges with Paper Process, GAO-18-59 (Washington, D.C.: Jan 24, 2018). The Coast Guard rolled out MHS GENESIS at pilot locations in August 2020. Full implementation began in May 2021 and consists of three segments. The first segment included system rollout in shore-based clinics and sickbays and, according to officials, was completed in November 2021. The second segment includes the migration of the paper health records to the new system by December 2024. The final segment includes system rollout in vessel-based sickbays by June 2028. Page 15 GAO-23-105574 Coast Guard Health Care deploying it across its medical facilities in 2017 and expects to have the system fully deployed at all facilities by the end of 2023. 32 DHA administers the MHS GENESIS contract, and the Coast Guard is reliant on DHA for configuring the system. 33 Coast Guard clinics use MHS GENESIS for clinical and administrative functions, such as maintaining patient health records, making appointments, and tracking referrals. However, at the time of our review, MHS GENESIS did not include performance metrics to monitor access to care in accordance with TRICARE access standards. DHA officials told us they are developing measures and plan to configure MHS GENESIS to allow for such monitoring; as of November 2022, DHA officials said they are in the process of finalizing these measures. Various Staffing Challenges May Affect Coast Guard Clinic Access; Tools such as Telehealth Have Helped Facilitate Access Coast Guard Officials In our interviews with Coast Guard health officials and officials from the Reported That Provider six selected clinics, officials commonly cited staffing shortages as an access-to-care challenge for active duty personnel seeking care at Coast and Technician Shortages Guard clinics. Specifically, clinic officials reported difficulty recruiting and Have Impeded Access to retaining USPHS providers, who typically serve as the medical and dental Care at Clinics providers in Coast Guard clinics. They also reported insufficient numbers of Coast Guard health services technicians, who provide clinical and administrative support, to meet the clinics' needs. 32GAO has previously reported on DHA's implementation of MHS GENESIS. See GAO, Electronic Health Records: DOD Has Made Progress in Implementing a New System, but Challenges Persist, GAO-21-571 (Washington, D.C.: Sept 20, 2021) and GAO, Electronic Health Records: Additional DOD Actions Could Improve Cost and Schedule Estimating for New System, GAO-22-104521 (Washington, D.C.: June 8, 2022). 33In2015, DOD awarded a contract to the Leidos Partnership for Defense Health to implement MHS GENESIS, based on commercially available products, including Oracle Cerner's electronic health record system. In 2018, DOD modified the contract to incorporate the Coast Guard and create a standardized baseline electronic health record between the Coast Guard, DOD, and the Department of Veterans Affairs. Page 16 GAO-23-105574 Coast Guard Health Care Commissioned Corps of the U.S. Public USPHS provider recruitment and retention challenges. Officials from Health Service (USPHS) four of the six selected clinics in our review reported difficulty recruiting or retaining USPHS providers. For example, as of April 2022, officials at three of the clinics said they had at least one vacancy for a USPHS provider, with one vacancy open since 2017. Officials at one clinic said that their vacancy created a backlog of appointments, while officials at another clinic noted that during the period of the USPHS vacancy, the clinic was only able to provide basic primary care. Officials at two clinics cited challenges with retention, noting that because USPHS providers are detailed to the Coast Guard, they do not have to stay with the service, Source: U.S. Public Health Service and can request transfers to other federal agencies before their 5-year detail is complete. The USPHS Commissioned Corps, a component of the Department of Health and Human Services, are a uniformed service of Coast Guard health officials corroborated the USPHS recruitment and health care personnel serving the nation's public health. USPHS Commissioned Corps retention challenges cited by clinic officials, noting these challenges were officers, such as physicians, dentists, and present across the service and particularly in remote areas. Coast Guard scientists, serve in federal agencies across clinic and health officials cited various possible reasons for challenges the country. These officers are detailed to serve in agencies such as the U.S. Coast with recruiting and retaining USPHS providers, such as the current Guard, Bureau of Prisons, Food and Drug nationwide shortage of physicians, the lack of assignment pay or other Administration, and Centers for Disease Control and Prevention. financial incentives for detailees to the Coast Guard, and fewer The Coast Guard relies on USPHS officers to opportunities for higher level positions in the Coast Guard. 34 serve as physicians and flight surgeons, dentists, pharmacists, physician assistants, and others in its clinics. The relationship Our analysis of USPHS vacancy rates in prior work supports these between USPHS and the Coast Guard is reported challenges retaining USPHS providers. Specifically, in February managed through a Memorandum of Understanding between the Department of 2022, we reported that the vacancy rate among the USPHS positions in Homeland Security and the Department of the Coast Guard was three times higher than other Coast Guard health Health and Human Services. USPHS officers are provided on a reimbursable basis and are subject to Coast Guard regulations and the Uniform Code of Military Justice. USPHS officers are also subject to Corps policies. Source: Department of Homeland Security, Department of Health and Human Services. | GAO-23-105574 34Assignment pay is available to USPHS officers detailed to certain agencies, such as the Indian Health Service, Federal Bureau of Prisons, and Immigration and Customs Enforcement, and who serve in locations with certain designations or in critical positions with a high vacancy rate. USPHS officials from the Department of Health and Human Services noted that USPHS and the Coast Guard could collaborate to determine if Coast Guard USPHS positions may qualify for these designations. While USPHS officers are considered for promotion by USPHS annual promotion boards, USPHS officials from the Department of Health and Human Services said that serving in a higher level position during their agency detail is one way a USPHS officer can demonstrate leadership, though it is not required for promotion through USPHS. Page 17 GAO-23-105574 Coast Guard Health Care services program vacancies. 35 We found that about 16 percent of USPHS positions in the Coast Guard were vacant, and in September 2022, the Coast Guard reported that the situation had not changed, with 18 percent of USPHS positions vacant. 36 The Department of Homeland Security Workforce Planning Model outlines recommended processes for components within the department, such as the Coast Guard, to follow with respect to their workforce planning. Such processes include documenting problems related to gaps in their workforce, and conducting analyses to determine the underlying reasons for these gaps. 37 The results of such analyses can be used to help entities to develop targeted strategies and actions that can reduce identified gaps in their workforce, such as USPHS vacancies. However, we found that the Coast Guard has not adopted these processes and collected information about the reasons for their challenges recruiting and retaining USPHS officers for detail in the Coast Guard. For instance, the Coast Guard does not have a standardized exit interview process for USPHS providers leaving their Coast Guard detail to determine the reason for their departures. 38 Consequently, the Coast Guard lacks information that could be used to develop targeted strategies to address recruitment and retention challenges. Collecting and analyzing such information, including sharing information with USPHS, could help increase USPHS provider availability, which in turn could lead to improved access to care at Coast Guard clinics for its personnel. 35GAO-22-105152. 36The Coast Guard reported that, as of September 2022, 34 of 186 (18 percent) USPHS officer positions were vacant. Of 816 Coast Guard active duty personnel positions in Coast Guard clinics and sickbays, 45 (5 percent) positions were vacant. 37Department of Homeland Security, DHS Workforce Planning Guide. 38Coast Guard officials said that typically their Chief Medical Officer contacts departing providers, but it is not a formal exit interview. Additionally, USPHS officials told us that they do not conduct exit interviews with their officers when they leave their details, though the agencies to which the officers were detailed may choose to do so. Page 18 GAO-23-105574 Coast Guard Health Care COVID-19 Challenges at U.S. Coast Guard Health services technicians staffing challenges. Officials from five of Clinics the six selected clinics reported needing additional Coast Guard health services technicians to serve in their clinics, even when the clinics were considered fully staffed and had no vacancies. Officials from two clinics cited surge deployments, which nearly quadrupled between 2018 and 2021, as one reason for this challenge. Clinic officials said that deployments of the health services technicians increases the workload of the remaining clinic staff, who are stretched thin trying to cover the additional duties. Some clinic officials stated that additional contributing factors-such as the implementation of MHS GENESIS and other competing administrative Source: GAO. duties-can compound the effects of having insufficient numbers of Officials from all six Coast Guard clinics in our health services technicians. For example, officials at one clinic said that review said that the COVID-19 pandemic increased their clinic workloads due to their health services technicians are responsible for arranging medical responsibilities for COVID-19 care, testing, travel and completing medical screenings for all personnel in their state. and vaccinations. Officials from one clinic noted that their call volume doubled during However, officials said that these additional administrative duties are not the pandemic. Officials from another clinic considered in the process of allocating health services technicians to the said that their medical staff were deployed clinic. more frequently than in previous years to administer COVID-19 tests and vaccines in other locations. To meet these increased Clinic officials explained that having an insufficient number of health responsibilities, three clinics we spoke with reported limiting other clinic services. For services technicians at their clinics can adversely affect access to care in example, officials from one clinic said that different ways. For example, officials at three clinics reported reducing when COVID-19 case rates were high, they appointments to manage the increased clinic responsibilities related to limited clinical services to just emergency care. deployments and MHS GENESIS implementation. Officials at two clinics Officials at three of the clinics also cited reported that they could not always meet appointment timeliness access challenges related to staff morale and burnout standards because of insufficient staff. due to the pandemic. Officials at two clinics said that these challenges led to attrition, with one clinic losing seven staff. In February 2022, we recommended that the Coast Guard implement Coast Guard clinic officials reported taking staffing standards for its health services program to determine the levels various actions in response to the pandemic. For example, to prevent a COVID-19 outbreak and types of staff needed at its clinics, and that such staffing standards among clinic staff, one clinic reported using an account for surge deployments. Implementing this recommendation would alternating staffing schedule. While this reduced the number of available be a first step toward ensuring that Coast Guard clinics have a sufficient appointments, officials said that they never number of health services technicians. The Coast Guard concurred with had to completely close the clinic. our recommendation and said it would conduct a manpower requirements Additionally, providers from two clinics reported using telehealth to provide care to minimize COVID-19 risk. Finally, officials at two clinics said that they used referrals to military medical treatment facilities or to local pharmacies for COVID-19 testing and vaccines to reduce their clinic workload. Source: GAO analysis of Coast Guard interviews. | GAO-23-105574 Page 19 GAO-23-105574 Coast Guard Health Care assessment of its clinics; as of December 2022, the Coast Guard had not implemented this recommendation. 39 Coast Guard Has Taken Based on our review of Coast Guard policies and procedures and Steps to Mitigate the interviews with Coast Guard health officials and the six selected clinics, we found that the Coast Guard has taken steps to address its clinic Effects of Clinic Staffing staffing challenges. These steps included the use of alternative staffing Challenges arrangements, telehealth, and initiatives to increase the number of available providers. Alternative staffing arrangements. The Coast Guard has several alternative staffing arrangements available to its clinics to address staffing vacancies, such as using contracted staff, leveraging providers from other clinics, and activating reservists. All six of the selected clinics used at least one alternative staffing arrangement to address their clinic staffing challenges. • Contracted staff. The Coast Guard has a staffing contract that it has used to fill some clinic vacancies for USPHS positions and to augment its health care personnel. Officials from all six clinics reported having at least one contractor working at their clinic. Coast Guard health officials told us that from their perspective, it is better to staff clinics with USPHS providers, but the staffing contract helps when they are unable to recruit a USPHS provider within 6 months of a vacancy. Officials from two clinics noted some trade-offs in using contracted staff, such as less flexibility with their hours and duties than USPHS providers or Coast Guard personnel. • Leveraging providers from other clinics. Coast Guard health officials also told us that when a clinic has a vacancy, providers from one Coast Guard clinic can be loaned to another to cover the vacancy on a short-term basis. For example, one clinic had a vacant behavioral health position that providers from other Coast Guard clinics covered in rotation for 2 weeks at a time. Officials at the clinic with the vacancy noted, however, that while the temporary arrangement met their basic needs, it reduced the continuity of care provided to beneficiaries. • Reservists. The Coast Guard can activate reservists when additional personnel are needed to meet its mission. Officials from three clinics told us that they activated Coast Guard reservists to serve as health service technicians during COVID-19. However, officials from all three 39See GAO-22-105152. Page 20 GAO-23-105574 Coast Guard Health Care clinics cited challenges with using reservists. For example, officials at one clinic said that the reservists were helpful in supplementing the clinic workforce; however, they noted that it was an expensive option due to the salary, relocation, and housing costs that are involved with activating reservists. Telehealth. The Coast Guard has several telehealth resources available to facilitate access to care for Coast Guard personnel. Officials from all six of our selected clinics reported using at least one telehealth resource. • Clinic telehealth. In 2020, following the onset of the COVID-19 pandemic, the Coast Guard launched a platform for video-based telehealth appointments. 40 Additionally, officials from five clinics reported conducting telephone appointments, in part due to reported patient and provider preference. Officials from two clinics said that telehealth appointments work well for the annual health assessments required for Coast Guard personnel. One official noted that the efficiency of telehealth appointments allowed the clinic to ultimately see more patients. Officials from two other clinics said that they use telehealth with members located in remote areas. • Employee assistance program. The Coast Guard's employee assistance program offers resources, including short-term counseling services, to beneficiaries through the telephone or web-based chat features. 41 • TRICARE telehealth appointments. Coast Guard providers also can refer personnel to telehealth appointments, such as for urgent care and mental and behavioral health care, through programs offered by the regional TRICARE managed care support contractors. However, officials at four clinics we spoke with noted limitations in using telehealth to facilitate access to care. For example, officials at two clinics reported technical challenges with using the video platform. Officials at 40In 2020, the Coast Guard solicited proposals and awarded a contract for a telehealth platform called Coast Guard Care Anywhere, which was available to clinics for use in 2021 and the first quarter of 2022, according to officials. As of November 2022, Coast Guard health officials said that video-based telehealth operations are being piloted through MHS Video Connect with Coast Guard behavioral health providers, with complete deployment across all Coast Guard clinics expected by summer 2023. 41Coast Guard's employee assistance program-known as CG SPRT-is available to both personnel and their dependents, among others. The program offers assessment and non-medical, short-term counseling for a number of issues, including anxiety, depression, stress, and substance abuse. Page 21 GAO-23-105574 Coast Guard Health Care another two clinics reported lacking a wireless connection in their clinic to use the tablets provided by the Health, Safety and Work-Life Service Center for video appointments. Officials at four clinics also noted that not all health care can be provided through telehealth, such as flight physicals. Finally, Coast Guard health officials said there is reluctance to use telehealth among some Coast Guard personnel and clinic providers. The Uniformed Services University of the Coast Guard provider initiatives. In 2022, the Coast Guard launched Health Sciences two initiatives to increase the number of available clinic providers to manage its long-term health care workforce needs. These initiatives will train physicians, dentists, and behavioral health technicians, among other needed health professions. • Health Service Officer Program. In July 2022, the Coast Guard launched an initiative to develop a Health Service Officer Program. The initiative includes (1) a direct commission officer program to recruit physicians and dentists, and (2) a formal advanced education program to sponsor Coast Guard personnel enrollment at the Source: Uniformed Services University of the Health Sciences. Uniformed Services University of the Health Sciences. Coast Guard The Uniformed Services University of the health officials said that, ultimately, they plan for the Health Service Health Sciences was established in 1972 as Officer Program to include providers beyond physicians and dentists, the only federally administered medical health sciences school in the United States. The such as physician assistants and nurses. Further, officials noted that university includes a medical school, a these commissioned officers will complement USPHS providers graduate school of nursing, a postgraduate serving in the Coast Guard. Officials told us that they established a dental program, and a college of allied health sciences. direct commission program in August 2022, and as of November The Secretary of Defense appoints the 2022, had recruited six physicians and four dentists to serve in the president of the university, who works with Coast Guard. Beginning August 2023, officials aim to sponsor medical each of the uniformed services to determine education for four Coast Guard personnel each year. their student enrollment and allocation numbers. • Behavioral health technician training. In July 2022, the Coast In exchange for attending the university at no- cost, students incur a service obligation to one Guard finalized a program to train its health services technicians to of the uniformed services. The service provide behavioral health care in Coast Guard clinics. In an obligations are completed after graduation agreement with the Navy, Coast Guard health services technicians and vary by academic program. For example, medical students are required to serve 10 will attend behavioral health training at the Medical Education Training years after graduation, including 7 years on Campus at Fort Sam Houston in Texas. Coast Guard officials said active duty. they would have 10 training spots in fiscal year 2023. The trained Source: Uniformed Services University of the Health Sciences. | GAO-23-105574 health services technicians will then provide behavioral health care to Coast Guard personnel at clinics under the direct oversight of a mental health provider. Page 22 GAO-23-105574 Coast Guard Health Care Remote Locations and Other Challenges May Affect Beneficiaries' Access to TRICARE, but the Coast Guard Has Programs to Address Some of These Issues Locations of Coast Guard Based on our analysis of relevant data and our interviews with Coast Units May Present Guard health officials and six selected clinics, we found that Coast Guard beneficiaries may experience challenges receiving timely medical and Challenges to Accessing dental care through TRICARE. These challenges appear to be TRICARE predominantly due to the remote locations of some Coast Guard personnel who may be assigned to Coast Guard units outside of Prime Service Areas-where the TRICARE managed care support contractors are required to develop networks of civilian providers and which generally include a DHA medical facility. We also learned about challenges related to the accuracy of the TRICARE civilian provider directories, which may affect access to care, and challenges with access to mental health care across different types of locations. Coast Guard unit locations. Our analysis of TRICARE enrollment data showed that Coast Guard beneficiaries were enrolled in TRICARE Prime Remote at more than twice the rate of beneficiaries of the other military services, as of October 2022. Higher rates of TRICARE Prime Remote enrollment indicate that Coast Guard personnel are often stationed farther away-more than 50 miles or 1-hour driving time-from DHA medical facilities and, by extension, the civilian provider networks established around those facilities, than active duty service members from other military services. Specifically, we found that 15.8 percent of Coast Guard active duty personnel were enrolled in TRICARE Prime Remote, compared to 6.6 percent of all other military service active duty members. Additionally, 16.9 percent of Coast Guard dependents were enrolled in TRICARE Prime Remote, compared to 4.9 percent of all other military service dependents. See figure 4. Page 23 GAO-23-105574 Coast Guard Health Care Figure 4: Percent of U.S. Coast Guard Beneficiaries Enrolled in TRICARE Prime Remote Compared to Beneficiaries of Other Military Services, as of October 2022 Note: Beneficiaries may be eligible to enroll in TRICARE Prime if they work or live inside a Prime Service Area, which is generally within 40 miles of a Department of Defense military medical treatment facility (medical facility), or within 100 miles of a primary care manager. TRICARE Prime Remote extends the TRICARE Prime benefits to those beneficiaries who live more than 50 miles, or 1-hour driving time, from a medical facility. Other military services include the Army, Navy, Air Force, Marine Corps, and Space Force. In this figure, "personnel" refers to active duty personnel and "dependents" refers to dependents of active duty personnel. Coast Guard beneficiaries may also experience difficulties accessing care if there are no nearby DHA medical facilities. 42 For example, we found that only two of the six Coast Guard clinics in our review have nearby DHA medical facilities to use for referrals. The remaining four selected clinics must either refer beneficiaries to civilian providers or to a geographically distant DHA medical facility. For one of these clinics, the closest DHA medical facility requires beneficiaries to travel 5 hours by vehicle. In addition, we also identified other difficulties with travel logistics that may impede access to care for beneficiaries at some Coast Guard locations. For example, clinic officials from our selected clinics and 42In addition to lacking DHA medical facilities as a source of care, beneficiaries located further away from these facilities may also have limited access to the TRICARE network of civilian providers, which is generally developed in the areas surrounding DHA medical facilities. Page 24 GAO-23-105574 Coast Guard Health Care contractor representatives noted that some beneficiaries experience challenges like seasonal traffic, ferries, bridges, and rugged terrain that can be onerous and time-consuming when traveling to an appointment. For example, clinic officials in Cape Cod, Massachusetts, noted that some personnel are stationed on nearby islands. To access care on the mainland, they have to take a ferry and pay extra to bring their car. At another clinic in Alaska, located on Kodiak Island, beneficiaries need to travel by plane to access certain types of specialty care. According to a local ombudsman, this can be challenging because weather can impact flights, compounding access difficulties. We also found that, as of May 2022, almost half of all Coast Guard clinics are in locations that have been designated by the Department of Health and Human Services' Health Resources and Services Administration as medically underserved areas or geographic health provider shortage areas. 43 Such locations may contribute to access challenges for Coast Guard beneficiaries seeking care from TRICARE civilian providers. Specifically, we found that almost 40 percent of Coast Guard clinics (17 of 43 clinics) are located in medically underserved areas, meaning beneficiaries may lack ready access to primary care. Additionally, about 25 percent of Coast Guard clinics (11 of 43 clinics) are located in at least one type of geographic health provider shortage area (primary care, mental health, or dental). Some Coast Guard clinics met more than one of these designations. See table 2. 43The Health Resources and Services Administration reports areas that have been designated shortage areas, including medically underserved areas and health professional shortage areas. We used this publicly available data from https://data.hrsa.gov/tools/shortage-area/by-address, accessed May 17, 2022, to conduct analyses on which Coast Guard clinics were located in medically underserved areas and geographic health professional shortage areas. Page 25 GAO-23-105574 Coast Guard Health Care Table 2: U.S. Coast Guard Clinics Located in Medically Underserved Areas and Health Provider Shortage Areas as Designated by the Health Resources and Services Administration, as of May 2022 Coast Guard Clinics in Medically Underserved Areas or Health Professional Shortage Areas Health Professional Shortage Area Primary Mental Coast Guard installation City and state Medically Underserved Area Care Health Dental 1. Base Ketchikan Ketchikan, AK     2. Base Kodiak Kodiak, AK  - - - 3. Air Station Sitka Sitka, AK - - -  4. Aviation Training Center Mobile, AL Mobile  - - - 5. Sector Humboldt Bay McKinleyville, CA   - - 6. Base Los Angeles Long San Pedro, CA Beach  - - - 7. Coast Guard Academy New London, CT  -  - 8. Headquarters Support Washington, DC Command    - 9. Sector Key West Key West, FL  -  - 10. Base Honolulu Honolulu, HI  - - - 11. Base Boston Boston, MA  - - - 12. Air Station Cape Cod Buzzards Bay, MA  - -  13. Air Station Atlantic City Egg Harbor Township, NJ  - - - 14. Base Astoria Warrenton, OR  -  - 15. Sector North Bend North Bend, OR  -  - 16. Air Station Borinquen Aguadilla, PR  - - - 17. Sector San Juan San Juan, PR  - - - 18. Sector Corpus Christi Corpus Christi, TX -  - 19. Training Center Yorktown Yorktown, VA  - - - 20. Air Station Port Angeles Port Angeles, WA - -  - Legend:  = Coast Guard clinic is located in medically underserved area and/or health professional shortage area, - = not applicable Source: GAO analysis of Coast Guard and Health Resources and Services Administration data. | GAO-23-105574 Note: Medically underserved areas are geographic areas designated by the Health Resources and Services Administration as lacking access to primary care services. Geographic health professional shortage areas are areas that have been designated by the Health Resources and Services Administration as having a shortage of primary, dental, or mental health care providers. Page 26 GAO-23-105574 Coast Guard Health Care Four of the six Coast Guard clinics in our review are in medically underserved areas, and officials at four of the clinics cited beneficiary challenges accessing specialty care in particular. When asked about types of specialties, officials from three clinics cited obstetrics and gynecology as particularly challenging for beneficiaries to access in their areas. For instance, an ombudsman at one clinic told us that, as of April 2022, only one obstetric practice in their area was accepting new patients and that some pregnant beneficiaries experienced a lapse in care due to this provider shortage. Our analysis of TRICARE managed care support contractor data corroborates the obstetrics and gynecology access challenges reported by officials from the selected clinics. We found that for TRICARE Prime beneficiaries located near all six of our selected clinics between January 1, 2018, and December 31, 2021, the average days to care for obstetrics and gynecology in the civilian provider network exceeded the TRICARE specialty appointment access standard of 28 days. (See appendix II for additional information on the timeliness of specialty appointments with TRICARE civilian providers for our six selected clinics.) Additionally, some beneficiaries cited dental access as challenging, particularly for dependents. Coast Guard ombudsmen at two clinics said that dependents, who generally receive dental care from civilian dentists, struggle to access general dentistry in their communities. In one of these locations, an ombudsman told us that most dependents drive to another town for dental care, but the drive can take between 25 to 90 minutes, depending on the season. Beneficiaries at two other clinics said that they do not have pediatric dentistry in their area, and have to drive 3 hours, or travel by plane, to access this care. Page 27 GAO-23-105574 Coast Guard Health Care TRICARE Civilian Provider Directories TRICARE civilian provider directories. Officials from all six clinics reported challenges related to inaccuracies in the TRICARE provider directories for medical and dental providers. Inaccuracies they cited included listings with incorrect phone numbers, or listings of providers who were no longer accepting new TRICARE patients. According to some officials, these inaccuracies can cause officials and beneficiaries to spend additional time searching for providers. Officials from two clinics noted that when they learn about directory inaccuracies after they have submitted a referral, they then have to resubmit the referral with a new provider, which can possibly lead to delays in accessing care. Further, Source: stokkete/stock.adobe.com officials at another clinic noted that the provider directory listed 13 TRICARE managed care support contractors providers in the area, but only three of them were accepting new are required to develop adequate networks of civilian providers and to maintain online TRICARE patients, as of May 2022. Officials noted that these listings can directories of them. According to contract make it appear as if beneficiaries have greater access to care than what requirements, these directories must be at least 95 percent accurate. Accuracy is defined is actually available. as a directory entry that contains correct information for the following elements: One of the TRICARE managed care support contractors and the dental • provider name, contractor told us that they require providers to inform them of any • provider specialty, changes to their listings to keep the directories updated. Officials at four • sub-specialty (if applicable), clinics said they also inform their regional TRICARE contractor about • gender, discrepancies in the directories when they are identified, but that the • work address, challenge persists. Prior GAO work has identified similar challenges with • work fax number, and the information in provider directories among other health care • work telephone number. programs. 44 Although the directories are to indicate whether network providers are accepting new TRICARE patients, this data field is not Mental health care. Officials at five of the six clinics we spoke with said included for purposes of accuracy calculations. Lastly, on-line provider they experience challenges referring beneficiaries for mental or directories shall be current and refreshed no behavioral health care. An official at one Coast Guard clinic told us that less frequently than once every 24 hours, there are no psychiatrists or psychologists in their area accepting according to contract requirements. Source: TRICARE contracts. | GAO-23-105574 TRICARE patients. At another clinic, officials said that a beneficiary in the area may have to wait up to 5 months for a mental health appointment. Additionally, we found that almost 20 percent of Coast Guard clinics (8 of 43) are located in mental health provider shortage areas, as defined by the Health Resources and Services Administration. 44See GAO, Veterans Community Care Program: VA Needs to Strengthen Oversight and Improve Data on Its Community Care Network Providers, GAO-23-105290 (Washington, D.C.: November 10, 2022); Mental Health Care: Access Challenges for Covered Consumers and Relevant Federal Efforts, GAO-22-104597 (Washington, D.C.: Mar. 29, 2022); Medicaid Fee-For-Service: State Resources Vary for Helping Beneficiaries Find Providers, GAO-16-809 (Washington, D.C.: Aug 29, 2016); and Medicare Advantage: Actions Needs to Enhance CMS Oversight of Provider Network Adequacy, GAO-15-710 (Washington, D.C.: Aug 31, 2015). Page 28 GAO-23-105574 Coast Guard Health Care To examine this issue more closely, we analyzed data on the timeliness of Coast Guard beneficiaries' access to mental health care provided at DHA medical facilities and by TRICARE civilian providers between January 1, 2018, and December 31, 2021. We found that the challenges related to mental health care access we heard from clinic officials were supported by the results of this national data analysis, showing that it takes beneficiaries longer on average to access mental health care from TRICARE civilian providers than from DHA medical facilities. Access to Urgent Specialty Care • DHA medical facilities. For care provided at DHA facilities, we GAO previously reported that there is no examined access to the first, non-urgent mental health appointment, TRICARE access-to-care standard for urgent which is to be provided within 28 days, similar to all other non-urgent referrals to specialty care. However, the specialty care. 45 We obtained data for these appointments from both Department of Defense has a general expectation that beneficiaries will access of DHA's electronic health record systems, including the legacy specialty care in 3 days or less upon receiving system and the new system. Overall, we found that Coast Guard an urgent referral to see a specialist. Source: GAO, Defense Health Care: Efforts to Ensure personnel and their dependents accessed their first mental health Beneficiaries Access Specialty Care and Receive Timely and care appointments at DHA medical facilities within 12 to 18 days, on Effective Care, GAO-21-143 (Washington, D.C.: Dec. 22, 2020). | GAO-23-105574 average. We also examined the timeliness of Coast Guard beneficiaries' access to urgent mental health care provided at these facilities and found that they were seen by DHA providers in 3 days or less on average during the period of our review, consistent with DOD's general expectation. 46 • TRICARE civilian providers. We also examined Coast Guard beneficiaries' access to mental health care provided by TRICARE civilian providers under the TRICARE Prime option. We found variation in the average days to mental health care by type of mental 45According to DHA's guidance for appointing in military medical treatment facilities, first non-urgent mental health appointments are to be provided within 28 days. See Department of Defense, DHA-Interim Procedures Memorandum 18-001, Standard Appointing Processes, Procedures, Hours of Operation, Productivity, Performance Measures and Appointment Types in Primary, Specialty, and Behavioral Health Care in Medical Treatment Facilities. We examined mental health appointments categorized as "Specialty" in the data because, according to DHA, this appointment type represents a patient's first non-urgent mental health care appointment. 46Specifically, we examined mental health appointments categorized as "24 hours" in the data because, according to DHA, this appointment type represents either urgent mental health care referrals from other clinics or when acutely distressed patients present to the clinic as walk-ins. Page 29 GAO-23-105574 Coast Guard Health Care health provider and TRICARE region. 47 Of the three mental health- related specialties we reviewed, beneficiaries waited the longest to access psychiatry, with some waiting up to 41 days to be seen, on average. 48 Beneficiaries were seen the fastest when referred to behavioral health facilities, with some being seen within 9 days, on average. See figure 5 for information on mental health care access in the TRICARE West and East regions. Managed care support contractors provided reasons why access may exceed the TRICARE access standard, including provider availability and beneficiary preference. Further, according to the Department of Health and Human Services' Health Resources and Services Administration, the nation faces a current shortage in the mental health workforce. 49 Figure 5: Timeliness to Routine Mental Health Care from Civilian Providers for U.S. Coast Guard TRICARE Prime Beneficiaries in the TRICARE West and East Regions 47Of note, DHA officials told us that dependents do not require referrals for most mental health appointments. Therefore, the number of referrals we examined for Coast Guard dependents' access to mental health care do not reflect all dependents' mental health appointments that occurred during the period of our review. 48To examine mental health care access in the TRICARE civilian networks, we examined days to care to psychiatry, behavioral health, and behavioral health facilities. 49Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, Designated Health Professional Shortage Areas Statistics (Sept. 30, 2022). Page 30 GAO-23-105574 Coast Guard Health Care Note: The Defense Health Agency (DHA) requires the managed care support contractors to monitor monthly access to care to 29 different specialties. We reviewed this list and identified the following specialties related to mental health: behavioral health, behavioral health facilities, and psychiatry. We reviewed access data for these specialties for the period between Jan. 1, 2018, and Dec. 31, 2021, including data prior to the onset of the COVID-19 pandemic, as well as during the pandemic. The average days to care represents the averages of the number of days from the date the referral was approved to the date of the patient's first appointment. The managed care support contractors do not track access data for follow-up appointments associated with referrals, as patients are responsible for scheduling those appointments with their providers. Lastly, DHA officials told us that dependents do not require referrals for most mental health appointments. Therefore, the number of referrals we examined for Coast Guard dependents' access to mental health care do not reflect all dependents' mental health appointments that occurred during the period of our review. We also examined the timeliness of Coast Guard beneficiaries' access to mental health care who are urgently referred to TRICARE civilian providers. We found that the average days to care for psychiatry and behavioral health appointments in both regions far exceeded DOD's 3- day expectation for urgent care, with dependents in the West region waiting over a month on average for these appointments. See figure 6 for information on urgent mental health care access in the TRICARE West and East regions. Figure 6: Timeliness to Urgent Mental Health Care from Civilian Providers for U.S. Coast Guard TRICARE Prime Beneficiaries in the TRICARE West and East Regions The Defense Health Agency (DHA) requires the managed care support contractors to monitor monthly access to care to 29 different specialties. We reviewed this list and identified the following specialties related to mental health: behavioral health, behavioral health facilities, and psychiatry. We reviewed access data for these specialties for the period between Jan. 1, 2018, and Dec. 31, 2021, including data prior to the onset of the COVID-19 pandemic, as well as during the pandemic. The average days to care represents the averages of the number of days from the date the referral was approved to the date of the patient's first appointment. Lastly, DHA officials told us that dependents Page 31 GAO-23-105574 Coast Guard Health Care do not require referrals for most mental health appointments. Therefore, the number of referrals we examined for Coast Guard dependents' access to mental health care do not reflect all dependents' mental health appointments that occurred during the period of our review. The Department of Defense's expectation is that beneficiaries urgently referred to mental health care should be seen by a provider within 3 days. Coast Guard Has We found that the Coast Guard has several ways to assist beneficiaries Screening and Travel who face challenges accessing care through TRICARE, including screening programs and programs that help with travel expenses. We Programs to Assist also heard about examples of clinic officials working with Coast Guard Beneficiaries in Accessing health officials and TRICARE contractors to address specific access Care through TRICARE issues in their areas. U.S. Coast Guard Screening Processes Screening processes. The Coast Guard has two processes for The Coast Guard requires screening of its screening personnel and their dependents for medical and dental needs personnel and their dependents for to help prevent assignment to a location where they could face assignment to most locations outside of the challenges accessing needed care: (1) the overseas screening continental United States, through the Coast Guard overseas screening procedures. procedures, and (2) the Special Needs Screening Program. Additionally, as of January 2022, the program also requires screening for the following locations within the continental United States • Overseas screening procedures. These procedures require because of access-to-care challenges in personnel and their dependents to be screened, including for medical these areas: (1) Sector Humboldt Bay and dental conditions, before certain assignments, such as those to (McKinleyville, California), (2) Station Brant Point (Nantucket, Massachusetts), (3) Station overseas locations or select locations in the continental United States Menemsha (Chilmark, Massachusetts), (4) with known access-to-care challenges. Three of our six selected Station Bayfield (Bayfield, Wisconsin), (5) Station Hatteras Inlet (Hatteras Island, North Coast Guard clinics use these procedures. Carolina), (6) Sector Key West (Key West, Florida), (7) Station Neah Bay (Neah Bay, • Special Needs Program. This program screens Coast Guard Washington), and (8) Station Quillayute (La personnel who have dependents with special needs to assign them to Push, Washington). a location that will have adequate medical care available to meet their Under the Special Needs Program, Coast dependents' needs, among other services. 50 According to the Coast Guard personnel with dependents diagnosed with special medical, psychological, physical, Guard, 3,363 Coast Guard families were enrolled in the program as of or educational needs are assigned a category July 2022, representing approximately 8 percent of its personnel. based on a review of their dependent's needs. These categories are then used in Special Needs Program officials told us that the most common determining appropriate assignment locations. medical reasons for enrollment are asthma, autism, and mental health Source: Coast Guard. | GAO-23-105574. 50Enrollment in the Special Needs Program is required for personnel with dependents diagnosed with special medical, psychological, physical, or educational needs. According to Coast Guard officials, the Special Needs Program is comparable to DOD's Exceptional Family Member Program, using the same forms and criteria to identify dependents with special needs. Page 32 GAO-23-105574 Coast Guard Health Care conditions. 51 To determine whether an assignment location is suitable, program officials said they identify at least three providers in the area who could treat the dependent and are accepting new patients. Despite these actions, some beneficiaries in the Special Needs Program told us about challenges accessing care for their dependents with special needs. For example, one beneficiary noted that because she is in an area with many other special needs families, there is competition for appointments. 51Families in the Special Needs Program are assigned a category (1 through 5) based on a review of their dependents' needs by a Coast Guard physician. A category 1 family has a dependent with a readily treatable condition and has no restrictions on their location. Comparatively, a category 5 family has a dependent who requires continuous care and must be located within 25 miles of a major medical area. Page 33 GAO-23-105574 Coast Guard Health Care TRICARE Prime Travel Benefit Travel programs. To address health care challenges as they arise, the Coast Guard can authorize travel for personnel and some dependents to receive necessary care that is not available locally, using two different processes-the Coast Guard's Travel to Obtain Health Care Program and individual Coast Guard unit funding. • Travel to Obtain Health Care program. This Coast Guard program serves personnel and dependents who are located outside of the continental United States. 52 Under this program, personnel and their dependents are entitled to travel reimbursement, including for Source: izzetugutmen/stock.adobe.com transportation and lodging, for non-elective health care that has been Within the continental United States, Coast authorized by a physician and is not available locally. A beneficiary Guard dependents who are enrolled in TRICARE Prime, including TRICARE Prime may also be eligible for a non-medical attendant to travel with them if Remote, may be eligible for the TRICARE they will need assistance during treatment and recovery. Prime Travel Benefit. The TRICARE Prime Travel benefit is • Individual Coast Guard unit funding. Coast Guard personnel available for non-emergency, medically stationed within the continental United States can have health care- necessary appointments that have been related travel authorized and funded by their unit if that care is not authorized by a dependent's primary care manager and would require travel over 100 available locally. Officials from three clinics in our review said they miles. If eligible, a dependent may receive had authorized and funded such travel for their personnel. For reimbursement for travel expenses such as mileage, lodging, and meals. The Defense example, officials from one clinic said that they regularly authorize Health Agency's Prime Travel Benefit Office beneficiaries to travel to the closest DHA medical facility-which is a administers the program for dependents of 5-hour drive and necessitates staying overnight to accommodate Coast Guard personnel. appointments. Officials at another clinic said that they will authorize Ombudsmen at three selected Coast Guard clinics reported limited awareness about the travel to the closest major metropolitan area, which is about a 3-hour TRICARE travel benefits among beneficiaries. drive, for health care not available locally. Officials at one of the clinics cited beneficiary difficulties with required paperwork. Officials from another clinic also noted that the mileage requirement does not account for the geography of some remote locations, like islands. . Source: TRICARE. | GAO-23-105574. 52Specifically,the program covers Coast Guard personnel and dependents who are located within Alaska, Hawaii, and other locations that are part of TRICARE Overseas, such as Puerto Rico. Page 34 GAO-23-105574 Coast Guard Health Care TRICARE Dental Program Non-Compliant Outreach to Coast Guard health officials and TRICARE contractors. Designation Coast Guard clinic officials may elevate access challenges they identify to Coast Guard health officials or the TRICARE contractors for assistance with resolution. Officials at five clinics reported taking such action on a range of access issues. For example, officials at two clinics said that they had worked with Coast Guard health officials and representatives from the regional TRICARE managed care support contractor on behavioral health access issues. Officials from one of the clinics reported that these efforts resulted in additional providers being recruited for the network near one of the Coast Guard clinics. Officials from another clinic faced Source: Draken/stock.adobe.com significant dental access challenges because a network dentist in the area retired. 53 After elevating the issue, Coast Guard health officials said The TRICARE Dental Program allows for a "non-compliant" designation for certain they worked with DHA and the dental contractor to designate the area as locations. In these designated locations, "noncompliant," which allowed beneficiaries to see non-network dentists beneficiaries can see a non-network provider for the same cost as a network provider. This for the same out-of-pocket costs as a network dentist. increases dental access by expanding the number of dental providers that a beneficiary can see in a location. Finally, some Coast Guard beneficiaries we spoke with said that they Certain zip-codes are automatically communicate with each other to share information, such as about designated as non-compliant if a certain provider availability. For example, one ombudsman said that she learned number of beneficiaries in the area lack from other beneficiaries when a major practice in the area stopped access to a network dental provider. According to Defense Health Agency officials, accepting new patients, although it was still listed in the TRICARE other locations may be given a non-compliant directory. Another ombudsman reported observing beneficiaries using designation based on other factors, such as travel challenges. For example, in social media pages to share information about whether certain providers Massachusetts, the island of Martha's are taking new patients. Vineyard is considered a non-compliant location because beneficiaries would have to travel by ferry to access network dental providers. Source: TRICARE and interviews with the Defense Health Agency. | GAO-23-105574 53Representatives from the dental contractor said that while there were other dentists in the area, one was not accepting new patients and the other was located further away. Page 35 GAO-23-105574 Coast Guard Health Care Coast Guard Does Not Routinely Monitor TRICARE Medical and Dental Access for Its Beneficiaries Coast Guard Leadership We found that Coast Guard health officials monitor beneficiaries' access Monitors TRICARE Access to medical and dental care through TRICARE on an ad hoc basis, when they become aware of specific access problems. Officials said that they on an Ad Hoc Basis but learn about access-to-care issues through various sources. These Does Not Routinely sources include three Coast Guard liaisons that are embedded within Receive or Use Available DHA, who in part help respond to any beneficiary complaints. Data from DHA and Contractors For example, the Coast Guard liaisons told us that they heard from beneficiaries about limited primary care and dental access in certain locations, and helped expand access to care by requesting primary care manager-unassigned designations, which allowed beneficiaries to see any TRICARE-authorized provider in the area. The TRICARE contractors also inform the Coast Guard about access-to-care problems. For example, Coast Guard health officials said they have monthly meetings with the TRICARE managed care support contractors and periodic meetings with the dental contractor, during which time they can discuss any access issues that have emerged. Page 36 GAO-23-105574 Coast Guard Health Care In addition, Coast Guard health officials maintain an internal spreadsheet U.S. Coast Guard Beneficiary Access-to- Care Complaint Tracking to document and monitor access-to-care beneficiary complaints. Data from the spreadsheet indicates that the Coast Guard has resolved 85 percent of the 93 complaints filed since 2018. Coast Guard officials provided examples of access issues they have helped resolve, including working with the dental contractor to reassign their personnel from DHA dental facilities to civilian providers in the Active Duty Dental Program when the DHA facilities could no longer accommodate them in a timely manner. However, the Coast Guard does not otherwise collect or analyze data to Source: GAO. routinely monitor beneficiaries' access to medical care. We found that Coast Guard Health Safety and Work-Life some medical data are available that could be used for such monitoring Service Center officials (health officials) monitor access-to-care complaints using a purposes, but those data were not routinely provided to or used by the tracking spreadsheet. The spreadsheet Coast Guard at the time of our review. 54 See appendix III for more includes information on the Coast Guard units affected, the nature of the complaint, and the information on the availability of Coast Guard access-to-care data. resolution, among other information. Coast Guard health officials said they follow-up on • DHA medical facilities. DHA maintains medical data on care complaints monthly, or more frequently if needed, until the complaint is addressed. This provided to all beneficiaries at DHA medical facilities in the Military includes contacting the relevant Department Health System Data Repository. 55 This includes data from the two of Defense contractor to help resolve issues, if needed. electronic health record systems-the legacy Composite Health Care We found that between January 2018 and System and MHS GENESIS. DHA generates monthly access-to-care December 2021, there were 93 access-to- reports for DHA medical facilities that include data on the total number care complaints documented in the of appointments and wait times for different types of care (e.g., spreadsheet. More than half of the complaints were related to few providers in particular primary and specialty care). However, these reports do not delineate locations or lengthy wait times for access by beneficiaries' branch of service; instead, they report on appointments. Other complaints were related to TRICARE civilian provider directory access to care in aggregate, regardless of branch of service, for all inaccuracies, access at military facilities, and beneficiaries receiving care at DHA medical facilities. DHA officials billing issues. were able to modify these reports for us, when requested, to reflect Source: GAO analysis of Coast Guard information. | GAO-23-105574 access to care specifically for Coast Guard beneficiaries. Coast Guard officials told us they, too, can request ad hoc reports from DHA on access to DHA medical facilities for their beneficiaries, but such requests occur infrequently, such as when concerns are raised. 54For dental care, we found that data are not available for monitoring Coast Guard beneficiaries' access at DHA dental facilities because the military services (Army, Navy, and Air Force) do not maintain dental access data by branch of service. Similarly, the dental contractor does not report on access to care by branch of service when reporting to DHA, nor is it required to, according to DHA and the contractor. 55The Military Health System Data Repository consolidates all military health records, from all systems used to document health care, into one standardized data source for use in analysis and reporting at an enterprise level. Page 37 GAO-23-105574 Coast Guard Health Care As of November 2022, no formal agreement exists between the Coast Guard and DHA regarding the routine sharing of access-to-care data for Coast Guard beneficiaries that receive care at DHA medical facilities. While DHA and the Coast Guard have an interagency agreement in place regarding the Coast Guard's participation in TRICARE, the agreement does not address data sharing between the two entities. The interagency agreement suggests that a separate document exists detailing the understanding between DHA and the Coast Guard regarding Coast Guard's participation in Military Health System information processes, but neither Coast Guard nor DHA officials could locate the document. However, DHA officials reported that Coast Guard officials can request data from DHA on their beneficiaries as needed. • TRICARE civilian medical providers. The managed care support contractors electronically submit monthly access reports to DHA that include data for all TRICARE beneficiaries, including the Coast Guard. These reports include data on the average days to care for beneficiaries receiving care from TRICARE civilian providers, broken out by 29 different specialties. The monthly reports allow for ready monitoring by TRICARE region, by the medical facility ordering the referral (including Coast Guard clinics), and by individual Prime Service Area, including those where only Coast Guard beneficiaries reside. The monthly reports can be delineated by branch of service, and the managed care support contractors can further modify the reports upon request for customized time periods and specialties. Coast Guard health officials told us that select officials have access to the contractors' online portals to retrieve access-to-care data on Coast Guard beneficiaries. However, officials also told us that the Health, Safety and Work-Life Service Center has limited staff to routinely monitor these data, although they agreed that the data should be examined. Further, Coast Guard health officials noted that individual Coast Guard clinics must contact the Health, Safety and Work-Life Service Center to request access to the online portals, as the clinics do not have automatic access to these data for their specific beneficiaries. Officials further noted that there are insufficient staff at the clinics to monitor these data routinely, although officials from five of the six selected clinics we visited reported retrieving access-to-care data through the online portals on an ad hoc basis. The Coast Guard's medical manual states that the Coast Guard strives to ensure beneficiaries receive timely health care services, which includes access to care in accordance with the established standards for Page 38 GAO-23-105574 Coast Guard Health Care TRICARE. 56 Establishing an agreement between the Coast Guard and DHA to facilitate data sharing would provide Coast Guard leadership with information it could use to monitor Coast Guard beneficiaries' access to care and thereby help ensure that beneficiaries have timely access to care at DHA medical facilities. Further, routinely monitoring managed care support contractors' data would help provide similar assurance of Coast Guard Prime beneficiaries' timely access to medical care provided by civilian providers. Establishing a process for the systematic monitoring of these data would help Coast Guard health officials to proactively identify and address any access challenges their beneficiaries may be facing, regardless of where they seek care. Limited Awareness of DHA During our interviews with the six Coast Guard clinics and DHA and Medical Facility Coast Guard health officials, we identified two issues related to DHA and Coast Guard practices that may impede the clinics' ability to monitor Appointment Capabilities TRICARE medical and dental referrals: (1) limited awareness of local and Inconsistent Use of DHA medical facilities' capability and capacity for accepting Coast Guard MHS GENESIS May active duty personnel referrals, and (2) inconsistent use of MHS Impede Coast Guard GENESIS for monitoring members' referrals. Clinics' Monitoring of Limited awareness of local DHA medical facility capability and TRICARE Referrals capacity for Coast Guard referrals. DHA medical facilities have the right of first refusal for all specialty care referrals generated in Prime Service Areas, including those from the Coast Guard clinics. 57 However, officials from three Coast Guard clinics reported limited awareness of local DHA medical facility capability and capacity for accepting referrals for their personnel. 58 Currently, such information is not systematically shared with Coast Guard clinics; rather, officials from two clinics told us they rely on personal relationships with local DHA facility staff to know whether their personnel can be accommodated, or if they should instead 56Department of Homeland Security United States Coast Guard, Coast Guard Medical Manual. 57The TRICARE Operations Manual stipulates that, within Prime Service Areas, the managed care support contractors must send specialty care referrals to the local DHA medical facility if the facility determines that it has the capability and capacity to provide the needed care. 58Officials from two other clinics told us they do not refer their members to DHA medical facilities for care because there are no facilities nearby within TRICARE access standards, and they have adequate TRICARE civilian providers to meet their members' needs. Officials from the remaining Coast Guard clinic reported a close working relationship with the local DHA medical facility and therefore they had the knowledge they needed to appropriately refer personnel to the facility or to civilian providers. Page 39 GAO-23-105574 Coast Guard Health Care be referred to the civilian provider network. Referrals sent to DHA medical facilities can be declined if the facility lacks the capability and capacity to provide the needed care. Officials from one Coast Guard clinic estimated that their local DHA medical facility declined approximately 60 percent of their referrals. When declined, the referrals must then be submitted to the managed care support contractor for authorization for civilian provider care. The clinic's medical officer noted that patients are often frustrated by these delays because they have to wait longer for care. The TRICARE Operations Manual instructs DHA medical facilities to inform the managed care support contractors about their capabilities and capacities to accept specialty care referrals, with facilities updating the contractors of any changes. According to DHA officials, medical facilities send capability and capacity reports to their relevant contractor, and update the reports as needed. DHA officials confirmed that its medical facilities are not sharing these reports with Coast Guard clinics, but said this would be easy to do if requested. Establishing a mechanism for sharing these reports with Coast Guard clinics would provide clinics with more accurate information on where to refer Coast Guard personnel, and help reduce potential delays with referrals. Inconsistent use of MHS GENESIS to monitor TRICARE referrals. Officials from all six selected Coast Guard clinics told us that they monitor the status their TRICARE medical and dental care referrals. However, we found that the mechanisms these clinics used to monitor the status of TRICARE referrals (e.g., whether the referrals remained pending, accepted, closed, etc.) varied. As of April and May 2022, officials from three clinics told us they use MHS GENESIS to monitor referrals. Staff at the other three clinics used their own local spreadsheets to track referrals. Coast Guard directives require clinics to track referrals within MHS GENESIS, and to discontinue using local spreadsheets. 59 However, Coast Guard health officials said that they have not monitored the 43 clinics' compliance with this requirement. By monitoring compliance with its policy that stipulates the clinics should use MHS GENESIS to track TRICARE referrals, the Coast Guard will have greater assurance that personnel are obtaining the care they need in a timely manner. 59See Department of Homeland Security, United States Coast Guard Health, Safety and Work-Life Service Center Technical Directives 2021-003, "TRICARE Medical Referrals Procedures, and 2021-004, "MHS GENESIS Procedural Guidance." Page 40 GAO-23-105574 Coast Guard Health Care Beneficiaries' Access to Medical Care under TRICARE Varied by Type and Source of Care; Access to Dental Care Was Generally within Requirements Coast Guard Beneficiaries Our analysis of DHA data shows that between January 1, 2018, and Generally Accessed December 31, 2021, Coast Guard beneficiaries generally accessed primary care from DHA medical facilities in less than 16 days on average; Primary Care from DHA for TRICARE civilian providers, 75 percent of Coast Guard dependents Medical Facilities and lived within 30 minutes of their primary care managers. 60 Civilian Providers within Standards 60We analyzed access to care for Coast Guard beneficiaries' enrolled in TRICARE Prime because the time and distance metrics can not be applied to TRICARE Select. A TRICARE Select enrollee may choose an appointment outside of "time and distance" standards, or may seek out-of-network care due to personal preference. Page 41 GAO-23-105574 Coast Guard Health Care DHA medical facilities. During the period of our review, our analysis of TRICARE Access-to-Care Standards for Primary Care DHA data showed that the average days to care for primary care The TRICARE access-to-care standards for appointments at DHA medical facilities ranged from 1 to 13 days for primary care appointments are: Coast Guard personnel. 61 Similarly, for Coast Guard dependents, the • 28 days for well visits; average days to care for primary care appointments ranged from 2 to 15 • 7 days for routine appointments; and days during this time. However, we were unable to distinguish whether • 30-minute drive time. these appointments were for routine or well visits because the Well visits include preventive services such as appointment types in DHA's electronic health record systems do not health screenings, tests, and examinations. Routine appointments include general office directly align with these terms. For example, there are no appointment visits for the treatment of symptoms, chronic types called "well visit" or "routine" in MHS GENESIS. 62 or acute illnesses and diseases, and follow-up care for ongoing medical conditions. Source: GAO based on Defense Health Agency information. | TRICARE civilian medical providers. The managed care support GAO-23-105574 contractors evaluate beneficiaries' access to primary care by analyzing the number of dependents who are enrolled in TRICARE Prime and are assigned to a primary care manager within the access standard of a 30- minute drive time. 63 We found that, as of October 2022, 75 percent of Coast Guard TRICARE Prime dependents who used the TRICARE civilian networks for primary care were enrolled with a primary care manager within 30 minutes of their residence. 64 According to officials, active duty service members are not subject to the drive-time standard. 61According to DHA, most primary care appointments are a mix of "24 hours" appointments and "Future" appointments, to maximize medical facilities' abilities to meet access standards. We examined and found average days to care for both appointment types when examining access to primary care. We obtained and separately analyzed data from two different electronic health record systems – DHA's legacy system, the Composite Health Care System, and MHS GENESIS, the new system currently being implemented. 62Appointment types in the legacy electronic health record system include "24 hours," "Acute," "Future," "Group," "Procedure," "Routine," "Specialty," and "Well;" however, both the "Routine" and "Well" appointments were rarely used in the data we examined. In MHS GENESIS, neither of these appointment types exist; rather, the appointment types in the new system include "24 hours," "Future," "Group," "Procedure," "Specialty," and "Virtual." 63The managed care support contractors said they are not required to track the number of days to primary care because TRICARE Prime beneficiaries can schedule their own primary care appointments if seeking care from their civilian primary care manger (i.e. no referrals are needed). The number of days to primary care received in DHA medical facilities, comparatively, can be tracked because the date the beneficiary requested an appointment can be tracked in the electronic health record systems. 64TRICARE beneficiaries can elect to waive this standard if, for example, they identify a network provider they would like to see that exceeds the drive time standard. Page 42 GAO-23-105574 Coast Guard Health Care Coast Guard Beneficiaries Our analysis of DHA and contractor data shows that during the period of Generally Accessed our review, Coast Guard beneficiaries' enrolled in TRICARE Prime generally accessed specialty care from DHA medical facilities within the Specialty Care from DHA standard; comparatively, access to specialty care through TRICARE Facilities within the civilian providers varied by specialty, and at times exceeded the standard Timeliness Standard, but of 28 days. Access from Civilian Providers Sometimes DHA medical facilities. For specialty care provided at DHA medical facilities, our analysis of DHA data showed that Coast Guard active duty Exceeded Standard personnel and dependents who were enrolled in TRICARE Prime accessed routine specialty care in accordance with the established standard of 28 days. Because DHA is in the process of transitioning TRICARE Access-to-Care Standards for Specialty Care electronic health record systems, we obtained and analyzed data from The TRICARE access-to-care standards for DHA's legacy system, the Composite Health Care System, and its new specialty care appointments are: system, MHS GENESIS. 65 Figure 7 illustrates the timeliness of Coast • 28 days for routine, non-urgent specialty Guard beneficiaries' access to their initial specialty care appointments at visits; and DHA medical facilities based on data from both electronic health record • 60-minute drive time. Source: GAO based on Defense Health Agency information. | systems. 66 GAO-23-105574 65Due to differences in the ways that these systems record and track appointments, we separately analyzed and reported each system's data. For example, the number of days to a specialty care appointment is measured differently in each system. According to a DHA official, days to care in the new system is measured starting with the date the appointment is made and ending with the date the appointment occurred. Comparatively, days to care in the legacy system is measured beginning with the date the referral was made, if known. If unknown, the DHA official said the days to care are then measured beginning with the date the appointment was made. 66We also examined the timeliness of Coast Guard beneficiaries' access to their follow-up appointments for specialty care, since those data are available in DHA's electronic health record systems. For care received from DHA medical facilities using the legacy health record system, we found that follow-up care was received within 28 days for all specialties, with the exception of optometry-the average days to care for this specialty was 29 days. For care received from DHA medical facilities using the new electronic health record system, we found that Coast Guard beneficiaries received all follow-up care in accordance with the 28-day standard. Page 43 GAO-23-105574 Coast Guard Health Care Figure 7: Timeliness of Routine Specialty Care for U.S. Coast Guard TRICARE Prime Beneficiaries at DHA Medical Facilities, as shown by Its Legacy and New Electronic Health Record Systems Page 44 GAO-23-105574 Coast Guard Health Care Note: Because DHA is in the process of transitioning electronic health record systems, we obtained and analyzed data from the legacy system, the Composite Health Care System, and the new system, MHS GENESIS, for the period of our review. The TRICARE access-to-care standard for routine specialty care is 28 days. Other includes other specialty services not listed. a Otolaryngology is a specialty that diagnoses and treats diseases of the ear, nose, and throat. b TRICARE civilian medical providers. The managed care support contractors routinely track the timeliness of initial specialty care appointments for TRICARE Prime enrollees obtaining care from civilian network providers, since they have to approve the referral before the beneficiary is seen for their initial appointment. 67 Our analysis of the contractors' data for the time period of our review showed that • Fifty-five percent of Coast Guard personnel in the TRICARE West region accessed initial routine specialty care appointments within 28 days, compared with 72 percent in the TRICARE East region. • Fifty-nine percent of Coast Guard dependents in the TRICARE West region and 72 percent in the TRICARE East region accessed such care within 28 days. The longer time to care in the TRICARE West region may reflect the more remote locations of the Coast Guard units in that part of the country. Average days to routine care varied by specialty, with certain ones exceeding the standard, in both regions. For example, in both regions, average days to dermatology and obstetrics and gynecology exceeded the standard. See figure 8 for TRICARE West region results, and figure 9 for TRICARE East region results. Managed care support contractors provided a number of reasons why access may exceed the TRICARE standard, such as (1) provider availability, (2) beneficiary preference, (3) continuity of care with a specific provider, (4) care being directed to specific provider outside of the access standard, and (5) traveling outside of the Prime Service Area. 67Beneficiaries are responsible for scheduling any follow-up appointments; therefore, the managed care support contractors do not have timeliness data for these appointments. Page 45 GAO-23-105574 Coast Guard Health Care Figure 8: Timeliness to Selected Routine Specialty Care for U.S. Coast Guard TRICARE Prime Beneficiaries Accessing Care from Civilian Providers in the TRICARE West Region, Jan. 2018 - Dec. 2021 Note: The Defense Health Agency requires the managed care support contractors to monitor monthly access to care to 29 different specialties; for the purposes of this review, we analyzed access to care to the top 10 specialties in the West Region, based on volume of referrals, between Jan. 1, 2018, and Dec. 31, 2021. This included data for years prior to the onset of the COVID-19 pandemic, as well as during the pandemic. Additionally, the average days to care represents the averages of the number of days from the date the referral was approved to the date of the patient's first appointment. The managed care support contractors do not track access data for any follow-up appointments associated with the referral, as patients are responsible for scheduling those appointments with their providers. a Ancillary services are professional services provided by a hospital or other inpatient health program. These may include X-ray, drug, laboratory, or other services. b Medical sub-specialties is a broad category that includes licensed providers in allopathic or osteopathic medicine. Page 46 GAO-23-105574 Coast Guard Health Care c Non-physician providers are health care providers who practice either in collaboration with or under the supervision of a physician, including physician assistants, nurse practitioners, and clinical nurse specialists. d Otolaryngology is a specialty that diagnoses and treats diseases of the ear, nose, and throat. Figure 9: Timeliness to Selected Routine Specialty Care for U.S. Coast Guard TRICARE Prime Beneficiaries Accessing Care from Civilian Providers in the TRICARE East Region, Jan. 2018 - Dec. 2021 Note: The Defense Health Agency requires the managed care support contractors to monitor monthly access to care to 29 different specialties; for the purposes of this review, we analyzed access to care to the top 10 specialties in the East Region, based on volume of referrals, between Jan. 1, 2018, and Dec. 31, 2021. This included data for years prior to the onset of the COVID-19 pandemic, as well as during the pandemic. Additionally, the average days to care represents the averages of the number of days from the date the referral was approved to the date of the patient's first appointment. The managed care support contractors do not track access data for any follow-up appointments associated with the referral, as patients are responsible for scheduling those appointments with their providers. Page 47 GAO-23-105574 Coast Guard Health Care a Ancillary services are professional services provided by a hospital or other inpatient health program. These may include X-ray, drug, laboratory, or other services b Hospital includes hospital and acute care facilities that provide inpatient services and may provide outpatient services (including clinical and ambulatory surgical services). c Medical sub-specialties is a broad category that includes licensed providers in allopathic or osteopathic medicine. d Non-physician providers are health care providers who practice either in collaboration with or under the supervision of a physician, including physician assistants, nurse practitioners, and clinical nurse specialists. Finally, we examined the distance Coast Guard TRICARE Prime beneficiaries had to travel to receive specialty care services from TRICARE civilian providers. We found that 83 percent of referrals for active duty personnel in the TRICARE West region and 87 percent of referrals for their dependents were within a 1-hour drive-time of their residence. Comparatively, more than 99 percent of referrals for Coast Guard active duty personnel and their dependents in the TRICARE East region were within 1-hour drive time of their residence. The longer distances to travel for care in the TRICARE West region may reflect the more remote locations of the Coast Guard units in that part of the country. Coast Guard Beneficiaries For Coast Guard personnel using the Active Duty Dental Program to Generally Accessed access specialty dental care from TRICARE civilian providers, we found that all specialty appointments for the 4 years of our review occurred Civilian Specialty Dental within 28 days. 68 Additionally, we found that all dental readiness class 3 Care within Requirements appointments-for conditions that could become dental emergencies if not treated-were also provided within the contractual time frame of 7 days. 69 68There are no TRICARE access standards for specialty dental care; however, the dental contractor was able to provide us with data on specialty care appointments that occurred within or exceeded 28 days. We did not analyze the number of days to routine dental care because beneficiaries may directly schedule these appointments with their TRICARE dental providers; thus, there is no start date from which to measure days to care. 69A dental readiness class 3 is for patients that have an oral condition that, if not treated, is expected to result in dental emergencies within the next 12 months. Page 48 GAO-23-105574 Coast Guard Health Care TRICARE Dental Program Access For Coast Guard dependents enrolled with the TRICARE Dental Standards for Routine Dental Care Program, we found that within 35 miles of their residences – The TRICARE Dental Program access standards for routine dental care are: • 99 percent of them were located near a general dentist; • 21 days for routine dental care; and • Less than 35 miles to dental providers • 92 percent were located near an orthodontist; from residences. Source: GAO based on Defense Health Agency information. | • 94 percent were located near an oral surgeon, and GAO-23-105574. • 98 percent were located near at least one specialist. 70 The Coast Guard's ability to ensure the medical and dental readiness of Conclusions its personnel is critically important for meeting mission demands. The Coast Guard has taken steps to improve health care access for its beneficiaries. However, Coast Guard health officials and officials from selected clinics reported facing persistent staffing challenges, including recruiting and retaining USPHS providers. The Coast Guard has taken steps to mitigate this challenge, such as recently initiating its own Health Service Officer Program, but it has not examined reasons for USPHS recruitment and retention challenges. Doing so would help the Coast Guard determine what, if any, actions it can take to address these challenges and help better ensure its clinics have sufficient staff to meet its medical mission. The TRICARE health plan is a critically important resource for facilitating access to care for all Coast Guard beneficiaries, particularly for those residing in remote locations or facing provider shortages in medically underserved areas. Coast Guard leadership has adopted some ad hoc mechanisms for monitoring TRICARE access among Coast Guard beneficiaries, but these mechanisms are not proactive or systematic for identifying potential access concerns. By working with DHA to establish data sharing for medical care provided at military facilities and routinely monitoring available data from DHA and the managed care support contractors, Coast Guard leadership would be better positioned to understand and take action to address potential access concerns and help ensure all beneficiaries receive timely care. This is important because while Coast Guard beneficiaries have generally obtained primary 70The TRICARE Dental Program distance standard for access is for beneficiaries to reside within 35 miles of a dental provider. Additionally, these percentages reflect access for all Coast Guard beneficiaries enrolled in the TRICARE Dental Program, which includes active duty dependents, Reserve sponsors, and Reserve family members. The dental contractor was unable to segregate the data for active duty dependents only; however, according to the contractor, active duty dependents represent more than 95 percent of all Coast Guard beneficiaries enrolled in the TRICARE Dental Program. Page 49 GAO-23-105574 Coast Guard Health Care care and dental care within access standards, access to specialty care has often exceeded the 28-day timeliness standard when provided by TRICARE civilian providers. With limited outpatient services offered at Coast Guard clinics, specialty care referrals-to DHA medical facilities or civilian providers-are an essential component of health care for Coast Guard active duty personnel. Coast Guard clinic officials reported positive working relationships with nearby DHA medical facilities, but these officials do not always know whether these facilities can accept their referrals. Requiring DHA medical facilities to share their capability and capacity reports with local Coast Guard clinics would provide these clinics with more reliable information on where to refer their patients, avoiding potential delays. Additionally, monitoring compliance with its policy that requires clinic staff to use MHS GENESIS to track referrals would help the Coast Guard ensure that all personnel are obtaining timely medical and dental care. We are making a total of seven recommendations, including five to the Recommendations for Coast Guard and two to DHA. Specifically: Executive Action The Commandant of the Coast Guard should collect information on the reasons for USPHS recruitment and retention challenges, such as information obtained through standardized exit interviews; analyze the information; and take action as appropriate, such as sharing relevant information with USPHS and developing targeted strategies for addressing the challenges. (Recommendation 1) The Commandant of the Coast Guard, in collaboration with DHA, should develop an agreement to outline the responsibilities for and facilitation of the routine sharing of data on Coast Guard beneficiaries' access to medical care provided at DHA medical facilities. (Recommendation 2) The Director of DHA, in collaboration with the Coast Guard, should develop an agreement to outline the responsibilities for, and facilitation of, the routine sharing of data on Coast Guard beneficiaries' access to medical care provided at DHA medical facilities. (Recommendation 3) The Commandant of the Coast Guard should establish a process to routinely monitor data on Coast Guard beneficiaries' access to medical care provided at DHA medical facilities, once routine data sharing is established with DHA. (Recommendation 4) Page 50 GAO-23-105574 Coast Guard Health Care The Commandant of the Coast Guard should establish a process to routinely monitor data available from the managed care support contractors on Coast Guard beneficiaries' access to civilian medical care through TRICARE. (Recommendation 5) The Director of DHA should require the military medical treatment facilities to share capability and capacity reports with Coast Guard clinics from which beneficiaries are referred, such as through a policy or a memorandum of understanding with the Coast Guard. (Recommendation 6) The Commandant of the Coast Guard should monitor clinics' compliance with its requirement that they use MHS GENESIS to track the status of TRICARE referrals. (Recommendation 7) We provided a draft of this report to the Department of Homeland Agency Comments Security, DOD, and the Department of Health and Human Services for review and comment. DOD did not provide comments, and the Department of Health and Human Services informed us it did not have any comments. In written comments from the Department of Homeland Security, reproduced in appendix IV, the department concurred with its five recommendations. • In response to our recommendation that the Coast Guard collect and analyze information on the reasons for USPHS recruitment and retention challenges, the department noted that the Coast Guard is updating its informal exit interview process to include a standardized questionnaire for each USPHS officer leaving the service. • In response to our recommendation on the routine sharing of data, the department stated that the Coast Guard is pursuing increased coordination across all facets of data sharing with DHA, and a data governance group will determine the appropriate access-to- care metrics for the agreement. • In response to our recommendation that the Coast Guard establish a process to routinely monitor data on beneficiaries' access to care at DHA medical facilities, the department stated that the Health, Safety and Work-Life Service Center will provide these data to Coast Guard clinics once they become available. Page 51 GAO-23-105574 Coast Guard Health Care • In response to our recommendation that the Coast Guard establish a process to routinely monitor managed care support contractor data, the department noted that while these data are currently available for Prime Service Areas, the Health, Safety and Work-Life Service Center would establish a process to monitor data on beneficiaries living outside of these areas. • In response to our recommendation that the Coast Guard monitor its clinics' compliance with the requirement to use MHS GENESIS to track the status of TRICARE referrals, the department stated that it implemented MHS GENESIS referral-tracking capabilities in February 2022. The department also cited other recent actions and positive feedback from beneficiaries and requested that we consider the recommendation implemented. We recognize the Coast Guard's various actions related to referrals and its new electronic health record system. However, to close this recommendation as implemented, we will need to obtain and review documentation demonstrating the Coast Guard's monitoring of its clinics' compliance with the requirement. The Department of Homeland Security, DOD, and the Department of Health and Human Services also provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional Committees, the Secretary of Homeland Security, the Secretary of Defense, the Secretary of Health and Human Services, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact Alyssa M. Hundrup at (202) 512-7114 or HundrupA@gao.gov. Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report. Other major contributors to this report are listed in appendix V. Alyssa M. Hundrup Director, Health Care Page 52 GAO-23-105574 Coast Guard Health Care Appendix I: Methodology for Examining Appendix I: Methodology for Examining Coast Guard Beneficiaries' Access to Medical and Coast Guard Beneficiaries' Access to Dental Care through TRICARE Medical and Dental Care through TRICARE To examine what available data show about Coast Guard beneficiaries' access to medical and dental care through TRICARE, we obtained Coast Guard data from the Defense Health Agency (DHA) and its contractors for the period from January 1, 2018, when health care delivery began under the current managed care support contracts, through December 31, 2021, the most recent years available. As a result, our analyses include data both before and during the COVID-19 pandemic, but we did not examine the data by pre-pandemic and pandemic time frames. We focused our analyses on access to primary care, specialty care, and dental care for Coast Guard personnel and their dependents. To assess the reliability of these data, we interviewed officials with DHA and its contractors and reviewed related documentation. We found these data sufficiently reliable for our reporting purposes. We analyzed the data by source of care; specifically, whether care was rendered through DHA military medical treatment facilities (medical facilities) or its private sector care system of TRICARE civilian medical and dental providers. 1 DHA medical facilities. For care provided at DHA medical facilities, we examined DHA's data on Coast Guard beneficiaries' total appointments and average days to care for primary care and specialty care, including mental health care. 2 We examined the data by different appointment types-for example, an initial specialty care appointment or a follow-up 1We were unable to examine Coast Guard beneficiaries' access to dental care from the military services' dental facilities. According to officials from the Army, Navy, and Air Force, they do not monitor access to care by individual branch of service (e.g. for Coast Guard beneficiaries). 2We examined mental health care that was provided either in a primary care or mental health care setting. We included mental health care provided in a primary care setting to align with DHA's policy that behavioral health services are to be provided in this setting to, among other things, improve patient access to such care. We excluded appointments where mental health care was provided as part of an appointment in other specialty care clinics, such as dermatology or orthopedics, because mental health care was unlikely to be the primary purpose of the appointment. Page 53 GAO-23-105574 Coast Guard Health Care Appendix I: Methodology for Examining Coast Guard Beneficiaries' Access to Medical and Dental Care through TRICARE appointment. 3 Because DHA is in the process of transitioning electronic health record systems, we obtained and analyzed data from the Composite Health Care System, DHA's legacy system, and from MHS GENESIS, DHA's new electronic health record system. Due to differences in the ways that these systems record appointments, we separately analyzed and report each system's data. 4 TRICARE civilian medical providers. For medical care provided through the TRICARE civilian provider networks, we examined Coast Guard TRICARE Prime beneficiaries' total number of referrals, average days to the initial specialty care appointment, and the percent of specialty care appointments that occurred within the TRICARE standard of 28 days, by select specialties, including those related to mental health. 5 We also examined the geographic distances TRICARE Prime beneficiaries had to travel to these appointments in accordance with TRICARE drive 3According to DHA, most specialty care appointments are a combination of two appointment types: (1) "Specialty," which represents the first non-urgent specialty appointment and (2) "Future," which is used for routine or follow-up care after the first specialty care appointment. We examined data for both appointment types to determine the timeliness of beneficiaries' access to specialty care. However, we found instances in the data in which multiple appointments for a patient were associated with the "Specialty" appointment type. Because we were not able to determine which visit represented the initial appointment, we did not include those data in our analysis. 4The number and types of medical appointments vary between the legacy system (eight appointment types) and those found in MHS GENESIS (six appointment types), with no crosswalk available to align them. Furthermore, days to care is measured differently in each system. According to a DHA official, days to care in MHS GENESIS is measured starting with the date the appointment is made and ending with the date the appointment occurred. Comparatively, days to care in the legacy system are measured beginning with the date the referral was made, if known. If unknown, then the days to care are measured beginning with the date the appointment was made. 5The managed care support contractors measure access to care by calculating the number of days from the date the referral was approved to the date of the patient's first appointment. Follow-up appointments related to a referral are not captured in these data, as these appointments are scheduled directly by beneficiaries. Additionally, the managed care support contractors are required to report on access to care for 29 different medical specialties. For the purposes of our review, we analyzed referral data for the top 10 specialty care services with the most referrals for each TRICARE region. The resulting lists of top 10 specialties were different across the two TRICARE regions. To examine beneficiaries' access to mental health care through the TRICARE civilian networks, we identified and examined any specialty related to mental health from the list of 29 specialties. Accordingly, we analyzed beneficiaries' access to psychiatry, behavioral health, and behavioral health facilities. Page 54 GAO-23-105574 Coast Guard Health Care Appendix I: Methodology for Examining Coast Guard Beneficiaries' Access to Medical and Dental Care through TRICARE time standards. We analyzed these data by TRICARE region-East and West-because the managed care support contractors use different referral priorities; therefore, we were unable to aggregate the two regions' data into a one analysis. 6 TRICARE civilian dental providers. For civilian dental care provided to Coast Guard personnel through the TRICARE Active Duty Dental Plan, we examined (1) the days to care for specialty dental care, (2) the number of referrals to endodontists and oral surgeons, and (3) the days to care for personnel with dental issues that made them otherwise unable to deploy. 7 There are no statutory access standards for this dental program, but DHA has contractual access requirements, such as providing routine dental care within 21 days. For civilian dental care provided to Coast Guard dependents through the TRICARE Dental Program, we examined the extent to which dependents had access to different types of dental providers within 35 miles of their residences, in accordance with the regulatory TRICARE access standard. 8 6Specifically, one contractor uses four priorities (routine, specialty, urgent, well visit), while the other uses three priorities (emergent, urgent, routine). 7There are four dental readiness classes. Class 1 is for patients who do not require dental treatment or reevaluation within a 12-month period. Class 2 is for patients that have an oral condition with the potential, but that is not expected to, result in dental emergencies within a 12-month period. Class 3 is for patients that have an oral condition that, if not treated, is expected to result in dental emergencies within the next 12 months. Class 4 is for patients who require dental examinations and whose dental classifications are unknown. 832 C.F.R. § 199.13(e)(3)(ii) (2021). Page 55 GAO-23-105574 Coast Guard Health Care Appendix II: Supplemental Site Visit Appendix II: Supplemental Site Visit Information on Selected U.S. Coast Guard Information on Selected U.S. Coast Guard Clinics Clinics We conducted site visits to six selected Coast Guard clinics to obtain perspectives from local leadership and clinic officials on any challenges active duty personnel and their dependents face accessing medical and dental care at Coast Guard clinics and from TRICARE civilian providers. Additionally, we interviewed the ombudsmen for each clinic location to obtain the perspectives of Coast Guard dependents. We selected the six clinics for variation by geographic location, number of clinic staff, and relative population density in the surrounding area. Perspectives obtained from these clinics cannot be generalized to all Coast Guard clinics, but rather provide illustrative examples of challenges beneficiaries may face accessing medical and dental care, and efforts the Coast Guard may take to address them. See figure 10 for the locations and the number of active duty personnel served by each of our six selected Coast Guard clinics. Page 56 GAO-23-105574 Coast Guard Health Care Appendix II: Supplemental Site Visit Information on Selected U.S. Coast Guard Clinics Figure 10: Locations and Number of Active Duty Personnel Served by Selected U.S. Coast Guard Clinics Included in GAO's Review The following provides information we collected and analyzed about each clinic, including clinic staffing information, examples of access-to-care challenges, and Coast Guard officials' efforts to address them. We also include data illustrating Coast Guard beneficiaries' access to care from TRICARE civilian medical providers between January 1, 2018, and December 31, 2021. Page 57 GAO-23-105574 Coast Guard Health Care Base Cape Cod The Kaehler Memorial Clinic at Base Cape Cod provides health care to active duty personnel in Southeastern New England. Clinic location: General Geographic and Number of Buzzards Bay, Demographic Information 4 affiliated sickbays Massachusetts Number of personnel Medically Underserved 750 served by the clinic Yes Area designationa as of November 2022 Health Provider Census designation: Yes, Rural Urban, urban cluster, rural Dental Shortage Area TRICARE-related Information designationb • Ambulatory care • Pharmacy Clinic • Dental care • Physical therapy Services • Laboratory services • Medical readiness services Number of clinic staff: Type of clinic staff: as of December 2022 as of December 2022 • U.S. Public • USPHS Health Service pharmacist TRICARE Region: East Region (USPHS) physician • 14 health service Proximity to nearest military medical 25 • Physician assistant technicians, treatment facility: 62 miles among others • USPHS dentist and various dental TRICARE Prime Remote designationc: contractors No Source: GAO analysis of Coast Guard and Defense Health Examples of reported access-to-care challenges Agency information and interviews with Coast Guard officials as of April 2022 (data); MapResources (maps). | GAO-23-105574 • Few providers accepting TRICARE: According to clinic officials, few providers in the Cape Cod area accept TRICARE, compared to more populous areas like a The Health Resources and Services Boston. Administration designates geographic areas lacking access to primary care services as •Ferries and bridges. Base Cape Cod's area of responsibility includes the medically underserved areas. islands of Nantucket and Martha's Vineyard from which beneficiaries have to take a b The Health Resources and Services ferry to travel to the mainland for appointments. Administration designates areas having a shortage of primary, dental, or mental •Seasonal traffic. During tourist season, traffic increases in the Cape Cod area. health care providers as geographic health For example, one beneficiary said that the 25-minute drive to the dentist can take professional shortage areas. 90 minutes with seasonal traffic. c TRICARE Prime Remote extends TRICARE Prime benefits to those beneficiaries who live more than 50 miles, or approximately 1-hour Coast Guard efforts reported to improve beneficiaries' access to care driving time, from a military medical treatment as of September 2021 facility in designated locations. •Screening. Officials in Cape Cod reported that they are using Coast Guard's d Coast Guard's overseas screening procedures overseas screening procedures to screen personnel and dependents for require personnel and their dependents to be screened, including for medical and dental medical and dental conditions before assignment to the islands in their area of conditions, before assignment to overseas responsibility.d locations or select locations within the continental United States, including Station •Elevating access-to-care issues. Clinic officials described working with Coast Brant Point (Nantucket, Massachusetts), Guard Health, Safety and Work-Life Service Center and the regional TRICARE Station Menemsha (Chilmark, Massachusetts) managed care support contractor to recruit additional mental health care providers which are part of Base Cape Cod's area of into the network. responsibility. 58 GAO-23-105574 Coast Guard Access to Care Base Cape Cod The timeliness of referrals varied by specialty. Overall, for active duty personnel the average days to care was 27 days, and 68 percent of their appointments fell within the 28-day standard. Timeliness of Routine Referrals to Select Specialties for U.S. Coast Guard TRICARE Prime Beneficiaries in the Cape Cod Service Area Average Average Specialty Active duty personnel days to care Dependents days to care All specialty referrals 68% 27 79% 19 Ancillary servicesa 72% 24 86% 18 Dermatology 40% 44 59% 29 General surgery 76% 20 58% 34 Hospitalb 82% 18 87% 16 Medical sub-specialtiesc 36% 41 85% 19 Non-physician providersd 45% 40 59% 29 Obstetrics and gynecology 64% 35 72% 21 Orthopedic surgery 86% 15 92% 11 Physical therapy 86% 15 100% 10 Radiology 83% 7 100% 6 0 10 20 30 40 50 60 70 80 90 0 10 20 30 40 50 60 70 80 90 Percentage within 28-day standard Percentage within 28-day standard Average days to care that exceeded TRICARE access-to-care 28-day standard Source: GAO analysis of Humana Military data, Jan. 2018 - Dec. 2021. | GAO-23-105574 Note: The Defense Health Agency requires the managed care support contractors to monitor monthly access to care to 29 different specialties; for the purposes of this review, we analyzed access to care to the top 10 specialties in the TRICARE East Region, based on volume of referrals, between Jan. 1, 2018, and Dec. 31, 2021. This included data for years prior to the onset of the COVID-19 pandemic, as well as during the pandemic. Additionally, the average days to care represents the averages of the number of days from the date the referral was approved to the date of the patient's first appointment. The managed care support contractors do not track data on the number of days to care for any follow-up appointments associated with the referral, as patients are responsible for scheduling those appointments with their providers. a Ancillary services are professional services provided by a hospital or other inpatient health program. These may include X-ray, drug, laboratory, or other services. b Hospital includes hospital and acute care facilities that provide inpatient services and may provide outpatient services (including clinical and ambulatory surgical services). c Medical sub-specialties is a broad category that includes licensed providers in allopathic or osteopathic medicine. d Non-physician providers are health care providers who practice either in collaboration with or under the supervision of a physician, including physician assistants, nurse practitioners, and clinical nurse specialists. 59 GAO-23-105574 Coast Guard Access to Care Air Station Detroit The area of responsibility for Air Station Detroit includes over 1,100 miles of shoreline, including the southern portions of Lake Huron and Lake Erie. Clinic location: Selfridge, General Geographic and Number of Demographic Information 3 affiliated sickbays Michigan Number of personnel Medically Underserved 504 served by the clinic No Area designationa as of November 2022 Health Provider Census designation: Urban Urban, urban cluster, rural No Shortage Area TRICARE-related Information designationb • Ambulatory care • Laboratory services Clinic • Dental care • Medical readiness services Services Number of clinic staff: Type of clinic staff: as of December 2022 as of December 2022 • U.S. Public Health Service 14 (USPHS) flight surgeon TRICARE Region: East Region • USPHS dentist and various Proximity to nearest military medical dental contractors treatment facility: 346 miles • 8 health service technicians, among others TRICARE Prime Remote designationc: No Source: GAO analysis of Coast Guard and Defense Health Examples of reported access-to-care challenges Agency information and interviews with Coast Guard officials as of September 2021 (data); MapResources (maps). | GAO-23-105574 • Clinic officials reported no major challenges due to sufficient health care access through the local TRICARE civilian network. a The Health Resources and Services Administration designates geographic areas lacking access to primary care services as Coast Guard efforts reported to improve beneficiaries' access to care medically underserved areas. as of September 2021 b The Health Resources and Services • Not applicable Administration designates areas having a shortage of primary, dental, or mental health care providers as geographic health professional shortage areas. c TRICARE Prime Remote extends TRICARE Prime benefits to those beneficiaries who live more than 50 miles, or approximately 1-hour driving time, from a military medical treatment facility in designated locations. 60 GAO-23-105574 Coast Guard Access to Care Air Station Detroit The timeliness of referrals varied by specialty. Overall, for active duty personnel the average days to care was 25 days, and 71 percent of their appointments fell within the 28-day standard. Timeliness of Routine Referrals to Select Specialties for U.S. Coast Guard TRICARE Prime Beneficiaries in the Detroit Service Area Average Average Specialty Active duty personnel days to care Dependents days to care All specialty referrals 71% 25 84% 17 Ancillary servicesa 80% 19 87% 13 Dermatology 57% 33 83% 19 General surgery 85% 16 86% 13 Hospitalb 80% 17 83% 16 Medical sub-specialtiesc 64% 35 80% 20 Non-physician providersd 64% 29 86% 15 Obstetrics and gynecology 47% 36 74% 24 Orthopedic surgery 85% 14 94% 10 Physical therapy 86% 17 100% 8 Radiology 92% 11 83% 12 0 10 20 30 40 50 60 70 80 90 0 10 20 30 40 50 60 70 80 90 Percentage within 28-day standard Percentage within 28-day standard Average days to care that exceeded TRICARE access-to-care 28-day standard Source: GAO analysis of Humana Military data, Jan. 2018 - Dec. 2021. | GAO-23-105574 Note: The Defense Health Agency requires the managed care support contractors to monitor monthly access to care to 29 different specialties; for the purposes of this review, we analyzed access to care to the top 10 specialties in the TRICARE East Region, based on volume of referrals, between Jan. 1, 2018, and Dec. 31, 2021. This included data for years prior to the onset of the COVID-19 pandemic, as well as during the pandemic. Additionally, the average days to care represents the averages of the number of days from the date the referral was approved to the date of the patient's first appointment. The managed care support contractors do not track data on the number of days to care for any follow-up appointments associated with the referral, as patients are responsible for scheduling those appointments with their providers. a Ancillary services are professional services provided by a hospital or other inpatient health program. These may include X-ray, drug, laboratory, or other services. b Hospital includes hospital and acute care facilities that provide inpatient services and may provide outpatient services (including clinical and ambulatory surgical services). c Medical sub-specialties is a broad category that includes licensed providers in allopathic or osteopathic medicine. d Non-physician providers are health care providers who practice either in collaboration with or under the supervision of a physician, including physician assistants, nurse practitioners, and clinical nurse specialists. 61 GAO-23-105574 Coast Guard Access to Care Sector Humboldt Bay Clinic location: Sector Humboldt Bay is responsible for McKinleyville, search and rescue and law enforcement, California among other missions, along 250 miles of the Northern California coastline. General Geographic and Number of Demographic Information 0 affiliated sickbays Number of personnel Medically Underserved 176 served by the clinic Yes Area designationa as of November 2022 Urban Census designation: Yes, Health Provider Primary Shortage Area TRICARE-related Information cluster Urban, urban cluster, rural Care designationb • Ambulatory care • Medical readiness services Clinic • Laboratory services Services Number of clinic staff: Type of clinic staff: as of December 2022 as of December 2022 • Contracted flight surgeon 7 • Physician assistant TRICARE Region: West Region • 5 health service technicians Proximity to nearest military medical treatment facility: 296 miles TRICARE Prime Remote designationc: Yes Source: GAO analysis of Coast Guard and Defense Health Examples of reported access-to-care challenges Agency information and interviews with Coast Guard officials as of August 2021 (data); MapResources (maps). | GAO-23-105574 | GAO-23- 105574 •Few, if any, providers in the area. Clinic officials noted that there are few local primary care providers for dependents that are accepting new patients, and few specialists in the area. Some specialties, such as ear, nose, and throat; specialty dentistry; and dietary counseling have no providers in the area, according to clinic officials. a The Health Resources and Services Administration designates geographic areas •Provider unfamiliarity with TRICARE. Clinic officials said that the few providers lacking access to primary care services as in the area may not be familiar with TRICARE, leading to difficulties processing medically underserved areas. referrals or the provider not accepting TRICARE. Some providers in the area did not accept insurance and only accepted cash payments, officials noted. b The Health Resources and Services Administration designates areas having a shortage of primary, dental, or mental health care providers as geographic health Coast Guard efforts reported to improve beneficiaries' access to care professional shortage areas. as of April 2022 c TRICARE Prime Remote extends TRICARE •Screening. Sector Humboldt Bay participates in Coast Guard's Overseas Prime benefits to those beneficiaries who live Screening Program to screen personnel and dependents for medical and dental more than 50 miles, or approximately 1-hour conditions before assignment to Humboldt Bay.d driving time, from a military medical treatment facility in designated locations. •Non-compliant market designation for dental care. Clinic officials reported d The Coast Guard's overseas screening dental access issues to Coast Guard's Health, Safety, and Work-Life Service procedures require personnel and their Center, who then worked with the TRICARE dental contractor to obtain a dependents to be screened, including non-compliant market designation for Humboldt Bay. This designation allows for medical and dental conditions, before beneficiaries to access dental care from network and non-network dentists. assignment to overseas locations or select Officials said that this change largely resolved dental access issues in the area. locations within the continental United States. 62 GAO-23-105574 Coast Guard Access to Care Sector Humboldt Bay The timeliness of referrals varied by specialty. Overall, for active duty personnel the average days to care was 27 days, but only 46 percent of their appointments fell within the 28-day standard. Timeliness of Routine Referrals to Select Specialties for U.S. Coast Guard TRICARE Prime Beneficiaries in the Humboldt Bay Service Area Average Average Specialty Active duty personnel days to care Dependents days to care All specialty referrals 46% 27 57% 36 Ancillary servicesa 83% 33 75% 32 Behavioral Health 68% 18 80% 18 Dermatology 35% 53 26% 55 Medical sub-specialtiesb 49% 32 42% 49 Non-physician providersc 31% 22 44% 29 Obstetrics and gynecology 42% 45 76% 27 Orthopedic surgery 38% 29 50% 59 Otolaryngologyd 45% 44 67% 33 Physical therapy 56% 19 86% 13 Radiology 48% 20 62% 27 0 10 20 30 40 50 60 70 80 90 0 10 20 30 40 50 60 70 80 90 Percentage within 28-day standard Percentage within 28-day standard Average days to care that exceeded TRICARE access-to-care 28-day standard Source: GAO analysis of Health Net Federal Services data, Jan. 2018 - Dec. 2021. | GAO-23-105574 Note: The Defense Health Agency requires the managed care support contractors to monitor monthly access to care to 29 different specialties; for the purposes of this review, we analyzed access to care to the top 10 specialties in the TRICARE West Region, based on volume of referrals, between Jan. 1, 2018, and Dec. 31, 2021. This included data for years prior to the onset of the COVID-19 pandemic, as well as during the pandemic. Additionally, the average days to care represents the averages of the number of days from the date the referral was approved to the date of the patient's first appointment. The managed care support contractors do not track data on the number of days to care for any follow-up appointments associated with the referral, as patients are responsible for scheduling those appointments with their providers. a Ancillary services are professional services provided by a hospital or other inpatient health program. These may include X-ray, drug, laboratory, or other services. b Medical sub-specialties is a broad category that includes licensed providers in allopathic or osteopathic medicine. c Non-physician providers are health care providers who practice either in collaboration with or under the supervision of a physician, including physician assistants, nurse practitioners, and clinical nurse specialists. d Otolaryngology is a specialty that diagnoses and treats diseases of the ear, nose, and throat. 63 GAO-23-105574 Coast Guard Access to Care Sector Key West Located in the southernmost city in the continental United States, Sector Key West has responsibility for over 50,000 square miles of water bordering the territorial seas of Cuba and Bahamas. General Geographic and Number of Demographic Information 2 affiliated sickbays Number of personnel Clinic location: Medically Underserved Key West, Florida 742 served by the clinic Yes Area designationa as of November 2022 Urban Census designation: Yes, Health Provider Mental Shortage Area TRICARE-related Information cluster Urban, urban cluster, rural Health designationb • Ambulatory care • Medical readiness services Clinic • Laboratory services Services Number of clinic staff: Type of clinic staff: as of December 2022 as of December 2022 • U.S. Public Health Service 7 physician TRICARE Region: East Region • 5 health service technicians, Proximity to nearest military medical among others treatment facility: 4 miles TRICARE Prime Remote designationc: No Source: GAO analysis of Coast Guard and Defense Health Examples of reported access-to-care challenges Agency information and interviews with Coast Guard officials (data); MapResources (maps). | GAO-23-105574 as of May 2022 • Limited number of providers in the area. Officials noted that there were a limited number of providers in the local area, likely due to the high cost of living. For example, there were only two psychologists and one OB-GYN accepting new TRICARE patients. a The Health Resources and Services •Traveling for health care. Patients generally have to travel to Miami for health Administration designates geographic areas care not available locally, which is about a 3-hour drive. lacking access to primary care services as medically underserved areas. b The Health Resources and Services Administration designates areas having a shortage of primary, dental, or mental health care providers as geographic health professional shortage areas. Coast Guard efforts reported to improve beneficiaries' access to care as of May 2022 c TRICARE Prime Remote extends the TRICARE Prime benefits to those beneficiaries • Screening. Officials said that they had recently started using the overseas who live more than 50 miles, or more than a screening procedures to screen personnel and their dependents for certain medical 1-hour driving time, from a Defense Health Agency medical facility in designated locations. conditions before assignment to Key West. Officials said that the screening tool has been effective at identifying members that would be unable to readily d The Coast Guard's overseas screening access certain medical services in Key West.d procedures require personnel and their dependents to be screened, including for medical and dental conditions, before assignment to overseas locations or select locations within the continental United States. 64 GAO-23-105574 Coast Guard Access to Care Sector Key West The timeliness of referrals varied by specialty. Overall, for active duty personnel the average days to care was 24 days, and 74 percent of their appointments fell within the 28-day standard Timeliness of Routine Referrals to Select Specialties for U.S. Coast Guard TRICARE Prime Beneficiaries in the Key West Service Area Average Average Specialty Active duty personnel days to care Dependents days to care All specialty referrals 74% 24 74% 24 Ancillary servicesa 64% 28 60% 34 Dermatology 63% 31 72% 25 General surgery 84% 15 90% 18 Hospitalb 85% 17 86% 16 Medical sub-specialtiesc 84% 16 82% 20 Non-physician providersd 75% 24 86% 17 Obstetrics and gynecology 67% 31 72% 26 Orthopedic surgery 72% 22 70% 23 Physical therapy 79% 20 86% 16 Radiology 77% 22 67% 14 0 10 20 30 40 50 60 70 80 90 0 10 20 30 40 50 60 70 80 90 Percentage within 28-day standard Percentage within 28-day standard Average days to care that exceeded TRICARE access-to-care 28-day standard Source: GAO analysis of Humana Military data, Jan. 2018 - Dec. 2021. | GAO-23-105574 Note: The Defense Health Agency requires the managed care support contractors to monitor monthly access to care to 29 different specialties; for the purposes of this review, we analyzed access to care to the top 10 specialties in the TRICARE East Region, based on volume of referrals, between Jan. 1, 2018, and Dec. 31, 2021. This included data for years prior to the onset of the COVID-19 pandemic, as well as during the pandemic. Additionally, the average days to care represents the averages of the number of days from the date the referral was approved to the date of the patient's first appointment. The managed care support contractors do not track data on the number of days to care for any follow-up appointments associated with the referral, as patients are responsible for scheduling those appointments with their providers. a Ancillary services are professional services provided by a hospital or other inpatient health program. These may include X-ray, drug, laboratory, or other services. b Hospital includes hospital and acute care facilities that provide inpatient services and may provide outpatient services (including clinical and ambulatory surgical services). c Medical sub-specialties is a broad category that includes licensed providers in allopathic or osteopathic medicine. d Non-physician providers are health care providers who practice either in collaboration with or under the supervision of a physician, including physician assistants, nurse practitioners, and clinical nurse specialists. 65 GAO-23-105574 Coast Guard Access to Care Base Kodiak The Rockmore-King Clinic at Base Kodiak provides health care to active duty personnel stationed on Kodiak Island, Alaska, the second largest island in the United States with an operational area of responsibility of over 3.9 million square miles. General Geographic and Number of Demographic Information 3 affiliated sickbays Number of personnel Medically Underserved 724 served by the clinic Yes Area designationa Clinic location: as of November 2022 Kodiak, Alaska Health Provider Urban Census designation: No Shortage Area TRICARE-related Information cluster Urban, urban cluster, rural designationb • Ambulatory care • Pharmacy Clinic • Dental care • Medical readiness services Services • Laboratory services Number of clinic staff: Type of clinic staff: as of December 2022 as of December 2022 • 2 U.S. Public Health • A USPHS Service (USPHS) pharmacist TRICARE Region: West Region physicians • 24 health service Proximity to nearest military medical • 2 physician assistants technicians, treatment facility: 425 miles and 2 nurses among others 37 • 2 USPHS dentists and TRICARE Prime Remote designationc: various dental contractors No for personnel; Yes for dependents Source: GAO analysis of Coast Guard and Defense Health Examples of reported access-to-care challenges Agency information and interviews with Coast Guard officials as of April 2022 (data); MapResources (maps). | GAO-23-105574 • Limited specialists in the area. Clinic officials reported that few specialists work on Kodiak Island. For example, there are no pediatricians or obstetricians, although there are some family medicine providers who may treat patients that would otherwise see these types of providers. Beneficiaries must travel off-island for most specialty care, generally to Anchorage or Seattle. • Travel challenges. Beneficiaries must travel by plane for any health care outside of Kodiak. While they can take Coast Guard-operated flights from the base to a a The Health Resources and Services military base in Anchorage, they still face challenges in doing so. These include Administration designates geographic areas flight delays and cancellations due to weather, as well as transportation logistics in lacking access to primary care services as Anchorage, as non-military personnel, including taxi and other drivers, are medically underserved areas. not allowed on base without clearance. b The Health Resources and Services Administration designates areas having Coast Guard efforts reported to improve beneficiaries' access to care a shortage of primary, dental, or mental as of April 2022 health care providers as geographic health professional shortage areas. • Rotating providers. To address provider vacancies, Coast Guard providers from c TRICARE Prime Remote extends TRICARE other locations haved served in the Base Kodiak clinic on rotating 2-week shifts to Prime benefits to those beneficiaries who live meet the base's short-term medical needs. more than 50 miles, or approximately 1-hour driving time, from a military medical treatment • Travel to Obtain Health Care program. This Coast Guard program funds travel facility in designated locations. Active duty for personnel and dependents who are stationed in Alaska. Base Kodiak officials personnel in Kodiak are not designated as administer this program for all beneficiaries located in Alaska. TRICARE Prime Remote because they can access certain medical and dental care from the Coast Guard clinic. 66 GAO-23-105574 Coast Guard Access to Care Base Kodiak The timeliness of referrals varied by specialty. Overall, for active duty personnel the average days to care was 19 days, but only 28 percent of their appointments fell within the 28-day standard. Timeliness of Routine Referrals to Select Specialties for U.S. Coast Guard TRICARE Prime Beneficiaries in the Kodiak Service Area Average Average Specialty Active duty personnel days to care Dependents days to care All specialty referrals 28% 19 72% 25 Ancillary servicesa 59% 26 50% 48 Behavioral Health 49% 24 91% 10 Dermatology 17% 41 33% 38 Medical sub-specialtiesb 41% 24 0% 88 Non-physician providersc 6% 12 89% 11 Obstetrics and gynecology 53% 36 50% 52 Orthopedic surgery 56% 19 75% 19 Otolaryngologyd 53% 33 57% 22 Physical therapy 32% 16 96% 16 Radiology 35% 13 100% 10 0 10 20 30 40 50 60 70 80 90 0 10 20 30 40 50 60 70 80 90 Percentage within 28-day standard Percentage within 28-day standard Average days to care that exceeded TRICARE access-to-care 28-day standard Source: GAO analysis of Health Net Federal Services data, Jan. 2018 - Dec. 2021. | GAO-23-105574 Note: The Defense Health Agency requires the managed care support contractors to monitor monthly access to care to 29 different specialties; for the purposes of this review, we analyzed access to care to the top 10 specialties in the TRICARE West Region, based on volume of referrals, between Jan. 1, 2018, and Dec. 31, 2021. This included data for years prior to the onset of the COVID-19 pandemic, as well as during the pandemic. Additionally, the average days to care represents the averages of the number of days from the date the referral was approved to the date of the patient's first appointment. The managed care support contractors do not track data on the number of days to care for any follow-up appointments associated with the referral, as patients are responsible for scheduling those appointments with their providers. a Ancillary services are professional services provided by a hospital or other inpatient health program. These may include X-ray, drug, laboratory, or other services. b Medical sub-specialties is a broad category that includes licensed providers in allopathic or osteopathic medicine. c Non-physician providers are health care providers who practice either in collaboration with or under the supervision of a physician, including physician assistants, nurse practitioners, and clinical nurse specialists. d Otolaryngology is a specialty that diagnoses and treats diseases of the ear, nose, and throat. 67 GAO-23-105574 Coast Guard Access to Care Base Portsmouth Base Portsmouth is the headquarters of the Coast Guard's operations in the Mid-Atlantic region, which encompass Clinic location: 156,000 square miles of ocean and waterways in six states Portsmouth, and the District of Columbia in the Mid-Atlantic region. Virginia General Geographic and Number of Demographic Information 14 affiliated sickbays Number of personnel Medically Underserved 3,268 served by the clinic No Area designationa as of November 2022 Health Provider Census designation: Urban Urban, urban cluster, rural No Shortage Area TRICARE-related Information designationb • Ambulatory care • Laboratory services Clinic • Behavioral health • Pharmacy Services • Dental care • Medical readiness services Number of clinic staff: Type of clinic staff: as of December 2022 as of December 2022 • U.S. Public • USPHS Health Service pharmacist TRICARE Region: East Region (USPHS) physician • USPHS nurse Proximity to nearest military medical • 4 physician assistants case manager treatment facility: 8 miles • 3 USPHS dentists • 25 health service and various dental technicians, TRICARE Prime Remote designationc: contractors among others No 47 Source: GAO analysis of Coast Guard and Defense Health Examples of reported access-to-care challenges Agency information and interviews with Coast Guard officials as of May 2022 (data); MapResources (maps). | GAO-23-105574 • Clinic officials said that there were generally no issues with beneficiaries' access to care through TRICARE due to the heavy presence of TRICARE providers in the area. a The Health Resources and Services Administration designates geographic areas lacking access to primary care services as Coast Guard efforts reported to improve beneficiaries' access to care medically underserved areas. as of May 2022 b The Health Resources and Services • Not applicable Administration designates areas having a shortage of primary, dental, or mental health care providers as geographic health professional shortage areas. c TRICARE Prime Remote extends TRICARE Prime benefits to those beneficiaries who live more than 50 miles, or approximately 1-hour driving time, from a military medical treatment facility in designated locations. 68 GAO-23-105574 Coast Guard Access to Care Base Portsmouth The timeliness of referrals varied by specialty. Overall, for active duty personnel the average days to care was 27 days, and 68 percent of their appointments fell within the 28-day standard. Timeliness of Routine Referrals to Select Specialties for U.S. Coast Guard TRICARE Prime Beneficiaries in the Portsmouth Service Area Average Average Specialty Active duty personnel days to care Dependents days to care All specialty referrals 68% 27 66% 29 Ancillary servicesa 65% 28 62% 32 Dermatology 43% 42 40% 43 General surgery 79% 23 72% 25 Hospitalb 82% 17 73% 22 Medical sub-specialtiesc 61% 32 55% 35 Non-physician providersd 55% 30 77% 23 Obstetrics and gynecology 64% 29 57% 34 Orthopedic surgery 72% 25 75% 24 Physical therapy 84% 17 85% 18 Radiology 86% 17 72% 22 0 10 20 30 40 50 60 70 80 90 0 10 20 30 40 50 60 70 80 90 Percentage within 28-day standard Percentage within 28-day standard Average days to care that exceeded TRICARE access-to-care 28-day standard Source: GAO analysis of Humana Military data, Jan. 2018 - Dec. 2021. | GAO-23-105574 Note: The Defense Health Agency requires the managed care support contractors to monitor monthly access to care to 29 different specialties; for the purposes of this review, we analyzed access to care to the top 10 specialties in the TRICARE East Region, based on volume of referrals, between Jan. 1, 2018, and Dec. 31, 2021. This included data for years prior to the onset of the COVID-19 pandemic, as well as during the pandemic. Additionally, the average days to care represents the averages of the number of days from the date the referral was approved to the date of the patient's first appointment. The managed care support contractors do not track data on the number of days to care for any follow-up appointments associated with the referral, as patients are responsible for scheduling those appointments with their providers. a Ancillary services are professional services provided by a hospital or other inpatient health program. These may include X-ray, drug, laboratory, or other services. b Hospital includes hospital and acute care facilities that provide inpatient services and may provide outpatient services (including clinical and ambulatory surgical services). c Medical sub-specialties is a broad category that includes licensed providers in allopathic or osteopathic medicine. d Non-physician providers are health care providers who practice either in collaboration with or under the supervision of a physician, including physician assistants, nurse practitioners, and clinical nurse specialists. 69 GAO-23-105574 Coast Guard Access to Care Appendix III: TRICARE Access Standards Appendix III: TRICARE Access Standards and Available Data for U.S. Coast Guard and Available Data for U.S. Coast Guard Beneficiaries Beneficiaries This appendix provides information on the availability of data regarding Coast Guard beneficiaries' timely access to care, based on the information the Defense Health Agency and the TRICARE contractors collect specific to medical care through TRICARE Prime and dental care under the different TRICARE programs. Under TRICARE, active duty service members, including Coast Guard personnel, are automatically enrolled in TRICARE Prime, a managed care option for military beneficiaries who work or live within a Prime Service Area or within 100 miles of a primary care manager. 1 Dependents may choose to enroll in Prime or another TRICARE benefit option. TRICARE access standards are only used to monitor TRICARE Prime enrollees' medical appointment wait times and drive times for care obtained at Defense Health Agency (DHA) military medical treatment facilities and from the network of civilian providers. Because TRICARE Select is self-managed and based on enrollee choice, standards for drive time and appointment timeliness are not monitored. A TRICARE Select enrollee may choose an appointment outside of "time and distance" standards, or may seek out-of-network care due to personal preference. Additionally, under TRICARE, active duty service members can obtain dental care at DHA dental treatment facilities or, if capacity has been reached or there is no nearby facility, from civilian dentists through the Active Duty Dental Program. Coast Guard dependents are eligible to enroll in the TRICARE Dental Program, which is a premium-based program that covers certain dental services. Both dental programs have appointment timeliness and drive time access standards. Table 15 provides information on the TRICARE access standards, by type of care, and the availability of such data by source of care. 1Prime Service Areas are geographic areas usually within an approximate 40-mile radius of a DHA medical facility in which the managed care support contractors offer enrollment in TRICARE Prime and develop networks of civilian providers. Page 70 GAO-23-105574 Coast Guard Health Care Appendix III: TRICARE Access Standards and Available Data for U.S. Coast Guard Beneficiaries Table 3: Access-to-Care Data Available for U.S. Coast Guard Active Duty Personnel and Dependents enrolled in TRICARE, by Type and Source of Care Type of care TRICARE Access-to-care Source of Care Data available standard(s) (Type of Beneficiary Served) Days to Distance to Days to care Distance to care care care Primary Care 7 days < 30 minutes Military medical treatment facilities Yesa Nob (routine) driving (Active duty and dependents) 28 days TRICARE civilian networks Noc Yesd (well visit) (Active duty and dependents) Specialty care 28 days < 60 minutes Military medical treatment facilities Yes Nob driving (Active duty and dependents) TRICARE civilian networks Yes Yese (Active duty and dependents) Dental (routine) 21 days Military dental treatment facilities Nof Nof (Active duty and dependents)g < 40 miles Active Duty Dental Program Noc No driving (Active Duty) < 35 miles driving TRICARE Dental Program Noc Yesh (Dependents) Source: GAO based on review of the TRICARE Access-to-Care Standards and Defense Health Agency (DHA) and contractor information. | GAO-23-105574 a DHA does not routinely monitor access-to-care data for Coast Guard beneficiaries; rather, these beneficiaries are included in the access-to-care reports that examine access for all beneficiaries through the military medical treatment facilities. However, DHA officials were able to extract the Coast Guard data for us to examine for our requested time period. Further, Coast Guard officials told us they have made ad hoc requests to DHA for access-to-care data on their beneficiaries. b DHA officials reported that they do not track drive times to care provided at military medical treatment facilities. People assigned to those clinics are within Prime Service Areas. c TRICARE contractors generally do not have data on days to care for primary care or routine dental appointments because beneficiaries may schedule these appointments with TRICARE civilian providers themselves (for example, no referral is needed if primary care is sought from their assigned primary care managers). Thus, there is no start date from which to measure days to care. One contractor provided us with data on days to care for the routine dental appointments they scheduled on behalf of active duty personnel during the 4 years of our review, but the number of appointments were too low for analysis. DHA officials confirmed that most service members schedule their own routine dental appointments; thus, we excluded these few appointments from our review. d Health Net Federal Services and Humana Military officials measure primary care access by analyzing the number of dependents enrolled with a primary care manager within 30 minutes of their residences. Active duty personnel are not subject to drive-time standards, but the managed care support contractors had data on this beneficiary group. e DHA does not require Health Net Federal Services and Humana Military to monitor drive time for specialty care referrals by branch of service; rather, they must report on the overall adequacy of the referrals satisfying the drive-time standard across the networks. However, as of May 2020, Humana Military started monitoring drive times for referrals by branch of service, including Coast Guard, after receiving a number of requests for information by service. Health Net Federal Services officials told us they do not monitor drive times by branch of service, but were able to share drive time data for Coast Guard beneficiaries with us when requested. Page 71 GAO-23-105574 Coast Guard Health Care Appendix III: TRICARE Access Standards and Available Data for U.S. Coast Guard Beneficiaries f According to DHA, Army, Navy, and Air Force officials, access-to-care data for military dental treatment facilities are not tracked by branch of service. g Dependents are only seen at military dental treatment facilities if space is available. Generally, they receive care through the TRICARE Dental Program. h United Concordia Companies, Inc. measures distance to dental care for TRICARE Dental Program enrollees by examining the percent of beneficiaries residing within 35 miles of a dental provider. Page 72 GAO-23-105574 Coast Guard Health Care Appendix IV: Comments from the Appendix IV: Comments from the Department of Homeland Security Department of Homeland Security Page 73 GAO-23-105574 Coast Guard Health Care Appendix IV: Comments from the Department of Homeland Security Page 74 GAO-23-105574 Coast Guard Health Care Appendix IV: Comments from the Department of Homeland Security Page 75 GAO-23-105574 Coast Guard Health Care Appendix IV: Comments from the Department of Homeland Security Page 76 GAO-23-105574 Coast Guard Health Care Appendix V: GAO Contact and Staff Appendix V: GAO Contact and Staff Acknowledgments Acknowledgments Alyssa M. Hundrup, (202) 512-7114 or hundrupa@gao.gov. GAO Contact Staff Acknowledgments: In addition to the contact named above, Bonnie Staff Anderson (Assistant Director), Kaitlin Asaly (Analyst-in-Charge), Caitlyn Acknowledgments Leiter-Mason, and Rebecca Abela made key contributions to this report. Also contributing were Sam Amrhein, Jason Berman, Jacquelyn Hamilton, Richard Lipinski, and Roxanna Sun. Page 77 GAO-23-105574 Coast Guard Health Care The Government Accountability Office, the audit, evaluation, and investigative GAO's Mission arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. 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