Service members are seeking mental health care at four times the rate they were 20 years ago, and a new government report found that the wait for an “urgent” appointment can be up to a month for a civilian provider.
The Defense Department, like the civilian world, does not have enough mental health experts and counselors to meet increased demand and the process of sending troops to civilian experts adds significant delays, according to a new report released Wednesday.
“Military service may carry a psychological cost for active-duty service members. Recent research has shown a fourfold increase in behavioral health conditions for this population. If left untreated, such conditions can affect deployment readiness, among other negative consequences,” according to the Government Accountability Office’s report released Wednesday.
Demand for behavioral health care has increased dramatically among active-duty service members, along with mental health-related diagnoses. Between 2005 to 2021, service members’ diagnoses increased fourfold, according to the Defense Health Board.
The GAO found that service members referred to TRICARE’s civilian providers waited 30 days on average for an appointment.
The GAO said that the DOD should monitor urgent referrals to civilian behavioral health providers to ensure timely care. The report was completed as a GAO requirement set by the House Armed Services Committee in the 2023 national defense bill to examine DOD mental health efforts.
“There is more demand than there is supply across the country, across health systems,” said Carrie Farmer, co-director of RAND’s Epstein Family Veterans Policy Research Institute. “It’s not a problem that’s unique to DOD.”
Lack of providers
For troops seeking outpatient behavioral health care, they must first go to a military treatment facility. If it lacks a specific service or timely availability for appointments, they can refer service members to TRICARE’s civilian providers.
Military Treatment Facilities, MTFs, lacked 43% (1,662 of 3,825) of its authorized civilian mental health care provider positions, as of January 2023, according to DOD data reviewed by GAO. More specifically, facilities had less than half of the number of psychologists they should have.
One military facility told the GAO that their specialty clinic had around 6,000 appointments in 2019 and 7,000 in 2021. In 2022, they lost staff and the number of appointments dropped to about 5,000.
Officials from each of the six MTFs reviewed by the GAO linked civil service and contractor mental health provider vacancies to the greater national shortage of mental health providers. They also pointed to competition for talent with other agencies and the private sector, a slow hiring process, and bureaucratic issues that come with hiring contractors. GAO also said that administrative vacancies contributed to appointment backlogs.
While the situation is less dire for uniformed mental health providers, according to the GAO report, MTF officials said that more assignments to deployable units and service-required collateral duties left them without adequate staff.
To overcome the lack of behavioral health providers at MTFs, officials have allowed more referrals to civilian network providers. In April 2023, one MTF reported that 75% of specialty clinic patients were referred to the civilian provider network which was up from 38% in 2018.
Because of the provider shortage, MTFs also began prioritizing initial meetings over follow-up appointments. One facility interviewed by the GAO said that instead of a once a week follow-ups, service members could only be seen once every 5 to 6 weeks due to availability.
In order to improve troops’ access to care with less staff, a DHA pilot encourages referrals to non-medical services, like chaplains, and increases the use of group therapy rather than individual therapy. The DHA is also increasing telehealth visits, creating a physician recruitment team and expanding the types of providers like counselors and therapists.
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Access to care
The GAO found that active-duty service members accessed their first non-urgent appointments for specialty behavioral health care like psychotherapy, and substance use disorder treatment within DHA’s timeliness standard of 28 days.
Due to workforce shortages, MTFs have referred patients needing urgent care to TRICARE’s civilian providers. DHA defines urgent care as “medically necessary treatment for a sudden illness or injury that is not life-threatening, but requires immediate attention to avoid further complications from non-treatment.”
For urgent referrals to civilian providers, which made up nearly 4% of all referrals, the GAO found that it took between 17 and 23 days for service members to get appointments.
“In the case of an urgent behavioral health need, that person needs to be seen really as soon as possible and if that can be accommodated within the military health system, for a lot of reasons that’s probably preferable,” Farmer said.
Regulations state that MTF patients seeking urgent care, whether through a provider or self-referral, should generally not exceed 24 hours for wait times. However, DHA does not apply the 24-hour standard to civilian providers.
Because the DHA does not apply and track the time standard for civilian mental health providers, the agency “does not know the extent” of civilian-care delays for troops with urgent behavioral health needs.
“It also is not able to identify factors that may be contributing to delays and in turn, address any timeliness issues,” the report said.
The GAO recommended that the DHA establish a policy-driven time frame for when service members and beneficiaries should receive appointments for urgent referrals to TRICARE providers. The office also said that the DHA should regularly monitor the contractors’ performance and take corrective actions if the time frame is not met.
In response to the GAO’s findings, the DOD said that its health agency will monitor the standards and take appropriate corrective action, but also noted “that access standards may not always be met due to the nationwide shortage of behavioral health providers.”
Farmer said servicemembers would better be served by expanding the capacity of the military health system by hiring more mental health providers or increasing the use of tele-mental health.
By staying within the military system, the DOD can control standards, require certain levels of training, and measure and monitor the quality of care, Farmer said.
“DOD really tracks outcomes as well,” she said.
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