Assessing Readiness in Service Members Who Receive Private-Sector Behavioral Health Care

Ensuring that service members receive routine assessments of individual medical readiness and deployability is critical to maintaining a ready military force, particularly for service members who receive behavioral health (BH) care. Active-duty service members need to be able to work in high-stress situations, such as during training exercises or deployment. Yet for service members with BH conditions, certain diagnoses or the use of certain medications could have temporary or permanent implications for a service member's military functioning. Therefore, military providers routinely assess service members in the context of clinical care to determine their medical readiness and ability to deploy, including whether they have BH needs that could limit their ability to perform their duties at their military installations. If BH-related duty limitations are identified, military providers proactively communicate identified duty limitations to commands when appropriate. These activities are separate from the Periodic Health Assessment and other structured health assessments that are conducted with service members at various points in the deployment cycle. However, although routine readiness assessments are typically included in clinical encounters at military treatment facilities (MTFs), service members do not always receive their BH care at MTFs. Nationwide and within MTFs, demand for BH care outstrips supply. The Military Health System (MHS) requires timely access to BH care for service members, whether that care is delivered directly at MTFs (i.e., direct care) or by private-sector providers who contract with TRICARE (i.e., private-sector care). Although referring service members to private-sector BH providers may facilitate better access to care, processes to assess readiness and communicate potential duty limitations that arise during the course of a service member's private-sector BH care may differ from those for direct-care provided at MTFs. Regardless of where service members receive their BH care, conducting routine readiness assessments and any required command communication for service members receiving private-sector BH care is critical to the health of the service member and also to the safety and functioning of their unit and force readiness overall.

To better inform policy and planning with respect to this issue, the Office of the Assistant Secretary of Defense for Health Affairs asked the RAND National Defense Research Institute to assess how MTFs conduct readiness assessment and command communication for service members who receive private-sector BH care. This study presents the findings and integration of two analyses—of administrative treatment data and of qualitative interviews with MTF administrators and clinical staff—that can inform policymaking and planning to improve readiness assessment and command communication for service members receiving private-sector BH care.

Research Approach

We analyzed administrative treatment data to examine trends and patterns of BH care for 751,621 active-duty service members using administrative treatment data that spanned five years, from October 2017 through September 2022. We linked multiple files that provided data regarding TRICARE eligibility, MHS health care utilization, and deployment history. We then de-duplicated and linked all records to the service members receiving the care. The first analysis evaluated trends in the receipt of BH care among service members in direct and private-sector care. In a second analysis, we examined patterns of care delivered to a cohort of 8,662 service members in the four months after initiating private-sector BH care. Service members were included if they initiated care from March through May 2022, had no private-sector BH care in the prior three months, and received at least three BH visits.

We supplemented these analyses with interviews with 32 staff members (four from each of eight included MTFs) to investigate how they approached readiness assessments and command communication for service members receiving private-sector BH care. MTFs were selected to represent a broad range of attributes, such as the size of the population referred to private-sector BH care (selecting from the top tertile of MTFs by number of unique service members who received three or more visits in the private sector for BH care) and the volume of BH care delivered within the MTF (direct care), service branch, geographic region, TRICARE region, and Defense Health Agency (DHA) market. The interviews were conducted virtually with administrators and BH providers from July to October 2023. Eligible administrators held leadership positions in a range of clinics and departments (e.g., BH specialty care, primary care, health care business operations, clinical operations) and eligible providers included licensed BH providers (e.g., psychologists, psychiatrists, social workers) and BH supportive clinical staff (e.g., BH technicians, nurse case managers). Most interviewees held dual administrative and clinical roles and worked in BH specialty care. Research team members analyzed data from the interviews using matrix analysis to identify common themes and reveal trends and relationships.

Key Findings

The Military Health System Has Increased Its Reliance on Private-Sector Providers to Deliver Outpatient Behavioral Health Care to Service Members

• From October 2017 to September 2022, the proportion of active-duty service members' BH visits with private-sector providers grew from 9 percent to 38 percent.
• In September 2022, the private sector delivered approximately 44 percent of BH specialty care visits and more than two-thirds of virtual BH (VBH) visits (specialty or nonspecialty BH). Among all BH visits in September 2022 (regardless of setting or mode of delivery), 52 percent of those for individual psychotherapy were delivered in the private sector.
• The most common pattern for treatment visits in a cohort of service members who initiated private-sector BH care was to receive only psychotherapy in the private sector (68 percent). This is consistent with interview findings that suggested some MTFs were explicitly trying to refer service members to private-sector care for psychotherapy and maintain those who needed treatment that could result in the receipt of duty-limiting medications in direct care.
• From October 2021 to September 2022, by the service branch of the MTF, the service branch with the largest proportion of private-sector outpatient BH visits was the Navy (41 percent), followed by the Air Force (36 percent), and the Army (19 percent). MTFs also varied widely in the percentage of BH visits that were delivered in private-sector care, from a low of 4 percent to a high of 78 percent. The number of unique service members seen in the private sector for BH care across MTFs ranged from 35 to 7,724 service members.

Readiness Assessments Are Not Adequately Captured in the Medical Record, but One-Third of Service Members Initiating Private-Sector Care Received Concurrent Direct Behavioral Health Care

• Among a cohort of active-duty service members who initiated private-sector BH care, 34 percent received any type of concurrent direct BH care at an MTF during a four-month observation period. About 11 percent of the service members who engaged in private-sector BH care had direct-care encounters that might have been associated with a routine readiness assessment (e.g., diagnostic assessment, care management). About 16 percent had concurrent psychotherapy in direct care, and about 23 percent had concurrent evaluation and management visits and medication management visits in direct care, which could also have included a readiness assessment.
• Although readiness assessments are routinely included in the clinical care provided at MTFs, no procedure code is explicitly designated for time spent related to readiness assessment for service members receiving private-sector BH care. Interview findings confirmed that MTF staff used a variety of approaches to document assessments for these service members, with some coding an encounter or activity in the electronic health record, some documenting it as an uncoded visit note, and some not entering any information in the record.
• Because of the current limitations of administrative data, it is not currently feasible to accurately estimate the direct-care resources that are needed to conduct readiness assessments for service members receiving private-sector BH care using administrative data. Administrative data do not provide enough clinical detail to determine whether concurrent direct BH care visits were duplicative or complementary to private-sector BH care.

Staff Member Approaches to Readiness Assessment for Service Members Receiving Private-Sector Behavioral Health Care Varied Substantially

• Interviews with administrators revealed that, in most cases, approaches were not guided by specific policies pertaining to readiness assessment for service members receiving private-sector BH care.
• Interviewed staff described varied approaches to readiness assessment. Although most staff reported screening service members within the context of clinical care prior to private-sector referral (e.g., to assess their level of risk for developing a duty-limiting BH condition), only some reported retaining higher-risk service members in direct care. Defense Health Agency Administrative Instruction 6490.01 (signed in February 2023) indicates that MTF providers are responsible for ensuring that service members with duty-limiting BH symptoms are not referred for private-sector BH care. Although some staff were routinely tracking all service members engaged in private-sector BH care, most were not. Tracking all service members referred for private-sector BH care is a requirement of Defense Health Agency Administrative Instruction 6490.01 (2023).
• The majority of interviewed staff reported that there were no dedicated roles for conducting readiness assessments for service members receiving private-sector BH care. These assessments were typically staffed ad hoc and conducted by multiple types of staff (e.g., psychiatrists, psychologists, social workers).
• Most interviewed staff were not conducting periodic readiness assessments with all service members engaged in private-sector BH care. Some stated that case managers conducted periodic check-ins to assess for changes in risk level or readiness; some reported monitoring high-risk service members on an ongoing basis; and others relied on ad hoc activities to prompt a readiness assessment, such as when prompted by a service member or referral from Deployment Health staff, other military providers, or command.

Staff Recommended Improving Access to Documentation of Private-Sector Behavioral Health Care

• The most common recommendation from staff was to improve MTF access to information and treatment records from private-sector BH providers. Although documentation from private-sector BH providers was the most commonly reported source of information used in assessing readiness, most staff reported difficulty accessing this documentation.
• Another common recommendation from staff was to educate private-sector BH providers to enhance their role in routinely assessing service member readiness within the context of clinical care, such as through education about documentation requirements or enforcement of these requirements by TRICARE-managed support contractors. Some staff considered private-sector BH providers ill-prepared to assess for duty limitations, and some mentioned a lack of understanding among these providers about the exception in the federal Health Insurance Portability and Accountability Act (HIPAA) allowing communication with the MTF about potential duty limitations.
• Other commonly reported staff recommendations were to increase MTF staffing for managing private-sector BH care (e.g., by hiring case managers or BH providers) and increasing MTF capacity for providing BH treatment. Staff from nearly all included MTFs stated that high demand for BH care made it difficult to track and assess readiness for all service members receiving private-sector BH care.

Recommendations

Recommendation 1. Ensure Adequate Staff to Provide Military Behavioral Health Care to Service Members and Readiness Assessment for Those Seen in Private-Sector Care

Interviewed staff voiced concerns about insufficient staffing, both for treating service members with BH-related duty limitations in direct care and for assessing and tracking the readiness of service members referred for private-sector BH care. In part because of inadequate staffing, most staff were not conducting periodic readiness assessments with all service members receiving private-sector BH care, and most were not tracking all these service members. Our analyses of administrative treatment data showed a marked increase in reliance on private-sector BH care in recent years that may reflect inadequate MTF capacity to deliver that BH care to service members. These results suggest that the military should take steps to ensure adequate MTF staffing both for providing BH care to service members (especially those with duty limitations) and for conducting readiness assessments for service members receiving private-sector BH care. Treating more service members with BH needs in direct care would be the most effective method for eliminating inefficiencies associated with tracking and readiness monitoring for service members engaged in private-sector care. Although there are efforts to maximize existing BH resources through initiatives, such as the DHA Targeted Care program (Military Health System, 2024) and the DHA BH System of Care (Defense Health Agency Administrative Instruction 6490.01, 2023), these may not fully address the lack of adequate BH staff. An MHS-wide staffing model could help MTFs to estimate the numbers and types of staff needed to meet demand, and a recent U.S. Department of Defense (DoD) report to Congress offered a model that could serve as a starting point (U.S. Department of Defense, 2022). DHA and the services might consider identifying and evaluating strategies to recruit and retain BH staff. For example, the MHS is evaluating the feasibility of a pilot program to cover tuition and fees for individuals to complete a graduate degree in BH in exchange for a commitment to work for the MHS (Public Law 117-263, 2022a; Hepner, Sousa, et al., 2021). DoD is also exploring the feasibility of establishing paid internship programs for training civilian clinical psychologists to provide BH care to service members at MTFs under the supervision of military BH providers (Public Law 117-263, 2022b). DoD efforts to maximize use of its hiring and compensation authorities to mitigate recruitment and retention challenges are also ongoing (U.S. Department of Defense, 2023). Building on such efforts, the military could explore special and incentive pay programs to better understand challenges and potential solutions. Second, for MTFs that are currently unable to meet access-to-care standards in direct care, DHA and the services should take steps to ensure the availability of adequate numbers of BH providers and administrative staff for tracking and readiness monitoring for service members referred for private-sector BH care. This will be particularly important at MTFs with higher volumes of service members engaged in private-sector care. The necessary staffing composition at MTFs might change over time as the proportions of service members receiving private-sector care also change, but an MHS-wide staffing model could help to inform long-term planning.

Recommendation 2. Clarify Minimum Requirements for Tracking and Monitoring the Readiness of Service Members Who Receive Private-Sector Behavioral Health Care

Most administrators we interviewed from July through October 2023 did not mention any policies that informed readiness assessment for service members receiving BH care at their MTFs. Staff described highly variable approaches to assessing readiness, but most were not tracking all these service members. Defense Health Agency Administrative Instruction 6490.01 (signed in February 2023) requires MTFs to retain active-duty service members with duty limitations in direct care, to track all active-duty service members referred to private-sector BH care, and to periodically assess their readiness yet does not explicitly indicate any minimum requirements for these activities (e.g., required information to track, frequency at which service members should be tracked or assessed). Thus, although the instruction remains relatively new, and staff may not have been aware of its existence at the time of our interviews, the lack of clear requirements could be contributing to variation within and across MTFs. These findings suggest that DHA should clarify its expectations for tracking and monitoring service members receiving private-sector BH care. In guidance clarifying these requirements, it could be useful to indicate the most essential elements of tracking and assessment activities and to distinguish these from activities that could be modified or conducted less frequently during periods of increased demand. Such requirements should be flexible enough to account for service branch differences, yet specific enough to support MTFs in deciding how to manage the potential risks they face when the demand for BH care exceeds MTF capacity. Air Force Instruction 44-172 (2015) could serve as a potential model for some of these clarifications because it offers examples of approaches to tracking and monitoring (e.g., options for different treatment settings of staffing models).

Recommendation 3. Identify Mechanisms to Improve Private-Sector Behavioral Health Providers' Information-Sharing to Inform Readiness Assessment and Command Communication

Documentation from private-sector BH providers was the most commonly reported source of information for assessing readiness, yet the majority of staff reported challenges accessing these records. Improving MTF access to information about the clinical or treatment status of service members receiving private-sector BH care was the most commonly reported staff recommendation, yet staff indicated that at least some private-sector BH providers are unaware of or uncomfortable with reporting requirements, in part because of confusion about HIPAA regulations. To improve information-sharing, DHA should determine what information is most important to collect from private-sector BH providers to help with readiness assessments and command communication. It could then develop a standardized form to collect that information or issue guidance on reporting requirements. DHA should also explore strategies for improving the processes for collection of readiness information, such as through a standardized approach at MTFs for obtaining a signed release of information. DHA could also explore possible enforcement strategies and consider recruiting TRICARE-managed support contractors to be involved in evaluating private-sector BH provider compliance with reporting requirements. Finally, DHA could explore how the MHS could develop existing electronic systems to support tracking readiness and duty limitations to further supplement information from private-sector BH providers.

Conclusions

This study highlights integrated findings and recommendations resulting from analyses of administrative treatment data on trends and patterns of care for services members receiving private-sector BH care and interviews with MTF administrators and BH providers on approaches to readiness assessment and command communication for these service members.