Health Services for Coast Guard Beneficiaries: Improving Access to Care for Active Duty Service Members, Reservists, Dependents, and Retirees

The U.S. Coast Guard is a military service operating under the U.S. Department of Homeland Security. Its mission is threefold. The first part is protecting those at sea through search-and-rescue and by enforcing marine safety regulations. The second part is protecting the nation against threats by ensuring the security of ports, waterways, and coastal areas. This includes supporting the U.S. Department of Defense (DoD) in national security operations as one of the armed services of the United States. Finally, the third part of the Coast Guard mission is to protect the sea itself and ensure that waterways are navigable. These tasks require operating cutters and icebreakers, flying fixed and rotary wing aircraft, and maintaining deployable special forces, to name just a few of the Coast Guard's capabilities.

Coast Guard policy requires all Coast Guard members to be medically ready for worldwide deployment in accordance with the Coast Guard's medical readiness standards (U.S. Coast Guard, 2018; U.S. Coast Guard, 2022, para. 3.a.2). The Coast Guard Health Services program is responsible for ensuring the medical readiness of active and reserve service members. Coast Guard Health Services must also ensure that health care is available to service members' dependents and Coast Guard retirees.

The Coast Guard ensures that health care is available to entitled service members and other beneficiaries (dependents, retirees) in three ways. First, the Coast Guard delivers some health care organically through clinics that it operates. Coast Guard clinics are limited to providing primary care, with some offering a few specialties, and generally provide care to service members only. Second, military medical treatment facilities (MTFs) operated by the Defense Health Agency (DHA) offer a wider array of specialties, including some inpatient care. Third, care is provided through the private-sector civilian TRICARE network, which is operated by managed care support contractors and administered by DHA (U.S. Government Accountability Office, 2023).

Issue

For service members to be healthy and ready to perform their missions, they must have reliable access to care—that is, care that is timely and located within a reasonable travel distance. Although access alone is not sufficient to guarantee medical readiness, we posit that access is necessary. Service members who cannot get access to health care providers will face delays in getting the care they need to stay fit for full duty, including deployment.

Congress has raised concerns about whether Coast Guard beneficiaries (including service members, dependents, and retirees) have adequate access to care. The National Defense Authorization Act for Fiscal Year (FY) 2023 required the Coast Guard to conduct a review and develop a strategic plan for Coast Guard health care (Pub. L. 117-263, 2022). The Coast Guard asked the Homeland Security Operational Analysis Center to take a strategic look at how Coast Guard Health Services can fulfill its mission of caring for the beneficiary populations for which it is responsible.

Approach

This work was carried out over two phases. In FY 2023, we focused on care delivered to active duty service members. We visited six Coast Guard clinics and conducted phone interviews with a randomly selected group of Coast Guard clinic staff. In FY 2024, we used quantitative data to expand our analysis of care received by service members and to examine care provided to the other beneficiary populations. We analyzed DHA health care appointment and enrollment data. In addition, we conducted semi-structured interviews with representative stakeholders to gather opinions on the current state of and challenges faced by health services delivery for Coast Guard dependents, reservists, and retirees.

Key Findings

The analyses identified access-to-care problems, the ways in which these problems likely pose a risk to readiness, the information needed to interpret available data, and existing data gaps, as follows:

• Coast Guard beneficiaries (i.e., active duty service members, reservists entitled to specific care, retirees, and dependents) have difficulty getting care that meets access standards. About 40 percent of referrals meet the access standard for private-sector specialty care from TRICARE Prime. Coast Guard clinics and DoD MTFs, depending on location, meet access standards 60 percent to 80 percent of the time. Coast Guard clinics have more trouble granting 24-hour appointments, with only 46 percent of appointments meeting the access standard. That said, existing DHA data do not provide a way to measure appointment scheduling attempts that that did not result in a scheduled appointment. The findings understate the difficulty that patients have in obtaining appointments in a timely manner.
• Gaps in data prevent a full understanding of access challenges. Access metrics for private-sector care cannot be computed for appointments that do not require referrals, including for TRICARE Select and primary care through TRICARE Prime and Prime Remote. Data on referrals originating from the private sector also lack sufficient geographic information, thus providing an incomplete picture of access to specialty care in remote areas. Furthermore, data do not indicate why referrals result in no care rendered, whether this is due to patient difficulties in accessing an appointment or for other reasons.
• Staffing shortages at Coast Guard clinics hamper access. By the Coast Guard's own estimation, clinics have an insufficient number of billets, and many existing billets are vacant. Even when billets are filled, deployment of medical personnel on operational missions means that some clinics operate without their full complement of staff.
• Interviewees report that access to care affects readiness, but it is difficult to quantify the impact of such access. Interviewees, including unit and regional leadership, report that difficulties in getting timely appointments affect service members' ability to do their jobs and affect readiness. However, we were not able to discover any systematic data that directly link access problems to effects on mission readiness.
• The Coast Guard lacks information to ensure that member assignments optimally address dependents' health needs.
  • The Coast Guard does not have visibility into how many active duty dependents are eligible for but not enrolled in the Special Needs Program (SNP). Interviewees suggested that non-enrollment in SNP negatively affects family readiness (e.g., members either live apart from their dependents, miss time at work to obtain dependents' care, or need reassignment to get that care).
  • The Coast Guard's SNP and Overseas Screening processes may not reflect current access to care. The Coast Guard maintains lists of continental United States (CONUS) locations (1) where any SNP family can be assigned and (2) for which all families need screening for health issues, as for overseas assignments, because of presumed poor access to care. Interviewees were unaware of whether the Coast Guard made systematic assessments of access to care to identify these locations. Furthermore, interviewees suggested that these lists may be outdated.
• Reservists have barriers to Periodic Health Assessments (PHAs) and Line of Duty (LOD) determinations.
  • The Coast Guard provides ambiguous guidance on where reservists can obtain a PHA. Reservists' primary barriers to obtaining a PHA are difficulty scheduling it and frustrations with the contractor. That said, a partially contributing barrier is language in the guidance that may be causing confusion. Many believe that they can obtain a PHA through a DoD MTF or Coast Guard clinic. However, they understand that there are capacity constraints on these resources, so most obtain their PHAs through the Remote Health Readiness Program (RHRP). Reservists who had not been activated for more than 30 days were generally required to use the RHRP for their PHAs, but a representative stated that most reservists did not appear to understand this. We identified language in several Coast Guard documents that may be causing confusion.
  • The process of obtaining care pursuant to a reservist's LOD determination is cumbersome. Coast Guard reservists' LOD determinations are not automatically submitted through the Defense Enrollment Eligibility Reporting System (DEERS). Interviewees reported that the manual process to overcome this issue is frustrating and time consuming for both reservists and Coast Guard staff.
• Retirees have confusion about their health benefits. Interviewees noted that retirees spend a lot of time troubleshooting their questions about health care coverage and eligibility across the fragmented sources of information available. The Coast Guard lacks data as to whether changes to health benefit–related information would avoid retirees' confusion and improve their ability to access care.

Recommendations

Our recommendations focus on fixing the access problems that we have identified, monitoring access on an ongoing basis, and collecting additional information to inform decisionmaking.

Work with DHA on Access Problems in TRICARE Prime and Prime Remote

We recommend that the Coast Guard use the statistics that we present in this study to engage DHA in finding fixes to access-to-care problems with private-sector care. The Coast Guard should also work with DHA to investigate access concerns at DoD MTFs to see whether capacity can be increased to accommodate Coast Guard needs. Furthermore, the Coast Guard should ensure that existing billets in Coast Guard clinics are filled so that those clinics can meet DHA access standards.

Clinics and units should document access problems faced by their members and elevate these concerns to the headquarters level for engagement with DHA. The Coast Guard should inform DHA about locations where service members must depend on private-sector care and have difficulty getting appointments, particularly in TRICARE Prime Remote. DHA should then prioritize updating provider lists and building the network of providers in those areas.

Create an Internal Capability to Periodically Monitor and Report Access

The Coast Guard should create an internal capability to monitor access to care and communicate the results to clinics and their respective commands. Creating this capability may require additional staff programming knowledge to pull data from DHA systems and analyze them. The Coast Guard should also ask DHA to modify its existing reports and dashboards to enable focus on Coast Guard beneficiaries and locations.

In addition, the Coast Guard should monitor the operating status of clinics, with special attention to when clinics are not mission capable because of lack of personnel or equipment. This information should be reported to Health, Safety, and Work-Life and the unit and district command whose personnel the clinic supports.

Work with DHA on Gaps in Data About Access to Care

Work with DHA on Alternatives for Assessing Access for TRICARE Select and TRICARE Prime Visits That Do Not Require Referrals

One way to measure access would be to assess the third next available appointment (TNAA) data, which estimate the number of days a patient must wait to get an appointment. The TNAA is used because the first and second available appointments may reflect openings created by last-minute cancellations and may not accurately measure true accessibility.

Work with DHA and Managed Care Support Contractors to Obtain Location Information on TRICARE Prime Remote Referrals

Location information on referrals is necessary to examine access to specialty care in TRICARE Prime Remote, areas cited by interviewees as places where appointments are hard to obtain. We recommend that the Coast Guard ask DHA to create access-to-care statistics corresponding to TRICARE Prime Remote locations where Coast Guard service members and other beneficiaries are located.

Survey Beneficiaries to Learn About Difficulties Related to Access

Survey Households Representing Active Duty, Reservists, and Dependents

Because access-to-care data are incomplete, we recommend that the Coast Guard field a survey to learn more about beneficiaries' experience with accessing care. Topics should include

• difficulty in getting appointments at Coast Guard clinics, DoD MTFs, and TRICARE
• reasons referrals resulted in no care rendered
• time lost from work because of difficulty in getting care for themselves or their family members
• impact of access challenges on members' decisions to stay in the Coast Guard.

Survey Active Duty Households Regarding Eligibility for the SNP

An anonymous survey could ask recipients whether they are enrolled in the SNP and whether they have a dependent with a health condition that would qualify for the SNP. The survey results should determine the size of the population unwilling to join the SNP and why.

Consider Including Retirees in a Survey of Coast Guard Health Benefits

Including retirees in a survey would allow the Coast Guard to understand how well the system is serving them and the prevalence and sources of confusion. Furthermore, the survey could determine the extent to which information dissemination about health benefits is leading to this confusion and could identify ways to improve such outreach.

Update SNP and CONUS Overseas Screening Processes

The Coast Guard should update SNP member assignment processes, especially if the Coast Guard builds capacity to systematically evaluate access to care. The Coast Guard can update the CONUS locations requiring overseas screening and then could consider tailoring assignments for SNP enrollees or those with family members who fail the overseas screening process for health-related reasons. The Coast Guard might make assignments based on the most recent TRICARE access-to-care data for the medical specialties that each family needs. These processes might open opportunities for service members based on their dependents' specific health needs and local access to care.

Use Access-to-Care Data to Determine When the Coast Guard Should Provide More Care Organically

If efforts to improve access at DoD MTFs or TRICARE are not sufficient, the Coast Guard might wish to consider providing more care organically. In this study, we have not made specific recommendations on which locations should have new clinics or added specialties. Instead, we created a framework for making such decisions that is based on weighing improved access, and thereby reduced risk to readiness, against the cost. However, information is needed on the following two key considerations.

Determine the Level of Acceptable Risk to Mission Readiness Caused by Difficulties with Access to Care

Although access often fails to meet standards, we cannot definitively say whether the level of access experienced poses an unacceptable risk to mission readiness. The Coast Guard should collect data to inform a determination of acceptable access and acceptable risk.

Determine the Cost of Improving Access

If difficulty in accessing care poses an unacceptable risk to mission readiness, the Coast Guard might wish to provide that care organically. Assessing that option requires knowing the true cost of providing that care and determining whether improving access would be worth that price. This assessment will require estimating the number of staff needed to support a patient population of a given size. The Coast Guard lacks estimates for certain specialties, most notably behavioral health. It would also need estimates for the cost of constructing and operating additional clinic space.

The Coast Guard will then have to compare the cost of providing organic care with that of having that care provided by TRICARE or DoD. TRICARE private-sector costs can be determined on a per-referral basis. However, the cost of a DoD MTF visit is harder to determine because the Coast Guard pays DHA an amount based on force size and past utilization rather than on a per-visit basis. Therefore, the Coast Guard should work with DHA to determine the average cost per visit of MTF care for specialties the Coast Guard might consider providing.

Address Health-Related Concerns Specific to Reservists

Clarify Policies on How Reservists May Obtain Their PHAs

Reservists' concerns about access to PHAs could stem, in part, from unclear or inconsistent Coast Guard policies on whether and in what circumstances reservists may obtain their PHAs at Coast Guard clinics or DoD MTFs. Revising and aligning these policies and providing education on pathways to access PHAs would help alleviate some of this confusion.

Work with DHA to Automate Reservists' LOD Eligibility in DEERS

We recommend working with DHA and the Defense Manpower Data Center to incorporate functionality for reservists' LOD eligibility into DEERS. The current manual process for adding this information is labor and time intensive, resulting in recurring process failures. This process would benefit from an automated solution in which LOD eligibility is loaded into DEERS.

Future Research

In addition to the recommendations made above, we identify steps the Coast Guard may wish to undertake to gain a better understanding of the risks associated with difficulties with access to care.

Access the Impact of Barriers to Health Services on Mission Readiness

Survey Unit Commanders to Assess the Effect of Health Care Delays on Missions

We recommend that the Coast Guard survey unit leaders to get a broader picture of the effect that health care has on the mission readiness of their units. A distinction should be made between asking about the health of members and the delays that members experience in receiving care.

Collect Quantitative Data on Lost Productivity Resulting from Difficulty in Accessing Health Care

Units could record instances when their service members experience delays in health care, whether for themselves or dependents, that affect their ability to perform their duties. Units should record the amount of time lost, as well as the effect, if any, on missions. We recognize that such data collection would place a burden on unit personnel.

Examine the Pipeline of Coast Guard Health Services Personnel

The Coast Guard should examine the pipeline of health services personnel, especially U.S. Public Health Service (PHS) officers and Coast Guard health service technicians. If there are long-term problems with PHS recruitment, the Coast Guard may need to reconsider the mix of PHS, Coast Guard, and civilian or contractor medical officers.