Access to Behavioral Health Care for Geographically Remote Service Members and Dependents in the U.S.

Although it is a well-recognized problem in civilian and veteran populations, geographic remoteness from health care among service members and their dependents has not, until recently, received the same attention. With many service members now returning to the United States from the recent conflicts in Iraq and Afghanistan, concern over adequate access to behavioral health care (treatment for mental, behavioral, or addictive disorders) has risen. Anecdotal reports describe particularly difficult conditions for some service members seeking behavioral health care, as well as the tremendous difficulties faced by families of reintegrating service members who do not receive adequate behavioral health care. Yet data remain very sparse regarding how many service members (and their dependents) reside in locations remote from behavioral health providers and the resulting impact on their access to and utilization of care. Little is also known about the effectiveness of existing policies and other efforts to improve access to services among this population. This article seeks to fill these gaps, focusing on three primary research aims and associated research questions:

• Aim 1: How many service members and dependents are remote from behavioral health care?
• Aim 2: How does remoteness affect access to and use of behavioral health care?
• Aim 3: What are current gaps in policy and practice for improving access to care among remote service members and dependents, as well as some promising solutions?

Findings for Aim 1: How Many Service Members and Dependents Are Remote from Behavioral Health Care?

To answer this question, we conducted a geospatial analysis using three main data sources: (1) the residential location of service members and dependents, (2) the location of behavioral health services, and (3) information regarding insurance coverage and regulations surrounding access to these services for different military subpopulations.

A number of patterns emerged from our data analysis. First, we found that roughly 1.3 million individuals (some 300,000 service members and an additional 1 million dependents) were at risk of living in an area remote from behavioral health care—that is, more than 30 minutes away from behavioral health care or in a low provider density area. As the most numerous group, Army service members contributed most heavily to these counts, especially members of the National Guard/Reserve (NG/R). A disproportionate number of Coast Guard service members also contribute to active component remoteness counts. A significant percentage of remote active component service members live within a Prime Service Area but more than a 30-minute drive from a military treatment facility (MTF), necessitating long drives to receive care. Active component service members are more likely to be remote if they are older, higher ranking, more educated, and married; this pattern was not found for the NG/R. Finally, and especially pertinent for the highly mobile military population, remoteness is not a static property but a risk that any service member or dependent could encounter over time. Over a five-year span, 10 percent of active component and 50 percent of NG/R service members spent at least some time in a remote area.

A significant limitation of this analysis is that we did not have access to the number of full-time equivalent behavioral health providers at MTFs, and therefore could not estimate potential shortages in military providers for populations within the MTF catchment area. Our analyses of community provider shortages were also hampered by limited access to TRICARE purchased care provider data. Finally, we were not able to specifically examine specialization of providers with the age, deployment history, or other characteristics of military service members or dependents. Such information might have helped match expected patient needs with provider characteristics—for example, to examine whether areas with military children had a sufficient number of child and adolescent therapists within a 30-minute drive.

Findings for Aim 2: How Does Remoteness Affect Access to and Use of Behavioral Health Care?

To answer this question, we first reviewed evidence in veteran and civilian populations concerning the impact of geographic remoteness on care-seeking and patterns of health care use. We then used our geographic definition of remoteness from Aim 1 to analyze medical claims data from TRICARE (including care received directly at military treatment facilities, as well as purchased care received from the community and reimbursed by TRICARE), conducting a longitudinal analysis of the impact of living in a remote area on use of behavioral health care.

Studies of civilian populations suggest that remoteness-related disparities in treatment (1) reduce access to care of any type and (2) increase the likelihood of receiving care in nonspecialist settings.

Our longitudinal analysis of TRICARE claims data revealed striking disparities in service use among the active component service members, which resemble in important ways similar disparities in the civilian population. In particular, we observed that remote service members (1) made fewer visits to any specialty behavioral care provider and (2) made fewer psychotherapy visits than nonremote service members.

As in the civilian population, differences related to remoteness with respect to nonspecialist care and use of psychiatric medications are much smaller in magnitude. In fact, there is some evidence of a substitution of nonspecialist care for specialist care in the active component that warrants further investigation. In contrast with the active component, we found no evidence that remoteness influences receipt of behavioral health care among either the active duty or the inactive Guard/Reserve.

A notable limitation of this analysis is that we do not have information on need or preferences for behavioral health care. If there are differences in need or preferences between remote and nonremote individuals, then the observed differences in use of care might not result simply from differences in access. The pattern of results, with differences in care specific to certain types of treatment that are less available in remote areas, suggests that our findings reflect differences in access, but alternative explanations cannot be definitively ruled out. To assess these alternative explanations empirically, we would need epidemiological data linked to service use data, such as that available in the Millennium Cohort Study.

Findings for Aim 3: What Are Current Gaps in Policy and Practice and Some Promising Solutions for Improving Access to Care?

Drawing on academic literature, white papers, and reports, we identified best practices for improving access to behavioral health care among military, veteran, and civilian populations in both military and civilian health care systems. We also examined existing programs and policies for addressing access to care among service members and dependents, consulting with experts on this as well.

In reviewing existing policies and programs, we discovered Department of Defense (DoD) guidelines for access to care but no evidence that DoD monitors adherence to those guidelines. We also identified two promising pathways for improving access to care among remote military populations: (1) telehealth and (2) collaborative care that integrates primary care with specialty behavioral care. Although the Military Health System (MHS) is taking steps to integrate these models into its care, we found the need for more systemwide assessments of the impact on outcomes, development and testing of innovative practices, and removal of existing technical and regulatory barriers to those practices' widespread implementation and use.

Recommendations

We recommend that DoD create an infrastructure for systematically monitoring and improving access to behavioral health care for service members and their families. Within this infrastructure, DoD should:

1. Establish clear policies for enhancing remote service member and dependent access to behavioral health care by
   • setting an official standard of a maximum 30-minute drive to behavioral health specialty care
   • working quickly on closing the gap for active component service members, as a target near 100 percent access to behavioral health specialty care within the United States is within reach
   • setting goals for increasing access for NG/R service members and military dependents.
2. Monitor implementation of these policies by
   • establishing the computing infrastructure and data visualization capabilities to support an interactive data portal to monitor access to care for service members and dependents
   • making this monitoring system part of a larger effort to develop, test, and assess alternative methods of delivery for behavioral health care in remote settings
   • supporting this monitoring effort by requiring regional managed-care contractors to share their provider database with DoD and to regularly update this database and provide all required data fields, to the best of their ability, which will make monitoring access to care outside of MTFs feasible.
3. Take steps to improve remote behavioral health care by
   • continuing to innovate and collect systemwide evidence on the effectiveness of telemental health and collaborative care treatment in military populations
   • removing outdated technical and regulatory barriers to telemental health and collaborative care approaches to behavioral health within the MHS
   • feeding the collected evidence back into monitoring systems so that it can systematically improve both access to and quality of care.

This research was sponsored by the Office of the Assistant Secretary of Defense for Health Affairs and the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute.