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Research Brief
A female soldier a listens to another soldier

Photo by Pat Molnar

Ensuring access to effective care for service members with behavioral health conditions, such as posttraumatic stress disorder (PTSD), depression, and substance use disorder, is a high priority for the Military Health System (MHS). Remote service members — those who are geographically remote from a military treatment facility — may face unique challenges in accessing high-quality care, putting them at risk for worse outcomes. Care for PTSD, depression, and substance use disorder that remote and non-remote service members receive differs in some ways. These differences suggest three key priority areas for the U.S. Department of Defense in its efforts to improve care for remote service members.

Priority 1

Reduce differences in quality of care between remote and non-remote service members with behavioral health conditions.

Increase receipt of psychotherapy among remote service members.

Remote service members were less likely to receive psychotherapy when starting a new episode of treatment, yet rates of receiving medication treatment were similar to those for non-remote service members. The MHS should increase efforts to ensure that remote service members have access to recommended treatment options that best align with patient preferences while reducing barriers to receiving psychotherapy.

Fewer Remote Service Members Received Any Psychotherapy After Starting a New Episode of Treatment

  Remote service members Non-remote service members
Post-Traumatic Stress Disorder 59% 70%
Depression 45% 57%
Substance use disorder 30% 55%

Note: For substance use disorder, psychotherapy received within 6 months of a new treatment episode; for PTSD and depression, within 4 months. All differences were statistically significant (p < 0.05).

Improve rates of follow-up for remote service members after initiating medication treatment.

Remote service members were less likely to receive timely follow-up after starting medication treatment, particularly for alcohol use and opioid use disorders. Strategies to minimize these differences could include the increased use of primary care, specialty care, and teleheath services for medication management.

Fewer Remote Service Members Received a Follow-Up Visit Within 30 days of Starting New Medication Treatment

  Remote service members Non-remote service members
Post-Traumatic Stress Disorder 36% 43%
Depression 38% 39%
Alcohol use disorder 28% 41%
Opioid use disorder 29% 42%

Note: PTSD and alcohol use disorder differences were statistically significant (p < 0.001).

Improve timely follow-up after psychiatric hospitalization for remote service members.

Service members may be at increased risk after discharge from a psychiatric hospitalization. Timely follow-up — in the form of an outpatient visit — may mitigate these risks. Remote service members were significantly less likely than non-remote service members to receive this timely follow-up. Given the risk associated with these transitions in care, reducing this difference should be a high priority for the MHS.

Fewer Remote Service Members Discharged from a Psychiatric Hospitalization Received a Timely Outpatient Follow-Up Visit

  Remote service members Non-remote service members
Within 7 days 51% 89%
Within 30 days 68% 95%

Note: Differences were statistically significant (p < 0.001).

Priority 2

Implement effective strategies, including telehealth, to meet the needs of remote service members.

Telehealth is the use of audiovisual technology to connect providers to service members to deliver care. Telehealth — particularly synchronous telehealth, in which the provider and the patient interact in real time — is a potential solution to meet the needs of remote service members. Few service members (less than 3 percent) received synchronous telehealth for any type of care (medical or behavioral health), suggesting a need to expand telehealth options for all service members. Increased use of telehealth may be particularly helpful in increasing access to psychotherapy and follow-up visits for remote service members.

Priority 3

Enhance approaches to monitoring access to purchased care for behavioral health conditions.

Remote service members were more likely to receive their behavioral health care from a civilian provider in the community who is contracted by TRICARE (referred to as purchased care). The MHS routinely monitors access to appointments at military treatment facilities, but it does not track access in the same way for purchased care providers. This could mask access differences for remote service members. The MHS should consider requiring purchased care providers to supply information that would support the use of access measures similar to those used to track access to behavioral health care in military treatment facilities.

Percentage of Service Members Who Received Behavioral Health Care Through Purchased Care or Direct Care Only

  Remote service members Non-remote service members
Purchased care only 79% 9%
Direct care only 11% 74%

Note: Differences are statistically significant (p < 0.0001).

Differences Between Remote and Non-Remote Service Members with Behavioral Health Care Needs

Remote service members tend to be older and are more likely to be white, non-Hispanic, and married than their non-remote counterparts. They are also more likely to be in the reserves or National Guard.

  Remote service members Non-remote service members
18 to 34 Years Old 49% 66%
35 to 64 Years Old 51% 34%
White, non-hispanic 74% 56%
Married 67% 62%
Active component 26% 91%
National Guard 49% 3%
Reserve 25% 6%

Study Approach

RAND researchers identified more than 93,000 service members (active-component, National Guard, and reserve personnel) who received a diagnosis of PTSD, depression, or substance use disorder. Remote service members were those eligible for TRICARE Prime Remote. Using administrative data, the researchers compared access and quality of care provided to remote (n = 11,669) and non-remote (n = 81,648) service members in 2016–2017 with any of the three target conditions over a six-month period after diagnosis.

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