Expanding Access to Mental Health Counselors Under TRICARE

Beneficiaries of the U.S. military's health care system access services through the TRICARE program, which covers most medically necessary mental health care. Licensed mental health counselors, like other mental health care providers, must meet certain training and eligibility requirements to serve TRICARE beneficiaries. But they must also meet two additional criteria: (1) obtain a physician referral for each new case and (2) undergo physician supervision while treating the patient.

In 2003, the U.S. Department of Defense conducted a one-year demonstration in which licensed mental health counselors were exempted from having to meet these additional requirements. The RAND Corporation evaluated the effect of this demonstration on the utilization, expenditures, and outcomes of mental health treatment by comparing data from a demonstration area with similar data from a non-demonstration area. Drawing from service claims, a beneficiary survey, and interviews with providers and managed care companies, RAND researchers compared in each area the findings for beneficiaries who sought care from licensed mental health counselors and those treated by other types of providers. They found that

• There were no differences between the two areas in how beneficiaries perceived access to mental health services, nor in their (self-reported) adherence to treatment or mental health status.
• Utilization and overall expenditures for mental health care increased during the demonstration, but this occurred in both areas. Consequently, these increases could not be attributed to the lifted requirements.
• For those treated by licensed mental health counselors, the demonstration had no key effects on expenditures, reimbursement, administrative costs, or patient confidentiality.
• Beneficiaries in the demonstration area were significantly less likely to see other mental health providers (e.g., psychologists or social workers) and physicians (including psychiatrists), so there was a substitution effect on the types of providers from whom they sought care. But design restrictions on the evaluation made it impossible to determine whether this affected clinical outcomes.
• Beneficiaries were significantly less likely to be prescribed a psychotropic medication during the demonstration. But restrictions on the types of data available made it impossible to identify a clinical effect.

This study stemmed from a perception among licensed mental health counselors that their administrative requirements are a barrier to mental health care for TRICARE patients. Temporarily lifting these requirements did not increase the perceived access beneficiaries had to mental health care, but did affect the types of providers and care they sought. It could not be determined, however, whether this affected clinical outcomes or quality of care. Future efforts to offer military personnel and their families greater access to mental health care should examine not only whether unmet demand can be met, but also how expanding access affects quality of care.