The authors evaluated access and quality of care provided to more than 93,000 service members with posttraumatic stress disorder, depression, or substance use disorder who reside remotely from a military treatment facility and compared their care with that received by non-remote service members. The assessment identified strengths in and areas for improvement for the Military Health System.

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Behavioral Health Care in the Military Health System

Access and Quality for Remote Service Members

by Kimberly A. Hepner, Ryan Andrew Brown, Carol P. Roth, Teague Ruder, Harold Alan Pincus

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Research Questions

  1. Do service members with PTSD, depression, or substance use disorder who reside remotely from a military treatment facility have similar access to care through the MHS as non-remote service members?
  2. What is the quality of care for service members with PTSD, depression, or substance use disorder, and does quality differ between remote and non-remote service members?
  3. What changes can the MHS make to ensure access to high-quality behavioral health care for service members, regardless of their remote status?

Geographic location can be a barrier to accessing and receiving high-quality behavioral health care for both civilians and military personnel. As a consequence, service members who reside far from military treatment facilities may be at higher risk for poorer clinical outcomes than those who are less remotely located.

The authors evaluate remote service members' access to Military Health System (MHS) care for those with posttraumatic stress disorder (PTSD), depression, or substance use disorder (SUD) and assess the quality of the behavioral health care they received. The report highlights how quality-measure performance varies by remote status, focusing on differences in quality of care that are large and potentially clinically significant. The authors also discuss policy implications and offer recommendations for how the military can use new strategies — including synchronous telehealth or technology-enabled interventions — to ensure access to high-quality care for all service members, regardless of location.

Key Findings

  • Remote service members — who were more likely to be White, Army, and senior enlisted — received more of their behavioral health care from primary care providers and from the private sector, and they were less likely to receive psychotherapy.
  • For appointments at military treatment facilities, remote service members had shorter average wait times than non-remote service members for routine and specialty direct care.
  • Few service members (less than 3 percent) received synchronous (i.e., real-time) telehealth at a military treatment facility, and fewer remote service members received synchronous telehealth than non-remote service members.
  • Remote service members were less likely to receive psychotherapy or other psychosocial interventions, and they were less likely to receive at least a minimally adequate amount of initial care when starting a new episode of treatment for PTSD or depression.
  • Rates of adequate duration of medication were similar for remote and non-remote service members, but remote service members were often less likely to receive timely follow-up after initiation of medication treatment.
  • Remote service members were less likely to receive a timely outpatient follow-up visit following discharge from a mental health hospitalization or emergency department visit.
  • Overall, the MHS showed strong performance on duration of pharmacotherapy and follow-up after mental health hospitalization or emergency department visit, but performance was lower for other measures.

Recommendations

  • Reduce differences in quality of care for remote service members with behavioral health conditions: Increase receipt of psychotherapy/psychosocial interventions for remote service members; improve timely follow-up after psychiatric hospitalization and mental health emergency department visits for remote service members; and improve rates of follow-up for remote service members after initiating medication treatment.
  • Implement effective strategies, including telehealth, to meet the behavioral health needs of remote service members.
  • Enhance approaches to monitoring access to behavioral health services for remote service members from private sector care providers.
  • Create a learning behavioral health care system to improve the quality of behavioral health care for all beneficiaries served by the MHS.
  • Identify drivers of observed differences in behavioral health care for remote and non-remote service members.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Methods

  • Chapter Three

    Remote Versus Non-Remote Differences in Demographics and Behavioral Health Care Utilization

  • Chapter Four

    Access to Direct Care for the Behavioral Health Cohort

  • Chapter Five

    Quality of Behavioral Health Care: Initial Care

  • Chapter Six

    Quality of Behavioral Health Care: Medication Management

  • Chapter Seven

    Quality of Behavioral Health Care: Transitions of Care

  • Chapter Eight

    Summary and Recommendations

  • Appendix A

    Sensitivity Analyses of Remoteness Definition

  • Appendix B

    Technical Specifications for Access and Behavioral Health Quality of Care Measures

  • Appendix C

    PTSD, Depression, and SUD Cohort Demographic and Service Characteristics

  • Appendix D

    Cohort Descriptive Data by Diagnostic Cohort

  • Appendix E

    Summary of Remote Versus Non-Remote Differences in Behavioral Health Quality Measures

Research conducted by

This research was sponsored by the Defense Health Agency and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute.

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