Thousands of troops and their family members may not be getting the mental health care they need because of a variety of issues with the Defense Department health care system, according to a new report from DoD auditors.

Auditors with the DoD Inspector General found that DoD isn’t consistently meeting the requirements under law and by DoD policy, for access to outpatient mental health care, causing patients to experience delays. Generally, the wait time for an urgent care visit must not exceed 24 hours; a routine visit must not exceed one week, and a specialty care referral must not exceed four weeks.

These delays across the board may have resulted in many beneficiaries not being able to see the right provider at the right time; get mental health care at all; or get timely follow-up treatment, auditors said.

And this could have jeopardized the safety of patients and hurt military readiness, according to the auditors. They interviewed personnel, and examined appointment booking and referral data at 13 military treatment facilities, for the period from December, 2018 to June, 2019.

Auditors found that — pre-COVID-19 — 53 percent of all active duty service members and their families who got referrals to Tricare because they needed mental health care didn’t receive the care. It’s not known why, because health officials don’t track the reasons. That represented an average of 4,415 out of 8,328 per month at those 13 MTFs who didn’t receive that care.

In response to the auditors’ recommendation that DoD track the reasons referrals aren’t used, DHA disagreed, stating it “would require invasive questioning of beneficiaries which could increase stigma and reluctance to seek medical care,” according to the response to the IG, signed by Army Lt. Gen. Ronald J. Place, director of the Defense Health Agency.

At one military treatment facility, a psychiatrist specializing in child and adolescent care gave auditors three examples of how delayed treatment may have contributed to patient safety issues, including second suicide attempts, and hospitalization. Another mental health provider said it could take up to seven weeks for a follow-up visit and the clinic isn’t tracking how well they can treat a patient once the patient is in the clinic. Nine of the 13 MTFs reported they weren’t able to meet evidence-based treatment guidelines or monitor treatment dosage for patients.

Auditors found that seven of those 13 military treatment facilities or their supporting Tricare networks didn’t meet the access standards for special mental health care each month.

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Two North Carolina MTFs — Fort Bragg’s Womack Army Medical Center and Naval Medical Center Camp Lejeune — met the standards for every month that entire reporting period. Two MTFs didn’t meet standards for access to care at any time during the reporting period — Malcolm Grow Medical Clinic and Surgery Center, Md., and Naval Medical Center Portsmouth, Va. Six others didn’t consistently meet the standards.

As for the remaining three: Because of data reporting problems of the new electronic health record called MHS Genesis, data was not available from three MTFs where it’s being used — Madigan Army Medical Center, Naval Hospital Bremerton, and Naval Health Clinic Oak Harbor, Wash. Staff members there used their own methods to try to measure access to care.

The IG’s findings are in line with those of an online survey conducted by the Military Family Advisory Network late last year, where about half of the participants — active-duty families, military retiree families or veteran families — reported they were satisfied with their ability to get mental health appointments.

Not enough staff

Part of the reason for problems with access to care was inadequate staffing. In interviews during site visits to the 13 MTFs, staff members at 11 of the MTFs said they would need more staff to meet standards for access to mental health care, or to care for both active duty members and their families.

The Military Health System doesn’t have a system-wide model to identify the appropriate levels of staffing needed in MTFs and in Tricare, auditors found. Some MTF providers told auditors they were concerned with the adequacy of the Tricare network in their area, in terms of enough mental health care providers, which has long been a concern of Tricare beneficiaries.

The auditors recommended that health officials develop a single system-wide staffing approach for the behavioral health system of care, that estimates the number of appointments and number of personnel needed.

In their response to the IG, health officials noted that Tricare is currently using a standard staffing model. DoD health officials are adopting a consistent approach to determining which beneficiaries get mental health care at an MTF, but mental health care will vary by MTF mission and capabilities. The seven-day standard for access will be applied to mental health providers embedded in the primary care setting; the 28-day access standard, which applies to all specialty care, will continue to be applied to behavioral health specialty care clinics in both MTFs and Tricare settings.

As recommended by IG auditors, DHA will also establish a standard process for mental health assessments, but the elements of that assessment will be tailored to each patient’s needs, officials stated in their response.

Auditors also recommended removing the eight-visit limitation for outpatient mental health visits from Defense Health Agency policy. DHA officials stated that policy is being rewritten to do so.

Among other findings:

*No centralized appointment booking for behavioral health appointments, as is required by law. DHA is developing a pilot project where beneficiaries can call military health system schedulers, who will perform a “warm hand-off” to private sector mental health providers and confirm availability of the appointment within the required time frame. The scheduling process in the pilot will be for those with a mental health specialty referral only. It will be voluntary for the patient, so that a self-referred patient isn’t required to use the appointment center to schedule an appointment.

*Inconsistent and unclear policies on access to mental health care. For example, DHA policy states that patients who are seen in primary care or who self-refer to behavioral health care must be seen within seven days. But Tricare policy doesn’t require this seven-day access policy for patients who self-refer.

The 13 MTFs the auditors visited were:

*Irwin Army Community Hospital, Fort Riley, Kansas

*Kimbrough Ambulatory Care Center, Fort Meade, Md.

*McDonald Army Health Center, Joint Base Langley-Eustis, Va.

*Madigan Army Medical Center, Joint Base Lewis-McChord, Wash.

*McConnell Air Force Base Medical Clinic, McConnell AFB, Kansas

*Malcolm Grow Medical Clinic and Surgery Center, Joint Base Andrews, Md.

*Langley AFB Hospital, Joint Base Langley-Eustis, Va.

*Naval Medical Center Camp Lejeune, Camp Lejeune, N.C.

*Naval Medical Center Portsmouth, Va.

*Naval Hospital Bremerton, Wash.

*Naval Health Clinic Oak Harbor, Wash.

*Walter Reed National Military Medical Center, Bethesda, Md.

*Womack Army Medical Center, Fort Bragg, N.C.