0720-0031_ssb_11.20.2025

SUPPORTING STATEMENT – PART B

B.  COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS

1.  Description of the Activity

The TRICARE Select Survey of Civilian Providers (TSS-P) is an annual survey designed to gather data on providers (physicians [including primary care physicians, specialist, and mental health providers] and non-physician behavioral health providers) to assess the extent to which they are aware of the overall TRICARE program, accept new TRICARE patients, the extent to which these providers accept Medicare patients, and the reason if they do not. The expected number of responding mental health providers is equal to the expected number of responding physicians. Based on that last iteration of the survey, the anticipated number of respondents is 7,700 providers.

The original legislation directing this information collection was Section 723 of Fiscal Year (FY) 2004 National Defense Authorization Act (NDAA), later modified by Section 711 FY06 NDAA (requiring collection from 2005-2007), subsequently amended by Section 711 of FY08 NDAA (P.L. 110-181 requiring collection from 2008-2011), and extended by Section 721 of FY12 NDAA, (Public Law (PL) 112-81) requiring collection from 2012-2015. Section 712 of FY15 NDAA has extended the requirement again to continue the survey from 2017 through 2020. Results from the TSS-P survey are now required by Managed Care Support Contractors (Health Net and Humana) for use in mandatory evaluations of the effectiveness of their network providers and programs in supporting TRICARE.

Section 701 of the FY17 NDAA established TRICARE Select as the replacement for TRICARE Standard as of January 1, 2018. TRICARE Select brings together the features of TRICARE Standard and TRICARE Extra in a single plan. Select enrollees may obtain care from any TRICARE authorized provider without a referral or authorization. The goal is to broaden access for beneficiaries to network providers in TRICARE Select and gives Select beneficiaries access to no-cost preventive services from network providers. To meet this goal, the Department of Defense (DoD) must establish mechanisms for monitoring compliance with access standards.

2.  Procedures for the Collection of Information

Sampling Procedure

TSS-P Universe. The TSS-P survey consists of physicians and mental health providers. The sample frame for physicians is the National Provider Identifier (NPI) and the National Plan Provider and Enumeration System (NPPES) from the Centers for Medicare and Medicaid Services (CMS). The NPPES database contains all provider NPI data and is published monthly by CMS. Because providers must have an NPI in order to submit claims to CMS, the database contains all individual, group and organizational providers that are eligible to submit claims to Medicare/Medicaid. As such, NPPES is a large public domain database of physicians and other medical providers. Physicians are randomly selected from the NPPES.

There is no one source of all types of mental health providers in the United States. Thus, the sample frame for mental health providers has several sources: NPPES for psychiatrists, the American Association of Marriage & Family Therapists for marriage and family therapists, the Medical Director Institute (MDI) State License list for Social Workers, the American Psychiatric Nurses Association list for psychiatric nurses, and state licensing lists (from LISTS Inc.) for psychologists and mental health counselors. Because the mental health provider sample is derived from several data sources, the sources are merged to deal with duplicates and to obtain the best contact information for each provider. Merging and de-duplicating occurs in two steps. In the first step, all the mental health data sources (except for NPI) are combined by last name, first name, and zip code and were de-duplicated using the following hierarchy: (1) Psychiatric Nurses, (2) Marriage & Family Therapists and Social Workers, (3) Mental Health Counselors and Social Workers. In the second step, the de-duplicated providers from step 1 and the NPI mental health providers are de-duplicated again by state, first name, and last name using the following hierarchy: (1) Psychologist, (2) Certified Clinical Social Worker, (3) Psychiatric Nurse, (4) Marriage & Family Therapist, (5) Pastoral Counselor, (6) Mental Health Counselor and were merged together by state, first name, and last name. Contact information from the NPI is given first priority because the NPI contains office (i.e. work) addresses and phone numbers. Contact information is then supplemented with contact information from the other data sources.

Fielding

Contact information for sampled providers is transmitted to the vendor responsible for fielding the survey. Each sample member is assigned an internally generated ID number. Only that ID is used when the survey is fielded. Responses are recorded and the response data is incorporated into the analysis file using the internally generated ID and reports are prepared.

A multi-mode data collection method is used through a mailed survey with internet option and a telephone follow-up survey. The initial and follow-up survey includes a cover letter signed by a senior DHA principal investigator requesting the recipient’s participation and requesting a response by return mail, internet, or fax, as well as providing a toll-free number to call with any questions and a web address to take the survey via the internet. If providers’ responses to the mailing are not obtained, their offices are contacted by telephone. The telephone survey uses a standardized Computer Assisted Telephone Interview (CATI) protocol.

Mailed surveys are sent to the provider’s stated work address to the extent the work address is different from the home address and can be discerned. Telephone follow-up is to the work address as well, and, similarly, to the extent the work telephone is different from the home address and can be discerned. These surveys are designed to be answered by the office manager or person responsible for the provider’s billing practices, to minimize the burden on the provider’s practice, and to obtain data the manager may be most knowledgeable about. If a recipient receives multiple surveys for multiple providers in the same office or practice group, the recipient is asked to complete a separate mail survey or answer to a separate scripted telephone survey for each provider.

The survey operations contractor administers the telephone survey. The vendor uses standard telephone survey research methodology in administering the telephone questionnaires to include documentation of interviewer training, valid retrievable call records, and a log of interview sessions. A computerized telephone matching service (if needed) and Directory Assistance are used to track current telephone numbers. To optimize the chances of locating respondents and enlisting cooperation, calls are made at different times of the day, on different days of the week, but calls are made only during normal business hours. Calls are not made during weekend or evening hours.

The survey is fielded only to providers with specialties reimbursed by TRICARE, and only to providers who offer care in an office-based practice. Information from the frame is not always sufficient to determine eligibility. Therefore, procedures for determining eligibility are incorporated in fielding and subsequent data processing methods, as described below.

TRICARE reimburses mental health providers of the following types:

• Psychiatrists (or other physicians)

• Clinical psychologists

• Certified psychiatric nurse specialists

• Clinical social workers

• Certified marriage and family therapists

• Pastoral counselors

• Mental health counselors

A respondent is counted as part of the final sample if they are eligible for the survey and a respondent to the questionnaire.

Blank returns are removed, non-respondents, and any respondents found to be ineligible for the survey from the database. In addition, among eligible respondents with a non-blank questionnaire, we included only questionnaires that were “complete” in the database.¹

To determine if a questionnaire is “complete”, we chose 3 key questions plus 2 supplemental questions. We accept questionnaires as complete if all 3 of these key items plus at least one of the supplemental questions had valid answers. Otherwise, we consider the questionnaire incomplete. These key survey variables and their valid answers are:

• PROVIDE (Question 1): Is [Insert Provider Name], [Credentials] in a practice providing treatment to patients?

• Respondents must answer “Yes” to have a valid answer for this question.

• We treated respondents who answered “No” as ineligible respondents.

• AWARE (Question 3): Are you aware of TRICARE Select (formerly known as TRICARE Standard or Extra)?

• Respondents must answer either “Yes” or “No” to have a valid answer for this question.

• NEWTRI (Question 7): As of today, is [Insert Provider Name], [Credentials] accepting new TRICARE Select patients?

• Respondents must answer either “Yes”, “No”, or “Don’t Know” to have a valid answer for this question.

The supplemental survey variables and their valid answers are:

• NEWTRI1-NEWTRI12 (Question 8): Why is [Insert Provider Name], [Credentials] not accepting new TRICARE Select patients? MARK ALL THAT APPLY

• Respondents must have values of “Yes”, “No”, or valid skips for all values of Question 8 to have a valid answer for this question.

• NEWMED1-NEWMED10 (Question 10): Why is [Insert Provider Name], [Credentials] not accepting new Medicare patients? MARK ALL THAT APPLY

• Respondents must have values of “Yes”, “No”, or valid skips for all values of Question 10 to have a valid answer for this question.

Dispositions are assigned and verbatim responses are coded by the survey administrator to facilitate analysis. The coded response data and the original responses are both returned to Altarum, where they are reviewed and incorporated into a file for subsequent processing and analysis.

Weighting

Sampling weights are equivalent to the reciprocal of the probability of each respondent’s selection into the sample. Sampling weights are further adjusted for non-response within the classes formed based on the percentiles of the propensity scores from the propensity model. Finally, we post stratified the non-response adjusted weights to the frame totals to obtain weighted totals equal to the population totals within each stratum and trimmed some extreme weights to lessen the effect of extreme weights on variance inflation (thereby reducing the mean square error).

Calculation of variance estimates in the TSS requires a design-based variance estimation technique that is available in most statistical software packages for analysis from a complex survey data, such as SAS/STAT® version 8 or higher, and STATA®. This technique requires sample design information, including the analysis weight and stratification information. As an alternative, a replication technique such as the Jackknife method can be used to calculate variance estimates. In the TSS, a series of 60 jackknife replicate weights are calculated and attached to each record in the database. These weights are computed by systematically dropping a one-sixtieth portion of each stratum and recomputing the weights then for the remaining 59/60ths of each stratum. We processed the replicate weights through all of the weighting steps so that all components of the final variance are accurately represented (effects of non-response in particular). The sum of squares from the jackknife replicate estimators generated using these weights will allow for a consistent variance estimator for both linear and nonlinear statistics (with coefficient 59/60).

Reporting and Analysis

An annual report and accompanying briefing slides will be produced from the results of this survey.

TSS-Provider results from the last report (2024) are shared below. Provider results are reported by physician and non-physician behavioral health providers. Within physicians, results are split out by primary care physicians (PCPs), specialists, and psychiatrists

FY 2024 TSS-Provider Report Summary: Findings

TRICARE Acceptance

• 85% of physicians and 57% of behavioral health providers were aware of TRICARE Select.

• 69% of physicians and 25% of behavioral health accept new TRICARE Select patients.

• Within physicians, 82% of PCPs, 87% of specialists, and 64% of psychiatrists were aware of TRICARE Select.

• Within physicians, 65% of PCPs, 72% of specialists, and 25% of psychiatrists accept new TRICARE Select patients.

Reasons for not Accepting TRICARE

• The top reasons for not accepting TRICARE Select were “Not aware of TRICARE Select,” “Other,” and “Not accepting new patients.”

• Physicians were more likely to not accept TRICARE Select because they were not accepting new patients.

• Behavioral health providers were more likely to not accept TRICARE Select because of “Other”, they were not aware of it, they had problems being accepted, or they only took private insurance.

• Open text analysis revealed many behavioral health providers were not eligible to be credentialed or worked in facilities or positions that did not accept insurance, such as in schools, prisons, or as social workers.

• Some providers stopped accepting TRICARE Select because of non-payment of claims.

3.  Maximization of Response Rates, Non-response, and Reliability

The cover letter that accompanies each mailed survey is the primary method used to encourage participation in the survey effort. Both the cover letter and telephone script include information about the purpose of the survey and a brief description of how the information will be used by DHA and the importance of completing this short survey for the benefit of military beneficiaries. For offices with multiple selected physicians and mental health providers, the billing manager recipient will receive separate surveys for each requested physician and will be asked to complete one survey for each. In addition, telephone interviewers are trained in interviewing techniques designed to minimize incidences of respondent refusals to participate in the survey. They ask respondents to answer separately for each physician in cases where multiple doctors are being surveyed in the same office.

Non-response analyses have indicated that membership in the TRICARE network is positively related to survey response. Thus, in order to ensure that the data can be generalized to the universe under study, an indicator of network membership is obtained by linking to the sample frame an indicator of network membership from membership lists provided by the TROs. If non-response adjusted sampling weights are employed, rates calculated from survey responses are representative of the population under study.

4.  Tests of Procedures

The sample and results of surveys fielded from 2012 to 2015 were evaluated by the Government Accountability Office (GAO) in 2017 and found to be statistically and methodologically sound.

5.  Statistical Consultation and Information Analysis

1. Provide names and telephone number of individual(s) consulted on statistical aspects of the design.

• Melissa Gliner, PhD

Chief Data and Analytics Office

Defense Health Agency

703-681-3636

• Christopher Duke, PhD

Altarum Institute

734-478-0922

• Kevin Baier, PhD

Westat

301-279-4593

2. Provide name and organization of person(s) who will actually collect and analyze the collected information.

• Melissa Gliner, PhD

Chief Data and Analytics Office

Defense Health Agency

703-681-3636

• Marielle Weindorf

DataStat

734-994-0540

• Christopher Duke, PhD

Altarum Institute

734-478-0922

• Laura Pinnock

Altarum Institute

734-302-4662

• Kevin Baier, PhD

Westat

301-279-4593

1 There were 30 respondents with an unknown eligibility status who also had complete questionnaires. We included these 30 respondents among the eligible respondents with complete questionnaires.

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