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Access to Counseling in Department of Defense’s TRICARE Health Services Program

02.02.09

(Updated February 2009)

LEGISLATION

Public Law 110-181 (originally H.R. 4986), “National Defense Authorization Act for Fiscal Year 2008”

Language was included in this legislation that required a study of professional counselors’ clinical qualifications and instructs the Department of Defense to issue regulations allowing LPCs to practice independently.

LATEST INFORMATION

In January of 2008, President Bush signed H.R. 4986, the National Defense Authorization Act for Fiscal Year 2008.

The enacted legislation requires Department of Defense to issue regulations outlining training credentials that would allow LPCs to practice independently under the TRICARE program. This means that counselors who meet those criteria may be granted independent practice authority under TRICARE, but the lack of a deadline in the legislation makes it difficult to forecast when those regulations might be issued.

The conference report also includes language instructing the Defense Department to contract with the Institute of Medicine (IOM) or a similar organization to carry out a study of the training and licensure of mental health counselors.

DOD expects that the regulations will not be issued for at least a year and does not anticipate being able to meet its March 2009 deadline for the study. Fortunately, the IOM has begun its study and has reached out to the ACA and AMHCA for information regarding professional counselors. We are currently working with the offices of Senator Claire McCaskill (D-MO) and Senate Armed Services Committee Chairman Carl Levin (D-MI) to ensure that regulations are issued in a timely manner and that there is a strong and fair study.

WHAT YOU CAN DO

Counselors are urged to contact their Members of Congress (especially Senators) on the TRICARE issue. All Senators’ and Representatives’ D.C. offices can be reached by calling the Capitol Switchboard at 202-225-3121 (or 202-224-3121) and asking for a particular Member's office. You can also find out who your Members of Congress are, or send an e-mail to them, by visiting the ACA internet legislative action center at http://capwiz.com/counseling.

SAMPLE MESSAGE

“As a constituent, I am calling to urge the [Senator/Representative] to support legislation allowing military personnel and their dependents increased access to mental health services. Specifically, Congress should allow mental health counselors to practice independent of physician referral and supervision. Counselors are currently the only masters-level mental health provider that cannot practice independently under TRICARE. This means that servicemembers must jump through bureaucratic hoops to get the therapy they both need and deserve.

The House of Representatives has passed this provision as part of their Defense Authorization for three of the past four years, but the Senate has failed to do so each time. Please ask the [Congressman/Congresswoman/Senator] to support independent practice authority for licensed TRICARE mental health counselors. Thank you for your consideration.”

BACKGROUND

Although counselors have been TRICARE providers for many years, they still lack independent practice authority under the program. Instead, service members must see their doctor first, who then must refer them to an LPC, and must supervise their treatment. Requiring physician referral and supervision is not only discriminatory against licensed professional counselors, but it provides an additional obstacle to care for a beneficiary population that is frequently hesitant to seek out mental health services. Service members continue to fear for their career advancement if they seek mental health treatment. The physician referral requirement also means mental health services are often overseen by a physician who has had no education, training, or experience in the use of therapy in treating mental and emotional disorders.

Many experienced counselors find themselves losing clinical supervisor positions to less experienced social workers and psychologists. Counselors in Department of Defense (DOD) clinics and hospitals are also often asked to provide services only under the direct supervision of another type of provider, or to have their clinical notes reviewed by a supervisor. Recently counselors in the DOD have been told that they will not be promoted unless they obtain another degree and that no more counselors will be hired to work in DOD facilities.

Representative Robin Hayes (R-NC) succeeded in getting his bill H.R. 1358 included as part of the broader defense spending authorization bills that passed by the House of Representatives for the past three years (Fiscal Year 2006, 2007, 2008). The Senate has failed to include similar provisions in its version of the Defense Authorization Act (DAA) each time.

The continued opposition of DOD and of Senate Armed Services Committee staff to letting licensed TRICARE mental health counselors practice independently is particularly surprising in the light of two reports. First, the RAND Corporation issued a report last year on the effects of a demonstration project testing independent practice authority for licensed TRICARE mental health counselors. The study concluded that TRICARE beneficiaries in the demonstration area had “greater odds of being able to ‘usually or always’ get an appointment as soon as desired.” The report also noted that according to self-report survey data, “the demonstration resulted in improved ratings of mental health services.” These outcomes were achieved without any significant increase in TRICARE costs or adverse effects on beneficiaries.

Second, the Government Accountability Office (GAO) recently issued a report (“Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its Providers Use to Make Mental Health Evaluation Referrals for Servicemembers”) faulting DOD for inadequate response to PTSD among servicemembers. GAO found that less than one in four servicemembers needing access to a mental health professional were referred by their general health care provider. In response to the critical report, DOD issued a statement saying that “numerous avenues to care” are available for servicemembers, and that “the absence of a referral does not preclude access to care.” In fact, DOD is arguing that when it comes to licensed TRICARE mental health counselors, the absence of a referral does preclude access to care.

While the ACA and AMHCA were not able to gain total recognition of counselors in 2008, we were able to make significant progress. The organizations were able to garner the support of Senator Claire McCaskill of Missouri, who will be championing our cause and has promised to remain dedicated to passing the provision for as long as it may take. Moreover, Senator McCaskill was able to collect the signatures of sixteen other Senators from across the country on a letter in support of removing the restrictions that TRICARE currently places on counselors. Thanks to the efforts of Representative Hayes and Senator McCaskill, the final conference version of the Defense Authorization provides for a study of LPC qualifications and calls on the Department of Defense to issue regulations allowing counselors to practice independently.

STATISTICS / FINDINGS

There is no justification for discriminating against licensed professional counselors based on their education and training. LPCs are licensed in 49 states and the District of Columbia. Counselors’ education and training requirements are nearly identical to other master’s level practitioners: typically, a licensed professional counselor possesses a master’s or doctoral degree in counseling, completion of 3,000 hours of supervised clinical experience, passage of a national or state-recognized counseling exam, and adherence to a strict code of ethics. In addition to licensure, TRICARE requires its mental health service providers to have a minimum level of experience. TRICARE and DOD allow full, independent practice and reimbursement of all other master’s-level providers with similar education and training requirements, including clinical social workers and marriage and family therapists.
As a result of this policy, soldiers and their families are limited from accessing the 100,000 mental health counselors licensed nationwide. Allowing independent practice authority of counselors could help address staffing shortages and oppressive waiting lists for mental health services, especially in remote locations and underserved areas.
Making beneficiaries see their physicians before they can see a mental health specialist adds an administrative obstacle, the additional cost of a doctor’s visit, and a longer waiting period before a service member can receive therapy, further discouraging TRICARE beneficiaries from seeking treatment.
Less than 10% of all service members who received mental health treatment after returning from OIF and OEF were referred through the screening program (JAMA).
35% of OIF veterans accessed mental health treatment after returning home and 12% were diagnosed with a mental health problem. (JAMA)
Data from the Post Deployment Health Re-assessment indicate that 38% of Soldiers and 31% of Marines report psychological symptoms. Among members of the National Guard, the figure rises to 49%. (An Achievable Vision: Report of the DoD Task Force on Mental Health)
23.6% of female OIF veterans reported a mental health concern, versus 18.6% of male veterans. (JAMA)
TRICARE covers both military personnel and their beneficiaries. According to Capt. Patricia Buss, deputy chief medical officer at Tricare Management Activity, “[c]hildren of active duty service members are potentially at a higher risk to develop mental health conditions common among children in the general population.” (Children and Behavioral Health Care, TRICARE Provider News, Issue 5:2006, p. 3).
Prolonged deployments and increased exposure to danger are raising suicide rates and rates of post-traumatic stress disorder among service members. Research from Walter Reed Army Institute of Research found depression, anxiety, and stress disorders rose sharply among troops sent to Iraq and Afghanistan (Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriersto Care, July, 2004).
Mental illness is detracting from military readiness. Service members who are hospitalized for a mental illness are five times more likely to leave the military within six months than those hospitalized for physical illness. In 2001, thirteen percent of all military hospitalizations were attributed to mental disorders (American Journal of Psychiatry, September, 2002).
Independent practice authority is an efficient way of increasing access; it is cost-free and saves time for the beneficiary, the physician,and the counselor.