oversight

Prescribing Psychologists: DOD Demonstration Participants Perform Well but Have Little Effect on Readiness or Costs

Published by the Government Accountability Office on 1999-06-01.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to the Chairman and Ranking
                 Minority Member, Committee on Armed
                 Services, U.S. Senate


June 1999
                 PRESCRIBING
                 PSYCHOLOGISTS
                 DOD Demonstration
                 Participants Perform
                 Well but Have Little
                 Effect on Readiness or
                 Costs




GAO/HEHS-99-98
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Health, Education, and
      Human Services Division

      B-280869

      June 1, 1999

      The Honorable John Warner
      Chairman
      The Honorable Carl Levin
      Ranking Minority Member
      Committee on Armed Services
      United States Senate

      The Military Health System (MHS) provides for the mental health care
      needs of the approximately 8 million active-duty members, retirees, and
      their dependents. To meet these needs, MHS employed 431 psychiatrists
      and 430 clinical psychologists in fiscal year 1999. Some functions of
      psychiatrists and clinical psychologists overlap. As physicians, however,
      psychiatrists are trained in and licensed to practice medicine and are
      permitted to prescribe medication for the treatment of both mental and
      physical conditions. Because no medical training is required to practice
      clinical psychology, clinical psychologists—whether in the military or the
      civilian sector—historically have not been permitted to prescribe drugs. In
      1991, however, MHS instituted the Psychopharmacology Demonstration
      Project (PDP), which was designed to train and use military psychologists
      to prescribe psychotropic medications.1 By June 1997, when the project
      was terminated, 10 psychologists had completed the training and were
      subsequently assigned to various Air Force, Army, and Navy military
      medical facilities across the country.2 At the time of our review, 9 of the 10
      program graduates were still treating patients and prescribing medications
      at military hospitals and clinics.

      The Senate report accompanying the fiscal year 1999 National Defense
      Authorization Act directed us to study the results of this program,
      including the use and performance of the PDP graduates. Based on the
      Senate report and subsequent discussions with your offices, our
      evaluation (1) describes how PDP graduates have been integrated into MHS,
      (2) provides information on the quality of care they provide to military
      personnel and beneficiaries, (3) discusses their effect on medical
      readiness, and (4) compares the costs of the program graduates to those of
      other military psychologists and psychiatrists. To address these issues, we
      talked with all 10 PDP graduates and other providers and officials at the
      facilities where the graduates were practicing or had practiced. Although

      1
       These drugs affect psychic function, behavior, or experience.
      2
       In April 1997, we issued a report on PDP, Defense Health Care: Need for More Prescribing
      Psychologists Is Not Adequately Justified (GAO/HEHS-97-83, Apr. 1, 1997).



      Page 1                                           GAO/HEHS-99-98 DOD Prescribing Psychologists
                   B-280869




                   one graduate left the military during the course of our review, our
                   evaluation includes information about this graduate’s service as a
                   prescribing psychologist before leaving the military to reflect the full range
                   of information available on the performance of the graduates. We also
                   reviewed the PDP graduates’ credentials files,3 performance reviews, and
                   relevant reports.

                   Our work was performed from June 1998 through May 1999 in accordance
                   with generally accepted government auditing standards. Further
                   information on our scope and methodology is included as appendix I.


                   The 10 PDP graduates seem to be well integrated at their assigned military
Results in Brief   treatment facilities. For example, the graduates generally serve in
                   positions of authority, such as clinic or department chiefs. They also treat
                   a variety of mental health patients; prescribe from comprehensive lists of
                   drugs, or formularies;4 and carry patient caseloads comparable to those of
                   psychiatrists and psychologists at the same hospitals and clinics. Also,
                   although several graduates experienced early difficulties being accepted
                   by physicians and others at their assigned locations, the clinical
                   supervisors, providers, and officials we spoke with at the graduates’
                   current and prior locations—as well as a panel of mental health clinicians
                   who evaluated each of the graduates—were complimentary about the
                   quality of patient care provided by the graduates.

                   However, granting drug prescribing authority to 10 military psychologists
                   cannot substantially affect the medical readiness of an organization staffed
                   by more than 800 psychiatrists and psychologists. Moreover, according to
                   military psychiatrists and psychologists we talked to, it is unlikely that the
                   graduates’ prescribing abilities and knowledge of psychotropic drugs
                   would be needed during wartime because these types of drugs are not
                   generally the treatment of choice in combat. Rather, in treating combat
                   stress, the preferred course of treatment according to service readiness
                   officials and field commanders is adequate rest, counseling, and a quick
                   return to the front lines. Nonetheless, clinic and hospital officials told us
                   that the graduates—by reducing the time patients must wait for treatment
                   and by increasing the number of personnel and dependents who can be



                   3
                    The credentials files contain information on education, licenses, performance evaluations, and other
                   information, as well as a record of any quality problems that resulted in adverse outcomes.
                   4
                    As used here, “formulary” refers to the set of prescription drugs that a provider is permitted to
                   prescribe to patients when treating illnesses.



                   Page 2                                            GAO/HEHS-99-98 DOD Prescribing Psychologists
             B-280869




             treated for illnesses requiring psychotropic medications—have enhanced
             the peacetime readiness of the locations where they are serving.

             We project that the Department of Defense (DOD) will spend somewhat
             more on these 10 prescribing psychologists than it would have spent to
             provide similar services without the prescribing psychologists. Primarily
             because of DOD’s higher training costs, we estimate that over the course of
             the PDP graduates’ careers, DOD will spend an average of about 7 percent
             more (or about $9,700 annually) per PDP graduate than it would spend on a
             mix of psychiatrists and psychologists who would treat patients in the
             absence of the PDP graduates.


             The principal mission of MHS is medical readiness. As defined by DOD,
Background   medical readiness encompasses both wartime and peacetime components.
             The wartime mission is primary, according to DOD’s Medical Readiness
             Strategic Plan (MRSP), requiring MHS “to provide top quality health services,
             whenever needed, in support of military operations.”5 In peacetime,
             according to MRSP, the military medical departments are “to maintain and
             sustain the well-being of the fighting forces in preparation for war.”
             Finally, MRSP states that the military may provide care to dependents or
             retirees in peacetime, “when not employed in preparation and training for
             the wartime role.” The Army, Navy, and Air Force all use military and
             civilian health care providers to meet their readiness needs.

             PDP was established by DOD in response to a conference report dated
             September 28, 1988, which accompanied the fiscal year 1989 DOD
             Appropriations Act (P.L. 100-463). The report directed DOD to “establish a
             demonstration pilot training program in which military psychologists may
             be trained and authorized to issue appropriate psychotropic medications
             under certain circumstances.”

             This training program began in August 1991 with four participants.
             Training for the initial class consisted of 2 years of classroom training at
             the Uniformed Services University of the Health Sciences plus 1 additional
             year of clinical training. For subsequent classes, however, the training was
             modified to consist of 1 year of classroom training and 1 year of clinical
             training. PDP participants obtained their clinical experience on inpatient
             wards and at outpatient clinics at Walter Reed Army Medical Center in
             Washington, D.C., or at Malcolm Grow Medical Center located at Andrews
             Air Force Base in Maryland. During the clinical part of the training,

             5
              See DOD, Medical Readiness Strategic Plan (MRSP) 1998-2004 (Washington, D.C.: Aug. 1998), p. 22.



             Page 3                                         GAO/HEHS-99-98 DOD Prescribing Psychologists
B-280869




participants were trained to take medical histories and incorporate them
into treatment plans and to prescribe medication for patients with certain
types of mental disorders.

Two prescribing psychologists graduated from the initial training class in
1994. The three subsequent graduating classes included 1 prescribing
psychologist in 1995, 4 in 1996, and 3 in 1997—for a total of 10 graduates.6
These 10 graduates—three women and seven men7—represented each of
the three services: 4 from the Navy and 3 each from the Air Force and
Army. In 1995, as part of the program, guidelines were issued on the
graduates’ roles, including a suggested drug formulary that they would
use, a scope of practice limited to patients between the ages of 18 and 65,
and the level of supervision or proctoring of graduates for 1 year after
graduation.

Several evaluations of the program have been completed since its
inception. The American College of Neuropsychopharmacology (ACNP),8
under contract to DOD, conducted six annual assessments of PDP and
issued a final report on the program in 1998. In conducting these
assessments, an ACNP evaluation panel interviewed PDP participants and
graduates, program officials, classroom instructors, clinical supervisors,
and others. Vector Research, Inc. (VRI), also under contract to DOD,
conducted an evaluation of the program to determine its cost-effectiveness
and feasibility. VRI’s report was issued in May 1996 and concluded that PDP
was cost-effective.9 In our April 1997 report, we expressed concern about
VRI’s analysis because in our view it was based, in part, on unrealistic
assumptions.

Additionally, as required by the National Defense Authorization Act for
fiscal year 1996 (P.L. 104-106), GAO conducted a study of PDP, which
included (1) an assessment of the need for prescribing psychologists in
MHS, (2) information on the implementation of PDP, and (3) information on
PDP’s costs and benefits. In our resulting 1997 report, we concluded that
training psychologists to prescribe medication was not adequately justified



6
 Three participants left the program during the training.
7
 To safeguard the graduates’ privacy, we use only masculine pronouns in this report.
8
 ACNP is a professional association of about 600 scientists from disciplines such as behavioral
pharmacology, neurology, pharmacology, psychiatry, and psychology.
9
 VRI, Cost-Effectiveness and Feasibility of the DOD Psychopharmacology Demonstration Project:
Final Report (Arlington, Va.: May 17, 1996).



Page 4                                            GAO/HEHS-99-98 DOD Prescribing Psychologists
                               B-280869




                               because MHS had not demonstrated a need for prescribing psychologists,
                               the cost of the program was substantial, and the benefits were uncertain.

                               In response to the same act, PDP was terminated in June 1997. However,
                               those psychologists who had graduated from or were currently enrolled in
                               the program were permitted by the legislation to continue prescribing
                               psychotropic medication.


                               PDP graduates are well integrated into MHS. They hold positions of
PDP Graduates Are              responsibility, such as clinic or department head, and treat a broad
Well Integrated Into           spectrum of patients, including active-duty personnel, retirees, and
MHS                            dependents. They can prescribe medication from comprehensive drug
                               formularies and have patient caseloads that are comparable to those of
                               psychiatrists and other psychologists who practice at their clinics and
                               hospitals. Although the graduates were initially supervised closely, all but
                               two have been granted independent status, meaning that they are subject
                               only to the same level of review as psychiatrists at their locations.
                               However, although the graduates are currently well integrated, several
                               experienced early difficulties being accepted at their locations.


PDP Graduates Hold             The nine program graduates remaining in the military at the time of our
Positions of Responsibility,   visits are serving as the chief of a clinic or department, suggesting the high
and Most Treat a Mix of        professional esteem in which they are held. For example, one serves as the
                               chief of an Army division mental health clinic, one as the commander of an
Patients                       Air Force mental health clinic, and another as the chief of a Navy
                               hospital’s mental health department. Serving as clinic or department chief
                               includes performing administrative duties, such as supervising other
                               mental health providers and managing the day-to-day operations of the
                               clinic. The one graduate who left the military did not serve as clinic or
                               department chief during his year of post-PDP service.

                               Although PDP guidance limits graduates to seeing patients between the
                               ages of 18 and 65, most graduates see a mix of patients, including
                               active-duty personnel, retirees, and dependents. Two graduates serve in
                               clinics that treat only active-duty personnel, and one serves in a clinic that
                               treats primarily active-duty personnel but also treats dependents when
                               mental health providers are available. The remaining seven treat a mix of
                               active-duty personnel, dependents, and retirees.




                               Page 5                               GAO/HEHS-99-98 DOD Prescribing Psychologists
                            B-280869




PDP Graduates Prescribe     To guide medical facilities when granting prescribing privileges to the
From Comprehensive Drug     program graduates, a suggested drug formulary listing psychotropic drugs
Formularies                 by name was created as part of PDP.10 Six of the 10 graduates are assigned
                            to facilities that granted the graduates drug formularies that are at least as
                            comprehensive as the drug formulary recommended for them. The
                            remaining four graduates have formularies that lack some drugs listed on
                            the suggested formulary but contain additional drugs not listed on the
                            suggested formulary. Although these four graduates’ formularies do not
                            include all drugs on the recommended formulary, none noted that this lack
                            of some drugs reduced their effectiveness in providing patient care.

                            Some graduates’ authority to prescribe is broader than others’. While four
                            of the graduates have formularies consisting of lists of specific drugs they
                            can prescribe, five have formularies listing classes of drugs from which
                            they can prescribe. Formularies listing drugs by class, rather than by
                            name, allow the flexibility to prescribe a new medication if it falls into a
                            class of drugs already authorized. Otherwise, the graduates have to
                            petition to have the new drug added to their authorized drug formulary.
                            One graduate’s formulary is even more flexible, granting the graduate
                            broad authority to prescribe “psychotropic drugs and their adjuncts.”11


PDP Graduates’ Average      Eight of the 10 graduates’ caseloads are comparable to those of
Monthly Caseloads Are       psychiatrists and other psychologists at the same location. (The remaining
Comparable to Colleagues’   two graduates practice at locations without psychiatrists or other
                            psychologists, so their caseloads could not be compared to other mental
                            health providers’.) For example, one graduate sees an average of 47 cases
                            per month—higher than both the average for other psychologists at the
                            same location (40 cases per month) and the average for psychiatrists at the
                            same location (30 cases per month). Another graduate—the chief of the
                            clinic in which he works—sees between 60 and 70 cases per month.
                            Although this is lower than the average of 100 cases per month seen by the
                            psychiatrist in the same clinic, the graduate told us that 30 to 50 percent of
                            his time is spent on administrative duties associated with his position as
                            chief.



                            10
                              Although all graduates received training in the use of psychotropic drugs to treat mental disorders in
                            patients, they may not prescribe medications until granted prescribing privileges by the medical
                            facility where they are assigned. Each facility is responsible for establishing the list of drugs, or
                            formulary, from which providers at the facility can prescribe.
                            11
                             Adjuncts are drugs that are commonly used in the treatment of the side effects of psychotropic
                            medications.



                            Page 6                                            GAO/HEHS-99-98 DOD Prescribing Psychologists
                           B-280869




                           Variation in the graduates’ average monthly caseloads—which range from
                           40 cases for one graduate to 185 cases for another—results in part from
                           the graduates’ locations and responsibilities. For example, the graduate
                           with the lowest monthly caseload is stationed overseas and treats only
                           active-duty personnel and their dependents who have been screened for
                           suitability for overseas assignment. In addition, this graduate is the chief
                           of the mental health department and of the hospital credentials committee
                           and serves on the medical staff executive committee. Conversely, the
                           graduate with the highest monthly caseload was the only graduate not
                           serving as a clinic or department chief, allowing this graduate more time to
                           treat patients.


Most Graduates Have Been   Initially, all graduates received close supervision by psychiatrists, in
Granted Independent        accordance with guidance issued as part of PDP. For example, each
Status                     graduate’s supervisor reviewed the graduate’s charts for patients receiving
                           medication. Other elements of supervision varied but included observing
                           patient sessions or meeting separately with patients; holding formal
                           weekly meetings to discuss cases; and requiring written approval for either
                           starting, stopping, or changing the dosage of medications. The level of
                           supervision was subsequently reduced for all graduates, seven of whom
                           were granted independent status—meaning that they are subject only to
                           the same level of chart review as other providers at their location. Another
                           graduate has been granted independent status for treating
                           outpatients—the bulk of the graduate’s caseload—but is supervised when
                           treating inpatients. Granting these graduates full or partial independent
                           status indicates hospital officials’ belief that the graduates need no more
                           supervision than do other prescribing providers.

                           The remaining two graduates have not been granted independent status.
                           Officials stationed at one graduate’s location told us that they had
                           anticipated granting him independent status; however, before officials
                           reevaluated his status, the graduate was transferred to a new location.12
                           The second graduate serves at a facility that has a policy requiring
                           continued supervision of all physician extenders (such as prescribing
                           psychologists, physician assistants, and nurse practitioners) who prescribe
                           medication, regardless of length of service or level of performance.




                           12
                            According to the graduate, hospital officials at the graduate’s new location have not yet determined
                           whether he will be granted independent status.



                           Page 7                                           GAO/HEHS-99-98 DOD Prescribing Psychologists
                           B-280869




Some Graduates             While ultimately well integrated at their locations, some graduates
Experienced Initial        experienced some initial difficulty in this regard. For example, a graduate
Problems With Acceptance   from one of the first PDP classes waited 10 months at his initial location to
                           receive prescribing privileges and waited another 3 months before treating
                           a patient requiring medication. Another graduate told us he learned that
                           certain drugs on his formulary had been eliminated only after being
                           informed by a patient that the hospital pharmacy had rejected a
                           prescription written by the graduate. However, both graduates have been
                           reassigned to different locations, and both have been accepted at their
                           new locations.

                           Some of the graduates encountered initial skepticism from supervising
                           psychiatrists, primary care physicians, nurses, and hospital officials who
                           were uncomfortable with the idea of allowing psychologists to prescribe
                           drugs. For example, one graduate told us that a physician at his location
                           was so opposed to giving him prescribing privileges that the doctor
                           resigned from the credentials committee after these privileges were
                           granted. One psychiatrist at another location told us that upon learning
                           that he was assigned to supervise a PDP graduate, he contacted the
                           American Medical Association to inquire about the ethical propriety of a
                           psychiatrist serving as a proctor for a prescribing psychologist. However,
                           nearly all of the physicians and others we spoke to told us that the
                           graduates’ performance subsequently convinced them that the graduates
                           were well trained and knowledgeable. Several physicians also told us that
                           they came to rely on the graduates for information about psychotropic
                           medications.


                           Overwhelmingly, the officials with whom we spoke, including each of the
Graduates Are              graduates’ clinical supervisors, and an outside panel of psychiatrists and
Reported to Provide        psychologists who evaluated each of the graduates rated the graduates’
Good Quality of Care       quality of care as good to excellent. Further, we found no evidence of
                           quality problems in the graduates’ credential files.

                           The graduates’ clinical supervisors have the most extensive knowledge
                           about the graduates’ clinical performance because they have been
                           responsible for reviewing the graduates’ charts, discussing cases with the
                           graduates, and observing the graduates’ interactions with patients. Without
                           exception, these supervisors—all psychiatrists—stated that the graduates’
                           quality of care was good. One supervisor, for example, noted that each of
                           the graduate’s patients had improved as a result of the graduate’s
                           treatment; another supervisor referred to the quality of care provided by



                           Page 8                              GAO/HEHS-99-98 DOD Prescribing Psychologists
                              B-280869




                              the graduate as “phenomenal.” The supervisors noted that the graduates
                              are aware of their limitations and know when to ask for advice or
                              consultation or when to refer a patient to a psychiatrist. Further, the
                              supervisors noted that no adverse patient outcomes have been associated
                              with the treatment provided by the graduates.

                              External evaluators also provided information on the graduates’ quality of
                              care. In 1998, an ACNP panel composed of board-certified psychiatrists and
                              licensed clinical psychologists performed a final evaluation of the
                              graduates—interviewing the graduates, their supervisors, and other
                              officials, and reviewing a portion of each graduate’s patient charts. In its
                              resulting report, ACNP described each graduate’s location and role,
                              discussed the results of interviews with the graduates’ clinical supervisors
                              and others, and discussed the results of patient chart reviews. In its report,
                              ACNP stated that the graduates had performed well in all the locations
                              where they were assigned, that they had performed safely and effectively
                              as prescribing psychologists, and that no adverse outcomes had been
                              associated with their performance.13


                              Although the graduates have been well integrated and have been reported
Graduates’ Effect on          to provide good care, their effect on DOD’s medical readiness could not be
Readiness Is Minimal          more than minimal. DOD has approximately 400 psychiatrists and 400
                              psychologists; granting prescribing privileges to 10 psychologists is
                              unlikely to affect combat readiness. Further, because psychotropic drugs
                              are not used extensively during combat, the graduates, if deployed in
                              combat, would likely have little effect on readiness beyond their role as
                              clinical psychologists. However, evidence we gathered suggests that the
                              graduates have modestly enhanced the peacetime readiness of military
                              personnel at their current locations.


Graduates Are Unlikely to     Many officials—including service readiness officials and field
Need Prescribing Ability in   commanders—told us that the graduates would likely have little effect on
Wartime                       readiness in combat because psychotropic drugs are not generally the
                              treatment of choice in combat and thus prescribing authority would not be
                              in great demand. Because none of the PDP graduates have been deployed to



                              13
                                During our review, we received allegations regarding certain graduates’ performance from two
                              individuals involved in overseeing or evaluating the graduates. In all cases, we reviewed available
                              evidence and held discussions with relevant officials. In all but one case, we found that there was not
                              sufficient evidence to support the allegations. In the one case, the hospital’s chief of medical staff
                              considered the issue insignificant.



                              Page 9                                            GAO/HEHS-99-98 DOD Prescribing Psychologists
                          B-280869




                          a combat zone, however, no data exist on the actual use of the graduates
                          in wartime situations.

                          According to many officials with whom we spoke, the preferred course of
                          treatment for combat stress is adequate rest, counseling, and a quick
                          return to the front lines. Soldiers who require medication are generally
                          evacuated to hospitals located away from combat areas. Psychologists’
                          counseling skills can be valuable front-line tools to handle stress, although
                          this can be accomplished without the special training given to prescribing
                          psychologists. A service-level medical readiness official told us that the
                          most effective techniques to minimize combat stress are proactive—that
                          is, counseling troops upon their arrival in the combat zone to reduce their
                          anxiety level before combat. According to officials, the social workers,
                          psychologists, and psychiatrists who provide this type of proactive
                          counseling have a far greater effect on the well-being of the troops in
                          battle than those who treat personnel after combat stress has set in. This
                          proactive approach does not require prescribing authority.


Graduates Contribute to   Although the PDP graduates’ prescribing skills may not be needed in
Readiness at Their        combat situations, the graduates reportedly improve medical readiness at
Locations                 their peacetime locations. According to officials, the graduates improve
                          readiness by reducing the time that patients must wait for treatment or by
                          increasing the number of patients who can be treated.

                          Before the graduates were stationed at their current locations, some
                          patients requiring mental health care received both psychotherapy from a
                          psychologist and drug therapy from a psychiatrist because psychologists
                          had not been permitted to prescribe drugs. Patients who needed to see
                          two providers for treatment could, according to officials, wait up to 3
                          weeks to get an appointment with a psychiatrist. Prescribing
                          psychologists, however, can treat some patients needing drugs who
                          otherwise would require an appointment with a psychiatrist. Since these
                          patients see only one provider—their prescribing psychologist—the time
                          and effort needed to receive treatment is reduced.

                          Other benefits may accrue as well. For example, one official told us that
                          when only a portion of the units in his division—which is staffed with a
                          psychologist and a psychiatrist—get an order to deploy, the division has to
                          consider which providers should remain at the division’s permanent
                          location so that the division as a whole has adequate medical support. In
                          the past, if the division decided to deploy its psychiatrist, the permanent



                          Page 10                              GAO/HEHS-99-98 DOD Prescribing Psychologists
                    B-280869




                    location would be without a prescribing mental health provider. Having a
                    prescribing psychologist enables the division to deploy one prescribing
                    provider while keeping another at the division’s permanent location.

                    The graduates may also contribute to medical readiness through the care
                    of dependents. According to several officials with whom we spoke,
                    personnel who are worried about whether their family members are
                    receiving adequate care may be affected in their ability to carry out their
                    duties. One official told us that the PDP graduate in his unit—who primarily
                    treats dependents—contributes to readiness in this manner. Because the
                    facility did not have enough psychiatrists to care for dependents before
                    the graduate was assigned to this location, those who needed to see a
                    psychiatrist were referred to civilian psychiatrists in a nearby city.
                    According to this official, many dependents did not seek care from these
                    psychiatrists because they could not afford the copayment. The PDP
                    graduate gives the facility the additional capability to provide care to
                    dependents without charging them. The official believes that,
                    consequently, more dependents seek and receive the care they need and
                    fewer active-duty personnel worry about their family members’ treatment.


                    We project that DOD will spend somewhat more on its 10 prescribing
PDP Graduates Are   psychologists than it would have spent on providing mental health
More Costly Than    services using the traditional mix of psychologists and psychiatrists. When
Traditional         all DOD expenditures for various mental health care providers—including
                    salaries and acquisition, training, and retirement costs—are averaged over
Psychologist and    the length of time the providers are expected to serve, the average yearly
Psychiatrist Mix    cost of a PDP graduate is about 7 percent higher than that of the
                    combination of psychologists and psychiatrists who would have provided
                    treatment similar to that provided by the graduates.14

                    Adapting a methodology developed by VRI,15 we analyzed and compared
                    DOD’s costs for providing salaries, training, retirement pay, and other
                    career-related benefits to military clinical psychologists, prescribing
                    psychologists, and psychiatrists. We found that mental health providers’
                    overall yearly costs to DOD are not identical. Of the three types of providers
                    we analyzed, the costs for military psychiatrists are the highest—in part
                    because psychiatrists receive more yearly pay than military clinical

                    14
                     Other physicians—such as family practice and internal medicine doctors—also prescribe
                    psychotropic medications. However, psychiatrists are the only physicians included in our analysis.
                    15
                      VRI previously evaluated PDP, under contract to DOD. We updated VRI’s model with more current
                    information.



                    Page 11                                          GAO/HEHS-99-98 DOD Prescribing Psychologists
                  B-280869




                  psychologists or prescribing psychologists. The PDP graduates’ costs are
                  the next highest and are considerably more than clinical
                  psychologists—primarily because the costs involved in training the
                  graduates and evaluating them (including evaluations by ACNP and VRI) far
                  exceed the training costs for clinical psychologists.

                  Considering all career-related costs, we project that, on average, the PDP
                  graduates will each cost DOD about $9,700 per year—or about 7 percent—
                  more than the cost of the combination of psychologists and psychiatrists
                  that would be used to treat patients in their absence. Appendix II
                  describes our analysis in more detail.


                  In comments received April 26, 1999, responding to a draft of this report,
Agency Comments   the Executive Director of DOD TRICARE Management Activity stated that
                  DOD agreed with the report and had no further comments.


                  Copies of this report are being sent to Representative Floyd Spence,
                  Chairman, and Representative Ike Skelton, Ranking Minority Member,
                  House Committee on Armed Services; and to the Honorable William
                  Cohen, Secretary of Defense. Copies will also be made available to others
                  upon request. If you have any questions about this report, please call me at
                  (202) 512-7101 or Ronald J. Guthrie, Assistant Director, at (303) 572-7332.
                  Other major contributors to this report are Steve Gaty, Sigrid McGinty, and
                  Arthur D. Trapp, Senior Evaluators; and Timothy J. Carr, Economist.




                  Stephen P. Backhus
                  Director, Veterans’ Affairs and
                    Military Health Care Issues




                  Page 12                             GAO/HEHS-99-98 DOD Prescribing Psychologists
Page 13   GAO/HEHS-99-98 DOD Prescribing Psychologists
Contents



Letter                                                                                              1


Appendix I                                                                                         16

Objectives, Scope,
and Methodology of
Our Review
Appendix II                                                                                        18

Analysis of PDP
Graduates’ Costs
Relative to Those of
Other DOD Providers
Table                  Table II.1: VRI’s Cost Estimates and GAO’s Cost Estimates                   24




                       Abbreviations

                       ACNP      American College of Neuropsychopharmacology
                       DOD       Department of Defense
                       MHS       Military Health System
                       MRSP      Medical Readiness Strategic Plan
                       PDP       Psychopharmacology Demonstration Project
                       USUHS     Uniformed Services University of the Health Sciences
                       VRI       Vector Research, Inc.


                       Page 14                            GAO/HEHS-99-98 DOD Prescribing Psychologists
Page 15   GAO/HEHS-99-98 DOD Prescribing Psychologists
Appendix I

Objectives, Scope, and Methodology of Our
Review

                 The objectives of our review were to

             •   describe how the 10 Psychopharmacology Demonstration Project (PDP)
                 graduates have been integrated into the Military Health System (MHS);
             •   obtain information on the quality of care they provide to military
                 personnel, dependents, and retirees;
             •   determine their effect on medical readiness; and
             •   assess the cost-effectiveness of the PDP graduates.

                 To address the first two objectives, we visited the current or former duty
                 locations of nine of the graduates and contacted the remaining graduate,
                 who is stationed overseas, by telephone. At the locations we visited, we
                 also interviewed the graduates’ clinical supervisors, the hospital
                 commander or designee, and various other clinicians and personnel to
                 obtain information about the graduates’ performance and level of
                 integration.

                 Lacking a uniform definition of integration, we used several measures of
                 how the graduates were used in order to assess their integration. We
                 obtained information on each graduate’s current position and role, scope
                 of practice, drug formulary, average monthly caseload, and level of
                 supervision received. We also reviewed the graduates’ credentials files and
                 performance reviews. We contacted all the members of an American
                 College of Neuropsychopharmacology (ACNP) panel that performed a 1998
                 review of the graduates to obtain their views about the quality of care
                 provided by the program graduates. We analyzed ACNP’s May 1998 report
                 and the report’s supporting documentation, as well as prior ACNP
                 evaluations of PDP.

                 To collect information on the PDP graduates’ impact on medical readiness,
                 we spoke with officials from each of the services and from the Office of
                 the Assistant Secretary of Defense (Health Affairs), as well as officials at
                 the graduates’ locations. In addition, we reviewed DOD’s Medical Readiness
                 Strategic Plan to determine the role of MHS in supporting DOD’s medical
                 readiness.

                 To assess the cost-effectiveness of the graduates, we used a model
                 developed by Vector Research, Inc. (VRI), under contract to DOD. Using
                 updated data and assumptions, we calculated the life-cycle costs of the
                 graduates, as well as those of other DOD psychologists, psychiatrists, and
                 other physicians, and compared the annual life-cycle costs of these
                 providers to determine the cost of the graduates relative to that of other



                 Page 16                             GAO/HEHS-99-98 DOD Prescribing Psychologists
Appendix I
Objectives, Scope, and Methodology of Our
Review




providers. Appendix II provides a more detailed description of the model
and the assumptions we used in calculating life-cycle costs.




Page 17                                     GAO/HEHS-99-98 DOD Prescribing Psychologists
Appendix II

Analysis of PDP Graduates’ Costs Relative
to Those of Other DOD Providers

                    This appendix presents the methodology, data sources, and principal
                    assumptions we used to calculate the career costs of military psychiatrists,
                    psychologists, and prescribing psychologists. It also discusses how we
                    compared the costs of prescribing psychologists to those of these other
                    mental health care providers. Our analysis builds on a 1996 VRI study, in
                    which VRI compared the cost of various types of military health care
                    providers to the cost of a prescribing psychologist and assessed the
                    relative cost-effectiveness of training the psychologists to prescribe
                    medication and having them deliver this service in MHS.16

                    For the purposes of this report, we have updated and extended the VRI
                    analysis, most notably by

                •   revising the figures used by VRI to represent the costs involved in training
                    the prescribing psychologists and
                •   estimating the career length of the graduates who currently remain in the
                    military, based on their career length to date, and calculating their career
                    costs.

                    Except where noted, the data we used—such as military pay rates and
                    health care costs—were provided by VRI. However, we did not verify the
                    accuracy of these data.


Cost Analysis       DOD uses several types of providers to deliver mental health care, including
                    psychologists, psychiatrists, family practice doctors, and internal medicine
                    doctors. However, their career-related costs—including salaries, training,
                    and retirement pay—are not identical and are generally lower for
                    psychologists than for these physicians. For example, psychologists are
                    not eligible for all special payments above salaries that physicians may
                    receive.

                    We calculated the average career costs of the graduates and other
                    providers and compared them to one another, using costs based on the
                    anticipated career length and overall cost to DOD of the PDP graduates and
                    other providers. Most PDP graduates spent a part of their military careers
                    as clinical psychologists (before they entered PDP) and part of their
                    military careers as prescribing psychologists (after they entered PDP). For
                    comparison purposes, we assumed that the mental health services
                    provided by PDP graduates as prescribing psychologists are comparable to

                    16
                      Other tasks in the study included identifying impediments to integrating prescribing psychologists
                    into MHS and evaluating the potential roles and functions of prescribing psychologists in DOD.



                    Page 18                                          GAO/HEHS-99-98 DOD Prescribing Psychologists
Appendix II
Analysis of PDP Graduates’ Costs Relative
to Those of Other DOD Providers




those provided by psychiatrists17—that is, they are trained to perform a
function (prescribing psychotropic medication) that psychiatrists would
have to perform in their absence.18

Because a PDP graduate’s career, on average, is a combination of the
functions performed by psychologists and psychiatrists, we compared the
portion of a PDP graduate’s career spent as a psychologist (that is, before
the graduate became a prescribing psychologist) to the yearly cost of a
military psychologist, and we compared the portion of a PDP graduate’s
career spent as a prescribing psychologist to the yearly cost of a military
psychiatrist. For example, one PDP graduate served about 10 years as a
military psychologist before entering PDP and, since then, has served about
4 years as a prescribing psychologist—for a total of 14 years. Thus, the
graduate spent 71.4 percent (10 years) of his practicing career in the
military as a clinical psychologist and 28.6 percent (4 years) as a
prescribing psychologist. The yearly cost of the graduate could then be
compared to 71.4 percent of the yearly cost of a psychologist plus
28.6 percent of the yearly cost of a psychiatrist.

Another PDP graduate served 3 years as a military psychologist before
entering PDP and has served 3 years as a prescribing psychologist, for a
total of 6 years. Thus, 50 percent of his practicing career in the military
was spent as a clinical psychologist and 50 percent was spent as a
prescribing psychologist. As a result, the yearly cost of this graduate could
be compared to 50 percent of the yearly cost of a psychologist plus
50 percent of the yearly cost of a psychiatrist.

The 10 PDP graduates differed in the length of time they had served as
military psychologists before entering PDP, ranging from not having served
in the military to having served 10 years,19 with a mean average of about
4.5 years as military psychologists. Similarly, the participants can be
expected to differ in the length of time each remains in the military as a
prescribing psychologist. We calculated the average length of their
projected careers as prescribing psychologists, based on the length of their

17
 Some—including ACNP and the American Psychological Association—have pointed out that the
graduates are not intended to replace psychiatrists. ACNP wrote, “PDP was not designed to replace
psychiatrists . . . and it did not do so. Instead, the program ‘products’ were extended psychologists
with [the] value-added component prescriptive authority provides.”
18
 Other physicians—such as family practice and internal medicine doctors—also prescribe
psychotropic medications. However, their annual life-cycle costs are higher than those of psychiatrists,
primarily because they serve shorter careers than psychiatrists and, thus, their overall costs are larger
on an annual basis. Because psychiatrists’ costs were the lowest of the physicians’ costs analyzed, we
used their costs in order to provide the most conservative comparison.
19
  Two PDP graduates entered PDP immediately upon joining the military.


Page 19                                           GAO/HEHS-99-98 DOD Prescribing Psychologists
                           Appendix II
                           Analysis of PDP Graduates’ Costs Relative
                           to Those of Other DOD Providers




                           military service to date and the rates at which DOD psychologists have
                           historically left the military. Using these data, we project that each
                           program participant will serve an average of 6 years as a prescribing
                           psychologist after entering PDP (including service to date as prescribing
                           psychologists). Thus, we expect the participants to serve an average
                           combined career total of 10.5 years in the military as clinical psychologists
                           and subsequently as prescribing psychologists: an average of 4.5 years (or
                           43 percent of their careers) as clinical psychologists, plus an average of 6.0
                           years (or 57 percent of their careers) as prescribing psychologists. The
                           average yearly cost of the graduates can thus be compared to 43 percent of
                           the yearly cost of a psychologist plus 57 percent of the yearly cost of a
                           psychiatrist.

                           Our estimates of the overall cost of the various types of providers included

                       •   acquisition costs that DOD incurs when recruiting someone into the
                           military;
                       •   training costs to provide DOD-sponsored training to military health care
                           providers;
                       •   force costs, which cover basic pay and allowances (such as allowances for
                           housing), special pay, miscellaneous expenses, and health care benefits
                           over the course of an active-duty career; and
                       •   retirement costs, which include retirement pay and retiree health care
                           benefits over the expected life of the retiree.


Data and Assumptions       Although our analysis resembles VRI’s—and in most cases relies on VRI’s
                           data and assumptions—in several instances we used data or assumptions
                           that differed from VRI’s. These differences reflect our emphasis on
                           incorporating data that reflect, to date, the actual costs and experience of
                           the program as it was implemented by DOD, rather than VRI’s projections of
                           how the program might be implemented. We discussed these changes with
                           a VRI official, who stated that while he disagreed with our estimate of the
                           cost of classroom training, the assumptions we used in our calculations
                           were reasonable given the history of the program. The remainder of this
                           appendix discusses the major assumptions we made in performing our
                           analysis and explains where and how our data or assumptions differed
                           from VRI’s.

Different Scenarios        In calculating the cost-effectiveness of PDP, VRI used two case scenarios:
                           start-up and optimal. Costs in the start-up scenario included the
                           nonrecurring, fixed costs associated with PDP development and initial



                           Page 20                                     GAO/HEHS-99-98 DOD Prescribing Psychologists
                      Appendix II
                      Analysis of PDP Graduates’ Costs Relative
                      to Those of Other DOD Providers




                      implementation, such as the cost of the external evaluation by ACNP, as
                      well as other costs that VRI believed would diminish or disappear in the
                      long run.

                      The optimal scenario represented PDP in a long-term, steady state during
                      which no nonrecurring costs associated with program start-up would
                      accrue. In this scenario, VRI set the cost of supplies and training to levels
                      that indicate long-term efficiency.

                      In contrast to VRI, we did not project different scenarios because the
                      program has been terminated. Instead, we used data that reflect, to date,
                      the actual costs and experience of the program as it was implemented by
                      DOD.


Pre-PDP Service       VRIassumed that PDP participants would have at least 6 years of experience
                      as military clinical psychologists when they entered PDP. However, we
                      found that although the 10 PDP graduates served an average of almost 7
                      years in the military before entering PDP, on average only about 4.5 of
                      those years were spent as a clinical psychologist. We did not include
                      nonpsychologist years in our cost comparison.

                      VRI assumed that the yearly continuation rates—that is, the probability that
                      a given provider will stay within a given service occupation during a given
                      year—for program participants before entering PDP were identical to those
                      for military psychologists, including some psychologists who leave the
                      military each year after the first 2 years of service. In contrast, based on
                      the experience of the program, we used yearly continuation rates that
                      reflect the fact that no participants left the military before entering PDP.20

PDP Characteristics   VRI used two different estimates of class size, depending on the scenario.
                      In the start-up case, VRI assumed that, on average, 3.25 psychologists
                      would enter each PDP class, from which 2.25 prescribing psychologists
                      would graduate. These numbers were based on the program experience at
                      the time of VRI’s report: 13 psychologists had entered the program and,
                      according to a VRI official, it appeared that 9 would graduate. VRI set the
                      retention rate during the program to reflect the assumption that 9 of 13
                      participants would graduate.

                      In the optimal case scenario, VRI assumed that, on average, 8.7
                      psychologists would enter PDP each year, while 6 prescribing psychologists

                      20
                       The continuation rate used affects the length of service calculated by the model. Because annual
                      costs depend in part on this expected length of service, different continuation rates will result in
                      different annual costs.



                      Page 21                                           GAO/HEHS-99-98 DOD Prescribing Psychologists
                   Appendix II
                   Analysis of PDP Graduates’ Costs Relative
                   to Those of Other DOD Providers




                   would graduate. The continuation rate during the program was identical to
                   that used in the start-up case.

                   However, of the 13 participants, 10—not 9—graduated from the four PDP
                   classes. Consequently, we used an average of 3.25 (that is, 13/4)
                   psychologists entering PDP each year and 2.5 (that is, 10/4) graduating. We
                   set the continuation rate during the program accordingly. Further, in order
                   to reflect the fact that 13 psychologists entered PDP—effectively “leaving”
                   the services’ clinical psychologist force for cost-comparison purposes—we
                   used a continuation rate for clinical psychologists that differed slightly
                   from the historical DOD rate to account for these psychologists.

                   Our estimates of the cost of training the graduates also differed from those
                   used by VRI. For its cost model, VRI estimated the overhead costs
                   associated with the program to be $2,890,343. However, based on ACNP’s
                   annual reports (some of which were not yet published when VRI conducted
                   its study) and our interviews with the former PDP training director, we
                   estimated the overhead costs to be about 14 percent lower at $2,474,578.

                   While our estimate of overhead costs is lower than VRI’s estimate, our
                   estimate of 1 year of classroom training at the Uniformed Services
                   University of the Health Sciences (USUHS) is markedly higher than that
                   used by VRI. VRI estimated the classroom training costs (which do not
                   include the PDP overhead costs it estimated) for participants to be $39,969,
                   based on its 1995 study of the costs of graduate medical education and on
                   a survey of the costs of graduate medical education in the Washington,
                   D.C., area. However, based on our previous analysis of USUHS costs,21 we
                   estimated the classroom training costs to be $110,028—or about
                   175 percent higher than VRI’s estimate.

Post-PDP Service   To project how long the PDP graduates could be expected to serve as
                   prescribing psychologists, VRI assumed no graduates would leave the
                   military for the 2 years immediately following the program. VRI also
                   assumed that the rate at which the graduates leave the military thereafter
                   would be identical to the rate at which other clinical psychologists leave.

                   In contrast, our projections of the graduates’ post-PDP careers were based
                   on their actual length of service to date. Because all graduates completed
                   at least 1 year of post-PDP service, we set the continuation rate for the first
                   year after the program to 1. However, the yearly rate for the second year

                   21
                    Military Physicians: DOD’s Medical School and Scholarship Program (GAO/HEHS-95-244, Sept. 29,
                   1995).



                   Page 22                                       GAO/HEHS-99-98 DOD Prescribing Psychologists
                   Appendix II
                   Analysis of PDP Graduates’ Costs Relative
                   to Those of Other DOD Providers




                   was set to 0.9, because only 9 of the 10 graduates completed a second year
                   of post-PDP service. To estimate how much longer the graduates who are
                   still in the military could be expected to remain in the military, we used
                   information gathered during our interviews with the graduates (such as
                   the graduates’ future plans for military service) as well as historical
                   continuation rates for DOD clinical psychologists. Based on these
                   calculations, we estimate that the participants will serve an average of
                   about 6 years as prescribing psychologists, including the productive
                   portion of their training.22 (We conducted a sensitivity analysis, described
                   at the end of this appendix, to determine the effect this estimate had on
                   our final cost estimates.)

                   VRI also assumed that the PDP graduates posed no more of a malpractice
                   risk to DOD than any other mental health providers delivering the same
                   treatment to the same types of patients. Further, VRI assumed that PDP
                   graduates did not receive the special pay paid to psychiatrists and other
                   physicians in the military, assuming instead that the salary for PDP
                   graduates was identical to that for military clinical psychologists. We also
                   used these assumptions.

Supervisory Time   VRI estimated that the PDP graduates would require 5 percent of a
                   supervisor’s time for the remainder of their careers. However, based on
                   our fieldwork, we reduced that estimate to zero. Although two graduates
                   have still not been granted independent status, supervision of the
                   graduates in general has been reduced significantly. For example, one
                   graduate required about 1 hour per week (or less than 3 percent) of
                   supervisory time during the first 18 months after the program; during the
                   subsequent 18 months, this graduate has required about 0.5 hours per
                   month (or less than 0.3 percent) of supervisory time. Eight of the
                   graduates currently require less than 1 hour per week of supervisory time.
                   However, not all supervisors were able to quantify the amount of time they
                   spent supervising the graduates. Even when supervisors could quantify
                   this time, it was often less than 1 percent, and as a result we used an
                   estimate of zero to provide a conservative estimate of the cost of the
                   graduates. Had we used a percentage larger than zero, our estimate of the
                   PDP graduates’ costs would have been higher. (We conducted a sensitivity
                   analysis, described at the end of this appendix, to determine the effect this
                   assumption had on our final cost estimates.)



                   22
                    In accordance with VRI’s estimate, we assumed that PDP participants were not productive (that is,
                   saw no patients) during the classroom portion of their training and were 50 percent productive (that is,
                   were half as productive as fully trained clinicians) during the clinical portion of their training.



                   Page 23                                          GAO/HEHS-99-98 DOD Prescribing Psychologists
                                       Appendix II
                                       Analysis of PDP Graduates’ Costs Relative
                                       to Those of Other DOD Providers




Retirement Costs                       Based on DOD figures, VRI calculated pension rates based on an average
                                       service time for military retirees of 22.5 years. However, our estimates of
                                       the graduates’ expected length of service yield an average service time for
                                       retirees in this group of 23.8 years. In other words, the graduates who
                                       serve at least 20 years in the military—and are thus eligible to earn a
                                       pension—will likely have served an average of 23.8 years. We calculated
                                       retirement costs accordingly.

                                       Further, since only some of the graduates’ years of service before entering
                                       PDP  were spent as military clinical psychologists and because some of the
                                       retirement costs for the graduates are associated with service as neither
                                       clinical psychologist nor prescribing psychologist, we believe it is not
                                       appropriate to include this portion of retirement costs in our cost
                                       comparison. As a result, retirement cost estimates for the graduates were
                                       reduced.

Updated Costs                          The data used in VRI’s earlier calculations were in 1996 dollars. For our
                                       analysis, we updated the figures to 1999 dollars using the most recent
                                       estimates of the DOD medical consumer price index.23

Results of Analysis                    Table II.1 shows the results of VRI’s calculations and our calculations.

Table II.1: VRI’s Cost Estimates and
GAO’s Cost Estimates                                                                                      Yearly life-cycle cost per
                                                                                                          full-time equivalent (1999
                                                                                                                    dollars)
                                       Provider group                                                          VRI total          GAO total
                                       Psychiatrist                                                           $188,472             $188,472
                                       Psychologist                                                              96,819               92,703
                                       Psychologist and psychiatrist combination                                136,895             147,532
                                       Prescribing psychologists (start-up case scenario;
                                                                                                                                                 a
                                       graduating class size set to 2.25)                                       133,942
                                       Prescribing psychologists (optimal case scenario;
                                                                                                                                                 a
                                       graduating class size set to 6)                                          120,463
                                                                                                                         a
                                       PDP graduates (based on program experience)                                                  157,226
                                       a
                                        Not applicable.




                                       23
                                        Neither we nor VRI discounted the costs included in these calculations. Discounting determines the
                                       present value of an amount of money that will be spent in the future. For example, a dollar paid by the
                                       government today is more costly than a dollar paid at some future date because it increases the burden
                                       of making interest payments on the national debt. See Office of Management and Budget, Guidelines
                                       and Discount Rates for Benefit-Cost Analysis of Federal Programs, Circular A-94 (Washington, D.C.:
                                       Office of Management and Budget, Revised Oct. 29, 1992).



                                       Page 24                                          GAO/HEHS-99-98 DOD Prescribing Psychologists
                       Appendix II
                       Analysis of PDP Graduates’ Costs Relative
                       to Those of Other DOD Providers




                       VRI’sestimates for the annual cost of the prescribing psychologists in both
                       the start-up case ($133,942) and the optimal case ($120,463) were less than
                       that of the combined psychologist and psychiatrist cost ($136,895). VRI
                       concluded that the program was cost-effective. On the other hand, our
                       estimate of the annual cost of prescribing psychologists ($157,226) was
                       higher than that of the combined psychologist and psychiatrist cost
                       ($147,532), by about $9,700.

                       Our estimate of the cost of the graduates is higher than VRI’s because of the
                       different data and assumptions we used, our estimate of the cost of the
                       psychologists is lower than VRI’s because we adjusted the psychologist
                       continuation rate slightly, and our estimate of the combination of
                       psychologist and psychiatrist costs is higher than VRI’s because our
                       estimates of the length of time the graduates served as military clinical
                       psychologists and will serve as prescribing psychologists differ somewhat
                       from VRI’s estimates. Because the combination of psychologist and
                       psychiatrist costs depends on the proportion of time the graduates spend
                       as clinical psychologists and prescribing psychologists, differences in
                       these proportions will result in different estimates for the combination of
                       psychologist and psychiatrist.

Sensitivity Analysis   To assess the influence that our assumptions of length of service and
                       supervisory time had on the results of our calculations, we performed a
                       sensitivity analysis on each of these assumptions. To perform each
                       analysis, we varied our assumptions about length of service or supervisory
                       time while holding all other values constant.

                       First, we performed a sensitivity analysis on our projections of the length
                       of time the graduates can be expected to remain in the military. Using
                       DOD’s historical continuation rate for psychologists, we projected that the
                       participants will serve for about 6 years as prescribing psychologists,
                       including service to date. This resulted in our estimate that the annual cost
                       of the graduates is about $9,700 more than the combined psychologist and
                       psychiatrist costs used for comparison. If the participants were to serve
                       for 7 years as prescribing psychologists, the estimated cost differential
                       between the PDP graduates and the combined psychologist and psychiatrist
                       costs is reduced to about $6,300. Projecting an average length of service of
                       8 years as prescribing psychologists reduces that differential to about
                       $3,800; 9 years, to about $2,100; and 10 years, to about $800. Thus, given
                       this program’s experience, the graduates would not be less expensive than
                       the combined psychologist and psychiatrist unless they served as
                       prescribing psychologists for an average of more than 10 years.



                       Page 25                                     GAO/HEHS-99-98 DOD Prescribing Psychologists
           Appendix II
           Analysis of PDP Graduates’ Costs Relative
           to Those of Other DOD Providers




           In addition, because we could not precisely quantify the amount of
           supervisory time required by the graduates, we assumed in making our
           calculations that the supervisory time was zero. To determine the effect
           that this assumption had on our final cost estimates, we performed a
           sensitivity analysis using other estimates of supervisory time. First, we
           used VRI’s estimate that the graduates would require 5 percent of a
           supervisor’s time throughout their career. This assumption raised the
           estimated differential between the cost of the graduates and the combined
           psychologist and psychiatrist cost from $9,700 to about $11,800. Assuming
           3 percent of a supervisor’s time raised the estimated cost differential to
           about $11,000 per year; assuming 1 percent of a supervisor’s time raised
           the estimated cost differential to about $10,100 per year.




(101619)   Page 26                                     GAO/HEHS-99-98 DOD Prescribing Psychologists
Ordering Information

The first copy of each GAO report and testimony is free.
Additional copies are $2 each. Orders should be sent to the
following address, accompanied by a check or money order
made out to the Superintendent of Documents, when
necessary. VISA and MasterCard credit cards are accepted, also.
Orders for 100 or more copies to be mailed to a single address
are discounted 25 percent.

Orders by mail:

U.S. General Accounting Office
P.O. Box 37050
Washington, DC 20013

or visit:

Room 1100
700 4th St. NW (corner of 4th and G Sts. NW)
U.S. General Accounting Office
Washington, DC

Orders may also be placed by calling (202) 512-6000
or by using fax number (202) 512-6061, or TDD (202) 512-2537.

Each day, GAO issues a list of newly available reports and
testimony. To receive facsimile copies of the daily list or any
list from the past 30 days, please call (202) 512-6000 using a
touchtone phone. A recorded menu will provide information on
how to obtain these lists.

For information on how to access GAO reports on the INTERNET,
send an e-mail message with "info" in the body to:

info@www.gao.gov

or visit GAO’s World Wide Web Home Page at:

http://www.gao.gov




PRINTED ON    RECYCLED PAPER
United States                       Bulk Rate
General Accounting Office      Postage & Fees Paid
Washington, D.C. 20548-0001           GAO
                                 Permit No. G100
Official Business
Penalty for Private Use $300

Address Correction Requested