The authors used the RAND Dynamic Retention Model to determine the most cost-effective way to increase the force size of the uniformed mental health provider workforce; specifically, accessing more providers or retaining more providers. The authors also compared military compensation for psychiatrists, clinical psychologists, social workers, and mental health nurse practitioners with expected civilian compensation for these types of providers.

Cost Trade-Offs Between Accessing and Retaining Uniformed Mental Health Providers

Avery Calkins, Michael G. Mattock, Shannon D. Donofry, Daniel Schwam, Anthony Lawrence, Kimberly A. Hepner

ResearchPublished Oct 29, 2024

The Military Health System does not have enough military mental health providers to meet demand among active-duty service members, despite efforts in the U.S. Department of Defense (DoD) to leverage special pays to recruit and retain staff. Maintaining adequate military mental health care services is important for maintaining the readiness of the overall force. To expand its mental health workforce and stabilize its care delivery system, DoD needs cost-effective options for increasing the force size of military mental health providers in both the short and long terms.

In this report, the authors used the RAND Dynamic Retention Model to simulate how changing retention bonuses for uniformed mental health providers increased active component retention and per capita personnel cost. Using these results, the authors determined the most cost-effective way to increase the force size of the uniformed mental health provider workforce; specifically, accessing more providers or retaining more providers. The authors also compared military compensation for psychiatrists, clinical psychologists, social workers, and mental health nurse practitioners with expected civilian compensation for these types of providers. DoD leaders and personnel managers can use the key findings and recommendations offered to make informed choices among potential strategies for expanding its uniformed mental health workforce.

Key Findings

  • Expected annual real military compensation for fully trained uniformed psychiatrists decreased approximately 10 percent during fiscal years 2014–2022. Nominal compensation increased for all provider types, and real compensation increased for provider types other than psychiatrists.
  • With the exception of psychiatrists, military mental health providers earn more than civilians. Psychologists and social workers tend to earn more in the military than they would in the civilian workforce. Mental health nurse practitioners earn about the same as their civilian counterparts in the early part of their careers and earn more than their civilian counterparts in the later part of their careers. Fully-trained military psychiatrists earn substantially less than they would in the civilian workforce; however, military pay for psychiatrists with less than five years of service is higher than average pay for civilian residencies.
  • Uniformed mental health providers vary in how responsive they are to relative changes in retention bonuses: The same percentage increase in bonus pay for providers who receive larger bonuses (e.g., psychiatrists) would be expected to affect retention differently than the same percentage increase in bonus pay for providers who receive smaller bonuses (e.g., social workers).
  • It is more economical in the long run to expand the accession pipeline. For all reasonable values of the cost of accessing and training military mental health providers, increasing retention bonuses increases total per-capita personnel costs, suggesting that accession is more efficient than retention for expanding the mental health provider workforce.

Recommendations

  • DoD should widen mental health provider accession pipelines. Because expanding accession will be more economical over the long term than increasing retention bonuses, DoD should widen accession pipelines for mental health providers into the military.
  • DoD should increase retention bonuses for uniformed mental health providers. It will take time to sufficiently widen the mental health provider pipelines. In the meantime, shorter-term strategies — such as increasing special and incentive (S&I) pays and, specifically, increasing retention bonuses — will also be needed to augment provider retention by helping retain mid- and late-career providers. The flexibility of these bonuses makes them particularly useful: They can be raised or lowered or turned on or off at will by DoD or service branches.
  • DoD should review S&I pays for mental health providers on a regular basis to ensure that they support retention goals. DoD should evaluate the type and value of S&I pays for military mental health providers on a frequent basis to ensure that compensation is set at a level that achieves the desired level of retention.

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Calkins, Avery, Michael G. Mattock, Shannon D. Donofry, Daniel Schwam, Anthony Lawrence, and Kimberly A. Hepner, Cost Trade-Offs Between Accessing and Retaining Uniformed Mental Health Providers. Santa Monica, CA: RAND Corporation, 2024. https://www.rand.org/pubs/research_reports/RRA2256-1.html.
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This research was sponsored by the Office of the Assistant Secretary of Defense for Health Affairs and conducted within the Personnel, Readiness, and Health Program of the RAND National Security Research Division (NSRD).

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