Choice Program Expansion Jeopardizes High-Quality VHA Mental Health Services

MYTH:If offered, the 14 of 20 veterans outside the VHA who are the target of this proposal would prefer to use VCP mental health options to get help.

FACT: There is no evidence that those veterans are VHA-eligible, otherwise uninsured, or would seek needed help. The VHA’s 2017 suicide report did not probe whether veteran suicide decedents who were not recent VHA patients were eligible for VHA care.¹ It did not ascertain whether they were veterans with other-than-honorable discharges or transitioning out of service, 2 cohorts that now qualify for VHA mental health care. It is known that the respondents’ average age was 54.3 years, an older population that in general is less prone to seek the care of a mental health provider (either in or outside the VHA) when needed.^12,13 It also is known that of all enrolled veterans, only a small section plan to forego VHA care, and they tend to be eligible for public insurance coverage (eg, Medicare, Medicaid, or TRICARE) and/or have private insurance coverage.¹⁴ Thus, establishing unrestrained Choice options may fail to capture most of those veterans such a plan purports to help.

Comprehensive Mental Health Care

Myth: The quality of mental health care provided to veterans in the community would be comparable with the quality of care they receive at the VHA.

FACT: The VHA expertise in treating veterans with posttraumatic stress disorder (PTSD) and depression is lacking in the community. More than 12,700 VHA mental health providers have received extensive training and supervision in the most effective evidence-based psychotherapies (EBPs). This includes more than 8,500 providers trained in prolonged exposure and/or cognitive processing therapy for PTSD and more than 2,200 providers in 1 of 3 EBPs for depression.¹⁵ Veterans who received EBPs in the VHA have experienced clinically meaningful and robust improvement in their PTSD and depressive symptoms.^16-22

By contrast, a RAND Corporation study of therapists who treat PTSD and major depressive disorder found that when compared with providers affiliated with the VHA or DoD, “a psychotherapist selected from the community is unlikely to have the skills necessary to deliver high-quality mental health care to service members or veterans with these conditions.”²³ Only 13% of community therapists were trained in and used an EBP and had veteran/military cultural competency. A separate 2017 study of community providers who treat veterans found that only a minority reported prior training in, or use of, any EBP for PTSD.²⁴ Also, as the industry leader in telemental health, the VHA’s delivery of EBPs to veterans in remote locations and/or having difficulty accessing clinic-based care is far beyond that of the private sector.

FACT: VHA patients are more likely to receive care consistent with the American Psychiatric Association (APA) guidelines than are patients treated in the community. Recent studies of pharmaceutical treatments for mental disorders have compared the VHA with the private sector. The studies found that for all 7 indicators, VHA performance was superior to that of the private sector by > 30%.^25,26 Another study found that 1% to 12% of private sector patients treated with antidepressants received care consistent with APA guidelines (with care of racial/ethnic minorities tending to be on the lower side of this range).²⁷ The VHA achieves higher quality because, as a unified, nationwide system, it has superior ability to assure providers’ adherence to assessment and treatment standards.

FACT: For older veterans who constitute the majority of veterans and the majority of veteran suicides, the VHA has more comprehensive and integrated mental health care services than are commonly found in community-based care.^1,4 The VHA provides comprehensive, integrated mental health evaluation and treatment services across the continuum of geriatric care, including geriatric primary care; home-based primary care; and nursing home, hospice, and palliative care.^28-30 For older adults, a population that is more prone to seek behavioral/mental health services if combined with their medical care, these integrated services optimize access to mental health care when needed and facilitate holistic, interdisciplinary care.^31-35 Although interest in integrated care is growing in the private sector, it is still not the norm.

VHA providers proactively screen veterans for PTSD, alcohol misuse, depression, military sexual trauma (MST), and traumatic brain injury. When problems are identified, primary care providers are able to deliver a warm handoff to mental health team members for further evaluation and intervention as needed. Such integration of services, required by VHA policy since 2008, appears related to increased detection and treatment of mental illness among older veterans.³⁶ Referred older veterans have shown significant reduction in depressive symptoms with antidepressant medication treatment.³⁷ Veterans with chronic obstructive pulmonary disease receiving brief cognitive behavioral psychotherapy in primary care clinics had decreased symptoms of depression and anxiety maintained at 12 months.³⁸

As the Commission on Care Final Report recognized, “Veterans who receive health care exclusively through VA generally receive well-coordinated care, yet care is often highly fragmented among those combining VHA care with care secured through private health plans, Medicare, and TRICARE. This fragmentation often results in lower quality, threatens patient safety, and shifts cost among payers.”³⁹

FACT: VHA’s comprehensive and integrated health care response to MST exceeds what is available in the community. When screened by a VHA provider, 1 in 4 women veterans and 1 in 100 men report that they experienced MST.⁴⁰ Because most veterans are men, they constitute almost 40% of all MST survivors seen in VHA. Military sexual trauma is associated with a wide range of mental and physical health conditions as well as lasting impairment in occupational and life functioning.^41-43 Those who experience MST have been shown to be at increased risk of death by suicide even when data were adjusted to account for age, mental health diagnosis, and other risk factors.⁴⁴

Given that many survivors never talk about their MST experience unless asked directly, the VHA’s routine screening, culturally competent sensitivity, and unflagging efforts to engage veterans are crucial ways to proactively reach survivors who might not otherwise seek care. Each VHA facility has a dedicated MST coordinator, mandatory MST training for all primary and mental health care providers, free MST-related treatment, and MST outreach efforts. All veterans enrolled in the VHA are screened for experiences of MST, and tailored treatment plans are created for survivors who need care. More than 1 million outpatient MST-related mental health visits were provided to veterans with a positive MST screen in fiscal year (FY) 2015, a 13% increase from the prior year.¹⁵ Widespread screening and treatment programs do not exist in the community-based care, where mental health care providers are less likely to have relevant experience or recognize that it is important to ask veterans about MST.

The DoD recently indicated that lesbian, gay bisexual, transgender (LGBT) service members experience disproportionately higher rates of MST, reporting sexual assault 5 times and harassment 3 times as often as non-LGBT service members.⁴⁵ Civilian research consistently identifies LGBT individuals as being at greater risk for suicide.⁴⁶ Although exact rates of LGBT veteran suicides are unknown, one study found that 47% of lesbian, gay, and bisexual veterans reported lifetime suicidal ideation compared with that of 22% of heterosexual veterans.⁴⁷ Each VHA facility has a dedicated LGBT care coordinator who works closely with the MST coordinator and mental health treatment teams to ensure timely referrals to appropriate care. Comparable care coordination does not exist in the community, where providers also are less likely to have relevant experience and training to address veteran-specific correlates of trauma for LGBT individuals.

FACT: Veterans with serious mental illness (SMI) who use the VHA have greater life expectancy and reduced inpatient days of care. Veterans with SMI conditions who receive VHA care live much longer on average than their counterparts in the general U.S. population.⁴⁸ Veterans with SMI who drop out of VHA care but then return have significantly lower rates of mortality than that of veterans who do not return.⁴⁹ Building on this success, the VHA implemented the SMI Re-Engage Program, an outreach to veterans with SMI who have not been seen in any VHA for at least 1 year, and are thus at an elevated risk for premature death. Since implementation began in March 2012, 24% returned to VHA care within 4 months.¹⁵

In the VHA’s Intensive Community Mental Health Recovery (ICMHR) program, mental health staff visit veterans with SMI at least weekly to provide recovery-oriented interventions, typically in the veteran’s place of residence, which ensures more routine follow-up and alleviates the burden of having to go to a medical facility. In fiscal year 2016, veterans enrolled in ICMHR services had an average of 12 to 27 fewer hospital days after admission to the program.¹⁵

FACT: The evidence-based interdisciplinary VHA approach to pain management rarely exists in the private sector. About 50% of veterans treated in primary care report at least 1 chronic pain complaint, disproportionately higher than that of American nonveterans.⁵⁰ Recent CDC and VA/DoD guidelines specifically recommend the use of cognitive behavioral psychotherapy, exercise therapy, and nonopioid medications as first-line treatments for chronic pain.⁵¹ Instead of routinely sending veterans with chronic pain to specialists, the VHA uses a stepped-care model in which patients receive biopsychosocial chronic pain care first within VHA primary care. These interdisciplinary clinics collocate and integrate primary care providers, psychologists, pharmacists and/or physical therapists to provide multimodal chronic pain care.

Preliminary results show decreases in pain, opioid risk, and opioid use as well as improved provider perception of pain care delivered in primary care.^52,53 For those veterans who require a higher level of care, the VHA has mandated the creation of tertiary pain programs, based on well-established models of more intensive, comprehensive treatment shown to be effective in the treatment of chronic pain.⁵⁴

Although interdisciplinary pain management continues to grow in the VHA, it very rare in the U.S. private sector where health care tends to be fragmented and truncated. The VHA accounts for 40% of the U.S. interdisciplinary pain programs even though it serves 8% of the adult population.⁵⁵ The importance of effective pain management, including behavioral interventions, is further highlighted by the fact that pain is the most commonly identified risk factor in VHA users whose suicides are reported to central office.⁵⁶