Mental Health Care Practice

Choice Program Expansion Jeopardizes High-Quality VHA Mental Health Services

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References

MYTH:Most veterans prefer a new care system that redirects funds from the VHA to VCP.

FACT: Veterans overwhelmingly want the VHA to be preserved and strengthened.57 Veterans like the VCP when it is presented as an add-on benefit. But when veterans are surveyed about possible changes like those in the proposals that drain money out of the VHA, they voice near unanimous opposition. The 2017 Veterans of Foreign Wars survey of 10,800 veterans found that 92% wanted the current VHA system to be improved, not dismantled. Only 5% wanted a new system of giving veterans free access to Choice care that bypasses the VHA.57

Anecdotal instances do arise where veterans express discontent about VA mental health services. That is no surprise in a large pool of millions of patients. One example was a 2016 VA Center for Innovation report, quoted during the October 2017 Congressional hearing, which asked about 40 veterans and 5 family members for their criticisms.58 Using an unrepresentative sampling method, the report found that some of the veterans desired more privacy and easier access to mental health care. The report also noted that the VA’s 300 Vet Centers and 80 mobile Vet Centers would provide such quick, confidential access, but many veterans did not know about that resource.

Conclusion

As VA Secretary David J. Shulkin, MD, has underscored, preventing suicide among all our nation’s veterans, is a sacred VA responsibility. The VHA must identify areas for improvement and mitigate obstacles that impede veterans receiving quality mental health care. When prompt access to VHA mental health care for enrolled veterans isn’t feasible, the VHA should continue to purchase services from VCP providers. For all veterans, their families, and non-VA professionals, the VHA should continue to share its educational and clinical expertise (as it has successfully done in efforts such as the Be There Campaign, VA Community Provider Toolkit, VA Campus Toolkit, PTSD Consultation Program and Suicide Risk Management Consultation Program.)

Nevertheless, in crafting policies, it is essential to ensure that there is no collateral damage to the overall superior quality, unique advantages, and cost-effectiveness of VHA mental health care. The guiding principle for all health care systems and providers, “first, do no harm,” must be heeded.

The VCP is intended to supplement not supplant the VHA, but the recent proposals would do the opposite. Furnishing vouchers to veterans that bypass VA preauthorization will weaken veterans’ mental health care and suicide prevention efforts. It sets in motion a gradual, persistent hollowing out of VHA care. In zero-sum budgets, VHA facilities will receive less money, vacant positions will not be filled, and mental health services will be cut. As the availability of VHA services diminishes, many veterans will be placed into VCP, leading to a vicious cycle of further VHA cuts. In the name of freedom of choice, veterans, especially the most vulnerable who depend on the VHA, will ultimately have fewer quality choices.

The stand-alone mental health clinic model runs completely counter to the VHA’s best practice interprofessional and integrated care approach. Veterans have more complex comorbidities and need greater, not less, integration of mental health services across the continuum, including primary care, specialty care, and geriatric/extended care programs.59

Implementing unrestrained choice, even as a pilot for newly transitioning service members or other groups of veterans, would be the initial step on a slippery slope to vouchers for the entire VHA system. Once mental health services are privatized, the remainder of VHA services, whose overall quality also has been determined to be equal or better than that delivered in the community, would follow in quick succession.11 In January 2018, the National Academies of Science, Engineering and Medicine published an exhaustive evaluation of VHA mental health care and hailed it as the preeminent system that is “positioned to inform and influence how mental health care services are provided more broadly in the United States.”60 It was decisive confirmation that, first and foremost, we must guarantee that VHA mental health care is fully funded and staffed and remains the coordinator and authorizer of care.

Acknowledgments
The considerations offered in this article are those of the author. The Association of VA Psychologist Leaders provided substantial help for the manuscript as well as for a prior white paper. Special thanks for factual assistance go to Heather Kelly, PhD, and the American Psychological Association; Suzanne Gordon; Ben Emmert-Aronson, PhD; Jennifer Boyd, PhD; Kaela Joseph, PhD; Tracey Smith, PhD; Jen Manuel, PhD; Brian Borsari, PhD; Jan Bowman, PhD; Gareth Loy, PhD; Karen Seal, MD; Ron Gironda, PhD; Sarah Palyo, PhD; Victoria Lemle Beckner, PhD, Joel Schmidt, PhD, Terri Huh, PhD, and Thomas Horvath, MD.

About this column
Mental Health Care Practice column is edited and occasionally authored by COL (Ret) Elspeth Ritchie, MD, MPH. Proposals for articles are encouraged and can be sent to elspethcameronritchie@gmail.com.

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