Seven years ago, Congress passed the VA MISSION Act with the explicit intention that veterans receive the highest-quality healthcare, whether from the Department of Veterans Affairs (VA) or the newly created Veterans Community Care Program (VCCP)—the option to see private providers outside the VA. The legislation’s emphasis on quality was unmistakable; the word appeared 50 times throughout the bill.

In particular, the 2018 legislation requires that VCCP mental health providers are trained in a manner comparable to the VA’s, particularly in clinical areas where the VA has “special expertise” (emphasis added). These specialized areas include, among others, post-traumatic stress disorder, military sexual trauma-related conditions, and traumatic brain injuries. Under this framework, VCCP providers are expected to complete mandatory training in scientifically recommended treatments before providing care to referred veterans.

But a harmful pattern of VA and congressional neglect has emerged, endangering veterans’ lives and threatening the quality that the MISSION Act aimed to protect.

A System Built to Fail

The authors of the MISSION Act understood that the training gap between VA and private sector mental health providers is wide. VCCP mental health providers generally have fewer years of graduate training than VA ones. Compared to the VA, VCCP providers are also far less likely than their VA counterparts to use—or even offer as an option—a scientifically supported psychotherapy for conditions like post-traumatic stress disorder (PTSD), depression, and other mental health conditions. A RAND Corporation study found that “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.” 

VA providers are required to conduct annual screenings for suicide, PTSD, substance use, military sexual trauma, and depression—mandated protocols that don’t exist in the privatized VCCP. Meanwhile, 57 percent of private mental health providers do not routinely screen for problems common among veterans, such as mental health and substance use issues or sleep-related problems.

To potentially help VCCP providers deliver better care, the VA developed eight comprehensive trainings that address veterans’ urgent mental health challenges—such as post-traumatic stress, suicide prevention, and opioid abuse—each about an hour long. The VA required its own providers to complete all modules, but VCCP’s private providers only need to take the opioid safety module. The remaining seven essential trainings were merely “recommended.” 

The Predictable Catastrophe

The VA’s decision to make critical trainings voluntary for VCCP providers has proven disastrous. A recent Government Accountability Office (GAO) report reveals that between 2021 and 2023, veterans received mental health referrals to 22,725 providers outside the VA. Of those clinicians, only 380—roughly 2 percent—completed a single training.

These failures are alarming, particularly when it comes to specific veteran subpopulations. During this period, more than 8,000 veterans flagged as active suicide risks were referred to providers who lacked any documented training in suicide prevention. While anxiety and stress-related disorders represented nearly half of patients’ diagnoses, barely any community providers had taken PTSD or military sexual trauma training.

Willful Blindness

Perhaps most troubling is that these lax standards for private providers didn’t happen in the dark. The GAO investigators discussed the training deficiencies with the VA, as the Office of Inspector General had previously. The VA said it prioritized “network adequacy”—having enough providers—over enforcing training standards. In other words, a glut of untrained providers is preferable to a smaller pool of well-trained ones. This aligns with Congress’s decade-long push—and this administration’s goal—to further privatize veterans’ mental (and physical) healthcare.

The problem is getting worse. Last week, the House Committee on Veterans’ Affairs (HVAC) advanced the Veterans’ ACCESS Act, allowing veterans to access mental health care in the community “without pre-authorization or referral.” While that may sound like it eases some bureaucratic roadblock, this legislation opens the gates to private-sector mental health clinicians who are undertrained to treat veterans.

Meanwhile, the No Wrong Door for Veterans Act, which the House Committee on Veterans’ Affairs just passed, and the nearly identical HOPE for Heroes Act, which passed the Senate Committee on Veterans’ Affairs, would also increase referrals to non-VA mental health providers. These bills similarly include no training mandates.

A Clear Path Forward

The training standards that govern VA mental health providers should apply to their private sector counterparts. Several key reforms can make it a reality.

First, enforce uniform training standards. All eight core training modules should be mandatory for any provider treating veterans in the VA or community settings. This is a low bar, but better than none.

Second, toughen accountability. Third-party administrators overseeing the VCCP should suspend private providers who fail to meet standards, without exception.

Third, demand transparency. The VA’s Provider Profile Management System (which functions as the main database of community providers used by VA medical center staff to schedule referrals) should display training records and be accessible to both veterans and the public. 

A Moral Reckoning

Representative. Sheila Cherfilus-McCormick, a Florida Democrat, introduced a bill during the HVAC hearing on the ACCESS Act in July, requiring community mental health providers treating veterans to meet the same rigorous training standards as VA clinicians. Committee Republicans immediately voted it down, yet the need only grew stronger this week when the VA announced that veterans are now allowed 52 weeks of mental health services in the VCCP before having to obtain VA reauthorization.

Congress and the VA can no longer ignore care quality—enforceable training requirements must be part of community care legislation. Anything less breaks the sacred trust between our nation and those who defend it.

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For four decades, the Office of Inspector General at the Department of Veterans Affairs has played an indispensable watchdog role, helping to ensure that veterans receive high-quality healthcare. Its investigators have repeatedly identified deficiencies in VA patient care and recommended corrections. The Inspector General’s office’s diligence is one reason that the quality of VA’s healthcare consistently outperforms the private sector’s.  

However, the Inspector General’s office does not scrutinize private providers with whom the VA contracts nearly as rigorously as it does VA facilities. The gap is highly consequential because private sector providers now deliver over a third of all healthcare services for the nation’s nine million enrolled veterans. Few other transformations in public healthcare delivery have been so speedy with such little oversight.  

The VA MISSION Act of 2018 established the Veterans Community Care Program to furnish more private services to veterans. The Inspector General’s office recognized that this expansion necessitated enhanced evaluation and boosted its personnel. In April 2022, it began issuing reports as part of its “Care in the Community” oversight program. And yet, in the following 12 months, only three private sector reports were completed versus 73 inspections of VA in-house care.  

The community reviews were not only few in number but narrow in scope, focusing on important but ultimately discrete topics of the adequacy of home dialysis services and whether mammography results were promptly delivered to their referring VA doctors. By contrast, last year, the Inspector General’s office investigated VA services related to many more matters, including broad and worrisome trends among veterans—suicide attempts, violent behavior, prostate cancer, hypertension, alcohol use, congestive heart failure, pain management, and other health conditions. 

At U.S. House and Senate hearings in June, Julie Kroviak, a top official with the Office of Inspector General, underscored that, when it comes to care in the private sector, there is “no reasonable assurance that veterans are getting the care they need.” She added, “I can’t tell you what type of quality of care is happening outside of the VA… concerns about the caliber, the credentialling, the experience of the providers…is definitely warranted.”  

More inquiry is forthcoming, vowed Kroviak, saying her office was in the “final stages of developing a Community of Care cyclical review.” Unstated was what will be the scope or scale of these reviews.  

There are ample opportunities—and indeed a great need—for the Inspector General’s office to probe Veterans Community Care Program services more extensively. For instance, third-party administrators who manage the private care program must forward all veterans’ complaints and grievances to the VA within two days of receipt. Those materials are available to the Inspector General’s office and are ripe for inspection and dissemination to advocates, lawmakers, and the public. 

In addition to privatizing many VA services, the MISSION Act directed the VA to establish training standards for private healthcare providers who treat conditions found among veterans, such as post-traumatic stress disorder, sexual trauma, and traumatic brain injury. The VA created tailored training and gave the contracted clinician discretion on whether to take them. Since training records of all providers are supplied to the VA, the Office of Inspector General (and the VA) could determine how many providers have taken them. Then, we’d know whether the contracted professionals are prepared to treat veterans’ complex and unique healthcare conditions as we do for VA providers. 

The same question applies to veterans who suffer from toxic exposures. Following recent legislation, the Office of the Inspector General should discover how many private sector providers have comprehensive toxic exposure training. 

Similarly, VA providers must perform annual suicide risk screening on veterans. We have no idea how many private healthcare providers, if any, adhere to the same regimen as the VA itself. The Office of Inspector General ought to investigate.  

The quality of private healthcare should be audited as vigorously as VA facilities. If more money and personnel are necessary, Congress should find the funds. When the House and Senate invite personnel from the Inspector General’s office to testify about the VA’s healthcare, it should always demand answers about the VA’s contracted private healthcare services. Veterans’ lives depend on it. 

The post The VA’s Inspector General Must Do More appeared first on Washington Monthly.

In 2019, with the number of U.S. veterans dying by suicide surpassing 6,000 for the 11^th consecutive year, Congress searched for fresh ideas to address the crisis. Representatives Jack Bergman, a Michigan Republican, and Chrissy Houlahan, a Pennsylvania Democrat, both veterans, crafted a new bill to help. The IMPROVE Act offered grants for community organizations to identify veterans at risk of suicide and deliver prevention services to them and their families. 

Arkansas Republican John Boozman, a senior member of the Senate Committee on Veterans’ Affairs, recognized the potential and took up the cause. An optometrist and son of an Air Force Master Sergeant, Boozman co-sponsored the legislation. “This approach is key to empowering organizations to work together in the fight against veteran suicide,” he said. 

The bill became law as the Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program in honor of a U.S. Army Infantry School sniper instructor who died of suicide at 25. Over three years, it allocated $174 million to non-profit, private, and government groups ranging from veterans associations to social service agencies to tribal nations. Interventions addressing veteran suicide included peer support, assistance navigating the maze of public benefits, and even equine-assisted therapy.  

Boozman, along with Bergman and Houlahan, wisely understood that comprehensive data would be needed to pinpoint which endeavors worked to save the lives of service members. He hailed the Fox Grant Program for establishing “a common tool to measure the effectiveness of our programs and promote better information sharing, data collection, and continual feedback in order to identify what services are having the most impact.”  

Organizations receiving Fox Grants were required to obtain and convey data so that their efforts could be evaluated. The law also stipulated that the Department of Veterans Affairs (VA) provide congressional committees with annual reports on the effectiveness of the grants and that an independent third party conduct a study of the program.  

It was an encouraging concept, except for one significant oversight: The law didn’t provide for the calculation and dissemination of grantee-specific data about their impact. Most of that information was rolled up into aggregate numbers for the whole program, which was a huge problem. There was no way to determine whether a particular organization’s services were effective. 

Thankfully, there’s now a perfect opportunity to fix that gap so that essential data about community prevention efforts is made widely and readily available. Jon Tester, the Montana Democrat who chairs the Senate Committee on Veterans’ Affairs along with Boozman, recently introduced the Not Just a Number Act, which would expand a key VA document, the National Veteran Suicide Prevention Annual Report, to correlate veterans’ suicides with the utilization of VA health care and benefits, such as the GI Bill, job training programs, and disability compensation. It mandates that these findings be shared with the public.  

Both Tester and Boozman recognize that publicizing and utilizing data are pivotal to forming policy that affects veteran suicides. Tester said, “when it comes to preventing veteran suicide, we’ve got to be looking at all the data we have on hand to see what’s working and what’s not.”  Boozman agreed: “Coordinating with successful veteran-serving organizations, (the Act) continues our commitment to modernize how we reach and serve veterans who struggle to get the mental health care and support they need. This legislation will help us make better data-driven policy decisions.”  

But the Not Just a Number Act needs one good tweak. Though the law makes the VA disclose its important suicide data, the measure doesn’t tap data generated by recipients of the Fox Grants—a trove of invaluable information that could help policymakers, veterans, social scientists, public health officials, and others drive down the still distressing number of veteran suicides. A simple amendment to the bill would make it fulfill its authors’ noble intentions.  

Each Fox Grant organization already administers five well-validated measures to veterans at the beginning and end of services. Those instruments examine suicidal ideation, mood-related symptoms, mental well-being, socioeconomic status, and social support. The data is transmitted to the VA.  

An amendment to the Not Just a Number Act should require the VA to crunch those pre-post figures, itemize them for each grantee, and place them in the public domain. Results should include items such as whether and how much scores on the five measures improve for veterans who complete the grantee’s services.  

Disabled American Veterans National Legislative Director Joy Ilem concurred: “Establishing open access to suicide-related data from veteran-serving organizations that receive VA funds promotes transparency and informs researchers and providers about the most effective suicide prevention interventions.” 

Revising the Not Just a Number Act would help fulfill the promise of the Fox Grant program to show what works when it comes to preventing veteran suicide by making the best data readily available. It would hold the recipients of Fox Grants to the high standards that apply to the VA. It would fulfill Senators Tester and Boozman’s vision and ultimately help save veterans’ lives. 

The post Preventing Veteran Suicides Through Better Data appeared first on Washington Monthly.

Most Americans probably aren’t aware that the Department of Veterans Affairs (VA) healthcare system, along with the National Institutes of Health (NIH), is the best and biggest medical research powerhouse in the United States. Millions of veterans have benefited from VA research breakthroughs, including pioneering treatments for PTSD, Agent Orange, and prosthetics.

But it’s not just veterans who benefit. All Americans have profited from VA advances, such as the shingles vaccine, the implantable cardiac pacemaker, and the nicotine patch. The VA is on the frontlines of investigations on the risks of long COVID and studying why prostate cancer is so lethal for Black men. 

Quite distressingly, this peerless research system is now under threat. In a November hearing before the Senate Veterans Affairs Committee, the VA’s Under Secretary for Health, Shereef Elnahal, warned of catastrophic consequences should the Senate fail to follow the lead of the House and pass the VA Infrastructure Powers Exceptional Research (VIPER) Act. This legislation reverses a misguided Department of Justice (DOJ) ruling prohibiting VA employees from being paid by academic affiliates for joint research initiatives. Elnahal explained that without VIPER, “major clinical trials answering key questions across all of American medicine” will be at risk.

For decades, the VA has partnered with 90 percent of the nation’s academic medical centers like Boston University, Dartmouth, Yale, and many others. Through these partnerships, VA researchers who devoted up to 40 hours a week doing research, teaching students, and caring for veterans, could secure supplemental funds to investigate everything from the impacts of burn pits to potential cures for Alzheimer’s disease. Although the VA has its own stream of research funding, these academic partners are the conduits for researchers to receive money from non-VA sources like the Department of Defense (DOD), the Centers for Disease Control and Prevention (CDC), the NIH, as well as numerous private foundations like the Prostate Cancer Foundation. These partnerships are critical because federal law prohibits the VA from administering such funds. The funding also supplements VA salaries which are not competitive with those in the private sector. It enables the VA to attract and retain top scientists who devote their careers to the care of the nation’s veterans.

The DOJ ruling that caused the current predicament was issued in 2021. It reinterpreted federal law governing the payment of federal employees conducting research at the VA in partnership with the private sector medical centers. This applies to many of the VA’s key academic partners, such as Columbia, Baylor, Stanford, and Harvard, among many others. For 75 years, VA researchers were permitted – even encouraged – to receive part of their funding from private-sector academic medical centers. Suddenly, the DOJ decided those supplemental payments were illegal. A peculiar double standard was applied to partnerships with public universities like the University of California at San Francisco, which were deemed permissible.

Some researchers could lose a third of their income and face criminal prosecution. After attending a recent meeting of VA trauma researchers, a former VA official said that many clinicians are “heading for the hills.”

The VIPER Act will keep them from fleeing, and that’s why it passed the House with overwhelming bipartisan support.  But time is the enemy in the slower-moving Senate as the last days of this congress tick away.

Critical research hangs in the balance. As the VA’s 2024 budget request states unequivocally, the VA’s most important studies and initiatives involve “large multi-center clinical trials and epidemiological studies,” which depend on collaboration between private and public academic medical centers.

Consider, for example, the VA COVID-19 Observational Research Collaboratory (CORC) – a multi-site project that includes public and private universities. The collaborative has a database of 250,000 veterans infected with COVID-19. VA researchers recently released two studies detailing the severe consequences of long COVID.

Another area that could be impacted is prostate cancer research. In 2016, the Prostate Cancer Research Foundation gave the VA a $50 million grant hailed as a “unique public-private biomedical research partnership.” Why? Because the VA, over time, has millions of patients who have prostate cancer, and their data goes back decades. As the CEO and president of the foundation said at the time, the VA can help clarify “why, of 287 different kinds of cancer, even with identical care, prostate cancer is more aggressive and lethal in African-American men.” [MC4] Since 2016, VA has worked with researchers at various public and private universities to answer other critical questions about prostate cancer.

If not immediately reversed, the DOJ rule will also have catastrophic effects on brain research that depends on the VA’s Biorepository Brain Bank.  This partnership with Boston University has the world’s most extensive brain tissue collection. The seven-component VA-BU brain banks focus on ailments including PTSD, CTE, and ALS.  In 2018, Time magazine named its director, Ann McKee, one of the 50 most influential people in health care.  Her research on the brains of veterans and football players has helped establish a link between multiple concussions and the development of CTE. McKee and her colleagues may have to curtail their vital work if the DOJ action is not reversed. PTSD research being conducted by the VA’s National Centers for PTSD in collaboration with Boston University and Dartmouth will also be impacted. 

Again, these VA researchers’ knowledge and innovations don’t just help veterans. They’ve helped first responders suffering from PTSD following the 9/11 attacks and many other emergencies. To get to the president’s desk before the end of the year, Senators must attach VIPER to must-pass legislation such as the National Defense Authorization Act or the Omnibus Appropriations bill. If VIPER passes this year, the VA’s pivotal role in the American research enterprise will survive intact.  If not, a letter supporting VIPER addressed this week to the Senate by the American Psychological Association and the Association of American Medical Colleges and signed by more than 86 primary medical schools, veterans service organizations, and medical foundations and associations warned “thousands of research projects focused on improving veterans’ health led by VA scientists” will be disrupted.

The post The Race to Save Medical Research appeared first on Washington Monthly.

On March 14, Department of Veterans Affairs Secretary Denis McDonough is expected to release a long-awaited list of VA facilities and services that may be shuttered in the coming years. McDonough’s potential hit list is required by one of the most problematic sections of the VA MISSION Act of 2018, legislation that vastly expanded the outsourcing of veteran care to private-sector providers. The law mandated the creation of the Asset and Infrastructure Review (AIR) Commission, which would consider which of the VA’s health care facilities to close, improve, repurpose, or consolidate. The secretary’s list will include not only entire medical centers but also inpatient units, emergency rooms, and outpatient clinics. Critics of the AIR process worry that commission members (who have yet to be announced) will ignore a wealth of studies demonstrating that the VA delivers better outcomes at a lower cost than the private sector. They worry, too, that the VA will close facilities and programs instead of improving infrastructure, hiring needed staff, and even expanding utilization.

If there was any doubt that the VA delivers higher-quality care at a lower cost than the private sector, that concern should definitively be put to rest by a new study in the British Medical Journal, one of the most prestigious scientific journals in the world. 

The study’s lead author is David C. Chan, professor of health policy at Stanford University and an investigator at the VA. Chan’s coauthors include four economists and researchers connected with Stanford University, the University of California at Berkeley, and Carnegie Mellon. Unlike many previous studies that contrasted the experiences of veterans cared for at VA facilities with non-veterans treated in the private sector, this study compared the outcomes of 583,248 veterans over the age of 65 who were enrolled in the VA health system and also covered under Medicare. When these veterans called an ambulance for a health emergency, they were randomly taken to either a VA or private-sector hospital. 

The differences were startling. Veterans treated at VA facilities were 20 percent less likely to die the following year than veterans taken to a private-sector hospital. Every one of the 140 VA hospitals in the study outperformed their private-sector counterparts. What the authors dubbed the VA’s “mortality advantage” was even greater for veterans who were African American or Hispanic. This advantage lasted months after the patients left the ER. Not only was private-sector hospital care less effective, its price tag was 21 percent higher than care at the VA.

In the typically understated fashion of medical journals, the authors advised that the “nature of this mortality advantage warrants further investigation, as does its generalizability to other types of patients and care. Nonetheless, the finding is relevant to assessments of the merit of policies that encourage private healthcare alternatives for veterans.” In other words: Stop privatizing the VA. 

It’s finally time to acknowledge what Phillip Longman of the Washington Monthly and the Open Markets Institute argued 20 years ago: The VA health care system offers the Best Care Anywhere and should serve as a model for all of us. 

The VA delivers such high-quality care, Chan and his colleagues explain, for several reasons. It has a fully unified electronic medical record, and care is fully coordinated and directed by effective primary care teams. 

Rebecca Shunk, a primary care physician at the San Francisco VA Healthcare System, explains what this kind of care coordination looks like in an emergency. “When one of my patients shows up in the emergency room,” she notes, “our primary care patient aligned care team (PACT)—which includes a primary care physician or nurse practitioner plus a registered nurse, licensed practical nurse, and medical support assistant—is immediately alerted.”

Shunk elaborates:

Shunk adds that the primary care team can quickly organize an appointment with a specialist like a cardiologist or a pulmonologist.

Studies show that this kind of coordination leads to the VA’s better outcomes. It’s not routine in the private sector. “In fact,” Shunk laments, “it’s hard to even get a patient’s record from a private-sector provider.”

Chan and his coauthors speculate that the VA mortality advantage may also stem from the follow-up care being determined by the patient’s need, not the private-sector provider generating revenue in a fee-for-service system. As the authors explain, VA staff members are salaried and have no incentive to overtreat. Outside of the VA, one in seven health care dollars is spent on unnecessary, sometimes toxic, and often futile treatment. 

In another paper published shortly after the BMJ article was published, Chan and two of his coauthors dug even deeper into the data about ER experiences at the VA and the private sector. Their analysis provides further insights into why private-sector care is more expensive and sometimes more dangerous. After an ER visit, private-sector providers are more apt to transfer patients to inpatient rather than outpatient care and keep them in the hospital longer: “Services with high reimbursement (under fee-for-service arrangements) are more likely to be performed in non-VA hospitals,” the authors note. 

As the VA Office of Inspector General has reported, thousands of private-sector providers under the MISSION Act’s Community Care Network have engaged in the notorious practice of “upcoding” when they bill the VA for services. To generate more revenue, they may bill for complex evaluation and management services they have not performed. The same seems to be true when billing during and following an emergency. As the authors write, “the odds of reporting high- vs. low-complexity services are more than five times higher in private hospitals vs. the VA.” 

The VA, on the other hand, increases the delivery of less remunerative outpatient and rehabilitation services. The authors add that the kind of rigorous telephone follow-up Shunk describes above “are only reported at the VA.”

The authors conclude, 

Tragically, documents leaked to the Washington Monthly indicate that the VA secretary has ignored long-standing evidence of the VA’s cost and quality advantage and recommends closing inpatient units and even some emergency departments across the country. Since a hospital can’t have an emergency room without an inpatient unit, this would mean shuttering even more ERs than any slated for closure. With the VA secretary and his consultants—many of them holdovers from the Trump administration—seemingly determined to ignore the scientific evidence, we hope that Congress and the AIR Commission will reject the recommendations. Because the coronavirus pandemic has led to dangerous hospital closures and understaffing in the non-VA health care system, it’s more important than ever to not just preserve existing VA capacity but possibly to even expand it.

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