Analysis: The Consequences of Improve Well-Being for Veterans Act
Released November 9, 2019
Outside Clinical Care in the Improve Well-Being for Veterans Act
The Improve Well-Being for Veterans Act (H.R. 3495, S. 1906) contains language that allows the provision of clinical care to veterans and their families through non-VA providers outside the Community Care Network (CCN). That includes direct mental health treatment, individual therapy, group therapy, family counseling, medication management and substance use reduction programming.
Under existing MISSION Act directives, non-VA mental health providers may join the CCN. Since the CCN is already a pathway for providers to deliver mental health care in the community to at-risk veterans, what would be the potential impact of creating another outside system for these providers?
The following analysis describes four deleterious consequences:
It duplicates and erodes the clinical mental health care offered by VHA and CCN.
Improve Well-Being Act’s direct mental health treatment, individual therapy, group therapy, family counseling, medication management and substance use reduction programming duplicate the clinical mental health services widely offered by VHA and CCN.
Care is targeted in the same geographic locations as VA facilities. The bill has no requirement that entities focus efforts in locations away from existing VA facilities where care is scarce or nonexistent. On the contrary, providers can be located close to VA Medical Centers, VA Community Based Outpatient Clinics, Vet Centers and CCN providers.
Rendering care outside the VHA/CCN system would fracture mental health efforts into multiple, disjointed programs, splinter resources and impede care coordination – the very opposite of effective veteran suicide prevention and something at which the VHA demonstrably excels.
For veterans who distrust the government or are reluctant to seek mental health help at a VHA facility, there are over 300 Vet Centers and 80 mobile Vet Centers available throughout the country.
It lowers the bar. VHA mental health and suicide prevention care is more effective, more evidence-based and has higher standards than is community providers’ care.
There is no requirement that grantee entities be held to comparable (or any) standards of mental health or suicide prevention training, provider qualification and documented best practices to which VHA holds itself.
The bill does not require entities to render services in a timely manner which is mandated in the VHA, especially critical for responding to at-risk populations.
There is no requirement that the entities track and report on suicide attempts of veterans who receive their services, as is mandated in the VHA.
Non-VA entities are not capable of using VHA’s big-data predictive analytics REACH VET to prospectively identify individuals who are at the very highest risk of suicide.
VHA’s superior care that was documented in the recent Veteran Suicide Prevention Annual Report1 is copied in Appendix A. (See the PDF for more information)
It would undermine VA’s model of providing health care.
Private sector clinical care in this bill would not require VHA pre-authorization. That’s a model that begins to replace VHA as a health care provider system to become an insurance provider.
With no parameters for co-payment responsibility, clinical care is permitted to be provided for free. While that’s laudable, it competes with and subverts the basic VA system for veterans’ priority group eligibility.
The level of accountability would be weakened in a system that is beyond VHA’s direct involvement.
It preempts the PREVENTS Task Force recommendations.
The White House/VA PREVENTS Task Force (Executive Order 13861) Roadmap will be issued in four months. This comprehensive task force Roadmap, developed by scores of experts, will include interventions for veterans who do not use VHA, encompassing universal (entire population), selective (increased risk sub-populations) and indicated (highest risk individuals) strategies. Hurrying the Improve Well-Being for Veterans Act ahead of PREVENTS recommendations could preemptively hinder their effectiveness.
Chart: Asserted & Actual Effects of IMPROVE
It is imperative to remain vigilant about with the welfare of veterans, and preventing their suicide is unquestionably a necessary priority. But as this chart illustrates, almost every element and rationale of the bill won’t do what it claims. Here are the shortcomings, and what an alternative effective veterans’ suicide prevention bill could include.
Analysis: IMPROVE Well-Being for Veterans Act
Released on August 29, 2019
S. 1906 Improve Well-Being for Veterans Act, and its companion H.R. 3495, is a bill intended to provide pilot funds to non-VA entities to offer suicide prevention services to veterans who either never use the VA for healthcare or live in geographic areas where the risk of suicide is high. However, at its core, it would duplicate and erode VA’s existing successful mental health services, ignore what interventions are most needed to reduce veteran suicide, and hasten outsourcing of veterans’ health care to the private sector.
1. Foremost, the bill is based on the false premise that non-VA mental health care entities are what’s missing to reach veterans who do not seek VA mental health care or live in areas where suicide rates are highest.
Veterans who do not seek VA mental health care were studied extensively last year in the National Academies of Sciences, Engineering and Medicine Evaluation of the Department of Veterans Affairs Mental Health Services.1 It found the main reasons that veterans do not seek VA care are that they do not know how to apply for VA benefits, are unsure whether they are eligible, are unaware that the VA offers mental health care or do not perceive a personal need for mental health services whether within or outside of the VA. The National Academies offered excellent recommendations for reaching this subset of veterans (see recommendations section below).
Regarding the 20 veterans who die by suicide daily, much is known about the 6 who used VA recently for health care. However, very little is understood about the remaining 14. It is not known whether they are already receiving mental health care in the community, lack knowledge about VA eligibility, or would refuse care in the community or VA even if offered. Community mental health entities awarded grants in this bill would not reach veterans in any of these scenarios.
2. Relatedly, the bill ignores VA’s growing telemental health capacity to reach vulnerable veterans, especially those who reside in rural areas where veteran suicide rates are highest.
VA’s evidence-based telemental health is the industry leader, and soon will be able to access nearly every veteran with mental health and suicide prevention services. It is closing the gaps in rural America, where mental health resources are sparse.
VA’s telemental health will also facilitate younger veterans obtaining services from the VA, given that younger veterans tend to be amenable to receiving mental health care using technology.
VA’s telemental health also resolves the impediments to in-person appointments for veterans with chronic health conditions, work/family schedule conflicts or discomfort with the pressures of a large institution.
3. For decades, the VA has used grants in special circumstances when outside entities could effectively augment services the VA could not provide itself. This bill, for the most part, duplicates and potentially supplants the critical function of the VA’s Office of Mental Health and Suicide Prevention to address veterans’ mental health needs.
The grantee entities are permitted to set up programs in the same locales where VA medical centers or CBOCs exist.
The mental health services offered by grantee entities are all provided by VA medical centers and CBOCs. (See Appendix A below for the list of grantee mental health services identified in the bill that duplicate the VA’s.)
One component of the bill provides up to 6 months of financial assistance and housing, vocational, childcare, legal, employment and rehabilitation counseling services for homeless veterans. That aspect does augment the VA and is to be commended and supported.
4. The National Strategy for Preventing Veteran Suicide 2018-20282 promotes expanded community partnerships, with VA as the hub of its efforts. VA is capable of coordinating, training and monitoring outside entities, and this organizing role is key to the appropriate and necessary organizing structure. However, the bill empowers outside entities to be the coordinator of suicide prevention services to veterans in many communities. VA is simply to be identified as “the payor” of such services. Fracturing VA efforts into multiple, disjointed programs dilutes the overall endeavor, splinters resources, and impedes care coordination – the very opposite of effective veteran suicide prevention and something at which the VA demonstrably excels.
Further, sending veterans to the community for suicide prevention eliminates the ability to use VA’s predictive analytics “REACH VET” for at-risk individuals who are at the very highest risk of suicide – those who have a 30-fold increased risk of death by suicide within a month. This cutting-edge, big-data approach allows the VA to identify veterans at risk for suicide and offer them enhanced care before a crisis occurs. The system notifies each veteran’s provider of the risk assessment and enables providers to reevaluate and enhance these veterans’ care. Some of these ultra-high-risk veterans might not have been identified based only on clinical signs. This is a crucial distinction because many veterans who die by suicide do not have a history of suicide attempts or recently-documented suicidal ideation.
5. There is no expectation that outside entities would be held to the high standards (or actually any standards) of training, provider qualification and documented best practices for mental health care to which VA holds itself.
American Psychological Association email@example.com
Association of VA Psychologist Leaders firstname.lastname@example.org
Association of VA Social Workers email@example.com
Nurses Organization of Veterans Affairs firstname.lastname@example.org
Veterans Healthcare Policy Institute email@example.com