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A Conversation on VA with Dr. Harold Kudler

VHPI recently had the opportunity to correspond with Harold Kudler, M.D., one of the nation’s most experienced physicians who has dedicated his career to treating and serving veterans.

Dr. Kudler’s comments are particularly relevant as Congress considers legislation that would increase the number veterans with mental health problems who would seek care from private sector providers.

Please note that these are Dr. Kudler’s personal opinions and not those of VA or Duke University.

In considering how best to improve access to mental health care for veterans, I’d like to call attention to a 2023 peer-reviewed article on access to psychiatric care in the community, which also includes an excellent set of references to past studies. This body of research clearly demonstrates the incredible difficulty which all Americans face in getting an appointment with a psychiatrist in the community - even if those doctors were publicly listed as part of a well-established, well-respected healthcare system in a city with one of the nation’s largest per capita distributions of psychiatrists. To summarize their findings, 97% of secret shopper calls seeking an appointment with a psychiatrist failed to obtain one and only half of those calls were ever returned! We’re left to wonder how long patients would have had to wait for those appointments.

Among the references in this article is a 2015 report in the respected journal, Psychiatric Services. This study was done at the same time as the VA Choice Act was being developed and reflects community capacity across three American cities. Its key findings were that, when secret shoppers attempted to reach 360 community psychiatrists, they were only able to get through to 33% of them on their first attempt. Of 216 unanswered calls, only 36% were ever returned. After two calling rounds, appointments were successfully made with only 93 psychiatrists (just 26% of all the psychiatrists contacted). Community capacity is clearly insufficient to meet the mental health needs of Americans (a fact well documented in the federal Health Services and Resources Administration’s reports on Mental Health Professional Shortage Areas). Sending up to nine million VHA-enrolled veterans into this system- up to one third of whom currently seek at least one mental health service every year- would be a disaster.

Taken together, these two articles (and the studies they reference) make it clear that the community lacks capacity to provide psychiatric services to veterans even if VA approved their care in the community. The problem is many times greater in rural America. This matters because veterans are twice as likely to live in rural areas as the average American.

VA wait times for mental health are variable across the nation but note what Carrie Farmer of RAND reported in her 2022 testimony to the Senate Committee on Veterans Affairs (SVAC). For individual mental health care, the average wait time for a new patient appointment at a local VA medical center was 34 days, but there was no wait for an appointment at a local VA community-based outpatient clinic. Dr. Farmer and her RAND team found that wait times for VA-delivered mental health care are shorter than for non-VA care in the private sector (Mean Wait Times for VA mental health care were 35 days vs. a 40 day wait time in the community). Of special importance, her testimony raises the essential question of quality of care received once a veteran is seen in the community.

There are already serious problems with fragmentation of care within the VA Community Care Network owing to lack of interoperable medical records, lack of co-located collaborative primary and mental health care systems outside of VA, lack of standardized assessments for PTSD, Traumatic Brain Injury (TBI), depression, and suicide risk (let along a standing suicide prevention system including facility-based Suicide Prevention Coordinators such as exists in VA). These problems represent a serious health risk for veterans and would be multiplied many times if pending legislation were to be enacted.

As RAND’s studies, Ready to Serve and Ready Or Not, document, community health providers and systems of care lack military/veteran clinical and cultural competence required to treat the unique medical and psychosocial needs of veterans. Further, community providers and administrators are almost always unaware of the huge range of benefits and services available to veterans through VA such as homelessness services, rehabilitation and residential care, sophisticated diagnostic testing and treatment for TBI, evidence-based treatments by certified clinicians for PTSD and Depression, advanced prosthetics (which are largely unavailable to the general population), occupational therapy and vocation rehabilitation services to name just a few). Veterans who are sent to the community to care are likely to lose access to these and many other programs which Congress and VA have spent a century developing to better serve veterans and their families.

VA plays a fundamental role in educating our nation’s healthcare workforce (for example, 70% of all American physicians receive training through VA and similar findings apply for psychologists, social workers, nurses, respiratory technicians, and for trainees in 60 other health disciplines and VA is virtually the only program that focuses research on the special health concerns of veterans.)

VA’s medical research program began at the end of World War II and has also led to tremendous gains in healthcare for all Americans. For example, by 1945 American military hospitals were flooded with veterans paralyzed by spinal cord injury but the U.S. health care system was unprepared for addressing these injuries or the wide-ranging complications associated with them. Spinal cord injury was often a death sentence. Congress acted to revitalize VA by funding its new research system. This enabled VA researchers to transform neurological rehabilitation. VA continues to lead in this area to the benefit of veterans and people everywhere.

Finally, under the National Disaster Medical System (NDMS), VA supports the Department of Defense in times of war and the Department of Homeland Security in the event of regional or national disaster. If the VHA budget is diverted to community care, VA facilities will predictably be closed and there is virtually no back up plan for maintaining the nation’s readiness for war or disaster.

All this is being traded off for the dubious gain of decreasing the average number of days until the next available appointment (a race which VA is already winning in the first place).

In terms of constructive action that can be taken, my personal opinion is that key priority is to perform a comprehensive assessment of VA’s Community Care Network and then make significant improvements so that community referrals are made in the best interests of the veteran by measurably improving their health outcomes and satisfaction with care (rather than by meeting arbitrary requirements for wait times). This will require significant investment in VA Central Office and across the entire VA system to enhance staffing and improve operations (as per the recent GAO report- fourth attachment) but those investments would be dwarfed by savings realized in improving the indiscriminate referral system currently in effect.

The real gain would be for veterans who would finally receive the range and quality of care which they deserve.

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