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Proposal: Expand Mental Health Care Services for Veterans

Millions of the nation's 22 million veterans suffer from mental health issues, ranging from post-traumatic stress disorder (PTSD) to the cognitive effects of traumatic brain injury to mental health issues associated with the transition from military to civilian life. Although the Department of Veterans Affairs (VA) spends approximately $7 billion a year to meet the health needs of veterans, these resources do not fully meet the needs of veterans seeking mental health care. Read on for recommendations for how to expand mental health care for veterans. 

The Issue

Problem Defined

Millions of the nation’s 22 million veterans suffer from mental health issues, ranging from post-traumatic stress disorder (PTSD) to the cognitive effects of traumatic brain injury (TBI) to mental health issues associated with the transition from military to civilian life. The Department of Veteran Affairs (VA) will spend nearly $7 billion this year to meet this need. However, these resources do not fully meet the needs of veterans seeking mental health care across the nation.

Background
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1.
1. The demand for additional mental health care resources for veterans is clear

The VA spent $6.6 billion on mental health in FY2014 and plans to spend $7.1 billion – about 12% of its entire $59 billion health care budget for the year – on mental health in FY2015. These expenditures make VA the largest provider for mental health care and research in the nation, as well as the most significant investor in mental health research.

Unfortunately, the VA has struggled to meet the demand for veterans’ mental health care. The VA has begun addressing the shortfall by hiring more clinicians, using contractors and other means. However, clinical appointment wait times remain long, and these approaches are not yet fully meeting demand, let alone building capacity to meet projected future demands. 

2.
2. Veterans’ mental health care needs rise over time

Veterans’ mental health care needs have risen sharply over time. Peak expenditures occur 10 to 20 years after the end of war. This was true for the Vietnam War cohort and will likely be true for the post-9/11 combat cohort as well. Now is the time for the VA to act decisively to meet these generations’ needs – while it has ample resources to do so, before the demand for mental health service among post-9/11 veterans spikes. 

3.
3. The benefits of early treatment are life-saving

Twenty-two veterans die by suicide each day. Data suggests that VA Mental Health outreach and care reduces suicide. Experts note that timely, early mental health care intervention services can improve veterans’ quality of life, address substance-use problems, prevent chronic illness, promote recovery, and minimize the long-term disabling effects of undetected and untreated mental health problems. 

4.
4. Investing solely into the current model will be ineffective in meeting increasing demand

There are three main ways to increase capacity within the VA health care system: 

  1. Hire more clinicians
  2. Expand utilization of existing facilities (by increasing hours, or deploying new delivery models or care approaches)
  3. Open new facilities

The current model allows the VA to expand its capacity within existing budgetary, human capital and facility structures. However, it offers limited scalability because of the finite capacity of internal VA systems, difficulties in hiring clinicians, practical limits on facility capacity, and the high cost and obstacles associated with opening and closing facilities to meet changing demand.

5.
5. The VA already has success with other models for expanding capacity on a local level

The VA currently surges its capacity by contracting with private firms to add clinical and support staff. These personnel work for their respective private firms, drawing pay and benefit from those companies. However, they integrate fully into the VA workforce, working for VA supervisory personnel (for purposes of providing mental health care) inside VA facilities. This approach addresses a significant shortfall in the VA’s existing business model: its ability to rapidly scale and adapt its workforce to meet changes in demand. It does this by leveraging a private sector workforce outside of the VA’s existing human capital systems. Unfortunately, most of this type of capacity generation is done at a very local level. There is no national effort to reap economies of scale from this type of scheme. 

Another model involves using private firms to build, operate and manage projects, clinics, or whole divisions of operations. The VA has not fully embraced this model, in part because of concerns that it might replace its “brick and mortar” facilities with non-VA providers and networks, reducing the overall national commitment to care for veterans.

Go deeper
2.
PASSING THE BATON: A Bipartisan 2016 Agenda for the Veteran and Military Community

Phillip Carter, Dr. Jason Dempsey, Katherine Kidder, and Amy Schafer - Center for a New American Security (2015)

http://www.cnas.org/sites/default/files/publications-pdf/CNASReport_PassingtheBaton_151104_final.pdf

The Papers for the Next President series explore the most critical regions and topics that the next president will need to address early in his or her tenure and will include actionable recommendations designed to be implemented during the first few months of 2017.

4.
Invisible Wounds of War

Terri Tanielian and Lisa H. Jaycox - Rand Center for Military Health Policy Research (2008)

http://www.rand.org/content/dam/rand/pubs/monographs/2008/RAND_MG720.pdf

A study on the post-deployment health-related needs associated with PTSD, major depression, and traumatic brain injury among OEF/OIF veterans, the health care system in place to meet those needs, gaps in the care system, and the costs associated with these conditions and with providing quality health care to those in need. 

Expert Authors

The mission of the CENTER FOR A NEW AMERICAN SECURITY (CNAS) is to develop strong, pragmatic and principled national security and defense policies. Building on the expertise and experience of its staff and advisors, CNAS engages policymakers, experts and the public with innovative, fact-based research, ideas and analysis to shape and elevate the national security debate. A key part of our mission is to inform and prepare the national security leaders of today and tomorrow.

Tseren Zurganov
Junior Policy Analyst - Chisel by More Perfect Union

Tseren recently graduated from Hofstra University with a dual-major in Economics and Philosophy and a minor in Philosophy of Law. He was born in Kalmykia, Russia and raised in New Jersey and is passionate about public policy.

The Solution

Proposed Recommendations
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1.
1. Embrace a portfolio approach

The VA should develop a portfolio approach that invests in various models, some of which have already been put into practice on local stages, investing most heavily in those approaches which have the potential for scalability, replicability and quality care. Over time, the VA should reinforce its successful programs, eliminate unsuccessful efforts and change its infrastructure to reflect the lessons learned through this evaluation. The key to success will be a rigorous monitoring and evaluation regime that assesses each VA program on efficiency, efficacy and programmatic metrics.

2.
2. Develop and share data regarding veterans’ mental health care

Both Veterans and Veteran-serving organizations in the private and nonprofit sector struggle to make smart, timely decisions in the absence of data. The VA should make available data on the utilization of its mental health care resources, including wait time data for specific facilities. This data should be made available in usable form for veterans, such as through geospatial information displays or through application interfaces like the VA’s PTSD application for smartphones. Such data would better enable VA personnel to coordinate and allocate resources, facilitate the allocation of resources within the private sector that also serves veterans, and improve decision-making by veterans based on the availability of mental health care.

As part of its efforts to generate more mental health care capacity, and use a portfolio approach to do so, the VA must also develop a comprehensive information environment that enables VA providers and partners in other sectors to communicate and share information. Such a system will improve care for veterans by providing better continuity across the range of public, private and philanthropic providers and also will give the VA better data regarding the population with which to allocate resources and make decisions about future agency operations.

3.
3. Develop and leverage community coordination strategies

If the VA is to partner more meaningfully and effectively with the private and philanthropic sectors, it must embrace a broader vision of its partnership, where the VA is an equal partner with these other sectors. The VA strategy should include a multicomponent structure for engagement with non-VA actors, including policies that foster such partnership, and rules within VA’s ethical and acquisition regulations that allow such partnerships to occur. The VA must also develop a governance and coordination structure, possibly by creating additional federal advisory committees, or local advisory committees in its health care regions or near its major medical centers. And the VA should invest in these community partnerships, using VA capital to fund the “best practice” organizations that are serving veterans in the philanthropic and private sectors, and arguably doing so as well as (or better than) the VA.

4.
4. Build a human capital pipeline

Current efforts to add clinical staff at the VA have been hindered by a national shortage of qualified, available mental health care personnel. The VA should address this by expanding its partnerships with academic medical programs to include additional programs that develop mental health care personnel. This expansion should build on the VA’s extensive program for clinical internships. The human capital pipeline should also leverage existing relationships between the VA and programs producing clinical social workers and psychologists with specializations in military social work or related disciplines, such as those at the University of Southern California and University of South Carolina. The VA should invest in these programs, expand them, and seek to replicate them, particularly where they can help produce additional clinical personnel to serve underserved populations (such as in rural areas). The VA should also look for opportunities to integrate veterans into its human capital pipeline, ranging from work in Vet Centers and outpatient clinics to service in VA medical centers. In furtherance of this goal, the VA should study the feasibility of a national scholarship, apprenticeship or training program (possibly tied to existing VA educational benefits) that would generate its own pipeline of veterans with the training and desire to provide mental health care services to fellow veterans in VA facilities.

5.
5. Invest in emerging technologies

Emerging technologies hold enormous promise for the VA and its efforts to provide mental healthcare services to veterans. Telemedicine holds promise for expanding VA care in underserved communities and for serving the digital natives of the millennial generation. Certain fitness monitoring and communications technologies can also expand the net of mental health care (such as the "FitBit," which monitors physical activity, sleep, weight and other behaviors, and software solutions such as the PTSD Coach, developed by the VA and fielded to more than 100,000 smartphone users.) Virtual reality technology can be used for both the training of clinical personnel and the treatment of veterans. 

Expected Results
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1.
1. Earlier and higher quality treatment

Because the current model (VA care with mostly VA personnel) offers limited scalability, a portfolio approach with staff augmentation, contracted networks, and local and private partnerships allows the VA to surge its capacity in meeting demand from veterans  for mental health care. This means that veterans can have their needs met in a timelier manner. Early treatment is paramount in preventing suicides.

With a “Human Capital Pipeline”, the VA will have a better trained and more experienced network of workers that can provide higher quality mental health care for patients. This addresses the national shortage of qualified, available mental health care personnel. 

2.
2. Higher enrollment rates

With further investments into telemedicine, VA care can be expanded into underserved communities (such as rural areas) and veterans from the millennial generation who are accustomed to online communication (such as Skype). Stronger cooperation with the private sector, where more veterans seek their care, can also be used to strengthen veteran care.

3.
3. Higher retention rates

The VA struggles to retain veterans once they make it through the doors, with retention rates for veterans in many treatment programs often falling bellow 50%. Timelier and higher quality treatment, in addition to easier access, can increase the retention rates for veterans enrolled in treatment programs. 

Budget
Budget Impact
Net Present Value

The Conversation

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