The proposed shift of billions of dollars to private health-care providers by the Veterans administration is controversial, but opens up opportunities for improvement. The advocates for contracting out services compare the proposal to TRICARE, the Department of Defense (DoD) program.
The TRICARE system came into effect many years ago with the drawdown of the military after the First Gulf War.
TRICARE also served as a safety net to the families when the active military were deployed. In general, DoD beneficiaries express satisfaction with TRICARE particularly as access to military hospitals and clinics has been constrained with deployment of medical personnel to Iraq and Afghanistan.
VA MISSION Act of 2018 gives the VA Secretary the authority to set access standards that can help with general medical services by reimbursing private insurers and providers more easily.
Paying out money to private insurers and providers is a first step, but not nearly sufficient to fix the problems that veterans have encountered. Simply transferring the money doesn't guarantee that veterans are going to get what they need and deserve. Some estimates are that it could add costs up to a $100 billion a year.
The axion applies — all health care is local. In fact, the VA is not “one system” but a vast and complex set of systems glued together in Washington. The breadth and depth of patients treated at VA hospitals and clinics across the country are broader and more complex than any other health-care system.
Over the years, the VA population has presented historic challenges: they are poorer than average, have a high incidence of alcohol, drug abuse, and post-traumatic stress disorders, are distressingly disadvantaged and are often unemployed or homeless. Veterans tend not to seek medical care early and they often present with late-stage or incurable disease.
Veterans have unique needs for quality mental health care and long-term services. The reluctance to seek care has been a particular problem for managing the high numbers of suicides (6000 per year): PTSD, other mental health problems, as well as the adverse consequences of Agent Orange and other wartime exposures.
Seventeen years of fighting in Iraq and Afghanistan have generated unique conditions of mild traumatic brain, co-morbid mental illnesses, and orthopedic injuries including amputations. Few, if any, private or academic centers in the country offer the extensive neuropsychiatric and long-term care that veterans need on a broad scale.
Furthermore, taking into account that many veterans live in outlying and rural areas, the option for getting the needed help is slim at best. Those of us on the ground floor for planning and implementing the TRICARE program in the 1990s learned valuable lessons that could help shape a better VA.
Simply put — it's not about if you contract out or buy services, but how you do it. We have learned that shifting health care to private providers insurers doesn't improve treatment in critical areas like mental health. In fact, mental health services in rural and outlying areas is undoubtedly deficient as the horrendous opioid epidemic has shown us.
The treatments for serious mental illnesses including substance abuse have not improved over the past years even with the implementation of parity laws that support comparable payments to mental health providers. For many reasons, both clinicians and insurers have shied away from treating serious mental illnesses that require intense resources and effort.
That is the dilemma — as the problems afflicting veterans fall into the bucket of serious illnesses that require progressive and coordinated care that is rarely available. Responsibility and burden for setting up the right treatment programs for veterans can only rest with the VA leadership. The military learned many years ago that no private or academic health-care system could substitute for what military medicine uniquely provides. The military is not just a job, it's a profession with a special culture and community that has been best helped by its medical system uniquely configured to support it.
The veterans who served in the military share the legacy of the military culture and community, and so deserve medical care that is customized for them. The Mission Act gives the VA Secretary the opportunity to uniquely redesign the VA to serve the needs and objectives of those special beneficiaries. Only the VA can set up treatment programs to manage the complicated and special needs of its patients.
That is because the effectiveness of the treatment goes beyond the specialties involved and requires innovative and dynamic leadership and coordination. In setting up TRICARE, we learned that we succeeded when we identified and empowered leadership to have optimal flexibility and tools for configuring a local health-care delivery system. We could buy or contract health care from the private sector, but would specifically arrange for those services to align with the military missions and quality of life.
In the same way, the VA has a responsibility to provide care to its veterans in support of their broader goals and quality of life, not just treating illnesses or diseases. Young veterans have a long life ahead of them and deserve to feel that they can be as productive and gratified in their personal lives and work as possible.
The VA doesn't have to provide all the health care directly, but needs to redesign itself to better accomplish its mission and goals. As such, simply buying services or contracting them out could jumpstart changes, but only if the leadership commits to transformation. The VA requires bold and innovative initiatives that empower local leadership and hold it accountable.
In addition to buying or contracting out care, it must implement major programs for setting up integrated and coordinated care, outreach to rural and outlying areas, proactively engaging neglected veterans, and creatively deploying technology. Contracting out the VA to private insurers and providers can succeed with organizational and operational changes that optimize and leverage the opportunities.
Stephen N. Xenakis M.D. is a child and adolescent psychiatrist and a retired Army brigadier general.