Choice Program Expansion Jeopardizes High-Quality VHA Mental Health Services

Last summer, the Department of Veteran Affairs (VA) published the most comprehensive analysis of veteran suicide in our nation’s history. That study examined 55 million records from every state and revealed that in 2014, an average of 20 veterans died by suicide each day.¹ Six of the 20 were recent users of Veterans Health Administration (VHA) services; the other 14 had not used VHA services in the prior 2 years.

Policy makers are currently deliberating whether expanding the Veterans Choice Program (VCP) is a judicious way to prevent these tragic deaths, especially for veterans who do not use the VHA. One proposal, presented at a congressional committee hearing in October 2017, advocates expanding the VCP.² Its core tenet—allowing veterans to seek mental health care from VCP providers without needing VHA preauthorization—is similar to provisions in other subsequent VCP bills regarding Access to Walk-In Carefor episodic physical and mental health care.³

The original Veterans Choice Act of 2014 was enacted with $10 billion supplemental funding for the VCP as well as $5 billion to augment VHA staffing. In contrast, these recent proposals include no supplemental allocations. Veterans could bypass VHA approval, obtain VCP services on their own; the VHA would be sent the bill and payment would be taken from the VHA facility’s budgets.

The set of proposals serves as a reminder of the need for further reflection and discussion about how the nation can best address the crisis of veteran suicide and, more broadly, how to optimize access to evidence-based, integrated mental health care services.

This article critiques the myths underlying the proposals’ rationale, gives factual evidence on veterans’ suicide prevention and comprehensive mental health care issues, and concludes with a cautionary warning about the risk of VCP expansion adversely impacting veterans.

Preventing Veteran Suicides

MYTH: Shifting funds from the VHA to mental health care providers in the community would be a more effective suicide prevention strategy.

FACT: The VA is better than the community in addressing veterans’ suicides. Between 2001 and 2014, age-adjusted rates of suicide for veterans not using the VHA increased by 38%; for veterans using the VHA, the age-adjusted rate increased by 5%. For the subgroup of VHA patients with either a mental health or substance use diagnosis, the rate decreased by 25%.¹ These comparative achievements occurred even though veterans who use the VHA are twice as likely to have a mental health condition when compared with veterans who do not use VHA services.⁴

FACT: The VHA’s approach to preventing suicides is far more comprehensive than that found in the community. Each of the 170 VA medical centers has at least 1 dedicated suicide prevention coordinator (SPC) position. The SPCs provide enhanced care coordination for veterans in VHA health care who are identified as high risk for suicide. The SPCs collaborate with the VHA’s integrated network of care providers and community partners to reduce suicide risk among vulnerable veterans

For veterans in VHA care who are at risk for suicide, mental health policies include regular screening, follow-ups to missed appointments, and safety planning. For high-risk veterans, suicide prevention policies also involve a medical record flagging and monitoring system with mandatory mental health appointments.

The 2010 National Strategy for Suicide Prevention report extolled VHA’s multiple levels of evidenced-based suicide prevention practices and recommended that other health care systems emulate the practices.⁵ Despite this, few community health care providers or systems have adopted a similar approach. As the Congressional Research Service observed in 2016, “Outside the VA, the use of suicide prevention coordinators has not been widely adopted.”⁶

FACT: The VHA’s innovative use of suicide predictive analytics to recognize at-risk individuals is more advanced than those available in the community. VHA has implemented a predictive analytics program that identifies veterans at risk for suicide and offers enhanced care to these veterans. The model uses clinical and administrative data to identify VHA-enrolled patients who are at the very highest risk of suicide, with a 30-fold increased risk of death by suicide within a month.⁷ The system notifies each veteran’s provider of the risk assessment and enables those providers to reevaluate and enhance these veterans’ care. Some of these ultra-high-risk veterans might not have been identified as being at risk based only on clinical signs. This is a crucial distinction because many veterans who die by suicide do not have a history of suicide attempt or recently documented suicidal ideation.^8-11 This cutting-edge, big-data approach allows the VHA to reach out and assist vulnerable veterans, before a crisis occurs.

FACT: The VHA can better coordinate the care of veterans who call the Veterans Crisis Line (VCL) when they are receiving care in the VHA rather than in the community.

Since its launch a decade ago, the 24-hour VCL has answered > 3 million calls from veterans and their family/friends, with > 500,000 follow-up referrals to local VA SPCs. Because the VCL links directly to VHA facilities, care coordination is more effective when a veteran’s provider is in the VHA. When the veteran is not a VHA patient, coordinating with his/her community provider is laden with logistic impediments.