DoD/VA Challenges and Exciting Opportunities: Although I am no longer on the U.S. Senate staff, it is intriguing to reflect upon how psychology and the other health professions are viewed on Capitol Hill. During her recent Senate testimony, the U.S. Army Surgeon General Patricia Horoho pointed out: "There are significant health related consequences of over ten years of war, including behavioral health needs, post-traumatic stress, burn or disfiguring injuries, chronic pain or loss of limb…. A decade of war in Afghanistan and Iraq has led to tremendous advances in the knowledge and care of combat-related physical and psychological problems. Ongoing research has guided health policy, and multiple programs have been implemented in theatre and post-deployment to enhance resiliency, address combat operational stress reactions and behavioral health concerns…. For those who do suffer from PTSD, Army Medicine has made significant gains in the treatment and management of PTSD as well. The DoD and VA jointly developed the three evidenced based Clinical Practice Guidelines for the treatment of PTSD, on which nearly 2,000 behavioral health providers have received training…. (Our) researchers develop strategies and advise policy makers to enhance and sustain mental fitness throughout a service member's career. Psychological health problems are the second leading cause of evacuation during prolonged or repeated deployments. (DoD) psychological health and resilience research focuses on prevention, treatment, and recovery of Soldiers and Families behavioral health problems, which are critical to force health and readiness. Current psychological health research topic areas include behavioral health, resiliency building, substance use and related problems, and risk-taking behaviors." Her considerable sensitivity to the critical importance of the behavioral sciences, including the psychosocial-cultural-economic gradient of care, undoubtedly reflects the fact that she is the first female and first non-physician Surgeon General in the history of the U.S. Army.
In considering the Fiscal Year 2013 funding for the Department of Veterans Affairs (VA), the Senate Appropriations Committee voted 30-0 to recommend a $135.6 billion budget. As of last Fall there were an estimated 22.2 million living veterans and their 34 million dependents (spouses and dependent children). The VA Health Administration (VHA) operates a national healthcare delivery system consisting of 153 hospitals, 1,102 outpatient clinics and Vet Centers, 133 nursing homes, and 107 VA residential rehabilitation treatment programs. VHA is the largest federal medical care delivery system in the nation. The unemployment rate of male veterans between ages 18-24 is 29%; almost double that of their civilian peers with over 847,000 unemployed veterans. A tragedy which strongly suggests that psychology has much to contribute.
The underlying vision for President Obama's Patient Protection and Affordable Care Act (P.L. 111-148) is the importance of providing high quality primary care through an interdisciplinary team approach, emphasizing integrated care. It is anticipated that the various health care professions will ultimately learn to work collaboratively, in a cost-effective manner. The Accountable Care Organization (ACO) and Medical Home provisions of the law are clear examples. For many of psychology's practitioners this approach represents a fundamental change in their role and clinical orientation. It will also require our educational systems to significantly modify their programs and expectations. In many ways, over the years, VHA has championed this approach. Accordingly, the Senate Appropriations Committee's expressed Interests/Concerns should be of considerable interest to those contemplating the future.
* Licensing Requirements at DoD/VA Collocated Facilities: In fiscal year 2012, the Committee directed the Department of Veterans Affairs and the Department of Defense to examine ways in which duplicative licensing requirements at collocated medical facilities might be eliminated. The findings of this examination were required to be reported to the Committees on Appropriations of both Houses of Congress. The Committee reiterates the expectation and importance that the VA submit this report. Upon receipt of the report, the Department is directed to provide regular reports on progress made in implementing any recommendations to streamline duplicative licensing requirements. An astute colleague working for VHA feels that the more DoD/VA operates like a business, the better off we will be. Very few in either Department understand "cash flow" or have ever had to live month to month, week to week, and day to day having to make a payroll. Those who have only worked in the public sector think they understand the "business model," but they have never had to make payroll. Payroll is always assured and never something they have to concern themselves with. The bottom line: They care deeply about patients and each other, but they never really worry if an action they take or don't take might influence whether they will or won't get their next pay check. Thus, they are comfortable allowing themselves the luxury of not doing what would be most cost-effective in the long run, especially if that would require fundamental change. For example, embracing prescriptive authority for well trained non-physicians and eliminating bureaucratic hassles such as duplicative credentialing.
* VA Nursing Academy: The Committee commends the VA for addressing the nursing shortage through the VeteransAffairs Nursing Academy. This pilot program established partnerships with competitively selected nursing schools to expand the number of teaching faculty in VA facilities and affiliated nursing schools in order to increase student enrollment in baccalaureate nursing programs. The Committee notes the VA's realization of a net-positive value for the pilot overall and urges VA to continue its collaboration with the Department of Defense through the Uniformed Services University of the Health Sciences by providing nurse faculty and nursing students in the graduate nursing education programs through the external evaluation period. Advanced Nursing Education: The Committee urges the VA, in conjunction with accredited schools of nursing, to explore the development of a fast-track doctoral training program which would facilitate completion of a doctorate in nursing by qualified nurses employed within the VA network who possess a bachelor of science in nursing. Nursing Research Program: The Committee supports the Veterans Affairs Nursing Research Program, which facilitates research on the specific nursing needs of combat veterans and aging veterans. The Committee strongly supports continuation of this program. The Committee also encourages collaboration between VA nurses and recipients of Tri-Service Nursing Research Program awards in the exploration of research proposals that improve the health and well-being of their shared beneficiary population.
* Rural America: The Committee recognizes that the demand for VA services in rural areas will only increase and believes that the VA must do more to plan for and provide quality healthcare to veterans living in rural and highly rural areas. Travel barriers, including long distances to VA medical facilities and lack of public transportation, make it difficult for the VA to serve rural veterans. Also, lack of specialized care in rural areas, including mental healthcare, make it difficult for veterans to obtain quality care at home. The VA is working to address these problems through a number of initiatives, including expanding the use and variety of telemedicine techniques, such as video consultations with practitioners, telephone healthcare monitoring and management, and audio-visual telemedicine diagnostic techniques. The Committee encourages the VA to pursue leading-edge telemedicine technology and innovative rural health demonstration projects, and to incorporate promising advances into its rural health delivery system. The Committee recognizes the ongoing challenges to recruit and retain highly qualified healthcare professionals, particularly mental health professionals, in rural areas. Staffing shortages ultimately lead to higher out-of-pocket costs for veterans as well as decreased quality of care. The Committee directs VHA to more thoroughly and aggressively evaluate and deploy innovative approaches to recruiting and retaining quality physicians, surgeons, mental health professionals, and other healthcare professionals in rural areas. These potential approaches should include additional flexibility for rural facilities to enhance salary offers and to offer contract incentives to qualified applicants. VA should investigate using innovative ways to rotate practitioners through rural areas, such as medical "circuit riders," fully staffed mobile clinics, and cooperative ventures using community hospitals or clinics as platforms for providing VA healthcare services.
* Mental Health: Access to VA's mental health services is imperative given the number of Iraq and Afghanistan war veterans suffering from combat related mental health problems. The Committee remains very concerned about the ability of veterans suffering from combat related mental health conditions to access clinical care in a timely manner. The Inspector General review found that first-time patients have not uniformly been provided timely mental health evaluations and existing patients often must wait beyond the desired date for appointments. The Department recently announced that it would add an additional 1,600 mental health clinicians and 300 support staff as part of an ongoing review of mental health operations. The Committee supports this effort.
There is clear Congressional recognition of the importance of providing high quality mental health and behavioral health care for DoD and VA beneficiaries. There is demonstrable interest in developing highly innovative approaches for delivering care, especially in remote and rural areas. We would ask: Whether the Congress or the Administration understands how psychology might meaningfully contribute to the underlying mission of DoD and the VA?
The Patient-Centered Outcomes Research Institute (PCORI): The Patient Protection and Affordable Care Act also established PCORI to conduct or commission research to provide information about the best available evidence to help patients and their health care providers make more informed decisions. The intent is to give patients a better understanding of the prevention, treatment, and care options available, and the science that supports them. The Institute Mission Statement: "PCORI helps people make informed health care decisions, and improves health care delivery and outcomes, by producing and promoting high integrity, evidence-based information that comes from research guided by patients, caregivers and the broader health care community." It is an independent, non-profit organization governed by a 21-member Board of Governors. During his APA Presidency, James Bray testified before the Institute of Medicine as to the importance of Comparative Clinical Effectiveness Research and psychology's potential contributions. "Comparative effectiveness research is a critically important tool for advancing an evidence-based approach to health care decision-making. However, the full public health benefits of such research will only be realized if behavioral, psychosocial, and medical interventions for the prevention and treatment of mental and physical health conditions are evaluated individually and in combination. Even when strictly medical treatments are compared, it is important to expand the range of outcome measures to include behavioral and psychological outcomes, such as quality of life and adherence to treatment protocols." In its initial research effort, PCORI proposed $120 million for these types of initiatives. This Summer, $96 million will be made available for those engaged in patient-centered outcomes research. PCORI maintains a broad scope of interest, rather than addressing specific disorders or conditions. The underlying research agenda contemplates five broad areas: Assessment of prevention, diagnosis, and treatment options; Improving healthcare systems; Communication and dissemination research; Addressing disparities; and, Accelerating patient-centered outcomes research and methodological research. Aloha,
Pat DeLeon, former APA President – Division 42 – June, 2012
