Thank you for the opportunity to submit a statement for the record on the Department of Veterans Affairs’ (VA) mental health staffing, quality and quantity; a topic critical to the thousands of Veterans and their families facing serious mental health issues. As mental health issues among our nation’s Veterans and service members continue to dominate the headlines, VA faces the challenge of meeting this growing demand for quality mental health care and services.
Humana Veterans Healthcare Services, Inc. (Humana Veterans), a part of the Humana Government organization, has answered the call and is helping VA to meet the mental health needs of our Veterans when the Department is unable to provide the care at a VA facility. Through contracts with VA, Humana Veterans provides access to quality non-VA healthcare through two congressionally-mandated pilot programs -- Project HERO (Healthcare Effectiveness through Resource Optimization) and Project ARCH (Access Received Closer to Home).
Last month, Secretary Shinseki announced VA’s intent to hire 1,600 mental health clinicians and 300 support staff. As the Committee examines the proper staffing levels of mental health providers at VA, we urge the Committee to consider the existing contractual resources such as Project HERO and ARCH, which are already available to Veterans and can quickly be mobilized to help meet their mental health needs. An understanding of all resources available to VA, including underutilized non-VA and VA resources, will help this Committee and VA to make informed decisions on the proper mental health staffing levels at the Department.
Mental Healthcare Quality and Staffing
The quality of mental health providers certainly has a direct impact on Veterans’ health outcomes. The mental health providers in Humana’s network are fully credentialed and qualified to deliver a very high level of care. When examining staffing quality and health outcomes, care coordination is a critical element that should not be overlooked. With Project HERO contract scheduled to end on September 30, 2012, VA is planning a follow-on national program referred to as Patient Centered Community Care (PCCC). Because mental health is among the planned services excluded from PCCC, this program will not result in Veterans receiving patient-centric coordinated mental health care. Exclusion of key services such as mental health goes against the very concept of care coordination, and makes it impossible for Veterans to fully realize the benefits of care coordination. Also, VA’s decision to exclude mental health from PCC is misguided, especially when research clearly shows that physical issues often accompany mental conditions. For example, Post Traumatic Stress Disorder (PTSD) is a mental health condition that often coexists with Traumatic Brain Injury (TBI), which is a physical condition. Last month the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a report that stated the following:
Research has found a strong relationship between physical and mental health. People with mental health illnesses are more likely to have co-occurring physical health conditions, resulting in higher healthcare costs and disability.Co-occurrence of mental and physical health problems can increase healthcare utilization and complicate treatment plans.
The lack of care coordination is further exacerbated by VA’s apparent decision to remove the administrative functions from PCCC that are associated with non-VA care authorizations, visits and treatment. VA is in the process of implementing a national program called NVCC (Non-VA Care Coordination), which requires the Department to invest significant resources, both in staff and necessary tools, to build in-house capacity to handle the “back door” administrative functions. For example, this includes helping Veterans make and keep medical appointments, ensuring the return of clinical information, and making timely payments to non-VA providers. Humana Veterans is in the business of providing cost-effective administrative services and has developed an excellent personalized service model in Project HERO, which produces excellent results through metrics reported every month to VA. VA apparently intends to attempt to duplicate a large portion of the model internally. VA intends to build internal functions that insurers and health plans have as a core capability. VA should do what it does best (i.e., providing excellent healthcare) and contract with commercial companies for required administrative services, which is what they do well. VA’s proposed course moves them closer to becoming more like a payor/insurance system similar to TRICARE and Medicare. Further, VA must recognize that an unintended consequence of removing contractor-provided administrative services from the proposed PCCC program threatens the contractor’s ability to maintain a provider network that is responsive to VA’s changing needs. It also means that VA will not be able to obtain advantageous pricing, since the contractor cannot negotiate a better price with their network providers in the absence of a predictable minimum workload and without the ability to guarantee a low no-show rate, and timely, predictable payments.
VA cannot ensure that Veterans receive high quality care if they move forward with the current plans for PCCC, which excludes mental health and other key administrative and care coordination functions. Instead, Veterans will receive only fragmented care that is neither effective, efficient nor timely, which is in effect the current Fee system.
Long-Term Effects of Combat
Combat and exposure to combat condition, especially wounded, dead and dying individuals, profoundly affects a service member’s future mental health status. A recently released research paper by the Syracuse University Institute for Veterans and MilitaryFamilies includes the following findings:
Veterans exposed to combat experience the lingering mental health effects of that trauma for decades after combat exposure; for many, the effects are permanent. This research shows that the effects of combat exposure are more pronounced for those whose service includes more traumatic events, such as exposure to dead, dying, or wounded people. Knowing this, our society can better predict the outcomes that these veterans will experience over time and the VA can better target resources and predict long-term resource demand.
Based on our Gulf War parameters, we estimate that the costs of mental health declines to be between $87 and $318 per year for each soldier with combat service and exposure to dead, dying, and wounded people.
Non-VA Mental Health Services Available
Humana serves Veterans in VISNs 8, 16, 20, and 23 through Project HERO, and provides care to Veterans living in four out of the five pilot sites for Project ARCH which includes Farmville, VA; Pratt, KS; Flagstaff, AZ; and Billings MT. For both of these pilot programs, Humana provides access to a competitively priced network of physicians, institutions, and ancillary providers to supplement the VA healthcare system while adhering to high quality and access to care standards. Currently, we have the authority to provide mental healthcare to Veterans living in any of the VISNs participating in HERO, but our authority to provide such care is limited to Pratt, KS under Project ARCH. Our robust network of mental health providers is comprised of 4,539 for HERO and 7 for the ARCH site at Pratt, KS. The geographic distribution of these providers is such that Veterans can easily access them by traveling an average of 14 miles for their care. VA’s utilization of these two programs for mental health referrals has been low. For example, since Project HERO’s inception in October 2007, we have received a total of 1,096 mental health referrals through 30 April 2012. We began implementing Project ARCH in Pratt, KS on 28 August 2011 and to date, have received zero mental health referrals.
There is abundant research that point to the mental health staffing shortage in our healthcare system. Thus, VA will likely face recruitment and retention challenges for the newly announced 1,600 mental health providers. There is certain to be delays in identifying qualified providers, and even when VA is able to do so, the bureaucracy of the Federal personnel system will further delay the on-boarding of the new hires. This could mean years before all 1,600 providers are deployed in the VA healthcare system and available to treat Veterans. VA should assess existing resources that can be deployed quickly. This includes an assessment of the existing contracts that VA has in place with community partners such as Projects HERO and ARCH, and tapping these underutilized resources to provide timely mental healthcare for Veterans. VA can also re-examine the pilot program’s eligibility criteria and the definition for the pilot sites, especially with ARCH, which Congress intended to be a VISN-wide program. In addition, VA should examine its current mental health workforce to determine ways to best maximize the productivity and efficiency of the staff, which requires proper metrics and incentives.
An informed decision on the proper staffing levels is only possible if VA identifies and maximizes underutilized non-VA and VA resources. Humana has a proven service model and stands ready to assist VA in delivering to Veterans quality mental health services in a timely manner. Humana Veterans has existing capacity to handle additional mental health referrals under Projects ARCH and HERO and is committed to further expanding our network, if needed, to properly accommodate the referrals from VA.
VA must not miss an opportunity to implement real care coordination of mental health and other services.
Improving the mental health and well-being of our Veterans is certainly a daunting task; however, our society cannot and must not fail the men and women who bravely served this Nation. No single entity has the capacity to fully address the mental health needs of our Veterans. This is a national problem and a local community problem. VA cannot do this alone just as the communities across the nation cannot do it alone. Instead, it will require collaborative partnerships and care coordination among all mental health assets. VA can begin by assessing the partnerships it has in place under existing contracts and programs such as HERO and ARCH. In addition, PCCC is an opportunity for the VA to mobilize networks of mental health providers in the communities where Veterans live. Rather than excluding mental health and other services inherent in a care coordination program from proposed PCCC model, VA should rethink their approach and infuse strong care coordination elements into the program design to include medical surgical, laboratory, mental health, and health & wellness elements. We look forward to continuing and enhancing our collaboration with VA to bring excellent mental health services to our Nation’s heroes.
Thank you, Mr. Chairman, for the opportunity to submit this statement for the record.
Tim S. McClain
TimS. McClain was appointed President, Humana Government and Other Business in February 2012 and has responsibility for business and administrative services contracts with the federal government. Previously, Tim was President and CEO of Humana Veterans Healthcare Services. He is a recognized expert in Veterans healthcare law and policy.
Mr. McClain has over thirty-five years ofexperience in executive leadership and management positions. He served as General Counsel for the U.S. Department of Veterans Affairs (VA) from2001-2006, a Senate-confirmed Presidential appointment position, serving two Cabinet secretaries and managing an office comprised of nearly 400 attorneys.
In 2005, Mr. McClain served concurrently as General Counsel and as Chief Management Officer for VA, with overall responsibilityfor the Cabinet department’s budget formulation and execution, procurementpolicy, acquisitions management, and business process oversight.
He is a graduate of the U.S. NavalAcademy, Annapolis, Maryland, and California Western School of Law, SanDiego, California. He is aretired Naval officer, having served as a Surface Warfare Officer and in the Navy’s Judge Advocate General’s (JAG) Corps.
Humana Veterans Healthcare Services, Inc., a subsidiary of Humana Military Healthcare Services, Inc. and part of the Humana Government and Other Business organization, is currently providing administrative services to the Department of Veterans Affairs under the following contracts:
Project HERO (Healthcare Effectiveness through Resource Optimization), originally awarded in 2007 and currently in the fourth and final option year. Humana Veterans provides administrative healthcare services to Veterans referred outside of the VA healthcare system for specialty care.
Project ARCH (Access Received Closer to Home), was awarded in 2011. Services under the contract began on August 29, 2011, and include administrative healthcare services to Veterans who meet certain eligibility criteria and agree to participate in the program.
 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), National Survey on Drug Use and Health. “Physical Health Conditions Among Adults with Mental Illlness,” April 5, 2012.
 “Combat Exposure and Mental Health: the Long-Term Effects Among Vietnam and Gulf War Veterans,” Daniel M. Gade, Ph.D. and Jeffrey B. Wenger, Ph.D. Institute for Veterans and Military Families, Research Brief, released May 4, 2012.