VHA Caregivers Provide Privatization Reality Check

Surveys show that veterans are not getting better or more timely care from the private sector.

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When the VA MISSION Act was passed three years ago, its congressional supporters argued that military veterans should have greater choice between in-house care delivered by the Veterans Health Administration (VHA) and treatment provided by outside doctors and hospitals, at government expense. Veterans would have the benefit of the nation’s largest public health care system and private-sector care that was more readily available. Partial privatization of the VHA would be, in theory, a “win-win” for everyone.

Today, if any of the VHA’s nine million patients has to wait or drive too long for an appointment at the VA, two private contractors (TriWest Healthcare Alliance and Optum) will help them access a MISSION Act–created Community Care Network (CCN). To try to maintain the VHA’s standards for quality and coordination, staff members are assigned to make referrals to and monitor the performance of “community care” providers.

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However, just as MISSION Act critics predicted, using private-sector contractors is no guarantee that veterans will get equivalent or better care in more timely fashion.

Two small but important surveys of well-informed VHA caregivers, along with interviews conducted by the Prospect itself, confirm that “community care” is neither quicker nor subject to effective federal oversight, despite its ballooning cost to the VHA. The surveys were conducted by two nonprofits, the Nurses Organization of Veterans Affairs (NOVA) and the Association of VA Psychologist Leaders (AVAPL).

While some veterans haven’t experienced long delays to see a private-sector provider, most are waiting between one and four months for mental-health, medical, and surgical appointments, according to VHA nurses who answered the NOVA survey. When patients do end up going outside the VHA, nurses often don’t receive required progress reports from private-sector providers.

Mental-health services are particularly at risk under the Community Care Network.

Nurses reported that such patient updates “may not be relayed in a timely manner,” or at all. “We don’t get information unless we continually ask,” said one. Things are “hit or miss,” another explained, while yet another cited the “great deal of time wasted while requesting clinical records and reports.” The vast majority of NOVA survey participants were unable to assess whether outside providers even know much about the military service–related conditions they have signed up to treat, as part of the CCN.

Mental-health services are particularly at risk under the CCN. Some observers who have been following VA mental health are concerned by reports that, in some VA medical centers around the country, hundreds of veterans who were referred to private-sector mental-health professionals were waiting for up to three months for just a telehealth appointment.

When surveyed by their professional organization and interviewed by the Prospect, VHA psychologists reported similar “community care” shortcomings. More than 90 percent of the clinicians who responded to the AVAPL survey noted that their private-sector counterparts failed to follow the VHA’s explicit treatment recommendations. When they tried to evaluate the progress of outsourced care, on a case-by-case basis, 94 percent of the VHA psychologists surveyed said they didn’t receive treatment plan updates. All of the respondents, 100 percent, said they didn’t get progress notes when private-sector providers requested authorization for additional sessions with veterans. Based on the information they did receive, 79 percent reported clinical practices by VHA mental-health contractors that would have been questionable if used in-house.

An anguished clinician, who works in a major urban VA medical center approving private-sector referrals for both initial and follow-up care, told the Prospect that she sometimes can’t sleep at night because she knows veterans aren’t getting high-quality care. Veterans with PTSD referred for cognitive processing and prolonged exposure therapy are getting less-effective therapy because so few private-sector providers have the skill with PTSD treatments that has been built up over the years at the VHA. The clinician said that the VA was actually asked to okay payment for a psychotherapy session conducted via text.

To make matters worse, nurses and other professionals also report that they are being diverted from delivering direct care to veterans to serving as “care managers” and CCN gatekeepers. One nurse surveyed by NOVA reported that their teams may be spending from 10 to 60 hours a week trying to monitor private-sector care, which means they can’t provide direct care to veterans. In some facilities, one or two mental-health professionals may be shifted from taking care of veterans to chasing down information from private-sector providers. Many said their direct-care positions are not backfilled. The result is a loss of perhaps 30 to 60 appointments a week. This leads to more delays when veterans try to seek care, and then more referrals to the private sector.

What is also causing demoralization among some clinicians are the conflicts that ensue if VA mental-health providers uncover serious quality problems with a private-sector therapist and try to reroute the veteran back to the VA. The veteran may become “enraged,” and direct their frustration at a primary-care physician, who in turn will complain to the Office of Community Care. Increasing conflicts over private-sector care are already disrupting the kinds of collegial relationships that make working at the VA so different from practicing in the private sector, where competition, rather than collaboration, is often the norm.

If Congress is truly concerned about providing high-quality care to veterans, it should begin to exercise meaningful oversight of the Community Care Network. To allow the CCN to continue unfettered in spite of information about increasing delays and uneven quality almost guarantees another VA scandal, where blame will fall on the agency rather than congressional privatizers, their right-wing allies, or private-sector providers.

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