Six Lessons from the COVER Commission on Veterans Mental Healthcare
In 2016, Congress established the Creating Options for Veterans Expedited Recovery Commission (Commission) to examine the evidence-based therapy treatment model used by the Department of Veterans Affairs (VA) for treating mental health conditions of Veterans and the potential benefits of incorporating complementary and integrative health treatments
available in non-VA facilities. The COVER Commission spent roughly eighteen months analyzing the nation’s veterans healthcare system, both inside of and outside of the VA.
The Commission conducted focus groups with veterans around the country and met with some of the nation’s leading mental health and suicide prevention researchers. The Commission submitted its report to the President of the United States, the United States Congress, and the Secretary of Veterans Affairs (VA) on January 24, 2020.
It was a comprehensive effort and I can say as one of the Commissioners that I am really proud of our analysis and the report that we developed with our subject matter experts and writing team. You can read that full report at this link.
I am writing this article to highlight some of the issues that really struck me personally in the Commission analysis as a veteran, a mental health advocate, a mental health researcher, and someone who has lost a family member to a combat-related post traumatic stress injury.
These highlights are just a few of the issues pointed out the by the Commission report. The Report has ten recommendations each with their own series of implementation steps. Each one of them providing an opportunity to make a different in the veterans’ mental health care system.
The VA runs on a fee-for-service model, a type of model being phased out throughout the United States healthcare system.
Healthcare in the United State is transitioning from a fee-for-service model into one that is more value-based. This is not an easy transition because it is asking the healthcare system to move from the relatively easy process of counting and billing for the number clinical visits and procedures to a less tangible process of reimbursing the care provider based upon the number of their patients, their characteristics (symptom severity, urban vs. rural, etc.), and whether their patients are getting better according to population health metrics.
I am a novice to the intricacies of the VA healthcare reimbursement process. Before this Commission, I had never heard of the Veterans Equitable Resource Allocation (VERA) process that the VA uses to determine the allocation of financial resources throughout the VA healthcare system. I was surprised that the VA was utilizing a fee-for-service model developed in 1997 for its research allocation methodology.
There is a lot to like about the overall VERA system. It has been painstakingly crafted to factor in differences in costs across regions and other complexities of providing healthcare in the VA system. Those factors are important and they should not be lost. From what I saw, the people that managed the VERA system were also brilliant. Yet, the underlying resource allocation metric needs an overhaul to help the VA transition into a modern, value-based medical system.
The COVER Commission described this as a facet of a broader a multi-pronged recommendation (Direct bulleted quote from page 72 of report):
- Transition VA’s Veterans Equitable Resource Allocation (VERA) system from a fee-for-service funding model to a per-patient model of funding with financial incentives for improving population health and person-centered metrics.
- Fully fund and integrate the whole health implementation plan into mental health, primary care, and specialty care throughout VA.
- Incentivize VA health care leaders and providers with both fixed payment and variable bonus processes to engage in continuous improvement with incentives for improving population-based and person-centered metrics.
- Create a continuous innovation and improvement center and network specifically focused on driving the VA Health Care Transformation Model.
- Integrate VA’s existing metrics systems (e.g., SAIL, VERA, Patent Experience Office) into a unified system that tracks quality, performance, and value based on the quadruple aim framework.
The VA needs a more specific model to explain what causes veterans‘ suicide and how to prevent it.
The suicide prevention community has been split by the issue of what level diagnosable mental health conditions interrelate with other risk factors for suicide. The COVER Commission commission found that the VA suicide prevention team had fallen into this same quandary which can be debilitating to decisions to choose interventions, research paths, etc. (Page 87)
The Commission determined that the “VA requires a suicide prevention model that explains the complex realities of suicide, suicide prevention, and treatment for suicidal behavior.” It recommended, the “stress-diathesis model… to form the foundation of a suicide prevention model for VA.”
The stress-diathesis model doesn’t get lost in questions of whether a person would qualify according to a symptom survey as having a mental illness. This model more broadly focuses on suicidal behavior as a result of the interaction between environmental stressors and susceptibility to suicidal behavior. (Page 87, citing Van Heeringen & Mann, 2014).
The VA needs a systematic research process for improving the diagnosis and treatment of brain health conditions through precision medicine.
The VA has one of the most strategic and proactive genetic health research programs in the world in the Million Veterans Program (MVP). MVP’s purpose is “to learn more about how genes affect health, and to improve health for Veterans and ultimately, everyone. ” Veterans participate MVP complete surveys about health, lifestyle habits, military experience, personal and family history. The veterans also provide a blood sample for genetic analysis and allow MVP access to their health records on an ongoing basis.
The MVP is a great example of how the VA can use the combination of the number of veterans under its care and its research expertise to advance clinical care. The VA needs to develop a similar strategic research initiative to improve the diagnosis and treatment of brain health conditions through precision medicine.
The COVER Commission described the powerful need for advances in this area on page 94 of the Report.
The critical nature of this issue to VA’s services is one of both issue severity (veteran suicide)and scope. According to VA’s Office of Research and Development (2019), “More than 1.8 million veterans received specialized mental health care from VA in fiscal year 2015.” VA serves almost 2 million veterans a year in a treatment system based on mental health diagnosis categorization that the former director of the National Institute of Mental Health has deemed not to be “predictive of treatment response” (Insel et al., 2010). That flaw in VA’s mental health treatment system presents a fissure in its ability to prevent veteran suicides.
The COVER Commission highlighted the VA’s existing precision mental health efforts, but called on Congress to dramatically expand its scope and nature. The COVER Commission specifically called for Congress to pass the Precision Mental Health Initiative in the Commander John Scott Hannon Veterans Mental Health Care Improvement Act. (Page 96)
The VA does not adequately serve veterans with treatment-resistant depression, a group that is at extremely high risk of suicide.
The most disturbing part of the COVER Commission analysis for me was the minuscule number of veterans received evidence-based care for treatment-resistant depression. Treatment-resistant depression places a significant symptom burden on the people who live with it and the treatment process involves multiple types of care that do not successfully improve the person’s symptoms.
Unsurprisingly, people who live with treatment-resistant depression are at extremely high risk of suicide. As described by Bergfeld, et al, thirty percent of patients with treatment-resistant depression attempt suicide at least once in their lifetime.
We cannot put a fixed number on percentage of veterans with depression who are treatment resistant. As mentioned above, the current diagnostic process has a lot of flaws. This is one of those areas. The diagnosis of treatment-resistance depression only occurs after a person’s depression has not improved with other treatments. Akil et al., 2018 was cited by the Commission and it described how almost 50% of patients with depression may fit this category. (Page 91)
The VA’s Clinical Practice guidelines recommend three treatments for clinical depression. One of them involve medication. The other two are electroconvulsive therapy and repetitive transcranial magnetic stimulation. To say that the the latter two treatment options are being underused is an understatement.
As described in the Report (Page 92),
According to data collected by the COVER Commission, only approximately 1166 patients VA-wide were referred for electroconvulsive therapy (ECT) in 2018 and about 772 were referred for repetitive transcranial magnetic stimulation (rTMS).
Those numbers make it clear that the VA is not taking treatment-resistant depression seriously. With 1.7 million veterans receive mental health services at the VA, it is deeply concerning that less than 2,000 veterans received these standard mental health treatments which are regularly used in the private sector to save the lives of people who are struggling to recover from their mental health condition and are at extreme risk of suicide.
In response, the Commission recommended that VA leaders, “Assess availability of care for treatment-resistant depression across the enterprise, and create and implement a plan for ensuring all veterans have access to this type of care.” (Page 93)
Exercise is one of the cornerstones of mental health. The COVER Commission found that the VA offers exercise options to a small fraction of its veterans and that it is illegal for the VA to offer health club memberships in a manner that is a standard service for many Medicare Advantage Plans.
The benefits of physical exercise to veterans mental health were highlighted a number of section in the COVER Commission Report. Physical exercise was one of the Comprehensive and Integrative Health modalities most often mentioned during the veterans focus groups. (Page 25) In talking about these focus groups, the Report stated that, “ Veterans who offered opinions about physical exercise, universally identified it as helpful in improving their mental health.” (Page 25)
Exercise was also featured in the Report’s discussion of research on Comprehensive and Integrative Health modalities in mental health care. Literature reviews shows that physical exercise had been demonstrated to show varying levels of effectiveness as an adjunct treatment intervention for post traumatic stress disorder (Page 43), major depressive disorder (Page 47), generalized anxiety disorder (Page 48), suicidal behavior (Page 53), and insomnia disorder (Page 54).
Unfortunately, the combination of veterans interest in exercise and the research benefits of exercise is not reflected in veterans access to exercise in VA. The Commission found that, “Despite the widely acknowledged health benefits of exercise, VA sports and exercise programs serve a total of about 15,000 individuals — a small fraction of the total veteran population receiving VA health care.” (Page 26) To put that number is perspective, 1.7 million veterans receive mental health services at the VA.
That number registered with the Commission. The stated in response, ““The limited availability of and participation in institutional exercise programs indicate that they may not be the best way to broadly engage veterans in exercise programming.” (Page 26)
The Commission recommended looking at a model that has been utilized by Medicare Advantage plans (Page 26):
A model that would have a greater reach would be one similar to United Healthcare’s Renew Active fitness plan, which is basically a gym membership model, provided to more than a million of its 4.8 million Medicare Advantage members. Renew Active memberships also include access to yoga, pilates, and tai chi which are also CIH modalities valued by veterans. Other Medicare plans use the Silver Sneakers plan to incentivize physical exercise among their members. Silver Sneakers members can access more than 16,000 health care facilities across the country.
The Commission found that model is currently illegal in the VA’s current regulatory scheme VA. The Commission recommended that, “VA should amend 38 CFR 17.38 to remove the restriction on providing gym memberships and create a program for providing mental health patients with vouchers to be used for gym memberships or memberships at facilities such as yoga, pilates, or tai chi studios.” (Page 36–37)
The VA’s process of eliminating benefits due when a veteran becomes employed has the unintentional effect of increasing veterans unemployment leaving them more at risk for mental health conditions and suicide.
One of the most difficult issues that the COVER Commission looked at was the relationship between veterans’ benefit reduction and worsening mental health conditions to the point of suicide.
The Commission found that, “Employment can produce benefits similar to those of clinical mental health interventions to include physical activity, social interaction, opportunities to play valued social roles, development of skills, distraction from clinical symptoms, and the indirect benefits of earning income, to include paid time off and employer-supported health insurance.” (Page 88).
The Commission also found that the current VA benefit system disincentivizes veterans with disabilities from seeking employment, due to the risk that employment may reduce or eliminate health care access and disability benefits. (Page 88)
While the Commission realized that altering this system would create some risk of increased benefits gamemanship, they placed the need to increase the employment of veterans with disabilities above the benefits gamesmanship concerns.
The COVER Commission focused on a targeted federal rule change to address this issue (page 89–90).
Modify 38 CFR Section 4 to ensure that veterans’ disability benefits other than those based on unemployability (38 CFR Section 4.18) will not be reduced based on employment, including nonmarginal employment. Allow veterans who qualify for disability rates for unemployability to seek a 2-year extension of unemployability benefits after being hired for nonmarginal employment. The purpose of this extension will be to ensure veterans’ vocation is stable before their unemployment benefits are reduced or eliminated.
As I mentioned above, these are just six of the highlights and issues pointed out the by the COVER Commission Report. The full document has ten recommendations each with their own series of implementation steps. Each one of them providing an opportunity to make a different in the veterans’ mental health care system.
The Senate Veterans Affairs Committee has already picked up one full recommendation and one sub-recommendation in the bipartisan Commander John Scott Hannon Veterans Mental Health Care Improvement Act, sponsored by Chairman Moran and Ranking Member Jon Tester (D-Mont.). I am hopeful that these are just the first of many recommendations that will be adopted in the months and years to come to help improve the care of America’s veterans with mental health conditions.
You can read the full COVER Commission report at this link.
