The VA Battles America’s Veteran Mental Health Crisis with Telehealth
February 13, 2019
Much of the focus on veterans’ mental illnesses centers around PTSD, which often results from their time on the frontlines. While the high rates of PTSD and TBI in veteran populations can be partially explained by the symptoms and brain injuries that arise out of active duty, there are also a lot of stressors veterans face after returning home. It is an inescapable fact: serving in the armed forces and returning to civilian life afterwards is difficult. Transition stress encompasses all of the pressures that veterans face when transitioning back into civilian life, which can also trigger mental health consequences. The extreme physical and mental duress that the men and women serving in the United States Military experience, both while serving and while transitioning back to civilian life, can trigger and exacerbate mental health issues. The risk for suicide was 22% higher amongst veterans than it was non-veteran civilians. Every day, 20 veterans commit suicide in the US. The U.S. Department of Veterans Affairs’ (VA) mental health report from June 2018 provides evidence that the suicide rate amongst veterans has grown by 25.9% from 2005 to 2015. In fact, veterans are one and a half times more likely to take their own life than nonveterans. These issues led former VA Secretary, Dr. David J. Shulkin, to make “suicide prevention [his] top clinical priority.” This mission, set forth by Shulkin’s administration, has received strong bipartisan support. Congress recently passed the VA MISSION Act in June 2018 to increase access to care for veterans through telehealth initiatives. The eVETS Act is a piece of proposed legislation that extends the goals of the VA MISSION Act by creating a pilot telehealth program for rural veterans. The expansion of funding and resources dedicated to telehealth initiatives solves two key problems that many veterans face: a shortage of mental health professionals to address patient demand as well as distance and logistical barriers to receiving care.
The rise in suicide rate shows that American veterans are not receiving the mental health care that they so desperately need. There are many barriers like geographic distance, schedule constraints, long wait times, a strong culture around self-reliance, and societal stigma that lead to incredibly high rates of untreated mental health patients. One out of every four veterans live more than 40 miles away from the nearest VA center. This distance poses an enormous barrier to ensuring that veterans are able to access the care they deserve. Not only does traveling to doctor’s appointments take up time, but it may also require money or time off from a job. The Health Resources and Services Administration designated eighty percent of U.S. counties as partial or whole Mental Health Professional Shortage Areas. These shortage areas are predominantly rural, and this issue is detrimental to veterans to an even greater degree than other patient populations because a quarter of veterans live in rural areas. Veterans in rural areas are also much more likely to not be under VA care, and rural hospitals and providers are far and few between. Solutions that can easily scale to large patient populations and reach patients remotely would be a valuable tool in this battle against mental illness. A disgruntled physician, Dr. Jose Mathews, voiced his concerns in 2013 about the care delivered at the John Cochran VA Medical Center in St. Louis. The wait time for mental health treatment at this VA location used to be a month or longer when subsequent federal investigations were conducted in 2014. Officials claim there is a full-time equivalent of 2.6 psychiatrists on staff, but Dr. Mathews argues that the number of available clinicians is lower. In early 2018, a veteran shot himself in the emergency room of that same VA center in St. Louis. Dr. Mathews believes that this suicide is a message about facing an uphill mental health battle that is further complicated by long wait times and other access-to-care issues. VA officials in St. Louis say that all mental health appointments can be booked within three to five days, but skepticism is rampant. Reported problems related to access-to-care do not just exist in one VA location; officials complain about understaffing in VA hospitals nationwide. It is encouraging that VA care is found to be just as good or of higher quality than private providers. However, quality of care metrics display significant variance between regions and populations.
Currently, the VA’s patients are facing two main problems concerning mental health care access. Firstly, there are many VA centers that are understaffed, like the St. Louis location, which leads to frustratingly long wait times and waitlists. Additionally, as mentioned earlier, many veterans live in Mental Health Professional Shortage Areas, making it difficult for them to find the right doctors within a reasonable distance. Thus, the VA needs a solution that makes accessing mental health care more convenient, in terms of increasing the number of providers available to patients and increasing the geographic area that these providers can cover. Telehealth can help solve these problems.
What is Telehealth and How Can It Help?
Telehealth allows patients to be able to access the resources of their doctor’s office in the comfort of their home. The definition of telehealth varies from state to state and even between federal agencies. The federal Health Resources and Services Administration (HRSA) defines telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.” Telehealth services are quickly gaining traction in the medical community as providers and health systems become more overworked and understaffed. For mental health patients, telehealth can consist of online, therapist-assisted self-management therapy, cognitive behavioral therapy (CBT), online diagnostic questionnaires, text reminders about homework assignments or medications, group chats with other patients receiving therapy, and educational webinars. Furthermore, telehealth allows providers to reach patients that were previously outside of their geographic area. Telehealth is able eliminate the transportation, logistical, and/or cost barriers that many veterans face when attempting to gain access to care. Skeptics question whether care delivered virtually can be as effective as in-person care. To answer these questions, a multitude of non-inferiority studies have been conducted in recent years. Non-inferiority studies are conducted to ensure “that the effect of a new treatment is not worse than that of an active control…” and are used in the research community when placebos are unable to be used for ethical reasons. In telehealth-focused non-inferiority studies, researchers usually designate traditional in-person therapy as the control. The results of such studies have produced encouraging results for telemental care and prove that telemental health is at least as effective as in-person care for PTSD, substance abuse, depression, and psychosis . In a recent letter to The New England Journal of Medicine, Kaiser Permanente published results showing how real-time patient-provider video visits were enormously successful with a variety of patients. In a survey, 93% of patients stated that they were satisfied with the service and the video visit met their needs.
Recently Congress has taken steps to increase access to telehealth for veterans. Research shows that telehealth initiatives that reach veterans who live in underserved rural areas are of equal quality when compared to in-person therapy and that they cost less than in-person services. The Veterans’ Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act was signed into law in 2018 and is a massive $52 billion reform targeting how veterans receive medical care, how veterans’ health data is exchanged between providers, and significantly increased veterans’ access to any type of telehealth. The bill aims to improve the VA’s health care delivery systems by allowing VA health care professionals to practice telemedicine regardless of the location of the provider or patient during the treatment. This piece of national legislation eliminates geographic barriers and makes accessing the care veterans need much easier. The pending Enhancing Veterans’ Experience with Telehealth Services (eVETS) Act also looks to expand access to care for veterans. The bill aims to create a pilot program for telehealth in ten rural states. Veterans who have been diagnosed with certain mental illnesses and reside in certain rural areas would be eligible for at least twelve sessions of care via video. Eligible veterans would be informed of their opportunity to participate in the program by the VA. After two years of the program, a report on the pilot program will be presented to Congress, and the VA Secretary will determine its future. The bill would also allow the VA Secretary to partner with private companies to expand broadband internet access. The VA could pay for internet access for veterans who are determined to be in need of the assistance.
State governments are also working to expand telehealth. Nineteen states have pending legislation that address expanding telehealth. Cross state licensing is currently the most debated topic; bills involving it are pending in ten states and in the federal government. Removing existing licensing barriers to allow medical professionals to see patients in multiple states increases access to care. Senate Bill 141 in New Mexico aims to increase access to psychological services by allowing remote practice across state lines, which is currently prevented by licensing regulations. This legislation will greatly help veterans living in Mental Health Professional Shortage Areas where there aren’t providers to meet patient demand. Other legislation topics range from broadband internet access to private payer reimbursement. House Bill 2173 in Oregon aims to create the Oregon Broadband Office to remove barriers to internet access, explicitly noting how broadband internet is used for telehealth. As more people gain quality internet access, the reach of telehealth grows. Rural veterans with poor access to both in person services and the internet would greatly benefit from improved internet that allows access to telehealth. Senate Bill 27 in Illinois amends the state insurance code so insurers cannot exclude coverage of services solely because they are administered through telehealth. As telehealth becomes more compatible with private insurance plans, an increased number of people have access to the service. Veterans relying on private insurance plans for their care would no longer have to pay out of pocket for telehealth.
The need for telehealth for veterans’ mental health is clear and only growing, especially in rural areas. Telehealth is our best solution because it ensures that veterans who live in more rural areas, deal with disabilities, or are unable to access transportation for their next VA appointment are still able to receive adequate mental healthcare. Furthermore, telehealth and the integration of digital health solutions into mental health treatment also increase patient’s homework compliance, thereby improving outcomes. Recently, Congress has started a variety of preliminary initiatives in partnership with the VA to ensure that more funding and resources can be put aside towards this endeavor. These are steps in the right direction, but more needs to be done to ensure twenty veteran suicides a day goes down to zero.
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