Veterans with mental health disorders consistently rated their experiences with private care as less satisfactory than those without a mental health condition -- a finding that indicates a need for better care coordination by the Department of Veterans Affairs, according to new research.
VA researchers examined survey results of 231,869 veterans who received VA-covered medical services from non-government providers and found that those with mental health conditions expressed lower satisfaction rates across nine categories than veterans without a mental health diagnosis.
Coupled with an earlier study that showed veterans with a behavioral health condition also reported worse overall experiences with medical services at the VA, the research raises questions on how to effectively manage caring for that vulnerable population, said the study authors, who hailed from four VA medical facilities and five universities.
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"It's clearly a call to improve care coordination across the board so that veterans can get the medical care they need," said Eric Roberts, an associate professor at the University of Pennsylvania School of Medicine, during an interview with Military.com.
According to the research, published May 21 in JAMA Network Open, satisfaction scores from veterans who used community care rose slightly from 2016 and 2021 on measures including quality of care, communication with clinicians, eligibility, appointment scheduling, care communication and billing.
Yet across those years, veterans with mental health conditions rated their community care consistently lower than those without.
While the study didn't show a causal relationship between having a mental health condition and dissatisfaction with private care, it did demonstrate the challenges that vulnerable veterans face when navigating care provided outside of the VA.
"[It highlights] an opportunity for targeted quality and care coordination strategies to improve community care for these veterans," the authors wrote.
The research arrived as the department is actively working to increase veterans' access to private health care.
The 2018 Mission Act vastly expanded eligibility for veterans to receive care in the community, introducing access standards that included those who faced a 30-minute drive or more for primary care or an hour or more for specialty care, or those who couldn't get an appointment within 20 days for primary and mental health services or 28 days for specialty care.
In a May congressional hearing, VA Secretary Doug Collins said the previous administration actively discouraged its medical centers from referring patients to private care in defiance of the 2018 Mission Act.
"Disturbing evidence has come up as we began to look at ... community care, which many of you hear about from your constituents all the time of not being able to get to their community doctors or not being accessed to community care. Why is that happening? Well, a lot of it was because the VA itself was not encouraging it," Collins said during a House appropriations subcommittee hearing May 15.
In 2022, then-VA Secretary Denis McDonough said private care accounted for 33% of the VA's total health care demand, up from 25% the previous year. At the time, McDonough said he was worried about the rate and expressed concern over the impact of shifting funding away from VA facilities when studies have shown that veterans in VA care have lower rates of suicide and improved overall health.
"We want to bring as many vets as possible into our care, because study after study shows that vets do better at VA," McDonough said in a hearing last year.
Collins has said that the VA health care system "will always" be there for veterans. During his confirmation hearing, he added that the Mission Act is about how "we make veteran care available to the veteran who needs it" because "they want to be able to have that choice."
But the way Collins is funding private care -- most recently, shifting $343 million in savings from canceled contracts to the program -- is not sitting well with lawmakers.
Collins notified Congress on April 24 of his intent to move the money. Republicans and Democrats on the appropriations committee say the law requires Collins to ask for approval to reallocate the funds.
"You are required to seek our approval. You [were] a member of Congress, you're aware of that, and you have not done that. You still owe us answers on why you sent a notification instead of a reprogramming," said Rep. Debbie Wasserman Schultz, D-Fla., ranking member of the House Appropriations Military Construction, Veterans Affairs and Related Agencies subcommittee.
"We want it done the way she has just said," said Rep. John Carter, R-Texas, the subcommittee chairman, referring to Wasserman Schultz's statement. "It's been done that way -- I've been on this committee for 20 years. It's been done that way for 20 years. We're not going to change it now."
Roberts said that, as reliance on private care grows among the VA population, the department should consider how it can better serve veterans who may need more help navigating the complexities of the health care environment.
The VA has programs to coordinate care for veterans, but research shows that the VA should consider a veteran's mental health condition as a marker for identifying those who need a higher level of care coordination.
"As the VA considers what type of care is reasonably retained in the VA versus provided through community partners, and what resources are needed to coordinate care across different systems, additional consideration should be given to vulnerable populations, including veterans with mental health conditions," the researchers noted.
In an article published May 24 in the New England Journal of Medicine, two pulmonologists with the VA Central Texas Health Care System warned that the Mission Act, and a bill introduced this year by chairmen of the Senate and House Veterans Affairs Committees that would allow some veterans to get private care without a referral, could harm veterans' medical care by increasing "care fragmentation" -- the lack of coordination of medical services between primary care physicians, specialists and other providers.
Drs. Pavan Ganapathiraju and Rebecca Traylor said that dispersing care across health networks and providers "could lead to poorer outcomes, higher costs, and reduced oversight."
"Without access to integrated health records or familiarity with veterans' service histories, private-sector clinicians may inadvertently contribute to care gaps, duplicative testing, or medication errors," they warned.
In the May 15 hearing before the House Veterans Affairs Committee, Collins pledged to hold the private care program to the highest standards.
"I don't agree that community care is a giveaway to private physicians and public hospitals," Collins said. "We're not taking VA care from one and giving it to another VA care. We've expressed in our hospitals, expressed in community care, which we're paying for, is VA care."
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