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APA, a longtime member of the Friends of V.A. Medical Care and Health Research, endorsed the coalition's proposed budget for Fiscal 1998 of $18.2 billion for medical care and $270 million for health research. This represents a $700 million increase for medical care and a $18 million increase for health research over Fiscal 1997.
Walker, chair of the department of psychiatry at Oregon Health Sciences University, spoke before the House Appropriations Subcommittee on VA-HUD and Independent Agencies. He urged subcommittee chair Jerry Lewis (R-Calif.) to fund special programs for veterans with substance abuse disorders, chronic severe mental illness, homelessness, and PTSD.
About 25 percent of all V.A. patients receive psychiatric treatment, yet resources are being diverted away from mental health and substance abuse programs in some "Veterans Integrated Service Networks" (VISN), noted APA's written testimony.
The VISN's are 22 regional, decentralized networks that have largely replaced the V.A.'s inpatient, hospital system. Special programs are now managed by the local networks.
Walker told Psychiatric News in an interview that "substance abuse treatment services are being reduced in some networks despite a growing number of veterans with substance abuse disorders."
Fewer veterans were treated in the V.A. for substance abuse disorders last year for the first time since Congress had approved expanding substance abuse treatment services in 1990, added Walker, who is the immediate past director of the V.A. Center for Excellence in Substance Abuse Treatment and Education in Seattle.
This finding was confirmed in the "First Annual Report to the Undersecretary for Health DVA by the Committee on Care of Severely Chronically Mentally Ill Veterans," distributed to Congress last month (see story below).
Four of the 22 VISN's reduced expenditures for substance abuse treatment programs by more than 20 percent between Fiscal 1995 and Fiscal 1996. Five networks treated 10 percent fewer patients in their substance abuse programs, and the quality of treatment declined in eight networks during that period, noted the report.
Moreover, overall net expenditures for substance abuse programs declined by 12 percent during Fiscal 1995 and Fiscal 1996.
The V.A. has also switched to a capitated health care system. Walker recommended implementing a separate funding mechanism for the severely chronically mentally ill to prevent arbitrary limits on mental health visits.
Thomas Horvath, M.D., chief of the Mental Health Strategic Health Care Group at the Department of Veterans Affairs (D.V.A.) in Washington, D.C., told Psychiatric News, "The V.A. is required by law to have mental health parity. If any medical center independently predetermines psychiatric benefits, I will call that to the undersecretary's attention."
The D.V.A. has switched to a capitated system that currently allows $35,000 per patient for special populations including the chronically mentally ill. In contrast, the general capitation rate is $2,500 per patient.
"We will resist a single capitation rate that doesn't include measures of psychiatric, medical, and psychosocial severity," said Horvath.
Walker also recommended that psychiatrists be included in VISN planning, especially regarding the redistribution of mental health and substance abuse resources. "A psychiatrist should be on the executive advisory committee of each VISN," he advised.
Horvath agreed, noting that psychiatrists have active advisory roles in some networks.
Walker also expressed concern that seriously ill homeless and unemployed veterans are losing access to care and services with the new emphasis on outpatient care. Large cuts in inpatient funding has meant fewer acute psychiatric beds for mentally ill homeless veterans.
APA recommended in its testimony that the V.A.'s Homeless Providers Grant and Per Diem Program be reauthorized for state and local governments, and nonprofit organizations to receive funding for buying, building, or renovating transitional residential care programs and service centers for homeless veterans.
Horvath commented that the D.V.A. is considering residential alternatives to inpatient care. "The Salvation Army, for example, could run a shelter on the V.A. premises, and we could provide psychiatric and medical services."
The V.A. should also continue its important role in training psychiatric residents, especially in addictions, testified Walker.
Horvath commented that psychiatric residency slots may be reduced in the future, but he believed that the cuts would affect only weaker programs that have trouble filling slots.
The V.A. should also continue its two-year Substance Abuse Fellowship Program, said Walker. The program came under review by the D.V.A. after the Accreditation Council for Graduate Medical Education decided to require only one year of training for addiction psychiatry subspecialization, said Horvath.
He noted that psychiatric research got a boost from the D.V.A. this fiscal year with funding approved for two new Mental Illness Research Education and Clinical Centers (MIRECC's). The D.V.A. plans to fund three more MIRECC's in the next two fiscal years.
The V.A.'s reorganization from a hospital inpatient system to a managed outpatient system has resulted in major shifts of resources, notes the first annual report by the V.A. Committee on Care of Severely Chronically Mentally Ill Veterans.
The Veterans Eligibility Reform Act of 1996 charges the committee with reporting to the V.A. Under Secretary for Health on how the V.A. is meeting the treatment and rehabilitation needs of this vulnerable population and making recommendations. The 11-member committee includes psychiatrists and non-M.D. mental health professionals working in the V.A. health care system.
Total V.A. resources devoted to hospital care declined by $80 million in Fiscal 1996 from Fiscal 1995 levels, while total outpatient resources increased by $40 million, the report notes.
At some medical centers, up to 70 percent of psychiatric beds were closed in Fiscal 1996.
"As inpatient psychiatric beds are closed, the committee considers it imperative that the V.A.'s community-based health care delivery systems be established or expanded to provide a full continuum of services for severely mentally ill patients," the report states.
This should include intensive community-based management programs and residential care programs. The committee found that more than two-thirds of V.A. medical facilities still lack community case management services for severely mentally ill veterans, including more than 20 located in large metropolitan areas, the report notes.
Residential treatment programs do not exist in several large metropolitan areas and are disproportionately small, according to the report.
The V.A. is also rapidly expanding access to primary care services through implementing Community-Based Outpatient Clinics (CBOC). "This initiative can expand the number of sites providing support to seriously mentally ill veterans," the report states.
Because few (34 percent) CBOC applications included basic mental health services for the mentally ill, the committee recommends that future applications include a needs assessment for providing such services.
The shift in dollars from inpatient to outpatient care has been most noticeable in substance abuse treatment programs, notes the report.
Total substance abuse inpatient costs decreased 19 percent from Fiscal 1995 to Fiscal 1996, while total outpatient costs increased 13 percent overall. Total mental health expenditures decreased by 1.6 percent during the same period, while the total number of patients treated in V.A. mental health programs increased by 3 percent, according to the report.
The report notes that 17 of the 22 Veterans Integrated Service Networks (VISN's) shifted mental health resources to non-mental health programs.
Fifteen of the 22 networks redistributed mental health resources from inpatient care to residential or ambulatory care without reducing the number of patients seen, said Thomas Horvath, M.D., chief of the Mental Health Strategic Health Care Group at the Department of Veterans Affairs in Washington, D.C., and a consultant to the V.A. committee. Four networks performed poorly, however, with a 20 percent decline in patients treated, he said.
The V.A. committee thus recommends monitoring the workload, allocation of resources, and quality-of-care indicators for mental health programs with specific attention to substance abuse programs.
The V.A.'s Northeast Program Evaluation Center will be responsible for the monitoring, as well as production of an annual mental health performance report.
The committee also recommends that mental health professionals, consumers, and service organizations for veterans have input into VISN reorganization plans, including reinvestment into community-based mental health services.
(Psychiatric News, June 6, 1997)