Enhancing Outpatient Behavioral Health for Veterans: A Cost-Benefit Study

Introduction

Veterans return with high rates of physical injuries, depression or trauma with prevalence estimates of post-deployed PSTD (Posttraumatic Stress Disorder) and depression ranging from 13% to 18%. This causes suffering and impairment contributing to military attrition, misconduct, sick call visits and absenteeism. However, less than half of this population receives timely or adequate mental health services. Access to quality mental health services in the military remains a public policy concern. Veterans aged 65 and above are eligible for health insurance under Medicare. They form the VA’s (Veterans Administration) user group. In the past few decades, the proportion of veterans has been increasing.Their healthcare service demand is affected by both the Medicare and the VA health care services due to the overlap.

Today, the VA is authorized to demonstrate feasibility by allowing veterans who are eligible to Medicare to utilize their Medicare benefits in the health care system in the Department of Veterans Affairs (VA) as per the Veterans Equal Access to Medicare Act of 1999 and the Veterans Medicare Reimbursement Demonstration Act of 2000. This aims at increasing the scope and the quality of the VA health care system. Initially, the VA’s system was designed and built for inpatient care. However, it has begun to redesign its systems in a bid to treat more veterans in community-based outpatient clinics (CBOC’s) closer to their residence (Lahiri & Xing, 2002). The bulk of Medicare can now be provided in outpatient clinics with the VA operating more than 800 ambulatory care and community-based outpatient clinics. This paper concentrates on feasibility and cost-benefit considerations when enhancing outpatient behavioral health visits for veterans over the next five years by proposing an economic initiative.

For instance, adopting collaborative care, an evidence-based practice for treating depression and PSTD. It is infrequently adopted by the Department of Veterans Affairs (VA) (Hedrick et.al. 2003). However, collaborative care is a method that is empirically supported in extending and improving the rich, quality and outcome of care especially among patients with anxiety or depression and other chronic health conditions like diabetes and asthma. Some VA medical centers use telephone-based collaborative care models where depression care managers support the education of patients, patient activation, and monitor adherence and progress over time. The first randomized controlled trial (RCT) of centrally assisted collaborative telecare (CACT) for PSTD and depression involving more than 600 participants for a period of 6 months was carried out. The Stepped Enhancement of PSTD Services Using Primary Care (STEPS-UP) trial compared CACT with the army’s preexisting program of integrating behavioral health in primary. The severity of PSTD and depression symptoms were assessed using the PSTD Diagnostic Scale (PDS) and the Hopkins Symptom Checklist depression items (HSCL-20). It was observed that CACT was more effective in reducing PSTD and symptoms of depression among veterans.

Even if collaborative care seems effective, there are potential missed opportunities and involved risks in the care settings. Veterans experience delays between initial mental health diagnosis and initiation of care which is attributed to age, marital status, income, medical illness burden and the distance to the nearest VA healthcare facility. They are also faced with the risk of committing suicide, guilt, and shame. Despite this, collaborative care initiative is said to be both ethically and culturally equitable in the sense that the model has strong effects in terms of outcomes and patient satisfaction. Providing care based on the needs and patient’s expectations is a key attribute of quality and integrated mental health care.

Collaborative care is a prominent set of models of integrated mental health care that regularly contacts patients using care management and collaborates with medical doctors and specialists to organize patient’s care. The model is also innovative by using dedicated care managers responsible for coordinating psychological treatment and monitoring progress (Lipschitz et. al., 2017). Ethical principles for collaborative care include the opportunity to serve as positive roles models and to inspire and motivate their clients, share a mutual respect for a patient’s family, status, age etc. They also encourage open discussion/effective communication and transparency in decision making. Since healthcare focuses on quality, efficiency, experience, and outcomes, veterans are not morally judged from their combat experience to achieve the aforementioned. In order to address the risks associated with the model, it is important for caregivers to adhere to the ethical principles and outpatient services for veterans to be available in non-VA health care centers.

Every economic initiative comes with cost interventions. To estimate the cost of intervention components of a collaborative care model, an electronic case management system was used to track all contacts and caseload review calls and regular case management calls between nurses/caregivers and the patients as well as emails or text messages. Cost estimates were calculated by multiplying the hourly wage of staff members/nurses/psychiatrist by the number and the average duration for each session. During the 12 month period, the CACT team comprised of a half-time administrative assistant, full-time psychologist and a half-time nurse coordinator whose cost is estimated in their salaries. Estimates for wages are based on the general pay scale. Other costs include emergency department visits, outpatient tests, and procedures, outpatient visits etc. (Lavelle et al., 2018).

Outpatient costs range from $8351-$10 293 while inpatient cost is $939 -$2412 per Quality Adjusted Life Year(QALY) meaning most veterans sick outpatient services with only a few with cases that call for inpatient services. Controlling healthcare costs while maximizing benefits remains challenging for health providers. For the Department of Veteran Affairs(VA) to remain effective using collaborative care programs for outpatients, there is need to come up with innovative ways to engage and involve patients in their own care, ensure equity of care by maximizing reimbursements, this way patients should not distort the truth to obtain benefits, ensure all veterans are covered under health insurance unlike today when the elderly are the main beneficiaries, ensure no disparities regardless of gender, marital status etc.

Conclusion

The Department of Veteran Affairs invests heavily in behavioral health integration and infrastructure. More than $ 50 billion is spent annually on health care for nearly 10 million beneficiaries. In the society, the health sector is very crucial in meeting the objectives of its members. Adopting a collaborative care model is a great move since it produces good results especially in treating PSTD and depression for outpatient veterans demonstrating its feasibility and cost-effectiveness. It also offers a sustainable way of improving the quality and outcomes for care patients in the military and veterans.

Appendix

1. Acronyms Meanings
2. Posttraumatic Stress Disorder (PSTD).
3. Veterans Affairs (VA).
4. Community-based outpatient clinics (CBOC’s).
5. Randomized controlled trial (RCT).
6. Centrally assisted collaborative telecare (CACT).
7. Stepped Enhancement of PSTD Services Using Primary Care (STEPS-UP).
8. Diagnostic Scale (PDS).
9. Hopkins Symptom Checklist depression items (HSCL-20).
10. Quality Adjusted Life Year (QALY).