Most Outside Mental Health Providers Unqualified to Care for Veterans

by U.S. Medicine

February 2, 2015

New Law Gives Broader Access to Care Beyond VA

By Brenda L. Mooney 

WASHINGTON – Passed with broad bipartisan congressional source support, the Veterans Access, Choice, and Accountability Act of 2014 (VACAA) was promoted as a quick and elegant solution to the problem of long wait times for veterans seeking VA care.

The temporary program, which includes a $10 billion fund to pay for care, allows eligible veterans to use healthcare providers outside the VA system in certain circumstances, most notably if the patient lives too far from a VA system or has to wait too long for an appointment.

The bill  was rushed through Congress in the wake of a scandal where data was falsified for more than 100,000 veterans awaiting appointments, at least partly so that VA officials could receive bonuses for meeting performance goals.

The only problem, according to a new study, is that, at least with mental health, most community-based providers are not adequately prepared to take care of the special needs of military veterans.

The new study, conducted by RAND Corp., was commissioned by United Health Foundation in collaboration with the Military Officers Association of America.

Based on a national survey of mental health providers, the report found few community-based providers meeting criteria for military cultural competency or using evidence-based approaches to treat problems commonly seen among veterans.

“Our findings suggest that community-based mental health providers are not as well prepared as they need to be to address the needs of veterans and their families,” said lead author Terri Tanielian, senior social research analyst at RAND, a nonprofit research organization. “There is a need for increased training among community-based providers in high quality treatment techniques for PTSD and other disorders that are more common among veterans.”


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Outside Care

Yet, based on the new law, veterans can seek outside care in the following circumstances:

  • The wait time at a local VA medical facility is more than 30 days from the preferred date or the date medically determined by a physician;
  • The veteran’s current residence is more than 40 miles from the closest VA healthcare
  • The veteran resides in a location other than Guam, American Samoa or the Republic of the Philippines and needs to travel by plane or boat to the VA medical facility closest to his/her
  • The veteran faces a geographic challenge, such as extensive distances around water or other geologic formations, such as mountains, that present a significant travel

RAND researchers surveyed a convenience sample of 522 psychiatrists, psychologists, licensed clinical social workers and licensed counselors to determine whether they used evidence-based methods to treat major depressive disorder and post-traumatic stress disorder (PTSD) and whether they had the training needed to be sensitive to the needs of veterans.

The study’s readiness criteria for both cultural competency and delivering evidence-based care was met by only 13% of the mental health providers surveyed. Providers who worked in community settings were less prepared than providers who are affiliated with the VA or military health system, according to the report.

One issue was training: Only one-third of psychotherapists reported receiving the education and supervision necessary to deliver at least one evidence-based psychotherapy for PTSD and at least one for depression.

High military cultural competency was found, meanwhile, in:

  • 70% of those providers working in a military or VA setting;
  • 24% of those participating in the TRICARE network, and
  • 8% of those without VA or TRICARE affiliation.
Kate Rubin

Kate Rubin

“Our veterans have served and sacrificed for our nation and deserve the very best care,” said Kate Rubin, president of United Health Foundation. “We hope this study will focus attention on the opportunity that exists to better prepare our mental health workforce to meet the unique needs of veterans and their families.”

For example, major depressive disorder and PTSD are more common in recent military veterans than the general, the report noted.

Landmines in Past

Programs involving the use of outside mental health providers have been landmines in the past for the VA. Even before the wait-time scandal broke at the Phoenix VA, leadership of the House Committee on Veterans’ Affairs toured the Atlanta VAMC in the spring of 2013 after multiple mental health-related deaths.

An audit from the VA’s Office of Inspector General found that the VA’s mental health service line (MHSL) managers failed to oversee or monitor contracted patient care services effectively and that the program lacked a specific quality-control process. In addition, patient complaints went untracked, and program managers did not conduct oversight visits to contracted sites, as required by VA directives and the contract.

Furthermore, according to the audit, the VA had no established process to verify that a patient had attended an initial appointment with contracted services or to track what happened with patients after referral, according to the audit. In fact, the OIG reported that 21% of patients referred to outside providers received no treatment either there or from the VA facility. This was due in part to a failure to provide “adequate staff, training, resources, support or guidance for effective oversight of the contracted [mental health] program. MHSL managers and staff voiced numerous concerns including challenges in program oversight, inadequate clinical monitoring, staff burnout and compromised patient safety.”

To improve the quality of care this time around, the RAND study recommends:

  • Better assessments of civilian mental health provider capacity — organizations that maintain registries or networks of providers should assess factors related to access and quality of care within these networks.
  • A hard look at the effectiveness of training in cultural competency on mental health provider capacity — training in military and veteran culture may not be enough to ensure competency and comfort; experience working with the population may be required.
  • Expansion of access to effective training in evidence-based approaches for posttraumatic stress disorder and depression, including incentives, if necessary.
  • Interventions to ensure that providers use evidence-based approaches in their practice settings.
Norb Ryan

Norb Ryan

“Veterans and their family members face unique challenges, and addressing their needs requires understanding military culture as well as their mental health challenges,” said retired Navy Vice Adm. Norb Ryan, president of the Military Officers Association of America. “It’s crucial that our civilian mental health providers acquire the training and perspective they need to guide their practice in the care of our military and veteran population.”

Choice Cards, which are necessary to participate in the program, began being mailed in November to veterans enrolled in VA healthcare as of Aug. 1, 2014, and to recently discharged combat veterans who enroll within the window of eligibility. Issued in three phases, the first Choice Cards were sent to veterans who may live more than 40 miles from a VA facility, and the next group was sent a few days later to veterans who are currently waiting for an appointment longer than 30 days from their preferred date or the date determined to be medically necessary by their physician. The final group of Choice Cards will be sent early this year for veterans who may find themselves eligible for the program in the future. To qualify for the program, a veteran must have a card as well as meet criteria for inclusion.

Click the graphic to expand to full-size in a new tab

Click the graphic to expand to full-size in a new tab

Q: Is the criteria 40 miles or 30 days?

A: Eligibility for the Choice Program is based on the veteran’s place of residence or the inability to schedule an appointment within the “wait-time goals” of VHA, which have been established as 30 days from the date preferred by the veteran, or the date medically determined by his/her physician. A veteran could be eligible under one or both of these criteria. Please note that veterans who are eligible based on their place of residence may elect non-VA care for any service that is clinically necessary.

Veterans who are eligible based on “wait-time” may select non-VA care only for an appointment for the service that cannot be scheduled within the “wait-time goals” of VHA.


Q: Does the 40 mile rule refer to whether the specialty need (for example, orthopedic surgery) is available within 40 miles, or 40 miles from any VA facility, whether or not the specialty, in this example orthopedics, is available there?

A: The law is clear that eligibility must be based on the distance from the veteran’s residence to any VA medical facility, even if that facility does not offer the specific medical service the veteran requires for that particular visit.


Q: What are the criteria used to determine the 40 mile radius? Is it similar to the Dashboard used to calculate mileage reimbursement?

A: VA will calculate the distance between a veteran’s residence and the nearest VA medical facility using a straight-line distance, rather than the driving distance. VA is developing an interactive tool that will be available on va.gov beginning in early November for veterans to determine their potential eligibility for the Choice Program based on their place of residence. Veterans will enter their address information into the tool, and the tool will calculate their distance to the nearest site of VA care and provide that mileage and information on their eligibility for the Choice Program to the veteran online.


Q. How will eligibility be determined for those veterans who receive a Choice Card, and are there limitations on what service they qualify for outside of the VA system?

A: Once a veteran receives a Choice Card, he or she will be eligible to use the program if he or she  meets the specific eligibility criteria discussed above and calls to receive approval for use. Veterans who are eligible based upon their place of residence will be eligible to use the Choice Program for any services that are clinically necessary. Veterans who are eligible because of the “wait-time” criterion will only be able to receive a non-VA appointment for the episode of care related to the service that cannot be scheduled within 30 days from his/her preferred date or the date medically determined by his/her physician.


  • Sid Pilkinton says:

    Transition and Care Management Services can help reduce the impact on Primary Care Meedical and Mental Health teams IF allowed to practice at the L.I.P.’s highest level of services.

    Transition and Care Managers, LCSW’s have the broad range of skills sets to accomplish the casemanagement, assessments, diagnosis, Tx planning, and deliver the evidenced based psychotherapies until the vettrans can be scheduled and seen by the PC Mental Health Teams.

    helping also to meet the performance 41 for psychotherapy sessions

  • Sid Pilkinton says:

    Transition and Care Management Services can help reduce the impact on Primary Care Meedical and Mental Health teams IF allowed to practice at the L.I.P.’s highest level of services.

    Transition and Care Managers, LCSW’s have the broad range of skills sets to accomplish the casemanagement, assessments, diagnosis, Tx planning, and deliver the evidenced based psychotherapies until the vettrans can be scheduled and seen by the PC Mental Health Teams.

    helping also to meet the performance 41 for psychotherapy sessions

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