Veterans’ Care: Improving protection for our protectors

In recommending priorities for veterans’ care, new study presents opportunities for quantitative analytics.

By Douglas A. Samuelson

Receiving timely healthcare remains a concern for many veterans.

Receiving timely healthcare remains a concern for many veterans.

As the nation moves into the 2016 presidential election cycle grappling with multiple military engagements, a large and growing veterans population and problems in the Veterans Administration, a group of experts have presented a comprehensive overview of issues and a plan with substantive recommendations for how the next president can best serve the veteran and military community. This work, by the Center for a New American Security (CNAS [3]), follows up on earlier work reported in OR/MS Today [5] and reflects the progress – and, in some areas, lack of progress – on the recommended courses of action. Systems analysis will continue to play a vital role, but more attention to institutional impediments will be required.

The new report is cast as a set of recommendations for the next president, but careful reading indicates that the authors would welcome initiation or intensification of these actions by the current administration as well. Key recommendations of the report include:

  • Continued focus by the next administration on immediate issues such as access to healthcare, transition to civilian employment and support to veterans in crisis (such as those facing homelessness or legal problems).
  • Structural reform of the Department of Veterans Affairs (VA) to better serve veterans, including better alignment of the VA’s resources and requirements.
  • Expanded data sharing between the government, private and nonprofit sectors that enables needs assessment, resource allocation and future planning.
  • Elimination of barriers to public-private-nonprofit partnerships that could help veterans better succeed in civilian life.
  • Identification of normative outcomes, and rigorous evaluation of how public, private and nonprofit programs perform against these outcomes.

“The 2016 elections will mark a watershed moment for the veteran and military community,” says Phillip Carter, CNAS Senior Fellow and one of the report’s authors. “This report outlines the critical issues and strategic issues facing this community as the nation ends two major wars, wrestles with an age of fiscal austerity, and enters a presidential election that will set the course of policy for this community and the nation.”

“Policies related to the care of our military, veterans and their families have far-reaching effects, not only on the government agencies providing care, but the entire private/public sector which must address any gaps in services,” adds Anne Marie Dougherty, executive director of the Bob Woodruff Foundation which helped fund the report. “This report not only creates a dialogue as we look to elect our next commander in chief, it’s the first of its kind to comprehensively break down the demographics and issues facing today’s veterans.”

According to the report, “The next president, like those before, will have to grapple with a military that remains forward-deployed and engaged in myriad theaters against a broad array of threats. The needs of the active and reserve force, their families and the veteran population continue, even as an age of fiscal austerity grips the federal government and affects the ability of federal agencies to serve the veteran and military community. At the same time, demographic, social, economic and geographic change within the veteran and military community will continue, or even accelerate in some cases, changing the profile for this community.”

Urgent and Immediate Issues

Some critical concerns facing the military and veteran community have attracted mostly political consensus, both on the problems and solutions. These concerns include support for transition back to civilian life, economic opportunity, healthcare access and mental health provision, as well as support to veterans in crisis such as homelessness. The report’s authors urge “immediate action (or effective continuance of current efforts) and signaling of dedicated oversight from the first day of the next administration.”

The report noted that many of these areas are being addressed but also pointed out that deficiencies remain. Support for transition, for example, includes employment counseling, but this counseling and related networking are usually provided at the service member’s last duty station. Typically this is not the service member’s intended civilian destination, so the benefit is diminished. Even veterans who are initially employed tend to spend several years under-employed compared to their non-veteran counterparts. The reasons for this phenomenon are not clear, but comparative disadvantages in networking and in obtaining information about one’s opportunities appear to play a role.

Support for transition via educational opportunities is reportedly less cohesive. The report recommended more training and education programs beginning months before separation, preparing the way for employment later, rather than having the choice of such programs wait until the person leaves military service.

Also, transition support for the service member’s family tends to be more sporadic and less well focused, and – again – often not connected to the area where the family will live. (Colin Powell, in an interview shortly after his military retirement, said that the biggest adjustment for his wife was learning how to find out which plumber to call when one was needed.)

The transition from provision of healthcare by the Department of Defense (DoD) to the Veterans Administration (VA) is better organized, but these support efforts downplay private-sector options. This gap is important because the vast majority of returning veterans take jobs in the private sector, with employer-provided health plans. Many veterans report considerable difficulty in finding out what coverage will work best for them.

Crisis intervention is perhaps the most problematical and troubling area of immediate need. Homelessness and suicide are persistently higher among veterans than among their non-veteran counterparts. A number of programs and organizations have addressed these issues with some success, but the report’s authors urge continuing effort and more effort are needed.

The report also identified, in addition to substance abuse, homelessness and suicide problems, less prominent areas of need for crisis support including deployment and transition support for families, assistance to wounded and ill veterans, assistance to caregivers, and assistance with legal and housing issues. The report elaborated, “These kinds of support are very different, often requiring public and private action tailored to the facts of individual cases. The difficulty of offering such bespoke support and the urgency of the situations for the individuals involved make these issues challenging for even the best-functioning public and private bureaucracies. Because of that, these issues merit inclusion in this agenda and for the next administration.”

Operational Issues

According to the report, “A combination of factors – from demographic change within the veteran community to pressure from federal budget fights – has exposed fissures, gaps and tension points within the system that serves the veteran and military community. These include such issues as access to veterans’ healthcare reform and benefits support, reform of the military personnel system and connection of the military to society. On these matters, some agreement exists as to the nature or scope of the problems, but there is sharp disagreement on how to address them. These issues deserve attention from the next president; however, the election will likely determine their priority and what answers the next administration favors.”

The VA operates one of the largest healthcare systems in the world.

The VA operates one of the largest healthcare systems in the world.

As reported previously in OR/MS Today [4], the integration of care, especially medical records, among multiple providers, crossing government-private sector lines, has been a persistent challenge. In turn, lost information is a critical driver, perhaps the most important one, of both lower quality of care, including tens of thousands of preventable deaths and higher cost. Even the most enthusiastically adopted innovations can be surprisingly slow to take effect. In September 2014, Analytics magazine [6] reported on Aneesh Chopra (the nation’s first chief technology officer) and the system improvement initiatives he had started and promoted in that capacity. One of the accomplishments he discussed was the improvement in the VA’s information technology and resulting improvements in patient care. Ironically, the public uproar about long delays and quality problems in the Phoenix, Ariz., VA hospital occurred in April 2014, as Chopra’s book, “Innovative State,” was between final proofs and publication. The Secretary of Veterans Affairs, Eric Shinseki, ended up resigning because of these problems.

The lesson here for OR/MS analysts and other systems improvers is that various kinds of organizational inertia can bog down even strongly supported system changes; a persistent strong push from the top of the organization is needed. This is a major reason why the authors of the recent CNAS report focus mostly on policy-level leadership and actions.

Among the most important of these actions are supporting and facilitating better data exchange among providers and creating more public-private partnerships, to provide better continuity of care and to give veterans more choices of providers. The Veterans Access, Choice and Accountability Act, passed in August 2014 in response to the outcry, mandated more use of private-sector providers and public-sector partnerships to ease VA overloading, but the funds have been under-utilized. Wait times have actually increased, as more veterans sought health care through VA. The report added that, “VA health care remains one of the areas of ‘high risk’ across the federal government, as rated by the Government Accountability Office (GAO), which cited five key areas of concern: ambiguous policies and inefficient processes, inadequate oversight and accountability, information technology challenges, inadequate training for VA staff and unclear resource needs and allocation priorities.”

Also required is a better set of performance metrics, so that comparisons of different care settings and approaches to care can be properly compared. Such comparisons have become more important because of the increasing quality of battlefield protection and battlefield medicine, so that more people with serious, long-term injuries survive. Acute care choices make a huge difference in long-term outcomes for ailments such as spinal cord injury and traumatic brain injury, but acute care improves only when its providers are kept aware of findings from the long-term care providers.

The report also noted that the VA is the largest provider of mental health care and research in the world, but “both the DoD and VA have struggled to fully leverage alternative and innovative therapies, even when such therapies have a base of evidence to support their use. ... The entire sector continues to work to reduce the stigma surrounding mental health problems, which often inhibits treatment and translates into bias against those who have sought help. However, surveys suggest that stigma remains a prominent challenge for the veteran and military community and that more can be done by all to further reduce the social barriers to seeking help for mental health issues.”

Strategic Opportunities

“Beyond the specific policy choices to be made by the next administration,” the report states, “there are a number of steps that can be taken by public-, private- and nonprofit-sector leaders to continue momentum from the past 15 years of support for the veteran and military community. These include opportunities to better share data inside and outside of government, use data to make better decisions affecting this community, and expand public-private-nonprofit partnerships to better serve the nation.” Here the emphasis shifts from primarily medical information to many other areas in which veterans, especially the newest ones, may need assistance: employment, career decisions, financial decisions, housing, education options and decisions about which communities to join, among others.

In the healthcare industry, policy-makers confront a long-standing (source unclear) adage: “We all want the best available medical technology, promptly, at low cost. You can have two out of three.” In VA, given the intense congressional scrutiny, pressures to adopt new technology and to keep costs down tend to dominate. Hence VA is most frequently criticized for delays in providing care. Improved scheduling methods have alleviated some of these problems and can do more, but possibly some policy-level re-evaluation of priorities is needed as well.

The primary areas of strategic importance, according to the report, are better coordination of benefits programs among relevant agencies; better data sharing; near-real-time needs assessment; future planning and resource allocation; effective cooperation with the private sector, nonprofits and public-private partnerships; and identifying and measuring outcomes. Clearly there is a role for quantitative analytics, embedded into and trusted by the policy-making hierarchies, in all these areas.

A ‘First 100 Days’ Agenda

In addition to the operational and strategic issues, the report outlined a “a first 100 days” agenda for the next president to signal immediately his/her commitment to the veteran and military community and take those necessary first steps to enable subsequent success.” These steps include establishment of White House priorities and staff for this area, appointment and confirmation of key agency leaders, development of budget submissions to support this community fully, and early statements of administration policy on key issues such as funding priorities and the value of public-private partnerships. The importance of these steps is greater than might be obvious to readers unfamiliar with the policy process: The earliest policy-level appointees have an advantage in pushing their budget requests and subordinate appointees through a crowded congressional calendar, as well as in preparing a strong statement for the president setting goals and affirming commitment. Conversely, a subtle but effective way to undercut a policy area is to delay appointing the people responsible for it.

Conclusion

The report concluded, “Effective support for the veteran and military community matters for many reasons. National security depends on the United States’ ability to recruit, retain, manage and support its service members and their families. Most veterans do well after service, but some struggle, often needing support to tackle health, economic and wellness challenges that impede their transition to civilian life. The government has a sacred trust with its veterans to help with these challenges and support private- and nonprofit-sector efforts to help, too. The nation benefits from the successful transition and future success of veterans in myriad ways, including the contributions these veterans make to society after service and the example they set for future generations weighing whether to join the all-volunteer force.”

OR/MS analysts can continue to support these efforts, perhaps with greater focus on the policy and political decisions that enable or hinder analytics-based improvements.

Doug Samuelson (samuelsondoug@yahoo.com) is president and chief scientist of InfoLogix, Inc., in Annandale, Va. The author gratefully acknowledges Barbara Mader for editorial review and assistance.

References

  1. Phillip Carter, “Expanding the Net: Building Mental Health Care Capacity for Veterans,” Center for a New American Security (CNAS) Policy Brief, November 2013.
  2. Phillip Carter, Jason Dempsey, Katherine Kidder, and Amy Schafer, “Passing the Baton: A Bipartisan 2016 Agenda for the Veteran and Military Community,” Center for a New American Security (CNAS) Policy Brief, November 2015.
  3. Center for a New American Security, www.cnas.org.
  4. Brent James and Douglas A. Samuelson, “Change We Can Live With: Building the Data Capabilities and Analytics to Make Critical Improvements in Patient Safety and Wellness,” OR/MS Today, October 2013.
  5. Douglas A. Samuelson, “Caring for America’s Veterans: New Initiatives Highlight Need for Systems-Based Approaches,” OR/MS Today, February 2014.
  6. Douglas A. Samuelson, “Can Government Drive Information Innovation?,” Analytics, September-October 2014.