The Department of Veterans Affairs (VA) is completing one stage of a comprehensive effort to project building and service needs for health care for the next two decades.
Final recommendations of the Capital Asset Realignment for Enhanced Services (CARES) Commission are due to VA Secretary Anthony J. Principi next month. The Committee on Care of Veterans With Serious Mental Illness (SMI Committee) and mental health advocates have expressed concern about aspects of the planning process in terms of their impact on mental health (see pages 2 and 9).
VA Undersecretary for Health Robert H. Roswell, M.D., in an interview with Psychiatric News, commented on the challenges of projecting needs for mental health care.
Roswell shares the doubts expressed by the SMI Committee and mental health advocates about the validity of the Condor-Milliman model as a tool to estimate need for outpatient mental health services. "We had no confidence in the projections," he said. "They showed such a marked decline in the need for services."
The problem, as pointed out by the SMI Committee and others, was that Condor-Milliman based its model on mental health services that are billable in the private sector, whereas the VA serves a population that is different from those covered by employer-based insurance.
Roswell believes that the use of the flawed model underestimated the need for outpatient mental health services by approximately 35 percent on a national basis. However, he cautioned against the use of a "quick and dirty fix" (such as adding 35 percent to estimated need) that would not "add value" to the CARES process.
"To collect data from each VISN and then identify gaps at this late date would unnecessarily delay the process," he said.
VISN refers to the Veterans Integrated Service Networks. A VISN is a service area within the network.
Roswell also pointed out that the CARES planning process was designed to focus on the VA’s long-term infrastructure needs. The original impetus for CARES was a 1999 report by the General Accounting Office that claimed that "billions of dollars might be used operating hundreds of unneeded buildings over the next five years or more."
He said, "Outpatient services, for the most part, are not dependent on physical structure." The VA has developed a validated model for the projection of need for inpatient mental health services.
He added that a strategic planning process for mental health services is under way that will take into account concerns of the SMI Committee about future need for outpatient services.
The Mental Health Strategic Planning Group, which is co-chaired by Larry C. Lehmann, M.D., chief consultant, and Mark Shelhorse, M.D., will issue a final report in August 2004.
Roswell explained that the campus-realignment proposals came about after he received proposed plans from the VISNs on April 15 and realized that there was a "wide variability in how people addressed issues related to the operational efficiency of infrastructure."
Respondents from three VISNs identified situations in which two medical centers administered by the same management team are in close proximity (30 miles or fewer) to each other. Those respondents suggested various forms of consolidations of the centers that would improve administrative efficiency and save money.
In addition, said Roswell, consolidation could improve quality of care. Now, in some situations, for example, a veteran who receives inpatient psychiatric care and shows symptoms of cardiac arrest might be transferred by ambulance to a non-VA medical facility.
He emphasized the idea that the CARES Commission recommendations submitted in December to Principi will not be a "definitive final product."
Roswell expressed sympathy with concerns of advocates that mental health services might be diminished by the realignments. "[I want to assure them] that we will not close one campus until we are able to relocate the psychiatric beds to another site. There will be no reduction in bed capacity," he said.
The VA has put a "tremendous amount of work" into developing an answer to the question posed by Sen. John D. Rockefeller IV (D-W.Va.) in a hearing about mental health services in July 2002. Rockefeller, who was then chair of the Senate Veterans Affairs Committee (SVAC), asked Roswell, "What would it cost to do the job right?"
"It is a sweeping and important question," said Roswell. VA staff came up with a model, which went through a validation process, to determine that number. In September a draft response to the SVAC was sent to the Office of Management and Budget for review.
Roswell pointed out that challenges for the VA in predicting need have come about because of improved models of psychiatric and other medical care within the VA and elsewhere.
Capacity is "fairly easy to predict," he said, only if we can assume that current models and needs are merely extended into the future.
"We have been remarkably successful, for example, in extending the lives of many, many veterans with serious mental illness," he said. But that success poses the problem of planning for integrated psychiatric and geriatric services in nursing homes and other settings. ▪
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