Joanna Sells is a US Department of Veterans Affairs (VA) and University of California, San Francisco (UCSF) Quality Scholar Psychology Fellow. John McQuaid is Associate Chief of Staff for Mental Health, both at the San Francisco VA Health Care System and Vice Chair, Department of Psychiatry Weill Institute of Neuroscience, UCSF. Correspondence: Joanna Sells (joanna.sells@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
The VA Office of Research and Development has existed for more than 90 years with a mission to improve veteran health and well-being via research and attract, train, and retain high-caliber researchers. VA provides a rich environment to conduct observational and interventional research due to its large, diverse veteran population, institutional support, and integrated information system with extensive EHR data.41 The success of the VA in facilitating research is evidenced by the fact that 3 VA investigators have been awarded Nobel prizes, and 7 have received Lasker Foundation Awards.42 The size of the VA allows for innovative large-scale research, such as the Million Veteran Program (MVP). The MVP study developed a mega-biobank of VA health records, questionnaires, and blood samples from nearly 1 million veterans to study genetic influences on health and disease and integrate genetic testing into health care delivery.43 In addition to producing high-quality, innovative research, more than 60% of VA investigators also provide direct patient care.42
VA research areas of focus include homelessness, polytrauma, traumatic brain injury, hearing and vision loss, spinal cord injury, mental health, pain management, precision medicine, prosthetics and amputation care, women’s health, and chronic diseases, such as Parkinson and Alzheimer diseases.44 The VA estimates that, in 2021, total VA research spending will include a request of $787 million in addition to $370 million from the National Institutes of Health, the Department of Defense, and the Centers for Disease Control and Prevention, and $170 million from other nonfederal sources, for a projected total of $1.3 billion. This budget will support 2,200 projects with direct research and reimbursable employment of 3,275 FTEs,which are key to supporting VA academic affiliations.45 These funds translate into substantial benefits to the UC system, including shared research and training resources, grant-funding opportunities for UC faculty, and the ability to recruit top researchers, educators, and clinicians to its institutions.
VA Reliance on Community Care
The current VHA model is an integrated health care system that provides comprehensive, wraparound services to enrolled veterans, which are cost-effective, high quality, and consistently found to have equal or superior quality of care compared with that in the community.6,46-50 Despite public criticism about wait times and access to care in the VA system, one study showed that VA wait-time statistics were comparable with or faster than those for community HCPs.51,52 However, VA care coordination has undergone several changes to address these public criticisms, namely, the Veterans Access, Choice and Accountability Act of 2014 (38 USC § 1703VACAA) and the VA MISSION Act of 2018 (42 USC § 274). VACAA was designed to increase access to care for veterans who live ≥ 40 miles from VA health care facilities or who are unable to been seen within 30 days of their preferred or clinically appropriate date.53 More than 2 million veterans (almost 25% of VHA-enrolled veterans) have received community care since the inception of VACAA in 2014.54
Recently, the MISSION Act mandated developing additional VA-coordinated community-based care through the establishment of a Veterans Community Care Program, which was established using existing VA 2019 fiscal year funds and did not include additional appropriations despite expanded criteria for community care referrals.55 Without additional future appropriations, VA funds would be shifted from VA care into community care. While increasing access to community care has in some cases led to care that is faster and closer and that was previously inaccessible in local VA specialty care, these efforts could reduce veteran engagement with the VA system.56
The changes implemented in VACAA and the VA MISSION Act were driven by important and valid concerns, including evidence of VA staff and officials covering up service deficiencies.51 Veterans in rural areas often have limited access to VA resources, and long travel to VAMCs or clinics can be an impediment. Veterans who have chosen community care tended to be those who have poorer health status, who live further away from VA facilities, women, and those who identified as White or Hispanic.56,57 While VA health care is on average equivalent to or better than community resources, there is significant variability in quality within the VA system. Advocates have argued that providing competition and choice for veterans places pressure on the VA to improve care where it is not meeting expectations. Therefore, access to community care is an important resource for veterans and needs to be implemented effectively and efficiently to help veterans receive the care they need. However, expansion of community care access, depending on how it is implemented, also can have effects on academic partnerships and the education and research missions that should be incorporated into planning.
Each VA health care system receives funding through the Veterans Equitable Reimbursement Allocation (VERA), which provides funds largely based on the number of enrolled veterans and the complexity of the care they receive.58 One potential implication of the shift among veterans to community care is a reduction in patients enrolled in VA programs, thus decreasing funding given to the VA to allocate for training and research. By definition, increased VA-managed community care means less opportunity for integrated training that brings together primary, mental health, and substance use care to meet patient needs. The Center for Medicare and Medicaid Services has developed a national initiative to help states develop programs in integrated care, particularly for individuals who are eligible for both Medicare and Medicaid.59 For states to develop integrated care, they need trainees who function well in this model. Integrated care training is particularly vulnerable to disruption because any portion of a veteran’s care being transferred to the community can impede integration. In effect, training in integrated care, likely the most efficient and cost-effective approach to health care for reasons discussed earlier, could be reduced as providers and trainees are required to manage and coordinate patient care between separate institutions.35
