VA Outsourcing Could Increase Veteran Tragedies
On Tuesday, March 17th, a mentally ill veteran shot a social worker at a Jasper, Georgia, outpatient clinic run by the Department of Veterans Affairs. The veteran was shot and killed by law enforcement, and the social worker died of his wounds the next day.
Although details are still scant, the incident highlights a serious problem in the Veterans Community Care Program (VCCP), the private-sector network mandated by the VA MISSION Act of 2018. The VCCP now comprises over 1.7 million doctors, nurses, therapists, social workers, and other providers, and treats over 40 percent of Veterans Health Administration (VHA) patients.
From its inception, the plan (embraced by Republicans and Democrats alike) did not address how private-sector providers, who generally have no experience dealing with veterans’ complex mental and physical problems, can protect themselves when caring for a small subset of veterans who are at risk of harming others.
In the VHA, staff routinely undergo a well-developed Prevention and Management of Disruptive Behavior program, intended to ensure that staff are protected and veterans who have behavioral challenges still get needed care. While this program, as we saw in Georgia, may not prevent every tragic incident, it has prevented enormous harm. There is no analogous program in the private sector.
Similarly, while the VHA has a robust suicide prevention program, the private sector lacks adequate mechanisms to monitor veterans at risk of harming themselves. In the VHA, electronic health records contain flags that indicate that a veteran patient is at risk for suicide or has problems with aggressive behavior. It’s not clear that private-sector providers receive such alerts.
The private sector lacks adequate mechanisms to monitor veterans at risk of harming themselves.
This is ironic, since outside the VHA, health care providers have grown increasingly concerned about the escalating risk of violence against staff. The Association of American Medical Colleges reports that “health care workers … are five times more likely to experience workplace violence than employees in all other industries.” Patient violence is due to many factors, including low staffing, patient anger and confusion, and mental health problems. Although the Joint Commission, the body that accredits hospitals, requires that hospitals establish programs that prevent workplace violence, many health care staff complain that their institutions have not taken this problem seriously enough. When a social worker at an HIV program at San Francisco General Hospital was killed by a patient this past December, staff complained about what they considered to be “radio silence” from hospital leaders when they had been contacted about threats to staff.
Very few private-sector providers are aware of the fact that veteran patients can contribute to the problem of workplace violence. That’s because military service and training in and of itself puts service members and veterans at a high risk for harming themselves and others.
As Lt. Col. Dave Grossman writes in his famous book On Killing, military training teaches people to overcome the “innate human resistance toward killing one’s own species,” employing many “psychological mechanisms” to reduce this resistance. Service members are taught to wield lethal weapons and to revere arms, particularly their guns or rifles. They are also socialized not to fear their own death and, sadly, not to seek professional help for treatable mental health conditions. (One Marine mantra, for example, is “Pain is weakness leaving the body.”) Some experts believe that this “habituation to fear of painful experiences” may be one of the reasons why the rate of veteran suicide is higher than in the general population.
Many veterans suffer from PTSD and other mental health conditions, as well as traumatic brain injuries, which can lead to heightened aggression. TBI is the signature injury of our wars in Iraq and Afghanistan. One survey of soldiers who had returned from combat in those wars found that many had problems with alcohol and aggression that often increased over time. Researchers have documented that aggressive behavior can result in high rates of intimate-partner violence. Another study of Afghanistan veterans who were referred to the VA for behavioral health problems found that 60 percent had exhibited physical violence toward a partner.
As David Swanson has noted, while veterans represent 15 percent of males aged 18–59 in the United States, 36 percent of American male mass shooters of that age are veterans. Timothy McVeigh, Ian David Long, and Albert Wong were veterans who committed incidents of lethal mass violence. Robert Card, the veteran who killed 18 civilians and injured 13 in Lewiston, Maine, was never deployed to a combat zone. As we are now learning, Card suffered from TBI after spending years as a grenade instructor, where he was exposed to literally thousands of blast injuries.
The VHA’s Prevention and Management of Disruptive Behavior (PMDB) program was developed because VA caregivers are all too familiar with veterans “setting a hospital bed on fire, pulling a fire alarm, throwing a chair through a window, or threatening lawsuits or to have people fired.” (VHA employees wear lanyards from which their ID cards dangle; if pulled by an angry patient or family member, they unclasp so that they cannot be used as a weapon.)
Sometimes veterans may act in aggressive or threatening ways not because they want to harm others but rather themselves. In 2015, a 77-year-old veteran, Johnie Wayne Roth, arrived at the Denver VA Medical Center for an appointment with his nurse practitioner (NP). He immediately pulled out a handgun and threatened the nurse, holding her hostage in a small exam room. Fortunately, as Kate McPhaul, then chief occupational health consultant at the VA, explained, the NP as well as VA police were trained in de-escalation techniques and managed to calm the veteran. They discovered that the veteran did not really want to harm the NP but planned to shoot at the ceiling in the hopes that VA police would come and shoot him—a phenomenon known as “suicide by cop.”
The PMDB program is critical not only for the safety of patients and staff but because the VHA is not allowed to reject patients who are considered recalcitrant, difficult, or potentially harmful to themselves or others. “At the VA, we don’t deny care,” according to Michael Drexler, who was a coordinator of the Workplace Violence program at the San Francisco VA. The program has created extensive mechanisms to identify problematic behavior and hopefully prevent serious harm by reaching out to angry veterans and working with them on reducing and/or containing aggression. In some instances, this may require that a veteran be escorted by a police officer when they come on campus and go to an appointment.
“I’ve had hundreds of threats over my career,” a former VA medical director told the Prospect. “We have expert committees assembled to assess the level and seriousness of these threats. Although 99 of 100 vets are not going to harm anyone, 1 out of that 100 could, and it’s critical to deal with that potential problem. It’s also critical to assure that veterans continue to get needed care.”
If private providers experience any kind of verbal or physical threats, a patient risks being “fired.”
When the Prospect asked the VA if community care referrals included suicide and behavioral alerts, spokesperson Peter Kasperowicz pointed to directives that advised “facility community care clinical staff to ensure” that information about veterans who had a “High Risk for Suicide Patient Record Flag (HRS-PRF)” be conveyed to community care providers. The VA’s response included no information about behavioral flags. When the Prospect asked several facility community care staff if they included information about patients with suicide and behavioral flags, they said guidance on this issue was very unclear. Indeed, the medical director who spoke above believed that there was no directive requiring that staff relay suicidal or disruptive behavior flags to community providers in their referral package.
Even if community care staff are informed about patients who are a danger to themselves and others, they are not equipped to act on this information. That’s because they are not required to take the same kind of trainings as VHA staff. In the VHA, for example, all staff (from housekeepers to schedulers to food service workers to dentists) are trained in the rudiments of suicide prevention. If a dentist hears a vet commenting dejectedly that they may not be “around to make my next appointment,” they are taught to try to discover if the vet is planning a Florida vacation or suicide. In the private sector, that training is not required.
If private providers experience any kind of verbal or physical threats or abuse, a patient risks being “fired,” not well managed. In the private sector, “firing” patients is routine, not only because a patient displays aggressive behavior but because they have missed too many appointments, fail to follow a physician’s advice or treatment recommendations, or don’t pay bills. Indeed, medical associations routinely provide physicians with advice about how to terminate a patient without being accused of patient abandonment. This presents a serious problem for disruptive veterans who risk being “fired” and thus denied needed care.
As one private-sector primary care provider told the Prospect, “We are simply unequipped to take care of veterans with serious mental health or behavioral problems. The VA is great, why don’t they just stay there?”
When it comes to the problem of workplace violence in the private sector, even conservatives like House Committee on Veterans’ Affairs member Rep. Mariannette Miller-Meeks (R-IA) are supportive of strong preventive action. Miller-Meeks is the co-sponsor in the House of the Save Healthcare Workers Act, which would make assaulting a health care worker a federal crime. Ironically, conservatives like Miller-Meeks also seem determined to ignore this problem with veterans’ care, as they pursue their agenda to entirely dismantle the VHA.
For example, a key component of the Critical Access for Veterans Care Act, which is supported by Republicans in both houses, allows veterans to access private-sector care without any VA input or even knowledge. One of the bill’s sponsors, Sen. Kevin Cramer (R-ND), has explicitly stated that he considers VA input in patient referrals to be “an unnecessary roadblock.” One of the roads that VA input may block, however, is the one that leads veterans down the path to harming themselves or others.
Update, March 27: This article has been updated with a comment from the Department of Veterans Affairs.
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