VETERANS HEALTH CARE: Services for Substance Use Disorders, and Efforts to Address Access Issues in Rural Areas

Substance use and illicit drug use are a growing problem in the United States. SUDs occur when the recurrent use of alcohol or drugs causes significant impairment, such as health problems. The veteran population has been particularly at risk. Veterans are 1.5 times more likely to die from opioid overdose than the general population, according to VA and Centers for Disease Control and Prevention data. Furthermore, veterans live in rural areas at a higher rate than the general population, which may affect their ability to access SUD services. VA is the largest integrated health care system in the United States, providing care to about 6.2 million veterans. VA provides SUD services through outpatient, inpatient, and residential care settings and offers various treatment options, including individual and group therapy, medication-assisted treatment, and naloxone kits to reverse overdoses.

Senate Report 115-130 included a provision for GAO to study VA's capabilities to treat veterans with SUDs. This report describes (1) trends in the number of and expenditures for veterans receiving SUD services, including specialty SUD services; and (2) any differences between veterans' use of SUD services in rural and urban areas, and the issues affecting access to those services in rural areas. GAO reviewed VA policies and data from fiscal years 2014 through 2018. GAO also interviewed officials from six VA health care systems, selected for their high percentage of veterans with an opioid use disorder and to achieve variation in geography and locations VA has designated as urban and rural.

VA provided technical comments, which GAO incorporated as appropriate.

The Department of Veterans Affairs (VA) treated 518,570 veterans diagnosed with a substance use disorder (SUD) in fiscal year 2018, a 9.5 percent increase since fiscal year 2016. Of these, 152,482 veterans received specialty SUD services in fiscal year 2018, a number that has remained relatively unchanged since fiscal year 2014. Specialty SUD services are those provided through a clinic or program dedicated to SUD treatment. Expenditures for VA's specialty SUD services increased from about $552 million in fiscal year 2014 to more than $600 million in fiscal year 2018. In the same year, VA expended about $80 million to purchase SUD services from non-VA community providers for more than 20,000 veterans, an increase since fiscal year 2014. The number receiving this care from non-VA providers may include veterans who also received services in VA facilities.

Note: Specialty SUD services are those provided through a clinic or program dedicated to substance use disorder treatment. SUD services include services provided by any type of provider.

VA data show that overall there was little difference in the percentage of veterans using SUD services, including specialty services, in rural and urban areas in fiscal year 2018. However, there were differences for some specific services. For example, in rural areas, 27 percent of veterans with an opioid use disorder received medication-assisted treatment—an approach that combines behavioral therapy and the use of medications—compared to 34 percent in urban areas. In providing SUD services in rural areas, VA faces issues similar to those faced by the general population, including lack of transportation. The agency is taking steps to address these issues, such as using local service organizations to transport veterans for treatment.

Substance use and illicit drug use is a growing problem in the United  States. Veterans are at particular risk for substance use disorders (SUD),  as veterans may use drugs or alcohol to help cope with the effects of  stressful events experienced during deployment or with difficulties they  encounter in readjusting from wartime military service to civilian life. For  example, the largest portion of drug overdose deaths in the United States  are attributed to opioids, and veterans are 1.5 times more likely to die  from opioid overdose than the general population, according to 2016 data  from the Department of Veterans Affairs (VA) and the Centers for Disease  Control and Prevention. Access to SUD services—a subspecialty of  mental health services—is important because of the harmful  consequences of untreated SUDs on veterans’ physical, psychological,  and social well-being. However, veterans may face greater issues  obtaining quality medical care, including SUD services and medicine,  because they live in rural areas at a higher rate than the general  population. Rural areas have traditionally experienced shortages of  health care professionals.

The Veterans Health Administration (VHA), which operates one of the  nation’s largest health care delivery systems, offers specialty SUD  services—services delivered in programs specifically dedicated to SUD  treatment in either a residential or outpatient setting—as well as non- specialty SUD services delivered in, for example, primary care or in  general mental health clinics. The majority of veterans who access health  care services through VHA, including SUD services, receive those  services in VA-operated medical facilities; however, veterans may also  obtain services that VHA purchases from non-VA providers in the  community either via specific programs, known as community care, or via  local contracts.

Senate Report 115-130 included a provision for us to examine VHA’s  capabilities and capacity for treating veterans with SUDs. In this report,  we describe:  1. trends in the number of and expenditures for veterans receiving SUD services, including specialty SUD services; and 2. any differences between veterans’ use of SUD services in rural and urban areas and the issues affecting access to those services in rural areas.

To describe trends in the number of and expenditures for veterans  receiving SUD services, we obtained VHA data for fiscal years 2014  through 2018 on 1) specialty SUD services (SUD services provided in  outpatient settings and residential treatment programs specifically  dedicated to SUD treatment) provided within VHA and 2) SUD services  (both specialty and non-specialty) provided through community care. We  analyzed these data to identify trends in the numbers of veterans  receiving services, expenditures for those services, and relevant clinical  staff providing those services. We also analyzed VHA data on veterans  who received any treatment (specialty or non-specialty services) from  VHA for a diagnosed SUD; we report these data in the background of this  report. Furthermore, we reviewed VHA data on reported average and  median wait times for admission to residential rehabilitation treatment  programs dedicated to SUD treatment, as well as our previous reports on  VHA wait times. VHA officials identified 12 residential rehabilitation  treatment programs dedicated to SUDs that did not have reliable wait- time data, which we excluded from our wait-time analysis. VHA data on  wait times for outpatient specialty SUD services were not available at the  time of our review. We assessed the reliability of the data we used for  these various analyses by interviewing officials responsible for overseeing  the data sources and examining the data for obvious errors. We  determined the data—with the exclusion of certain residential  rehabilitation treatment programs’ wait-time data, as described above— were sufficiently reliable for this reporting objective. In addition to our data  analyses, we reviewed VHA documentation related to the number of and  expenditures for veterans receiving specialty and non-specialty SUD  services, such as agency budgetary submissions, and interviewed  agency officials regarding the data and documents we reviewed.

To describe any differences between veterans’ use of SUD services in  rural and urban areas and the issues affecting access to those services in  rural areas, we reviewed agency policies and other documents and  interviewed agency officials regarding services for veterans with SUDs.  We also analyzed data from VHA’s 140 health care systems—that is, VA  medical centers grouped together with their affiliated outpatient clinics  and other medical facilities—by location to compare specialty SUD  service use at health care systems designated by VHA as urban to those  designated as rural. We assessed the reliability of these data by  interviewing officials responsible for overseeing the data sources and  examining the data for obvious errors. We determined the data were  sufficiently reliable for this reporting objective. See appendix I for an  interactive map of VHA’s health care systems. In addition, we selected six  VHA health care systems—three urban and three rural in various  geographic regions, from among the health care systems with the highest  percentages of veterans with an opioid use disorder diagnosis—and  interviewed officials regarding their services for and issues serving  veterans with SUDs. We selected VHA health care systems in Bath, New  York; Cincinnati, Ohio; Coatesville, Pennsylvania; Lexington, Kentucky;  Roseburg, Oregon; and White River Junction, Vermont. See appendix II  for more information on our selection process and on selected site  characteristics. We also identified and reviewed articles to corroborate the  issues officials from the selected VHA health care systems identified in  providing services to veterans with SUDs. We reviewed articles obtained  via research databases such as ProQuest, as well as publications  identified through citations in those articles and in agency documents,  and reviewed their methodologies. The results of our analyses based on  the six selected VHA health care systems cannot be generalized to all  VHA health care systems.

We conducted this performance audit from August 2018 to November  2019 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.

In fiscal year 2018, VHA data show that 518,570 veterans received any  treatment (specialty or non-specialty services) from VHA’s health care  systems for a diagnosed SUD, a 9.5 percent increase from fiscal year  2016 (see figure 1). Because these data include non-specialty services,  the data do not indicate the extent to which the veteran received SUD  services. For example, a provider briefly discussing the SUD of a veteran  in long-term recovery during a primary care visit would be included in  SUD treatment data. VHA data show that the majority of veterans who  received any treatment from VHA’s health care systems for a diagnosed  SUD had an alcohol use disorder.

Veterans received any treatment from VHA for a diagnosed SUD at a  higher rate than the general population. Data from the 2017 National  Survey on Drug Use and Health indicate that 1.5 percent of individuals  aged 18 or older nationwide received any SUD treatment in the past  year. In comparison, 8 percent of veterans getting health care provided  or purchased by VHA received any treatment for a diagnosed SUD in  fiscal year 2017, including individuals who received specialty SUD  services as well as individuals who received non-specialty services in, for  example, primary care or general mental health clinics.

VHA’s health care systems provide specialty SUD services in three  settings increasing in intensity (see figure 2):

Outpatient services. Individual and group therapy, either in person or  via telehealth, among other services. VHA also offers intensive  outpatient programs, which provide services for 3 or more hours per  day, 3 days a week at a minimum.

Residential rehabilitation treatment programs. Medically  monitored, high-intensity care in a 24-hour supervised environment  specifically dedicated to treating SUDs. These programs may also  provide social services for community reintegration and treatment for  other medical conditions during a veteran’s stay.

Inpatient services. Acute in-hospital care, which may include  detoxification services.

Medication-Assisted Treatment for Opioid Use Disorder

For veterans with opioid use disorder—a subset of SUDs—VHA’s health  care systems provide medication-assisted treatment. Medication- assisted treatment combines behavioral therapy and the use of certain  medications, including methadone and buprenorphine. Medication- assisted treatment has proven to be clinically effective in reducing the  need for inpatient detoxification services for individuals with opioid use  disorder, according to SAMHSA.

Methadone. This medication suppresses withdrawal symptoms  during detoxification. It also controls the craving for opioids in  maintenance therapy, which is ongoing therapy meant to prevent  relapse and increase treatment retention. Methadone is a controlled  substance and, when used to treat opioid use disorder, may generally  be administered or dispensed only within a certified opioid treatment  program to help prevent diversion.

Buprenorphine. This medication eliminates opioid withdrawal  symptoms, including drug cravings, and it may do so without  producing the euphoria or dangerous side effects of other opioids. It  can be used for detoxification and maintenance therapy.  Buprenorphine is also a controlled substance, and when used to treat  opioid use disorder, may be administered or dispensed within an  opioid treatment program, or prescribed or dispensed by a qualifying  provider who has received a waiver to do so. Providers who receive  this waiver are limited in the number of patients they may treat for  opioid use disorder.

In addition to medication-assisted treatment, VHA has initiatives aimed at  preventing opioid-related overdose deaths. For example, VHA’s Opioid  Overdose Education and Naloxone Distribution program includes  education and training regarding opioid overdose prevention as well as  naloxone distribution. Naloxone is a medication that can reverse opioid  overdoses.

Veterans may receive services from community providers via local  contracts or community care. For local contracts, individual VA medical  centers establish contracts with local community providers. For example,  a VA medical center may develop a contract with a community residential  rehabilitation treatment program provider to set aside a number of beds  specifically for veterans.

For community care, veterans may be eligible if, for example, VHA does  not offer the care or service the veteran requires or VHA cannot provide  the care or services consistent with its access standards. In general,  community care services must be authorized in advance of when  veterans access the care. Prior to June 6, 2019, eligible veterans could  receive community care via one of multiple VHA community care  programs. In 2018, the VA MISSION Act required VA to implement a  permanent community care program that consolidated several community  care programs. On June 6, 2019, the consolidated community care  program, the Veterans Community Care Program, went into effect.

Number of Veterans Receiving, and Expenditures for, VHA Specialty SUD Services Have Remained Unchanged in Recent Years; Community Care SUD Services Have Increased

Number of Veterans Receiving Specialty SUD Services in VHA’s Health Care Systems and Related Expenditures Were Relatively Unchanged Between Fiscal Years 2014 and 2018

Among the 518,570 veterans who received SUD services in fiscal year  2018, VHA provided specialty SUD services to 152,482 veterans in fiscal  year 2018. This number has increased slightly but remained relatively  unchanged since fiscal year 2014, as shown in table 1 below. These  veterans received care in VHA’s health care systems—that is, in VA  medical centers or in one of the medical centers’ affiliated outpatient  clinics and other medical facilities. During the same time period, VHA  expenditures for these specialty SUD services increased from $552  million in fiscal year 2014 to $601 million in fiscal year 2018. Total  specialty SUD expenditures per capita increased from $3,691 to $3,941  from fiscal years 2014 through 2018. Adjusted for inflation, however, per  capita expenditures remained relatively unchanged between fiscal years  2014 and 2018.

Most Veterans Received Specialty SUD Services in Outpatient Settings; Medication-Assisted Treatment Has Increased for Opioid Use Disorders in Recent Years

Our analysis of VHA data shows that veterans received specialty SUD  services from VHA’s health care systems in multiple settings from fiscal  years 2014 through 2018, with most veterans receiving these services in  outpatient settings. Veterans may receive specialty SUD services across  multiple settings within a year. Below, we provide information on  utilization and expenditures for specialty SUD services in outpatient and  residential treatment programs and for medication-assisted treatment for  veterans with opioid use disorder.

In fiscal year 2018, nearly all veterans who received specialty SUD  services from VHA’s health care systems received this care in outpatient  settings at some point during the year. Of those veterans who received  outpatient specialty SUD services, 17 percent received intensive  outpatient specialty SUD services, with little change from previous  years. Expenditures for outpatient specialty SUD services increased  from fiscal years 2014 through 2018, as shown in table 2 below. During  this time period, outpatient specialty SUD expenditures per capita  increased from $2,176 to $2,348. Adjusted for inflation, per capita  expenditures grew 1.5 percent between fiscal years 2014 and 2018. In  addition, we found little change in the number of full-time employee  equivalents that actively provided outpatient specialty SUD services from  fiscal years 2015 through 2018.

VHA did not provide specialty outpatient wait-time data because,  according to VHA officials, the data do not reliably capture veterans’ wait  times to receive SUD services in outpatient settings. VHA officials  explained that veterans may receive non-specialty SUD services in  various outpatient settings, including primary care and general mental  health clinics. Therefore, developing a wait-time measure for specialty  SUD services would not accurately capture whether veterans are waiting  for SUD services not previously provided or services that would continue  ongoing treatment begun in a primary care or general mental health clinic.  As a result, we did not analyze outpatient wait-time data. In prior work, we  have made recommendations to VHA on ways it can improve its  outpatient wait-time data (see sidebar).

Specialty Residential Rehabilitation Treatment Programs

As of fiscal year 2018, VHA had residential rehabilitation treatment  programs available for veterans with complex and long-term mental  health needs at 113 facilities, and 67 of these programs were dedicated  to SUD treatment. The number of residential rehabilitation treatment  programs dedicated to SUD treatment increased from fiscal years 2014  through 2018, as did the number of beds available. Figure 3 shows the  location of all 67 residential rehabilitation treatment programs specifically  dedicated to SUDs with the corresponding number of beds in fiscal year  2018. See appendix III for more information on residential rehabilitation  treatment programs dedicated to SUD treatment.

The number of veterans participating in VHA’s specialty SUD residential  rehabilitation treatment programs (that is, those dedicated to SUD  treatment) remained relatively stable from fiscal years 2014 through 2018,  as shown in table 3. Of the veterans who received specialty SUD  services in fiscal year 2018, approximately 10 percent participated in one  of VHA’s 67 residential rehabilitation treatment programs dedicated to  SUD treatment, similar to previous years. Meanwhile, expenditures for  VHA’s residential rehabilitation treatment programs dedicated to SUD  decreased from fiscal years 2014 through 2016, but increased in fiscal  years 2017 and 2018. Similarly, specialty SUD residential expenditures  per capita decreased from $15,386 in fiscal year 2014 to $12,526 in fiscal  year 2016 and increased again to $16,031 in fiscal year 2018. After  adjusting for inflation, specialty SUD residential expenditures per capita in  2018 were about 2 percent less than what they were in 2014.

From fiscal years 2014 to 2018, veterans’ average length of stay for  VHA’s specialty residential rehabilitation treatment programs specifically  dedicated to SUD generally decreased, while wait times varied across  programs. Across VHA’s residential rehabilitation treatment programs  dedicated to SUD treatment, veterans’ average length of stay generally  decreased from fiscal years 2014 to 2018, from nearly 40 days to nearly  36 days. VHA officials said that average length of stay may have  decreased as a result of multiple factors, such as programs with longer  lengths of stay adjusting their treatment approaches. The median wait  times to enter residential rehabilitation treatment programs dedicated to  SUD treatment varied considerably, ranging from 0 days to 56 days  across the programs in fiscal year 2018, although not all residential  rehabilitation treatment programs had sufficient—and therefore reliable— data on wait times.

Specifically, out of the 67 residential rehabilitation treatment programs  dedicated to SUD, VHA officials identified 12 that did not have sufficient  wait-time data, which we excluded from our analysis. VHA officials noted  that some specialty residential rehabilitation treatment programs do not  have sufficient wait-time data because the facilities do not consistently  code whether a patient’s visit included a screening for admission to the  program. As such, VHA cannot tell when patients were initially screened  for admission. In fiscal year 2019, officials implemented changes to  address the lack of reliable data from some facilities. However, it is too  early to tell if the new changes will address the data reliability issues in  wait-time data for residential rehabilitation treatment programs.

VHA health care systems offer veterans medication-assisted treatment for  opioid use disorder in a variety of settings, including outpatient specialty  SUD settings and residential rehabilitation treatment programs dedicated  to SUD treatment, as well as in non-specialty settings, such as primary  care and general mental health clinics. Our analysis of VHA data shows  the number and proportion of veterans with an opioid use disorder who  received medication-assisted treatment from VHA’s health care systems  has risen in recent years, as shown in table 4. In fiscal year 2018, 23,798  veterans received medication-assisted treatment, which was 33.6 percent  of veterans diagnosed with an opioid use disorder. Veterans with an  opioid use disorder may receive medication-assisted treatment through  VHA at a lower rate than individuals who received care through private  insurance. According to a study by the Department of Health and Human  Services, 50.6 percent of individuals diagnosed with an opioid use  disorder and enrolled in private insurance received medication-assisted  treatment in 2014 to 2015. Some veterans may also have private  insurance and may have received their medication-assisted treatment  through that private insurance.

In fiscal year 2018, 9,132 (38 percent) of the veterans who received  medication-assisted treatment received their care at one of VHA’s 33  opioid treatment programs, which is the only setting where methadone  can be administered to treat opioid use disorder. Expenditures for these  opioid treatment programs increased from $35.9 million in fiscal year  2014 to $39.1 million in fiscal year 2018.

In fiscal year 2018, VHA had 2,036 providers with a waiver to prescribe  buprenorphine, a 17.6 percent increase from fiscal year 2017.  According to VHA officials, VHA has encouraged its providers—including  those who are not specialists in treating SUDs, such as primary care  providers—to obtain the waiver required to prescribe buprenorphine to  treat opioid use disorder. In fiscal year 2018, there were about 29 VHA  providers with a waiver to prescribe buprenorphine for every 1,000  veterans with opioid use disorder, a 14 percent increase from fiscal year  2017.

VHA’s naloxone kit distribution increased exponentially from 646 in fiscal  year 2014 to 97,531 kits in fiscal year 2018. A total of 204,557 naloxone  kits have been distributed through fiscal year 2018. VHA health care  systems distributed naloxone kits to VA staff, including VA first  responders and VA police officers, and veterans with opioid use disorder.  Factors contributing to the increase may include:  In 2014, VHA implemented the Opioid Overdose Education and  Naloxone Distribution initiative to decrease opioid-related overdose  deaths among veterans, with one of its key components focused on  encouraging naloxone kit distribution. Since the program’s  implementation, all VHA health care systems dispense naloxone kits.

The Comprehensive Addiction and Recovery Act of 2016 directed  VHA to maximize the availability of naloxone to veterans and to  ensure that veterans who are considered at risk for opioid overdose  have access to naloxone and training on its proper administration.

More Veterans Have Received SUD Services through Community Care in Recent Years; VHA Seeks to Collect Reliable Data on Usage by Community Care Settings

Veterans Health Administration (VHA)  Community Care Wait Times  GAO has a body of work highlighting  challenges VHA has with the reliability of its  wait-time data. See below for recent reports  about this issue.  We have highlighted the importance of  reliable community care wait-time data in a  testimony regarding VHA’s efforts to address  our previous recommendations on these  issues. See GAO, Veterans Health Care:  Opportunities Remain to Improve  Appointment Scheduling within VA and  through Community Care, GAO-19-687T  (Washington, D.C.: July 24, 2019).  We have designated our past  recommendations related to community care  wait-time data as priorities for the agency.  See GAO, Priority Open Recommendations:  Department of Veterans Affairs, GAO-19- 358SP (Washington, D.C.: Mar. 28, 2019).  We have previously made recommendations  to VHA to capture the necessary information  and improve the reliability of wait-time data  for community care. These recommendations  remain outstanding as of October 2019. See  GAO, Veterans Choice Program:   Improvements Needed to Address Access- Related Challenges as VA Plans  Consolidation of its Community Care  Programs, GAO-18-281 (Washington, D.C.:  June 4, 2018).

Through its community care programs, VHA purchased SUD services  (specialty and non-specialty) for 20,873 veterans in fiscal year 2018, a  significant increase since fiscal year 2014 (see table 5). VHA officials  noted that veterans can receive community care in addition to, or instead  of, care at a VHA facility; therefore, the number of veterans served  through community care cannot be combined with the number who  received services within VHA to provide an overall number of veterans  receiving care. Expenditures for these SUD services purchased by VHA  also increased over time, from nearly $6 million in fiscal year 2014 to over   $80 million in fiscal year 2018. Between fiscal years 2014 and 2018, on a  per capita basis, SUD services purchased by VHA increased from $3,021  to $3,852. Per capita expenditures adjusted for inflation also increased  during this time period. These increases coincided with the  establishment of the Veterans Choice Program in early fiscal year 2015,  which expanded eligibility for community care. Wait-time data for SUD  services purchased through community care were not available because  of data reliability issues, VHA officials told us. See sidebar for more  information on our previous recommendations to VHA regarding  community care wait-time data.

While VHA is able to report on the overall number of veterans receiving  SUD services through community care, data limitations prevent VHA  officials from reliably determining whether veterans received this care in  residential or outpatient settings. These issues are as follows:

Residential rehabilitation treatment programs. VHA uses billing  codes on paid claims to track the settings in which veterans receive  community care; however, according to agency officials, there is no  specific billing code for a residential setting. VHA officials told us that  community residential rehabilitation treatment programs may record  treatment provided using inpatient or outpatient billing codes—or a  combination of the two—in submitting claims to VHA. As a result, VHA  is unable to use claims data to reliably identify veterans who received  residential rehabilitation treatment through community care.

Outpatient settings. Because some residential care data are coded  using outpatient billing codes, outpatient data may contain residential  services counted as outpatient services. As a result, VHA is unable to  reliably identify veterans who received SUD services in community  care outpatient settings.

Currently, VHA is taking steps to address these coding issues. VHA  officials told us they are developing a payment code that will bundle  together common residential program services, which will allow VHA to  identify veterans receiving residential rehabilitation treatment for SUDs  through community care. Officials explained that using this code for  residential SUD services will allow VHA to better distinguish between  residential and outpatient community care because residential care will no  longer need to be identified using outpatient codes.

In contrast to its community care programs, VHA does not centrally track  SUD services provided via local contracts. Rather, the individual medical  centers that established the contracts with local community providers are  responsible for tracking and documenting SUD services provided to  veterans. In fiscal year 2019, VHA began conducting market  assessments, a broader agency initiative to better understand the supply  and demand of all services at all VA medical centers, including both what  is available within VHA as well as what is available in the local  communities. We reviewed one of the data collection instruments the  agency is using as a part of this work and found that it should allow VHA  to identify, among other things, the number of community residential  rehabilitation treatment beds contracted by individual medical centers to  serve veterans with SUDs, as well as the number of veterans who  received SUD services through local contracts or community care for  SUDs. Agency officials said that they expect the market assessments to  be completed in 2020.

Veterans’ Usage Differed Between Urban and Rural Areas for Some Specialty SUD Services; VHA Is Taking Steps to Address Access Issues in Rural Areas

Although overall use of SUD services was similar among veterans in rural  and urban areas, VHA data show the utilization rates of some specialty  SUD services differed. The literature and agency documents we reviewed  and VHA officials consistently cited several issues, such as recruiting  SUD providers and accessing necessary prescriptions for SUDs, which  affect the use of services by veterans with SUDs in rural areas. According  to agency documents and officials, VHA is taking steps to address these  issues.

Overall Use of SUD Services Was Similar for Veterans in Rural Areas Compared to Urban Areas, but Use of Some Specialty SUD Services Differed in Fiscal Years 2014 through 2018

Overall, veterans’ use of SUD services was similar in rural areas  compared to urban areas, but use of some specialty services differed.  Our analysis of VHA data shows that across VHA’s 140 health care  systems, there was relatively little difference in the overall utilization of  SUD services (specialty and non-specialty) in rural and urban areas from  fiscal years 2016 through 2018. In fiscal year 2018, for example, 7.5  percent of veterans in rural areas received any SUD services compared  with 8.8 percent of veterans in urban areas. However, VHA data also  show there were some types of specialty services, such as intensive  outpatient specialty services, residential rehabilitation treatment  programs, and medication-assisted treatment for opioid use disorder, that  rural veterans with SUDs tended to use more or less of than their urban  counterparts.

Intensive Outpatient Specialty SUD Services

Among veterans receiving specialty SUD services across all 140 VHA  health care systems, those veterans in rural locations used intensive  outpatient specialty SUD services at a slightly higher rate (19 percent)  than veterans in urban locations (17 percent) in fiscal year 2018. While  veterans’ utilization of these specialty SUD services has decreased in  both rural and urban locations in recent years, the decreases have been  larger in rural areas. In rural locations, the percentage of veterans using  intensive outpatient specialty SUD services decreased from 25 percent in  fiscal year 2015 to 19 percent in fiscal year 2018. In comparison, in urban  areas, the percentage of veterans using these services decreased from  18 percent to 17 percent during this same time period.

Officials from VHA health care systems in three urban locations and two  rural locations we spoke with indicated that they offered intensive  outpatient specialty SUD services in conjunction with either residential or  outpatient services. According to officials from the rural VHA health care  system that did not offer this service, the location did not have sufficient  staff to provide the additional hours of intensive outpatient specialty SUD  treatment each week.

Veterans in rural locations using specialty SUD services participated in  residential rehabilitation treatment programs dedicated to SUD treatment  at a higher rate (17 percent) than veterans using these services in urban  locations (10 percent) across all 140 VHA health care systems in fiscal  year 2018. From fiscal years 2014 through 2018, there was a slight  increase in the percentage of rural veterans using specialty SUD services  who participated in residential rehabilitation treatment programs  dedicated to SUD treatment, from 13 percent to 17 percent. VHA officials  told us rural communities often face difficulties with transportation that  may make residential programs more feasible than accessing intensive  outpatient specialty SUD services, which are at least 3 days per week, at  VHA health care systems. All six of the VHA health care systems we  interviewed offered residential rehabilitation treatment programs. VHA  reported the agency is currently conducting market assessments that may  help determine gaps in services for veterans with SUDs, including  residential rehabilitation treatment, once the assessments are complete.

Across all 140 VHA health care systems, veterans with an opioid use  disorder received medication-assisted treatment (in specialty and non- specialty settings) at a higher rate in urban locations (34 percent) than in  rural locations (27 percent) in fiscal year 2018. We also found differences  in the availability of medication-assisted treatment services between rural  and urban areas:

Methadone. The only setting in which methadone may be used to  treat an opioid use disorder is an opioid treatment program. All of  VHA’s opioid treatment programs are located in urban areas. Only  one of the six selected VHA health care systems in our review had an  opioid treatment program. Officials from the other five VHA health  care systems we spoke with told us they typically referred out to  community providers if a veteran needed methadone. Regional VHA  officials indicated that some locations, especially rural ones, may not  have the number of veterans with opioid use disorder needed to justify  the resources required to run an opioid treatment program.

Buprenorphine. The number of waivered providers per 1,000  veterans with opioid use disorder was slightly higher in rural areas  (29.9 providers) than in urban areas (28.7 providers) in fiscal year  2018. Non-specialist rural providers, such as primary care providers,  may feel a greater responsibility to obtain a waiver because there are  fewer specialists for them to refer their patients to, according to VHA  health care system officials. Despite the similar rates of waivered  providers in rural and urban areas, as previously mentioned, rural  veterans with opioid use disorder use medication-assisted treatment  at a lower rate.

VHA Taking Steps to Address Provider Shortage and Access Issues in Rural Areas for Veterans with SUDs

VHA requires that all rural and urban health care systems offer the same  range of SUD services (specialty or non-specialty). However, rural areas  have historically faced difficulties delivering all types of health care,  including SUD services, according to literature, agency documents, and  VHA health care system officials we spoke with. VHA is taking steps to  address several issues that affect the delivery of health care services  generally, and SUD services in particular, in rural areas.

Officials from three of the six VHA health care systems we interviewed  noted a shortage of SUD specialists in their area, including addiction  therapists and providers with a waiver to prescribe buprenorphine.  According to one study and agency documents we reviewed, veterans  may reside in mental health professional shortage areas at a higher rate  than the general population, therefore they may have less access to  providers qualified to offer medication-assisted treatment or other mental  health treatment. One study found that efforts to improve access for  veterans in rural areas by purchasing care from community providers may  have limited effect, because these areas are relatively underserved  generally.

Officials from two of the three VHA health care systems in rural areas we  selected expressed difficulty hiring and retaining providers to provide SUD services. Because of the shortages, recruiting and retaining  providers to deliver care to rural veterans is critical. Based on the  literature reviewed and half of VHA health care system officials  interviewed, rural communities struggle with recruiting and retaining  providers, including SUD providers. Some rural areas report provider  shortages with ongoing, long-term vacancies.

To respond to these provider shortages and hiring and retaining  challenges, VHA has implemented new initiatives and practices to  increase the supply of rural health professionals. A VHA official noted that  these efforts include rural health training and education initiatives to  provide rural health experience to health professions trainees, including  those who provide SUD services. The agency also plans to use expanded  recruitment tools, like greater access to an education debt reduction  program, improved flexibility for bonuses for recruitment, relocation, and  retention, as well as piloting a scholarship program authorized under the  VA MISSION Act of 2018 to hire mental health professionals. However,  recruiting health professionals in rural areas, including mental health  providers and social workers, remains an issue for VHA and the  community at large, and VHA officials noted that data are not yet  available to understand the long-term effect of the newly trained providers  on the availability of SUD services.

Availability and Use of Telehealth Services for the Delivery of SUD Services

Officials from two VHA health care systems we interviewed noted that  providing services, such as medication-assisted treatment, through  telehealth technology is difficult, especially when the SUD service  requires monitoring for medication compliance. However, a VHA official  told us the use of telehealth services overall has grown exponentially at  VHA’s health care systems and goes beyond traditional video conference  capabilities to include advanced technology that can be attached to  computers or videoconference equipment like an exam camera to allow  for an interactive examination. The official added that the provision of  SUD services using telehealth can be supported by medical personnel  located at the closest VA facility to complete necessary tests, such as  urine screening, when the service is provided at a VHA location.

VHA officials from one health care system we spoke with and literature  noted that providing medication-assisted treatment via telehealth  technologies requires a cultural change within the profession. Officials  from one VHA health care system we spoke with told us that delivering  medication-assisted treatment using technology is risky. For example,  buprenorphine is a controlled substance with a risk of misuse. This official  added that many providers may not be open to the idea of delivering this  level of treatment using telehealth. One study we reviewed confirmed that  acceptance within the profession appears to be the main barrier to the  successful implementation of telehealth services. However, VHA’s  budget and strategic plan show continued support for the use of  telehealth for SUD treatment. Studies have shown that telephone  services, a type of telehealth service, potentially have the same outcomes  as in-person services.

Officials from all six VHA health care systems we selected mentioned  they had mental health telehealth services available to facilitate the  delivery of care to veterans in both urban and rural areas for SUD  services. To ensure adequate access to care, VHA has multiple  telehealth initiatives underway. For example, between fiscal years 2017  and 2019, VHA allocated $28.5 million for mental health telehealth hubs  at 11 sites. In another instance, VHA allocated more than $750,000 for  rural facilities in fiscal years 2018 and 2019 toward a nationwide initiative  to improve participation in a program that establishes video connections  in the homes of rural veterans to receive mental health treatment,  including for SUDs, with psychotherapy and psychopharmacology. While  VHA has initiatives underway, the success of these efforts is contingent  on rural areas having broadband and internet connectivity, which remains  a challenge, according to agency documents and officials.

VHA’s Clinical Practice Guidelines for SUDs recommends methadone  and buprenorphine, among others drugs, to treat opioid use disorder.  However, accessing these drugs in rural areas can be challenging,  according to literature we reviewed and VHA officials we spoke with. For  example, one national study found that opioid treatment programs  providing methadone are generally absent from the treatment options in  rural areas. Within VHA, all of the opioid treatment programs are in  urban areas. In addition, in rural areas generally, a small percentage of  providers nationwide have received waivers to prescribe buprenorphine.

VHA officials told us they are steadily expanding the availability of  medication-assisted treatment for veterans with opioid use disorder. VHA  had an interdisciplinary team of VA staff from a single facility within each  region receive training on implementing medication-assisted treatment for  opioid use disorder. These teams were responsible for spreading  information to other facilities. Thus far, VHA reported it has trained over  300 providers using this model. In a separate initiative, a VHA official  reported that its Office of Rural Health provided over $300,000 in fiscal  year 2019 for a pilot program that trains primary care and mental health  providers in the Iowa City VHA health care system on how to provide  medication-assisted treatment for opioid use disorder.

The availability of transportation is vital for veterans receiving medication- assisted treatment due to the necessity for frequent travel to the VHA  health care systems for treatment. When using methadone for opioid use  disorder treatment, the medication generally needs to be administered  through an opioid treatment program at a specific location on a daily  basis. In addition, during the initial stages of buprenorphine treatment,  patients must also come into a facility frequently. Veterans living in rural  areas who need this level of care may have to travel long distances every  day to receive this medication.

Distance and lack of transportation impede access to care, including SUD  services, for rural veterans. Specifically, the literature we reviewed noted  distance, time, and access to transportation as barriers to care.  Veterans may lack access to transportation or are no longer able to drive  because of age, health status, or driving restrictions. Some rely on family,  friends or vans available through community service organizations;  however, they may have other difficulties like reaching pick-up locations  or the organization not having vans that are wheelchair-equipped.  Officials from all six VHA health care systems we selected noted the lack  of transportation as a barrier to accessing SUD services. Officials from  two rural locations of the six selected VHA health care systems  mentioned that volunteers, including a local veteran service organization,  assist with getting veterans from their homes to their appointments;  however, they added that these services operate on an abbreviated  schedule and veterans are sometimes subjected to riding in the vehicle  for long periods of time (2 hours each way). Over the last 10 years, a  VHA official told us that the agency has allocated between $10 and $12.9  million for its Veterans Transportation Service for new vehicles, drivers,  and mobility managers to assist with rural transportation needs.

Additional VHA Plans to Address Rural Health Issues for SUD Services

The VA MISSION Act of 2018 includes provisions that specifically  address the need to improve veterans’ access to health care in areas with  shortages of health care providers, including those providing SUD and  mental health services. Based on this legislation, in June 2019, VHA  published a plan organized in three areas: increasing personnel, using  technology to connect veterans to care through public and private  partnerships, and expanding VHA’s infrastructure through the building or  acquiring of space to address the problem of underserved facilities. For  example, VHA has a pilot program with 11 Walmart sites and 15-20  additional sites planned with Philips Healthcare, the Veterans of Foreign  Wars, and the American Legion to enable veterans who lack the  necessary technology in their home and live far from a VHA facility to  receive remote health care at a convenient location. VHA’s plan indicates  that while all VHA health care systems can use any of the strategies  covered under this legislation, they will provide specific additional  technical assistance for underserved facilities, monitor the effectiveness  of these strategies, and share the findings of this work throughout the  broader VHA system.

We provided a draft of this report to VA for review and comment. VA  provided written comments, which are reprinted in appendix IV, and  technical comments, which we incorporated as appropriate. VA’s  comments note that the agency generally reports obligations and that the  agency is unable to confirm some of our financial data. However, the  data provided by VA during the course of this engagement were  regarding expenditures, and thus we report them as such. VA’s  comments also provide information on additional efforts to expand mental  health telehealth and ways the agency recruits providers in rural areas.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Veterans Affairs, and other interested  parties. In addition, the report is available at no charge on the GAO  website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at deniganmacauleym@gao.gov. Contact points  for our Offices of Congressional Relations and Public Affairs may be  found on the last page of this report. GAO staff who made key  contributions to this report are listed in appendix V.

Appendix I: Map of 140 Veterans Health Administration Health Care Systems, Fiscal Year 2018

Figure 4, an interactive graphic, shows the location and rurality of the  Veterans Health Administration’s health care systems, as well as  information on veterans treated by these health care systems.

For an accessible version of the data used in this map, see  https://www.gao.gov/products/GAO-20-35.

Appendix II: Site Selection Methodology and Selected Health Care System Characteristics

To describe any differences between veterans’ use of substance use  disorder (SUD) services in rural and urban areas and the issues affecting  access to those services in rural areas, we selected six Veterans Health  Administration (VHA) health care systems and interviewed officials  regarding their SUD services and issues serving veterans with SUDs.  Because opioid use disorders may pose a greater risk to veterans than  the general population, we selected the six VHA health care systems from  among those with the highest percentages of veterans with an opioid use  disorder diagnosis in fiscal year 2018. We also selected these six health  care systems to achieve variation in representation among VHA’s five  geographic regions and to include both urban and rural locations. See  table 6.

Appendix III: Veterans Health Administration Substance Use Disorder Residential Rehabilitation Treatment Programs

The Veterans Health Administration had 67 residential rehabilitation  treatment programs dedicated to substance use disorder treatment in  fiscal year 2018. See table 7.

Appendix IV: Comments from the Department of Veterans Affairs

Appendix V: GAO Contact and Staff Acknowledgments

Mary Denigan-Macauley, (202) 512-7114 or  deniganmacauleym@gao.gov.

In addition to the contact named above, Lori Achman, Assistant Director;  Hannah Marston Minter and Carolina Morgan, Analysts-in-Charge; Sam  Amrhein; Amy Andresen; Shaunessye D. Curry; and John Tamariz made  key contributions to this report. Also contributing were Giselle Hicks,  Diona Martyn, Ethiene Salgado-Rodriguez, and Emily Wilson Schwark.

Veterans Health Care: Opportunities Remain to Improve Appointment  Scheduling within VA and through Community Care, GAO-19-687T.  Washington, D.C.: July 24, 2019.

VA Health Care: Estimating Resources Needed to Provide Community  Care, GAO-19-478. Washington, D.C.: June 12, 2019.

Drug Policy: Assessing Treatment Expansion Efforts and Drug Control  Strategies and Programs, GAO-19-535T. Washington, D.C.: May 9, 2019.

Priority Open Recommendations: Department of Veterans Affairs,  GAO-19-358SP. Washington, D.C.: March 28, 2019.

Behavioral Health: Research on Health Care Costs of Untreated  Conditions is Limited, GAO-19-274. Washington, D.C.: Feb. 28, 2019.

Veterans Choice Program: Improvements Needed to Address Access- Related Challenges as VA Plans Consolidation of its Community Care  Programs, GAO-18-281. Washington, D.C.: June 4, 2018.

VA Health Care: Progress Made Towards Improving Opioid Safety, but  Further Efforts to Assess Progress and Reduce Risk Are Needed,  GAO-18-380. Washington, D.C.: May 29, 2018.

Opioid Use Disorders: HHS Needs Measures to Assess the Effectiveness  of Efforts to Expand Access to Medication-Assisted Treatment,  GAO-18-44. Washington, D.C.: October 31, 2017.

Opioid Addiction: Laws, Regulations, and Other Factors Can Affect  Medication-Assisted Treatment Access, GAO-16-833. Washington, D.C.:  September 27, 2016.

VA Health Care: Reliability of Reported Outpatient Medical Appointment  Wait Times and Scheduling Oversight Need Improvement, GAO-13-130.  Washington, D.C.: December 21, 2012.

Veterans coping with the stresses of deployment or with readjusting to civilian life are at particular risk for drug and alcohol addiction. The VA pays for addiction treatment. We looked at these treatment services and veterans’ access to them.

Overall, veterans living in rural areas use VA’s addiction treatment services at the same rate as those in urban areas. But providing treatment services in rural areas poses specific challenges to veterans and non-veterans alike, such as a shortage of specialized providers and lack of transportation. The agency is taking steps to address these challenges in rural areas.