Demands for posttraumatic stress disorder (PTSD) services among service members and veterans are at unprecedented levels and are climbing. This chapter offers the Department of Defense (DoD) and the Department of Veterans Affairs (VA) an approach for assessing the value of the PTSD services that they provide. If each department better understands the outcomes and costs associated with PTSD care in their systems, they can work toward maximizing the value of that care.
The recent Institute of Medicine (IOM) report Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis (IOM, 2013a), states that value in health care may be defined in many ways, none of them universally accepted. The DoD military health system (MHS) defines value as the readiness, experience of care, and population health, divided by per capita cost (Middleton and Dinneen, 2011). VA has defined value as the sum of technical quality, access to care, patient functional status, and service satisfaction divided by the cost or price of care (Kizer and Dudley, 2009). These values may be impossible to quantify but they serve to help identify components of a conceptual model of health care value. This report adopts the definition of value from the 2008 IOM report Evidence-Based Medicine and the Changing Nature of Health Care as the quality of care achieved, in terms of outcomes, relative to the cost of delivering health care and related services (IOM, 2008). To determine whether high-value care is being delivered, a health care system must measure and track outcomes in the population receiving the care and compare them with the amount or cost of care that is delivered. One practical method for monitoring outcomes is the electronic health record. Costs of PTSD care must also be
monitored and accurately connected to specific services (such as sessions of psychotherapy or drug prescriptions) and to the patients’ outcomes associated with the services.
Prevention, screening, diagnosis, treatment, and rehabilitation services for PTSD can result in better quality of life, healthier relationships, improved vocational and financial performance, and better overall function, all of which are of intrinsic value to affected people, their families, and their communities. Evaluations of cost-effective interventions and programs must factor in the intrinsic and practical value PTSD management activities in addition to assessing the direct and indirect financial costs of care. Direct costs associated with preventing and treating PTSD include psychotherapy and pharmacotherapy, but there are other costs that may affect annual operating costs of the departments such as compensation (salary, bonuses, and incentives) for new and current staff members, training and hiring costs, information technology requirements, and administrative charges. Ineffective treatments or no treatment for PTSD may also lead to increased societal and monetary costs if they result in adverse patient outcomes and increased disease burden requiring further medical care, or in other conditions such as homelessness or unemployment.
DEPARTMENT OF DEFENSE
Maintaining a fit and ready force is of primary importance to DoD. Treatment and rehabilitation of service members who are injured or ill can lead to great cost savings for DoD, given that the costs of recruiting and basic training for each service member average around $75,000 (AMSARA, 2012). If high-value PTSD care is provided to those who need it, DoD can see savings in health care costs for the service member and in the larger costs of maintaining a fit and ready force. This section presents data on the current costs of PTSD care in DoD and projections for future annual expenditures for the treatment of and rehabilitation for PTSD in service members. Family members and other beneficiaries of the MHS may have PTSD as a result of the service member’s PTSD or their own trauma. However, the costs associated with treating PTSD in those beneficiaries is beyond the scope of the committee’s task and is not considered in this report, although it is expected that such treatment would add to DoD’s overall costs for PTSD care. The section concludes with findings on DoD’s challenges in achieving high-value PTSD care.
Cost of Care
The total cost of PTSD care in DoD includes the cost of services provided in general medical and mental health clinics, specialized outpa-
tient treatment programs, inpatient hospital settings, and by TRICARE purchased-care providers, as well as the cost of prevention and screening efforts. A recent Government Accountability Office (GAO) report on the funding of DoD mental health programs provides some background for an analysis of the cost of PTSD care (GAO, 2012). Beginning in 2007, $900 million in DoD appropriations supported mental health and traumatic brain injury (TBI) activities. GAO reported that from 2007 through 2010, DoD spent more than $2.7 billion on activities related to treatment for and research on these conditions; however, the report did not present information specifically on the cost of PTSD care.
Although the costs of PTSD prevention efforts were not available for this report, it is expected that those efforts are of high cost to DoD. For example, it is estimated that the Army’s Comprehensive Soldier and Family Fitness program had initial implementation costs of $125 million and incurs annual costs of $50 million (U.S. Army, 2009; Zoroya, 2013).
To examine the current and projected DoD annual expenditures for PTSD treatment, the DoD Office of Strategic Management was asked to provide information on the use of PTSD care and its associated costs. Table 5-1 shows the number of service members who had diagnoses of PTSD and the costs of DoD PTSD treatment and rehabilitation in 2004–2012.
Total expenditures for PTSD care increased substantially over the 8-year period, from $29.6 million in 2004 to $294.1 million in 2012. The increase was driven primarily by the increase in the number of service members who had PTSD, but there was also an increase in the average cost per treated service member; total cost per treated service member increased by 32.0% and inpatient cost increased by 36.5%. Outpatient and prescription drug costs per service member remained relatively flat over the period after adjustment for inflation (Kennel and Associates, 2013).
It is important to note that those costs include only services for which PTSD was the primary or secondary diagnosis. If costs of other services, such as comorbidities, are included, total health care costs increased from $9,693 per PTSD patient in 2004 to $18,259 in 2012, an increase of 88.4%. That is a much larger increase than the one seen in non-PTSD patients. For a non-PTSD patient who had a mental health disorder, inflation-adjusted total health care costs increased from $3,020 in 2004 to $4,278 in 2012 (41.7%), but the costs per non-PTSD patient who did not have a mental health disorder actually decreased from $2,250 to $1,951 (–13.3%) (Kennel and Associates, 2013).
An increasing proportion of PTSD care for service members is being provided through TRICARE as purchased care. The percentage of total cost that is spent on TRICARE services increased from 19% in 2004 to 40% in 2012 (Kennell and Associates, 2013). Total costs for PTSD care delivered by purchased care providers increased dramatically from 2007
TABLE 5-1 DoD Costs for PTSD Care of Eligible Service Members Who Have Primary or Secondary Diagnoses of PTSDa
|Year||No. of Service Members Who Have PTSD||Total PTSD Costs (millions)||Total Cost per Service Member Who Has PTSD||Inpatient Cost per Service Memberb||Outpatient Cost per Service Memberb||Prescription Drug Cost per Service Memberb|
aCosts are limited to direct costs of services associated with a diagnostic code of PTSD. Costs are adjusted for inflation and are reported in 2012 dollars. A diagnosis of PTSD was considered confirmed if a service member had one inpatient stay with the diagnosis or two outpatient visits at least one day apart with the diagnosis. The diagnosis may be the primary or a secondary diagnosis. An eligible service member is defined as anyone who is eligible to receive care in the MHS, and was ever on active duty. Some service members may leave active duty, but remain eligible for care in the MHS as retirees, or dependents. These costs do not include those associated with training, recruiting, or retaining mental health providers.
bCosts among users of the service only.
SOURCE: Kennell and Associates, 2013.
to 2012, from $22.4 million to $131 million, and purchased care costs as a percentage of total costs increased from 29.6% to 44.6% (Kennell and Associates, 2013).
Data collected by the Armed Forces Health Surveillance Center show that from 2006 to 2012 the number of hospitalizations of service members for PTSD increased by 192% (numbers not given). The mean length of stay for PTSD hospitalization increased from 10 days in 2000 to 17 days in 2012. There were significant differences in hospitalization rates for PTSD between the service branches: Army, 114.1/10,000 person-years; Marine Corps, 65.2; Navy, 20.8; and Air Force, 19.5. Those hospitalized for PTSD had many comorbidities (Armed Forces Health Surveillance Center, 2013). Such increases in hospital care for PTSD can have substantial associated costs.
As shown in Figure 5-1, PTSD care costs have increased substantially over the last several years. If the trend continues, total costs for PTSD could exceed $500 million by 2017. However, in light of the recent troop drawdown, that is unlikely. Instead, with fewer active-duty service members and fewer deployments, the number of new PTSD cases among service members might decline, resulting in a leveling out or potentially a decrease in total
FIGURE 5-1 Costs of direct care for PTSD, cost of TRICARE for PTSD, and total cost of care for PTSD over time, 2004–2012. Costs are not adjusted for inflation.
SOURCE: Kennell and Associates, 2013.
DoD costs in the future, assuming no new conflicts. The drawdown may also change DoD’s medical mission. If the need for PTSD care decreases, DoD medical assets will probably decrease as well, and more care may be shifted to the TRICARE network or, in the case of retiring and separated service members, partially shifted to VA.
Projecting costs is difficult given the uncertainty around service member levels, military treatment facility (MTF) capacity, and the potential for future military engagements. The primary driver of costs is the number of service members, and therefore any projection of future PTSD costs must be based on estimates of the number of future service members. The committee was unable to identify any such projections and so was not able to estimate future PTSD costs. If data on the projected number of service members were available, DoD could use that number and the incidence of PTSD to generate the projected number of service members who may have PTSD and then multiply that product by the average cost per service member who has PTSD to get an estimate of total PTSD costs. Such an approach involves a number of assumptions, however, such as the prevalence of PTSD and the treatment cost per service member remaining constant. Considering that the total number of service members who may experience trauma that leads to PTSD will be smaller as the current military operation in Afghanistan continues to wind down, the number of service members who have incident PTSD is likely to decline in the near future. However, the assumption in this case is that, unlike troops who served in Vietnam, service members who were in Afghanistan and Iraq and who have symptoms of PTSD will seek mental health care sooner rather than waiting years, so the costs may be more immediate.
Determining and Achieving High-Value Care
In addition to reporting the cost of current PTSD care and projections of future expenditures, it is important to try to determine the value of PTSD care that is currently provided in DoD. As discussed above, value was defined as the quality of care achieved, in terms of outcomes, relative to the cost of delivering that care. This section is a consideration of how high-value PTSD care can be determined in DoD for prevention, screening, and treatment activities.
Prevention and Screening
Recent reports and studies, presentations by DoD representatives, and the committee’s site visits substantiate that DoD does not systematically collect data on the effectiveness of its stress prevention efforts (IOM, 2013b,c, 2014; Weinick et al., 2011). In phase 1, each service branch was asked for
outcome data from PTSD prevention programs, but no useful data were provided. The costs of the programs are not well tracked although it is clear that considerable resources are being invested in many of those prevention efforts. The committee was also unable to determine the costs of administering the postdeployment health assessment and the post-deployment health reassessment that are used to screen for mental health problems in service members who have deployed. Therefore, given the lack of outcome data and cost information, it is impossible to determine whether DoD is providing high-value prevention and screening services for PTSD.
As mentioned in Chapter 3, service members who have PTSD can receive direct care in MTFs and associated clinics or from TRICARE purchased-care providers. If the PTSD programs or services offered in garrison are at capacity or unavailable, service members may be referred to purchased-care providers or specialized programs in the community that are part of the TRICARE network. TRICARE covers outpatient psychotherapy sessions for up to two sessions per week in any combination of individual, family, group, and collateral sessions, as long as two therapy sessions of the same type do not occur on the same day. Individual psychotherapy sessions are covered for up to 60 minutes or, for crisis sessions, 120 minutes. However, this allotted time is not sufficient for delivering certain first-line psychotherapies with fidelity to their manualized protocols. For example, a prolonged exposure (PE) therapy session should last 90 minutes (Foa et al., 2007), but this “extra” time is not covered for reimbursement by TRICARE. Purchased care providers may also provide 90-minute sessions of family, conjoint, or group psychotherapy (TRICARE Management Activity, 2013). Intensive outpatient care is one of the core services offered in private, VA, and other public mental health plans, but TRICARE requires that patients be referred to inpatient programs, which may be farther from where they live and may cost considerably more. For example, in VA, the average cost of intensive (inpatient) programs for PTSD in 2012 was $20,497, compared with $1,638 in specialized outpatient programs (VA, 2012). TRICARE has been criticized for not covering intensive outpatient services for mental health conditions, including PTSD, despite acknowledgement by TRICARE that such services are an important component of mental health care (e.g., DoD Task Force on Mental Health, 2007). TRICARE does cover partial hospitalization programs. Intensive outpatient services could be appropriately offered and reimbursed if this obvious deficiency in TRICARE’s mental health coverage were corrected.
Patient treatment outcomes are not systematically tracked in either DoD programs or TRICARE network programs although the costs of the
services are available. In 2012, the most recent year on which complete data are available, DoD spent $294.1 million on services for PTSD in MTFs and TRICARE, of which $131.2 million (44.6%) was for TRICARE services alone (Kennell and Associates, 2013). Without tracking patient outcomes over the long-term and connecting them with costs of care, it is impossible to know the value of the PTSD treatment services. One effort to compare the cost of PTSD care provided by a specialized DoD program with the cost of PTSD care in a network residential program was identified. The Naval Medical Center San Diego compared Overcoming Adversity and Stress Injury Support (OASIS), a 10-week residential PTSD program (see Chapter 3 for a description), with residential treatment programs at two civilian care facilities in San Diego. The OASIS program treats about 160 patients per year with annual operational costs of $2.24 million, or about $14,000 per patient. OASIS program leaders reported that the program delivers higher-quality care at lower cost than the civilian programs (Ken Richter, Director, OASIS, personal communication, April 9, 2013). However, the specifics of how the OASIS program staff came to that conclusion, whether they factored in the indirect costs of program operation, and what data demonstrated that they provided “higher-quality” care were not provided. Care provided by on-base DoD programs may indeed be more cost effective than purchased care programs, but without an analysis of comparable long-term patient outcomes among programs, this cannot be determined.
DoD pays for direct care and purchased care services by volume—for example, number of patients seen—and not value. Although DoD has begun to track the types of mental health interventions offered in mental health programs and patient outcomes (see Chapter 4), these efforts are not consistent among programs and do not extend to all PTSD care settings. Should outcome data eventually be available, the results will need to be connected to costs to estimate the relative value of PTSD care in DoD, but at present such estimates cannot be made. In a 2013 report to Congress, DoD describes plans to increase value in its beneficiary health care system by aligning incentives with health and readiness outcomes to reward value creation (DoD, 2013). That effort applies broadly to all DoD health care, but anxiety disorders constitute one of five targeted conditions to be addressed by the changes. The pay-for-value model will be piloted before its planned implementation in October 2015 (DoD, 2013).
DEPARTMENT OF VETERANS AFFAIRS
Reducing the PTSD burden is of particular interest to VA, which is responsible for all medical and disability costs associated with PTSD in benefit-eligible veterans. Prevention efforts, early intervention in, and treatment for PTSD and co-occurring medical conditions may have cost-saving
effects far into the future for veterans of the current conflicts (Geiling et al., 2012; Tuerk et al., 2012). Some veterans may improve after brief, acute treatment and need little aftercare, but others may have more persistent or chronic PTSD and need longer-term rehabilitation. Regardless of a veteran’s PTSD course, in the context of limited resources, a high-performing system of PTSD care will provide high-value treatment for each patient population.
This section presents data on the current costs of PTSD care in VA and projections for annual expenditures for treatment and rehabilitation for PTSD. It concludes with findings on challenges to achieving high-value PTSD care in VA. The costs associated with treating veterans’ family members who have PTSD—who are not currently eligible for care in the VA health care system—are not considered in this report.
Cost of Care
The cost of PTSD care in VA includes services provided in general medical and mental health clinics, other general treatment and rehabilitation venues, and specialized PTSD programs. Several recent studies have examined the medical and societal costs of the current conflicts in Iraq and Afghanistan (Bilmes, 2007; Goldberg, 2007; Tanielian and Jaycox, 2008) or calculated the cost of PTSD care in VA for recent combat veterans (Congressional Budget Office, 2012). The VA Health Economics Resource Center estimated that the minimum cost of mental health service utilization was $93.22 per appointment in 2009 (VA, 2011). The RAND Corporation and Altarum Institute conducted a mental health program evaluation for VA that focused on quality of service, service use, and costs of service for 837,000 veterans who have PTSD, major depression, substance use disorders, schizophrenia, or bipolar I disorder. On the basis of 2007 data, 16.5% of the total VA veteran population had one of these diagnoses, of whom 42.7% had a diagnosis of PTSD. The total annual cost for health care for a veteran who had PTSD was estimated to be $11,342, which was more than double the annual VA health care cost of a veteran without PTSD; 73.1% of health care costs for veterans who had PTSD was for non-mental health services (Watkins et al., 2011). The Congressional Budget Office (2012) has examined VA’s treatment services for PTSD and TBI and found that PTSD and TBI were highly comorbid in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. The cost of treating veterans who have PTSD was at least three times greater than the cost of treating veterans who do not have PTSD or TBI; the first year of treatment was the most expensive, possibly because of the need to treat additional health problems such as combat injuries, although specific data were not given.
VA responded to extensive data requests to capture the cost of PTSD treatment in direct care and purchased care for all veterans in 2002–2012.
The number of veterans who have PTSD and sought care in VA increased by 249%, from 143,791 in 2002 to 502,546 in 2012 (VA, 2012), driven by an influx of OEF and OIF veterans. The VA Northeast Program Evaluation Center reported that in 2012, 108,745 veterans received care in specialized outpatient PTSD programs (SOPPs), at a total cost of $178,077,961, or $1,638 per patient. In addition, 4,275 veterans were admitted to specialized intensive PTSD programs (SIPPs) at an average cost of $20,497 per patient. However, veterans treated in those specialized programs made up only 30% of the 502,546 veterans who had diagnoses of PTSD and received VA services. Costs of PTSD services throughout VA, but excluding treatment provided in the specialized programs, are not available. Tables 5-2 and 5-3 show the numbers of veterans who had PTSD and total PTSD costs through VA from 2010 to 2012 (NEPEC, 2014).
Data from the Veterans Benefits Administration on service-connected compensation for PTSD, including compensation for many veterans who did not seek health care in VA, show that from 2003 to 2013 the number of veterans from all eras evaluated and adjudicated to have service-connected PTSD increased from 196,641 to 653,249; the latter figure includes 205,309 OEF and OIF veterans (VBA, 2014). Cost information on compensation for veterans with service-connected PTSD was not requested.
Many veterans of all eras seek counseling or treatment for PTSD symptoms in Vet Centers rather than or in addition to care in VA medical facilities. Although this is not specific to PTSD care, VA has requested an increase in Vet Center funding from $197 million in 2013 to $208 million in 2014 (VA, 2013). Costs of PTSD care in Vet Centers are not available and were not included in the cost data received from the VA on its specialized PTSD programs.
As in DoD, any projections of PTSD costs in VA have to be based on the number of veterans who seek PTSD care in VA and would involve a number of assumptions. Although the VA Office of the Actuary provides data on the projected number of veterans through 2040, the actual number will depend on whether the United States engages in any future military conflicts and other factors. Given such estimates, however, VA could multiply the number of veterans by the proportion that use VA services and by the proportion of veterans who use VA services that have a diagnosis of PTSD. Finally, VA could multiply the latter by the average cost per treated veteran who has PTSD to derive a projected cost of PTSD care. However, as in the case of DoD, that assumes that the proportions and average costs will remain constant or change in predictable ways. As the number of OEF and OIF veterans who seek VA care increases with the DoD drawdown over the next several years, there may be an increase in the number of OEF and OIF veterans who seek care for PTSD as service members who were reluctant to seek care while in the military may be more likely to seek care
TABLE 5-2 Number of Veterans Who Have PTSD and PTSD Costs
|Year||Veterans||Veterans Using VA||Veterans Who Have PTSD||PTSD|
|N||%||N||% of Those Using VA||Costs (millions)a|
aBased on the average cost of mental health care per patient who had a diagnosis of PTSD.
SOURCE: NEPEC, 2014.
TABLE 5-3 Number of OEF and OIF Veterans Who Have PTSD and PTSD Costs
|Year||OEF/OIF Veterans||OEF/OIF Veterans Using VA||OEF/OIF Veterans Who Have PTSD||PTSD|
|N||%||N||% of Those Using VA||Costs (millions)a|
aBased on the average cost of mental health care per patient who had a new diagnosis of PTSD.
SOURCE: NEPEC, 2014.
as veterans. Hence, any projected costs would be rough estimates at best and should be interpreted with caution.
Determining and Achieving High-Value Care
VA has no consistent system for tracking patient outcomes and connecting them to costs of care, so whether VA provides high-value care for PTSD cannot be determined. In addition, without standardized system-wide metrics of patient outcomes and costs in VA, DoD, and other health care systems, it is impossible to compare the value of PTSD services provided by these organizations. The VA SIPPs track patient outcomes and costs of care, but whether the data are used to improve quality or value cannot be determined. For example, in 2012, the 39 SIPPs had 3,792 entrants for a total cost of $88,572,953, or $23,578 per patient. The average PTSD Checklist (PCL) scores for veterans at admission to the programs and 4 months after discharge were 65.9 and 60.2, respectively. That indicates that most program graduates met the criteria for clinically significant PTSD after discharge on the basis of a PCL cutoff score of 50 (VA, 2012). Furthermore, VA does not track similar data on outcomes for any of the SOPPs or in the general mental health clinics, so it is impossible to assess the value of these programs and services. The 2012Long Journey Home report showed that 93% of veterans in the SOPPs completed a PCL at admission with an average score of 62.0, but PCL scores are not collected at treatment completion (VA, 2012).
Several approaches may help reduce future costs of providing PTSD care, including the use of evidence-based treatments. A small study of 70 veterans who received PE or cognitive processing therapy (CPT) demonstrated substantial reductions in mental health service use and costs (Meyers et al., 2013). The authors found that direct costs for mental health care decreased by 39.4% during the 1-year period when veterans received PE or CPT. Assuming that the decrease in mental health service use was due to a decreased need for such services, evidence-based treatments such as CPT and PE may constitute high-value care for PTSD. In a study of 60 veterans who had PTSD and were followed for 12 months before receiving PE and 12 months after treatment, Tuerk et al. (2012) found that the 44 treatment completers (defined as attending at least 7 PE sessions) had clinically and statistically significant decreases in PTSD symptoms, as measured using the PCL. Mental health service use in the 12 months post-PE treatment decreased by a mean of 3 appointments compared with pre-treatment, whereas non-completers had slightly more service use post-treatment. The average annual cost of health care services for both completers and non-
completers was about $693 prior to treatment but after treatment decreased to $386 for completers and increased to $810 for non-completers. Providing effective care for PTSD might therefore improve patient outcomes and lead to cost savings.
VA refers veterans to community providers when a medical facility does not have the capacity to provide the care that they need. Over the last 10 years, purchased care in VA has expanded from an infrequently used adjunct to care in VA medical facilities to a critical element of clinical care delivery. Data on purchased care costs of PTSD were not included in VA’s response to the committee’s data requests. However, a previous study of use and costs of VA health care service for veterans in the year after service in Afghanistan and Iraq found that purchased care was responsible for 5.5% of mental health costs for male veterans and 3.8% for female veterans (Leslie et al., 2011).
A 2011 assessment by the National Academy of Public Administration found that the management of administrative and other support systems for purchased care had not kept pace with its increased use. The report concluded that the quality of care provided through purchased care and the return on investment in this program were indeterminate, in part because information on which to ascertain its value was not readily accessible. The report also noted that VA used antiquated administrative systems and technology, but several actions were under way to improve it (Pane et al., 2011). As part of its Patient-Centered Community Care initiative (see Chapter 6), VA has recently awarded two 5-year contacts for a combined $9.3 million to two health care management companies to consolidate and standardize the quality of purchased care providers via nationwide networks of providers. Those networks are not yet established, and their value and costs cannot be determined (Philpott, 2013). The lack of a system for comparing patient outcomes with the cost of their care makes it especially challenging to determine whether purchased care for PTSD is of high value.
To deliver high-value health care, an organization must be able to determine patient outcomes and costs. However, neither DoD nor VA is in a position to do that, primarily because of the lack of outcome data and a lack of cost information for specific treatment modalities (with the exception of pharmacotherapy, where the costs of drugs can be determined). Costs of PTSD care are high in both DoD and VA. In 2012, the most recent year on which data are available, DoD spent $294.1 million and VA just
over $3 billion on PTSD care for service members and veterans, respectively. DoD costs may be even higher, given its responsibility to treat eligible family members or other dependents who have PTSD as well. Although those costs might be expected to decrease in DoD in light of the recent drawdown, there will be a corresponding increase in VA costs as service members transition to VA care. In addition, there is an increasing reliance on purchased care in both systems, and even less is known about the value of care delivered in such settings.
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