In April, Dr. Brett Rusch was named the first permanent director of the White River Junction Veterans Affairs Medical Center in more than two years. The White River Junction hospital, and its related Vet Centers and outpatient clinics dotted throughout the state, serve roughly 26,000 veterans in Vermont and New Hampshire.
Rusch, a psychiatrist, has served in various administrative and clinical roles in his four years at the White River facility, including chief of staff to then-director Alfred Montoya. Before moving to Vermont, Rusch worked in various health care roles in Wisconsin, including as an assistant professor of psychiatry at the University of Wisconsin’s School of Medicine and Public Health.
While the Department of Veterans Affairs has historically been free from politics, a scandal in the summer of 2014 at a VA hospital in Phoenix propelled the agency into the spotlight and changed the positive perception many had held. That year, it was revealed that hospital administrators had tampered with scheduling data, making it appear veterans were receiving timely care when many had to wait months for an appointment.
The scandal spurred passage of the Veterans Access, Choice and Accountability Act, which made it much easier for veterans to seek care in the private sector, and ignited a deeply divisive national debate over the government’s ability to deliver health care. (Ironically, a lead co-sponsor of this law was Sen. Bernie Sanders, I-Vt., who has long supported a larger role of government in health care delivery.)
The 2014 law solved few agency issues, and created many new ones. Yet in 2018, Congress and President Donald Trump approved the VA Mission Act, which is set to further expand private health care options. As the law heads toward a June implementation, many veterans advocates are portraying it as an unnecessary push to privatization, and worry the agency will repeat many of the mistakes made in 2014.
Dr. Rusch spoke with VTDigger about the Mission Act, the needs of New England veterans, and why he believes the VA is still the best institution to serve the complex health needs of veterans. The interview has been edited for length and clarity.
VTDigger: You arrived at White River Junction in 2015, which was an important and tumultuous time for the VA. That was a year after the Phoenix Scandal, which spurred a pretty nasty political fight over the quality of care at the VA. The VA took a serious reputational hit from Phoenix. Did you feel that at the VA? Is it your belief that the agency’s reputation has bounced back?
Dr. Brett Rusch: I was providing inpatient psychiatry at the Madison, Wisconsin VA when Phoenix happened. When those events transpired it was difficult for all of us because it was so much negative press around the VA and the quality of care in the VA. But it was so contrary to our experience.
I’ve worked in a number of mental health settings, including universities, private clinics, state hospitals, and private hospitals. I can tell you that the mental health that’s provided throughout the country at the VA is at the level if not usually above the level available in most communities. Access to mental health services has always been excellent. In Madison, a community health center often had mental health wait times of a year. At the VA in Madison, we had same-day mental health services.
The reason I became attracted to White River Junction is because the longstanding mental health chief, Andy Pomerantz, and his team worked over two decades to literally invent the system of primary care and mental health integration that’s become the model throughout the nation. I came here in 2105 to be the chief of mental health, the role Andy previously had, and that was an incredible affirmation of how great how the VA actually is.
Whether it’s mental health, primary care, specialty health, surgery, pain medicine, rehab, geriatrics, physical therapy, there are a lot of really high-quality providers here who are dedicated to veterans. We get people in the door and provide outstanding care.
VTD: The Choice Act was the resulting legislation from Phoenix. It expanded private community care options for veterans. That community care program has now been made permanent in the form the VA Mission Act.
There were a number of significant issues that came out of Choice, including problems with contractors mishandling payments or bungling appointments, veterans going into private sector facilities and receiving subpar care, or VA having trouble getting medical records back. There’s also evidence that veterans are more likely to be overprescribed opioids in the private sector than in the VA. Knowing all of this and now having to pretty quickly get up and running with the Mission Act, are you confident White River can handle and implement this new law? Is everything in place to ensure seamless transition to this new permanent community care program?
BR: We are certainly working as hard as we can to be as prepared as possible for that future. We are going to be a rural implementation site for the Northeast to adopt the Mission Act and the contracts sooner than many other VAs will. So we want to be as ready as possible. And we have put quite a bit of investment into hiring staff, in terms of schedulers and nurse case managers, to help ensure that when veterans do go out into the community, we have the individuals here who can help coordinate the care in the private sector.
You are right, there are risks that when an individual leaves a highly organized coordinated setting like the VA. There are opportunities for things to fall through the cracks. That’s why we are creating an infrastructure of care teams to try and prevent that from happening.
We also have a community care oversight council here made up of our clinical leaders on the medical staff to monitor data and issues of quality, safety and value for community care.
It is important veterans have access to care, close to home, when we are not able to provide the services in White River Junction. Or when it makes sense medically. We welcome new partnerships with the private sector. But as you said, there is lots of evidence, from a recent Dartmouth study for instance, that shows our outcomes are particularly good and our wait times are as good or better than most community models. It is going to be true, in many circumstances, that staying within the VA is going to be a veteran’s best choice.
VTD: What are the unique challenges of Vermont and New Hampshire’s veterans? Where will your focus be as medical director?
BR: Our focus remains on delivering excellent primary care and mental health services.
One of the things I’m most proud is if you were to go to our Community Based Outpatient Clinics, you will see fully functioning primary and mental health care at those clinics. Within the larger VA system, Vermont is unique in that way. Our commitment to those rural outlying clinics is important in this region.
Our priorities also continue to be focused on things like pain management and rehab, to include around opioid use. We’ve made some incredible strides over the last five years to reduce the frequency with which opioid pain medications are prescribed coming out of White River. This has been associated with tremendous gains in wellness among veterans. We will continue to turn towards alternative strategies to manage pain and disability, whether that’s through physical or occupational therapy, whole health modalities to include acupuncture, chiropractic treatment, yoga, and other things in that area. As I talk to younger veterans in Vermont who are coming out of Iraq and Afghanistan, they say those are important things for them to have access to. So we are continuing to build out programs to meet that need.
VTD: Let’s shift to burn pits. You recently spoke to the Valley News about how the VA is already offering care to veterans with rare cancers or other diseases that may have been caused through toxic exposure. We both know there are a number of Vermont National Guard folks who have become sick, or even died after being exposed to these pits. What would your message be to veterans in the state who were exposed to burn pits and don’t know if they are eligible for care, or are curious about the agency’s burn pit registry, or are generally confused about the VA’s approach to this issue?
BR: If a veteran is eligible for care and wants to receive care, they can and should come here. We have a team available to help determine eligibility. If veterans are unsure if they are eligible, or if they need care, it’s never wrong to come to the VA and develop a relationship with the provider and ask the questions that may help them develop goals for their health care futures.
As far as the burn pit registry is concerned: we have 293 participants in White River Junction. One hundred and ninety-eight of them have requested exams. Of that, 152 have had their exams completed. So we are doing quite a bit of this work already. The purpose of the registry is to help all of us understand the consequences of exposure to the burn pits. It does not necessarily convey benefit or lead to a certain type of health care delivered. This is a long-term effort to understand the scope of exposure and watch over time for the consequences of those exposures. In the meantime, if people are sick, we will provide them care.
VTD: Last year, Sen. Chris Murphy out of Connecticut passed legislation that opened up mental health care services to more veterans with “Other Than Honorable” discharges. There has been some frustration in Congress and elsewhere at the VA’s flawed outreach and education efforts concerning this new benefit. What is your message to Vermont veterans who have these discharges and believe they aren’t eligible to receive care at the VA?
BR: My message is, if you are a veteran and are in a mental health crisis, first, call the [crisis line.] It’s 1-800-273-8255. Press 1. You will receive the help that you need.
The next message is: If a veteran in crisis comes into our emergency room, we are going to help them. Yes, in that process there may be some determination that needs to be made regarding eligibility and what category a person falls into. But help will be provided, whether that’s here in our own inpatient unit or residential substance abuse program or if that’s partnering with community providers like Dartmouth-Hitchcock or the UVM Medical Center or the Brattleboro Retreat. We have many ways to help veterans. What is true universally is that if a veteran comes seeking help, help will be found here.
