In the current issue of Digestive Diseases and Sciences, Dunn et al. [1] report the results of a national, comprehensive survey of clinical sites providing care for advanced liver disease (ALD) patients in the Veteran Health Administration (VHA). The survey captured data related to access and barriers to ALD care for the Veteran population.

The most remarkable aspect of Dunn et al.’s survey of providers caring for patients with ALD is that it simply exists. Despite the sizeable costs of the care of patients with ALD and its complications [2, 3], the rising incidence of nonalcoholic (NASH) and alcoholic-associated liver disease (AALD) [4], and the increasing complexity of care and focus on outcomes and quality in the American medical system [5], no major healthcare system has published data on ALD patients’ access and barriers to health care. Therefore, VHA’s providers, who delivered care to > 6 million Veterans in 2018—of which an estimated 1% of Veterans are diagnosed with ALD—should be commended for providing overall excellent care to this complex patient cohort and Digestive Diseases and Sciences for publishing the results.

The challenge for the VHA will be implementing a plan to reduce the gaps in care revealed in the survey’s report. Most sites reported at least one barrier to access to care. The survey reported that 20% of Veterans with ALD do not have access to complete multidisciplinary care, defined as access to mental health, substance use, palliative care, and endoscopy. Less than 25% of sites offered pharmacologic treatment for alcohol use disorder. Around 50% of providers struggled to navigate the complex liver transplantation referral process. It is worrisome that < 25% of ALD patients were referred to palliative care services, despite the well-documented high morbidity and mortality rates and limited survival associated with decompensated liver disease [6]. The reasons for the disparities among sites are multifactorial and likely not fully captured by the survey instrument, but include the lack of: providers, timely scheduling, access to facilities, access to transportation, and knowledge of resources available. The VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 established a permanent community care program for Veterans [7]. The MISSION Act could be used to refer Veterans to local community centers with access to specialty liver-related care, endoscopic procedures, and mental health providers, although the community health networks also face a growing shortage of specialty physicians, including gastroenterologists and hepatologists [8].

The VHA as an integrated healthcare system is well positioned to close these gaps so that all patients with ALD have increased access to multispecialty care and improved quality of life. The survey data could be used to justify hiring of more primary care, specialist physicians, and support personnel. Telemedicine could be further leveraged to increase access to experts in liver disease, transplantation, mental health, nutrition, and addiction medicine, particularly in networks that cover large geographical areas [9]. It would be helpful to know in an updated survey if complexity of the referral process remains the most common barrier to liver transplantation evaluation, as the survey was completed soon after the rollout of VHA’s TRACER (Transplant Referral and Cost Evaluation/Reimbursement), a secure electronic intranet referral portal that standardizes and facilitates the transplantation process, which includes a checklist for liver transplantation referrals [10]. Hiring of additional transplant support personnel at referral facilities could also reduce barriers to transplant care. Finally, the MISSION Act contains specific language to help Veterans access community transplant care, including dual listing at a community-approved transplant program and living donor liver transplantation [11].

The recent success of VHA in curing almost all of the Veteran population of HCV represents a major milestone in modern American healthcare history. Furthermore, it also provides a robust model to better address the rising burden of chronic liver diseases [12]. The survey results reported by Dunn et al. offer initial directions to guide VHA in improving the lives of all Veterans with ALD, as well as a charge for the leaders in the rest of the American health system to identify and remove obstacles preventing providers from delivering optimal care to their patients with advanced liver disease.