Bringing 21st Century Medicine to America's Veterans

Strategic Partnerships and Leadership Initiatives at the Department of Veterans Affairs (VA)

• Creation of a New Strategic Role: The VA established a new "Senior Advisor for Strategic Partnerships" position (held by Matthew Collett) to address a historical cultural aversion to external collaboration.

  • Context: Prior to this role, the VA had turned down millions of dollars in in-kind services due to an inability to facilitate partnerships.
  • Origin: The role was created by Secretary Bob McDonald with a "startup" approach, initially without a dedicated staff or budget, tasked with leveraging the VA's existing $169 billion budget and 345,000 employees.
  • Mission: To shift the culture from "spending our way to success" to "partnering our way to success" to address mental health, employment, and homelessness issues beyond statutory obligations.

• Current VA Capabilities and Scale:

  • Infrastructure: The VA operates 152 medical centers, approximately 900 Community-Based Outpatient Clinics (CBOCs), and 134 national cemeteries.
  • Benefits: The system administers over $75 billion in benefits annually.
  • Reach: There are 9 million veterans enrolled in the VA system and a total of 23 million living veterans in the US.

Mental Health and Brain Disease Research

• Crisis Statistics: The VA reports that over 22 veterans die by suicide daily, with a significant portion linked to undiagnosed or untreated PTSD and Traumatic Brain Injury (TBI).
• Cohen Veterans Bioscience (CVB):
  • Model: A nonprofit founded with funding from philanthropist Stephen A. Cohen to address the mental health crisis through a "Cooperative Alliance Model."
  • Strategy: CVB acts as an independent, trusted third party to manage intellectual property, data sharing, and orchestrate a common research roadmap among diverse stakeholders (industry, academia, government).
  • Data Approach: The organization aims to move from descriptive behavioral syndromes to molecular biology and omics-based understanding of disease mechanisms.
• VA-Partnered Research Initiatives:
  • Scale: The VA is conducting the largest longitudinal study of its kind on brain research, involving 4,000 West Point cadets and 4,000 Air Force Academy cadets in collaboration with the NCAA.
  • CTE Research: Partnerships are being formed to identify biomarkers for Chronic Traumatic Encephalopathy (CTE) prior to death, building on the work of Dr. Ann McKee.
  • Brain Trust: The VA convened 350 experts (including medical technology and clinical care leaders) to develop a coordinated roadmap for TBI and PTSD prevention, diagnosis, and rehabilitation.

Precision Oncology and Clinical Performance

• VA Clinical Superiority: The VA outperforms the fee-for-service private sector in preventive, acute, and chronic care, including cancer screening and management.
  • Screening Metrics: Over 80% of VA veterans over age 50 receive colon cancer screenings, exceeding the national average of 60% and the "80 by 18" national goal.
  • Access Speed: Patients can see an oncologist within four weeks, often same-day; this is cited as faster than access at academic institutions like UCLA.
• Precision Medicine Infrastructure:
  • Internal Labs: The Los Angeles VA operates its own molecular pathology lab with a large panel of assays, allowing for immediate genomic analysis without outsourcing.
  • Demographics: Prostate cancer represents nearly one-third of all VA cancers, offering a critical model for studying biological differences between African American and Caucasian populations.
• Extreme Responder Case Study:
  • Discovery: Through a Team Science program funded by the Prostate Cancer Foundation, the VA identified signaling pathways in metastatic prostate cancer not detected by standard genetic testing.
  • Treatment Outcome: An "extreme responder" patient with advanced prostate cancer, who had failed four to five prior therapies, received an FDA-approved melanoma drug targeting the identified pathway.
  • Results: The patient's PSA levels dropped from 120 to single digits within three months, severe anemia resolved, and the patient returned to work, extending life from weeks/months to over a year.

Industry Perception and Future Opportunities

• Perception vs. Reality: The biotech and pharma industry often perceives the VA as insular, disconnected from the clinical state-of-the-art, and lacking transparency.
  • Reality Check: The VA possesses a "treasure trove" of longitudinal, multi-modal data (diet, lifestyle, genetics) that exceeds most private databases.
  • Market Access: The VA's electronic medical record system is consistent and integrated across the nation, offering a unique platform for large-scale data analysis.
• Biotech Investment Logic:
  • De-risking: Collaborations with the VA allow small biotechs to access high-quality patient pools and Key Opinion Leaders (KOLs) to de-risk clinical trials.
  • Patient Access: Partnerships can solve the "access pinch point" where up to 80% of prescriptions for drugs like PCSK9 inhibitors are currently turned down by managed care systems.
• Proposed Solutions and "Prescriptions" for Change:
  • Streamlined Processes: Industry leaders call for a "super streamlined" IRB process, single contracts for IP and material transfer, and an "Uberized" network to allow small companies to conduct "N-of-1" or precision trials instantly.
  • Central Leadership: There is a demand for a central "Air Boss" or point person within the VA to oversee precision oncology and coordinate partnerships, rather than relying on fragmented bottom-up efforts.
  • Visibility Campaigns: Foundations and public-private partners are encouraged to publicize "easy victories" and positive narratives to counter negative media inertia and change the perception of the VA as a "whipping boy" for federal agency failures.

Cultural Shift and Partnership Models

• The "Cooperative Alliance Model": A framework where a foundation manages diverse stakeholder interests to define a common roadmap and crowdsource solutions, rather than a centralized top-down approach.
• Triage and Empowerment: The VA has implemented a triage system to vet external partnership proposals and empowered its 350,000 employees to engage in partnerships, providing legal cover and "champion" support.
• High-Impact Partnerships:
  • Example: A partnership with the Elks organization resulted in a $4 million donation over four years to address veteran homelessness.
  • Example: A collaboration with Google utilized VR headsets to allow veterans to experience parades virtually, generating over 20 million video views and demonstrating the potential for media amplification through external partners.
• Future Outlook: The leadership at the VA under Bob McDonald has created a culture comfortable with ambiguity, transparency, and innovation, positioning the VA to potentially become the premier engine for precision medicine for the entire U.S. population if the current barriers are removed.