Worries mount as VA races to launch private-care program in June

HARRIS MEYER  April 27, 2019 01:00 AM

With just a few weeks to go before its June 6 launch, lawmakers, providers, and advocates are wary about the Veterans Affairs Department’s ability to roll out an expanded private-care program for veterans on schedule without experiencing major glitches like the last time.

They fear the 9.2 million veterans eligible for VA-paid healthcare will continue having trouble accessing timely, high-quality care outside of Veterans Affairs hospitals and clinics.

Non-VA providers hope the new Veterans Community Care program, mandated by the VA Mission Act enacted last year, will improve their ability to share patient data with VA facilities and receive timely payment for serving veterans. Those have been major problems for the Veterans Choice program, which ends when the new program begins. 

The VA selected Optum Public Sector Solutions as the third-party administrator for three regions, though that selection is being contested, while contractors for three other regions haven’t yet been selected. TriWest will continue as interim administrator for the Choice program while the new contractors ramp up their networks and processes over the coming year.

There also are concerns about whether the private providers in the new third-party administrators’ networks will be held to the same standards of quality and levels of familiarity with veterans’ health issues that VA providers must meet. That’s a particular worry for mental health screening and treatment, given the nearly 20 suicides among veterans every day. The VA will issue quality standards in June, an agency spokeswoman said.

Under the new law, the VA retains responsibility for coordinating care provided outside its Veterans Health Administration system. But that could prove challenging unless the agency is able to overcome long-standing problems with interchange of electronic health records. 

The VA has resisted calls to adopt the same interoperability model other federal programs use. Instead, it’s opting to use existing health information exchanges, the VA spokeswoman said. The VA declined to provide an official to interview.

Given all the uncertainties, some groups, including the Disabled American Veterans, are urging a partial delay in the new program.

But VA officials insist they’re ready to launch the Community Care program in June, as required by Congress, and that they’re prepared to cope with any implementation bumps. They say they learned the lessons from the disastrous, rushed launch of the Choice program in 2014. 

“Will we deliver care June 6? Yes,” Dr. Richard Stone, the executive in charge of the Veterans Health Administration, told the Senate Veterans’ Affairs Committee April 10. “We will get this right, but we will get better every day. … Some things don’t go right on the first day.”

Experts question whether the VA has underestimated the number of patients who will take advantage of the broader eligibility rules to seek care outside VA facilities, draining dollars needed to keep the huge veterans’ healthcare system strong. 

The launch of the new private-care program is the latest flashpoint in a long-running political battle over the government’s proper role in providing healthcare to veterans. Some conservative groups, led by the Koch brothers-funded Concerned Veterans for America, tout the program as enhancing competition between private and VA providers and offering greater choice to vets. VA supporters warn, however, that expanding local care is a deliberate step by the Trump administration to shrink or dismantle the Veterans Health Administration system and privatize veterans care.

Shulkin’s take

“The VA has made some assumptions that there won’t be fewer veterans seeking care in the VA system,” said Dr. David Shulkin, chief innovation officer at Sanford Health and a former Veterans Affairs secretary who was pushed out by President Donald Trump last year. “I want to understand better why they made that assumption so we don’t have the unintended consequence that the VA system ends up weakened and unsustainable.”

Under the Mission Act, the VA will consolidate seven existing programs that pay for veterans’ care outside the VA system, including Veterans Choice, into one. 

The 2018 law was designed to remedy long waits for care and payment under the Choice program, which itself was created by Congress to address excessive waits for care. 

The VA has significantly reduced wait times for appointments since a scandal over the covering up of long wait times erupted in 2014. Veterans now can see VA primary-care physicians and some specialists much faster than they see private-sector doctors, Stone recently told senators.

The Mission Act also allows veterans access to private urgent-care centers and includes provisions to boost VA staff recruitment and speed up payment to providers. It requires the VA to shift from manual claims processing to an electronic claims system, a measure applauded by providers.

VA Secretary Robert Wilkie said in January that the Community Care program “will revolutionize VA healthcare as we know it,” adding that the VA’s current patchwork of community programs is “a bureaucratic maze that’s hard to navigate.” 

He refuted claims that the program is a move to privatize the VHA, which he said generally delivers higher-quality care than other providers and retains the trust of veterans.

Still, both Republican and Democratic lawmakers have voiced doubts about whether the June 6 launch of Community Care will be initially successful, particularly given the VA’s leadership changes and turmoil over the past two years.

“I learned lessons from the Choice program, but that was three VA secretaries ago,” quipped Tennessee Rep. Phil Roe, the senior Republican on the House Veterans’ Affairs Committee, who admits he’s nervous about whether the program is ready to launch. “The C-suite has changed, and I don’t know if they know the lessons.”

In February, the VA proposed new eligibility standards for access to VA-paid care in the community, which the department says will be published in final form June 6, the day the new program starts. Veterans would be eligible for Community Care if they must drive 30 minutes or more to a VA facility for primary care or mental health services, or 60 minutes or more for specialty care. 

They’d also be eligible for private care if they have to wait 20 days or more for primary care or mental healthcare or 28 days or more for specialty care. 

Other factors qualifying veterans for Community Care would be if the services they need aren’t offered by the VA; there is no full-service VA facility in their state; their local VA facility is deemed deficient in quality or timeliness; or the veteran and the referring physician agree receiving care outside the VA would be in the veteran’s best medical interest.

Drive-time dependent

Critics say the criteria are too vague and could lead to veterans feeling they were unfairly denied access to Community Care. For instance, drive time depends on the time of the day when it’s calculated. 

“I’ll be on the borderline of qualifying for Community Care, and they’ll probably turn me down,” fretted Navy veteran Ray Rubio, who lives in Chicago’s south suburbs and prefers private-sector care because he’s been dissatisfied with the VA care he’s received.

The Disabled Veterans of America wants new access standards tested before the program launches. 

The access standards for Community Care would significantly increase the number of VA enrollees using VA-paid healthcare rather than the other health insurance most veterans have, such as Medicare or an employer plan, according to a Milliman analysis. Enrollees’ reliance on VA-paid care would rise from 36% to 40% by 2021, with the VA spending an estimated $18.7 billion more over five years.

The U.S. Digital Service reported in March that the proposed drive-time standards would hike the number of veterans eligible for community-based care from 685,000 under the Veterans Choice program to 3.7 million. 

It warned, however, that flaws in the digital support tool the VA is developing to determine eligibility would slow appointments and lead to VA physicians seeing 75,000 fewer patients a day, causing major disruptions. Wilkie denied that claim.

The sharp increase in the number of veterans eligible for community-based care has raised alarms among lawmakers and VA supporters about whether higher spending will squeeze funding for the VA system. Congress did not appropriate additional money for the new program, though the VA says it has sufficient funding for 2019.

“These increased costs for Community Care will likely come at the expense of the VA’s direct system of care,” a group of Democratic senators led by Montana Sen. Jon Tester warned in January.

Kayla Williams, director of the veterans program at the nonpartisan Center for a New American Security, shares that concern. An Army veteran who served in Iraq, Williams said she’s received both VA care and private-sector care through the military’s TriCare insurance plan, and that her care in the VA system was better coordinated and more comprehensive.

“I don’t completely oppose this new Community Care program because bringing all these programs into one system makes more sense,” she said. But expansion of care in the community “should not come at the expense of a strong VA.”

She and other experts say private-sector providers generally can’t match the VA’s 172 hospitals and 1,069 outpatient clinics in delivering care that’s attuned to military culture and the unique medical needs of veterans, who tend to be sicker on average than non-veterans. Those special needs include toxic exposures, spinal cord injuries, prosthetics for lost limbs, and post-traumatic stress disorder, with which many community providers have little or no familiarity.

Williams said three female veterans she knows were diagnosed with breast cancer in their 30s because VA providers were aware of their exposure to toxins and ordered mammograms at a younger age than is typically recommended. “There’s nothing that shows civilian providers would know what to screen for,” she said.

The VA has not yet said how it will ensure that non-VA providers are culturally competent to serve veterans and able to provide the range of services veterans need. Up to now, there has been no systematic analysis of the timeliness or quality of care that veterans receive through VA community programs, according to the RAND Corp.

Indeed, a RAND survey last year of hundreds of private-sector providers in New York state to assess their readiness for treating veterans with service-connected health issues found that only 2.3% met a number of key readiness criteria. Those included familiarity with military culture, preparedness to screen for and treat conditions common among veterans, and accommodation for patients with disabilities. 

Nearly 60% of the New York providers said they did not want additional training for working with veterans.

“The number of providers who met our full criteria for readiness was much lower than we anticipated or that is desired,” said Terri Tanielian, a senior behavioral scientist at RAND who worked on the New York study. “Our findings support concerns about the uneven level of quality between VA and community providers.”

There are health systems, however, that have developed close working relationships with VA facilities and whose providers have gained substantial experience in serving veterans since the Choice program started in 2014. 

One is Northwell Health, which built a clinic to serve veterans and their family members in collaboration with the Northport (N.Y.) VA Medical Center. On one side, VA providers serve the veterans, while on the other side Northwell providers serve the family members.

Even with the experience of serving thousands of military families, it’s no small task for Northwell to train its clinicians in the unique needs of veterans and get ready for a possible increase in patients under the expanded community program.

That means helping clinicians understand the different physical and behavioral conditions veterans may present with, how to accommodate patients with disabilities, and the availability of special programs and resources for veterans, said Dr. Tochi Iroku-Malize, Northwell’s family medicine chair.

Given clinicians’ busy schedules, she plans to use online training modules and clinical rounds focusing on veterans’ needs. “The case of the day may be a veteran with PTSD and what’s causing his heart rate to go up so fast,” she said. “I have to make sure my clinical workforce is prepared for this.” 

Former VA Secretary Shulkin said Congress must be ready to jump in fast if problems with the new Community Care program arise after its launch. 

“This is an aggressive time schedule, but that isn’t a problem,” he said. “You have to be really committed to monitoring the impact of this very closely, and be open and transparent. No one wants to see a well-intended policy result in disaster.”

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