By Tom Philpott
Special to Stars and Stripes
Published: July 31, 2014
Note: In addition to the $15 billion, the Congressional Budget Office reported Thursday a measure in the bill calling for leases on 27 new medical centers in 15 states and Puerto Rico would cost about $1.27 billion.
Veterans reading only headlines, hearing only sound bites, might have a few misconceptions about how Congress and the VA plan to use non-VA healthcare providers to ensure more timely and convenient access to care.
A magical sounding item called a “Veteran’s Choice Card,” for example, won’t be a limitless credit card given qualified veterans to cover whatever health services they receive from whatever physician they use.
And veterans not already enrolled in VA health care won’t gain accelerated access to outside care as promised by the legislation – unless they serve in areas of combat operations within five years of enrollment.
The centerpiece of the Veterans Access, Choice and Accountability Act of (HR 3230) is a special $10 billion Veterans Choice Fund. Over the next three years, VA is to use the fund as needed to buy care from non-VA care providers for veterans if they face long waits for VA care – defined initially as more than 30 days – or if they reside more than 40 miles from VA care.
The intent is to eliminate VA patient wait lists that some VA health administrators and staff conspired to hide in recent years, thus compromising the integrity of performance reports and putting patients’ health at risk.
VA leaders and veteran service organizations prefer to attack wait times through improved resourcing. They want VA spending raised to meet actual patient demand from wars in Iraq and Afghanistan, from the expansion of diseases presumed caused by defoliants used in Vietnam, and from higher costs of caring for aging veterans.
So HR 3230 also authorizes VA to spend $5 billion more to expand its own capacity to deliver care, by hiring more medical and support staff and also building and leasing more space.
House-Senate conferees, in shaping the final bill, categorized the Choice Fund as emergency money so the $10 billion gets added to the nation’s debt but not to VA budgets. The $5 billion for more VA-delivered care is to be paid through cuts elsewhere in VA, including executive bonuses and by deferring planned rate cuts for some types of VA home loans.
The legislation mandates use of a new Veteran’s Choice Card but it isn’t a golden key to private sector care. It will be more like an informational insurance card to be presented to non-VA health care providers to identify the veteran and to verify eligibility for episodes of care that, sometime earlier, were arranged through and approved by a VA care coordinator.
The administrative challenges ahead for VA in coordinating a vast expansion of private sector care, monitoring outside care quality and integrating those medical records back into VA health care will be profound. But the bill is said to set aside only $300 million for these added tasks.
Indeed, in reviewing the new law’s requirements, VA officials are weighing whether current Veteran Identification Cards (VICs), which are issued when veterans enroll in VA health care, might be modified to serve as the “choice card” that the new law mandates.
Other details in the reform package will disappoint reformers who seek to fully “privatize” VA care. The bill is a series of compromises between near-term action to address the patient wait-time scandal and steps to shore up the integrated VA health care system so prized by many veterans and their service organizations. Here’s more on how non-VA care will grow:
ELIGIBILITY – The hurdles to gain easy access to non-VA care go beyond how far veterans reside from a VA clinic or how long their wait for care. To be eligible, veterans must have enrolled in VA health care by Aug. 1, 2014 or, if they enroll later, they must have served on active duty in a theater of combat operations within five years of enrolling.
These restrictions address cost concerns fiscal conservatives had after the Congressional Budget Office projected that up to two million more veterans would drop current health insurance and enroll with VA if given the chance to use current doctors and have VA foot the bill.
NO FIRM 30-DAY GOAL – Architects of HR 3230, Sen. Bernie Sanders (I-Vt.) and Rep. Jeff Miller (R-Fla.), would like non-VA care offered to any vet who can’t get a VA appointment within 30 days. But their legislation allows VA to set a different wait-time goal if they can defend it. What VA finally decides will be part of interim rules for implementing the law, to be published within 90 days of President Obama signing the bill into law.
The bill would require that if VA can’t offer a timely appointment then it must inform the veteran electronically or, if the veteran chooses, by mail, and explain that outside care is authorized. Last year, VA spent $4.8 billion on non-VA health care but half of that involved emergency services.
40 MILES AS CROW FLIES – Veterans who reside more than 40 miles from a VA medical facility or who must travel by air, boat or ferry to access VA care are to be offered non-VA care instead. VA is to use “geodesic distance” or the shortest route between two points on Earth, or, if you like, “as the crow flies.” VA’s early estimate is that 500,000 vets will qualify.
However, House-Senate conferees in their explanatory report on HR 3230, say they do not intend the 40-mile criteria “to preclude veterans who reside closer” to a VA facility “from accessing care through non-VA providers, particularly if the VA facility…provides limited services.”
So VA will have to clarify in regulation what 40 miles really means.
CHOICE OF PROVIDER – Not all veterans who become eligible for non-VA care will get to choose their outside provider, and not every non-VA care provider will opt to treat veterans through the VA coordinated care program, even if the vets are existing patients. One issue for physicians will be the level of reimbursement and another the timeliness of VA payments.
VA has existing contracts with individual physicians and with pools of private sector providers. Many more such arrangements are expected. But VA cannot pay rates higher than Medicare allows, with exceptions possible if care is delivered in very rural areas.
Timeliness of VA payments to non-VA care providers has been a significant concern for years. The reform bill has language urging VA officials to improve their payment procedures.