Veterans opting for private health care
Survey finds satisfaction, but advocates still worry about quality
WASHINGTON — The Veterans Health Administration has sent more than 50,000 veterans to private care in the San Antonio and Houston regions since June, the latest development in an outsourcing trend that marks the biggest change in veterans services in a generation.
Based on the Mission Act passed last year by Congress, the Veterans Affairs Department in June relaxed access requirements for private care, paving the way for shuttling 223,000 Texas veterans into surrounding communities for treatment of many ailments, including, for the first time, urgent care needs.
A network of some 35,000 care providers outside the VA has been built in Texas — 6,100 in the Houston area and 5,180 in San Antonio — according to TriWest Healthcare Alliance, the Phoenix-based third-party administrator handling the program in Texas.
By one measure, the program is working: A Veterans of Foreign Wars survey in September of thousands of veterans nationally found that 8 in 10 were satisfied with VA Community Care and that more than half had chosen outside care over the VA when
given the choice.
Yet some advocates worry about the quality of private care for the complex ailments of veterans, particularly treatment for post-traumatic stress disorder and mental health needs. They note that providers aren’t required to collect and report data on wait times, treatment and other details of care.
Another concern emerged last week with the disclosure that a company handling the program in most states, Optum Public Sector Solutions, is having problems building a network of doctors. The company said it could need an infusion of millions of dollars in taxpayer money, according to congressional aides. The New York Times first reported the problem.
The revamped system also is renewing fears about the effects of resources shifted away from the nation’s largest government health care system, which operates more than 1,400 clinics and hospitals and serves 9 million veterans a year. That concern is raised in a new book by David Shulkin, who was fired by President Donald Trump last year as VA secretary.
In “It Shouldn’t Be This Hard to Serve Your Country,” Shulkin writes of pressure from forces in the Trump administration hostile to government.
In an interview, he described “behind-the-scenes, closed-door sessions” in which advocates driven by ideology pressed him to speed the pace of outsourcing.
Others with influence in the administration “believe that if there is a transfer of resources from the public sector to the private sector, there will be financial gains,” he contended.
Shulkin argued that the new access standards should be based on clinical need rather than easier access to care.
“It is a consequential policy decision that may, if not watched closely, lead to a move of resources from the VA to the private sector and a deterioration of the VA system,” he said.
The VA responded that Shulkin’s concern about standards “is a false, fringe view” and that privatization is “a myth.”
A VA spokesman referred to a recent op-ed by VA Secretary Robert Wilkie asserting that the new program “shows that the Trump administration is willing and able to buckle down and deliver real reform.”
Successes claimed in Texas
Under the new rules, veterans who must drive at least 30 minutes to a VA clinic or wait 20 days for an appointment can get care outside the VA. In the old system, which evolved after a wait-time scandal five years ago, veterans facing a 40mile drive or a monthlong delay in care had VA-funded private options.
Deploying software called Decision Support Tool, VA staff across the country referred more than 1.8 million veterans to private care from June 6 through Sept. 30, according to the agency.
In the four months this year before Community Care started, more than 1.45 million veterans were referred outside the VA for treatment. The department says no conclusions can be drawn from those numbers because of seasonal changes in treatment needs.
VA officials and TriWest say more care has been directed outside the VA since June, when Community Care started, but that they haven’t determined yet how much. In response to worries that the VA could be diminished, they assert that the agency is handling more appointments than ever. And they point to Texas, which has some of the nation’s fastest-growing VA clinics, as an example of where the new system is working and where the VA continues to grow.
“In Texas, we’ve done very, very well,” said Dr. Richard Stone, executive in charge of the Veterans Health Administration, noting early difficulties elsewhere arranging outside care.
Stone cited a “robust military presence” in the San Antonio area as one reason the VA regards Texas as a success.
“These are patriotic people in Texas, and there’s been great participation in the commercial sector,” he said in an interview.
From the June 6 start of Community Care through Oct. 31, the San Antonio VA referred 28,308 veterans to private care; the Houston VA sent 25,426, according to the VA. In all of Texas, 223,000 veterans got private care referrals.
VA officials assert that the increasing workload within the agency shows that the system is not being “hollowed out,” as skeptics warn. In Houston and San Antonio combined, outpatient visits grew by 156,000 last year, they report.
Jennifer MacDonald, the VA’s director of clinical innovation and education, said in an interview that “the VA is really driving into a new era of veteran empowerment and, I believe, leading U.S. health care into new patient empowerment.”
Christopher Sandles, San Antonio-based director of the South Texas Veterans Health Care System, said Community Care and other programs provide flexibility to send veterans to private care when government clinics lack the capacity or when veterans can get better care outside the VA.
“Things change,” he said, when asked about privatization. “I can assure you that any organization that’s been around for a long time — you pick the industry, you pick the company — hasn’t stayed the same because the environment in which they operate has changed.”
Sandles, 39, added: “Unlike some of my counterparts, I’m still a pretty young guy. When I think about the VA, I think about the need for it to survive. My expectation is to be with the Department of Veterans Affairs for the duration of my career.”
Quality concerns aired
VA Community Care replaced the VA Choice Program, which expanded private care with a $10 billion appropriation after a scandal in 2014 at a VA hospital in Phoenix, where dozens of veterans died while waiting months for appointments.
The Mission Act, which made the new system possible, passed last year with broad bipartisan support and the backing of many organizations that advocate for veterans. In polarized Washington, veterans issues typically have escaped the rancorous fights between administrations and Congress.
But Democrats and veterans groups complained often that they were shut out of planning to implement the Mission Act, a dispute that boiled over in June when staff from the Democratic-run House Veterans Affairs Committee fanned out to observe the start of the new program.
They encountered what they described as “coordinated and unprecedented obstruction from the VA” in gathering information, according to a report of the visits obtained by Hearst Newspapers.
Congressional staff that traveled to Florida, Michigan, Colorado, Virginia and Puerto Rico wrote that they were prohibited from speaking with VA officials about what they considered insufficient training and a lack of outreach into communities where veterans would be sent for care.
The committee is “deeply concerned by these initial observations and the potential impact VA’s communication failures and inconsistent guidance could have on our nation’s veteran population,” they wrote.
Veterans advocates worry about the VA’s capacity to ensure quality care.
“We agree that veterans have more choice, but choice of what?” asked Adrian Atizado, deputy national legislative director for Disabled American Veterans.
“The idea was to create an integrated health care network. What we have are two health care networks: one in the VA and one in the private sector, with two different standards of quality,” he said.
He added: “If providers don’t want to be transparent with the quality care they provide, do we want them in our network?”
Heather O’Beirne Kelly, the American Psychology Association’s director of military and veterans health policy, pointed to studies finding a lack of high-quality private care for veterans in need of treatment for PTSD and related conditions.
“Because we want veterans to get effective, high-quality mental health care, APA urges the VA to require that outside psychologists meet the same professional standards as VA psychologists,” she said. “This is one way to guarantee some basic level of competency.”
TriWest overcharged
In August, the VA awarded TriWest a seven-year contract to administer Community Care in Texas and a dozen Western states. TriWest, which has a history of multibilliondollar contracts with the government, has been a third-party administrator for much of the country as the program gets off the ground and care networks get built.
Two years ago, TriWest was forced to repay the government nearly $40 million after an audit found that it had overcharged the Choice program for private care. In 2011, the company paid $10 million to settle a lawsuit alleging that the company had defrauded the Pentagon’s Tricare health insurance program for military members, their dependents and retirees.
TriWest president and CEO David McIntyre defended his company in an interview, saying it has been “audited, poked at and investigated” routinely over the years.
“You don’t win contracts in this environment without the government being attentive to what the facts are,” he said, referring to the August award.
McIntyre, a former aide to the late Sen. John McCain of Arizona, said veterans in Texas can look to an alliance with hospitals in the Rio Grande Valley that his company helped forge in 2016 as a successful example of private care.
“Prior to that, veterans either drove five-and-a-half hours to Houston or San Antonio for special care, or they did without,” he said.
He contended that it became clear as far back as World War II that the VA needs “elasticity” to supplement what it does with outside care.
“There’s a very delicate balance here that has to be struck,” he said. “We’ve all invested in bricks and mortar, in footprint and VA personnel, but sometimes that footprint is insufficient to meet veterans’ needs.”