Hos­pi­tals brace for chal­lenges serv­ing more vets

Modern Healthcare - - NEWS - By Vir­gil Dick­son

The Obama ad­min­is­tra­tion’s new pol­icy of re­fer­ring more vet­er­ans for care out­side the overwhelmed Vet­er­ans Af­fairs health sys­tem could end up strain­ing non-VA hos­pi­tals be­cause of po­ten­tial lags in pay­ment and pa­tient needs that civil­ian providers aren’t nec­es­sar­ily pre­pared to han­dle.

With the VA scan­dal over long waits for vet­er­ans at VA fa­cil­i­ties grow­ing, the White House and the VA an­nounced that more vet­er­ans will be able to use pri­vate med­i­cal ser­vices. Un­der the new Ac­cel­er­at­ing Care Ini­tia­tive, VA fa­cil­i­ties must of­fer a re­fer­ral to an out­side provider if they don’t have the ca­pac­ity to give an ear­lier ap­point­ment to any new pa­tient who is on a wait list or has a visit sched­uled more than 30 days out.

VA In­spec­tor Gen­eral Richard Grif­fin con­cluded last week that 1,700 vet­er­ans in need of care in Phoenix were kept off the fa­cil­ity’s of­fi­cial wait­list, and the aver­age wait time was 115 days, al­though VA guide­lines say vet­er­ans should get ap­point­ments within 14 days of their re­quest. He said that VA of­fi­cials in Phoenix fal­si­fied data to hide the long waits and that sim­i­lar ma­nip­u­la­tion was “sys­temic” through­out the 153-hospi­tal VA sys­tem serv­ing 9 mil­lion vet­er­ans a year.

The first re­fer­rals were ex­pected May 30, ac­cord­ing to the VA. The agency be­lieves it will take up to 90 days to fully im­ple­ment the pol­icy, which is ex­pected to be­come per­ma­nent. Vet­er­ans will be able to seek care only at pri­vate clin­ics and hos­pi­tals in ar­eas where the depart­ment’s ca­pac­ity to ex­pand is limited. The VA did not pro­vide an es­ti­mate of how many pa­tients might re­ceive re­fer­rals un­der the pol­icy.

The VA typ­i­cally re­im­burses out­side providers only for emer­gency care or for vet­er­ans who live in ru­ral ar­eas with­out ac­cess to a VA fa­cil­ity. It some­times grants spe­cific re­quests to see pri­vate providers.

In fis­cal 2013, the VA paid for such care for 1 mil­lion vet­er­ans at a cost of $4.8 bil­lion, nearly 10% of the agency’s budget.

Hospi­tal as­so­ci­a­tions in states with large vet­eran pop­u­la­tions ex­pressed con­cern about get­ting claims paid in a timely way by the vet­er­ans sys­tem. Weeks be­fore the first al­le­ga­tions of long waits and deaths made head­lines, the U.S. Govern­ment Ac­count­abil­ity Of­fice re­leased a re­port de­tail­ing cases of claims from non-VA hos­pi­tals that were wrongly de­nied be­cause of poor ad­min­is­tra­tive pro­cesses. It found that the VA lacks suf­fi­cient over­sight mech­a­nisms and data to en­sure that VA fa­cil­i­ties do not in­ap­pro­pri­ately deny claims. When pri­vate hos­pi­tals were not re­im­bursed by the VA, they billed vet­er­ans di­rectly.

“Be­cause our hos­pi­tals have his­tor­i­cally ex­pe­ri­enced chal­lenges with timely re­im­burse­ment for VA pa­tients, we are await­ing fur­ther in­for­ma­tion from our federal part­ners as to any mod­i­fi­ca­tions to pay­ment poli­cies as­so­ci­ated with (the) an­nounce­ment,” said Julie Henry, a spokes­woman for the North Carolina Hospi­tal As­so­ci­a­tion. That state is home to about 950,000 vet­er­ans.

Sim­i­lar con­cerns were raised in Michi­gan, with an es­ti­mated 1 mil­lion vet­er­ans. “Michi­gan hos­pi­tals op­er­ate on tight op­er­at­ing mar­gins … so slow re­im­burse­ment can add to the fi­nan­cial bur­dens hos­pi­tals en­dure,” said Laura Ap­pel, vice pres­i­dent for federal pol­icy and ad­vo­cacy for the Michi­gan Health & Hospi­tal As­so­ci­a­tion.

Still, the North Carolina and Michi­gan as­so­ci­a­tions stressed that their mem­ber hos­pi­tals will treat any vet­er­ans who come through their doors, re­gard­less of abil­ity to pay.

An­other worry is the ca­pac­ity of civil­ian providers to treat vet­er­ans for ser­vice-re­lated con­di­tions such as Agent Or­ange ex­po­sure, Gulf War syn­drome, post-trau­matic stress dis­or­der and trau­matic brain in­jury. “There can be a lack of un­der­stand­ing of vet­eran cul­ture and how they can ex­pe­ri­ence some­thing like PTSD dif­fer­ently from other pa­tients,” said Dr. Craig Bryan, di­rec­tor of the Na­tional Cen­ter for Vet­er­ans Stud­ies at the Univer­sity of Utah. “This could lead many ser­vice­men who seek care to drop out of treat­ment pre­ma­turely.”

But Terri Tanielian, a se­nior so­cial re­search an­a­lyst at RAND Corp. who spe­cial­izes in mil­i­tary and vet­er­ans health pol­icy, said treat­ing ser­vicere­lated con­di­tions should be no dif­fer­ent from han­dling other less com­mon in­juries and dis­eases.

The re­sponse from vet­er­ans or­ga­ni­za­tions to the Obama ad­min­is­tra­tion’s ex­pan­sion of care in pri­vate fa­cil­i­ties has been mixed. “If im­ple­mented prop­erly, and as­sum­ing the man­age­ment at the VA med­i­cal-cen­ter level in the field do what they have been in­structed to do by VA cen­tral of­fice, this could cer­tainly help al­le­vi­ate some of the ac­cess con­cerns,” said Carl Blake, act­ing as­so­ciate ex­ec­u­tive di­rec­tor of govern­ment re­la­tions at Par­a­lyzed Vet­er­ans of Amer­ica.

Oth­ers, though, said the pol­icy does not fully ad­dress the chal­lenges vet­er­ans face get­ting ac­cess to care. “The fact is, pri­vate care has wait­ing lists, too,” said Joe Davis, pub­lic af­fairs di­rec­tor for Vet­er­ans of For­eign Wars. “You just don’t hear about them be­cause civil­ian hos­pi­tals ei­ther don’t track or don’t re­port them. When was the last time you had or ever had a same-day ap­point­ment?”

VA In­spec­tor Gen­eral Richard Grif­fin said wait­list ma­nip­u­la­tion was “sys­temic.”

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