What does the Shulkin ouster mean for ex­pan­sion of VA Choice?

Modern Healthcare - - News - By Su­san­nah Luthi

Vet­er­ans’ health­care, the sprawl­ing, ex­pen­sive sys­tem within the na­tion’s sprawl­ing, ex­pen­sive sys­tem, is com­pli­cated and ap­pears to be get­ting more so.

The sud­den Twit­ter fir­ing of Vet­er­ans Af­fairs Sec­re­tary Dr. David Shulkin reignited the pol­i­tics around VA Choice— even as law­mak­ers and stake­hold­ers said they hope the lead­er­ship shakeup won’t fur­ther stall long-awaited ex­pan­sion of the pro­gram.

One day after Pres­i­dent Don­ald Trump fired Shulkin and nom­i­nated the pres­i­dent’s per­sonal physi­cian, Dr. Ronny Jack­son, to re­place him, dis­cus­sions about the best way for­ward with VA Choice picked up again, a White House aide said. One Shulkin critic seized the op­por­tu­nity to say the for­mer sec­re­tary had be­come a dis­trac­tion from ad­vanc­ing leg­is­la­tion. A Demo­cratic aide, how­ever, said the lat­est draft bill for VA Choice, blocked last week by House Democrats, likely won’t make it on the leg­isla­tive cal­en­dar.

At stake is the care for more than 9 mil­lion peo­ple—roughly the size of the Oba­macare in­di­vid­ual mar­ket; a huge bump in po­ten­tial busi­ness for al­most half a mil­lion com­mu­nity providers who al­ready con­tract for vet­er­ans care de­spite com­plaints that pay­ments come in slowly or not at all; and tighter over­sight of the two pri­vate pay­ers, Health Net Fed­eral and TriWest, who run the pri­vate net­works for all el­i­gi­ble vet­er­ans. (Health Net’s con­tract will not be re­newed after Septem­ber.)

There is also the is­sue of more than 1,200 VA med­i­cal fa­cil­i­ties that range from big cam­puses to small out­pa­tient sites, in­clud­ing never-used and hardly used build­ings. Should the govern­ment shut­ter some of th­ese sites, or more ef­fi­ciently merge pub­lic and pri­vate sys­tems? And how much of a fi­nite pot of money should be di­verted from the VA’s own sys­tem for the pri­vate sys­tem?

Th­ese ques­tions frus­trated Shulkin, the for­mer CEO of Beth Is­rael Med­i­cal Cen­ter in New York. Those prob­lems would shift to Jack­son—who has lit­tle man­age­ment ex­pe­ri­ence and would face some VA staff mem­bers who had been openly de­fi­ant of Shulkin.

Jack­son’s ap­point­ment will need Se­nate con­fir­ma­tion; in the in­terim, Un­der­sec­re­tary of De­fense Robert Wilkie will serve in the post. So Shulkin’s fir­ing leaves an im­me­di­ate vac­uum in del­i­cate ne­go­ti­a­tions that led to clashes within the ad­min­is­tra­tion and among law­mak­ers over the past few months.

The lat­est par­tial deal on VA Choice re­forms was struck by GOP and Demo- cratic Se­nate Vet­er­ans’ Af­fairs Com­mit­tee law­mak­ers, House Vet­er­ans Af­fairs’ Com­mit­tee Repub­li­cans, the White House and the VA the week­end be­fore Congress passed its $1.3 tril­lion om­nibus spend­ing plan. House Democrats, in­clud­ing Tim Walz of Min­nesota, the rank­ing Demo­crat on the cham­ber’s VA com­mit­tee, uni­formly op­posed the bill. House Mi­nor­ity Leader Nancy Pelosi (D-Calif.) blocked it from get­ting in­cluded.

The draft text of this com­pro­mise, ob­tained by Mod­ern Health­care and dated March 18, in­cor­po­rates de­mands from the White House and Sen. Jerry Mo­ran (R-Kan.), who was a linch­pin in the pri­va­ti­za­tion ef­fort. The bill out­lines ac­cess stan­dards for VA clin­ics.

A VA clinic’s fail­ure to meet those stan­dards for any veteran would trig­ger VA Choice el­i­gi­bil­ity for that pa­tient, who could then seek care from a pri­vate provider. The pro­vi­sion was added in a White House and VA draft of the Se­nate leg­is­la­tion.

The bill also adds a com­pro­mise for Democrats and other stake­hold­ers to hold pri­vate providers ac­count­able for the same ac­cess stan­dards, a Demo­cratic aide said. If pri­vate providers can’t meet the stan­dards, the VA sec­re­tary would have the dis­cre­tion to end their con­tracts.

But the lan­guage around those stan­dards isn’t as strong for the pri­vate providers as it is for the VA, be­cause their fail­ure to mea­sure up wouldn’t block them from work­ing with vet­er­ans.

The White House pushed back on mak­ing th­ese same qual­ity stan­dards manda­tory for com­mu­nity providers on the grounds that it was un­work­able, ac­cord­ing to a Demo­cratic aide.

This lat­est draft—as in pre­vi­ous ver­sions—would stream­line all the com­mu­nity care pro­grams un­der Choice

and al­low vet­er­ans along with their physi­cians to de­cide whether to opt for a com­mu­nity provider over the VA. This the­o­ret­i­cally opens up Choice for who­ever wants a pri­vate physi­cian or hos­pi­tal. The bill also man­dated prompt pay­ment to providers—an is­sue Shulkin said was un­der­min­ing pri­vate net­works.

For some stake­hold­ers, this par­tial deal ap­peared to be the break­through that would make it into law. And they ar­gue that it still could be, even with the po­ten­tial dis­rup­tion of the lead­er­ship shakeup.

“We have had th­ese dis­cus­sions for four years,” said Car­los Fuentes, who as leg­isla­tive di­rec­tor for Vet­er­ans of For­eign Wars has been in­volved in the stake­holder dis­cus­sions. “We know where the ad­min­is­tra­tion has been, and where Congress stands. We know where we want the pro­gram to go. We al­most had the agree­ment, and there is a frame­work there for an agree­ment. We need to con­tinue the mo­men­tum so that we can get this done.”

A Demo­cratic aide shrugged off the idea that Shulkin’s dis­missal changes the al­ready-testy Choice ne­go­ti­a­tions, in­di­cat­ing that for House Democrats at least, the bill on the ta­ble isn’t ac­cept­able.

“House Democrats’ con­cerns that the pack­age would have dan­ger­ously moved closer to VA pri­va­ti­za­tion are the same no mat­ter who is serv­ing as sec­re­tary,” the aide said.

An­other Demo­cratic staffer said the leg­is­la­tion makes an al­ready com­plex sys­tem even more com­plex ad­min­is­tra­tively, since it adds ex­tra per­for­mance de­mands for VA clin­ics and myr­iad ways vet­er­ans could qual­ify for com­mu­nity care that could lead to con­fu­sion for pa­tients and ad­min­is­tra­tors.

As stake­hold­ers and law­mak­ers spoke out about Shulkin’s dis­missal, they also dug in their heels about the Choice pro­gram, sig­nal­ing that the bat­tle isn’t over. “We are hope­ful that this change will end the re­cent dis­trac­tions at the VA and put the fo­cus back on ad­vanc­ing pol­icy that will en­sure vet­er­ans get the health­care and other ben­e­fits they have earned,” said Dan Cald­well, ex­ec­u­tive di­rec­tor of Con­cerned Vet­er­ans for Amer­ica—a group funded by con­ser­va­tive mega-donors Charles and David Koch that has lob­bied hard on the Choice is­sue and had ini­tially backed Mo­ran’s pro­posal. The lat­est draft leg­is­la­tion has his en­dorse­ment.

“Congress is go­ing to need to pass leg­is­la­tion that fixes Choice and com­mu­nity care pro­grams,” Cald­well told Mod­ern Health­care. “There are still hun­dreds of thou­sands of vet­er­ans need­ing med­i­cal care. We be­lieve the leg­isla­tive lan­guage that was go­ing to be in­cluded in om­nibus would have gone a long way to re­duce ac­cess is­sues.”

But Pelosi came out swing­ing in her state­ment on Shulkin’s ouster, blast­ing the re­cent ef­fort on Choice as she called the sec­re­tary’s dis­missal “a trou­bling step in the Trump ad­min­is­tra­tion’s ul­ti­mate goal of VA pri­va­ti­za­tion.”

“From day one of this ad­min­is­tra­tion, the pres­i­dent has openly en­cour­aged and em­braced Koch broth­ers-led forces as they work around Congress and be­hind closed doors to dis­man­tle vet­er­ans’ health­care,” Pelosi said.

Fuentes said though no side will get ev­ery­thing it wants, his ad­vice to Congress from a vet­er­ans ser­vice or­ga­ni­za­tion is to keep pro­mot­ing the draft.

“When you’re con­sid­er­ing vet­er­ans who don’t have ac­cess to care, you need cer­tainty, and there is ur­gency,” Fuentes said, not­ing that since Septem­ber Congress has sim­ply punted on au­tho­riz­ing the Choice pro­gram per­ma­nently by adding stop­gap fund­ing. The last batch of fund­ing is pro­jected to run out in June. “It’s about get­ting to­gether to mit­i­gate any dif­fer­ences and chart the way for­ward.”

Fuentes added that VA mat­ters tra­di­tion­ally have been bi­par­ti­san. “I hope that con­tin­ues,” he said.

The top Demo­crat for the Se­nate VA Com­mit­tee added his voice to the cho­rus of law­mak­ers ask­ing to fin­ish up a bill. “Mov­ing for­ward, the VA needs a strong leader at the top who will lis­ten to vet­er­ans, strengthen the VA, and work with Congress to im­ple­ment bi­par­ti­san re­forms,” Sen. Jon Tester (D-Mont.) said.

Yet as law­mak­ers and stake­hold­ers jos­tle, one key item is miss­ing from the de­bate: how the ex­panded role of pri­vate providers would ac­tu­ally work.

On March 1, the RAND Corp. re­leased a sur­vey look­ing only at New York state health­care providers and their readi­ness to ac­cept vet­er­ans as pa­tients. Re­searchers stud­ied of­fer­ings of “cul­tur­ally com­pe­tent care” that take into con­sid­er­a­tion con­di­tions and med­i­cal his­tory common to vet­er­ans.

An­a­lysts said that of the 92% of New York providers ac­cept­ing new pa­tients, only 2.3% met all the re­searchers’ des­ig­nated cri­te­ria “for ef­fec­tively serv­ing the veteran pop­u­la­tion.”

That echoes con­cerns some in the provider com­mu­nity have ex­pressed (See edi­to­rial, p. 26).

More than 800,000 vet­er­ans, half of whom are un­der 65, live in New York. Nearly half of the VA’s $6.3 bil­lion an­nual ex­penses in the state is spent on health­care. Fewer than 5% of the health­care providers sur­veyed by the re­searchers said they were part of VA Com­mu­nity Care. Men­tal health pro­fes­sion­als, a ne­ces­sity for vet­er­ans deal­ing with trau­matic is­sues, were the least likely to be en­rolled in the pro­gram.


The ouster of Vet­er­ans Af­fairs Sec­re­tary Dr. David Shulkin has height­ened the de­bate over VA pri­va­ti­za­tion ef­forts.

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