New VA rules on health-care ac­cess leave many un­knowns

The Progress-Index - - MILITARY LIFE - Tom Philpott

The num­ber of vet­er­ans el­i­gi­ble for health care ser­vices in their com­mu­ni­ties, us­ing net­works of pri­vate sec­tor providers con­tracted by the Depart­ment of Vet­er­ans Af­fairs, is ex­pected to jump this sum­mer when reg­u­la­tions set­ting new ac­cess stan­dards for com­mu­nity care be­come fi­nal.

Vet­eran ser­vice or­ga­ni­za­tions and con­gres­sional com­mit­tees with over­sight re­spon­si­bil­i­ties for the Depart­ment of Vet­er­ans Af­fairs con­tend that the bare­bone de­tails re­leased last week raise many more ques­tions than they answer.

Top among them are whether VA will have the bud­get dol­lars, the com­plex pro­ce­dures and the en­hanced ad­min­is­tra­tive tools in place to avoid the kind of calami­tous launch that scarred the Choice pro­gram from its in­cep­tion in late 2014.

The new ac­cess stan­dards will be based on fac­tors gen­er­ally fa­mil­iar to vet­er­ans who sought pri­vate sec­tor care un­der Choice: av­er­age drive time to get VA care and wait times to get VA ap­point­ments. But a VA spokesman said the new ac­cess screens “are based on an in-depth anal­y­sis of all of the ac­cess best-prac­tices in both gov­ern­ment and pri­vate sec­tor health care sys­tems and tai­lored to the needs of our vet­eran pa­tients.”

Vet­er­ans will be el­i­gi­ble to use net­works of lo­cal providers for pri­mary care, men­tal health care and non-in­sti­tu­tional ex­tended care ser­vices if their av­er­age drive time to get such care from VA is 30 min­utes or longer. They will be al­lowed to use the out­side providers for spe­cialty care if av­er­age drive time to a VA spe­cial­ist is 60 min­utes or more.

These rules will re­place the more rigid dis­tance rule un­der Choice that vet­er­ans must re­side more than 40 miles from a VA fa­cil­ity with a pri­mary care provider. VA es­ti­mates that this change alone will make 20 per­cent more vet­er­ans el­i­gi­ble for out­side pri­mary care and 31 per­cent more vet­er­ans el­i­gi­ble for net­work spe­cialty care than un­der cur­rent com­mu­nity care pro­grams in­clud­ing Choice.

More vet­er­ans also will gain ac­cess to lo­cal providers us­ing new wait-time trig­gers. Choice al­lows com­mu­nity-based care if vet­er­ans face waits for VA ap­point­ments longer than 30 days. The new stan­dard will make them el­i­gi­ble to use the pri­vate sec­tor if waits for VA ap­point­ments are longer than 20 days for pri­mary care, men­tal health care and non-in­sti­tu­tional ex­tended care ser­vices, and longer than 28 days for spe­cialty care.

The new ac­cess stan­dards are only one of six cri­te­ria Congress ap­proved to ex­pand and re­shape vet­er­ans’ el­i­gi­bil­ity for com­mu­nity-based care un­der the mam­moth VA Mis­sion Act en­acted last June. Reg­u­la­tions on ac­cess stan­dards will be fol­low by more to gov­ern com­mu­nity care: in lo­cales where VA ser­vices are un­avail­able; for vet­eran re­sid­ing in states with no full-ser­vice VA med­i­cal fa­cil­ity; to en­sure grand­fa­ther pro­tec­tions to vet­er­ans who gained ac­cess to out­side care us­ing the 40-mile Choice stan­dard; to en­sure com­mu­nity care de­ci­sions con­sider the med­i­cal best in­ter­est of pa­tients, and to gov­ern el­i­gi­bil­ity when VA de­ter­mines one of its own med­i­cal ser­vice lines isn’t pro­vid­ing care that meets VA qual­ity stan­dards.

On Jan. 31, VA pub­lished pro­posed rules on what is sure to be one the most pop­u­lar new ben­e­fits

by the Mis­sion Act: vet­er­ans ac­cess to des­ig­nated civil­ian-run ur­gent care clin­ics without prior ap­proval from VA.

Vet­er­ans en­rolled in VA health care and need­ing treat­ment for a sore throat, a sprained an­kle or some other episodic or tem­po­rary health need will be able to walk into par­tic­i­pat­ing ur­gent care clin­ics rather than visit VA emer­gency care clin­ics or hos­pi­tals or sched­ule an ap­point­ment with their pri­mary care provider.

The first three ur­gent care vis­its in a cal­en­dar year will be free to vet­er­ans with dis­abil­i­ties or other cir­cum­stances that place them in Pri­or­ity Groups 1 through 5 for ac­cess­ing VA health care. Cer­tain en­rolled vet­er­ans in Group 6 and all vet­er­ans fall­ing Groups 7 and 8 will be charged a co-pay of $30 for each visit.

To dis­cour­age overuse of ur­gent care, the $30 co­pay­ment will be charged any vet­eran af­ter their third walk-in visit, to in­clude those with ser­vice-con­nected dis­abil­i­ties.

That de­tail will be chal­lenged by some vet­er­ans ser­vice or­ga­ni­za­tions.

The ur­gent care reg­u­la­tion em­pha­sizes that the new ben­e­fit is not to be used by vet­er­ans need­ing treat­ment for chronic con­di­tions, which should con­tinue to be man­aged through their pri­mary care providers.

But the com­mu­nity care ac­cess rules are draw­ing the most at­ten­tion from vet­eran groups and mem­bers of the vet­eran af­fairs com­mit­tees.

Many of them are com­plain­ing that af­ter part­ner­ing with VA to shape com­mu­nity care re­form lan­guage in Mis­sion Act, they’ve been kept largely in the dark by VA Sec­re­tary Robert Wilkie and his staff dur­ing the months

Vet­er­ans en­rolled in VA health care and need­ing treat­ment for a sore throat, a sprained an­kle or some other episodic or tem­po­rary health need will be able to walk into par­tic­i­pat­ing ur­gent care clin­ics rather than visit VA emer­gency care clin­ics or hos­pi­tals or sched­ule an ap­point­ment with their pri­mary care provider.

they drafted im­ple­ment­ing rules.

As a re­sult, when VA re­leased first de­tails on ac­cess stan­dards last week, many pre­vi­ously sup­port­ive law­mak­ers and vet­er­ans groups ex­pressed only cau­tion, claim­ing not to un­der­stand from pre­lim­i­nary brief­ings how de­ci­sions were made, how they will im­pact vet­er­ans and VA bud­gets, and how VA pro­ce­dures and tools can be made ready in time to sup­port a launch in June as planned.

Democrats on the Se­nate Vet­er­ans Af­fairs Com­mit­tee crit­i­cized Wilkie for lack of trans­parency and VA’s fail­ure to en­gage while pre­par­ing its new ac­cess rules.

“Once briefed, we were dis­ap­pointed that VA couldn’t pro­vide ba­sic in­for­ma­tion on how the pro­posed wait and drive-time stan­dards would affect the Depart­ment, the vet­er­ans who rely on it for care and the Amer­i­can tax­payer,” the sen­a­tors in Feb. 5 let­ter to Wilkie.

Carl Blake, ex­ec­u­tive di­rec­tor of Par­a­lyzed Vet­er­ans of Amer­ica, and Randy Reese, ex­ec­u­tive di­rec­tor of Dis­abled Amer­i­can Vet­er­ans, said in sep­a­rate in­ter­views that they have no choice but to re­main cau­tious on the ac­cess stan­dards.

Key ques­tions DAV needs an­swered, said Reese, are whether the ac­cess rules are fully funded, are re­al­is­tic and fea­si­ble to im­ple­ment. One great un­known, he said, is whether VA-funded com­mu­nity provider net­works will be suf­fi­ciently staffed to de­liver faster, more con­ve­nient and qual­ity care to vet­er­ans.

With re­vised net­work con­tracts de­layed by chal­lenges from a los­ing bid­der, VA con­ceded to vet­eran groups that con­trac­tors haven’t been able to pro­duce mar­ket as­sess­ments on the avail­abil­ity com­mu­nity care for vet­er­ans na­tion­wide.

“The as­sump­tion is the VA can’t and pri­vate providers can. But they don’t know that that’s true,” Reese said.

Blake said an­other crit­i­cal un­known is how VA in­tends to mea­sure drive time for ac­cess to out­side net­works. A trip of 20 min­utes to a VA clinic at mid­day might ex­ceed 60 min­utes in rush hour. VA sig­naled it will adopt new com­puter soft­ware for the task, Blake said, but its record in in­for­ma­tion sys­tem up­grades does not in­spire con­fi­dence.

An­other is­sue, Blake said, is how VA will re­solve dis­putes with vet­er­ans who dis­agree with how their av­er­age drive time to nearby VA fa­cil­i­ties was cal­cu­lated.

He also wor­ries that VA touts the fact that TRICARE, the mil­i­tary health plan, also uses av­er­age drive time to de­ter­mine el­i­gi­bil­ity. But TRICARE uses drive time to make ini­tial en­roll­ment de­ci­sions, not “as a de­ci­sion point for ac­cess to care,” Blake said.

Per­haps the num­ber one con­cern about the new ac­cess stan­dards, he added, is whether VA’s bud­gets will be large enough to cover the sig­nif­i­cant jump in com­mu­nity-based med­i­cal costs ex­pected from ex­pand­ing ac­cess, en­sur­ing that VA hos­pi­tals and clin­ics don’t see their bud­gets get squeezed.

“I be­lieve the answer to that right now is no,” Blake said.

To com­ment, write Mil­i­tary Up­date, P.O. Box 23111, Centreville, VA, 20120 or email milup­[email protected] or twitter: Tom Philpott @ Mil­i­tary_

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