USA TODAY International Edition

VA managers blocking vets from getting outside care

Mission Act supposed to give vets private options

- Jill Castellano inewsource

When Christine Russell read the message from the San Diego VA Medical Center announcing it would no longer pay for her cancer treatment, all the pain came rushing back.

For nearly three years, the federally funded veterans health care system had misdiagnos­ed her breast cancer as mental illness, she and her team of advocates contend. After discoverin­g the cancer in late 2018 – when the tumors had already spread – the Department of Veterans Affairs agreed to pay for the former Navy Reserve lieutenant to get care from other doctors in the area.

Russell filed four federal complaints in February this year about her challenges accessing health care, medication and caregiver services through the VA. Days later, a group of San Diego VA administra­tors mailed her a letter that called her “disruptive” and announced they would no longer fund her appointmen­ts outside the VA because her health care was too “fragmented.”

Russell was $ 30,000 in debt from medical expenses since developing cancer. She couldn’t afford to see her doctors if the VA didn’t pay for it.

An inewsource investigat­ion in

partnershi­p with USA TODAY has found that, like Russell, veterans across the country are caught in the crossfire of the VA’s battle to retain patients and funding since the passage of a landmark health care law known as the Mission Act.

When Congress and then- President Donald Trump passed the bipartisan law in 2018, they said it would ensure that Americans who fight to protect the U. S. can access high quality medical care after leaving the military. When the VA can’t deliver that care for any of six reasons, it’s supposed to pay other health care systems to do it instead.

A review of thousands of pages of department manuals and medical records, along with interviews with dozens of patients, advocates and providers, shows that VA administra­tors are overruling doctors’ judgments and preventing them from sending patients outside the VA.

This bureaucrat­ic process has ramped up over the past two years as part of an effort to save money and retain patients in the VA, records show.

“That’s tragic and jarring,” said Ryan Gallucci, a national director for Veterans of Foreign Wars. “I think it warrants an organizati­on like ours asking more pointed questions and ensuring the VA is upholding the intent of the Mission Act.”

The U. S. is facing urgent demands from veterans for medical and mental health care. Veterans have faced almost 20 million canceled or delayed health care appointmen­ts during the coronaviru­s pandemic, and the U. S. withdrawal from Afghanista­n in August has caused crisis hotline calls to spike as former service members have struggled to process the unfolding events.

Dozens of veterans and caregivers in Southern California described struggles to access care outside the VA since the Mission Act was passed: A partially blind skin cancer survivor was told to take a dangerous trip to the VA when a new lesion developed, instead of visiting his neighborho­od dermatolog­ist. A veteran with a seizure condition has waited years for a course of treatment outside the VA. Suicidal patients were cut off from what they considered “lifesaving” mental health treatments by employees overwhelme­d with paperwork – against the advice of the VA’s own psychiatri­sts.

In interviews, service groups and members of Congress from both political parties said veterans should be offered the best health care available, and money should not affect the quality of care they receive.

“We just spent trillions of dollars prosecutin­g this 20- year war in Afghanista­n, and by comparison we’re arguing nickels and dimes in caring for the veterans who prosecuted those wars,” Gallucci said.

In late 2019, the VA began the “referral coordinati­on initiative” to return veterans to its hospitals. An internal department manual shows the changes are supposed to help the VA make “good financial decisions” and “maintain funding of specialty care” in the future.

Under department policy, VA doctors usually don’t send their patients outside the health care system on their own, records show. They can make recommenda­tions that go through reviews by other staff who can cancel treatment requests and insist patients come to the VA instead. Following the VA’s new initiative, department hospitals have also set up select teams of health care personnel who can review medical records and use algorithms to decide if patients qualify for care outside the VA before interactin­g with those patients.

“It basically defeats the whole purpose of the Mission Act,” said Darin Selnick, senior adviser to Concerned Veterans for America.

Selnick, who helped draft the Mission Act, worked in the Trump administra­tion and the VA to implement the law until July 2020. He read excerpts of the department manuals obtained by inewsource.

“If I was still at the VA and someone showed me this in July, I would have ripped it to shreds and I would have said there’s no way in hell you’re going to use this stuff,” Selnick said.

Doctors and managers at the VA said they believe they can deliver the most effective care internally because they offer high- quality services and can more easily coordinate treatments and paperwork.

Dr. Kathleen Kim, the San Diego VA chief of staff, said physicians sometimes incorrectl­y try to relocate patients for treatments her hospital can offer, and administra­tors are “regularly educating” them to help keep veterans at the VA.

“Because of the nature of the Mission Act, the VA is sending a lot of care in the community, and frankly we’re worried that we’re not going to be able to pay our bills,” Kim said.

Kim said it’s often best for patients to come to the VA, even if that’s not what their doctors want. “The reality is that does not trump the fact that the service can be provided at the VA within a timely fashion,” she said.

Over the past two years, the VA has started putting treatment requests in the hands of “referral coordinati­on teams” of registered nurses and other personnel, according to the manuals. A team member is supposed to spend 10 to 25 minutes reviewing a patient’s medical charts and deciding if they qualify for care outside the VA.

The initiative “shifts the referral responsibi­lity” so most doctors aren’t choosing to relocate their patients themselves, the documents show, which will “decrease inconsiste­nt and inappropri­ate” treatment plans.

Hospital leaders are told to monitor health care costs as a “key performanc­e indicator” of success, and community care staff are supposed to “consider funding availabili­ty” when offering treatment options to patients.

“That is not what the Mission Act says,” said Rep. Mike Bost, R- Ill., ranking member of the House Committee on Veterans’ Affairs. “If they have a problem with the budget, they need to come and talk to Congress. They don’t need to go ahead and try to figure out how to take services away from our veterans.”

The Mission Act created a network of VA- approved community providers and expanded the reasons veterans could visit them. But Southern California veterans said they are still struggling to get appointmen­ts with private doctors.

“It’s not working here,” former Army Capt. Gary Shearer said. “It hasn’t been working for some time.”

Shearer suffers from chronic neck pain and has gone blind in one eye, making treks to the VA dangerous. He lives in Yucca Valley, almost 50 miles from his VA primary care doctor and 80 miles from the closest veterans hospital.

Because of the long drives, Shearer qualifies for private doctor’s visits closer to home, but the VA has asked him to return to its own offices for checkups and assessment­s.

In December, Shearer saw a bump on his forehead that he knew needed attention. The veteran, who has a 20- year history of skin cancer, wanted the Loma Linda VA to help schedule an appointmen­t with a neighborho­od dermatolog­ist. The federal health care system insisted he have a checkup with a VA primary care doctor first.

Shearer didn’t want to take any chances, so he went to the dermatolog­ist on his own.

His lesion was diagnosed as basal cell carcinoma and required an urgent surgery with a price tag of $ 3,000. It was too steep for him to pay out of pocket, but he was able to use his private insurance plan to cover the cost.

About one- quarter of working- age veterans – more than 730,000 people – don’t have such a second medical payment option. If he didn’t have a backup insurance plan, he said, he would have to rely on the VA’s medical decisions.

VA manuals say veterans can receive an unlimited number of outsourced treatments, but only if reviewers deem them “clinically appropriat­e.”

Since the Mission Act launched, the VA decided to handle outsourced health care requests itself – taking over the job from its contractor­s – so its employees could have direct contact with veterans about their needs. But the department was critically understaffed and unable to handle the workload, according to federal reports from the Government Accountabi­lity Office.

The staffing shortage has impacted veterans seeking medical care. In mid- 2020, patients were waiting an average of three weeks for the VA to process specialty care requests and six weeks until their community appointmen­ts. By comparison, referrals from one VA doctor to another took one week.

National spokespeop­le said veterans with urgent needs are prioritize­d, and processing time for non- VA treatments is now under two days.

“Because of the nature of the Mission Act, the VA is sending a lot of care in the community, and frankly we’re worried that we’re not going to be able to pay our bills.”

Dr. Kathleen Kim San Diego VA chief of staff

 ?? ZOË MEYERS/ INEWSOURCE ?? Veterans such as Christine Russell are caught in the crossfire as the VA tries to save money.
ZOË MEYERS/ INEWSOURCE Veterans such as Christine Russell are caught in the crossfire as the VA tries to save money.
 ?? ZOË MEYERS/ INEWSOURCE ?? Darin Selnick said VA policies to decide who can get outside care defeat the purpose of the Mission Act, which he helped draft.
ZOË MEYERS/ INEWSOURCE Darin Selnick said VA policies to decide who can get outside care defeat the purpose of the Mission Act, which he helped draft.

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