VHCAC
A 501(c)(4) organization Lobbying for Veterans Healthcare Legislation

VHCAC


Analysis of the MISSION Act of 2018 

(click on title for pdf copy)

H.R. 5674

and

Senate Bill 2732

A big step toward privatization 

Analysis by

Veterans Healthcare Action Campaign

Association of VA Psychologist Leaders*

Association of VA Social Workers*

Nurses Organization of Veterans Affairs*

(*An independent organization, not representing the Department of Veterans Affairs)

May 8, 2018

We understand that the bipartisan VA MISSION Act of 2018 will be marked up on May 8, 2018. As a collective group who has previously presented statements for the record to your Committee, we want to convey our appreciation of the provisions of the bill that would improve how the Veterans Health Administration (VHA) provides healthcare into the future. We also wish to express our serious concern with components that will accelerate a one-directional flow of patients and resources out of the VHA to private sector providers, many of whom are ill equipped to take care of veterans’ complex needs. Problematic provisions include:

  • Access to walk-in care at non-VHA facilities without pre-authorization.
  • Establishment of a Commission that will close VA facilities and force veterans into community care.
  • Problematic expansion of automatic eligibility for care from non-VHA providers.
  • Insurance payment pilot programs that would pave the way for fuller privatization of the VHA.

We also are concerned that the bill diminishes the quality of care veterans receive by creating less rigorous standards for non-VHA providers than VHA providers, and by failing to fully commit to adequately staffing VHA facilities. We summarize these, and other key aspects below, and suggest alternative language that would accomplish the bill’s objectives in a more productive manner.

Problematic Access to Expensive Walk-in Care in the Community Without Pre-authorization

This newly proposed benefit (Sec. 105, p. 49) allows walk-in, non-emergency care in the community. It isn’t simply intended for veterans to obtain a same day visit, like for a flu shot at Walgreens or pink eye treatment at an urgent care center. This benefit allows veterans to seek open-ended care in the community for almost any condition. The only exclusion is for “longitudinal management of conditions.” The program would provide vouchers, for example, for treatable mental health diagnoses such as PTSD, depression, anxiety, insomnia, substance use, marital problems and stress associated with the transitioning to civilian life. The provision would likewise allow veterans to seek treatment at community clinics for primary care and specialty care other than for “management.”

The first two visits at walk-in clinics per year are free, as if to imply that copayments for subsequent services would dissuade further utilization. Yet, copayments will be stratified by enrollment group as currently exists for in-house VHA care and are likely to be nominal for high priority groups. The benefit may be used frequently, placing enormous financial strain on an already stretched system. That’s even more the case because veterans would not need VHA pre-authorization to use the benefit; the VHA would be sent the bill after treatment.

There is also concern that the kind of providers who staff these clinics are less experienced in detecting and treating underlying conditions to which veterans are highly vulnerable. For example, a nurse practitioner in a community clinic is less likely to explore how insomnia stems from combat related PTSD. Walk-in-care by definition fragments the consistent, coordinated, integrated VHA healthcare approach so essential with to our nation’s veterans.

Moreover, there is no stipulation that requires walk-in clinics to refer veterans back to the VHA for needed and appropriate follow up care. Although it may not be intended, this type of same-day service may move more veterans into the community thus depleting services and care within the Veterans Healthcare System.   

Recommended Solution:

  1. Veterans have access to walk-in care for a maximum of two visits yearly at no cost, and no additional visits.
  2. Walk-in care facilities refer veterans who use this benefit to nearest VHA facility for follow up care.

 Establishing an Asset and Infrastructure Realignment Commission that Will Close VA Facilities and Force Veterans into Community Care

The goals of achieving structural efficiencies and saving taxpayer money without sacrificing high-quality healthcare for veterans are laudable and timely. However, establishing a commission (Section 201, pp. 126-175) with the potential to close down VHA facilities will likely produce the opposite result. It would leave veterans to fend for themselves in the fragmented private health care system. The intrinsic expenses would drain the VHA of resources needed for staffing up the VHA and fixing its problems, jeopardizing its long-term viability.

This bill differs in important ways from the Department of Defense’s Base Realignment and Closure (BRAC) process upon which it is modeled. When a military base is closed, all its servicemembers move and are absorbed by other bases. In contrast, when a VHA is closed, its veterans would NOT go to other VHAs. In nearly all cases, other facilities are too far away and/or have little capacity to absorb the veterans. The veterans enrolled at the closed facility would immediately be forced into non-VHA care. Those who prefer and rely on VHA’s care would no longer have that choice. In many regions, there isn’t a large enough supply of private sector options. Veterans emphatically prefer the VHA system and its facilities to be improved, not dismantled.

Closing VHA medical centers and CBOCs would vastly increase, not decrease, overall costs. There are two main reasons for this budget-busting impact. (1) There are nearly as many “eligible” or “enrolled” veterans who do not use the VHA as those who do. When a local VHA is closed, veterans who use it as well as those who do not would become eligible for vouchers, and outlays will skyrocket. (2) Managing the influx of veterans receiving care in the community would require contracting with a third-party administrator, adding more costs, and as has been seen with the current Choice program, more inefficiencies. Closing facilities will drain money out of the entire VHA system, leaving less available to preserve VHA’s capacity to offer care.

Recommended Solutions:

  1. Prohibit the realignment of facilities if doing so will increase long-term costs.  
  2. Prohibit facility closures that will result in automatic utilization of private care.
  3. Adopt the no-cost alternative idea (proposed in the Commission on Care Final Report): “Allow veterans’ family members and currently ineligible veterans to purchase VHA care through their health plans in areas where VHA hospitals and other facilities are underutilized and might otherwise need to close.” This plan would ensure veterans continue to have the option of local VHA care, and has many potential benefits:
  • bringing in new sources of revenue to contribute to the funding for veterans’ healthcare,
  • optimizing patient safety, productivity, and cost-effectiveness by ensuring sufficient patient volumes in currently under-utilized facilities,
  • preserving mission critical veterans’ programs that would otherwise need to be terminated in parts of the country.

 Problematic Expansion of Automatic Eligibility for Non-VHA Care

1. Automatic eligibility for non-VHA care based on problematic metrics. There will always be need for VHA to supplement its services by utilizing non-VHA partners. However, this bill proposes that VHA implement an untested, problematic algorithm to grant all veterans in dozens of health care service lines automatic authorization for non-VHA care.

The first part of the algorithm (p. 12, line 16) pinpoints VHA service lines whose timeliness is slower than other VHA facilities. This utilization of VHA-to-VHA comparisons -- rather than VHA to non-VHA clinics -- completely contradicts the rationale for outsourcing care. VHA service lines whose wait times are shorter than those in their community could still be targeted if other VHAs have even better access to services.

The second part of the algorithm (p. 12, line 20) compares a service line’s quality metrics to those at (undefined) non-VHA locations. A VHA service line could be designated as underperforming without ever comparing its performance to that of the local community. (Even if it did compare numbers, contrasting VHA with community metrics is misleading, since private sector statistics are based on non-veteran patients who, on average, are younger and have fewer medical and mental health conditions than veterans.) Furthermore, quality metrics generally don’t measure the very things that matter most to patients -- functional improvements and symptom reductions.  

Hence, without any attempt to verify that veterans will get better or faster care in their community, especially for the symptoms they need addressed, the bill grants automatic vouchers to tens of thousands of veterans. Once veterans have left the VHA system, it is highly improbable that they would return. This process will progressively diminish the option to seek VHA care for other veterans, since there will be a steady flow of funds out of the VHA and into the private sector. This would lead to cuts in VHA staffing, services and programs. 

2. Automatic eligibility for non-VHA care based on state of residence. The bill establishes that all veterans in the five lowest population density states (right now they are Alaska, Wyoming, Montana, N. Dakota, S. Dakota) will automatically be eligible for non-VA care. As with any overly inclusive expansion of non-VHA care, money that is unnecessarily diverted to the private sector undermines the financial strength of the VHA’s system.

Recommended Solutions:

  1. Commit to first staff up VHA facilities when problems in access to care are due to staff shortages.
  2. Require VHA to be the first point of access and coordinator of care.
  3. Purchase non-VHA care when:
  •  the VHA is unable to provide timely, needed care, and
  •  the private sector can verifiably provide it sooner, and
  •  a covered veteran and his/her VHA provider both agree that non-VHA care is clinically indicated.
  1. Mandate that PCP panel sizes used for VHA should apply to non-VHA providers. Verify that the panel size in the community is in fact smaller than VHA’s before referring a veteran to a community provider.
  2. Require that metrics used for decisions to refer to community care be based on functional and symptom improvement.
  3. Require that any referral to outside care must follow a VHA diagnostic assessment.
  4. Conduct thorough studies in every state to assess the capacity and readiness of private sector providers to care for the complex conditions and needs of veterans before referring to those providers.

 Pilot Programs that Undermine VHA Mission as a Provider of Care

The bill mandates the creation of pilot VHA programs that use insurance models of paying for care (Sec 152 p 101). The VHA may subsequently “expand (including implementation on a nationwide basis) the duration and scope of a model” (p. 11, line 17).  This will pave the way for turning the VHA into a payer, rather than a provider, of care. We must register the same level of alarm that Veterans Service Organizations expressed in November 2017 when it was revealed that shifting to a TRICARE model was being considered for VHA operations.

Recommended Solutions:

A better pilot is the aforementioned suggestion to allow veterans’ family members and currently ineligible veterans to purchase VHA care through their health plans in areas where VHA facilities are underutilized.

Problematic Provisions of the Bill Besides Accelerating Privatization

Double standards.

The bill holds non-VHA care to lower standards than for VHA care: Veterans are to be surveyed about their satisfaction with care they received from VHA, but not with non-VHA care (p.46 line 23 and p. 57 line 15). Veterans are given information on what to do when they have a complaint about Department care, but not about non-Department care (p 79 line 18). Wait times are used for evaluating VHA service lines, but not community’s (p 12 line 16). All VHA facilities must make evidence-based psychotherapies available to veterans, but non-VHAs must do so only “to the extent practicable” (p 90, line 12). Non-VHA providers will have access to, but are not required to undertake, the veteran-specific continuing education that VHA providers are mandated to complete (p 70 line 18). Non-VA clinicians have no mandate to complete the multitude of screenings that are required for in-house VHA care.

Recommended Solutions:

  1. Non-VHA performance should be measured and publicly reported using the same metrics as VHA providers. Non-VHA providers must always be required to meet VHA’s high standards for quality of services.
  2. Non-VHA providers must perform needed screenings and be subject to the same continuing education and knowledge of military culture requirements as VHA providers.
  3. Surveys must ask veterans about their non-VHA care as well as VHA care.
  4. Non-VHA providers must be required to collect service related data that can be used to identify future healthcare problems.

Insufficient staffing resources

The bill downplays the importance of strengthening the VHA. Although it establishes processes to identify staffing gaps (p 23 line 20; p 63 line 20), there is no prioritizing or commitment to rectify staffing levels that fall below guidelines. It does encourage remediation of staff shortages through enhanced use of the special hiring incentives, including the Educational Debt Reduction Program (Sec. 303, p 183) though these are for rural areas and only for physicians. It says nothing about providing market rate salaries to VHA employees so that the VHA can compete with private sector. Without adequate funding, VHA shortages will be inevitable and services will erode.

The bill’s focus on outsourcing VHA care will also discourage new recruits from filling much needed positions in the system.  It will be hard to convince people to work with very complex patients, for less money than is offered in the private sector, if the VHA appears to be an unreliable employer.  We are already hearing troubling reports of an exodus of VHA staff and administrators. Strengthening VHA should go hand in hand with any Choice program redesign.

Recommended Solutions:

  1. Special efforts should be made to permanently fund and fill clinical, support and administrative vacancies in VHA facilities where wait lists exist due to demand outstripping capacity.
  2. All VHA facilities should be assured of sufficient staff, space, IT, and financial resources to provide comprehensive, high quality care.
  3. All VHA employees receive market rate salaries and are assured stable employment.

Payment of private sector providers

According to the bill, in the event that is practicable, private sector providers will be paid Medicare rates. This vague terminology “in the event that is practicable, opens the door for providers to be paid in excess of Medicare rates, not only in high rural areas.  Already, health financing experts are highlighting the fact that physicians may be unwilling to accept complex veteran patients at Medicare rates.  If physicians demand higher rates, then costs for veteran care will explode and more staff will be laid off, veteran eligibility may change, veterans may be asked to pay more out of pocket, or services and programs will be eliminated.

Elements that are Steps in the Right Direction (But Need Further Modification):

Enhanced VHA Coordination of Care and Training. The bill tasks the VHA with performing additional administrative tasks, including establishing and managing networks, coordinating care between VHA and these networks, developing and managing educational curriculum, soliciting and responding to complaints, educating veterans about private sector care, sharing records and documents, etc. These are important, yet daunting, responsibilities.  The bill, however, provides no new allocations for staff to execute the sizable extra workload. By necessity, additional administrative positions will be paid for by downsizing clinical staff who provide care to veterans. This shift has already begun to occur. Fewer clinical staff translates to further delays and further outsourcing of care.

Recommended Solution:

Allocate supplemental funding to cover additional administrative facility and staff costs associated with this bill.

Enhanced Telemedicine (p.97) As we’ve indicated in previous analyses, expanding telemedicine is a highly effective means of reaching rural veterans. The provisions of the bill, especially enabling care that crosses state lines, keep VHA as the industry leader of anywhere-to-anywhere health services.

Recommended Solution:

Since VHA will soon be able to reach all eligible veterans wherever they live via telemedicine, there is no reason for the VHA to pay for non-VHA providers to duplicate this service.

Peer Specialist Pilot in Medical Center PACTS (p. 219)

No other healthcare is as veteran-centric and veteran-sensitive as the VHA’s, and peer specialists are an essential part. They are uniquely suited to engage veterans in ongoing care and to instill hope and expanding their presence in PACT teams to help integrate Mental Health and Substance Use Disorder into Primary Care is highly beneficial.

 Enhanced Hiring Incentives

We applaud Sec. 305 that allocates $20 million in bonuses for recruitment, relocation and retention incentives and increases the current amount of Education Debt Reduction payments.

Recommended Solution:

To maximize these incentives, a strong Human Resources Department with a full-time recruitment specialist is needed to fill critical positions. VHA must be given the tools and funding to hire and retain high quality health care providers across the spectrum of specialties.

As health care professionals providing services to veterans across the country, we would be happy to further assist with language that accommodates any of the issues mentioned in our analysis.

Contacts:

Veterans Healthcare Action Campaign info@vhcac.org

Association of VA Psychologist Leaders president1@avapl.org

Association of VA Social Workers president@vasocialworkers.org

Nurses Organization of Veterans Affairs tmorris@vanurse.org

 


Caring for Our Veterans Act of 2017

Analysis by

Association of VA Psychologist Leaders*

Nurses Organization of Veterans Affairs*

Association of VA Social Workers*

Veterans Healthcare Action Campaign

(*An independent organization, not representing the Department of Veterans Affairs)

 December 10, 2017

We appreciate the Senate Committee on Veterans’ Affairs bipartisan efforts to make needed changes to how the Veterans Health Administration (VA) provides quality healthcare for our nations’ veterans. Although the draft Caring for Our Veterans Act of 2017 contains positive provisions that would improve care, it also contains numerous provisions that markedly harm the continuity of and quality of care. The legislation introduces an untested, unworkable set of criteria for non-VA eligibility that would significantly increase unnecessary use of non-VA care. It would drain the VA system of needed staffing resources, and accelerate a one-directional, permanent flow of veterans’ health care out of the VA and into the private sector. It glaringly accepts lesser standards for non-VA care than for VA care. We summarize key aspects below.

Elements That Undermine Provision of Quality Care to Veterans:

1. Double Standards for Satisfaction and Timeliness of Care.  In five different places, the bill establishes standards for VA care that aren’t applied to non-VA care. Veterans are to be surveyed about their satisfaction with care they received from VA, but not with non-VA care. Veterans are given information on what to do when they have a complaint about VA care, but not about non-VA care. Service line’s wait times are compared to other VA’s, but not to their community. VA clinics, but not non-VA providers, must provide appointments within access guidelines.

Both VA and non-VA care should always be held to the same high standards of care. Not holding community care providers accountable is a disservice to veterans and to the taxpayers who are paying for that care. Criteria should be established as to whether VA facilities as well as non-VA sources of care are meeting the Department’s wait-time goals. The bill should require the VA to verify that patients will receive care appreciably sooner before authorizing non-VA care. It should create a non-VA care oversight office that evaluates and publically reports how private sector care is faring. There also should be surveys and other avenues for veterans to comment on excellence in VA and non-VA care.

2. Unworkable Criteria for Outsourcing Patients to Non-VA Care. There will always be need for the VA to supplement the care it provides by utilizing non-VA partners. The 2014 Veterans Access, Choice and Accountability Act Care developed time and distance criteria for doing so, but those were quickly recognized as needing revision. This bill does not correct the issue, but instead proposes unproven, new criteria based on access and quality metrics. Such metrics are presently unwieldy and insufficiently granular to be useful. Neither the VA’s Access and Quality Tool website http://www.accesstocare.va.gov nor Medicare’s Hospital Compare website https://www.medicare.gov/hospitalcompare/search.html have the data that’s needed to make informed decisions.  

o   There is little data on effectiveness in reducing symptoms or functional deficits.  

o   There is little data on outpatient care. 

o   There is no data on community access.

The bill specifies that when a VA medical service line’s access or quality metrics fall below the standard, all veterans in that clinic will automatically be authorized for non-VA care. However, that determination does not need to compare the VA’s to the local community’s data. Even if it did, contrasting VA with community scores is somewhat misleading, since they are not apples-to-apples comparisons. Private sector statistics are based on non-veteran patients who, on average, are younger and have fewer medical and mental health conditions than veterans.

Quality metrics are still crude and generally do not measure outcomes, functional improvement or symptom reduction. If the VA begins using them to shut down clinics or outsource care, 36 medical service lines – representing many tens of thousands of patients -- would become authorized to receive non-VA care when it may be unnecessary or not in the best interests of their medical needs. This process will incrementally remove the option for veterans seeking to use the VA for care. There will be a steady flow of funds out of the VA and into the private sector. If funds that could have been used to make improvements are diverted to pay for non-VA care, VA facilities that lag behind will never catch up. This is the steady route to privatization of VA healthcare.

Also, these metrics are more apt to obscure than help clarify an individual veteran’s decision making. For example, suppose a veteran with PTSD checks VA’s Access and Quality Tool website. The only published mental health metrics are two scores for antidepressant medication management, statistics that would be of no help to the veteran or his clinician in making a sound clinical decision where to obtain psychotherapy. Consider another example of a patient seeking primary care. Half of the VA website measures pertain to advising tobacco users to quit. The Medicare website has even less pertinent information for these kinds of outpatient decisions.   

3. Lack of Clarity about Whether VA Is the Authorizer of Care. The bill is ambiguous about who makes the final decision when there are disagreements about eligibility for non-VA care. For services the VA doesn’t provide, the bill explicitly, and rightly, grants veterans the choice to receive non-VA care. But for services the VA does provide, when the veteran disagrees with a PCP recommendation for VA rendered care, she can appeal. If the appeal reaches no agreement, there is no language about who makes the final call. By contrast, the current House Choice bill H.R. 4242 stipulates that the veteran has that prerogative, and this stipulation has significant ramifications. It shifts the final say in their eligibility to receive services from a non-VA provider from the VA to the veteran. It undercuts VA’s ability to control costs if veterans can opt for private sector care even when the local VA is able to provide treatment that is less expensive, clinically superior, quicker and/or closer. A statement is needed in the Senate bill that would clarify this.  Such a statement might read: “…the Secretary shall give due consideration to the veteran…” to make it clear that the veteran’s desires will be considered, but not determinative unequivocally.

Consider this recent instance: A 70-year-old veteran scheduled a visit with his VA primary care physician. VA surgeons had evaluated him and recommended a laparoscopic inguinal hernia repair that they could perform that month. The veteran was adamant that the operation by done by a Choice Program surgeon that a civilian friend had used. His immovable request was granted. Under the existing regulations, the supplemental Choice Program account paid the invoice. Under the new legislation, the local VA would have to draw down its resources to pay, even though it could have done the surgery as effectively and quickly.

4. Expensive Options for Walk-in Care. This new benefit allows veterans to seek walk-in, non-emergency care in the community, as long as it is not for “longitudinal management of conditions.” That could include primary care, and much specialty care. It’s not only expensive, it ignores that community providers have less expertise in detecting and treating underlying conditions to which veterans are highly vulnerable. For example, a practitioner is less likely to explore PTSD as the reason for chronic insomnia, the impact of traumatic brain injury on mood and decision-making, or that a particular condition – asthma induced by burn-pits or diabetes produced by Agent Orange exposure– is related to military service. It also undermines VA’s integrated healthcare approach. There are no protocols stipulated that require walk-in clinics to refer veterans back to the VA for any further care that is needed. One could easily imagine a situation in which private sector providers make arrangements with (or set up) walk-in clinics to funnel veterans into private sector referral networks at higher cost. 

Elements that are Steps in the Right Direction But Need To Go Further in Order to Enhance the Provision of Quality Care to Veterans:

1. Allocations. The bill provides $3 billion to keep Choice operating and $1 billion for VA educational, training and employment incentives. There is no money for staffing or infrastructure that would strengthen VA’s capacity to provide care. While these allocations are urgently needed, the three to one ratio of non-VA to VA funding reinforces the notion that outsourcing is a preferred solution when VA’s are understaffed. That’s not a solution that saves money, but is one that accelerates privatization of veterans care.

2. VA as Coordinator of Care. The bill identifies local VA offices of community care to serve as coordinators of intersecting VA-community care. This is a useful structure, although it requires a significant increase in staffing. The bill does not recommend any additional funding for this role, which means funding would have to come out of budgets for the staff who provide care to veterans. Supplemental VA allocations are warranted if this is to be effective.

3. Modification of Pay Caps for Nurses. The bill includes a much-needed increase in pay rates for nurses in areas where there are shortages. We applaud the committee for including this language and would like to see other pay caps removed and locality pay changes made permanent.

4. Expanded Provider Networks. The bill’s goal is to develop high-performing networks that link the private sector to the VA. However, the responsibility for developing these networks is given to outside contract entities. It would be less expensive and assure higher quality if the VA managed this process. As above, VA management of private sector providers would require funding for additional staff.   

5. Reappraisal of Capacity and Quality. The bill authorizes the Secretary to conduct an annual evaluation of gaps in the services provided, the quality and timeliness of services rendered. The VA must submit a plan for addressing and remediating these gaps, including a budget that reflects needed resources to help remedy such gaps. As noted above, these evaluations should examine VA and non-VA alike.

6. Peer Specialists in PACT Pilot. No other healthcare is as veteran-centric and veteran- sensitive as the VA’s, and peer specialists are an essential part. They are uniquely suited to engage veterans in ongoing care and to instill hope, and expanding their presence in PACT teams is highly beneficial.

 7. Improved Telemedicine. As we’ve indicated in previous analyses, expanding telemedicine is an effective means of reaching rural veterans. The provisions of the bill keep VA at the forefront of anywhere-to-anywhere health services.

As health care professionals providing services to veterans across the country, we would be happy to assist with language that accommodates any of the issues mentioned in our analysis.

Contacts:

Nurses Organization of Veterans Affairs tmorris@vanurse.org

Association of VA Psychologist Leaders president1@avapl.org

Association of VA Social Workers president@vasocialworkers.org

Veterans Healthcare Action Campaign info@vhcac.org

H.R. 4242 - Care in the Community

Analysis by VHCAC

 
 

Nurses Organization of Veterans Affairs*, Association of VA Psychologist Leaders*, Association of VA Social Workers*, & Fighting for Veterans Healthcare

August 28, 2017

* An independent organization, not representing the Department of Veterans Affairs

What we support and stand for in Veterans Choice Program renewal legislation:

1. VHA must be the first point of access and coordinator of care.

2. Community care is used only in situations where it supplements services not readily available within local VHA.

3. All VHA facilities are assured of sufficient staff, space, IT and financial resources to provide comprehensive, high quality care.

4. Special efforts are made to permanently fund and fill vacancies in VHA facilities where wait lists exist due to demand outstripping capacity.

5. There are sufficient IT resources and technical support to ensure that home telehealth is available to rural veterans.

6. Choice providers must meet VHA’s high standards, use evidence-based treatments driven by measurement-based care, have knowledge of military culture and competence in veteran-specific problems, perform needed screenings and be subject to the same continuing education requirements as VHA providers.

7. Community providers and VA employees receive mandatory training to improve coordination of care provided to veterans.

8. Choice providers’ performance, timeliness of the provision of inpatient and ambulatory services, and promptness of providing medical documents are measured and publicly reported using the same metrics as VHA providers.

9. All VHA employees receive market rate salaries, and strong incentives are offered to encourage hiring in rural areas.

10. Congressional budgeting processes and plans for construction and renovation allow for future projections of utilization.

 

Why we support the above requirements:

Policy Analysis
Proposals for the Veterans Choice Program Redesign
and their Impact on Veterans’ Health Care

Download copy HERE

 Developed by
Fighting for Veterans Healthcare
Association of VA Psychologist Leaders*
Association of VA Social Workers*
Nurses Organization of Veterans Affairs*
The American Geriatrics Society
July 10, 2017

* An independent organization, not representing the Department of Veterans Affairs

Background

Over the last decade, as the rising demand for veterans’ healthcare services outpaced the Veterans Health Administration (VA)’s capacity to meet it, excessive delays developed at some VA facilities. In 2014, Congress enacted the temporary Veterans Choice Program whose goal was to reduce delays by offering non-VA options to veterans who had to wait long or travel far for care. To date, over 1.6 million veterans have utilized the program.1

There are two basic ways to address VA’s lack of capacity to meet this overall rising demand – bolster the VA by augmenting its number of clinicians and support staff, or purchase more services in the private sector. Those two options offset each other, since increases in Choice would be carved out of the VA.  

As Congress deliberates Choice program redesign, policy makers should consider not only the plan’s ability to remedy access problems, but also its broad impact. Congress must ensure that the next Choice program does not compromise VA’s overall quality of health care – care that has been demonstrated, with geographic variations, to be at least equal to and often superior to non-VA care. Congress must ensure that the VA’s innovative, integrated interprofessional care model is preserved. It must assure that the system for clinically training the majority of U.S. healthcare professionals is maintained. It must make sure that the VA is able to sustain its research mission that benefits not only veterans, but also every American. It must ensure that the private sector has the capacity to absorb an influx of veterans, which includes older, medically complex veterans, in a timely manner, and delivers excellent care. Given that non-VA care is more expensive than VA care, Congress must ensure that Choice is used judiciously so that there is no reduction in the level of services available to veterans. Finally, it must ensure that the VA is improved, not dismantled, because that’s what veterans overwhelmingly prefer, and have been promised by administration and Congressional officials. Our analysis of major policy ideas for the next version of Choice concludes that only one proposal does all this.  

As Congress deliberates Choice program redesign, policy makers should consider not only the plan’s ability to remedy access problems, but also its broad impact. Congress must ensure that the next Choice program does not compromise VA’s overall quality of health care – care that has been demonstrated, with geographic variations, to be at least equal to and often superior to non-VA care. Congress must ensure that the VA’s innovative, integrated care model is preserved. It must assure that the system for clinically training the majority of U.S. healthcare professionals is maintained. It must make sure that the VA is able to sustain its research mission that benefits not only veterans, but also every American. It must ensure that the private sector has the capacity to absorb an influx of veterans in a timely manner, and delivers excellent care. Given that non-VA care is more expensive than VA care, Congress must ensure that Choice is used judiciously so that there is no reduction in the level of services available to veterans. Finally, it must ensure that the VA is improved, not dismantled, because that’s what veterans overwhelmingly prefer, and have been promised by administration and Congressional officials. Our analysis of major policy ideas for the next version of Choice concludes that only one proposal does all this.

Proposals for Veterans Choice Program Renewal

At least four ideas for modifying Choice have been proposed by policy makers and veterans’ stakeholders. One – which we endorse – would fortify VA-delivered care and its management of the network of Choice providers. The other three concepts, although structured differently and still lacking specific details, would eliminate distance and wait time requirements, purchase far more care in the private sector, cut VA services and incrementally privatize veterans’ healthcare.

The following are the four ideas, and their potential impact on veterans’ healthcare if enacted:

 

Veterans Healthcare Action Campaign is the political affiliate of Fighting for Veterans Healthcare.  It is a group of veterans, health care providers, health care experts and citizens who believe the VHA needs to be strengthened and reformed, not dismantled and privatized. Our mission is to (a) provide a platform for voices of veterans who want to preserve and improve VHA care, (b) disseminate objective research and information about VHA care, and (c) inform veterans and the public about imminent threats to veterans healthcare, including what would be lost if the VHA vanished.

Background:

The VHA far outperforms the private sector on preventive and outpatient care, and performs equally well on other measures (according to independent RAND Corp evaluations). In contrast to the fragmented care that characterizes the broader healthcare system, the VHA offers comprehensive integrated care. More importantly, for over 70 years, the American taxpayer’s investment in the VHA has created a system whose providers have amassed great expertise in the specific problems of those who served in the military. Even a partially privatized veterans healthcare system would not able to replicate this kind of expertise. It would also cost more, which would likely lead to fewer veterans being eligible for care in order to balance the VA budget.

The primary VHA mission is to care for the eight million eligible men and women who served their country. However, the VHA does far more than meet the special needs of veterans. It supports research that has pioneered new treatments and improved patient safety for all Americans, and trains the majority of US doctors, nurses and other health care professionals.

Due to shortages of staff and surges in veteran enrollment, there will be instances when the VA should utilize private sector partners to ensure veterans get timely care. But this needs to be done by using supplemental resources, not at the expense of existing services, and must be carefully coordinated with VHA providers. Opinion polls consistently show that most veterans — and their advocacy organizations — want the VHA to be improved, not replaced.

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PLEASE CONSIDER THE BELOW TEXT FOR ANY CORRESPONDENCE WITH LEGISLATORS:

“I am writing about upcoming decisions for renewal of the Veterans Choice Program to urge you to preserve and strengthen the VA and its incomparably comprehensive, integrated care. While there are instances in which outsourced care for veterans is necessary, caution should be exercised in how Choice is authorized. Some are suggesting that Choice be automatically available to veterans where local VA metrics fall below a composite score, but no relevant metrics now exist to make those decisions. At the very least, you should continue with the current Choice Program eligibility until reliable measures are tested and can assure improved veterans’ healthcare.

In the longer term, Veterans Choice Program reform – whether by changing eligibility to composite scores or universal Choice cards -- runs the grave danger of draining the VA budget and destroying it. Those concepts could set in motion a hollowing out, downward spiral in which over time, local VA's will have less money, vacant positions won’t be filled, medical services will be cut back and clinics closed. They will steadily and inevitably privatize veterans’ healthcare. It’s imperative that outsourced care be offered as an option only to fill in gaps that the VA cannot provide itself. Please ensure that America’s veterans get the health care they deserve.”