The VA's Illusion of Choice
John Dougherty
In urban areas, the Veterans Choice Program is more a political stunt and illusion than a new benefit that provides real choice, real benefit, or a real business opportunity for providers. The Veterans Choice Program’s primary purpose is to divert attention from the problems that are coming to light regarding VA patient care and to buy time for the VA to their act together. While there is a thread of truth about the choice the program provides to Vets in urban areas like Los Angeles that is all it is, a thread.
Background:
In August of 2014, Congress passed H.R. 3230, The Veterans Access, Choice, and accountability Act of 2014 which became Public Law No. 113-146. The stated objective of the law is to Improvement of Access to Care from Non-Department of Veterans Affairs Providers. The law requires that hospital care and medical services to be furnished to veterans through agreements with specified non-Department of Veterans Affairs (VA) facilities if the veterans:
Have been unable to schedule an appointment at a VA medical facility within the Veterans Health Administration's (VHA's) wait-time goals (longer than 30 days) for hospital care or medical services and such veterans opt for non-VA care or services.
Reside more than 40 miles from a VA medical facility. The forty miles had been “as-the-crow-flies” miles even if that meant 100 drive miles and a three-hour trip. In a press release from the VA dated March 24, 2015, a policy change will be made through regulatory action in the coming weeks from a straight line distance to driving distance.
All veterans living in the greater Los Angeles area live within forty miles of a VA facility so the benchmark that is applicable to LA relates to the greater than 30-day wait times for appointments. Given the shenanigans with the original interpretation of the 40 mile rule, one cannot help but to wonder if there is manipulation going on with the 30-day rule.
The bill authorizes and appropriates $10 billion for this purpose. This program is authorized for three years or until these funds are exhausted, whichever is earlier. This is a temporary program. The three-year period will end July 2017.
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A sister program to the Veterans Choice Program, the Veterans Affairs Patient-Centered Community Care (VAPC3) was launched in spring of 2014. This program helps to fill services gaps that the locals VA experience. Patient-Centered Community Care (PC3) is a Veterans Health Administration (VHA) nationwide program that offers health care contracts to provide eligible Veterans access to:
~ Primary care
~ Inpatient specialty care
~ Outpatient specialty care
~ Mental health care
~ Limited emergency care
~ Limited newborn care for enrolled female Veterans following the birth of a child
The VAPC3 program does not include services for dental care, nursing home care, Long-Term Acute Care Hospitals (LTACs), homemaker, and home health aide services, dialysis, and compensation and pension examinations.
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The Veterans Choice Program has been intentionally designed to be a very difficult to execute for Vets who wish to use community providers and thus, keep patient utilization within the VA system. To use the Choice Card will require initiative and determination, beyond the capabilities of the average veteran and their families.
1. Under the Veterans Choice Program, the Vet can opt to use a community provider in the LA basin, only if they cannot get an appointment scheduled within 30 days.
2. If the patient wishes to see a community provider, and the Vet does not already have a Choice Care, the Vet must first apply for a Choice Card. This process can take a month or two.
3. If the Vet cannot get an appointment within 30 days – who are the community providers with whom they can get an appointment and how long will that take? (The system is rigged so that it will probably longer than 30 days for the Vet to get an appointment with a community provider.) First, TriWest does not provide a list of contracted providers on their website. The Vet must call TriWest to obtain a list of contracted providers. TriWest currently does not provide a website where patients can search for providers online as is the standard for most insurers.
a. If the physician that the patient wishes to see is not a contracted provider, the physician must go through the application process (This can take 4 to 5 months as it include credentialing).
4. The patient is responsible for obtaining eligibility and authorization. This is a process that most people would not expect, nor understand. Practically all insurers require the Provider to call the payer to verify eligibility and obtain an authorization, not the patient.
5. Standard practice allows the patient to schedules their appointments directly with their doctor’s office since the patient and doctor’s office more easily perform this task. When patients communicate directly with the doctor’s office the sense of urgency is usually communicated better.
a. Under the Veterans Choice Program, the TriWest website indicates that appointments are made through TriWest creating another layer of bureaucracy with which the patient needs to deal.
b. For most community based physician specialties, the lead time for appointments is 3-6 weeks unless there is an urgent situation.
6. The TriWest website indicates that TriWest will transfer the patients’ medical record to the community physician. There is no indication how long this takes or if it is a prerequisite to scheduling the doctor appointment.
7. If the patient needs to be referred to another specialist or hospital, the patient needs to either go back to the VA for care, or work through the above process again to obtain authorization for a contracted provider. In general, TriWest contracts with individual providers, not a provider network where primary care physicians work with a team of specialists the make it more efficient to refer patients to the specialty network. Contracting with individual physician providers greatly slows the referral process for the Vet.
8. The patient is limited to assignment to the community provider for only one year. The Veterans Choice Program is secondary to the VA system. In LA, it can only be used if the Vet cannot get an appointment within 30 days and the Vet wants to go through the hassle of seeking a community provider. Approval to see community providers is authorized for one year. If the VA physician specialty no longer has an appointment backlog, authorizations to community providers can be withheld. There is no requirement for continuity of care.
9. When does the Veterans Choice Program actually pay for the services? The Veterans Choice Program only pays for the service when the patient does not have any other insurances like commercial coverages, Medicare, or Medicaid. The Veterans Choice Program is considered a secondary payor/payor-of-last-resort if any other health care coverage exits. The Veterans Choice Program is considered the primary insurance only if the patient has no other health care coverage. Information regarding other health care coverages are to be provided to TriWest so that they can limit the amount of their payment.
a. If the Vet has Medicare, there is no Choice benefit. Under current law, VA cannot pay secondarily if Medicare is your primary insurance. As such, if one gives the provider your Medicare information during an authorized Choice Card visit, the Choice Card will provide no coverage, and the Vet will be responsible for all Medicare co-payments, deductibles, and other out-of-pocket expenses.
b. If the vet has TriCare, there is not Choice benefit. Under current law, VA cannot pay secondarily if TRICARE is one’s primary insurance. As such, if one gives the provider their TRICARE information during an authorized Choice Card visit, the Choice Card will provide no coverage, and the Vet will be responsible for all TRICARE co-payments, deductibles, and other out-of-pocket expenses.
Conclusion: