HVAC Health Subcommittee Meeting
September 14, 2012
STATEMENT OF
SHANE BARKER, SENIOR LEGISLATIVE
ASSOCIATE
NATIONAL LEGISLATIVE SERVICE
VETERANS OF FOREIGN WARS OF THE UNITED
STATES
BEFORE THE
COMMITTEE ON VETERANS’ AFFAIRS
SUBCOMMITTEE ON HEALTH
UNITED STATES HOUSE OF REPRESENTATIVES
WITH RESPECT TO
VA Fee Basis Care: Examining Solutions to a Flawed System
WASHINGTON, DC September
14, 2012
Madam Chairwoman, Ranking Member
Michaud and Members of this committee, on behalf of the more than 2 million
members of the Veterans of Foreign Wars of the United States (VFW) and our
Auxiliaries, I would like to thank you for the opportunity to present our views
on the Fee Care Program.
The VFW is very appreciative of the
efforts made by this Subcommittee to better understand and address a
persistent, growing challenge for VA. Your
interest in this issue is critical to affecting positive change as we enter
into a pivotal time in the life of the Fee Basis Program. Our veterans are from all walks of life and
live in urban and rural areas. Some live
in what we describe as highly rural areas, and their access to care is limited
as a result. VA has for decades operated
the Fee Basis Program to meet their needs by allowing them to utilize civilian
doctors as part of the care VA provides.
I would like to take this opportunity to identify some shortcomings of
that program, and how we can address them to both save money and enhance the
quality of care we provide.
We have no shortage of evidence to
convince us that change is necessary. Between
Fiscal Year (FY) 2005 and FY 2011, overall costs for the Fee program increased
nearly 200%, from $1.6 billion to nearly $3.9 billion per year. During this same period the population size
rose 95%, adding nearly 400,000 patients to the program and bringing the total
to 893,421 unique veterans. However, VA
constrained overall cost per unique veteran to 33%. During that time, it rose from $3,246 to
$4,331 per year. For all the cost
increases and more veterans utilizing the program, care is not coordinated
between the private sector and VA in the traditional Fee program. Because of inadequate technology and an
aversion to change that persisted within VA for years, VA did not consider this
a priority. We hope that sentiment is
changing, and are hopeful about the direction in which VA seems to be
heading.
As we face the reality of fiscal
restraint, cost increases of this magnitude rightfully cause us to pay attention
and work to enhance the performance of this program. The VFW is convinced that it can be done, and
we want to be a part of the solution. This
committee obviously understands the need to restrain unnecessary growth in the
Fee program to ensure the program survives over the long-term, and we
appreciate your efforts to put it on a more solid footing.
Fee Basis Care was created to ensure
that a civilian doctor is meeting the needs of veterans when VA is unable to
meet the demand. It has been in place to
meet the needs of eligible veterans for decades, ensuring that those who live
great distances away from a VA medical facility or require non-VA provided
specialty care are granted care through a civilian doctor closer to home. VA is mandated to consider allowing a veteran
to use the Fee program based on distance from VA facilities, their portfolio of
services, wait-times, and the availability of the specific doctors and
treatments a veteran requires. Obviously,
this function is a necessary and inextricable part of VA’s mission. VA’s ability to decide when a veteran should
be able to utilize the Fee program is an inherent strength of the program, and
the VFW strongly believes that VA must retain absolute responsibility for their
patients when they receive care in the private sector. There are many implications that emanate from
this conviction that VA retain ultimate control for every veteran they send
into the private sector, and VA bears the burden of responsibility for their
well-being regardless of where they seek treatment.
The shortcomings of the Fee Basis
program were painstakingly detailed in a September 2011 report of the National
Academy of Public Administration (NAPA).
The report paints a stark picture of the current state of the program,
and validates many of our long-standing concerns with the lack of care
coordination and spending controls. Of
their many specific and disconcerting findings, the totality of the situation
led NAPA to find that VA is utterly lacking in the ability to discern the
return on investment for the program. There
is not one single factor that would lead NAPA to make such a serious claim;
rather, the numerous inefficiencies taken as a whole are the culprit.
Administration
from VA Central Office
The Fee program is orchestrated from
the Chief Business Office (CBO) in VA Central Office (VACO). However, their influence over how the program
is operated at lower levels in the system is limited. CBO enjoys limited cooperation with the field. CBO gathers no standard performance metrics,
has no mechanism to receive documentation from providers, and does not validate
credentialing of private physicians. CBO
has no way to verify that billed services have been rendered, and far too often
pays rates that are far too high for billed services. VACO also does not audit how Fee Basis
dollars are spent at the local level. To
our knowledge, they do not conduct the oversight needed to analyze when the Fee
program operates within budget, and when available funds are exhausted earlier
than expected.
NAPA recommended consolidating the
authorization and claims processing function of the 100 plus Fee Basis program
offices nationwide, eliminating the vast majority and creating a regional
system of three to five sites. They make
clear in their report that this change would not centralize clinical decisions
or leave them to the bureaucracy.
Clinical decisions would still be made by medical staff. The VFW believes this recommendation makes
sense. However, in considering such
change, the VFW hopes the committee will be mindful that the lack of a
comprehensive IT solution may complicate a regional approach to administering
the Fee program.
Technological
Limitations
For years VA has relied upon antiquated
technologies that are simply out of step with the private sector and among other
federal agencies such as the Center for Medicare and Medicaid Services (CMS). Policymakers
in the Chief Business Office have very limited access to clinical data from veterans
episodes of care in the civilian sector.
This is an enormous disadvantage that directly impacts the quality of
care for veterans. It slows down
civilian and VA doctors by eating away at their time and making decisions more
complicated. It also hinders VA’s ability
to detect and prevent improper payments, creating an environment that is
susceptible to waste, fraud and abuse.
The Fee program does not have the
ability to broadly automate incoming or outgoing bills or payments. By way of
comparison, the Department of Defense (DoD) aggressively pursues automation wherever
possible. They are currently contracting
with Wisconsin Physician Services (WPS) through the TRICARE Management Activity
(TMA) to process the vast majority of their claims. In doing so, TMA saves both time and money
for DoD, allowing that department to focus on core competencies. We believe it is time for VA to consider what
they can do to bring their operations in line with industry standards and
generate dollars through such efficiencies.
To their credit, VA is working to
resolve many of these issues. VA has
openly acknowledged the shortcomings and failures in their IT infrastructure,
and it is our understanding that VA has been working to affect change at many
levels – including within the acquisition process. VA’s Office of Information & Technology (OI&T)
seems to be adopting a more modern and lean process to build the IT systems
needed to coordinate and provide care in today’s complex healthcare
infrastructure. Changes like the
implementation of agile systems development hold the promise of faster,
cheaper, more usable software solutions.
Though we have seen some evidence of success at VA, it is just a
start. VA is working on a common
platform to provide civilian doctors with an easy way to provide CBO with
searchable clinical data from visits resulting from using the Fee program. Though we do not know the development and
implementation timeline, the possibility of providing doctors with an IT
solution that gives VA the information they need – and is quick and easy enough
for doctors to use without unnecessary burden – holds great promise. The VFW will continue to closely monitor the
development of IT projects underway.
The
Question of Contracted Care
Over the years, VFW has heard many stories
of veterans who enter into the Fee program, only to be confused and
disappointed by the experience. What
should be an easy and convenient alternative to direct care for veterans often
leaves them feeling detached from VA.
The reasons are clear: VA does not reach back to the veteran to gauge
their satisfaction with episodes of care in the civilian sector; veterans are
left to make their own appointments, completely independent of any VA
facilitation; and they are sometimes responsible for getting patient records to
VA from their civilian providers when possible.
Once they enter the Fee program, they have little contact with VA, and are
given no direction from them.
Congress attempted to address this
issue in 2005 with the ongoing Project on Healthcare Effectiveness
through Resource Optimization (Project HERO) pilot program. To date, it is VA’s single foray into the business of contracting for the provision
of private care to veterans, and it has achieved generally positive
results. We all know that the 5-year
pilot program had a rough start. However,
VA responded to the concerns of the Veteran Service Organization (VSO)
community and the program is drawing to a close with a successful record. It regularly met quality measures outlined by
VA, while also saving money. For this
and other reasons, the VFW is concerned it may be ending too soon.
Project HERO is still meeting VA
requirements for customer satisfaction and distance metrics. The data shows they have greatly reduced
missed appointments through regular communication with patients, providing them
with timely reminders. Because VA gets
clinical notes from providers Humana has contracted with for Project HERO, care
is being coordinated properly. VA can be
certain of this because they regularly receive all the metrics they have asked
for from their remaining contracted partner, Humana Veterans Healthcare
Services, Inc. Unfortunately, the
traditional Fee Basis program provides no such metrics.
One benefit of coordinated care has
been the elimination of many duplicative services. As a result, VA has saved money even though
referrals into the program were low throughout the life of the program. In addition, VA doctors have the requisite
information to bring veterans back to VA when it was in the best interest of
the veteran. Humana’s contract was
extended beyond the planned termination date until March 31, 2013 to allow for
more time to transition out of Project HERO and to prevent veterans using
current Project HERO providers from any interruption of service. It should be noted that VA still plans to end
the contract with Delta Dental, their other partner in Project HERO, on the
original contract termination date of September 30, 2012.
Meanwhile, VA has been working on their
plan to replace Project HERO with a permanent program, known as
Patient-Centered Community Care (PCCC) for some time. This program was designed to incorporate the
lessons learned over the past five years working on Project HERO alongside
Humana and Delta Dental. To the best of
our knowledge, this program is being crafted to allow VA Central Office to
establish numerous contracts for coordinating timely and high-quality care that
could comprise both VA and non-VA providers at the discretion of VA
clinicians. Veterans would have to be
referred into PCCC by a VA physician, thereby ensuring the decision to send a
veteran into these contracted networks would be maintained in-house. VA doctors would also have the benefit of
detailed clinical notes from each patient visit in the network, and thus would
be far better equipped to make a decision to transfer to a different provider
or bring a veteran back into VA care based on clinical data. VA would coordinate the care for these
veterans through the Patient-Aligned Care Teams, in cooperation with a care
coordinator working for the PCCC contracted network provider. Doctors would potentially have the latitude
to treat one condition in a VA setting, while allowing the veteran to remain in
PCCC for other conditions. For example,
a female veteran with PTSD could be sent into the network for maternity care,
while continuing to visit the VA clinicians she has already bonded with at her
VA facility.
According to VA, initial market
research began in November 2010. In June
2011, PCCC became an official program through an Executive Decision Memorandum
of the National Leadership Council. In
the closing months of 2011, VA released a Request for Information (ROI) and
held three “industry days” to allow companies to dialogue with VA on a
one-on-one basis.
Since then, VA has worked to prepare
the Request for Proposals (RFP) and had intended to release it last month. Because of various delays, we now expect the
RFP to be released in November 2012. The
VFW looks forward to the release, as it should answer many remaining questions
about PCCC. So far, we have learned that
PCCC is projected to include five regions, which we assume will be managed by
different contractors. We have learned
that contract care provided through PCCC will be prioritized over other avenues
of non-VA care; a departure from Project HERO, as it was given a low priority
when being considered for Fee Basis services.
Unfortunately, the issue of mental health services being included in
PCCC is still an open question. The
November 2, 2011 RFI regarding PCCC explicitly stated that mental health would
not be included. However, this committee
and VA are now assuring us that mental health will be a part of PCCC. We hope that the RFP will make VA’s
intentions clear.
The contract award for PCCC is
scheduled for March 2013, barely six months from now. Project HERO – a relatively small pilot
program that got off to a slow start – is scheduled to end the same month. The VFW is concerned about a possible service
gap between the end of Project HERO and the indeterminable point in the future when
PCCC can serve veterans at full capacity.
The VFW believes extending Project HERO for six months was the right
thing to do. We also believe that they
should extend Project HERO until contracts under PCCC are mature enough to handle
the full caseload for every veteran in the program with a fully capable
nationwide network of all contracted services.
It is unfair to our veterans to give them a cold handoff from Project
HERO to PCCC. Though we are confident VA
would do all they can to ensure a smooth transition, they deserve someone on
the civilian side of the equation as well.
VA’s
Plan to Improve Internal Shortcomings in the Fee Basis Program
The VFW believes VA is finally taking
the shortcomings in the traditional Fee Basis Program seriously. Since the release of the 2011 NAPA report, VA
has initiated an ambitious plan to meet many of the NAPA recommendations by
significantly overhauling referral management processes. The initiative, known as Non-VA Care
Coordination, (NVCC) seeks to establish end-to-end documentation for patients
admitted to civilian facilities. If
properly implemented, NVCC will also standardize all business rules to document
the reasons for using the Fee program, thereby facilitating administrative and
clinical reviews of such decisions. It is
designed to establish a system-wide practice that will avail veterans to all
internal services, such as sharing agreements with DoD and university
affiliates before being referred into the Fee program. NVCC is intended to decrease missed
appointments by engaging veterans in the appointment management process, and
will also move VA to a system of form templates to smooth out the paperwork and
create a database that is searchable. A
fully implemented NVCC program would also notify patients when Fee Basis – or
non-VA, as it is now referred to – care is available to them. Through bulk purchasing of care, NVCC will
hopefully save money and standardize the care provided across the country,
leading to better outcomes for veterans and metrics for VA to use for
continuous improvement of the program.
The VFW will be watching how NVCC is
implemented, both at Central Office and across the country. We believe it is vitally important that such
an ambitious program not reside solely within VA Central Office. It must be implemented at the local level,
even if the up-front costs are high. We
must not allow more failings at VA because of low morale or a culture of
indifference. The changes envisioned
must take effect. Today, NVCC stands as
the best vehicle for these changes to take place, and we fully support the
stated goals of the program.
VA has a tall order ahead. PCCC must retain the successes of Project
HERO, and NVCC must fix the internal shortcomings of the traditional Fee
program. None of these changes
will succeed without leadership. In the
end, it always comes back to leadership.
Leaders at the highest levels of VA must commit themselves to a coherent
and sensible approach that meets each of these objectives. Policies that are made must be clear,
comprehensive and must be enforced at all levels within VA. Solutions must leverage the best practices in
program management, design and information technology. Any long-term success must also include
cultivating relationships with a number of entities in the private sector that
believe VA is a capable and responsible partner.
The VFW believes these shortcomings
represent a clear-cut opportunity to fix a badly broken system, and we are
confident that veterans can receive better quality of care with greater
coordination at a lower cost. With that
in mind, the VFW hopes this committee will take a holistic approach to fixing
the Fee program. Each circumstance that
we resolve creates opportunity, and a systematic fix has the potential to both
save a considerable amount of money and improve the quality of care for
veterans using the program.
Madam
Chairwoman, this concludes my statement.
I am pleased to address any questions you or other members of the
committee may have.
Information Required by Rule
XI2(g)(4) of the House of Representatives
Pursuant to Rule XI2(g)(4) of the House
of Representatives, VFW has not received any federal grants in Fiscal Year
2012, nor has it received any federal grants in the two previous Fiscal Years.
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