Choice Consolidation: Evaluating Eligibility Requirements for Care in the Community










Choice Consolidation: Evaluating Eligibility Requirements for Care in the Community

WASHINGTON, D.C.           


Mr. Chairman and members of the Subcommittee:

On behalf of the men and women of the Veterans of Foreign Wars of the United States (VFW) and our Auxiliary, thank you for the opportunity to offer our thoughts on the Department of Veterans Affairs’ (VA) plan to consolidate its community care programs.

The VFW strongly believes that veterans have earned and deserve timely access to high quality, comprehensive, and veteran-centered health care. For the past year, Congress and VA have devoted time and resources to determining when such care should be delivered at VA medical facilities and when veterans should be afforded the opportunity to receive care through private sector health care providers. To the VFW the answer is simple: when a veteran and his or her doctor determine it is clinically necessary, the highest quality and the most accessible option.

Since the access crisis erupted in the spring of 2014, the VFW has taken a proactive approach to evaluating the state of the VA health care system. Through our work we have collected direct feedback from tens of thousands of veterans regarding their experiences receiving health care. What we have learned is that veterans turn to VA despite 80 percent of them having other health care options because they like the quality of care they receive, they believe VA health care is an earned benefit, and VA is best suited to care for their service-connected injuries and illnesses. While VA is the preferred option for eligible veterans, it is not always the most convenient one. That is why the VFW strongly believes that community health care providers must be integrated into the VA health care system to expand access to timely, high quality, comprehensive and veteran-centric health care to the veterans who rely on VA for their health care needs.

The VFW supports many aspects of VA’s plan to consolidate its community care programs. Specifically, the VFW strongly supports VA’s plan that would move away from federally mandated wait-time standards and enable veterans and their doctors to determine how long they are clinically able to wait for their health care. We agree with VA that the amount of time veterans wait for care should not be confined by statute. The number of days a veteran is able to wait for care must be a determination based on his or her medical conditions and symptoms. For example, a veteran who is likely to have heart complications and is experiencing chest pain cannot wait 30 days to be seen by a cardiologist, which is the current practice, regardless if it is at a VA medical facility or private sector hospital. However, a veteran who requires a routine medical examination may be able to wait longer than 30 days.

Furthermore, allowing access to be defined by a patient and his or her doctor would align VA access standards with industry best practices. In a recent Institute of Medicine (IOM) study on access standards, IOM recommended that “decisions involving designing and leading access assessment and reform should be informed by the participation of patients and their families.”

IOM’s study also recommends that VA “continuously assess and adjust the match between the demand for services and the organizational tools, personnel, and overall capacity available to meet the demand.”  That is why the VFW supports VA’s intent to create high performing networks based on the availability and capabilities of each health care market. Doing so would ensure VA is able to identify private sector providers who are ready and able to deliver timely, high-quality, comprehensive and veteran-centric health care and empower those providers to care for America’s veterans.

However, the VFW does not agree with VA’s plan to continue to use the arbitrary 40-mile standard to determine when veterans are afforded the opportunity to access the private sector providers within its high performing networks. Instead of using distance to determine when veterans are able to leave VA, distance should be used to determine when VA must expand health care options to ensure all veterans are afforded the opportunity to receive veteran-centric and coordinated care when they need it and where it is most appropriate.

That is why the VFW strongly believes that private sector health care providers who participate in VA’s high performing networks must be integrated into the VA health care system and considered an extension of VA health care. Meaning, a veteran must receive equal or greater quality of care through a high performing network private sector provider than a veteran would receive from a VA medical facility. To the VFW, this includes the ability to seamlessly schedule and navigate from a VA medical facility to a private sector provider and vice versa. 

For example, a veteran who has a private sector primary care provider must be able to schedule a specialty care appointment at a VA medical facility and have all related medical records from that visit transmitted to the veteran’s provider to ensure the veteran’s care is integrated as it would be if he or she were receiving all his or her care at a VA medical facility. Conversely, a veteran who receives his or her primary care at a VA medical facility must have a seamless experience when receiving specialty care through a network provider.

That is why the VFW believes that once a veteran and his or her doctor determines clinically based limits on a veteran’s ability to travel, that veteran must be allowed to pick from options available within the local high performing network, including all public and private sector options.

To properly size high performing networks to each community, the VFW recommends establishing metrics to identify clinical access gaps based on veteran population density and distance to care and services available within high performing networks, including VA and community providers. Such access gap metrics would serve to identify areas where the veterans’ health care system must expand capacity through agreements with community health care providers, sharing facilities with private or public health care entities, or building capacity.

We do not have to look far for an example of how distance is used to expand capacity instead of determining when veterans are able to consider non-VA options. Instead of requiring every veteran who lives within 75 miles of a national cemetery to be interred in that cemetery, the National Cemetery Administration’s (NCA) goal is for 96 percent of all veterans to have interment options within 75 miles of their home. This includes viable burial options at cemeteries that have been built, expanded, or improved through NCA cemetery grants.  

When the demand exists, NCA proposes the construction of a new national cemetery. However, NCA also uses agreements and grants with states, United States territories and federally recognized tribal organizations to establish, expand, or improve veterans’ cemeteries in areas where NCA has no plans to build or maintain a national cemetery. Cemeteries assisted by an NCA grant are required to be exclusively reserved for veterans and eligible family members and maintained by the same standards as an NCA managed national cemetery - meaning that veterans interred in NCA assisted state, territorial, or tribal cemeteries are afforded the same honors as those interred in a national cemetery.

The VFW also supports VA’s plan to expand access to urgent care at VA medical facilities and through private and public urgent care clinics across the country to fill the gap between emergency room care and outpatient care. We also support VA’s plan to loosen its definition of an emergency to expand access to private sector emergency room care. However, the VFW strongly opposes any recommendation to bill veterans for service-connected care. Any cost share associated with emergent or urgent care eligibility must be aligned with VA’s current copayment structure, which exempts veterans who do not have the financial means to pay cost shares and veterans who receive cost-free care due to service-connected disabilities. 

To curb overreliance of emergency room and urgent care, the VFW recommends that VA establish a national nurse advice line that would help veterans determine the appropriate level of care needed to address their medical concerns. The Defense Health Agency (DHA) has reported that the TRICARE Nurse Advice Line has helped triage the care TRICARE beneficiaries receive. As a result, the number of beneficiaries who have turned to an emergency room for their care is much lower than those who intended to use emergency room care before calling the nurse advice line. VA could leverage its existing pool of nurse and medical advice lines to establish a national advice line to emulate DHA’s success or partner with DHA to expand the TRICARE Nurse Advice Line to veterans. 

As this Subcommittee continues to evaluate VA’s plan to consolidate its community care programs, the VFW will continue to ensure the voice, preference, and health care needs of veterans are prioritized and ensure VA health care reforms serve the best interest of our Nation’s veterans.

Information Required by Rule XI2(g)(4) of the House of Representatives

Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW has not received any federal grants in Fiscal Year 2016, nor has it received any federal grants in the two previous Fiscal Years.

The VFW has not received payments or contracts from any foreign governments in the current year or preceding two calendar years.