"Examining the Veterans Choice Program and the Future of Care in the Community"

Statement of
Carlos Fuentes, Director
National Legislative Service
Veterans of Foreign Wars of the United States

Before the

United States Senate
Committee on Veterans' Affairs

With Respect to

“Examining the Veterans Choice Program and the Future of Care in the Community”

WASHINGTON, D.C.                   

Chairman Isakson, Ranking Member Tester and members of the Senate Committee on Veterans’ Affairs, on behalf of the men and women of the Veterans of Foreign Wars of the United States (VFW) and its Auxiliary, thank you for the opportunity to provide our views on the Choice Program and how to consolidate and improve the Department of Veterans Affairs’ (VA) community care.

In the past three years, the VFW has assisted hundreds of veterans who have faced delays receiving care through the Choice Program, and has surveyed more than 8,000 veterans specifically on their experiences using VA community care. Through this work, the VFW has identified a number of issues and has proposed more than 15 common sense recommendations on how to improve this important program. The VFW would like to thank the committee for its leadership in addressing many of the issues the VFW has identified, such as making VA the primary payer for Choice Program care, removing restrictions on when VA is able to share medical records with Choice providers, making clinical necessity the trigger for community care, and recalculating how mileage is measured to account for how humans drive, not how birds fly.

The VFW must also commend VA and the third party administers for their willingness to work with us to address issues veterans encounter when obtaining care through the Choice Program. VA has made more than 70 modifications to the Choice Program’s contract to address many of the pitfalls that have plagued the program, such as allowing the contractors to conduct outbound calls when they have the proper authorization to begin the scheduling process.

However, the Choice Program continues to face several challenges that must be addressed. That is why the VFW is very concerned that the Administration has requested to make the Choice Program a permanent mandatory program. The VFW believes this program must be improved and consolidated with other VA community care programs, but we oppose making it a continuing it as a mandatory program. VA’s medical care accounts are under discretionary spending and subject to sequestration budget caps. Having the Choice Program as the only VA health care program not subject to spending caps could lead to a gradual erosion of the VA health care system.

The biggest issue that the VFW hears from veterans who use the program is the breakdown of communication between VA, the third party administrators, Choice providers and veterans. This breakdown has a significant impact on the care veterans receive. The VFW has heard from too many veterans that they were sent to the wrong doctor because VA and the contractor could not figure out how to make certain the veteran sees the specialist that can provide the care the veteran needs. For example, veterans who need to receive the recently developed cure for Hepatitis C have been sent to hepatologists who cannot provide them the lifesaving medications they need.

The VFW has also heard from veterans that the breakdown in communication between VA, contractors and Choice providers often delays their care because their Choice doctors do not receive authorization to provide needed treatments. What is concerning is that veterans are left to piece together the entire story or else they do not receive the care they need; or they are left to pay for the care out of pocket because their Choice doctors performed treatments that are beyond the scope of the Choice authorization.

VA has taken a number of steps to address this breakdown in communication. It is in the process of implementing a new authorization management system to eliminate the confusion regarding which provider veterans need to see. It has also worked with TriWest Healthcare Alliance and Health Net, Inc. to have contractors co-located with VA community care staff at VA medical facilities to address and issues in approving secondary authorizations or ensuring veterans are sent to the right doctors. The VFW has received good feedback from VA employees and veterans at facilities with co-located VA and contract staff.

However, the underlying issue that causes this breakdown in communication is the fact that TriWest and Health Net are required to maintain their own systems to track Choice casework. VA transmits information to them instead of granting the contactors access to VA systems or using the same systems, which would eliminate the need to transmit data and documents between VA and the third party administrators. To avoid having to go through a third party when scheduling Choice Program appointments, VA has proposed to have its community care staff resume responsibilities for all the scheduling, which they have done in the past and continue to do under other community care programs.

The VFW supports utilizing VA community care staff to schedule Choice Program appointments when possible, but it is unreasonable to expect VA to be able to staff up enough to keep pace with the expanded use of the Choice Program. For that reason, the VFW recommends VA build on its co-located staff model and rely on contracted staff to support VA’s community care staff when demand for Choice Program care spikes. To ensure veterans are not negatively impacted when they are rolled over to contract staff, VA must ensure the contracted staff has access to the same systems as VA community care staff.

As the VFW has highlighted in our two Choice Program reports, which can be found on our VA health care watch website, www.vfw.org/vawatch, the eligibility criteria for the Choice Program must also be reformed. The VFW firmly believes that VA must reevaluate how it measures wait times. In the VFW’s most recent VA health care report, only 67 percent of veterans indicated they had obtained a VA appointment within 30 days, which is significantly less than the 93 percent VA reported in its most recent access report. This is because the way VA measures wait times is not aligned with the realities of scheduling a health care appointment.

VA uses a metric called the preferred date to measure the difference between when a veteran would like to be seen and when they are given an appointment. However, this completely ignores and fails to account for the full length of time a veteran waits for care. For example, when veterans call to schedule an appointment they are asked when they prefer to be seen. The first question they logically ask is, “When is the next available appointment?” If VA’s scheduling system does not preclude them from doing so, schedulers have the ability to input the medical facility’s next available appointment as the veteran’s preferred date –– essentially zeroing out the wait time. VA must correct its wait time metric to more accurately reflect how long veterans wait for their care.

However, VA’s wait time measurement must not be used as an eligibility criterion for the Choice Program. While the VFW agrees that using a clinically indicated date to determine eligibility is the right approach, we do not believe Congress or VA should dictate how long veterans must wait before receiving care from community care providers. Arbitrary thresholds such as 30-days or 40-miles do not reflect the health care landscape of our country. Veterans may not need to be seen within 30 days for appointments such as routine checkups. Likewise, such arbitrary thresholds do not account for veterans with urgent medical needs for which they need to be seen before 30 days, or veterans who suffer from disabilities which prevent them from traveling 40 miles.

A recent independent assessment on VA access standards by the Institute of Medicine (IOM) was unable to find a national standard for access similar to the Choice Program’s 40-mile and 30-day standards. Instead of focusing on set mileage or days, IOM found that industry best practices focus on clinical need and the interaction between clinicians and their patients. That is why Congress should not dictate eligibility for community care with arbitrary or federally regulated access standards, such as 30-days or 40-miles. When and where a veteran needs to be seen is a clinical decision made between a veteran and his or her doctor.

Several ideas have been proposed to replace the 30-day and 40-mile eligibility criteria for the Choice Program. Several members of Congress have suggested that veterans should be free to choose between VA and community care providers whenever they want and every time they seek care. While this proposal may sound enticing, it is unsustainable because of cost and the VFW would vehemently oppose any proposal to pass that cost onto veterans. This choose your own adventure approach to health care also leads to veterans receiving fragmented health care that the Commission on Care determined leads to lower health care outcomes and endangers patient safety. Veterans deserve the highest quality health care possible, not fragmented care that fails to meet their health care needs.

Other proposals have focused on allowing a certain segment of the veteran population or veterans who are in certain circumstances to openly choose whether to receive care from VA or community care providers. The VFW believes what is important is that veterans receive the care that fits their clinical needs and care that accommodates their preferences. This is best achieved by empowering veterans to have a discussion with their care teams every time they need an appointment.

When scheduling veterans for medical appointments, whether it is with VA or a community care provider, VA must take into account veterans’ clinical needs and personal preferences. If a veteran has an urgent care need that must be met within a 48 hours, that veteran must be seen within 48 hours. Additionally, VA must take measures to meet veterans’ preferences when seeking care. For example, a male veteran who was sexually assaulted by a male may want to seek care from a female provider. VA should not have to interrogate veterans every time a veteran needs care, but it must give veterans the opportunity to discuss their preferences.

This would also require VA care coordinators to be able to view the availability and characteristics of VA and community care providers. VA must invest in information technology systems that would allow it to compile appointment availability for community care and VA. Doing so would enable veterans to truly work with their care teams to determine what options are best for them.

Overall, Congress and VA must take the lessons learned from the Choice Program and other community care programs such as Project ARCH, Project HERO, and PC3, to create a single, sustainable community care program. The VFW and our Independent Budget partners have proposed a veteran centric framework for how to integrate community care into the VA health care system, which can be found at www.vfw.org/vawatch. VA has outlined its vision for consolidating its community care programs in a report it was required to send Congress under Public Law 114-41, the Surface Transportation and Veterans Health Care Choice Improvement Act of 2015. It is time for Congress to act to ensure VA is able to transform the way it provides community care.

In its consolidation report, VA requested authority to develop a nationwide system of urgent care at existing VA medical facilities, and to reimburse veterans for urgent care they receive from smaller urgent care clinics around the country to fill the gap between emergency care and traditional appointment-based outpatient care. Doing so would ensure veterans with acute medical conditions that require urgent attention, such as the flu, infections, or non-life threatening injuries, do not wait days or weeks for a primary care appointment. Establishing urgent care would also curb the reliance on emergency rooms for non-emergent care, which is more expensive for veterans and VA. The VFW urges Congress to consider and swiftly pass legislation authorizing VA to reimburse veterans for using community urgent care clinics.

The VFW also urges Congress to swiftly pass provider agreement legislation. Authorizing VA to enter into non-federal acquisition regulation (FAR) based agreements with private sector providers, similar to agreements under Medicare, would ensure VA is able to quickly provide veterans with care when community care programs like the Choice Program are not able to provide the care.

Provider agreements are particularly important for VA’s ability to provide long term care through community nursing homes. The majority of the homes who partner with VA do not have the staff, resources or expertise to navigate and comply with FAR requirements and have indicated they would end their partnerships with VA if required to bid for FAR contracts. In fact, VA’s community nursing home program has lost 400 homes in the past two years and will continue to lose 200 homes per year without provider agreement authority. This means thousands of veterans are forced to leave the place they have called home for years simply because VA is not able to renew agreements with community nursing homes. Congress must end this injustice by quickly passing provider agreement legislation.

The VA health care system delivers high quality care and has consistently outperformed private sector health care systems in independent assessments. The VFW’s numerous health care surveys have also validated that veterans who use VA health care are satisfied with the care they receive. In fact, our latest survey found that 77 percent of veterans report being at least somewhat satisfied with their VA health care experience. When asked why they turn to VA for their health care needs, veterans report that VA delivers high quality care which is tailored to their unique needs and because VA health care is an earned benefit.

VA has made significant strides since the access crisis erupted in 2014 when whistleblowers across the county exposed how long veterans were waiting for the care they have earned and deserve. However, VA still has a lot of work to do to ensure all veterans have timely access to high quality and veteran-centric care. Veterans deserve reduced wait times and shorter commutes to their medical appointments. This means turning to community care when needed, but also means improving VA’s ability to provide direct care.

The VFW thanks Congress for its commitment to improving VA’s community care authorities and programs. VA also needs the resources and authorities to quickly recruit and properly compensate a high performing health care workforce, properly train its employees, hold wrongdoers accountable, and update its aging capital infrastructure. Community care must continue to supplement direct VA health care. This means VA and Congress must continue to invest in VA to ensure it remains a premier health care system.

Mr. Chairman, this concludes my testimony. I will happy to answer any questions you or the committee members may have.