Questions Raised About Oversight of Program
Sen. Jon Tester (D-MT
WASHINGTON, DC ― The VA is approaching a point where one-half of all care paid for by the healthcare system will be delivered through community providers. Outside care accounted for 44% of all VA health services last year, it said.
Since 2014, when Congress passed the Veterans Access Choice and Accountability (Choice) Act, the VA has been paying for U.S. veterans to receive increasing amounts of private sector, non-VA, care. In 2018, the program was replaced by the more comprehensive Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act.
The program leading to those changes is not considered an unqualified success by policymakers and analysts, however.
While the access to community care provided through the MISSION Act was designed to combat long wait times, there’s no evidence that veterans using community providers have shorter waits for appointments. Of equal concern to agency watchdogs is that VA has little way of determining the quality of care veterans are receiving in the community compared to at VA facilities.
“I want to make sure we are continuing to emphasize that veterans deserve top-notch care whether they are seen in VA or the private sector―and the department is accountable for making sure that’s what they receive,” Sen. Jon Tester (D-MT) said during a Senate VA Committee hearing on the topic. “Private sector providers who treat veterans in the community should have to meet the same wait time rules as VA. It makes no sense to develop access standards VA is required to meet and then give veterans the option for community care where they may wait longer than if they had stayed at VA.”
Tester also noted that, as of now, a veteran harmed while receiving care in the community is unable to file a claim to receive compensation for a new disability or the worsening of an old one due to medical error.
“If problems are occurring at the VA, we have an Office of the Inspector General and Government Accountability Office to tell us what’s going wrong and how to fix it,” he declared. “We have none of those protections for vets when they go into the community.”
According to a recent RAND Corp. study, more than 3 million veterans have used VA community care since 2014. During that time, community care went from accounting for 12% of VHA spending to 20% of spending. That number is expected to increase to 25% by 2024.
“Whether this [increase] has resulted in more timely, high-quality care for veterans is not well understood,” testified RAND senior policy researcher Carrie Farmer. “There’s no data comparing VA wait times to community care wait times. But what data does exist suggests VA’s wait times may be comparable or shorter.”
Farmer explained that, in a recent VA analysis of 22 million veteran appointments, wait times for VA-delivered care were shorter than for VA community care, and those shorter wait times were seen throughout different areas of the country.
The authors of the RAND report recommend that VA track and publish wait times for community care so veterans can make more informed choices.
“It may be difficult in some parts of the country,” Farmer noted. “The number of visits may not make sense to add together, so it may have to happen at the VISN level. But I do believe there is some way to record this information to help dispel what I believe is a myth. That getting care in the community is going to be faster than getting care from the VA facility.”
Farmer also testified that, while wait times can be measured relatively easily, quality of care by community providers is a different story.
“VA tracks and reports on dozens of quality measures and makes much of this data available. Equivalent data is not available for community care,” she said.
According to the report, the department should monitor what quality data does exist for community providers and make that publicly available along with wait times.
Sharing of Information
“Third-party administrators responsible for managing VA’s community care network routinely collect information about community providers that is not shared with VA because it’s not required by contract,” Farmer said. “VA should explore contract changes [to require sharing of that information].”
Also present at the hearing was VA Secretary Denis McDonough, who testified that while he did not plan to explore changing access standards for community care, as he’d suggested at a previous hearing, VA was planning to incorporate telehealth appointments into determinations regarding eligibility.
“I know this will require careful consideration, and that’s why we will welcome public and congressional input on the proposal when we make it,” McDonough said.
He also explained that access standards―wait times and a veteran’s distance from the needed VA provider―are only one of the factors that go into deciding whether or not a veteran should seek care in the community.
“The state of VA infrastructure is a factor,” he said. “I heard from our experts in Des Moines last week that infrastructure too often impacts their decision as to whether a veteran can receive care at the VA facility.”
McDonough also fielded continuing accusations and intimations that VA is seeking to undermine the community care process to funnel resources to its own facilities.
“Are there individuals refusing to move patients into the community? Maybe. But that’s not my experience,” McDonough said.
He noted that, with the increase in posted VA wait times and the corresponding increase in the number of veterans being referred to the community, if there is an institution-wide conspiracy to sabotage community care, it was an exceptionally ineffective one.
