At a Senate Committee on Veterans Affairs hearing last week (June 7, 2017), committee members discussed the future of the Veterans Choice Program. Secretary of the Department of Veterans Affairs Dr. David Shulkin testified and put forth a preliminary proposal for a revised Choice program he is calling the Veterans Coordinated Access Rewarding Experiences program, or CARE program.
The Choice Program
After a 2014 scandal in which several veterans died waiting for care at the VA Medical Center in Phoenix, AZ, Congress acted swiftly to pass the Veterans Choice Act. Ninety days and $10 billion later, the Choice program went into effect, making private sector healthcare available to veterans who have waited at least 30 days for an appointment at a VA facility or who live more than 40 miles from a VA hospital.
Since the Choice Program’s enactment, over 1 million veterans have received care from 500,000 private “community care” providers. In Fiscal Year 2016, VA processed 18.9 million claims for all community care programs—a 15 percent increase from Fiscal Year 2015.
Complexity, Confusion, and Criticism
Despite the high rates of enrollment, lawmakers, veterans, and community care providers have criticized the program, some even claiming that it has actually made access worse for veterans. NPR reported that wait times have indeed increased at VA medical facilities since the Act’s passage in 2014—with 70,000 more appointments that kept a veteran waiting at least a month to get care.
At last week’s hearing, Senator Jon Tester of Montana called the current Choice program “a train wreck.” He claimed it hasn’t improved access for veterans in his state and “in the process, it’s caused a lot of veterans and community [healthcare] providers to lose faith in the VA.”
There are eight separate programs for paying community care. In a briefing at the White House press room on May 31, Secretary Shulkin called for their consolidation. The complexity of the community care programs, he said, not only confuse veterans but VA employees as well. As a result, VA rejects 20 percent of community care claims, a “much higher [rate] than what you’d find in the private sector.”
Problems with Providers
Many private providers enrolled in the program have expressed frustration with late payments from the VA. According to Secretary Shulkin, VA has about $50 million in out-patient bill charges that are six months or older. The delays are such that some providers have opted to leave the program.
The VA had to create a hotline in March of 2016 to help veterans who have issues with their credit because VA hasn’t paid their doctors.
Mental health practitioners from the VA and the private sector have raised concerns about the continuity of care. They worry that providers might leave the program because of payment issues, leaving vets with severe mental health issues at risk. For this reason, Maine and Montana have passed legislation to exclude mental health care from the Choice program in their states, using other programs to pay for it.
Other providers say they want to join the Veterans Choice program but can’t “jump through the hoops to get certified,” NPR reports.
Because interested providers are hard to come by, thousands of veterans have given up on Choice and returned to the VA for care. Some veterans left because the program couldn’t find a doctor for them. And, according to data NPR obtained from the VA, 28,287 veterans left because the private doctor they were told to see was too far away.
In April of 2017, Congress passed the “Veterans Choice Program Improvement Act,” the most recent of over 70 amendments and modifications to the original legislation. The Act removed the expiration date for the Choice Program, which was set to expire at the end of this fiscal year. It also made VA, rather than outside contractors, the primary coordinator of benefits in an attempt to improve information exchange between VA and community providers.
The Act authorized VA to spend the rest of the $10 billion originally allocated to the program. But Shulkin said he expects the money to dry up by the end of Fiscal Year 2017.
The CARE Program
At last week’s Senate VA Committee hearing, Secretary Shulkin proposed a redesigned Choice Program. The program would be called the Veterans CARE (Coordinated Access Rewarding Experiences) Program. Though he did not provide many details, Shulkin described several “key elements” of CARE.
Eligibility based on clinical need and quality of care. Eligibility for community care would no longer be based on wait times and geographical location. Instead, veterans would make a joint decision with their VA doctor about whether VA or community care would be best for them. Decisions, Shulkin suggested, would be based on the quality of care at that particular VA and specific clinical needs of the patient. At a minimum, if your VA does not offer a service—obstetrics or gynecology, for example—you would have the choice to receive community care instead.
Expanded access to urgent care. Veterans would have access to a network of walk-in clinics if they need care immediately. They would also be able to get treatment for minor illness or injury at facilities such as CVS Minute Clinics.
A high-performing, integrated network that includes VA, federal partners, academic affiliates, and community providers.
Coordination of care for veterans served by multiple providers. VA, rather than outside contractors, would coordinate with community providers and facilitate the exchange of health information.
A standard of industry-level quality for patient satisfaction, payment models, health care outcomes, and exchange of health information.
Though VA has not publicly released a plan for the new program and legislation has yet to be introduced, Shulkin hopes to push the new CARE program through Congress by September 30, the end of this fiscal year.
Lawmakers and veterans service organizations have expressed concerns that expanding the Choice Program, which was originally intended as a temporary measure to reduce wait times, could lead to the eventual privatization of the VA. Some critics have even accused the administration of “stealth privatization.”
Though Shulkin has repeatedly denied any intention to privatize the VA, lawmakers pressed him on the matter at last week’s Senate VA Committee hearing.
“The large increase for community care is seemingly being made at the expense of in-house VA care,” said Sen. Tester at the committee hearing. “I’m not going to be the guy up here to allow the administration to chip away at VA health care.”
The president’s proposed budget for the VA in fiscal year 2018 calls for $2.9 billion in new spending for the community care program. It requests an additional $3.5 billion for the program in 2019 and every subsequent year.
“Our job is to improve what already works reasonably well and not to dismember it,” Sen. Bernie Sanders of Vermont said. “That is a fear that many veterans service organizations have, and it is a fear that I share.”
Veterans service organizations have largely come out in support of Shulkin’s proposed revision of the community care program. However, they have expressed deep concerns that other benefits and funding for VA hospitals could be cut to fund the private sector program. The current budget proposal cuts $3.2 billion from Individual Unemployability benefits for an estimated 208,000 severely disabled, elderly veterans. Shulkin has defended the cuts as a reallocation of resources “that are going currently to some veterans, to help additional veterans.”
“Here’s what’s missing from the conversation: how you plan to actually build and strengthen the VA system for the long term,” said Sen. Patty Murray of Washington. “You have not put forward a comprehensive plan to do some of the things that the VA really needs to do, [like] get more front line providers, increase appointments, expand services, build and upgrade facilities [and] bring more veterans into the system. Those, to me, are the things that you do if you’re trying to build and strengthen the VA system that we have, that veterans want.”
Committee Chairman Sen. Johnny Isakson of Georgia added that, if the program is successful in reducing wait times and providing quality care, veterans with currently have private insurance may be more attracted to VA healthcare. This could additionally increase the need for funding, putting more pressure on the VA.
Shulkin responded to lawmakers’ concerns by drawing on the momentum surrounding recent legislation. “We have to be as open-minded on making Choice work in the future as we had been on finally getting accountability done yesterday,” he said. “There are going to be some things that some people are going to find hard to take or hard to talk about.”