It remains unclear what a permanent, less restrictive version of Veterans Choice would cost or how it would be funded by Congress.

Feb. 28—The new leader of the Department of Veterans Affairs (VA) plans to push to make permanent a temporary program that allows veterans to access outside providers, according to published reports.

David Shulkin, MD, who was confirmed this month as secretary of the VA, said he was formulating a plan to redesign the Veterans Choice Program—which allows veterans to seek non-VA health care—and would push Congress to eliminate the program’s scheduled August expiration date, according to a report in Stars and Stripes. The report said Shulkin’s plan would end rules that require veterans to face waits of more than 30 days for an appointment or live more than 40 miles from a VA facility before qualifying for care from a non-VA provider.

Such a move would be a big departure for the agency, which—along with most veteran-service organizations—had opposed such broadened access over concerns it would divert resources away from VA facilities. Terrence Hayes, a VA spokesman, said Shulkin plans to submit to Congress “a comprehensive choice program (Choice 2.0),” which will combine “the best of VA and private sector care” while replacing the Care program’s distance and time requirements.
There is no existing Choice legislation yet backed by the VA, he said.

However, the reported comments echoed some of Shulkin’s testimony during his Feb. 1 confirmation hearing, at which he told senators he planned to return to Congress with a proposed redesign of Veterans Choice. He specifically mentioned bringing back in-house customer service functions that the program had outsourced to private contractors.

Veterans Choice, which was launched as a temporary response to a nationwide scandal in which widespread delays in care resulted in some deaths, has been plagued by its own challenges. Veterans have complained of delays and administrative obstacles to care, which must be first approved by the VA, and providers have cited lengthy waits for payment or even nonpayment for services provided to veterans.

“People can’t use Choice because the VA has come up with reasons why they can’t,” Sen. Jerry Moran (R-Kan.) said at the confirmation hearing.

Launched in November 2014, the program was appropriated $9.7 billion for veterans to receive care from non-VA providers. Although the program got off to a slow start, according to an Office of Inspector General report, eventually more than 1 million veterans made 6 million appointments for care from non-VA providers. In comparison, 21.3 million appointments were made in FY15 through the preexisting Patient-Centered Community Care (PC3) program, which also authorizes outside providers to care for veterans.

As of January, more than 425,000 hospitals, clinics, and providers were in the Choice network, an increase of 60 percent since January 2016. The two programs were consolidated, along with previously created VA programs that used outside providers, into a program called New Veterans Choice.

“Our priority is to make sure the VA Choice program works well with some of the existing mechanisms and to improve on some of those existing mechanisms to accomplish the goals that the VA Choice program is trying to achieve,” Matthew Shick, director of government relations and regulatory counsel for the Association of American Medical Colleges, said in an interview.

Hospital Impact

The hospital impact of such programs was highlighted by John Kerndl, formerly the senior vice president and operations CFO for LifePoint Health, which served veterans at hospitals and other provider settings in 22 states. Payment after discharge among all LifePoint payers—including self-pay patients—averaged 54 days, while payments in the PC3 and Veteran’s Choice programs typically took 113 days.

Such delays created financial challenges for LifePoint, Kerndl—now the CFO at Beaumont Health in suburban Detroit—said at an October 2016 briefing on Capitol Hill. But the delays were much more serious for small, independent community hospitals, which sometimes only have an average of 69 days cash-on-hand, he said.

“So it’s difficult where you then become almost a financing arm for these patients,” Kerndl said. “So I think a lot of our sister independent rural hospitals don’t participate, just because of the cost issue.”

Hayes said the VA is working with the Choice contractors to improve timeliness of provider payments and formed a provider rapid response team to address payment issues. Additionally, the VA is offering more provider education on the billing and payment processes to reduce errors with claim submissions. “VA is partnering with Congress to address the root cause of these payment issues: simplifying steps that providers and VA must follow to process and pay a claim, and aligning standards with the rest of the healthcare industry,” Hayes said.

Shick said his member academic medical centers have reported that payment delays have improved since Veterans Choice launched but have not gotten much better at other VA outside-contracting programs. AAMC backed Shulkin’s effort to continue to consolidate those programs. Together with Veterans Choice, such programs provide between 30 and 40 percent of all care for veterans, said Sen. Thom Tillis (R-N.C.).

“Sometimes it surprises people how much care is provided by non-VA providers,” Shick said.

Legislative Push

In a Nov. 30 letter to then-President-Elect Donald Trump, the American Hospital Association (AHA) urged the establishment of a permanent Veterans Choice Program and the removal of “impediments preventing veterans from using” the program.

However, the AHA or any other hospital advocacy group have yet to endorse one of the leading bills to expand the Choice program. The Full Choice for Veterans Act, which was sponsored by Rep. Bradley Byrne (R-Ala.), would allow any veteran eligible for VA care to qualify for the Choice program, and eliminate the mileage and wait time requirements.

Previous efforts to make the program permanent, such as the Care Veterans Deserve Act of 2016, failed to advance for reasons that included projections of steep costs. It remains unclear what funding would be provided for any permanent extension of Veterans Choice. For instance, the Congressional Budget Office has yet to score the cost of the Byrne bill. But recent developments made the congressman more optimistic it will be enacted.

“With the President championing veteran choice, we think there is real potential to get something done on this issue,” Seth Morrow, a Byrne spokesman said in an email. “It also helps that Secretary Shulkin has made comments recently in support of expanding the Choice Card program.”

If the August expiration date is removed, the VA expects that the existing funding would allow the program to continue through January 2018.

Legislators also are hoping to strengthen the Choice program. A 2016 bill, the Veterans First Act, would have required the VA pay for veterans’ care before any private insurance they have covers non-service-related conditions.

That Veterans Choice requirement that private insurance veterans may have pays first had delayed payment to providers and landed many veterans in collections, according to published reports. The Veterans First bill also would allow the VA to buy care from medical providers under agreements far less burdensome than current federal contracts.

“Even when the VA sometimes approaches our institutions to put together one of these contracts, their own bureaucracy can get in the way and keep veterans from getting the care they need,” Shick said.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare



Publication Date: Tuesday, February 28, 2017