In Baltimore, federal administrators saw trouble with a growing population of veterans three years ago. Wait times for appointments were supposed to stay within 30 days, but they were starting to approach twice that time in some cases. Steps had to be taken to keep the situation under control.
So a new-patients clinic was built expressly to process new enrollees into the system. Additional hours on Saturdays also were scheduled into the system to accommodate new patients, and a new physician position was created to help handle the patient load at Department of Veterans Affairs centers throughout Maryland.
The result, says Sunil Sinha, director of primary-care services at the VA Maryland Health Care System, is that wait times on average have stayed below the 30-day goal.
But for many veterans around the country, trying to access the VA health system could mean a much longer wait-often lasting six months or more.
The problem has gotten so bad that Congress has gotten involved, and in recent months the VA has taken controversial steps to try to alleviate the backlog of patients. Whether they will be enough to significantly improve operations remains uncertain.
According to the VA's estimates, 235,000 veterans waited six months or more for an appointment last year, in part because of the increase in the number of veterans who have enrolled in the VA healthcare system. From 1996 through the end of last year, the number of veterans in the system has jumped more than twofold, from 2.9 million to 6.8 million. Last year alone, 830,000 new veterans enrolled in the VA health system, which has a 2003 medical-care budget of nearly $24 billion.
More quality, more patients
The spurt in enrollment was driven by changes in a law enacted in 1996 that loosened eligibility rules for who can get care at VA centers. Traditionally, VA healthcare was meant for low-income veterans with illnesses related to or injuries received during their service. But when Congress changed the rules to allow almost any veteran to access a VA health center, the floodgates were opened.
At the same time, the VA, which had been plagued for nearly two decades by questions about the quality standards at its facilities, took immediate steps to improve conditions at their medical centers.
"There's no question that (the) VA was criticized for the quality of its care," says Kenneth Kizer, undersecretary of health at the VA from 1994 to 1999 and now president and chief executive officer of the Washington-based National Quality Forum, an organization that helps set standards of quality for the healthcare industry.
During the past decade, the system took careful steps to improve quality, creating standard performance measurements for use throughout all VA medical centers in the system. Customer service also was upgraded and a state-of-the-art information technology system was implemented, making it possible for doctors to better track patient records electronically. The VA had no estimate of how much the improvements have cost.
The department also expanded its network of outpatient clinics, making it possible for more veterans living in rural outposts to see a VA provider without having to drive for hours to a VA hospital. In the past four years, says VA spokesman Jim Benson, about 400 VA outpatient centers have been built, bringing the total to about 700.
The result is that the VA system quickly has become attractive once again to veterans who, in turn, have overwhelmed the system.
"We almost feel the VA is a victim of its own success," says Paul Hayden, deputy director of legislation for the Veterans of Foreign Wars, an advocacy group based in Washington.
Frozen in time
In January, though, in an effort to control the backlog of patients, VA Secretary Anthony Principi froze through September enrollment of new veterans with nonservice-related illnesses and injuries. The suspension of such services for what's known as Category 8 veterans is expected to reduce the number of future enrollees by 164,000, saving the system about $30 million this year. The veterans will have to access care through their own doctors. Although that figure is small compared with the total number of veterans already in the system, Principi's move was not well-received by the House Veterans' Affairs Committee.
"For some, the secretary's decision to cut off enrollment of 164,000 Category 8 veterans was a solution; to me and many others, it is a problem," committee Chairman Rep. Christopher Smith (R-N.J.) said during a hearing in January.
Principi wants to continue the suspension through September 2004. The VA had no figure on how many veterans would be shut out of the system if such a move was made, but Benson, a VA spokesman, says the number of estimated Category 8 vets would reach 522,000 through fiscal 2005.
Benson says the suspension of new Category 8 veterans is just one step the department took to reduce wait times. Other initiatives include looking at more efficient ways for patients to call in to providers for assistance with minor health issues. In addition, the department is trying to use technology to monitor patients at home. Patients would wear electronic devices enabling providers to monitor indicators such as blood pressure, heart rates and rhythms.
"The VA has come a long way in improving the quality ... and the secretary is unwilling to sacrifice quality," Benson says.
Indeed, even veterans' rights organizations, upset about the suspension of benefits, expressed an understanding that Principi had few other tools at his disposal.
"The VA just has to ration care; that's the bottom line," says Joy Ilem, assistant legislative director for Disabled American Veterans, a not-for-profit advocacy group.
An aide to the Veterans' Affairs Committee's health subcommittee also says Principi took the most humane step in trying to tackle the wait-time issue.
"Our intention was not to remove people from the system but to better define what VA healthcare pays for," says the aide, who asked to remain unidentified. "I think he brought relief to the system in the sense that we don't have the continual line of new enrollees."
Principi is able to suspend benefits because of the legislative changes in 1996 that, along with opening up eligibility requirements, gave the secretary the ability to freeze enrollment. He also could have taken the same step with other categories of veterans.
Sparing the neediest
The VA has a total of eight categories for veterans, based on income, whether their illnesses or injuries are service-related and the extent of any disability, among other criteria.
Category 8 veterans, in addition to having nonservice-related illnesses, have incomes that are above the Department of Housing and Urban Development's thresholds for the very neediest.
By choosing to freeze enrollment of Category 8 veterans, Principi made sure that those who were hurt while in service and those most needing VA medical services were spared.
"They're going to take care of the poorest pensioned vet or the vet who took a bullet to the chest," the VFW's Hayden says.
Suspending enrollment of Category 8 veterans also was a politically savvy move because it ensures that no one already receiving benefits would have anything taken away. At the same time, the maneuver caught the attention of both the media and legislators, and in doing so trained a spotlight on some of the VA system's challenges.
The long-term benefits of the suspension are unclear at the moment. In the meantime, Principi also has proposed charging veterans with incomes above $24,000 an annual enrollment fee of $250 and increasing copayments. Vets will have to pay $20 for outpatient primary care, up from $15, and $15 for prescription drugs, up from $7.
While some in Congress object to the changes, there is also a recognition that these moves might be inevitable, especially because health plans in the private sector have taken the same approach to hold down their costs, Ilem says.
Discussions are also under way regarding the creation of a separate prescription drug program for veterans. In such a program, veterans would be able to go directly to the VA pharmacy to get a prescription filled without having to see a VA doctor first. Legislators have tried introducing legislation to create such a program in the past, although none has gotten very far. If such a move were taken, the backlog of patients waiting for appointments could be severely cut because many older veterans use VA services in lieu of Medicare because that federal program has very limited outpatient drug benefits, unlike the VA system.
Because federal agencies cannot bill each other, the VA also cannot bill for services given to veterans who are on Medicare.
Earlier this month, however, the House Veterans' Affairs Committee's health subcommittee passed a bill sponsored by Smith allowing the VA to charge Medicare for services rendered in a VA center to a veteran who qualifies for Medicare. The subcommittee also passed a bill sponsored by Rep. Bob Beauprez (R-Colo.) allowing the department to receive full reimbursements from private health insurers for the cost of care given to veterans with private insurance. Some plans have refused to pay the VA when their members receive care at a VA center.
The VA also is watching closely while Congress and President Bush try to craft a Medicare prescription drug bill, because that also could profoundly affect the backlog of veterans.
In the meantime, the VA and HHS are allowing Category 8 veterans who have been excluded from the VA system and are Medicare-eligible to enroll with private health plans and access their care through a VA facility. The VA then would be reimbursed for the cost of services from the health plan.
The VA+Choice Medicare plan is expected to become effective in the fall, with 25,000 enrollees expected initially.
Much of the discussion in Washington centers on making funding of VA healthcare mandatory rather than discretionary. It is still early in the budget process, but it appears the VA will be getting more funding next year. In fiscal 2003, $23.8 billion was budgeted specifically for VA medical care. The Bush administration is requesting $25.2 billion strictly for VA medical care in 2004, while the House committee is recommending $27.5 billion. So far the Senate hasn't weighed in on the issue.
"This is the first time they've ever hit our number," Hayden says, referring to the $27.5 billion figure.
Because funding is discretionary, however, how much the VA system gets from year to year is unstable. A bill introduced in January by Sen. Tim Johnson (D-S.D.) would make funding mandatory, but so far it has stalled in Congress.
A coalition of veterans is pushing hard for such change nonetheless.
"We believe that's the only way the VA can be properly funded," says Ronald Conley, national commander of the American Legion. Because the final 2003 budget wasn't signed until February, five months late, veterans' hospitals had to operate during that period not knowing how much money they would be getting.
"Who's to say someone wasn't going to come in and slash funds to hospitals after they've been operating for (five) months expecting a certain amount of funding?" Conley says.
The House Veterans' Affairs Committee is exploring options that, though falling short of making VA funding mandatory, would guarantee enough funding to the system to provide care for enrolled veterans.
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