Hospitals brace for challenges serving more veterans

The Obama administration's new policy of referring more veterans for care outside the overwhelmed Veterans Affairs health system could end up straining non-VA hospitals because of potential lags in payment and patient needs that civilian providers aren't necessarily prepared to handle.

With the VA scandal over long waits for veterans at VA facilities growing, the White House and the VA announced that more veterans will be able to use private medical services. Under the new Accelerating Care Initiative, VA facilities must offer a referral to an outside provider if they don't have the capacity to give an earlier appointment to any new patient who is on a wait list or has a visit scheduled more than 30 days out.

VA Inspector General Richard Griffin concluded last week that 1,700 veterans in need of care in Phoenix were kept off the facility's official waitlist, and the average wait time was 115 days, although VA guidelines say veterans should get appointments within 14 days of their request. He said that VA officials in Phoenix falsified data to hide the long waits and that similar manipulation was “systemic” throughout the 153-hospital VA system serving 9 million veterans a year.

The first referrals were expected May 30, according to the VA. The agency believes it will take up to 90 days to fully implement the policy, which is expected to become permanent. Veterans will be able to seek care only at private clinics and hospitals in areas where the department's capacity to expand is limited. The VA did not provide an estimate of how many patients might receive referrals under the policy.

The VA typically reimburses outside providers only for emergency care or for veterans who live in rural areas without access to a VA facility. It sometimes grants specific requests to see private providers.

In fiscal 2013, the VA paid for such care for 1 million veterans at a cost of $4.8 billion, nearly 10% of the agency's budget.

Hospital associations in states with large veteran populations expressed concern about getting claims paid in a timely way by the veterans system. Weeks before the first allegations of long waits and deaths made headlines, the U.S. Government Accountability Office released a report detailing cases of claims from non-VA hospitals that were wrongly denied because of poor administrative processes. It found that the VA lacks sufficient oversight mechanisms and data to ensure that VA facilities do not inappropriately deny claims. When private hospitals were not reimbursed by the VA, they billed veterans directly.

“Because our hospitals have historically experienced challenges with timely reimbursement for VA patients, we are awaiting further information from our federal partners as to any modifications to payment policies associated with (the) announcement,” said Julie Henry, a spokeswoman for the North Carolina Hospital Association. That state is home to about 950,000 veterans.

Similar concerns were raised in Michigan, with an estimated 1 million veterans. “Michigan hospitals operate on tight operating margins … so slow reimbursement can add to the financial burdens hospitals endure,” said Laura Appel, vice president for federal policy and advocacy for the Michigan Health & Hospital Association.

Still, the North Carolina and Michigan associations stressed that their member hospitals will treat any veterans who come through their doors, regardless of ability to pay.

Another worry is the capacity of civilian providers to treat veterans for service-related conditions such as Agent Orange exposure, Gulf War syndrome, post-traumatic stress disorder and traumatic brain injury. “There can be a lack of understanding of veteran culture and how they can experience something like PTSD differently from other patients,” said Dr. Craig Bryan, director of the National Center for Veterans Studies at the University of Utah. “This could lead many servicemen who seek care to drop out of treatment prematurely.”

But Terri Tanielian, a senior social research analyst at RAND Corp. who specializes in military and veterans health policy, said treating service-related conditions should be no different from handling other less common injuries and diseases.

The response from veterans organizations to the Obama administration's expansion of care in private facilities has been mixed. “If implemented properly, and assuming the management at the VA medical-center level in the field do what they have been instructed to do by VA central office, this could certainly help alleviate some of the access concerns,” said Carl Blake, acting associate executive director of government relations at Paralyzed Veterans of America.

Others, though, said the policy does not fully address the challenges veterans face getting access to care. “The fact is, private care has waiting lists, too,” said Joe Davis, public affairs director for Veterans of Foreign Wars. “You just don't hear about them because civilian hospitals either don't track or don't report them. When was the last time you had or ever had a same-day appointment?”

Follow Virgil Dickson on Twitter: @MHVDickson