The political grandstanding is over. Now the real work begins in reshaping how private hospitals and physicians work in the veterans' healthcare system.
Congress sent the long-stalled VA Choice reforms bill to President Donald Trump, who as of deadline is slated to sign it on D-Day, June 6, according to an administration staffer. The legislation—dubbed the VA Mission Act—puts the onus on the Veterans Affairs Department to address problems that have plagued not just the Choice program but veterans healthcare overall. The department has a year to write sweeping regulations reshaping the program before it expires next year, giving way to new expanded-care options. Lawmakers and private providers—those currently working with veterans and those patiently waiting on the sidelines for the new program—will be scrutinizing the department's progress.
"For once, I want to have a VA program that, when you unroll it, actually works," House Veterans' Affairs Committee Chair Phil Roe (R-Tenn.) said May 23 as the Senate was poised to pass the legislation.
Roughly one-third of all medical appointments already are outside of the Veterans Health Administration. About 640,000 new veterans are projected to move into community care annually in the early years of the program, the Congressional Budget Office predicted. As the ranks of veteran patients swell, providers hope the Mission Act will help relieve the VA's significant problems and make it easier to treat veterans.
Top of mind for private providers is billing and reimbursement. The history of VA Choice—the youngest of seven VA community care programs, all of which will now be merged into one under the Choice umbrella—has been fraught with billing issues, misunderstandings over reimbursements and sometimes messy relationships with third-party payers.
The legislation mandates prompt payment for providers: 30 days for electronic claims and 45 days for paper claims. Hospitals and physicians are also watching whether the VA starts using regional claims processors as the CMS does for Medicare.
Some of the VA's problems are attributed to lack of manpower in processing claims and lack of experience as a payer. In an apparent nod to providers—which, no matter how much they want to care for veterans, are hard-pressed to wait months for reimbursement—lawmakers included a provision that steers the VA toward outsourcing those operations.
The CBO projected that with the "more than doubling of non-VA healthcare," by 2022 the department would need to add 1,300 more contractors to process claims.
Private providers are also watching how the VA treats payment rates. As in the previous Choice statute, the Mission Act says that reimbursement can't exceed Medicare rates; the exceptions are highly rural areas, Alaska and Maryland, which has an all-payer model that allows higher rates to be negotiated. But the legislative language gives the department latitude. Providers could see lower reimbursements if the veteran has a VA copay that is lower than Medicare's, and the VA doesn't make up the difference.
In some situations, reimbursement headaches have led to legal tangles. An attorney representing hundreds of private independent practices said the VA has a recovery audit contractor, which works on a contingency fee, looking to claw back about $300 million in overpayments resulting from a third-party payer improperly paying physicians commercial rates instead of Medicare rates.
The matter is still being sorted out, but the VA is working to resolve it, according to the attorney. A VA spokesperson did not confirm the issue.
Right out of the gate, the department will have to wade into the politically charged task of defining access standards for VA clinics. These will clarify how and when the VA sends a veteran to a private practice or hospital. These access standards were a sticking point in negotiations between the Trump administration and Sen. Jerry Moran (R-Kan.) and will be key to defining congressional demands on the VA's health system.
The politically charged issue is at the center of the debate over whether the Mission Act could lead to privatizing care even though the rhetoric has calmed in Congress for now. Sen. Jon Tester, the ranking Democrat on the Senate Veterans' Affairs Committee, praised the legislation for striking a balance between expanding options for veterans and bolstering the VA health system. He was joined by committee Chair Sen. Johnny Isakson (R-Ga.) and a flank of representatives of veteran services organizations in pushing back against privatization talk, calling reports that perpetuated it "misleading."
Still, the political angst isn't likely to go away. One official at a VA medical center noted that a barrage of bad publicity and investigations into badly performing clinics has hurt morale even as standards of care have improved.
A recent study by the RAND Corp. found that the VA medical system is working as well or better than other health systems, albeit with the caveat that there was "high variation" in quality across facilities.
"The only way we can change the culture within the VA is to force the VA to fight for veterans' healthcare," said Bob Carey, a lobbyist for the Independence Fund, which advocates for catastrophically wounded veterans.
