VA has yet to detail criteria for community care

Six months after Congress passed a sweeping bill aimed at streamlining and expanding the private sector's role in veterans' healthcare, the Veterans Affairs Department has yet to disclose the criteria it will use to send a veteran out to a community physician or hospital.

These criteria, or "designated access standards" in VA and congressional parlance, will determine how expansive the community program will be. As a result, debate over what they should be is a political linchpin, driving sharp warnings from key Democrats that the Trump administration's handling of them will lead to a privatizing of the VA.

VA Secretary Robert Wilkie, during a Wednesday briefing to members of both Senate and House VA committees on implementation of the VA Mission Act, promised that he would give details to Congress on the department's criteria once President Donald Trump has approved them. One lawmaker noted that staff has told him Trump will announce the criteria early next year at the State of the Union Address, although administration officials and other congressional staff did not confirm that by deadline.

Congress gave the VA parameters for these criteria, but ultimately the department has authority to decide the specifics.

The Senate VA Committee's Ranking Democrat, Jon Tester of Montana, told Wilkie he believes the VA "has decided to head in a completely different direction" than the parameters lawmakers had agreed to.

"The VA now indicates it plans to designate access standards that will apply to each and every type of care a veteran might need," he said.

The VA has until June 6 to launch the expanded program across the country. The system will be split into four regions with provider networks managed by third-party insurers. The last insurer contract won't be in place until the end of March.

While he had scant details on the criteria for outsourcing veterans' care, Wilkie and his deputies said the department will use off-the-shelf software to process all outside claims electronically. This answers a long-simmering concern under the VA Choice program where private providers saw significant delays to their pay, or received the wrong pay.

The question of payment and the role of third-party administrators also loomed large over Wednesday's hearing in light of a new investigative analysis from ProPublica and PolitiFact that found the VA Choice contractors TriWest and Health Net were paid billions of dollars in overhead that accounted for 24% of their actual expenses. This is well above the federal cap for contracted insurers.

Wilkie, who is still relatively new to the post of VA chief, blamed the excessive payments on the hasty implementation of VA Choice, saying that the department was forced by a tight timeline into contracts that took advantage of the government.

This has been rectified in the Mission Act, he said. He did not explain how.

Melissa Glynn, a VA official from the Office of Enterprise Integration, said the Mission Act will also modify how the VA funnels money to third-party contractors to make sure they don't run out of money, while also bolstering oversight into potential fraud, waste and abuse.

The VA fired Health Net and in October took over management of the claims the company had been processing.

Faced with hazy details on the community care criteria, policymakers who don't want VA health centers to lose funding to the private sector issued warnings of privatization.

"We're in the process of dismembering the VA and putting resources into the private sector, and the outcome will be that the veterans won't get the quality of care they deserve," said Sen. Bernie Sanders of Vermont, an independent who caucuses with the Democrats and who also pointed out that he didn't support the Mission Act.

"As written and without needed funding, this law puts people into a situation where the VA pays for private-sector care at the expense of investment into its own infrastructure," Sanders said, noting understaffing of medical professionals in the VA's system.

Wilkie pushed back, noting the nationwide shortage of mental health, women's health and primary-care clinicians and the fact that the VA "doesn't exist in a vacuum."

"We are competing for those," he said. "What has happened with the Mission Act is, I have the opportunity to offer more impressive packages to bring those providers into the VA."