Provider and veterans’ groups watched warily last week as the Veterans Affairs Department launched a new, expanded program of paying for care outside of the giant VA system.
The agency finalized a rule spelling out which veterans are eligible for the Veterans Community Care program mandated by Congress last year. It also issued a final rule granting veterans coverage for urgent care outside VA facilities, without prior VA approval but with a copayment.
The program, established by the Mission Act, started June 6.
But experts question whether department leaders underestimated the number of patients who will take advantage of the broader eligibility rules to seek care outside VA facilities, draining dollars needed to keep the huge veterans’ healthcare system strong.
Carlos Fuentes, director of legislative services for the Veterans of Foreign Wars, worried that the VA is setting veterans up for disappointment in promising short waits for appointments with private providers. “They say they have training in place to implement everything smoothly,” he said. “We doubt that’s the case. We’ll be working with the VA to address issues that arise, so that veterans aren’t negatively impacted.”
Under the Community Care rule, veterans must be enrolled in the VA healthcare system and meet at least one of six conditions to qualify for outside care.
Among other criteria, veterans are eligible if the Veterans Health Administration does not offer the needed care or services; if it’s not able to provide services in a way that meets the VA’s quality or timeliness standards; or if the veteran and referring clinician agree that receiving care outside the VA would be in the veteran’s best medical interest.
“President Trump promised to give veterans greater choice,” VA Secretary Robert Wilkie said in a written statement. “We are honoring that promise by making sure veterans have access to timely, high-quality care, whether from our VA facilities or our community providers.”
VA officials say the agency has conducted extensive testing and training, and that all enrolled veterans have been notified about the changes.
Provider and veterans groups hope the program will roll out without major glitches, unlike when the VA hastily launched the Veterans Choice program in 2014. But they worry that the 9.2 million veterans eligible for VA-paid healthcare will continue having trouble accessing timely, high-quality care outside of VHA hospitals and clinics.
Non-VA providers are watching to see if the new program improves their ability to share patient data with VA facilities and receive timely payment. Those have been major problems under the expiring Veterans Choice program.
Robyn Bash, vice president of government relations at the American Hospital Association, said the Mission Act’s requirement that the VHA adopt an electronic claims system should make a big difference in timely claims payment.
Still, she expressed caution about whether the VHA is ready to launch the Community Care program without hitches, noting that the agency is still working through the contracting process for fiscal intermediaries in several regions around the country.
TriWest will continue as interim administrator for the Choice program while new contractors, including Optum Public Sector Solutions, ramp up their networks and processes.
Under the new rule, veterans are eligible for the Community Care program if they must drive 30 minutes or more to a VA facility for primary care or mental health services, or 60 minutes or more for specialty care.
They’d also be eligible for private care if they have to wait 20 days or more for primary care or mental healthcare, or 28 days or more for specialty care.
The agency said it would issue a separate rule setting competency standards and requirements for provision of care by non-VA providers in clinical areas where the VA has developed special expertise.
That grows out of concerns about whether private providers will be held to the same standards of quality and levels of familiarity with veterans’ health issues that VA providers must meet.
The Community Care program is intended to remedy long waits for care and payment under Choice, which itself was created by Congress to address excessive waits for care.
In the final rule, the VA acknowledged receiving comments that the drive-time and wait-time access standards were not realistic. But it said other public programs such as Tricare and state Medicaid plans use similar standards, and it was reasonable to follow those criteria.