Many U.S. military veterans will gain a choice in their health care decisions Thursday, and depending on who’s talking, this new freedom will either give them greater access to doctors closer to their homes or sabotage the quality of care delivered by the U.S. Department of Veterans Affairs.
The debate hinges on implementation of a piece of federal legislation, the MISSION Act. It’s more formally known as the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018.
The law allows veterans to choose to get care in from private-sector providers if they meet certain criteria. Among the reasons a veteran could opt for treatment outside the VA:
- They need a service that isn’t available at a VA medical facility.
- They live in a U.S. state or territory that doesn’t have a full-service VA medical facility.
- The VA can’t offer care in a timely fashion. For instance, the VA is looking at giving veterans the option to opt out of the VA network if the wait time for primary care or mental health care exceeds 20 days or if their drive time to a VA facility exceeds 29 minutes.
“The new legislation...takes the decision about whether to wait for care in the VA or go to a community provider away from the VA and lets the veteran be the one who controls” it, said David Stockwell, who leads the VA Northern California Health Care System.
The VA tested this concept with a pilot program over the last five years, Stockwell said. The pilot, known as the Veterans Choice Program, ended Wednesday, he said, and the MISSION Act launched Thursday. The U.S. Congress set aside a separate pot of money to provide this new benefit to veterans, Stockwell said, so his budget for the NorCal VA was not affected. In fact, he said, it increased by 8 percent.
Yet some people predict that the MISSION Act will spell the ruin of the veterans’ health system. In study after study, VA hospitals have been shown to perform at the same level as or better than private hospitals, said Suzanne Gordon, author of “Wounds of War: How the VA Delivers Health, Healing and Hope to the Nation’s Veterans.”
“Veterans...have very specific and very complex problems that you really have to know about,” Gordon said. “There’s no requirement on private sector providers that they have this kind of expertise. They’ve said over and over again that they will not require private-sector providers to have the same kind of training that VA providers have because they won’t join the program. There’s also a lot of questions about the capacity of the private sector to handle veterans.”
Already, Gordon said, civilians have problems finding primary care and mental health providers, especially in rural areas, where most veterans have to drive farther to access VA hospitals. Fifty-five percent of all U.S. counties, all of them rural, have no psychiatrist, psychologist or social worker, she added, so where are they going to get mental health care?
La Pria Johnson, a patient safety specialist at the Northern California VA, protested the MISSION Act with a handful of her colleagues Wednesday outside the Mather facility in Sacramento County. She said that veterans using the Choice program found it difficult enough to find a doctor who would accept the VA’s payment levels, which are lower than what HMOs or PPOs pay, but it was just as hard to maintain them because doctors weren’t receiving payments in a timely fashion.
It also can be difficult, she said, to coordinate care because not every health system’s electronic record can smoothly send paperwork or patient records to the VA. Patients may need to see a specialist at the VA, she said, but that specialist can have trouble getting notes and test results.
“What it’s coming down to is depreciation in patient care,” Johnson said. “We want to be able to provide effective and efficient service, and the way we can do that is by making sure that our workforce here is stable and that we do have all of our positions filled. We cannot meet the need and the demand if we don’t have enough employees to staff.”
Stockwell said there were some delays in the Choice program because the VA was using a third party to schedule appointments, but VA employees will do that work for the MISSION Act.
“We know which vendor we actually sent the patient to, so our ability to reconcile medical records or notes actually should improve because we’ll know on the front end exactly who we’re sending the patient to see,” he said.
He acknowledged, though, that if patients had MRIs or X-rays, those images might be difficult to get, and that could lead to duplication of some imaging. Stockwell said the VA will prioritize care for veterans who have more complex conditions to try to keep them in the network.
“We’re newly in competition, at some level, with the private sector,” he said. “We need to make sure that our patients are feeling customer satisfaction with the VA, that we’re providing care timely, that we’re providing high-quality care, so veterans will continue to choose the VA.”
Gordon said the MISSION Act robs the VA of fundamental advantages that allowed it to outperform private health systems. Their coordination of care, she said, was exceptional, and the changes will chip away at that. VA medical teams offer culturally competent care, allowing them to quickly identify health problems common to veterans deployed in certain war zones, she said, and medical providers outside the VA can’t compete with that when veterans will likely make up just 2 to 5 percent of their patient load.
“This MISSION Act is going to be a total disaster, and rather than blaming Congress or the veteran service organizations that lobbied for this, Americans are going to blame the VA and it’s going to be even worse,” Gordon said. “I fear...that you’re going to see a lot more problems and even more suicides because of the failure of the private sector to understand veterans’ health needs.”
The average 65-year-old has three to five presenting problems, she said, but the average Vietnam veteran has nine to 12.
The VA gets many things right, Gordon said, but they don’t make the headlines. At the VA, “there is superiority in diabetes care,” she said. “There is superiority in cancer care. There is superiority in management of mental health. In mental health, the VA has the only functioning mental health system in the United States. In the VA, you have integration of primary and mental health care. You have evidence-based therapy for PTSD and other kinds of depression.”
Stockwell said he expects most veterans will continue to use the VA. Of the 100,000 veterans served annually at Mather, he said, only about 3,000 took advantage of the Choice program, yet approximately 20,000 were eligible.
Care for veterans would improve immensely, Gordon and Johnson said, if the VA would focus on filling its roughly 50,000 open jobs. That also troubles Keith Boylan, deputy secretary for veterans services at the California Department of Veterans Affairs.
“We support the VA’s efforts to increase accessibility and build out their system of care,” he said, “but one challenge that we think is just crucial to the success of this program is that the VA address the 50,000 vacancies they have.”
Stockwell said he can’t speak for all VA regions, but he has a vacancy rate of about 10 percent at the Northern California VA, and he considers that normal for a health care operation.
The shortages are affecting patient care, however, said Jamie Bowman, a benefits management specialist protesting alongside Johnson at Mather. Because of physician shortages in the orthopedic clinic there, she said, some veterans were opting to see private providers, and they encountered delays in care as a result.
“I’ve seen patients go out to an outside doctor, and they don’t cover everything,” she said.” They don’t read the fine print. Sometimes, their braces aren’t covered. They have to try to come back here to get things they need. I’ve seen a patient wait six months to get into physical therapy because he couldn’t get the right document signed between our provider and outside provider, and he couldn’t get his physical therapy done.”
Boylan said these are the sort of complaints that he gets from veterans at his office, so he’s hoping that the VA has a plan to ensure that veterans are well-educated about whether they qualify and what will happen if they opt for private providers under the MISSION Act.