“All of these programs have been layered on top of each other without someone saying, ‘How do we rationalize them?'” VA Secretary Robert McDonald said in an interview.
“We want an integrated network,” he said. “We want the very best providers connected with us. This is a big deal, and it will be a big improvement over what we have now.”
VA officials are scheduled to provide details of their strategy Wednesday at a hearing before the House Veterans Affairs Committee.
The proposed overhaul of the system that allows veterans to use private doctors at government expense if they live too far from a VA hospital or need a specialist is the agency’s latest effort to recover from a scandal over patient wait times. VA is struggling to serve an influx of veterans returning from the wars in Iraq and Afghanistan and an aging Vietnam-era population needing more care.
The agency’s failure to manage this demand was exposed last year in Phoenix, where whistleblowers revealed that employees were manipulating wait times to hide long delays for patients. The problems had unfolded nationwide.
Congress passed a $16 billion overhaul that included a new program to boost the number of veterans eligible to seek care from private doctors if they cannot get an appointment with a VA physician within 30 days. But the Choice program, touted as a fix to the massive appointment backlog, has been slow to take off, partly because patients are not made aware of it by VA staff who are accustomed to referring them to other private-care programs.
“We have so many different ways of buying care in the community that it creates confusion,” said Dr. Baligh Yehia, the agency’s assistant deputy undersecretary for Health for Community Care. “It makes it hard for employees to administer and providers to understand all the rules.”
He compared VA’s current system of outside care to a private health plan: “When you sign up for your own health insurance, it’s pretty clear how many eye exams you get and what is your co-pay. Here, for veterans, it’s not being aware of what the benefits are. A lot of this is not knowing what they can and cannot access.”
“What we’re trying to do is to make this [system of private care] as simple and as clear as possible,” Yehia said.
VA has long referred veterans to private doctors as a way to fill gaps in what its system can provide, particularly in rural areas. About 10 percent of medical appointments are now private. But VA leaders are increasingly recognizing that the path to caring for veterans must include a more robust system of outside health care.
Politically, it’s a touchy shift. Conservatives generally favor more private care as a potentially less costly option, with less overhead, than staying entirely within the VA system, while liberals tend to believe that the government is better at caring for veterans.
“The culture until now has been for VA to do it themselves and only contract out in emergencies or exceptional situations,” said Phillip Carter, a veteran of the war in Iraq and senior fellow at the Center for a New American Security, focusing on veterans.
“Private care wasn’t systemic before,” Carter said. “The question now is how to build a better system with the best care for veterans.”
The current system has varying reimbursement rates for doctors, emergency rooms, nursing homes. Veterans are eligible for some private care arrangements and not others, depending on where they live. There are contracts with health networks and individual vouchers provided to veterans to find their own doctors. The system is disjointed.
To expand access, VA hopes to set up one system with a single set of rules that streamlines the system of who gets referred to outside care and to which doctors. Officials also hope to improve the claims, billing and reimbursement systems for doctors, which is so complex that it turns some good practitioners away. VA would also improve its own medical recordkeeping.
The plan has a new focus on how competent doctors are, following a growing movement in the health-care field to measure the quality of care. So veterans would be given a list of doctors to choose and their ratings by health plans.
The overhaul needs approval from Congress, which passed legislation last summer that directed VA to come up with a plan to consolidate outside medical care programs. The consolidation would be costly. VA estimates spending between $1.2 billion and $2.4 billion to redesign the system in each of the first three years, according to the proposal. Expanded access to emergency services and urgent care would cost an additional $2 billion a year. VA officials say they anticipate the extra costs would be largely a result of increased demand from veterans as access to private doctors gets easier.
The agency spent about $7 billion a year on outside medical care before the Choice program took effect; officials say Choice is likely to cost $6.5 billion a year if it continues in its current form.
House Veterans’ Affairs Committee Chairman Rep. Jeff Miller, (R-Fla.) said last week that the plan deserves close consideration and has merits.
“VA has always had fee-for-services but it wasn’t used in the way the veterans expected it to be used,” he said at an event on Capitol Hill last week. “What we are trying to do is not tear down VA brick-by-brick but supplement it.”