David Sandman

David Sandman

The U.S. Department of Veterans Affairs (VA) is poised to implement a new program that could mean more and better health care options for the nation’s 18.2 million veterans. Or it could be a fiasco.

Veterans say they want and need both a strong, accessible, high-quality VA and community-based options for their care. About half of veterans prefer to get care in their communities, while half prefer the VA. And it doesn’t and shouldn’t have to be an either/or scenario. As just one example, my colleague, a U.S. Marine veteran, goes to the VA for some types of care but chooses to get mental health services from a private provider in his own community.

Most veterans make their health care decisions for very practical reasons. For some, the nearest VA facility is too far away from home. Others want to get their care in the same place as their spouses and children; they don’t want their family’s care to be fragmented. Or they may not want the stigma associated with getting care from the VA, especially for mental health issues. But for others, the VA feels like home, a place that is particularly well attuned to the specific culture and needs of veterans. It can feel comfortable. And it often provides care that is of high quality; VA health care outperforms private sector care on more than 95% of measures of outpatient treatment such as diabetes care and cancer screenings.

Basic facts also confirm we need both a strong VA and community-based options to coexist. Even if every veteran wanted to get care exclusively from the VA, the system is simply stretched too thin. Demand for VA care is increasing as the veteran population ages and as battle-related injuries and disabilities continue to climb and become more severe. Annual outpatient VA visits more than doubled between 2002 and 2015. VA facilities are aging, as well. Community-based providers are needed to complement VA services to meet the growing demand for care among veterans.

Next week, on June 6th, the Mission Act is set to go into effect, exactly one year after it was signed into law. The Mission Act establishes a new Veterans Community Care Program that expands community-based options for veterans who don’t have easy access to a VA facility. It replaces the Choice program, which was implemented in 2014 as a knee-jerk response to the Phoenix wait-time scandal, during which at least 40 veterans died while waiting months for health care appointments at the VA. The Choice program was supposed to allow veterans to see non-VA doctors if they had to endure long wait times or long distances to get care at a VA facility. Specifically, it allowed veterans to visit a community provider if they lived 40 miles away from the closest VA medical facility or if they had been waiting 30 days or longer for VA care.

Under the Mission Act’s new access standards, veterans can see a community provider if they’ve been waiting for more than 20 days for primary, mental health, and non-institutional extended care services, or if they face a 30-minute drive to the nearest VA facility. Average drive and wait times go up to 60 minutes and 28 days for certain kinds of specialty care.

It could be a big change. Using these criteria, it is estimated that roughly 40% of the VA population will be eligible now to see a doctor within the community — as opposed to the 8% who can use the department’s disparate community care programs now.

The Choice program was well-intentioned, but it was troubled from the start. An unrealistic and rushed implementation schedule and a lack of stable funding set it up for failure. I’ve heard story after story of confusion about eligibility, of community providers not getting paid in a timely way, and of veterans stuck in the middle, sometimes unable to get an appointment for needed care and sometimes saddled with bills for care that should have been covered.

The Mission Act should enable us to do better this time around. In addition to expanding the eligibility criteria for community care, it includes provisions for sharing medical records, establishing regional medical networks, expanding access to urgent care and telehealth services, providing high-quality customer service, and ensuring continuity of care for veterans seeing providers outside of the VA. Very importantly, the new Community Care Program consolidates the current web of seven different community care options into a single program. What had been a tangled bowl of spaghetti of multiple programs should become more coherent, easier to manage, and simpler to navigate.

The VA has been working hard to make sure that the new system succeeds; it’s dubbed this month “Mission May” and has made effective implementation the Department’s top priority. The VA promises that it will be ready to go on June 6th, even if some wrinkles will need to get ironed out over time.

But there is reason for concern that we may repeat some of the mistakes made with Choice all over again. The main worry — and it’s a significant one — comes down to the technology. First, the Community Care Program is set to use an electronic health records platform that is not widely used outside of the VA. That means that information-sharing and coordination of care across many providers will continue to rely on communication by fax or e-mail, rather than through a shared record that is integrated into a veteran’s electronic file. Who communicates by fax anymore in 2019?

But the bigger issue is the technology that will be used to transition from the Choice program and to determine eligibility for the Community Care Program. The data that will be used to assess eligibility are housed across multiple systems that don’t talk to each other, which means that much of the work must be done manually. An independent review by the U.S. Digital Service (USDS) — which works with federal agencies to improve their technology — was nothing less than scathing. In March, it said that the tool was so flawed that it should be scrapped and the VA should start over. Slow run times and other usability and responsiveness issues could lead to fewer patient visits as providers spend more time trying to navigate the system. USDS noted, “This degradation goes against the spirit of the Mission Act to improve the veterans’ experience and quality of care.”

The Choice program didn’t work in part because it was rushed through without adequate time to implement it well. That failure makes it especially critical that the Community Care Program under the Mission Act be done right, right out of the gate. If the technology fails, if veterans can’t schedule needed appointments, if the system doesn’t work, word will spread fast and trust will further erode. It’s admirable that the VA wants to meet its commitment to a June 6th launch. But we also need to learn and apply one of the key lessons of the Choice program: doing it right is more important than doing it fast.

By David Sandman, President and CEO, New York State Health Foundation
Published in Medium on May 30, 2019

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