In response to highly-publicized concerns regarding Veteran deaths and Veterans' access to care in the Veterans Health Administration (VHA), Congress enacted the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113-146) (Veterans Choice Act, or VCA) to improve access to timely, high-quality healthcare for Veterans. PL 113-146 allowed VHA to expand the availability of hospital care and medical services for eligible Veterans through agreements with eligible non-VHA entities and providers through section 101 of the Act (38 CFR 17.1500). Veterans already enrolled in VA health care and who were waiting longer than 30 days for VHA care would be eligible for non-VHA (Choice) care through an approved non-VHA provider. Similarly, Veterans residing further than 40 miles from the nearest VA Medical Center (VAMC) or Community-Based Outpatient Clinic (CBOC), or Veterans residing in a state or territory without a full service medical facility, would also be eligible for Choice care. In May 2015, Public Law 114-19, the Construction Authorization and Choice Improvement Act of 2014, was signed into law and expanded the eligibility of Veterans to use the Choice Act by redefining limitations of the 40-mile rule due to unusual and excessive burden for travel to a VHA medical facility. For example, Veterans may still meet the 40-mile eligibility if travel is less than 40 miles but that travel involves geographic or environmental challenges such as mountain passes, roads through restricted areas (military bases), or hazardous weather conditions. Overall, approximately 70% of those initially approved for Choice Care were those Veterans who had been waiting longer than 30 days for care, while the remaining 30% were for Veterans that lived greater than 40 miles from the nearest VAMC or CBOC. When the legislation was first introduced, approximately 500,000 Veterans were eligible for Choice, either through wait time or distance standards.
All non-VHA care provided through VCA was subcontracted to two large contractors, Health Net and Tri West, to assist VHA in administering the Choice program. The contractors were responsible for managing Choice Program card distribution, a call center to assist Veterans with problems related to Choice appointments, Veteran counseling, provider management, appointment management, reporting, and billing. Community providers interested in joining the Choice network were required to enter into an agreement with VHA to furnish care, maintain similar credentials and licenses as VHA providers and provide medical documentation back to VHA after providing care to Veterans. Although Congress mandated that VCA must begin within 90 days of passage of the legislation, no guidelines were provided in the legislation to ensure that Veterans had access to an adequate number of community providers across different specialties of care or distinct geographic areas, including rural areas of the country.
Policy revisions of the VCA magnitude present substantial implementation challenges for VHA, which is the largest integrated health care system in the country, with 150 VAMCs across 50 states and nearly nine million Veterans enrolled in VHA care and six million Veterans who use VHA care annually. In itself, VCA also represents a substantial departure in VHA care policy, as historically VHA has sought to limit use of non-VHA care by requiring its Veterans to receive care within VHA facilities, even Veterans were required to drive hundreds of miles to the nearest VHA facility to receive needed care. With the implementation of Choice, however, many Veterans who would have previously waited weeks or months for VHA care were being referred to Choice care, and previous research suggests that receiving care from two different healthcare systems presents an opportunity for poor care quality due to fragmentation, lack of coordination, and poor communication between two healthcare systems that do not share the same electronic health record.
Therefore, the goal of this study was to examine perceptions and experiences with implementation of Choice among a sample of VHA providers and staff at five VA Medical Centers.
We conducted a qualitative study of VHA staff and providers by conducting in-person interviews at five VAMCs in the West, South and Midwest United States. These facilities were chosen because their rural locations were conducive to understanding Choice implementation, especially among Veterans who may be eligible for Choice due to their lack of geographic proximity to the closest VAMC or CBOC. We sent a study introduction letter to each VAMC director explaining the study, and asked to interview VHA staff and providers at each facility most familiar with VCA. Once we received permission from the VAMC Director, we asked the Director to identify appropriate individuals at each facility to interview, and then we contacted those individuals. Because we had an email of support from each VAMC Director, we had a 100% response rate of the targeted individuals to interview. Specifically, we sought interviews with the VAMC Director, Business Office Manager (and/or Choice Champion, who was responsible for working with Tri West and/or Health Net to ensure Veterans were scheduled for non-VHA appointments), the Chief of Staff or Chief of Ambulatory Care, the Chief of Mental Health, and 1-2 Designated Women's Health Providers, so that we could be sure to understand Choice for women Veterans. Interview questions focused on perceptions and experiences with VCA and challenges related to implementation for VHA staff and providers. Each interview lasted approximately 45 minutes and all interviews were conducted between May-August 2015. Across all five VAMCs, we interviewed 43 VHA directors, staff and medical providers familiar with the Choice program.
Using information gained from our interviews with VHA staff and clinicians, we identified three major themes to describe participants' perceptions and experiences with Choice implementation. Those themes were: (1) VCA was implemented too rapidly with inadequate preparation; (2) community provider networks were insufficiently developed; and (3) communication and scheduling challenges with sub-contractors may lead to delays in care.
This study represents one of the first comprehensive assessments of the implementation of the Veterans Access, Choice, and Accountability Act of 2014, a policy developed with the goal of broadening access to care for Veterans in VHA care. Our evaluation suggests that VCA was implemented far too rapidly, with little consideration given to the adequacy of community provider networks available to provide care to Veterans. Furthermore, the rapid implementation did not allow time for training of VHA staff regarding provisions of the Choice directive, nor for the development of systems of communication between Veterans, VHA staff, and Third Party Administrators regarding eligibility and scheduling of non-VHA care. The rapid policy implementation also left VHA facilities without adequate staffing or financial resources to handle the additional administrative burden of managing Choice, and left Veterans confused about the new system of care.
Because Congress mandated that Choice be implemented within 90 days of legislation, the VHA was responsible for developing, disseminating, and launching a massive new care delivery program to all 150 VAMCs and 500,000 Veteran users initially eligible for Choice over a period of three months. Veterans who had become accustomed to contacting their VHA providers directly for questions related to their healthcare were now directed to third party call centers, and call center employees were often uninformed of Veterans' specific healthcare needs or conditions as they did not have direct access to VHA medical records. Veterans experienced substantial delays while waiting for their non-VHA appointments through Choice, and often, these wait times were longer than the VHA waiting time would have been had their appointment remained in the VHA.
Furthermore, because all providers must register as Choice providers with either Health Net or Tri West before they are able to provide non-VHA care, it has taken a substantially longer period of time to build sufficient provider networks in the community for non-VHA care. Though most commercial health plans, as well as Medicaid and Medicare, are required to meet network adequacy standards set by regulatory and accrediting bodies, no such network adequacy standards currently exist in the VHA Choice program, and so there have been uneven distributions of provider networks, both by geographic area as well as by medical care specialty. For example, near the end of the first year of VCA, only six obstetricians were registered as Choice providers for the entire state of Montana. Examining ways to increase community provider participation will be important for specialty care services, especially in more rural areas of the country where specialty care services are already insufficient.
Recently, in an effort to address many of the problems associated with Choice, Congress enacted PL 114-41 (Surface Transportation and Veterans Health Care Choice Improvement Act of 201510) to consolidate all purchased care programs into one new Veterans Choice Program (VCP). The VCP aims to clarify eligibility requirements, build on existing infrastructure to develop a high-performing network, streamline clinical and administrative processes, and implement a continuum of care coordination services. Importantly, PL 114-41 points to the importance of comprehensive care coordination services, including patient navigation, care/disease management, case management in the context of information technology (IT) systems that allow the sharing of information between VHA and non-VHA entities. Given the challenges we've highlighted in VCA implementation, it is imperative that the VHA continue to develop care coordination systems that will allow the Veterans to receive seamless care in the community.
- Mattocks KM, Mengeling M, Sadler A, Baldor R, Bastian L. The Veterans Choice Act: A Qualitative Examination of Rapid Policy Implementation in the Department of Veterans Affairs. Medical care. 2017 Jul 1; 55 Suppl 7 Suppl 1:S71-S75.