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Plan to replace 'choice' also will modernize VA health system

Congress, the Department of Veterans Affairs and veterans service organizations will begin to spar this month over final details of a plan that not only will replace the much-maligned Veterans Choice program but empower VA to modernize large parts of its health care system.

The plan, which VA titled the Veterans CARE (Coordinated Access & Rewarding Experiences) Act, was unveiled last week and has an overall structure that major veteran groups applaud, in part because they helped to shape it.

They don't like everything, however. And the House and Senate Veterans' Affairs Committees are expected to offer their own replacement plans for Choice this fall, perhaps to include more statutory safeguards and more details to improve access to care, that veteran advocates worry aren't spelled out yet in the VA plan.

The idea behind Choice remains a primary goal for CARE: to ensure greater access to care for veterans in their communities when timely, quality care isn't available at a nearby VA medical facilities. But CARE directs that clinicians, consulting with patients, decide when outside care is needed, rejecting Choice's reliance on driving distance and wait times to set eligibility and hold down costs.

CARE also seeks authorities for VA to build out high-performing provider networks, relying on private sector partners and other federal agencies, and to ensure closer integration of VA health services with those in nearby communities.   

Before 2014, the VA health care system had various ways to access non-VA care. But too often referring patients to the private sector was a business decision, said Louis Celli, director of veterans' affairs and rehabilitation for The American Legion. Would referral make economic sense considering other options and a facility's budget?

When a patient wait-time scandal erupted across the VA medical system by spring that year, Congress hastily created Choice to expand access to private sector care. Initially the idea was to give every VA-enrolled veteran a card entitling them to use community care at VA expense when necessary. The projected cost turned out to be enormous, however, so lawmakers added last-minute cost controls.

No veteran could use Choice unless they lived more than 40 miles from a VA care facility or faced waits for VA appointments of more than 30 days. Meanwhile, responsibility for scheduling appointments, transfer of medical records and payment of fees relied heavily on third-party contactors, causing delays and complaints.

In time, to ease the complaints, VA regained control of Choice appointments, records transfer and fee payments, and the role for contractors shifted to building out networks of care providers to support a steady rise in community care referrals.

Choice was meant as a temporary solution to the wait-time scandal and is funded through December. But community care grew from 20 percent to more than 30 percent of veterans' health care in the last three years. CARE would consolidate non-VA care programs but still spend $4 billion on private sector health care.

At one time, veteran service organizations saw Choice as a threat, a tool that critics of big government could use to dismantle VA care by sending more and more patients to the private sector.

"There are some in Congress who want unfettered Choice," said Garry Augustine, executive director of Disabled American Veterans. "Give everybody a card and let them go wherever they want. We're against that and believe it would lead to a dismantling of the VA system as needed resources are drained away and VA [health care] withers on the vine."

But CARE is seen as striking the right balance, with initiatives to strengthen VA health care with more VA providers, improved support systems and streamlined processes, but with a commitment to build high-performing and integrated provider networks by partnering with the private sector or at other federal agencies.

Major vet groups do have concerns they want addressed, if not by VA then by Congress. Celli noted, for example, that while clinicians are to decide with patients when to use private sector care, CARE also would allow veterans using a VA medical center that performs poorly to elect community care instead.

"We understand and support the intent of the provision…to ensure veterans get the highest quality care available, whether inside or outside VA," Celli said. "What we cannot support [is] a provision that allows VA to siphon patients away from a medical center that is under performing. We want to see a comprehensive plan to rehabilitate any poorly performing [VA medical center]. You can't just abdicate leadership responsibility by taking patients away, which will cause less traffic into the VAMC less utilization, more evidence the VAMC can be defunded."

Vet groups also oppose a provision in the plan that would have veterans, including those with service-connected disabilities, pay a modest portion of program costs by rounding down monthly benefit checks to the nearest dollar.

"We have always been against that. We have a resolution saying that we will not support any kind of situation where you are taking one benefit away to pay for another, which this is," said Augustine for DAV.

Those the COLA provision would expire in 10 years, Augustine said, "for my generation of Vietnam veterans, we are at that part of our life cycle where 10 years mean we probably won't see it again. And anytime you have a 10-year suspension of something you usually don't see it come back."

On this point, the Legion also is adamant. By definition, rounding down costs a veteran no more than $12 a year, but "it's not about the money," Celli said. "As Americans, if we choose to use that money, especially for veterans' health care, what we're saying is that it is now all right to ask service-disabled veterans to give up a portion of their check each month to pay for their own health care or for somebody else's services."

 A feature of CARE getting mixed reviews, for lack of detail, would allow access commercial walk-in clinics for minor illnesses or injuries. VA Secretary David Shulkin earlier said VA would charge a $50 co-pay and the first few visits a year would be free. Those details aren't in the plan now. Nor is there word on whether service-connected disabled would face a full co-pay or any added cost.

CARE would have VA adopt prompt payment standards common in the health industry: doctor reimbursement within 45 days of receiving of a "clean" paper claim and 30 days for an electronic claim. Augustine said DAV wants to ensure private sector care providers also are barred from billing veterans if VA doesn't pay on time, a practice that has marred Choice for many users.

Veterans also should have private sector appointments in hand when they leave VA clinicians after a determination that community care is necessary. How VA will ensure that is another detail not yet clear, Augustine said.

Some groups including the American Federation of Government Employees oppose CARE, saying the ultimate goal is to dismantle the VA health system and to privatize all medical care for veterans. Major veteran groups support the reforms but vow to challenge every line that might weaken VA's ability to deliver care.

"It's a big picture advocacy and not a myopic view," Celli said of the Legion's support. "The Department of Veterans Affairs has a $165 billion budget; that's not going away anytime soon. If a new secretary were to come and try to change a stable-based VA, we would advocate against, and the American people would either support us or wouldn't. We have to have faith and trust in the Department until they prove to us they no longer have earned that trust."

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