New VA Rules on Access to Outside Care Leave Many Unknowns

The number of veterans eligible for health care services in their communities, using networks of private-sector providers contracted by the Department of Veterans Affairs, is expected to jump this summer when regulations setting new access standards for community care become final.

Veterans service organizations and congressional committees with oversight responsibilities for the VA contend that the barebone details released last week raise many more questions than they answer.

Top among them are whether the VA will have the budget dollars, complex procedures and enhanced administrative tools in place to avoid the kind of calamitous launch that scarred the Choice program from its inception in late 2014.

The new access standards will be based on factors generally familiar to veterans who sought private-sector care under Choice: average drive time to get VA care and wait times to get VA appointments. But a VA spokesman said the new access screens "are based on an in-depth analysis of all of the access best practices in both government and private-sector health care systems and tailored to the needs of our veteran patients."

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Veterans will be eligible to use networks of local providers for primary care, mental health care and non-institutional extended care services if their average drive time to get such care from the VA is 30 minutes or longer. They will be allowed to use the outside providers for specialty care if average drive time to a VA specialist is 60 minutes or more.

These rules will replace the more rigid distance rule under Choice that veterans must reside more than 40 miles from a VA facility with a primary-care provider. The VA estimates that this change alone will make 20 percent more veterans eligible for outside primary care, and 31 percent more veterans eligible for network specialty care, than under current community-care programs, including Choice.

More veterans also will gain access to local providers using new wait-time triggers. Choice allows community-based care if veterans face waits for VA appointments longer than 30 days. The new standard will make them eligible to use the private sector if waits for VA appointments are longer than 20 days for primary care, mental health care and non-institutional extended care services, and longer than 28 days for specialty care.

The new access standards are only one of six criteria Congress approved to expand and reshape veterans' eligibility for community-based care under the mammoth VA Mission Act enacted last June.

Regulations on access standards will be followed by more rules to govern community care: in locales where VA services are unavailable; for veterans residing in states with no full-service VA medical facility; to ensure grandfather protections to veterans who gained access to outside care using the 40-mile Choice standard; to ensure community-care decisions consider the medical best interest of patients; and to govern eligibility when the VA determines one of its own medical service lines isn't providing care that meets its quality standards.

On Jan. 31, the VA published proposed rules on what is sure to be one of the most popular new benefits authorized by the Mission Act: veteran access to designated civilian-run urgent care clinics without prior approval from the VA.

Veterans enrolled in VA health care and needing treatment for a sore throat, a sprained ankle or some other episodic or temporary health need will be able to walk into participating urgent care clinics rather than visit VA emergency care clinics or hospitals or schedule an appointment with their primary-care provider.

The first three urgent care visits in a calendar year will be free to veterans with disabilities or other circumstances that place them in Priority Groups 1 through 5 for accessing VA health care. Certain enrolled veterans in Group 6 and all veterans falling into Groups 7 and 8 will be charged a co-pay of $30 for each visit.

To discourage overuse of urgent care, the $30 co-payment will be charged any veteran after their third walk-in visit, to include those with service-connected disabilities. That detail will be challenged by some veterans service organizations.

The urgent care regulation emphasizes that the new benefit is not to be used by veterans needing treatment for chronic conditions, which should continue to be managed through their primary-care providers.

But the community-care access rules are drawing the most attention from veterans groups and members of the Veterans Affairs Committees. Many of them are complaining that, after partnering with the VA to shape community-care reform language in Mission Act, they've been kept largely in the dark by VA Secretary Robert Wilkie and his staff during the months they drafted implementing rules.

As a result, when the VA released first details on access standards last week, many previously supportive lawmakers and veterans groups expressed only caution, claiming not to understand from preliminary briefings how decisions were made, how they will impact veterans and VA budgets, and how VA procedures and tools can be made ready in time to support a launch in June, as planned.

Democrats on the Senate Veterans Affairs Committee criticized Wilkie for lack of transparency and the VA's failure to engage while preparing its new access rules.

"Once briefed, we were disappointed that VA couldn't provide basic information on how the proposed wait- and drive-time standards would affect the department, the veterans who rely on it for care and the American taxpayer," the senators wrote in a Feb. 5 letter to Wilkie.

Carl Blake, executive director of Paralyzed Veterans of America, and Randy Reese, executive director of Disabled American Veterans, said in separate interviews that they have no choice but to remain cautious on the access standards.

Key questions the DAV needs answered, said Reese, are whether the access rules are fully funded, are realistic and feasible to implement. One great unknown, he said, is whether VA-funded community provider networks will be sufficiently staffed to deliver faster, more convenient and quality care to veterans.

With revised network contracts delayed by challenges from a losing bidder, the VA conceded to veterans groups that contractors haven't been able to produce market assessments on the availability of community care for veterans nationwide.

"The assumption is the VA can't and private providers can. But they don't know that that's true," Reese said.

Blake said another critical unknown is how the VA intends to measure drive time for access to outside networks. A trip of 20 minutes to a VA clinic at midday might exceed 60 minutes in rush hour. The VA signaled it will adopt new computer software for the task, Blake said, but its record in information system upgrades does not inspire confidence.

Another issue, Blake said, is how the VA will resolve disputes with veterans who disagree with how their average drive time to nearby VA facilities was calculated.

He also worries that the VA touts the fact that Tricare, the military health plan, also uses average drive time to determine eligibility. But Tricare uses drive time to make initial enrollment decisions, not "as a decision point for access to care," Blake said.

Perhaps the No. 1 concern about the new access standards, he added, is whether the VA's budgets will be large enough to cover the significant jump in community-based medical costs expected from expanding access, ensuring that VA hospitals and clinics don't see their budgets get squeezed.

"I believe the answer to that right now is no," Blake said.

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