The Roseburg Veterans Affairs Medical Center, along with VAs across the nation, rolled out their new program this month for veterans seeking care from private doctors outside the VA system.
The VA Mission Act took effect June 6, simultaneously bringing its predecessor, the Choice program, to an end. The VA hopes the Mission Act will be simpler than Choice, making it easier for veterans to receive care from private doctors and for those doctors to get paid for the services they provide. For veterans, the change has raised hopes of better, faster care and fears that it could be the first step on a road toward privatization of VA services.
What’s new under Mission
Under the Mission Act, veterans are eligible for private care if they would have to wait too long or drive too far to get that care at the VA. That was true of the Choice program, too, but the Mission Act makes it easier to qualify. A patient with a 30-minute drive time or 20-day wait for primary or mental health care could seek outside care under the new act. So could a patient with a 60-minute drive or 28-day wait for specialty care. Drive times take into account not just the distance but the typical traffic for the route.
Under the Choice program, the drive was measured in miles instead of minutes, and veterans had to live more than 40 miles from the nearest VA facility with a primary care provider to qualify. The Choice program also set a higher maximum appointment wait time, at 30 days.
Some veterans will be eligible to be grandfathered in to keep the Choice program until June 2020, if they meet specific conditions.
There are also some additional ways for Roseburg VA patients to qualify for Mission. If the service they need isn’t provided at any VA, or if the local VA doesn’t meet the VA’s own quality standards for performance of the procedure they need, or if the doctor and veteran agree it’s in the veteran’s best medical interest to see a private provider — if, for example, the VA’s oncologist is inexperienced in treating the type of cancer the patient has.
Another important change under Mission is a new urgent care benefit, under which patients in need of immediate, non-emergency care can obtain it in the community and have it paid for by the VA. Many veteran patients will have a co-pay for this service, and they must be eligible for VA care and have been seen by a VA provider or a provider whose services were paid for by the VA within the past 24 months.
All these types of community care must be provided by facilities and doctors who have contracted with the VA to be in the VA’s network. The VA won’t foot the bill for an out-of-network doctor. Veterans must receive prior authorization from the VA before seeking outside care, except for urgent or emergency care. The emergency care benefit remains the same, with the patient needing to provide the VA notice within 72 hours in order to get the bill paid.
Office of Community Care Director Rocky Phillips said the number of in-network doctors is growing, with 11,379 providers across Oregon and Northern California and urgent care facilities in Brookings, Grants Pass, Medford and Lebanon. The VA expects to have at least one urgent care in-network in most urban centers in Southwest Oregon within the next month or so, he said.
The Mission Act also offers a new pharmacy benefit, with veterans eligible to fill a 14-day supply of medication for urgent or emergency conditions at ExpressScripts pharmacies.
Veterans can find participating doctors, urgent care facilities and pharmacies at www.va.gov/find-locations/.
Hopes for improvement
Douglas County Veterans Forum President Larry Hill is hopeful that Mission will work better for veterans than Choice did. Choice, he said, was poorly implemented in part due to bad communication between the VA and TriWest, the company that processed the claims and made the payments.
“It was just absolutely terrible. It improved with age but not that much to where you could really trust them,” Hill said. “There were all kinds of bill pay problems at the time. And there were folks being chased by bill collectors from hospitals. Doctors were refusing to accept patients. So there were a whole bunch of negatives.”
Hill’s a bit worried that TriWest is still going to be administering bill payment under Mission. However, he credited the VA for making more effort to explain this new program to veterans, including a series of town hall meetings.
“They’re trying this time to come out and explain things more fully, the nuances of the program, who’s eligible, here’s how you do it,” he said.
Phillips said TriWest currently serves as the Third Party Administrator, which means they provide the network of private providers, make the appointments and pay the claims. In December, a new contract will be awarded for what’s called the Community Care Network. That contract will shift much of that responsibility back to the local VA.
Who will approve care under Mission depends upon the category of the patient’s eligibility. A primary care doctor would determine whether it would be in the patient’s best interests to obtain private care. A scheduling clerk would determine whether the wait is too long.
The VA will also be receiving a new referral software system at the end of the month that Phillips believes will drastically improve processing times.
That’s no small job.
“Last year we coordinated nearly 28,000 episodes of care for approximately 15,000 Veterans and expect that to increase by about 20%” Phillips said.
Already, Phillips said, payments are being made more quickly.
“Recently we have been seeing providers receiving reimbursement in less than 14 days, which is admittedly much faster than what they were being paid under the Choice program,” he said.
Fears of privatization
Karl Tanner, president of the American Federation of Public Employees Local 1042 that represents Roseburg VA employees, said so far VA staff members are just rolling with the new program. Nobody expects to directly lose their jobs despite the likelihood that more veterans will seek care in the community.
However, Tanner believes there’s no doubt the VA is moving toward privatization. Nationwide, it has 49,000 unfilled positions, he said. It has the money to hire people to fill those positions, and it would be cheaper to do that than to send veterans into the community for care, he said.
The only way that makes sense, he said, is if the end goal is to reduce services so veterans are motivated to seek help from private doctors.
“Pretty soon they’re happy out in town. They say we don’t need those types of services at the VA, and you can privatize it,” he said.
In rural areas like Roseburg, though, that scenario would present some additional challenges. Tanner said there are so few private doctors here that they’ll be inundated if large numbers of veterans begin seeking private care.
Tanner said the VA would do better to fill those 49,000 positions with physicians and provide services at VA facilities.
“’Cause we do great care. Our facility does great care. I don’t care how many negatives you hear, we have great care here,” he said.
If the VA continues to lose staff, though, Tanner believes it will be through attrition rather than layoffs.
“There’s no talk of an RIF, which is a reduction in force. There’s no talk of staff members not being able to work here,” he said.
Hill said many veterans, too, are worried this is the first step toward privatizing the VA, but he doesn’t think the VA’s planning for its own demise.
“The one thing that a lot of the guys are absolutely afraid of is this is the beginning of the end, of getting rid of the VA as we know it. That’s the big bugaboo that’s going to be hanging over like a pall. It really will. It’s going to be there until such time as they’re educated,” he said.
Phillips said he recognizes and understand veterans’ fears about privatization.
“As a Veteran myself who receives my healthcare at the VA I am concerned as well with the future of the VA, however I also believe the intent is not to privatize the VA, but instead to expand the capability of the VA to meet the needs of our Veterans by leveraging services both internally and externally with our community resources,” Phillips said in an email.
“Without Mission and the ability to refer Veterans to a specialist in the community, we would simply be unable to meet their healthcare needs. I don’t think anyone wants to go back to Veterans waiting on lists for care,” he said. “The VA Mission Act is a good thing as it brings much improvement to how the VA can deliver care to our Veterans.”
Overall, Phillips said he’s been hearing a lot of positivity from veterans, especially those who used to have to travel to Portland or farther for specialty care. There’s more uncertainty about the urgent care benefit, he said, since it’s brand new and the network is still being developed.
Hill said he’s adopting a wait-and-see attitude about Mission himself, but he expects medical providers to be happier right away while many veterans will need a lot of hand-holding before they’re able to fully accept it.
“I do anticipate it’ll go somewhat smoother than Choice, but there’s going to be a real hesitation on the part of the consumer,” he said.
For more information
Veterans with additional questions can find information online at www.va.gov/communitycare/. Selecting option 6 at 541-440-1000 goes to a national call center where questions can be answered. The Roseburg VA Office of Community Care can be reached at 541-440-1286.
The VA will hold a town hall meeting to discuss the Mission Act at 5 p.m. June 25 at the Roseburg VA Auditorium, 913 NW Garden Valley Blvd., Roseburg.