Friday, March 06, 2015





"The Choice Act has been shocking underutilized," declared Senator Richard Blumenthal at last Thursday's Senate Veterans Affairs Committee hearing.  Blumenthal is the Ranking Member, Senator Johnny Isakson is the Chair.  The hearing was about the VA's budget request and the first panel was composed of VA employees led by Secretary of the VA Robert McDonald.  The others were Dr. Carolyn Clancy, well known fabulist Allison Hickey, Ronald Walters, Stephen Warren and Helen Tierney.

Ranking Member Richard Blumenthal:  As I outlined earlier, Secretary McDonald, the choice card program basically seems not to be working.  I think you and I, in our conversations, have talked about the potential reasons that it is so underutilized a small fraction of the veterans who  are eligible to use it in practical terms are doing so.  The 40 mile rule may be a cause.

Before we go further, let's all get on the same page.  The House Veterans Affairs Committee offers the following highlights of The Veterans Access, Choice and Accountability Act of 2014:
To improve access to and quality of care for veterans, the law:
  • Requires VA to offer an authorization to receive non-VA care to any veteran who is enrolled in the VA health care system as of August 1, 2014, or who is a newly discharged combat veteran if such veteran is unable to secure an appointment at a VA medical facility within 30 days (or a future published goal established by VA) or resides more than 40 miles from the nearest VA medical facility, with certain exceptions.
    • Requires VA to provide a Veterans Choice Card to eligible veterans to facilitate care provided by non-VA providers.
    • Provides $10 billion for the newly-established “Veterans Choice Fund” to cover the costs of this increased access to non-VA care. Choice program authority would end when funds are exhausted or three years after enactment, whichever occurs first.
  • Requires an independent assessment of VA medical care and establish a Congressional Commission on Care to evaluate access to care throughout the VA health care system.
  • Extends the ARCH (Access Received Closer to Home) pilot program for two years.
  • Extends for three years a pilot program to provide rehabilitation, quality of life, and community integration services to veterans with complex-mild to severe traumatic brain injury.
  • Improves the delivery of care to veterans who have experienced military sexual trauma as well as care for Native Hawaiian and Native American veterans.

To expand VA’s internal capacity to provide timely care to veterans, the bill would:
  • Provides $5 billion to VA to increase access to care through the hiring of physicians and other medical staff and by improving VA’s physical infrastructure.
  • Authorizes 27 major medical facility leases in 18 states and Puerto Rico.

To provide real accountability for incompetent or corrupt senior managers, the law:
  • Authorizes VA to fire or demote Senior Executive Service (SES) employees and Title 38 SES equivalent employees for poor performance or misconduct.
    • Provides an expedited and limited appeal process for employees disciplined under this authority. Appeals would go to a Merit Systems Protection Board administrative judge, who would have 21 days to decide on the appeal. If a decision is not reached within that 21-day period, then VA’s decision to remove or demote the executive is final.
    • Prohibits SES employees from receiving pay, bonuses and benefits during the appeal process.
  • Reduces funding for bonuses available to VA employees by $40 million each year through FY 2024.

To improve education benefits for veterans and dependents, the law:
  • Requires public colleges to provide in-state tuition to veterans and eligible dependents in order for the school to remain eligible to receive G.I. Bill education payments.
  • Expands the Sgt. Fry Scholarship Program to provide full Post 9/11 G.I. Bill benefits to spouses of servicemembers who died in the line of duty after 9/11.

According to the Congressional Budget Office, the bill would result in net spending of roughly $10 billion from 2014 - 2024, making it less expensive than previous VA reform packages passed by the House and Senate.

Along with backlog claims issues, the VA has suffered from the scandal of not delivering timely care and inventing a system not to fix that but to hide it.  The simplest explanation is that the VA kept two sets of books on appointments -- the false one had veterans receiving timely care when they called in to schedule appointments, the reality version -- which was hidden from Congress --documented the lengthy wait times.

As a result of veterans being denied timely care -- and the health problems and, yes, deaths that resulted from these actions led to the passage of the 2014 act.

It was hoped that this measure allowing veterans living "more than 40 miles from the nearest VA medical facility" to utilize a non-VA facility and doctor would allow for more timely health care.

To be clear, veterans can utilize that and could before the bill -- minus the 40 miles clause.  But to do so they had to get a written referral from a VA doctor and present that at whatever appointment/consultation with a non-VA doctor.  This clause in the act was supposed to simplify this process.

But that did not happen.

Today, Tom Philpott (Stars and Stripes) noted Senate VA Committee Chair Johnny Isakson is calling for the 40-mile aspect to be loosened:

  As we reported here several times last year, the law is more restrictive than early Capitol Hill tweets had indicated.  For each episode of care, regional VA healthcare managers still must authorize outside care, and VA usually will direct patients into a contracted network of health care providers.
Meanwhile, the 40-mile rule narrows eligibility to use cards in two ways.  First, the law uses “geodesic” or as-the-crow-flies distance to determine if a veteran lives more than 40 miles from VA care.  This denies access to private sector care to many vets who reside within 40 miles of VA care if one uses a map and ruler.  Actual drives for care can be much longer.
Second, the 40-mile rule applies to the nearest VA health facility, not nearest VA facility providing needed care. So veterans who reside within 40 miles of a VA clinic that can’t treat their conditions still aren’t eligible to use the Choice Card.  Those are two problems that need fixing, Isakson said.
“We need to make sure that if [VA] health care within 40 miles of the veteran doesn’t provide chemotherapy or doesn’t provide a heart transplant or doesn’t provide a specialty the veteran needs, they get to exercise the 40-mile rule because the health care they need is not available,” said Isakson.

“We also need to be certain we look at how long it takes to drive there…This straight-line application is crazy,” Isakson said.  “It needs to be the time [or mileage] from leaving the garage of the veteran to pulling into the parking lot of the Veterans Administration.”

I understand why the act was passed, I understand the reasoning behind it -- and I actually support that.  But I'm confused to this day of why the lawmakers seem unaware of what was already available.

Veterans had to jump through hoops -- whether they were VA, TRICARE or CHAMPVA to get those referrals unless their VA primary care doctor was a good one.  (A sign of a good one?  They retroactively authorize it if you're on vacation and have to see a non-VA doctor out of your area.  Which they can do but only very few will.)  (If your visit is not authorized -- prior to the appointment or retroactively -- you are responsible for the cost of the visit, your veterans plan is not covering it.)

It appears the hope was that by the wording of the 40 miles, it would be easier for the veterans to receive the referral for care.  I think it was stupid to rely on the same system that was already a problem -- VA doctors -- to give the same referrals. 

I'm glad Isakson wants to reform it and I agree with his comments but more needs to be done.  The easiest thing would be to have some sort of clearance that took place online and by phone (because everyone doesn't have a computer -- shocking though that is to America's so-called 'creative class').  So a veteran would log on or dial in and enter their address -- already on file with the VA -- and request a referral for a visit to a non-VA facility.  The computer or phone system would know that the address was X number of miles from the nearest VA and if was 40 or more a referral would automatically be sent out to the veteran.

The thinking seems to have been that by putting it into law the VA doctors would be less hesitant about providing the referrals.  But the problem was more the issue of accessing the doctors and getting the referral -- the time involved for both -- and this was time while you were waiting for treatment.  The system should have been automated.

If the doctors are part of the reason for the delay -- and they are and that's chiefly because of the time involved -- then the solution was to automate the process.

RECOMMENDED: "Iraq snapshot"