By Sandra Basu
WASHINGTON—The VA has sent draft legislation to Congress that would revamp criteria for outside care, including eliminating the controversial “30-day/40-mile” rule.
“We want veterans to work with their VA physicians to make informed decisions that are best for their clinical needs, whether in the VA or in the community, and this bill does just that, while strengthening VA services at the same time,” VA Secretary David J. Shulkin, MD, said in announcing the effort.
Current rules for VA’s Choice program restrict use of the community care program to veterans who reside more than 40 miles from the closest VA medical facility with a full-time primary care provider or are experiencing wait times of 30 days are more or when the service is unavailable at their VA facility.
Under the proposed Veterans Coordinated Access & Rewarding Experiences (CARE) Act, this wait-time and distance eligibility criteria for the Choice Program would be replaced with criteria that “place the veteran and his or her physician at the center of the decision process on how and where to get the best care available; ensures VA is improving medical facilities and staffing levels to meet veterans’ needs in areas where VA care is substandard, and; offer options for veterans to use a network of walk-in clinics for minor illnesses and injuries.”
The bill also includes proposals for new workforce tools to assist “in maintaining and strengthening” VA’s medical staff, among other issues. In addition, the bill would consolidate all of VA’s community care programs under one umbrella.
VA’s Choice Program, which was created by Congress in 2014, has been the source of ongoing debate. At a Senate committee hearing earlier this year where Shulkin sought support from lawmakers for his proposal, he called the current criteria to access community care as “arbitrary” and “unnecessarily cumbersome.”
“Our goal is to modernize and consolidate community care. We owe veterans a program that is easy to understand and simple to administer and meets their needs,” he told lawmakers at that hearing.
He explained at that time that, instead of the current wait and distance criteria used for outside care that under the CARE Act, a clinical assessment by a VA clinician would result in a decision about what would best meet the patients’ needs: a VA specialist or community care.
“If community care is the answer, then the veteran chooses the provider from a high performing network…assessment tools help veterans evaluate community providers and make the best choices themselves,” Shulkin said. “We may help veterans schedule appointments in the community or in some circumstance veterans may schedule the appointments themselves.”
The VA secretary further explained that the effort was all about “individualized, convenient, well-coordinated modern healthcare and a positive experience for the veteran.”
No ‘Unfettered Access’
Still, he said that he was not recommending “unfettered access” to community care. That has been a source of concern for veterans’ groups that have worried about funding favoring care in the private sector at the expense of care at the VA.
The VA’s draft bill isn’t the only legislation under consideration. Other bills have been proposed by members of Congress to change VA’s infrastructure, including how it relates to outside care.
At a hearing last month on legislation to review VA’s facilities, Disabled American Veterans (DAV) National Legislative Director Joy Ilem suggested that efforts underway to reform the Choice program should be “merged with efforts to reform VA’s infrastructure in a plan that is cohesive and that overlaps.”
“Given the overarching goals of VA health care reform, it is impossible to separate how health care is delivered from where it is delivered. Therefore, DAV recommends that the two draft bills—one to reform VA infrastructure and the other to revise the choice program—be merged into a single bill focused on comprehensive reform of the VA health care system,” she said in written testimony.
In a related matter, Sen. John McCain (R-AZ) and other lawmakers have introduced a bill that they say would ensure the VA budgets accurately and responsibly. They cited Choice Program spending as one of the concerns that led to the bill.
In August, President Donald Trump signed the VA Choice and Quality Employment Act of 2017, which authorized $2.1 billion in additional funds for the program as a short-term temporary funding solution.
“The VA has requested $3.2 billion in emergency funding for the Choice Program twice this year alone—in March and July. Congress provided funding that the VA initially said would last through February 2018, but reports have recently questioned if the funding provided in July would last through the end of this year,” a statement from McCain’s office explained.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.