Commission on Care report reignites VA 'choice' debate
Twelve of 15 commissioners appointed by Congress and the president to propose reforms to veterans' health care have endorsed 18 "bold" steps to transform the system, but in the end rejected a push to dismantle it and to shift most veterans' care into the private sector.
And yet, say critics of the Commission on Care including several veteran organizations, its final report released last week still proposes to expand veterans' rights to choose outside health care providers, enough to put traditional VA health care at significant risk over time.
The dangers, opponents contend, is that a steady shift of patients from VA to the private sector care by relaxing "choice" rules could explode VA spending, in turn forcing Congress to crimp on resources for VA-provided care including cutting edge specialty programs for the most disabled vets.
The commission's 10-month study of VA care resulted in a 308-page report (http://tinyurl.com/a5) that portrays the system as problem-plagued but also repairable if the VA, Congress and veteran service groups unite behind a new governing structure and other sweeping changes.
That includes allowing veterans to choose their own primary care providers from either physicians at VA facilities or from VA-screened networks of community-based providers. The primary care doctors, in turn, would have be responsible for coordinating the veterans' care, including referrals to specialists whether inside or outside of the VA.
So the first of 18 report recommendations is for the Veterans Health Administration (VHA) to establish high-performing community health care networks, to be known as the VHA Care System, by integrating its staff and facilities with local civilian health services to ensure access to quality care.
In a phone interview, commission chairperson Nancy M. Schlichting, chief executive officer of the Detroit-based Henry Ford Health System, acknowledged the depth of concern among veteran groups for this critical element of the report, shaped largely by health industry executives.
The report itself says "choice" was the "most contentious issue" negotiated, with some commissioners advocating "complete choice of providers for veterans with no requirement for care coordination," even by primary care physicians. "Others advocated for a tightly managed model with VHA controlling access to community providers, as is done today."
Schlichting said it's important for veterans groups to realize VHA would still manage community provider networks and even determine their size, based on how best to serve veterans in each community. Civilian providers would be trained on care coordination, patient data transfer, military and cultural competency and other requirements to ensure appropriate care for veterans.
"This creates a much more organized approach of having private physicians available to serve veterans as needed. Giving them the choice within that network is very different than just total open choice," she said.
Carl Blake, associate executive director of government relations for Paralyzed Veterans of America, said PVA supports better integration of VA health care and private sector providers. But the idea of allowing veterans to choose primary care physicians from either VA clinics and hospitals or pools of private sector doctors, triggers alarms.
No group is as interested as PVA in preserving the VA system of care for spinal cord injuries, Blake said. There's no program like it in American medicine. That's also probably true, he said, for other VA specialty care of amputees, blinded vets, poly-trauma cases, traumatic brain injury, post-traumatic stress and other mental health care.
"So what happens to those services if more and more veterans leave the VA system and go into the community to access care?" Blake asked. Assurances from the commission that VA specialty care programs will be spared any belt tightening are "predicated on the idea that those services would operate in a vacuum. But they don't," Blake said. "So if you encourage more veterans to leave the system, then you risk undermining those services which are the bedrocks of VA healthcare."
Louis Celli, director of veterans affairs and rehabilitation for The American Legion, said it "firmly believes based on our research that any attempts to outsource or take services away from the campuses of VA will be financially unsustainable for the treasury and will ultimately start to transfer the cost obligation on to the veteran with service-connected disabilities."
Something similar occurred over decades for military retirees, Celli said. They were promised free care from base hospitals and so for decades retirees opted to live nearby. Then CHAMPUS and the follow-on TRICARE program began offering low-cost insurance to be able to use private sector care. Now TRICARE beneficiary co-pays are rising, Celli said.
The same could happen in VA if its health system is restructured to rely more heavily on private-sector providers rather than to modernize VA medical centers, hospitals and clinics to meet patient demand.
Two of three commissioners who wrote dissents rather than sign the report had backed a "straw man" document last March that called for phasing out VHA hospitals and clinics and making it "primarily a payer" of care purchased for veterans from the private sector.
The third dissenting commissioner, however, is Michael Blecker, executive director of Swords to Plowshares, a support program for homeless veterans in San Francisco. He said the push to expand choice is a ruse to dismantle VA-run care by opponents of large, costly bureaucracies.
"The commission's insistence on making 'choice' a core element of its plan will, according to the commission's economists, likely (will) divert 40 percent of the VHA's service base," Blecker wrote. That would "threaten the viability of VA care for the millions of veterans who rely on it."
Design of the commission's VHA Care System, he added, "has prioritized users' access to the private health care system above all else: above cost, above quality, above preserving the choice of comprehensive veteran-specific care for those who need it."
Schlichting said most recommendations in the report focus on strengthening the VHA, from information technology and supply chain practices to leadership development and support staff. So clearly the commission's plan is not to dismantle VA health care, she said.
But getting even 12 commissioners to support one set of recommendations on VA care was "the hardest leadership task I've every had in my life. And I come from Detroit where we had 30 percent population decline in the last 10 years, our city go bankrupt, two of our major auto companies go bankrupt and yet I was able to lead a health system through that. But that looks easy compared to this," she said.