Physicians Step Up Amid VA Crisis
Legislative Affairs Feature — September 2014
Tex Med. 2014;110(9):33-40.
By Amy Lynn Sorrel
As Congress and the embattled U.S. Department of Veterans Affairs (VA) work to resolve overwhelming backlogs in medical care for the nation's veterans, the Texas Medical Association and physicians across the state are enlisting to stand in the gap and help alleviate the documented access-to-care problems.
The move comes as VA takes fire for excessive wait times and falsified records over those wait lists. Several senior leaders have resigned. Although the access-to-care problems vary by region, a national audit of the VA system found "systemic problems" that included tens of thousands of veterans who either asked for medical appointments but never received them or ended up on months-long wait lists for their first care visits.
In Texas — which at 1.7 million has the second-largest veteran population in the country behind California — wait times ranged from 37 days in San Antonio to 85 days in the Rio Grande Valley for new patient primary care appointments and up to 145 days for specialty care. (See "Average Texas VA Appointment Wait Times.")
VA has turned to private-sector physicians in the past, mostly for specialty care. While ready and willing to help, however, physicians say the current system inadvertently creates more fragmented care for veterans. They ask that the nation's leaders clear existing bureaucratic landmines — slow payment and lack of interaction between VA and the private sector, for instance — so they can get veterans the timely care they need.
Baytown general and colorectal surgeon Monira Hamid-Kundi, MD, was among the first physicians to sign up on TMA's registry of private doctors willing to care for veterans. (See "Enlist Now!") She often sees veterans in the emergency department "because they have nowhere else to go." But VA rules typically require her to transfer patients to VA clinics or hospitals, which, despite their condition, takes days.
"I see people sitting in [Washington] D.C. and they can go anywhere for treatment, and nobody asks questions. But those who serve our country have to go through so many loopholes. We treat our veterans like they are at the bottom of the list, and it's not right," she said. "I want them to know they can have a physician in their own location and get treated quickly and be on their way to getting better."
A retired U.S. Army veteran, San Antonio pulmonologist John R. Holcomb, MD, had no second thoughts about signing up, even though he anticipates the same kind of administrative difficulties and payment uncertainties he experiences with the Medicaid program.
He says VA is the safety net for many veterans in the same way Medicaid is the safety net for a similar population without military service. The veterans on the long waiting lists typically have a lot of unmet needs, no pension because they weren't in military service long enough to retire, no secondary insurance through a steady job, and nowhere else to turn for care.
"We are going to sign up. That's what we do. We sign up for Medicaid, and that has similar problems. And if they [VA] want us to treat veterans, we will sign up for that, as well," Dr. Holcomb said.
Calling Community Physicians
Amid the crisis, organized medicine strongly called on leaders at VA and in Washington, D.C., to pave a smoother path for veterans to more swiftly access outside care and for physicians to easily provide it. At press time in late July, Congress answered that call with a $17 billion fix that awaited President Barack Obama's expected signature.
"Our veterans have stepped up and served our country, so physicians want to be able to step in and serve them," TMA President Austin King, MD, wrote to the president in June and again in July. "This is an access-to-health care crisis. … Any further delay is unconscionable."
TMA helped lead the charge for federal action at the American Medical Association's Annual Meeting in June. AMA's House of Delegates voted overwhelmingly to ask that President Obama "take immediate action to provide timely access to health care for veterans utilizing the health care sector outside the Veterans Administration until the VA can provide health care in a timely manner." AMA also urged Congress to rapidly enact long-term solutions so eligible veterans can always have timely access to entitled care.
As part of that plan, TMA was one of the first state medical societies to establish a physician registry to share with VA authorities. At press time, despite the well-known problems of working with VA, more than 350 physicians had signed up.
"Our veterans are special. They already made their contribution, and it's incumbent on us [physicians] to the extent we can to do our best to provide some interim bridge to relief while permanent solutions are being crafted," said Asa Lockhart, MD. The Tyler anesthesiologist and AMA delegate spearheaded the AMA resolution along with the Florida Medical Association and helped facilitate talks between TMA and local VA leaders. "This is very much something private-sector physicians could play a very meaningful role in — if we can find a mechanism that is not bogged down in bureaucracy. There are some obvious impediments that need to be overcome. But my guess is we [physicians] can help find a solution."
Wendell Jones, MD, is chief medical officer for VA region 17, the VA Heart of Texas Health Care Network, one of three VA regions that encompass Texas. (See "Map of Texas VA Regions.") Region 17, the largest in Texas, stretches from the Oklahoma border to the Lower Rio Grande Valley and includes about 1 million veterans.
Dr. Jones acknowledges physicians' frustrations and the need for certain improvements. But not unlike access-to-care issues that exist outside the VA, the bottom line, he says, is the VA needs more doctors.
"Overall, we do provide good access to care for veterans," and good quality care, Dr. Jones said. "There are definitely some red-tape issues [Congress] is trying to make easier. And all of us get frustrated with red tape outside of VA and inside of VA. But you can only put in so many efficiency steps. At some point you just need more providers."
Finding a Fix
On July 31, just one day before the August recess, Congress passed the Veterans Access, Choice, and Accountability Act of 2014, which calls for system-wide administrative improvements and increased transparency within VA. In addition to more money for VA to hire in-house medical staff, the measure includes an expansion of VA's ability to contract with private physicians and others, for three years or until appropriated funds run out. The bill allows veterans to seek outside care from Medicare-enrolled doctors when waiting times at VA facilities grow beyond 30 days, or if veterans live more than 40 miles from the nearest VA facility. Other provisions call for systems to ensure prompt payment for VA and non-VA care. VA also "would be expected to seek payment rates for providers of contracted care (such as doctors and hospitals) equal to Medicare's rates, but the department would be authorized to negotiate higher rates under certain circumstances," according to the Congressional Budget Office.
In the meantime, the Veterans Health Administration in May had launched the Accelerating Access to Care Initiative, giving VA more "flexibility" to use outside referrals, according to a VA fact sheet.
AMA praised Congress for taking action, and the association supported the legislation "because it is an important step to connecting veterans with physicians who can help them right now," President Robert M. Wah, MD, said. "All Americans should have timely access to health care, especially those who bravely serve our country. Our nation's physicians can and should be a part of the solution to ensure America's veterans can access the care they need and deserve."
VA currently spends about $4 billion a year — 9 percent to 10 percent of the VA's budget — on contracts for non-VA care. Dr. Jones told Texas Medicine that figure is about $280 million for the region he oversees in Texas.
The need is apparently growing: From 2008 to 2013, non-VA care outpatient visits grew 72 percent nationally, with 1 million veterans receiving outside care in 2013.
At press time, organized medicine officials said VA had yet to work out the specifics of how it would negotiate agreements with private physicians in light on the new legislation.
Before its passage, TMA officials spoke with the VA Heart of Texas Health Care Network to explore various options. The other two Texas VA networks have not reached out to TMA.
Dr. Lockhart says some non-VA contracts, for example, are local agreements with a single physician or clinic, and physicians who sign up on TMA's registry could be included in a VA rotation list for referrals for a particular specialty.
Other contracts, known as Project ARCH (Access Received Closer to Home) — which the new legislation reauthorized — and PC3 (Patient-Centered Community Care), operate more like commercial networks of physicians and other health care professionals and facilities in multiple locations, and physicians could join the regional network, TriWest. Still other agreements are for more specific locum tenens services.
Texas VA representatives identified a number of specialty areas in critical need, including dermatology, ophthalmology, orthopedics, gastroenterology (colonoscopies in particular), urology, neurology, and nonmedical services such as physical therapy and audiology. The need also varies regionally, Dr. Jones says. For example, VA uses more contract care in the Rio Grande Valley where there is no VA hospital.
VA does have "some outreach for primary care, especially in rural areas and occasionally in certain urban areas," he added. But the system mostly outsources for specialty care and takes careful consideration of veterans' needs when it comes to specialized services best handled within VA, such as mental health and combat-related treatment.
Still, Dr. Lockhart encourages physicians of all specialties to sign up. "Just because they [VA] don't have the need [for a particular specialty] today doesn't mean they won't have the need tomorrow," he said.
Hitting a Wall
To bolster that recruitment, however, TMA leaders emphasize the need for a seamless, transparent, and reliable system for physicians when it comes to administrative requirements and payments.
Dr. Lockhart says TMA emphasized to VA officials that any contracted care include such assurances. Dr. King's letter to President Obama also requested that any private-sector option "include an effective and rapid payment system for the private-sector physicians who step up to provide care" and that any emergency intervention "be continued until timely transition of care can safely be handed off to the VA."
One idea behind the new legislation's use of Medicare physicians for outside care was that existing Medicare systems could help facilitate and speed up credentialing and payments.
TMA's Payment Advocacy Department has received complaints from physicians about months-long delays in VA claims payments, as well as incorrect payments. If your practice has experienced outstanding VA claims, send documentation to TMA's Hassle Factor Log program.
In addition to prompt payment provisions, the new legislation calls for a U.S. Government Accountability Office audit of the timeliness of non-VA payments one year after the bill's enactment. A March GAO report reveals administrative shortfalls have in the past led to inappropriate claims denials.
Dr. Lockhart says some of the payment and administrative problems may stem from the fragmented VA structure within Texas, managed by various regional networks and budgets.
While Dr. Holcomb praised VA's outreach for specialty care, he also expressed concern about the gaps in primary care.
"If you're in the system, you have a considerable amount of benefits available," such as full coverage of medications, he said. "The gap is getting in the door. Getting that first contact with a primary care provider is the problem."
When he does see veteran patients, Dr. Holcomb often hits a wall when trying to communicate with the VA system.
"We see them in the hospital and take care of them. But we can't get records from the VA, so we don't know what [treatment] happened to them over there. We can't transfer them to the VA. And we never get paid. I wouldn't even know how to send the bill," he said. "The only way I'm able to reliably get their records is to say, 'You have to go over to the VA and sit in the triage area as long as it takes and have them deliver your medical record to you.'"
Baylor Scott & White Health (BSWH) has reached out to the Temple VA to provide additional help, despite having trouble breaking through the same barricades, says Chief Health Policy Officer and former TMA President J. James Rohack, MD.
Even though BSWH and VA both use electronic health records (EHRs), the cardiologist can neither retrieve nor send patient records electronically. Nor can he e-prescribe into the VA system. Dr. Rohack has to handwrite a prescription and fax it in and send medical records the same way. That also means he runs the risk of unnecessarily repeating tests or procedures because he can't easily see what tests VA has done.
"Veterans give up part of their lives to serve our country, and this is one way we [physicians] can give back," Dr. Rohack said. "But it does highlight some of the challenges we have when veterans leave the VA system and go to the private sector. So there's a recognition that this congressional legislation shouldn't be considered a solution to the problem. It's a patch that needs more thoughtful, long-term discussion on the future of the VA health system."
Some congressional members who opposed the legislation expressed concern that it did not fully address the underlying problems at VA, especially given the high price tag.
Region 17's Dr. Jones acknowledges certain shortcomings but says some of them are not unique to VA. He points to some improvements VA has made.
"There are some pockets where we have access issues geographically or by specialty," he said. "But we've been very aggressive in covering those, and the amount of patients who are not seen in a timely manner within our region is very small compared to the number of veterans we serve."
Texas VA representatives add they have largely resolved problems with slow pay over the past few years, and now with a more centralized payment system, VA pays 95 percent of claims within 30 days. Over the years, VA also has increased the amount it can pay outside specialists, particularly in scarce specialty areas, Dr. Jones says.
The other 5 percent of claims, however, "are not paid for a variety of reasons. Sometimes we made mistakes, and we've tried to correct those," he said. At the same time, officials travel throughout Texas to hold town hall-type meetings with physicians and other professionals on how to correctly file VA claims.
As for medical records access, Dr. Jones touted the VA's EHR system, which helped make veterans' records available nationally among VA facilities and helped improve their care. Those records are not off limits to outside physicians, he says. At the same time, certain department and federal rules bind VA, such as stringent privacy protections.
"We can't just transfer that record without the patient [consenting] to do that. And that's for the protection of the patient, and that's by law," he said. "Adapting to different systems can be frustrating at times, and I understand the frustrations providers have with our or any system. But it's not really a VA-specific issue."
Whether it's the Affordable Care Act or VA, Dr. Kundi says her paperwork and administrative load are increasing anyway. She hopes to see the bureaucracy swept away, but for now is looking past it and asks her colleagues to do the same and join TMA's registry.
Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
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Amid the ongoing crisis, more than 350 member physicians have signed up for TMA's registry of private-sector doctors willing to see veteran patients. You can join, too, by visiting the TMA website. Access to the registry is limited to TMA members.
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Q&A: Time for Change?
Edward J. Sherwood, MD, a Marine Corps veteran and former chief of medicine and director at the Amarillo Veterans Affairs (VA) Medical Center, spoke to Texas Medicine about the current access-to-care problems for veterans. He worked in the VA system over the course of three decades before taking his current position as associate dean for strategic initiatives at Texas A&M University Health Science Center College of Medicine in Round Rock.
Texas Medicine: Were you surprised to hear about the recent access-to-care problems at the VA?
Dr. Sherwood: I'm not surprised. When I was with the VA from 2006 to 2009, they implemented standards for access to care that said many clinic appointments had to be within 30 days of when the veteran wanted it — that's a little different than when the doctor thinks they need it — and others had to be within 14 days. To set the bar so high is commendable. The problem is that bar proved to be absolutely unachievable in some cases. But people were still being held accountable for achieving it, and some started playing games with the reporting.
Texas Medicine: What, if any, access-to-care challenges did you experience while working at the VA?
Dr. Sherwood: The VA has changed its posture tremendously about purchasing care from the private sector. It was very difficult to do that 30 years ago, and the restrictions both in terms of funding and how much we could pay were onerous, so we depended back then on the generous support of [private] physicians. The VA has loosened up on that a great deal, and it is now possible — I won't say easier — to buy care from the private sector when you can't provide it in the VA system.
Of course, it's not always readily available, depending on where you are located. The extent of the [current] problem of providing timely access to quality care of veterans has varied both geographically and over time. There was a drastic change for the better in the quality and availability of primary care. Over the last three decades, VA went from a system where people just showed up and whoever was available saw them to developing a policy where every patient will have a primary care physician. So over the past three decades, most of the issue has been specialty care. In recent years, it has been clear that some of the problem is primary care.
Texas Medicine: TMA physicians want to step up and help, but many report a number of administrative hurdles that get in the way: payment delays and difficulty accessing medical records, to name a few. Were you privy to any of these reported problems?
Dr. Sherwood: While VA has made great strides in creating a culture of continuous performance improvement on the clinical side of the house, that culture and commitment have failed to penetrate the administrative side of the VA. I frequently encountered problems with administrative support services not providing timely, appropriate support to clinical care.
I can remember an example in Amarillo when I received notice from the local electric company that it was going to cut off our power because our bill hadn't been paid for more than six months. I know that at times [physician] payments were delayed. It made me furious when I was working for the VA, and it still does. Regarding medical records, the VA is held to federal [privacy and security] standards, and VA takes [that] very, very seriously. But in that culture, employees are cautious to avoid ever making an error, and that makes them lean on the side of saying no, when sometimes the right answer is yes.
Texas Medicine: The VA has used outside care before, but now Congress and others are looking to expand that option to ease the current crisis. Can this work?
Dr. Sherwood: It certainly could help, and it's certainly a movement in the right direction. The question is, is it going far enough? Are we putting a Band-Aid on a gaping wound that needs a more drastic intervention? The last time VA was fundamentally redesigned was at the end of World War II. It's time.
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