NOVA Submits Testimony on Implementation of Veterans Community Care Program
Monday, April 15, 2019
Posted by: Kristy Cohen
NURSES ORGANIZATION OF VETERANS AFFAIRS (NOVA)
SENATE COMMITTEE ON VETERANS’ AFFAIRS
“VA MISSION Act: Implementing the Veterans Community Care Program”
April 10, 2019
Chairman Isakson, Ranking Member Tester and members of the committee, on behalf of the Nurses Organization of Veterans Affairs (NOVA) we thank you for allowing us to submit our views on today’s important hearing.
As nurses who provide the coordination and care for millions of Veterans throughout the VAHealth Care System, we believe we have a unique voice and ground level view of how VA care should look and perform in the future.
Since the passage of the VA MISSION Act in June 2018, NOVA has voiced its concerns about how the Veterans Community Care Program (VCCP), to include new access standards, would change internal VA systems, but more importantly, if it continues to provide the “right” care for our Veteran patients.
The rollout of access standards for the VCCP, did little to alleviate our concerns. The new standards set arbitrary wait times and drive-times that do not take into consideration “quality of care” and access to providers who would be subject to the same high standards as VA demands. This creates a double standard under which “community care” is held to a lower standard while seemingly offering Veterans “choice,” but at what cost?
We believe all care provided the Veteran patient must demonstrate and meet access and quality standards whether they choose to receive care in the community, under the VCCP or remain at a VA Medical Center, or other VA facility.
The credentials, training, competency and performance standards that VHA requires of its own clinicians should be the benchmark for providers in the VCCP. Yet, the proposed standards for the program indicate that the minimal qualification and quality standards used to contract providers for the Veterans Choice Program will remain unchanged. Choice was nothing if not a lesson in contract negotiations gone terribly wrong.
NOVA members who coordinate care for non-VA care/Choice programs reported a myriad of problems being made by outside providers that led to delays in care, the wrong care given, or in many cases, the Veteran not being seen by an outside provider at all. Failure to ask the question “access to what kind of care?” can compromise the health and well-being of Veterans.
One of the core justifications for the MISSION Act was to give Veterans comparative information on the quality of VHA and non-VA provider care in order to make health care decisions. While robust metrics exist for a limited number of inpatient process measures, there are very few accurate ones for outcome measures. Almost no measures exist that compare the quality of individual providers or clinics in the private sector to those within VHA. The regulations state that provider quality ratings will be published, but most of the relevant comparative information that Veterans need to make health care decisions will not be available.
How can Veterans make an educated choice on their health care if this information is not available?
We are also troubled by the lack of attention to internal VHA staffing needs with respect to implementing the VCCP. It is widely known, that VHA has over 45,000 vacancies – nurses are among many of those positions unfilled.
For the VCCP to be implemented properly, staff within VHA will be responsible for making appointments, coordinating care, obtaining documentation, collecting Veteran copayments, discussing options with Veterans, etc. But there is no assessment of, or accommodation made for extra staff needed to perform this huge expansion of workload. No consideration has been made as to how the VA is going to case manage all the Veterans that will be going out into the community. Those coordinating outside care are struggling with enough staff to keep up and balance changes in contracts, IT solutions and other workforce issues within VCCP.
NOVA asks that given this, how can new duties be effectively undertaken without significant numbers of additional staff? If these duties are executed by diverting staff from other clinical care needs – it has been mentioned that Patient Aligned Care Teams (PACT) would carry out some of these functions - remaining staff will become overburdened with more appointments in shorter periods of time, which could sacrifice timely access to quality care. VA's own report to Congress (required by the MISSION Act) on quality standards, recognized fragmentation of care is at risk. Shouldn’t some of the burden in fact be borne by non-VA providers who are being paid to care for Veterans? VA can, and should make this a condition of contracting with non-VA primary care providers.
VA’s own Impact Analysis recognizes that meeting the wait time regulation would require significant increase in staffing, but never considers adding FTEs to VHA to meet those standards. Is there consideration to provide grants or funding to hire more nurses and support staff to satisfy increases assessed under VCCP?
The Impact Analysis predicted that the new access standards would significantly increase the number of Veterans who receive VCCP care, all of which must be reimbursed by VA. The Independent Budget (IB), which NOVA has endorsed, notes that the Administration’s budget proposal falls far short of covering associated VCCP costs1.
The IB is asking for $18.1 billion in medical community care for FY 2020 which includes current services, estimated spending (not including full cost of wait time and drive time access standards which VA estimates will increase by 29% for PCP and 14% for Mental Health) under Choice and VA Mission Act.
The importance of VA properly estimating community care costs is critical and we would remind the Committee that Congress had to twice provide “emergency funding” for Choice due to improper forecasting the demand for care among Veterans. We are confident that Congress does not want to repeat past mistakes and put VHA funding in jeopardy in the coming fiscal years. We stand by the IB estimates and ask that funding for community care be allocated separately and adequately to not deplete VHA funds.
NOVA recognizes and understands that community providers are a crucial part of an integrated network designed to provide care where there are shortages. Providers should be used to supplant VA care, not replace it, and be held accountable for performance, quality, and timeliness of care and services. Most importantly, VA must remain the first point of access and coordinator of all care.
VA provides high quality care to millions of Veterans across the country, many of whom have indicated through surveys* that they prefer to use VA because they believe the quality of care is higher and that VA’s ability to treat service-connected conditions is unmatched by any care in the private sector.
As Congress and VA move toward final implementation of the VCCP, we ask that they consider a delay until such time that access and quality standards for the program are equal for both internal and external care. Care that is fair, accountable and of the highest quality is what Veterans deserve now and into the future.
Thank you for allowing us to submit our comments and recommendations.
NOVA is a nationwide, nonprofit professional organization whose members are nurses working for the Department of Veterans Affairs Medical Centers and Clinics. NOVA is not part of the VHA, nor is NOVA sanctioned or endorsed by the VHA.
1The Independent Budget Statement on VA’s FY 2020 Budget Request www.independentbudget.org
*VFW 2015, 2017, 2018 surveys relayed in its “Our Care Report” at https://www.vfw.org/advocacy/va-health-care-watch shows large number of Veterans prefer VA care.