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June 7, 2019

New rule funds private care for 20-30% of veterans

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    Veterans Affairs (VA) on Wednesday finalized rules to provide veterans with greater access to VA-funded care at private health care providers.

    The final rules, which took effect Thursday, outline how CMS will implement new initiatives created under he VA MISSION Act of 2018 to increase veterans' access to health care by providing them with federally subsidized care at non-VA facilities.

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    VA said it plans to release a separate rule to establish competency standards and other requirements for private providers in VA's specialized areas of care, Modern Healthcare reports. The impetus for the yet to be released rule stems from concerns over whether private providers will be held to the same standards as VA providers.

    Final rule expands access to private care

    One of the final rules sets the criteria for the Veterans Community Care Program (VCCP), which effectively replaces the existing Veterans Choice Program. VA finalized new eligibility thresholds for veterans to seek VA-funded care from private providers to include veterans who have to:

    • Drive 60 minutes or more to receive specialty care from a VA facility;
    • Drive 30 minutes or more to receive primary or mental health care from a VA facility;
    • Wait more than 28 days to receive specialty care from a VA facility; or
    • Wait more than 20 days to receive primary or mental health care from a VA facility.

    Previously, veterans who lived more than 40 miles from a VA facility or had to wait more than 30 days for an appointment at a VA facility to seek VA-funded care from private providers.

    Veterans under the final rule also are eligible to receive care from private providers if providers from the Veterans Health Administration:

    • Agree, along with the veteran, that it is in the veteran's best medical interest to receive care from a private provider;
    • Do not offer the care or services a veteran needs; or
    • Cannot provide veterans with the services they need in a manner that meets VA's quality standards.

    VA in the final rule noted it received comments from stakeholders who said the drive and wait time access standards are not realistic, but VA noted other public health insurers have set similar standards, including Tricare and Medicaid plans.

    Overall, VA estimated VCCP will cost $17.9 billion over the next five years, but VA Secretary Robert Wilkie said the department potentially could spend less on the program because a growing number of veterans are using VA care instead of private care.

    Final rule expands access to urgent care clinics

    A second final rule allows veterans with certain urgent care needs to use VA-approved walk-in clinics run by private health care providers. Most veterans who use the clinics will be charged a $30 copayment after the third visit, CQ News reports.

    Stakeholders are optimistic, but wary

    VA officials have said the changes make about 20% to 30% of veterans eligible for VA-funded private health care services, up from 8% under the previous rules. However, VA press secretary Curt Cashour said VA "does not expect a significant increase" in veterans using private care," because "[e]ligibility for [VA-funded private] care is not the same as actually opting for [VA-funded private] care." He added, "Veterans like the care VA offers, and eligible veterans will always have the choice to receive internal VA care or to receive community care."

    Providers and veterans groups expressed concerns that 9.2 million veterans eligible for private care might continue to face problems accessing timely and high-quality care under the new program, but said they hope there are no major glitches with the program's roll out.

    Carlos Fuentes, director of legislative services for the Veterans of Foreign Wars, said, "We would have preferred the VA not use wait time in the Community Care eligibility criteria. That's setting an expectation they won't be able to meet, and veterans won't be happy." He added, "They say they have training in place to implement everything smoothly. We doubt that's the case. We'll be working with the VA to address issues that arise, so that veterans aren't negatively impacted."

    Private providers have said they hope the new program will help them share patient data with VA facilities and receive timely payments for medical services provided to veterans, according to Modern Healthcare.

    Gayle Lee, director of physician payment and quality for the Association of American Medical Colleges (AAMC), said AAMC will closely monitor the new program's rollout to assess whether VA has taken steps to improve how it processes claims from private providers.

    Robyn Bash, VP of government relations at the American Hospital Association (AHA), said AHA is pleased with VA's final rule. However, Bash acknowledged VA might not be ready to launch the new program without experiencing any issues, because the department is still working through contracts (Clason, CQ News, 6/4 [subscription required]; Slack, USA Today, 6/5; Rappleye, Becker's Hospital Review, 6/5; Meyer, Modern Healthcare, 6/5).

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