|
|
|
|
WASHINGTON — The Department of Veterans Affairs is preparing to shift billions of dollars from government-run veterans’ hospitals to private health care providers, setting the stage for the biggest transformation of the veterans’ medical system in a generation.
Under proposed guidelines, it would be easier for veterans to receive care in privately run hospitals and have the government pay for it. Veterans would also be allowed access to a system of proposed walk-in clinics, which would serve as a bridge between V.A. emergency rooms and private providers, and would require co-pays for treatment.
Veterans’ hospitals, which treat seven million patients annually, have struggled to see patients on time in recent years, hit by a double crush of returning Iraq and Afghanistan veterans and aging Vietnam veterans. A scandal over hidden waiting lists in 2014 sent Congress searching for fixes, and in the years since, Republicans have pushed to send veterans to the private sector, while Democrats have favored increasing the number of doctors in the V.A.
If put into effect, the proposed rules — many of whose details remain unclear as they are negotiated within the Trump administration — would be a win for the once-obscure Concerned Veterans for America, an advocacy group funded by the network founded by the billionaire industrialists Charles G. and David H. Koch, which has long championed increasing the use of private sector health care for veterans.
For individual veterans, private care could mean shorter waits, more choices and fewer requirements for co-pays — and could prove popular. But some health care experts and veterans’ groups say the change, which has no separate source of funding, would redirect money that the current veterans’ health care system — the largest in the nation — uses to provide specialty care.
Critics have also warned that switching vast numbers of veterans to private hospitals would strain care in the private sector and that costs for taxpayers could skyrocket. In addition, they say it could threaten the future of traditional veterans’ hospitals, some of which are already under review for consolidation or closing.
President Trump, who made reforming veterans’ health care a major point of his campaign, may reveal details of the plan in his State of the Union address later this month, according to several people in the administration and others outside it who have been briefed on the plan.
The proposed changes have grown out of health care legislation, known as the Mission Act, passed by the last Congress. Supporters, who have been influential in administration policy, argue that the new rules would streamline care available to veterans, whose health problems are many but whose numbers are shrinking, and also prod the veterans’ hospital system to compete for patients, making it more efficient.
“Most veterans chose to serve their country, so they should have the choice to access care in the community with their V.A. benefits — especially if the V.A. can’t serve them in a timely and convenient manner,” said Dan Caldwell, executive director of Concerned Veterans for America.
Robert L. Wilkie, the secretary of veterans affairs, has repeatedly said his goal is not to privatize veterans’ health care.
One of the group’s former senior advisers, Darin Selnick, played a key role in drafting the Mission Act as a veterans’ affairs adviser at the White House’s Domestic Policy Council, and is now a senior adviser to the secretary of Veterans Affairs in charge of drafting the new rules. Mr. Selnick clashed with David J. Shulkin, who was the head of the V.A. for a year under Mr. Trump, and is widely viewed as being instrumental in ending Mr. Shulkin’s tenure.
Mr. Selnick declined to comment.
Critics, which include nearly all of the major veterans’ organizations, say that paying for care in the private sector would starve the 153-year-old veterans’ health care system, causing many hospitals to close.
“We don’t like it,” said Rick Weidman, executive director of Vietnam Veterans of America. “This thing was initially sold as to supplement the V.A., and some people want to try and use it to supplant.”
Members of Congress from both parties have been critical of the administration’s inconsistency and lack of details in briefings. At a hearing last month, Senator John Boozman, Republican of Arkansas, told Robert L. Wilkie, the current secretary of Veterans Affairs, that his staff had sometimes come to Capitol Hill “without their act together.”
Although the Trump administration has kept details quiet, officials inside and outside the department say the plan closely resembles the military’s insurance plan, Tricare Prime, which sets a lower bar than the Department of Veterans Affairs when it comes to getting private care.
Tricare automatically allows patients to see a private doctor if they have to travel more than 30 minutes for an appointment with a military doctor, or if they have to wait more than seven days for a routine visit or 24 hours for urgent care. Under current law, veterans qualify for private care only if they have waited 30 days, and sometimes they have to travel hundreds of miles. The administration may propose for veterans a time frame somewhere between the seven- and 30-day periods.
Mr. Wilkie has repeatedly said his goal is not to privatize veterans’ health care, but would not provide details of his proposal when asked at a hearing before Congress in December.
In remarks at a joint hearing with members of the House and Senate veterans’ committees in December, Mr. Wilkie said veterans largely liked using the department’s hospitals.
“My experience is veterans are happy with the service they get at the Department of Veterans Affairs,” he said. Veterans are not “chomping at the bit” to get services elsewhere, he said, adding, “They want to go places where people speak the language and understand the culture.”
Health care experts say that, whatever the larger effects, allowing more access to private care will prove costly. A 2016 report ordered by Congress, from a panel called the Commission on Care, analyzed the cost of sending more veterans into the community for treatment and warned that unfettered access could cost well over $100 billion each year.
A fight over the future of the veterans’ health care system played a role in the ousting of the department’s previous secretary, David J. Shulkin.
A fight over the future of the veterans’ health care system played a role in the ousting of the department’s previous secretary, David J. Shulkin.CreditDoug Mills/The New York Times
Tricare costs have climbed steadily, and the Tricare population is younger and healthier than the general population, while Veterans Affairs patients are generally older and sicker.
Though the rules would place some restrictions on veterans, early estimates by the Office of Management and Budget found that a Tricare-style system would cost about $60 billion each year, according to a former Veterans Affairs official who worked on the project. Congress is unlikely to approve more funding, so the costs are likely to be carved out of existing funds for veterans’ hospitals.
At the same time, Tricare has been popular among recipients — so popular that the percentage of military families using it has nearly doubled since 2001, as private insurance became more expensive, according to the Harvard lecturer Linda Bilmes.
“People will naturally gravitate toward the better deal, that’s economics,” she said. “It has meant a tremendous increase in costs for the government.”
A spokesman for the Department of Veterans Affairs, Curt Cashour, declined to comment on the specifics of the new rules.
“The Mission Act, which sailed through Congress with overwhelming bipartisan support and the strong backing of veterans service organizations, gives the V.A. secretary the authority to set access standards that provide veterans the best and most timely care possible, whether at V.A. or with community providers, and the department is committed to doing just that,” he said in an email.
Veterans’ services organizations have largely opposed large-scale changes to the health program, concerned that the growing costs of outside doctors’ bills would cannibalize the veterans’ hospital system.
Dr. Shulkin, the former secretary, shared that concern. Though he said he supported increasing the use of private health care, he favored a system that would let department doctors decide when patients were sent outside for private care.
The cost of the new rules, he said, could be higher than expected, because most veterans use a mix of private insurance, Medicare and veterans’ benefits, choosing to use the benefits that offer the best deal. Many may choose to forgo Medicare, which requires a substantial co-pay, if Veterans Affairs offers private care at no charge. And if enough veterans leave the veterans’ system, he said, it could collapse.
“The belief is as costs grow, resources are going to shift from V.A. to the private sector,” he said. “If that happens on a large scale, it will be extremely difficult to maintain a V.A. system.”
|
|
|
The NY Times article (VA Healthcare to be privatized?) regarding plans to increase veterans’ use of the private healthcare system is generally a fair discussion of the intent and possible effects of the original “Choice Act” and the more recent “Mission Act. Both laws passed overwhelmingly by Congress are intended to increase access to care (i.e. doctors, physician assistants, nurse practitioners, etc.) and make that care more geographically available.
Although VA has always had authority to send vets to the private sector, the funds to pay for that care came from VA’s overall medical care budget for each hospital. Unfortunately, VA hospitals were reluctant to send vets to the private sector because those funds would then not be available for the hospital. As a result, vets had long waits for VA care and many had to drive hundreds of miles to use the VA system.
Under the “Choice Act”, a separate fund was set aside for private sector care. Over the years since original passage, the Choice fund has been renewed with billions of dollars. It is my understanding that the Mission act again mixes VA and private sector care into one account but give more power to vets as to use VA or private medicine. The Times article also notes concerns that more vets increasing care in the private sector would “strain care in the private sector”. In response I would offer that switching a relatively small portion of the 7 million who get their care from VA to the private sector will only do two things: put less of a demand for care on the VA thus reducing wait times at VA and not be a noticeable addition to 300 plus million Americans who get their care in the private sector.
According to GAO, VA employs about 11,000 doctors and 2,800 contract physicians plus an unknown number of interns and residents. In the United States, there are about 1 million active Medical Doctors (MD) and Doctors of Osteopathic Medicine (DO) plus about another 160,000 inactive MDs. I now live in Delaware and VA employs 153 doctors to serve about 71,000 vets who live in the state. There are also about 2,600 private sector doctors in Delaware so the numbers are clear that a vet has a better chance to see a private doctor than in the VA: 27 vets per private sector doc vs. 464 vets per VA doc.
There have been numerous articles about VA’s difficulties in hiring new healthcare providers of all types, especially mental health providers. Obviously, the quickest way to increase the number of doctors available to vets is to send more vets to private sector healthcare providers. That solves both issues of provider availability and hopefully, geographic convenience.
The Times article also noted concerns that increased vets’ use of the private sector would starve the VA system and lead to reductions in the number of VA facilities. While true that VA would have to compete with private sector medicine, any reductions would most likely come from the group of VA facilities that are obsolete, difficult to access geographically, and providers of historically low quality care. I believe the average age of a VA facility is around 50 with many dating back to the WW1 era and badly in need of replacement (VA’s recent hospitals cost over $1 billion apiece) and every dollar spent out of VA’s budget on bricks and mortar are dollars not available for veterans’ care. Therefore, the question facing VA is whether to use those limited dollars to build more hospitals or improve access to more doctors to provide more care?
As a Navy retiree, I get my care through the TRICARE FOR LIFE program. In general, I can choose my doctors and since I retired in 1988, I have had no issues with my medical care. Some of the providers have been trained by VA, some not. Some were vets themselves, many not but I saw no lack of appreciation for my military service from any of my healthcare providers. So I fail to understand why all vets should not have the same choice (whether retirees should have some advantage over non retirees is a separate issue).
The Times article also mentioned that quoted Secretary Wilkie as saying vets are “happy with the service they get at VA…”. Obviously that is a good thing and one would hope they are happy given the billions of dollars spent on VA. For example, in 2008, VA’s healthcare budget was about $36 billion. The VA request for 2019 is about $80 billion. With various estimate for the increased access to private sector care in the $60 billion range, Congress will be challenged to find funding for VA as it is currently known. The question will be is whether vets will find a smaller VA and increased access to the private sector a better deal than they have now?
|
|
|
Sorry all. I got the budget numbers a bit wrong. Here's the straight scoop from my friends at HVAC:
$80B is for one year CVA medical Care and Services – the $60B for community care would likely cover a 5 year span (14.2B budgeted for FY19). VA asked to merge the two accounts but Congress did not go along with that and has retained the two separate line items.
Again, my apologies for the earlier post numbers.
|
|
|
Your numbers on doctors are interesting, as we graduate fewer medical doctors it is difficult to find doctors who are accepting new Medicare patients, assuming that vets will compete for the diminishing pool of doctors .. The VA provide health care for all "covered" veterans... something the private sector can just say no to... as we watch critical discussions on the availability and access to healthcare for citizens, I fail to see how tossing veterans into that same pool can be a positive solution... All sound so much like "outsourcing", downsizing, shrinking the government that has worked so well...? Then there is the discussion on how far a veterans lives from a VA health care facilty...anyone following population trends understands that the shift is, and has been for over 20 years to major population centers..in the last 10 the populations are moving from the suburbs to the cities... it's where the jobs are, doctors in rural areas a a rare commodity. Recent trends in immigration have closed the doors to foreign doctors and medical students...the main resource for small towns and rural areas.
All sums up to veterans are better off with centrally located VA facilities with dedicated doctors and hospital beds...preceived "poor management" is no reason to end the system...neither is a new VA director every six months...
|
|
|
Data from the Association of American Medical Colleges show that applications to med school have constantly increased. Graduates from med schools have also increased from 18,072 in 2013 to 19,533 in 2018. There is also a slow increase in the number of medical schools.
It is correct that the US population, including medical and other professionals, continues its gradual shift from rural areas to cities. The 2010 census data shows a roughly 81% / 19% spilt between urban and rural populations. But that shift only shows the importance of changing the model of care for veterans to a more flexible version. In the past, VA concentrated on large hospitals, many of which are located in rural areas which no longer contain large enough vet populations to make those hospitals economically viable. In the mid-1990s, VA began shifting to a more local clinic-based system to feed those VA hospitals but instead of reducing those inefficient hospitals and referring vet clinic patients to local community hospitals, continued to operate them despite the cost.
As a result, obsolete and economically inefficient hospitals soaked up budget dollars from more efficient and newer facilities. When posed with constituent pressure related to a potential closing of a hospital in their district, Members of Congress rarely if ever supported such moves despite data showing the system as a whole would be better off with a new, more flexible model of providing access to care. As I said in an earlier discussion, in my 15 years on the staff of the House Committee on Veterans’ Affairs, the 2 most numerous complaints about the VA system was the distance too many vets had to travel and the time it took to get an appointment. A more flexible system proposed by the Choice Act and Mission Act attempted to address those issues.
To limit care to a VA system that has shown itself to be nearly impervious to reform resulting in far too many instances of fraudulent data on care outcomes, wasteful spending like the millions spent on art to decorate a couple VA hospitals in CA and out-of-control construction costs.
Most Americans have a choice in how they receive their healthcare. While that choice is limited by the economic resources they have in terms of insurance costs, it is still a choice and veterans should have no less freedom to choose between care from VA or the private sector.
|
|
|
The VA is the only gov organization that currently negotiates prices for pharmaceuticals... veterans, and everyone else would be put at the mercy of for profit drug companies... The US is graduating fewer doctors, and those that do persevere through 12 years of unpaid education and training graduate in debt well in excess of $300,000... this is forcing their debt load onto the "paying public"...doctors are increasingly limiting Medicare access....privitizing the VA forces vets to compete for access to doctors who cannot afford to care for them
|
|
|
The VA is the only gov organization that currently negotiates prices for pharmaceuticals... veterans, and everyone else would be put at the mercy of for profit drug companies... The US is graduating fewer doctors, and those that do persevere through 12 years of unpaid education and training graduate in debt well in excess of $300,000... this is forcing their debt load onto the "paying public"...doctors are increasingly limiting Medicare access....privitizing the VA forces vets to compete for access to doctors who cannot afford to care for them
|
|
|
I NEVER, again NEVER heard anyone suggest that VA should cease to exist. What IS being suggested is that VA expand its already existing fee for service program that will provide more choice for veterans. In that sense, VA becomes a combination of direct service provider and healthcare insurance company.
As I said before, according to the Association of American Medical Colleges - https://www.aamc.org/, - US medical schools are graduating MORE new MDs, NOT fewer. Osteopathic Med schools are also graduating more new DOs. The obvious answer to the need for more docs is to expand enrollment in med schools and license more docs trained at foreign med schools.
I agree that drug companies and pharmacies are akin to the Robber Barons of old and that VA is authorized to negotiate drug prices. I would also note that regardless of the price VA pays, I believe vets pay only around $10 for a month's supply. It is also worth noting that of the 7 million vets seen by VA, a significant percentage use VA ONLY for their prescriptions.
A local doc recently told me of a patient who needed a certain drug. The price at her local chain drug store was $1,100 per month. Another chain charged $500 per month. She could not afford the drug at either chain store. Her MD suggested she contact a company that negotiates drug prices with local pharmacies and they found her a mom and pop drug store that sold her the same drug for $35 per month. A small example, but illustrative of how bad the drug/PBM/pharmacy companies operate. US consumers are literally subsidizing the cost of drugs sold in foreign countries. For example, the recently released HEP C drug treatment course costs VA about $80,000. The same treatment in some European countries costs a small percentage of VA's cost.
As long as we are bashing the medical establishment, let's go back to the number of docs available. Could it be that med schools and the medical associations like the AMA and AAMS are deliberately limiting the number of docs being trained as a way to use the old "supply and demand" rule to keep prices high? Need to charge high prices to pay back the costs to go to med school? As I am sure you are more familiar with that than I am, there are lots of ways to spread/reduce that cost, like for having Uncle Sam pick up the tab in return for practicing medicine at places like VA, the Public Health Service, Indian Health Service for a set number of years. Add the DoD med school at Bethesda to the ways for a "free med school" can be had.
Here's some data on physician pay from Forbes Magazine online:
"With a base pay offer of $189,000 a year, on average, family practitioners, pediatricians, and psychiatrists are offered the lowest pay of all physicians, according to the medical search and consulting firm Merritt Hawkins & Associates’ 2012 Review of Physician Recruiting Incentives.
That might seem like serious money, but it pales in comparison an orthopedic surgeon’s $519,000 paycheck. Cardiologists make an awful lot, too. They are guaranteed an average base salary of $512,000, according to the Merritt Hawkins data. The third highest-paying specialty: Urology. These specialists earn an average of $461,000, not including production bonuses or benefits. Why are specialists offered so much more than primary care physicians? One reason is they simply bring in more revenue per doctor."
|
|
Locked
