VHPI Steering Committee Members and Senior Policy Analysts sat down with VHPI Executive Director Brett W. Copeland to discuss their predictions on how the VA MISSION Act would perform after it rolled out on June 6 - and who will take the blame if it fails. The conversation has been lightly edited for clarity and length. Please note that the opinions expressed below belong to the individual.
What are veterans going to experience when being referred out to the Community Care Network on June 6? Do you think you’ll notice a difference?
Suzanne Gordon, VHPI Policy Analyst, Veterans’ Healthcare Journalist: There’s going to be a lot of confusion because the staff has not been adequately trained and the decision-making tool isn’t ready. Veterans that I’ve talked to are wondering why this is happening. If they like VA care, they want to stay at VA care, but will they be able to?
There’s just a lot of confusion from employees at all levels, about the roles, the standards, and concern about the kinds of burdens that will be imposed on VA employees managing care in the private sector.
Russell Lemle, Ph.D., former Chief Psychologist at the San Francisco Department of Veterans Affairs Health Care System: I have a different prediction about what happens on ‘day one’ versus ‘month one.’ I think on day one there’s not going to be a whole lot that’s apparent. Veterans eligibility will be confirmed at their next appointment when a clinical consult is needed or when they request a community provider. That is more likely to occur over the first month than on Thursday, June 6.
Bridget Lattanzi, National Guard, (1996-2016) and Operation Iraqi Freedom II Veteran: I have an appointment with my acupuncturist, which is outside the VA. He has problems getting paid with Choice, and didn’t get paid for a year and a half. He doesn’t send us to collection agencies, but he can’t take on any more veterans.
Lemle: For some conditions and in some markets, there still is an inadequate Community Care Network.
Do you think there will be confusion about which private sector providers are in the Community Care Network?
Lemle: For the new Urgent Care benefit, that’s totally true. The differentiation between which Urgent Care providers are in the network and which are not is clear as mud to the veteran. The VA has its list, but the veteran won’t have a quick way to know.
Lattanzi: I live kind of far from the VA. I went to an Urgent Care where they have pretty specific things they treat. Like if you had a sprained ankle, they’d send you to the ER. But they’d still bill because they saw you – even if they just referred you to the VA.
I have an issue with my ears – chronic sinus infections. After I’d been twice, they said ‘we can’t treat this anymore because you have a chronic condition. You need to go to a specialist. We don’t do this, and you should go to the VA.’ I still got charged for $80 for no reason, and still had to go to the VA.
Walgreens and CVS MinuteClinics, they’re not looking for veteran-specific connections. They have a very limited amount of time they spend with each patient, so they’re not looking for other problems you may have. When I go to the VA, even though I’ve been medically retired for three years, they still go down a list of questions, asking me about my mental health.
One time I was with my VA provider for something else and I had a high heart rate. She put me in for a sleep study and it turned out that I had sleep apnea. Urgent Care isn’t looking for stuff like that, so a lot of stuff will be missed.
Lemle: Walk-in Urgent Care clinics exist in lots of locations, but many of those clinics are not in VA’s Community Care Network. If a veteran walks into the wrong clinic, they will be responsible for the full amount. The veteran will have a hard time figuring that out while hastily trying to make a decision where to go during an urgent situation.
Lattanzi: Urgent Care is also not the best place for veterans to be – they will pick up stuff. Lots of people in there for Strep throat, or colds. And if they’re sent to the non-VA ER’s, then that brings up a whole bunch of other issues. If it comes to the point where veterans are mostly using non-VA ERs, I foresee some problems. Putting all the medical misunderstanding to the side, the environment is important. If we’re mostly using non-VA emergency rooms especially in places like Chicago, there can be long wait times and triggering events. Gunshots, stabbings. I’ve been at the ER in the VA, I’ve seen someone get restrained maybe one time. It’s nothing like in the private sector care – not only for veterans to be seen in a timely manner but just for the trauma of being there.
What hasn’t been addressed in the rollout?
Lemle: At this point, there are no access standards to which the community is held. There are essentially no quality standards to which the community is held. Where there are standards, like with PTSD, they are far inferior to the standards for high-quality care in the VA. Also, the issue of coordination of care between providers in the community or between the non-VA provider and the VA has not been fully addressed.
Gordon: On that issue, VA employees have told me there is no way that they can coordinate care in the community if the patient has a primary care provider in the community, and if the patient has a primary care provider in the VA, but is able to go to specialists in the community. There won’t be coordination.
What will be even worse is if a veteran is eligible for primary care and specialist care because of wait and drive time, then who will know anything about that veteran?
Lemle: VA leaders have said that there’d be a trade-off in quality in order to have expanded access by private providers, that’s important to set standards at a low enough level that providers are willing to see veterans. The VA has said ‘we cannot expect too much of Community Care Providers, we can’t expect them to do measurement-based or evidence-based care, or many of the things we already do in the VA because we will not get enough providers to see our patients.’
The VA is deliberately setting the bar low enough to just get more providers, irrespective of whether they have quality or competence. Every non-VA provider is going to be required to have a one-hour introduction to the VA to qualify to be a private provider. That presentation includes military and veterans culture, common problems that occur among our veterans including PTSD, opioid prescriptions and suicide prevention. When they’ve taken that one-hour online course, the VA will deem them as “qualified” to see veterans.
Copeland: You mean they’ll have one hour of training per topic?
Lemle: No, it will be 60 minutes for all those topics combined – and they don’t even have to have it completed by June 6. They have to take it within the next six months. And that’s essentially the extent of background qualifications. That’s a really low bar.
What do Veteran Service Organizations (VSOs) not understand about the MISSION Act?
Paul Cox, VHPI President, American Legion member, and Vietnam Veteran: There is a great deal of apathy within the American Legion’s [National Headquarters]. They haven’t studied it at all. The Legion officially has come out in favor of the MISSION Act. They haven’t said anything officially or anything negative about the MISSION Act or how it’s rolling out. Maybe some folks in the grassroots and the upper echelons behind closed doors have talked about this.
People always say they love the VA, they wouldn’t want to see it privatized, but I don’t think there’s a great understanding of the dangers of the law itself and the way it’s going to be implemented in a very poor fashion. I think that will start changing over the next six months as VHPI continues to document the fallout.
Lattanzi: A couple things that concern me are with women veterans’ health care. I have had experiences going out to private providers. A common problem is that women aren’t recognized as veterans – and that spills over into our health care.
I had an issue with my ear. I had this partial hearing loss from Iraq. My friend who is a nurse in the private sector, I was telling her about it and she said, “Well I don’t understand why you got that – women aren’t allowed in combat.” People don’t get it. They only know what they see in the movies. And it’s kind of scary.
As good a nurse as my friend is, I still wouldn't want to go to her for my medical care because she just doesn’t treat my population. I spoke to another veteran who was my dental hygienist. She was in the Marines and we were talking about how we have chronic migraines. She got hers from a neck injury from exercise in training – where they were carrying a telephone pole on their shoulders. She has insurance and everything. She went to a neurologist in Chicago – supposedly one of the best.
In this instance, the guy refused to treat her because he didn’t think she got the injury in the military. He thought it was the way she was wearing her hair. And she’s had this injury for years.
So once again, they’ll still take your money. But they just refused to evaluate her. So with women, there’s a lot of prejudice or ignorance. Private healthcare providers are very disconnected from veterans – like if we, as adults, went to the pediatrician. The private sector is not familiar with us as a patient population.
What do you expect from the cottage industry is being set up to go after veterans as customers?
Gordon: I think there’s just a host of big corporate health care vultures who are circling the veteran population, hoping to profit from their ills. From drug companies to groups who are trying to claim they can treat PTSD better than the VA, or insurers who are proposing new types of products like veteran advantage plans. Hospitals that want to get more veterans and channel them into specialist referral networks for episodic, high-cost care.
I think you're going to see groups claiming to be the ones who will qualify people as veterans’ specialist in veterans’ care. President Trump and his VA appointees, Wilkie and Stone are openly cultivating these groups. And opening the doors to welcome them in. I think there are all kinds of groups that are trying to be vendors and profit from taking care of veterans even though they don’t really know how to take care of veterans.
What were some big issues that Congress missed in the legislation and rollout of the VA MISSION Act?
Gordon: Almost everything. The Senate and House Veterans’ Affairs Committees are running the largest healthcare system in the country. And, as the board of directors, they know nothing about healthcare.
There are some lawmakers who are physicians and medical specialists, but I would argue that doesn’t mean anything when it comes to understanding healthcare. They may know how to care for and treat patients, but they don’t know about healthcare at-large. They haven’t learned much through this process and they are still not asking the right questions. The same is true of congressional aides. There’s a very significant disconnect in congressional offices where the staff who are assigned to the VA are also assigned to foreign policy, veterans, and the military. They know nothing about health care. And the health care staff know nothing about the VA. And the same is true of the media who cover the VA. They’re political reporters, but they're reporting on a healthcare system. So how could they ask the right questions? Obviously, there are some lawmakers and congressional staff who are well-versed in veterans’ healthcare – there are some who do have very sharp people. But the majority of them, don’t know enough which is why VHPI wrote our Congressional Guide to Veterans Healthcare.
Lemle: There is very little information about the quality. When private sector quality metrics are reported, they’re usually not reported for specific health conditions or for outpatient care. They’re often just surrogate measures. We know very little about the quality of care delivered by the vast majority of the providers in the network.
Gordon: That’s because there’s no granular metrics that compare Joe Smith at the VA to John Jones at Stanford because they don’t have those kinds of individual provider comparisons. You send somebody to Hospital Compare, which is a Medicare website which is very confusing to most people. You can compare one hospital to another hospital for 30-day mortality rates. But there’s not granular data about an individual private sector provider’ compared to an individual VA provider.
Lemle: What Congress also got wrong, is that they only gave 12 months for this program to be operational. The VSOs had been asking for a longer term creation of a supplemental network of providers in the community for occasions when a local VA got inundated with requests for care or lacked adequate resources. With a longer timeframe, you could build it out over many years, identifying the needs of veterans, vetting providers, and getting it all in place, and then starting the program. Lawmakers went in the opposite direction. The Administration didn’t vet the providers, they haven’t done market analyses – they just started the program in a rush.
Gordon: The VSOs, like the American Legion and so forth, have pushed for this, and they signed on to this bill. The long-term transition may have been what they wanted, but that was not written into the MISSION Act.
Cox: The national staff of the American Legion requested a post down in Santa Clara to hold a town hall meeting for people concerned about issues related to the Palo Alto Medical Clinic. They for this open house and to tell the national staff. Most veterans brought their issues that parking was bad or some clerk was rude to them, but most of them, even if they had complaints they said the hospital was great.
Nobody brought up privatization until I said “you know, we’ve got this VA MISSION Act, we’re all going to be screwed.” And the chair of the Committee at the American Legion said you should bring a resolution to the VA. And I said, ‘no what needs to happen in this situation is we have paid staff to watch out for us, they’re not doing their job. The American Legion and everyone else got really rolled on this issue.’ Interestingly enough, nobody from the national staff came to talk to me afterward. The level of apathy at that point was pretty intense because people have read the two-hundred-plus-page MISSION Act and that was prior to the proposed regulations.
Gordon: I spoke to someone from the Legion at a meeting in Sacramento, and I said ‘are you concerned about this?’ And he said ‘no, we’ll just have to see how it rolls out.’ Someone from IAVA said the same thing, ‘we’ll just have to see what happens.’ Well, their job is to make sure nothing bad happens not to stand by and watch it happen.
I think the power of VSOs is diminished without the VA as a target. One of their reasons for being is gone because good luck changing the practices of more than 6,000 private sector hospitals and 1.1 million physicians.
Lattanzi: They don’t think that far ahead. I’m a member of the American Legion, and an at-large member of the VFW. These things are never discussed at meetings. There’s a certain attitude within VSOs that is defeating to veterans. When stuff goes wrong, people are going to complain. But they don’t really get out in front of it – and that’s confusing.
What will you be watching for as the MISSION Act is fully implemented?
Lemle: I think there are four main takeaways here: First - the VA MISSION Act could easily lead to a privatization of veterans healthcare. VHPI has written about the VA’s active, ongoing campaign to deny that privatization is occurring. But by any common definition privatization is what’s happening. It’s important to understand the danger of funds flowing out of the VHA permanently, even while it’s being denied. Second – it is important to make sure to correctly identify who is to blame when there are problems and difficulties. We must be careful not to blame the VA providers and staff and even the VA system, without cause. The MISSION Act was imposed by vested outside interests. Federal workers are doing what they have been asked to do. The blame for the problems should be assigned to those leaders who set up an impossible task. Third - There is a danger in willingly accepting lower standards from community providers of eroding the hard-won, high quality standards inside the VA.– If VA providers are supported to do the ethical and professionally responsible thing of telling veterans that it is in their medical best interest to get care in the VA when the quality of care in the community is lacking, then I would feel more optimistic. Lastly, is a big unanswered question. Although there are some set-aside funds for Community Care, no one has an answer to where more funds will come from when these are used up. The probability is the VHA will have to draw from funds for existing staffing and programs, or there will be a reduction in veterans’ benefits – neither of which veterans want or deserve.
Gordon: Given the data that we have on practitioners adhering to best practices when people are tired and burnt out, and overworked, I fear VA providers will not get into contentious discussions with veterans about what’s in their best medical interest. Because they don’t want to erode their relationships with their patients. We have a lot of data that prescriptions of antibiotics increase when providers are tired because they’re tired and hungry and it’s the end of the day.
I predict, I wish I were wrong, but I predict that many VA providers will just say ‘You know what? I don’t care where you get a colonoscopy, I just care that you get it. And I’m not going to fight with you about it.”
It’s going to get tiring for people to have this discussion if it’s necessary over and over again. And you know, this whole idea of having providers discuss with you where you should be getting care is ridiculous. When I’m with my gastroenterologist, he doesn’t spend his precious time with me comparing his services to other doctors near me. His time is spent on telling me why I need a colonoscopy and what to expect. Only in this double standard world do we have this imposed on the VA. And if providers are discussing where the veteran should get care, they’re not talking with the veteran about their anxiety or about how to take their medication or their suicidal ideation.
Another one of the real dangers of this program is the information that we will lose about veteran conditions. The VA was able to recognize PTSD and Agent Orange and burn pits, not only because veterans pushed them to do so, but also because clinicians had pattern recognition.
And we’re going to lose the ability to identify the next Military Sexual Trauma (MST) or Burn Pits or PTSD because veterans are going to be scattered across the private sector. I think that’s partly the intent, actually. If you lose the information, then you’re not responsible for the conditions that the information brings to light. And then the taxpayer and the government is not responsible for the real costs of war.
Lattanzi: Who is going to track this falling apart? I don’t see anyone but VHPI. Unfortunately, there will likely be some pretty bad instances and experiences from veterans before anybody wakes up to the shortfalls of MISSION. I hope it’s not before the VA is actually gone.