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Veterans air frustrations over Choice program

Hugh Lessig
Contact Reporterhlessig@dailypress.com

A congressional watchdog agency recently issued a report citing delays with the Veteran's Choice Program, which started three years ago to provide faster health care for selected veterans.

Linda Miller of Hampton says she can relate.

Miller, who served in the Army, said the Hampton VA Medical Center entered her into Veterans Choice because she faced a wait of more than 30 days for total hip replacement surgery.

That's the basic idea behind the Choice program: In lieu of long waits or drive times, a VA hospital can refer a patient elsewhere. VA launched the program in 2014 after scandals erupted over long waits at veterans hospitals in Phoenix and elsewhere.

Miller's surgery at a local hospital went well, she said, but problems began with her post-discharge care. Miller said she stayed in the hospital for eight days while hospital representatives tried to set up her rehab. Ultimately, she said she was discharged without any arrangements for in-home therapy.

For the next two weeks, she stayed home, trying to care for herself.

"I was just really depressed," she said. "I could not believe I wasn't receiving the care that I needed."

She documented her experience in a series of emails as she tried to move things along. Her primary care doctor at the Hampton VA worked on her behalf, but nothing happened quickly.

Eleven days after her discharge, she sent an email to the Hampton VA that read: "Once again, I am contacting you in regards to care ... I'm suffering alone trying to care for myself after having a major operation. Receiving no home health or therapy. Please, I am begging you for assistance."

Miller said she received visits from a physical therapist and occupational therapist about two weeks after her discharge. The home care was suppose to last two weeks. It lasted one week.

She has since gone on to outpatient therapy at the Hampton VA and is recovering at home. The therapists at the Hampton VA there are "wonderful," she says.

But the experience soured her on the Veterans Choice program, which she says is too complex and suffers from poor communication. She decided to go public in hopes that policymakers will change the program for the better. If this has happened to her, she says, it must have happened to others.

"I saw President Trump when he came here, and what he's talking about with expanding the military and taking care of them," she said. "What are you doing for them once they served their country? Are we just going to get the bare necessities and that's it?"

Hampton VA officials could not comment on individual cases, so it's difficult to say exactly what happened in Miller's case. Hospital officials acknowledged that delays are possible at several points in the process, and many veterans are frustrated.

What's more, the program's workload has required the Hampton VA to more than double the staff that work to refer patients outside the VA network. Their work has also become more complex.

But that also points to some improvements along the way — both in Hampton and throughout the program — and they are anticipating more changes as new VA Secretary Robert Shulkin settles into his job.

The Government Accountability Office's watchdog report on Veterans Choice examined cases at six VA medical centers across the country. The closest one to Hampton Roads was in Durham, N.C.

The report reviewed 55 authorizations into the Choice program for routine care. On average, it took 64 days for veterans to be referred into the program, for the referral to be accepted, and for an appointment to be completed.

Bureaucracy constricts health care

Theodore Reiff of Hampton said he had a similarly frustrating experience with Veterans Choice program. His care issues went unresolved for months, and he just recently reached the point where a slate of appointments have been scheduled.

Several months ago, he initiated a request for a pain consultation at the Hampton VA. Reiff, 87, is a retired physician, medical educator and researcher. The Reiff Center for Human Rights and Conflict Resolution at Christopher Newport University is named in his honor.

For his consultation, Reiff wanted to discuss a treatment that uses radio frequencies to alleviate nerve pain. But when he finally saw a doctor in February, whom he described as highly qualified, Reiff said the VA had not provided the doctor the equipment for that particular treatment.

Reiff was referred to the Choice program for a pain consultation. He was also in the program for two other concerns: an MRI for a painful foot and ankle injury, and a consultation with a podiatrist.

A meticulous note-taker and letter writer, he documented the often frustrating back-and-forth communication between himself, the Hampton VA and the third party provider, Health Net.

For example, he spoke to Health Net in early March and was told that only one of his requests — for the pain management consultation — was in the system. The representative said he had no knowledge of the other two. The very next day, he called again. After being transferred and waiting on the phone for 35 minutes, it was verified that all three authorizations were in the system.

His odyssey did not end there. Reiff said he discovered in mid-March that because Health Net had not scheduled the needed appointments within five days of the receipt of authorization, the authorizations were canceled, requiring the Hampton VA to resubmit the authorizations.

He found this out during a visit to the Hampton VA patient advocate's office, where staff members have been helpful. After a representative from that office spent about 30 minutes on the phone trying to resolve his case, Reiff asked to be handed the phone. He described the resulting conversation as anything but helpful.

In a letter sent to multiple organizations, including the Hampton VA and Health Net Federal Services, Reiff said, "In my discussion with the cited representative, during which I had been appropriate in language and demeanor, she began to yell at me."

Eventually, he was able to work through the system to schedule the three needed appointments, which are pending this month. And to be fair, other conversations with Health Net representatives have been more helpful. But the experience has prompted him to write to Sen. Mark R. Warner.

In a letter to Warner dated March 20, Reiff credits the health-care providers at the Hampton VA, but not the rules that constrain them.

"Most of the physicians, nurses, therapists and other VA facilities are highly qualified and dedicated to providing quality care," he wrote. "However, they do not receive adequate support from the VA bureaucracy."

Rules create frustration

Sigrid Andrew is the associate director for operations at the Hampton VA Medical Center. Neither she nor other Hampton officials could talk about specific cases, but the frustrations voiced by patients such as Miller and Reiff are not new.

She noted that VA Secretary Shulkin has talked about the importance of cutting red tape. Veterans Choice was a three-year program, scheduled to expire in August. Shulkin has said he wants to continue it, but with changes.

"He's talked about how it needs to have less steps," Andrew said. "It's very complex for the veterans and the VA staff."

Carla Garcia sees that complexity up close. She's the business manager for Non-VA Coordinated Care at the Hampton VA, which includes Veterans Choice. She cites several points in the process where a delay could occur.

First, a few basics.

A veteran can be referred to the Choice program if they require a service that a VA hospital offers, but can't provide it within 30 days — like Miller's example. They can be referred if they need a type of care that a VA hospital doesn't provide. A third reason: veterans who live 40 miles from the nearest VA facility, because the travel time is seen as an inconvenience.

When Hampton VA patients enter the Choice program, their information is uploaded to a system that can be accessed by Health Net Federal Services. This company has a contract to serve as a go-between, connecting the patient to health providers in the community.

Once Health Net picks up the case, it must call the veteran to "re-opt" them into Choice, Garcia said.

"There's a potential for a lag right there," Garcia said, "because we're opting them in and they're calling to re-verify that we opted them in."

There's more. The Hampton VA provides Health Net with a patient's available phone numbers. That might be a land line and mobile phones for work and personal use. Per the contract, Health Net can only use one number.

If a representative calls a land line the first time, he or she must call the same number the second time. A cellphone would be off limits.

After two calls, Health Net sends a letter.

Veterans "sometimes get frustrated," Garcia said. "We've already opted them in, so they think it's redundant."

Another potential snag is when Health Net asks a veteran for other insurance. That's required — again by contract.

The veteran might not want to provide it because the VA is paying for the procedures. They don't want to end up with a bill.

Delays such as this can result in Health Net kicking the case back to the VA. If that happens, everything starts over. The Hampton VA must create a new case and upload the information.

"At that point, the clock starts ticking again," said Garcia.

Changes, improvements

When Veterans Choice was introduced, an authorization to seek care outside the VA network lasted 60 days. That was a problem.

"A lot of care cannot be completed in 60 days," said Andrew. "If you have surgery, physical therapy, you might not be done in 60 days."

For expectant mothers, this was more than a problem, Garcia said. It was downright impossible.

"They're not going to give birth in 60 days," she said.

That's changed. Authorizations now last for one year, and that's a big improvement.

Sometimes, veterans who have been bounced back and forth simply call the community health-care provider directly. That's OK as long as the appointment was authorized through Choice. That veteran will end up with a bill, but Choice will cover it, Garcia said.

The Hampton VA offers other solutions for veterans whose cases get kicked back from Health Net. One fix is a simple one: A three-way phone conversation between the veteran, the Hampton VA and Health Net, Garcia said.

The other involves the Hampton VA making a direct referral by signing agreements with community providers. The workaround allows Hampton to use Choice funds, but bypass Health Net.

"We're kind of reverting back to what we used to do," Garcia said. "This allows us to use Choice funding instead of facility funding."

The hospital is working on other improvements as well. As part of a pilot project, the hospital welcomed a Health Net specialist on site. The specialist focuses on urgent cases and helps resolve conflicts that would otherwise require a phone call or two.

"We're so thrilled to have her," Garcia said. "It's such a positive thing because she gets to know the providers locally and build those relationships.

Lessig can be reached by phone at 757-247-7821.

Legislative update

The Senate this week approved legislation that would extend the Veterans Choice program, the Associated Press reported.

It would allow the program to continue operating until its money runs out, expected to be early next year. Absent any legislation, the program will expire on Aug. 7 with nearly $1 billion left. The VA wants to use that money to continue to provide care until the program can be changed, AP said.

The House will now consider the bill.

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