Lawmakers on Capitol Hill mulling legislation to extend a program that lets veterans seek health care in the private sector have revived their longstanding complaints about long wait times for care at the Veterans Health Administration facilities. Veterans Affairs Secretary David Shulkin and Dr. Baligh Yehia, the agency's assistant under secretary, appeared before the House Committee on Veterans Affairs to testify on HR 369, a bill that would allow the Veterans Access, Choice, and Accountability Act to continue past its sunset date of August 2017.
In 2014, after revelations of wait-time problems at some Veterans Health Administration (VHA) facilities, Congress created the three-year Choice program allowing eligible veterans to seek care in the private sector if they live 40 miles from a VHA facility or have to wait for more than 30 days for an appointment. The bill would let the VHA spend what remains of the initial $10 billion (about $1 billion) allocated to Choice on care in the private sector.
At the hearing earlier this month, House Committee on Veterans Affairs Chairman David "Phil" Roe, a Republican from Tennessee, complained of VHA wait times as long as 81 days. His comments and those made by other committee members suggest that congressional Republicans are determined to ignore any evidence that outsourcing care to private sector providers won't do much to improve access to or coordination of care for veterans. They seemed unaware, for example, that wait times for private-sector health care are also a significant problem.
A 2014 study of wait times in American hospitals by health-care consulting firm Merritt Hawkins found long wait times and large disparities depending on location. In their just released 2017 study of wait times, the firm found that wait times in 15 metropolitan areas had increased by 30 percent since 2014. The average wait time for a new physician appointment was 24 days. In Boston, the average wait time to see a family physician was 109 days while in Albany patients had to wait 122 days. Some practices were entirely closed to new patients. In Boston patients who had to wait to see a cardiologist for 133 days in 2014 were now waiting as much as 365. In Houston the longest wait for a heart doctor jumped from 26 to 43 days. In Denver the longest wait to see a dermatologist went from 180 to 365 days while the shortest delays increased from one to seven.
A 2013 Commonwealth Fund report found that, of those adults surveyed, 26 percent reported six or more days for a primary care appointment when they were actually "sick or needing care." As the report stated "Among the 11 nations studied in this report; Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States-the U.S. ranks last, as it did in 2010, 2007, 2006, and 2004."
The American Prospect recently reported on an independent assessment of VHA performance and access which concluded that, "Enrollees living more than 40 miles from VA facilities are much less likely to have geographic access to specialized services in non-VA hospitals … they are much less likely to have access to academic and teaching hospitals, the sites in which more complex care is offered."
VHA wait times mirror those in the private sector for the same reason, a nationwide shortage of primary care providers and mental health professionals. Another contributing factor is that a government agency like the VHA is unable to offer market-rate salaries to healthcare professionals. In high-cost urban areas, health care professionals who want to work at the VHA are being offered thousands, sometimes tens of thousands, more in the private sector. Not surprisingly, they follow the money. During the committee's three-hour hearing, the issue of how low pay affected the quality of care never came up.
Committee members also considered another Choice Program problem, the coordination of care between VHA and private sector providers. Committee members offered a number of short-sighted observations, including defining care coordination exclusively in terms of giving private sector providers access to the VHA's electronic medical records.
Coordinating care for VHA patients who are, on average, sicker, older, poorer, and have more chronic mental health conditions than their counterparts in the private sector, requires far more than access to data. The VHA has pioneered a model of care coordination: Clinicians who work in the VHA system and often in the same work on multidisciplinary teams that have been trained to engage in face-to-face communication (sometimes via Telehealth) about the complex needs of their patients.
As many studies have consistently documented, this is one of the main reasons that the VHA often delivers care that is superior to that treatment delivered by private sector providers. It is also why, as Dr. Shulkin testified, of the 1.2 million veterans who have had appointments through the Choice program in the private sector, only 5,000 of them chose to receive care only from private sector providers.
Shulkin has promised to unveil a new version of the program, what he likes to call Choice 2.0, sometime this fall. The future of the VHA will depend on how this program is configured and if members of Congress are willing to consider whether private sector providers can actually deliver high quality care. The Choice program has not worked well because it was designed hastily and implemented far too rapidly. If the recent House hearing is any indication, Congress may be poised to repeat history with Choice 2.0.
This story has been updated to include newly released data on wait times.
