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The Veterans Choice Act: A Qualitative Examination of Rapid Policy Implementation in the Department of Veterans Affairs

Mattocks, Kristin M. PhD, MPH*,†; Mengeling, Michelle PhD, MS‡,§,∥; Sadler, Anne RN, PhD‡,¶; Baldor, Rebecca MPH*; Bastian, Lori MD, MPH#,**

doi: 10.1097/MLR.0000000000000667
Original Research
Free

Background: Congress enacted the Veterans Access, Choice, and Accountability Act of 2014 [Veterans Choice Act (VCA)] to improve access to timely, high-quality health care for Veterans. Although Congress mandated that VCA must begin within 90 days of passage of the legislation, no guidelines were provided in the legislation to ensure that Veterans had access to an adequate number of community providers across different specialties of care or distinct geographic areas, including rural areas of the country.

Objective: To examine VCA policy implementation across a sampling of Veterans Health Administration (VHA) Medical Centers.

Research Design: We conducted a qualitative study of 43 VHA staff and providers by conducting in-person interviews at 5 VA medical centers in the West, South, and Midwest United States. Interview questions focused on perceptions and experiences with VCA and challenges related to implementation for VHA staff and providers.

Results: We identified 3 major themes to guide description of choice implementation: (1) VCA implemented too rapidly with inadequate preparation; (2) community provider networks insufficiently developed; and (3) communication and scheduling problems with subcontractors may lead to further delays in care.

Conclusions: Our evaluation suggests that VCA was implemented far too rapidly, with little consideration given to the adequacy of community provider networks available to provide care to Veterans. Given the challenges we have highlighted in VCA implementation, it is imperative that the VHA continue to develop care coordination systems that will allow the Veterans to receive seamless care in the community.

*VA Central Western Massachusetts Healthcare System, Leeds

Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA

Center for Comprehensive Access & Delivery Research and Evaluation (CADRE)

§VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region (VRHRC-CR), Iowa City VA Medical Center

Departments of Internal Medicine

Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA

#VA Connecticut Healthcare System, West Haven

**Department of General Internal Medicine, Yale University School of Medicine, New Haven, CT

Supported by Veterans Health Administration QUERI VCA.

The opinions expressed here are those of the authors and do not represent the official policy or position of the US Department of Veterans Affairs.

The authors declare no conflict of interest.

Reprints: Kristin M. Mattocks, PhD, MPH, Staff/Research, VA Central Western Massachusetts Healthcare System, Building 12, Room 113, 421 North Main Street, Leeds, MA 01053. E-mail: kristin.mattocks@va.gov.

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BACKGROUND

In response to highly publicized concerns regarding Veteran deaths and Veterans’ access to care in the Veterans Health Administration (VHA), Congress enacted the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113–146) [Veterans Choice Act (VCA)] to improve access to timely, high-quality health care for Veterans. PL 113–146 allowed VHA to expand the availability of hospital care and medical services for eligible Veterans through agreements with eligible non-VHA entities and providers through section 101 of the Act (38 CFR 17.1500). Veterans already enrolled in VA health care and who were waiting longer than 30 days for VHA care would be eligible for non-VHA (Choice) care through an approved non-VHA provider. Similarly, Veterans residing further than 40 miles from the nearest VA medical center (VAMC) or community-based outpatient clinic (CBOC), or Veterans residing in a state or territory without a full service medical facility, would also be eligible for Choice care.

In May 2015, Public Law 114–19, the Construction Authorization and Choice Improvement Act of 2014, was signed into law and expanded the eligibility of Veterans to use the Choice Act by redefining limitations of the 40-mile rule due to unusual and excessive burden for travel to a VHA medical facility. For example, Veterans may still meet the 40-mile eligibility if travel is <40 miles but that travel involves geographic or environmental challenges such as mountain passes, roads through restricted areas (military bases), or hazardous weather conditions. Overall, ∼70% of those initially approved for Choice care were those Veterans who had been waiting longer than 30 days for care, whereas the remaining 30% were for Veterans who lived >40 miles from the nearest VAMC or CBOC. When the legislation was first introduced, ∼350,000 Veterans were eligible for Choice, either through wait time or distance standards.

All non-VHA care provided through VCA was subcontracted to 2 large contractors, Health Net and Tri West, to assist VHA in administering the Choice program. The contractors were responsible for managing Choice program card distribution, a call center to assist Veterans with problems related to Choice appointments, Veteran counseling, provider management, appointment management, reporting, and billing. Community providers interested in joining the Choice network were required to enter into an agreement with VHA to furnish care, maintain similar credentials, and licenses as VHA providers and provide medical documentation back to VHA after providing care to Veterans. Although Congress mandated that VCA must begin within 90 days of passage of the legislation, no guidelines were provided in the legislation to ensure that Veterans had access to an adequate number of community providers across different specialties of care or distinct geographic areas, including rural areas of the country.

Policy revisions of the VCA magnitude present substantial implementation challenges for VHA, which is the largest integrated health care system in the country, with 150 VAMCs across 50 states and nearly 9 million Veterans enrolled in VHA care and 6 million Veterans who use VHA care annually.1 In itself, VCA also represents a substantial departure in VHA care policy, as historically VHA has sought to limit use of non-VHA care by requiring its Veterans to receive care within VHA facilities, even Veterans who were required to drive hundreds of miles to the nearest VHA facility to receive needed care. With the implementation of Choice, however, many Veterans who would have previously waited weeks or months for VHA care were being referred to Choice care, and previous research suggests that receiving care from 2 different health care systems presents an opportunity for poor care quality due to fragmentation, lack of coordination, and poor communication between 2 health care systems that do not share the same electronic health record.2–6

Therefore, the goal of this study was to examine perceptions and experiences with implementation of Choice among a sample of VHA providers and staff at 5 VAMCs.

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METHODS

We conducted a qualitative study of VHA staff and providers by conducting in-person interviews at 5 VAMCs in the West, South, and Midwest United States. These facilities were chosen because their rural locations were conducive to understanding Choice implementation, especially among Veterans who may be eligible for Choice due to their lack of geographic proximity to the closest VAMC or CBOC.

We sent a study introduction letter to each VAMC director explaining the study, and asked to interview VHA staff and providers at each facility most familiar with VCA. Once we received permission from the VAMC Director, we asked the Director to identify the appropriate individuals at each facility to interview, and then contacted those individuals. Because we had an email of support from each VAMC Director, we had a 100% response rate of the targeted individuals to interview. Specifically, we sought interviews with the VAMC Director, Business Office Manager (and/or Choice Champion, who was responsible for working with Tri West and/or Health Net to ensure Veterans were scheduled for non-VHA appointments), the Chief of Staff or Chief of Ambulatory Care, the Chief of Mental Health, and 1–2 Designated Women’s Health Providers, so that we could be sure to understand Choice for women Veterans. Interview questions focused on perceptions and experiences with VCA and challenges related to implementation for VHA staff and providers. Each interview lasted ∼45 minutes and all interviews were conducted between May and August 2015. Across all 5 VAMCs, we interviewed 43 VHA directors, staff, and medical providers familiar with the Choice program.

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Data Collection and Analysis

A semistructured interview guide was developed for VHA staff and providers that allowed respondents to talk freely about their knowledge of VCA, their perceptions of VCA implementation at their facility, and their views on challenges related to VCA care coordination for Veterans. The interview guide was revised during the course of data collection and analysis so that categories and dimensions (properties) of categories could be found and more fully explored. Interviews were audio-recorded, transcribed, and entered into Atlas.ti, a qualitative analysis software program.

Transcribed qualitative data from interviews were analyzed using standard qualitative analysis methods.7 Analysis was guided by the constant comparative method, a systematic data coding and analysis procedure.8 In this approach, specific quotes from participants are categorized into themes with the use of codes (tags or labels assigning meaning to segments of text) developed iteratively to reflect the data. Each transcript was read in its entirety by 2 members of the study team to gain a sense of each participant’s experience. We used open coding, where each coder independently reviewed the transcripts line-by-line, creating code definitions as concepts emerged inductively from the data. Coders met to compare codes, resolve discrepancies, and review the code structure. Codes were refined until we reached a final coding structure, including a total of 20 codes capturing the major concepts in the data, which was then applied to all of the transcripts. The themes presented in the current analysis emerged from specific codes focused on knowledge, perceptions and experiences with VCA, and challenges related to VCA implementation.

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Findings

Using information gained from our interviews with VHA staff and clinicians, we identified 3 major themes to describe participants’ perceptions and experiences with Choice implementation. Those themes were: (1) VCA implemented too rapidly with inadequate preparation; (2) community provider networks insufficiently developed; and (3) communication and scheduling challenges with subcontractors may lead to delays in care.

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VCA Implemented Too Rapidly With Inadequate Preparation

Across all 5 VAMCs, VHA administrators, staff, and clinicians spoke of highly complex, confusing, and rapidly changing processes related to provision of Choice care. Participants noted that VCA guidelines were “pushed out to the field” (VAMCs) from VA Central Office with little time allotted to fully understand and implement the policies at the local level and little regard for local staffing availability to support programmatic changes associated with Choice. Several VAMC administrators noted that their facilities were severely understaffed to comply with VCA regulations, and 1 manager noted that she had to hire 5 additional nurses over a 3-month period just to keep up with the number of Choice consults entered into the system. One VHA facility director commented on the challenges of implementing a national policy at the local level in a rapidly changing policy environment.

Choice was rapidly implemented, without a lot of instruction and discussion ahead of time. The rapid implementation caused a lot of problems. And since then, it’s gone through a lot of iterations and changes, with the 40-mile rule and all that. And now they’ve got something called Choice First. And so the speed at which it was rolled out and the number of changes already has led to mass confusion for our staff here, trying to keep up on what the latest rule and regulation of the week is.

Other facility directors recognized the value in Choice, but thought VHA could have thought more carefully about how existing community relationships could have been better leveraged to address wait time problems and improve care coordination between VA and non-VA providers.

Choice was a good idea. It was giving resources so that Veterans could access care in the community when their VA couldn’t provide it. I applaud that. I think that’s great. I think where we fell down significantly and severely was creating another process. We had to do it in 90 days and that is a Herculean feat to do in a couple of years, let alone 90 days. I think it would have been my preference if they turned to the VAs and had said “What do you need to coordinate care in the community? Do you need more nurse care coordinators? Do you need more providers?” Because we’ve been doing this a long time. I know who my providers are in the community that provide good care. And so, so that knowledge of the community, and those relationships with the community … I think that if we leveraged that, and said, use the non-VA care process you have, and you leverage those partnerships in the community, and you follow these rules, where if you can’t get them in within 30 days, or they live more than 40 miles away, you coordinate their care in the community. I think that we, locally, could have figured it out better and faster, and we would have had fewer upset Veterans.

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Community Provider Networks Insufficiently Developed

One problem identified by participants across all VAMCs was the relatively small number of community providers enrolled in the Choice program to provide care for Veterans. Many staff and providers at rural VAMCs noted that the availability of specialty providers across the state or region was low to begin with, particularly for highly specialized fields like gynecologic oncology. As a result, many Veterans who may have had to wait 35 days for care in the VA were being shifted to the community, where wait times could approach 3–6 months for certain specialty services. However, because VCA mandated that all Veterans with wait times longer than 30 days must be placed on the Veterans Choice List and receive care in the community, many Veterans were transferred from long VA waiting times to long community waiting times. One VHA staff member noted the tension in sending the Veteran out for Choice care in the community when she knew the community wait times were longer than they were in the VA:

So even if we’re scheduling over 30 days in the VA, telling them to go to Choice, we only have specialists, maybe one deep, in the whole state sometimes. And so the wait times in the community are just as long, and it becomes this tedious process, and putting the Veteran through having to call, and go through that long process, only to be told that they’re scheduled just as far out in the community as he is in the VA.

Another VHA staff member echoed these sentiments, and spoke about how difficult it was to encourage community providers to participate in Choice when there were not that many community providers available in the first place:

The number of Choice providers we have has gotten off to a slow start. There just aren’t that many {providers} around as there are in some of the bigger places, you know? I’m sure places like Ohio, California, New York—the magnitude and volume of providers available there outpace what we could ever hope to have here in our state.

Several participants interviewed also talked about the VA’s existing relationships with community providers, and how the Choice program did not appear to value existing relationships with community providers. Especially in some of the small, rural VA facilities VHA staff and providers noted that the VA had enjoyed long-standing relationships with community partners, and that Choice had introduced an element of discontinuity in those relationships.

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Communication and Scheduling Problems With Subcontractors May Lead to Further Delays in Care

Across all 5 VAMCs, one of the biggest problems identified with Choice implementation was working with the subcontractors (Health Net and Tri West), and the length of time it was taking them to schedule appointments with community providers. Nearly all staff members spoke of the significant disparity between the number of consults they had entered into the system and the number of scheduled appointments that had been made for Veterans:

In two months’ time, we have entered 500 patients on the Veterans Choice List, and only 60 have come back to us as being scheduled. So basically, in two months, you have, you have 450 people who are just waiting for a scheduled appointment. And when I talk to them, you know, I’ve gotta put on a nice face and say, we hope that this works just right for you, and you should receive a call within seven days. But, in the back of my mind, I’m saying, it’s gonna be 30 days. But I can’t say that to them. That’s not good care. That’s not good customer service.

One VHA women’s health provider spoke of his frustration trying to get a specialty care appointment scheduled with his patient.

I did an endometrial biopsy on her, and she had endometrial sarcoma, which is an aggressive endometrial cancer. The closest gyn-oncologist is 400 miles away, and I needed to get this gal there. Eventually, two and a half weeks later, she finally got an appointment. But it took an intense amount of … pressure isn’t the right word, but fastidiousness to stay on top of it. And the reason she finally got an appointment is that this case sat on my desk, and every day or two I would call (patient) for an update. So it’s a little disturbing to think a patient with this kind of cancer who had myself and multiple people really watching this and it took this long to get her in. In the private sector, I would have this gal scheduled for an appointment within a day.

The existence of the subcontractors in negotiating the relationship between the VHA and community providers resulted in additional confusion, and gave rise to delays in care. These relationships with community providers have been especially complicated by the existence of the call center, which is comprised of either Tri West or Health Net contracted employees. Nearly all those interviewed spoke of frustrations with contract call center employees and their lack of knowledge of Veteran patients.

Now, I know the contractors are struggling, you know, and I these hear these reports where they’ve hired 4000 more people. And I’m like why would you hire 4000 people? How are you gonna train 4000 people? And then I find out that they didn’t really hire 4000 people. They subcontracted with a call center who knows nothing about the VA. But they were answering the phone before they had access to the computer systems. So I would call and say, I’m (name), I’m a Veteran, you know, my VA put in a consult, they told me to call you in three days. And they say we can’t see it. They had no access to any of the systems. None! They had no clue who the Veterans were, or why they were calling them. So they were just answering the phone, listening to the people talk, and say, I’m sorry, I don’t see that in the system.

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DISCUSSION

This study represents one of the first comprehensive assessments of the implementation of the Veterans Access, Choice, and Accountability Act of 2014, a policy developed with the goal of broadening access to care for Veterans in VHA care. Our evaluation suggests that VCA was implemented far too rapidly, with little consideration given to the adequacy of community provider networks available to provide care to Veterans. Furthermore, the rapid implementation did not allow time for training of VHA staff regarding provisions of the Choice directive, nor for the development of systems of communication between Veterans, VHA staff, and Third Party Administrators regarding eligibility and scheduling of non-VHA care. The rapid policy implementation also left VHA facilities without adequate staffing or financial resources to handle the additional administrative burden of managing Choice, and left Veterans confused about the new system of care.

Because Congress mandated that Choice be implemented within 90 days of legislation, the VHA was responsible for developing, disseminating, and launching a massive new care delivery program to all 150 VAMCs and 500,000 Veteran users initially eligible for Choice over a period of 3 months. Veterans who had become accustomed to contacting their VHA providers directly for questions related to their health care were now directed to third party call centers, and call center employees were often uninformed of Veterans’ specific health care needs or conditions as they did not have direct access to VHA medical records. Veterans experienced substantial delays while waiting for their non-VHA appointments through Choice, and often, these wait times were longer than the VHA waiting time would have been had their appointment remained in the VHA.

Furthermore, because all providers must register as Choice providers with either Health Net or Tri West before they are able to provide non-VHA care, it has taken a substantially longer period of time to build sufficient provider networks in the community for non-VHA care. Although most commercial health plans, as well as Medicaid and Medicare, are required to meet network adequacy standards set by regulatory and accrediting bodies,9 no such network adequacy standards currently exist in the VHA Choice program, and so there have been uneven distributions of provider networks, both by geographic area as well as by medical care specialty. For example, near the end of the first year of VCA, only 6 obstetricians were registered as Choice providers for the entire state of Montana. Examining ways to increase community provider participation will be especially important for specialty care services, especially in more rural areas of the country where specialty care services are already insufficient.

Recently, in an effort to address many of the problems associated with Choice, Congress enacted PL 114–41 (Surface Transportation and Veterans Health Care Choice Improvement Act of 201510) to consolidate all purchased care programs into 1 New Veterans Choice Program. The Veterans Choice Program aims to clarify eligibility requirements, build on existing infrastructure to develop a high-performing network, streamline clinical, and administrative processes, and implement a continuum of care coordination services. Importantly, PL 114–41 points to the importance of comprehensive care coordination services, including patient navigation, care/disease management, and case management in the context of information technology systems that allow the sharing of information between VHA and non-VHA entities. Given the challenges we have highlighted in VCA implementation, it is imperative that the VHA continue to develop care coordination systems that will allow the Veterans to receive seamless care in the community.

This study has several limitations. First, only 5 VAMCs were included in the analysis, and therefore a broader examination of VCA implementation issues is warranted. Second, the evaluation spanned a critical implementation period during the first year after VCA was implemented, and many of the early implementation problems may be addressed over time. Third, this study focuses only on the experience of VHA staff and providers, and not on the experience of Veterans. However, further research should continue to examine implementation problems with regard to Choice, particularly in the area of patient satisfaction, provider networks, and quality of non-VHA care.

The VCA represents an opportunity for the VHA to ensure that Veterans receive timely, high-quality care from knowledgeable providers, whether those providers are in the VHA or in the community. Although VHA medical centers provide a wide range of services including traditional hospital-based, specialty care, and outpatient services, the volume of Veterans requiring care may occasionally give rise to more timely care provided by community providers. When non-VHA care is necessary, the VHA should continue to ensure that sufficient numbers of community providers are enrolled in the Choice network, and that strong systems of communication and care coordination are developed between VHA and non-VHA providers.

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REFERENCES

1. US Department of Veterans Affairs. Veterans Health Administration. About VHA. Available at: www.va.gov/health/aboutVHA.asp. Accessed November 7, 2016.
2. Lampman MA, Mueller KJ. Experiences of rural non-VA providers in treating dual care Veterans and the development of electronic health information exchange networks between the two systems. J Rural Soc Sci. 2011;26:201–209.
3. Nayar P, Nguyen A, Ojha D, et al. Transitions in dual care for Veterans: non-federal physical perspectives. J Community Health. 2013;38:225–237.
4. Gaglioti A, Cozad A, Wittrock S, et al. Non-VA primary care providers’ perspectives on comanagement for rural Veterans. Mil Med. 2014;179:1236–1243.
5. Borowsky S, Cowper D. Dual use of VA and non-VA primary care. J Gen Int Med. 1999;14:274–280.
6. Ross J, Keyhani S, Siu A, et al. Dual use of Veterans Affairs services and use of recommended ambulatory care. Med Care. 2008;46:309–316.
7. Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative data. BMJ. 2000;320:114–116.
8. Glaser B, Strauss A. The Discovery of Grounded Theory Research: Strategies for Qualitative Research. Chicago: Aldine; 1967.
9. National Committee on Quality Assurance. Network adequacy and exchanges. 2013. Available at: https://www.ncqa.org/Portals/0/Public%20Policy/Exchanges&NetworkAdequacy_2.11.13.pdf. Accessed November 7, 2016.
10. H.R. 3236. Surface Transportation and Veterans Health Care Choice Improvement Act of 2015. Title IV—Veterans Provisions. 2015. https://www.congress.gov/bill/114th-congress/house-bill/3236/text. Accessed November 7, 2016.
Keywords:

veterans; health care access; choice; policy; implementation

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