The Veterans Choice Act and Dual Health System Use

T he Veterans Access, Choice and Accountability Act (Choice Act), formally enacted on August 7, 2014, arose largely in response to outrage about delays in veteran access to health care and falsification of wait time records by Veterans Administration (VA) employees. The law includes a number of provisions to improve care for veterans, including increasing health care staffing and residency training positions, streamlining employee disciplinary procedures, improving treatment of military sexual trauma, and establishing a Presidential Commission on Care to evaluate access to VA health care. The most well-known, and perhaps controversial, provision is the Choice Program, which established a mechanism for eligible veterans to receive care outside the VA for 3 years. Veterans unable to schedule an appointment within 30 days of their preferred date or who live more than 40 miles from a VA facility are now eligible to receive care from non-VA providers. However, many of these veterans will also continue to use VA facilities and services, and this ‘dual use’ of health care systems may lead to care fragmentation and its ensuing adverse consequences. This commentary describes the problems of dual use and care fragmentation, the complexity of the Choice Program, and some ideas for ensuring its safe and effective implementation. The challenges surrounding the implementation of the Choice Program have been monumental. In the 90 days between passage of the law and the start of the program on November 5, 2014, the VA developed a system for identifying and reaching out to eligible veterans, tracking Choice Program visits, and paying for services through the program. As of April 2015, the VA had coordinated more than 45,000 Choice Program medical appointments and dispensed more than 3,200 Choice prescriptions. However, this implementation has received tremendous public criticism because of the relatively low uptake of services compared to the perceived need for immediate care. In response, in May of 2015, the U.S. Senate unanimously voted to amend the Choice Act, expanding access to veterans living within 40 miles of a VA facility if it does not offer them the needed medical care. The measure, however, has not passed the U.S. House of Representatives. The Choice Program is not the first time that an expansion of non-VA care for veterans has increased the complexity or fragmentation of care. In 2006, the rollout of Medicare Part D prescription drug coverage gave millions of VA patients the opportunity to obtain prescription drugs through the private health care system. Despite almost 10 years having elapsed since Part D’s implementation, however, and the concerns related to dual use, there are limited data on its impact on care fragmentation among veterans. In 2014, the Affordable Care Act (ACA) again expanded access for veterans to non-VA care through both the private insurance marketplace and Medicaid. Similar concerns have been raised about increased care fragmentation with dual use as a consequence of the ACA, although the full impact will not be known for some time. Even before these insurance expansions, veterans with Medicare coverage were known to receive care through both Medicare and VA. Prior work has documented convincing evidence that dual use of Medicare and VA services comes with inherent risks of care fragmentation and duplication of services, including, for example, higher rates of hospitalization for ambulatory care-sensitive conditions, higher cost and worse outcomes in cancer, and higher rates of rehospitalization. 4 Despite the best efforts, care received outside the VA cannot be seamlessly integrated into the sophisticated electronic medical record (EMR) and decision support systems that unify the VA. Physicians outside the VA do not have access to the VA’s EMR and ordering systems, leading to risks of duplication of services, errors, and inefficient care. These risks of care fragmentation with dual use extend to the Choice Program, especially given its complexity. As an example, consider how prescription drugs are dispensed through Choice. Under the Program, non-VA providers must prescribe within the same formulary rules that guide VA providers. Choice providers do not have access to the electronic ordering with decision support that helps VA providers prescribe within formulary guidelines. In 2003, when VA temporarily implemented the Transitional Pharmacy Benefit for patients waiting more than 30 days for their initial primary care appointment, roughly 40% of prescriptions received from non-VA providers were non-formulary, substantially increasing the workload and costs for VA pharmacy. Each Choice prescription must be faxed, mailed, or delivered in person to a VA facility to be processed; verbal and telephone prescriptions Published online August 20, 2015