House Veterans’ Affairs Committee Issues Report on VA Care in Community Act (Part 1 of 3)

WASHINGTON, March 7 -- The House Veterans' Affairs Committee issued a report (H.Rpt. 115-585) on legislation (H.R. 4242) to amend title 38, U.S. Code, to establish a permanent VA Care in the Community Program. The report was advanced by Rep. Phil Roe, R-Tennessee, on March 5.

Excerpts of the report follow:

Purpose and Summary

H.R. 4242, as amended, the "VA Care in the Community Act," would improve the provision of care and services to veterans through Department of Veterans Affairs (VA) medical facilities and through VA providers in the community. Representative David P. Roe of Tennessee, the Chairman of the Committee on Veterans' Affairs, introduced H.R. 4242 on November 3, 2017.

Background and Need for Legislation

TITLE I--IMPROVED ACCESS FOR VETERANS TO NON-DEPARTMENT OF VETERANS AFFAIRS MEDICAL CARE

VA operates the largest integrated health care system in the country and provides care to approximately nine million veteran patients.1 The majority of the health care that veterans receive through VA is provided by VA-employed medical professionals and support staff at VA medical facilities, which are managed by the Veterans Health Administration (VHA).2 However, since 1945, VA has also collaborated with medical professionals and support staff in the community who are not VA employees to provide veterans with timely, accessible, high- quality care.3 This is generally referred to as "community care" though has previously been referred to as "non-VA care," "fee basis care," or "purchased care." Over time, Congress has authorized VA to use community care when a needed clinical service cannot be provided by a VA facility and the veteran cannot be transferred to another VA facility, when VA cannot recruit a needed clinician, when a veteran cannot access a VA facility due to geographic inaccessibility, when there is an emergent situation in which a delay in care in order to travel to a VA facility could be considered life-threatening, and in order to meet patient wait time standards.

1About VHA. Veterans Health Administration. https://www.va.gov/ health/aboutVHA.asp. Accessed November 14, 2017.

2United States Cong. House Committee on Veterans' Affairs. "The State of VA's Fiscal Year 2015 Budget" June 25, 2015. 114th Cong. 1st sess. Washington: GPO, 2015 (statement of the Honorable Sloan Gibson, Deputy Secretary of Veterans Affairs).

3January 11, 2017, MyVA Advisory Committee Meeting, Georgetown University, Washington, D.C.

The most recent VA community care authority is the Choice program (Choice). Choice was established by the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113- 146; 128 STAT. 1754). Choice expanded the availability of community care to veteran patients by setting specific triggers that would require VA to give veterans the option of receiving care in the community rather than in a VA medical facility. In general, veterans are eligible to receive care through Choice if they are unable to secure an appointment at a VA medical facility within 30 days or if they reside more than 40 miles from the nearest VA medical facility. Through Choice, veteran patients are referred to regional networks of community providers who are managed by Third Party Administrators. However, under other community care programs, VA refers veteran patients to community providers through agreements with the Indian Health Service, the Department of Defense, or academic affiliates; through the Patient Centered Community Care program; or through national or local contracts or sharing agreements.4

4United States Cong. House Committee on Veterans' Affairs. "The State of VA's Fiscal Year 2015 Budget" June 25, 2015. 114th Cong. 1st sess. Washington: GPO, 2015 (statement of the Honorable Sloan Gibson, Deputy Secretary of Veterans Affairs).

Each of VA's current community care programs and authorities contain different eligibility criteria, reimbursement rates, payment structures, referral and authorization requirements, and contracting approaches.5 According to VA, "this has resulted in a complex and confusing landscape for veterans, community providers, and [the] VA employees that serve and support them."6 As a result, "veterans face excessive bureaucracy, access based on administrative eligibility, and minimal care coordination [which] inhibits the delivery of high-quality personalized care."7 This led VA and the Committee to conclude that, "it is imperative for VA to modernize how care is provided through a high performing integrated network which includes care provided both in VA and in the community."8

5January 11, 2017, MyVA Advisory Committee Meeting, Georgetown University, Washington, D.C.

6May 24, 2017. U.S. Department of Veterans Affairs Fact Sheet. "A Consolidated and Modernized VA Community Care Program."

7Ibid.

8Ibid.

That imperative has been exacerbated by a significant increase in veteran demand for community care in recent years. Since the establishment of Choice in fiscal year 2014, community care appointments have increased by 61 percent overall and by 41 percent as a percentage of total VA appointments.9 In fiscal year 2016, 31 percent of all completed appointments across the VA health care system were held in the community.10 However, Choice represents a relatively small portion of the overall community care landscape, accounting for just 23 percent of all community care appointments in fiscal year 2016.11

9January 11, 2017, MyVA Advisory Committee Meeting, Georgetown University, Washington, D.C.

10United States Cong. House Committee on Veterans' Affairs. "The State of VA's Fiscal Year 2015 Budget" June 25, 2015. 114th Cong. 1st sess. Washington: GPO, 2015 (statement of the Honorable Sloan Gibson, Deputy Secretary of Veterans Affairs).

11January 11, 2017, MyVA Advisory Committee Meeting, Georgetown University, Washington, D.C.

Despite the increased demand for and utilization of community care, VA has struggled to effectively administer community care programs and veterans do not always receive timely care when utilizing community care. For many years, the VA Inspector General has documented substantial problems with VA's management of community care programs, including issues authorizing and scheduling appointments, managing consults, ensuring network adequacy, and promptly paying community providers.12 The IG concluded that, "our audits, reviews, and inspections have highlighted that VA has had a history of challenges in administering its purchased care programs. Veteran's access to care, proper expenditure of funds, timely payment of providers, and continuity of care are at risk to the extent that VA lacked adequate processes to manage funds and oversee program execution."13 The Government Accountability Office (GAO) has found similar problems with community care programs. Most recently, in March 2017, GAO found that veterans who were referred to Choice for routine care because such care was not available through a VA medical facility in a timely manner could potentially wait up to 81 calendar days to obtain Choice care.14 GAO also found that VA had failed to establish standardized processes and procedures for Choice, to issue program guidance, and to track or monitor how long it took VA medical centers to refer a veteran to Choice (a process which GAO found was duplicative and could take as long as 21 days).15

12United States Cong. House Committee on Veterans' Affairs. "Shaping the Future: Consolidating and Improving VA Community Care" March 7, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement of the Honorable Michael Missal, Inspector General, U.S. Department of Veterans Affairs).

13Ibid.

14United States Cong. House Committee on Veterans' Affairs. "Shaping the Future: Consolidating and Improving VA Community Care" March 7, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement of Randall B. Williamson, Director, Health Care, Government Accountability Office).

15Ibid.

The Committee concurs with the IG and GAO regarding the long history of challenges with regard to VA community care programs. The Committee also concurs with VA's assessment about the need to consolidate VA's multiple community care programs and authorities in order to create a more seamless network of care in VA medical facilities and in the community to better serve veterans and achieve improved health outcomes, patient satisfaction, care coordination, and efficiency.16 Accordingly, Title I of the bill would establish a permanent VA Care in the Community Program (the Program) to provide hospital care, medical services, and extended care to veteran patients through contracts or agreements with network providers. In this program, VA would be required to establish regional networks of community providers and to coordinate the care veterans receive through network providers as well as provide case management, where appropriate. A veteran would be eligible to receive primary care through the Program if VA is unable to assign that veteran to a primary care provider in a VA medical facility and would be eligible to receive specialty care through the Program if that veteran is referred by his/her primary care provider. In determining whether or not to provide specialty care to a veteran in a VA medical facility rather than through the Program, VA would be required to consider whether the VA medical facility is within a reasonable distance of the veteran's residence and to take into account any unusual or excessive travel burdens and geographical or environmental challenges the veteran may face, the veteran's medical condition, and the recommendation of the veteran's primary care provider. Once a veteran is referred to a community provider through the Program, VA would be required to ensure that the veteran receives care through the completion of an episode of care including specialty and ancillary services and to ensure appropriate medical documentation of such care is returned to VA. VA would be required to establish a process to review disagreements regarding the eligibility of a veteran to receive care or services from a community provider using the Program. Under the Program, community providers would be reimbursed in accordance with Medicare rates with certain exceptions allowed for, for example, highly rural areas, Alaska, states with all- payer models, and federal or tribal entities. In addition, VA would be authorized to enter into value-based reimbursement models. To ensure the care veterans receive through the Program is high quality, VA would be required to develop quality standards to track the quality of network providers.

16May 24, 2017. U.S. Department of Veterans Affairs Fact Sheet. "A Consolidated and Modernized VA Community Care Program."

Title I of the bill would require the Program to be funded out of the Community Care account established by the Surface Transportation and Veterans Health Care Choice Improvement Act of 2015 (Public Law 114-41; 129 STAT. 443) and stipulate that remaining funds, if any, in the Veterans Choice Fund established by the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113-146; 128 STAT. 1754) to be transferred to the Community Care account one year after enactment. Importantly, it would also terminate VA's existing care in the community programs and authorities upon commencement of the Program, which would occur no later than one year after enactment via interim final regulations after VA has certified to Congress that each community care provider and VA employee is trained to furnish care under the Program and has established standard, written guidance with respect to the policies and procedures of the Program.

The Committee strongly believes that VA's ability to accurately process timely payments to community provider providers in compliance with the prompt payment rule is critical to the Program's success and to ensuring access to community care for the increasing number of veterans who rely on it. However, in 2014, GAO issued a report which found that community providers experienced "lengthy delays" in the processing of their claims that, in some cases, took years to resolve.17 According to GAO, this resulted in an environment where community providers are hesitant to provide care to veterans due to fears they will not be paid for services provided on VA's behalf.18 These findings were echoed in testimony GAO provided in 2016, which stated that "the substantial increase in utilization of VA care in the community programs poses challenges for VHA, which has had ongoing difficulty processing claims from community providers in a timely manner."19 As such, Title I of the bill would also establish a prompt payment standard in which claims are required to be submitted 180 days after care is provided (or a network provider is paid by a contractor) and clean paper claims are either paid or denied within 45 days of receipt and clean electronic claims are either paid or denied within 30 days of receipt. If a claim is denied and additional information has been submitted, adjudication would be required within 30 days of receipt. Pursuant to this authority, VA would be required to pay interest payments for overdue claims, allow for the recovery of overpayments through deductions of future payments or refunds from the claimant, and prohibited from requiring receipt of medical records as a requisite for payment. Title I of the bill would also require VA to establish a Center for Innovation to test and develop innovative pilot models for payment and service delivery for community care. The Committee believes this could potentially reduce expenditures while preserving or enhancing the quality of care furnished by VA.

17GAO-14-175, Actions Needed to Improve Administration and Oversight of Veterans' Millennium Act Emergency Care Benefit. http:// www.gao.gov/assets/670/661404.pdf.

18Ibid.

19United States Cong. House Committee on Veterans' Affairs, Subcommittee on Health. "Choice Consolidation: Improving VA Community Care Billing and Reimbursement" February 11, 2016. 114th Cong. 2nd sess. Washington: GPO, 2016 (statement of Randall B. Williamson, Director, Health Care, U.S. Government Accountability Office).

The Committee recognizes that, in certain cases, veterans may require community care outside of the Program. In general, VA's community care authorities utilize traditional Federal Acquisition Regulation (FAR)-based contracts to do business with private providers. However, the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113-146; 128 STAT. 1754) granted VA the authority to purchase community care through non-FAR based provider agreements. This was in recognition of the difficult and sometimes burdensome processes and requirements that the FAR imposes on community providers who are small or unaccustomed to federal contracting. VA has requested legislative authority to enter into non FAR-based provider agreements since 2015.20 In particular, some community providers have cited their classification as federal contractors subject to the audit and reporting requirements of the Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) as especially onerous. VA has claimed that provider agreement authority would ". . . ensure that veterans receive the necessary care they earned through the fullest complement of non-VA providers" and, the absence of such authority, "has resulted in complications with extended care providers and other [non-Choice providers as] some small, long- term care facilities have already withdrawn their support of veterans due to the overwhelming administrative requirements of the FAR."21 The American Health Care Association concurs and has testified about the "onerous reporting requirements and regulations" that have "dissuaded nursing care centers from admitting VA patients" which "limits the care available to veterans needing long term care in their local communities."22 This has created an acute need in some areas, particularly for those veterans who live in rural areas where VA facilities are far away and community providers are scarce. Title I of the bill would authorize VA to enter into provider agreements to deliver care to veteran patients when furnishing such care at VA facilities is impractical or inadvisable for a particular veteran and such care is not available from a community provider under a traditional FAR- based contract or sharing agreement. This provider agreement authority would be limited to not more than $5 million for community providers furnishing homemaker or home health aide services and to not more than $2 million for other community providers. VA would be required to establish a process to certify eligible providers and ensure they meet certain terms, conditions, and quality standards. Importantly, Title I of the bill would stipulate that provider agreements under this authority are not subject to competitive procedures and are exempted from any provision of law that Medicare providers are exempted from but are subject to the Civil Rights Act of 1964. Title I of the bill would also modify VA's authority to enter into agreements with State Veterans Homes by stipulating that such agreements are not subject to competitive procedures or laws that Medicare providers are exempt from but are subject to all laws regarding integrity, ethics, fraud, and that would protect against employment discrimination.

20January 2, 2017. U.S. Department of Veterans Affairs, The Honorable Secretary Robert McDonald. "Caring for Those Who Have Borne the Battle: Cabinet Exit Memo." https://www.va.gov/opa/publications/ docs/VA-Exit-Memo.pdf.

21Ibid.

22United States Cong. House Committee on Veterans' Affairs. Legislative Hearing. October 24, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement for the record from the American Health Care Association).

The Committee is committed to ensuring that the care provided through the Program supplements but does not supplant the care provided in VA medical facilities and that VA continues to provide timely, high quality care to veterans both in the community and in VA. To that end, Title I of the bill would also require VA to conduct periodic (defined as not less often than once every three years) capacity and commercial market assessments in each Veterans Integrated Service Network and VA medical facility to identify gaps in care and recommend how such gaps could be filled via changing how care is furnished and/or building or realigning VA resources or personnel.

Section 109. Transplant procedures with live donors and related services

VA has offered solid organ transplant services for eligible veteran patients since 1962 and bone marrow transplant services for eligible veteran patients since 1982.23 Through VA's National Transplant Program, VA provides transplants primarily through 13 VA transplant centers located in: Palo Alto, California; Portland, Oregon; Seattle, Washington; Houston, Texas; San Antonio, Texas; Salt Lake City, Utah; Iowa City, Iowa; Madison, Wisconsin; Birmingham, Alabama; Nashville, Tennessee; West Roxbury, Massachusetts; Bronx, New York; Pittsburgh, Pennsylvania; and Richmond, Virginia.24

23VA National Transplant Program. https://www.va.gov/health/ services/transplant/ Accessed October 30, 2017.

24Ibid.

The Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113-146; 128 STAT. 1754) created the Choice program to increase access to care in the community for veteran patients unable to receive care at VA medical facilities due to long waiting times for VA appointments or lengthy travel distances to VA medical facilities. Since the implementation of the Choice program, the Committee has heard an increasing number of complaints about the VA transplant program from veterans who are concerned about the lengthy travel required for many veterans to reach a VA transplant center and barriers to receiving transplant care in the community. For example, in 2016, Charles Nelson--a 100 percent service-connected veteran from Leander, Texas--attempted to receive a kidney transplant through the VA health care system.25 Mr. Nelson's non-veteran son, Austin, was willing and able to serve as Mr. Nelson's live donor.26 Rather than travel to VA transplant centers in Nashville, Tennessee, or Portland, Oregon, to receive his kidney transplant, Mr. Nelson asked VA to authorize him to receive his transplant at the University Hospital in San Antonio via the Choice program.2728 Though his request was approved by local VA officials in Texas, VA Central Office in Washington, D.C. denied Mr. Nelson's request to receive his transplant through the Choice program, arguing that because Austin was not a veteran VA would be unable to use Choice funds to cover the costs of his care.29 Though Choice is just one of several care in the community programs that VA could have used to cover the costs of Mr. Nelson's transplant at the University Hospital in San Antonio, Mr. Nelson eventually received his transplant at that facility using his Medicare benefits, private donations, and personal savings to cover the cost of his care.30

25United States Cong. House Committee on Veterans' Affairs. Legislative Hearing. October 24, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement for the record Representative John Carter).

26Ibid.

27Ibid.

28Fox 7, "Leander Veteran Fighting for VA to Pay for Kidney Transplant," May 24, 2016, http://www.fox7austin.com/news/local-news/ disabled-leander-veteran-fighting-to-get-va-to-pay-for-kidney- transplant. 29United States Cong. House Committee on Veterans' Affairs. Legislative Hearing. October 24, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement for the record Representative John Carter).

30Ibid.

On June 29, 2016, the Journal of the American Medical Association published an article which found that greater distance from a VA Transplant Center was associated with a lower likelihood of receiving a transplant and a greater likelihood of death among certain veteran transplant patients.31 Given the article's findings the Committee believes that veterans residing far from VA transplant centers should be given the option of receiving their transplant from transplant centers in the community closer to the veteran's place of residence. The Committee also believes that, wherever possible, VA should remove barriers to transplant care in the community for veteran patients. Consistent with those goals, section 109 of the bill would authorize veterans to obtain a transplant outside of the region of the Organ Procurement and Transplantation Network if veteran's primary care provider opines that there is a medically compelling reason and also authorize VA to support the cost of a donor transplant operation, including perioperative care and care performed in a non-VA facility, for a live donor who is not a veteran but who is donating an organ for a veteran.

31Journal of the American Medical Association, "Association of Distance from a Transplant Center with Access to Waitlist Placement, Receipt of Liver Transplantation, and Survival Among U.S. Veterans, June 29, 2016, https://www.ncbi.nlm.nih.gov/pubmed/24668105.

TITLE II--OTHER ADMINISTRATIVE MATTERS

Section 201. Reimbursement for emergency ambulance services

While VA has experienced long-standing difficulties complying with prompt pay rules in general, VA has had particular challenges issuing timely reimbursement for ambulance providers. In June 2015, American Medical Response, the nation's largest single ambulance provider, testified before the Subcommittee on Health that they have had "consistent difficulty" receiving reimbursement from VA and, despite working with VA for a year, had a payment backlog totaling approximately $12 million.32 Section 201 of the bill would require VA to reimburse an ambulance provider or other emergency transport service for providing transportation to a veteran for purposes of receiving emergency medical care at a community facility if the request for transportation was made as a result of the sudden onset of a medical condition of such a nature that it meets the prudent layperson standard and the veteran is transported to the most appropriate medical facility.

32United States Cong. House Committee on Veterans' Affairs. "Assessing VA's Ability to Promptly Pay Non-VA Providers." June 3, 2015. 114th Cong. 1st sess. Washington: GPO, 2017 (statement for the record from American Medical Response).

Section 202. Improvement of care coordination for veterans through exchange of certain medical records

Since fiscal year 2014, VA community care appointments have increased by 61 percent overall and by 41 percent as a percentage of total VA appointments.33 In FY 2016 alone, 25.5 million appointments--or 30 percent of all VA appointments-- occurred in the community rather than in VA medical facilities.34 Given the dramatic increase in VA community care demand in recent years and the need to ensure that the care veterans receive both in VA medical facilities and in the community is effectively coordinated to ensure quality, the Committee believes that it is critically important for VA and community providers to be able to share pertinent medical record information about the veteran patients they are jointly treating while also ensuring appropriate protections are in place to secure patient privacy.

33January 11, 2017, MyVA Advisory Committee Meeting, Georgetown University, Washington, D.C.

34Ibid.

Accordingly, section 202 of the bill would amend section 7332 of title 38 U.S.C. to permit VA to share confidential medical information with a public or private health care provider in order to provide care or treatment to a shared patient and to a third party in order to recover (or collect) reasonable charges for care furnished to a veteran for a non- service connected disability with the stipulation that such sharing must be in accordance with relevant health record privacy laws (including HIPPA). The Committee believes this would improve the provision of care to veteran patients from both VA providers and community providers while also ensuring that personal patient information is safeguarded from inappropriate disclosure.

Section 203. Elimination of copayment offset

As a condition for receiving VA health care services, veterans with income greater than VA income thresholds must agree to pay a copayment for care VA provides that is not related to a service-connected condition.35 Section 1729 of title 38 United States Code authorizes VA to bill a veteran's private (third party) health insurance reasonable charges for treatment of a veteran's non service-connected conditions and to reduce any copayment amounts such veteran would otherwise owe to VA dollar for dollar based on the collection from the private insurer.36 Funds collected by VA from private insurers are deposited in the VA Medical Care Collections Fund (MCCF) and used to augment VA's medical care accounts and cover expenses incurred by VA as a result of first and third-party collections. VA estimates that approximately twenty-three percent of veterans enrolled in the VA health care system pay copayments to VA for treatment in connection with a non-service connected condition have billable private insurance plans.37 According to VA, the practice of reducing a veteran's copayment amounts using money from such veteran's private insurer ". . . reduces the total collections received by VA that is available for use in providing direct medical care and does not align with standard health care industry practice."38 The Committee concurs with VA's assessment.

35VA Fiscal Year 2018 Budget Submission, Volume 2, VHA-347.

36Ibid.

37Ibid.

38Ibid.

As such, section 203 of the bill would eliminate the current requirement for VA to offset a veteran's copayment with amounts recovered from the veteran's third party insurance. VA estimates that this will result in improved collections totaling approximately $62 million.39 While the Committee does not believe that eliminating the requirement for VA to offset a veterans copayment amount with collections from private insurance companies is, on its own, sufficient to incentive a veteran to abandon his/her other health insurance, the Committee intends to closely monitor how the number of veteran patients with other health insurance and MCCF collection rates are impacted by enactment of this section of the bill.

39Ibid.

Section 204. Use of Department of Veterans Affairs Medical Care Collections Fund for certain improvements in collections

The Balanced Budget Act of 1997 (Public Law 105-33; 111 STAT. 251) established the VA MCCF and required that amounts collected or recovered after June 30, 1997, be deposited into the MCCF and used to furnish medical care and services to eligible veterans and to cover expenses incurred to collect amounts owed by first or third parties for the medical care and services furnished by VA.40 VA's fiscal year 2018 budget submission notes that the Department has re-estimated collections in 2017 and 2018 downward due to broader healthcare payer changes that have resulted in third-party payers proposing reductions to their reimbursement levels.41 The Committee is increasingly concerned that VA is not sufficiently collecting revenue from first and third party payers. As a result, section 204 of the bill would include automatic data processing and information technology improvements as an MCCF expense allowed in the billing, auditing, and collecting of such revenues.

40VA Fiscal Year 2018 Budget Submission, Volume 2, VHA-173.

41VA Fiscal Year 2018 Budget Submission, Volume 2, VHA-174.

Section 205. Department of Veterans Affairs health care productivity improvement

The Committee believes it is important that VA achieves and maintains a high level of productivity among VA clinicians in order to maximize veteran access to care and ensure a prudent use of taxpayer dollars. However, recent analyses have called into question how well VA tracks provider productivity and how productive they are compared to their non-VA counterparts. For example, the 2015 Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs found that VA specialty providers are less productive than their private sector counterparts on two industry measures--encounters and relative value units (RVUs).42 RVUs are a commonly used measure of a provider's productivity that take into account the time, technical skill, mental effort, and stress that are needed for a clinician to provide a given clinical service.43 More recently, the Government Accountability Office released a report in 2017, which found that VA lacks complete and accurate information on clinical productivity and efficiency because VA's existing productivity metrics and efficiency models do not account for all providers and clinical services, may not accurately reflect the intensity of clinical workloads or staffing levels, and may be adversely impacted by inaccurate data.44 GAO also found that VA Central Office does not systematically oversee productivity and efficiency and, thus, cannot ensure that low productivity and clinical inefficiencies are addressed at individual VA medical facilities or identify and correct patterns that could increase productivity and efficiency across the VA health care system. Accordingly, section 205 of the bill would require VA to track RVUs for all VA providers, to ensure that all VA providers attending training on clinical procedure coding, and to establish RVU-based performance standards as well as remediation plans to address low clinical productivity and inefficiency.

42CMS Alliance to Modernize Healthcare Federally Funded Research and Development Center, September 1, 2015, "Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs," https://www.va.gov/opa/choiceact/ documents/assessments/Integrated_Report.pdf.

43January 12, 2015, National Health Policy Forum, "The Basics: Relative Value Units," https://www.nhpf.org/library/the-basics/ Basics_RVUs_01-12-15.pdf.

44GAO-17-480, May 2017, "Improvements Needed in Data and Monitoring of Clinical Productivity and Efficiency," https:// www.gao.gov/assets/690/684869.pdf.

Section 206. Licensure of health care professionals of the Department of Veterans Affairs providing treatment via telemedicine

As a national, integrated health care system, the Veterans Health Administration (VHA) has a responsibility to ensure that veteran patients receive access to care no matter where the veteran patient is located.45 This is a particular challenge for veteran patients residing in remote, rural, or medically underserved areas far from VA medical facilities and for veteran patients with mobility or other issues that impact their ability to travel to VA medical facilities to receive care.46

45Authority of Health Care Providers to Practice Telehealth. https://www.federalregister.gov/documents/2017/10/02/2017-20951/ authority-of-health-care-providers-to-practice-telehealth. Accessed October 31, 2017.

46Ibid.

Telemedicine refers to "the use of telehealth technologies to provide clinical care in circumstances where distance separates those receiving services and those providing services."47 By allowing VA clinicians to provide "the right care in the right place at the right time," telemedicine is critical to VA's ability to deliver health care to veteran patients who could not otherwise access such care.4849 According to VA, "[telemedicine] increases the accessibility of VA health care, bringing VA medical services to locations convenient for beneficiaries, including clinics in remote communities and beneficiaries" homes."50 In fiscal year 2016, VA health care providers provided more than 2 million episodes of care via telemedicine to more than 700,000 veteran patients, approximately 12 percent of VA's total patient population.51 Veteran patients who have had experience with VA telemedicine programs have demonstrated improved health outcomes, including decreases in hospital admissions.52

47VA Telehealth Services. https://www.telehealth.va.gov/ Accessed October 30, 2017.

48Ibid.

49Authority of Health Care Providers to Practice Telehealth. https://www.federalregister.gov/documents/2017/10/02/2017-20951/ authority-of-health-care-providers-to-practice-telehealth. Accessed October 31, 2017.

50Ibid.

51Ibid.

52Ibid.

However, the continued expansion of telemedicine across the VA health care system is constrained by restrictions on the ability of VA providers to practice telemedicine across state lines without jeopardizing their state licensure and facing potential penalties for the unauthorized practice of medicine.53 VA claims that this disparity--between VA health care practice and state medical licensure laws--has severely inhibited the provision of telemedicine in VA and, therefore, reduced the availability and accessibility of care for veteran patients.54

53Ibid.

54Ibid.

In response to this, VA announced on August 3, 2017, that VA would be amending regulations to allow VA health care providers who are licensed, registered, or certified in "a state" to practice in any state when they are acting within the scope of their VA employment--regardless of individual state licensure, registration, or certification restrictions except for applicable state restrictions on the authority to prescribe and administer controlled substances.55 VA claims that this action would serve to "authorize VA health care providers to furnish care, consistent with their employment obligations, through [telemedicine], without fear of adverse action by any state."56 Despite this rulemaking, VA testified during a Committee hearing that legislation was needed to "[provide] statutory protection and [codify] VA's longstanding practice of allowing VA providers to practice in any state as long as they are licensed in a state."57

55Ibid.

56Ibid.

57United States Cong. House Committee on Veterans' Affairs. Legislative Hearing. October 24, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement from the Honorable David Shulkin M.D., Secretary of Veterans Affairs).

Therefore, section 206 of the bill would exercise preemption of state licensure, registration, and certification laws, rules, and regulations or requirements to the extent such state laws conflict with the ability of VA providers to engage in the practice of telehealth while acting within the state of their VA employment and authorize a VA licensed health care provider to practice telemedicine at any location in any state, regardless of where the provider or patient is located and whether or not the patient or provider is on federal government property. The Committee believes that the continued expansion of telemedicine across the VA healthcare system will aid veterans in receiving timely, quality care from VA and in achieving improved health outcomes. Further, the Committee concurs with the American Medical Association that providing VA healthcare providers the authority to practice telemedicine across state lines would "address the significant and unique need to expand access to health care services for veterans being treated within the VA system while also ensuring that important patient protections remain in place, including the direct oversight, accountability, training, and quality control specific to VA-employed physicians and other health care professionals."58 Section 206 of the bill would also require VA to submit a report to Congress on the Department's telemedicine programs, which would allow the effectiveness of VA telemedicine to be better understood.

58United States Cong. House Committee on Veterans' Affairs. Legislative Hearing. October 24, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement for the record from the American Medical Association).

Section 207. Establishment of processes to ensure safe opioid prescribing practices by non-Department of Veterans Affairs health care providers

Overdose deaths involving prescriptions have quintupled since 1999. Between 1999 and 2016 more than 200,000 deaths were attributed to overdoses from prescription drugs.59 The opioid epidemic has impacted veterans and overdose deaths among veterans remain elevated when compared to the civilian population. Due to the prevalence of chronic pain in the veteran population, many being treated with opioids, VA instituted the Opioid Safety Initiative (OSI), a program using evidence-based management guidelines, including dosing and monitoring guidelines, to treat pain and to mitigate the risks of prescription opioids.60

59Prescription Opioid Overdose Data, Centers for Disease Control and Prevention; https://www.cdc.gov/drugoverdose/data/overdose.html.

60Department of Veterans Affairs, Office of Inspector General report no. 17-01846-316, Healthcare Inspection: Opioid Prescribing to high-Risk Veterans Receiving VA Purchased Care, July 3, 2017.

Over the past several years, VA has implemented purchased care programs to enable veterans to access care by non- department providers in the community. This care includes the management of chronic pain conditions for which veterans are prescribed opioids.61 This raises the potential for inconsistencies in management between the community provider and guidelines promulgated by VA increasing risk to the veteran. Moreover, medical information may not be shared between the community provider and VA further exacerbating such risks.62 GAO recommended that community providers receive and review the guidelines in the OSI, that VA implement a process to share up to date veterans' medication records with community providers, require community providers to submit opioid prescriptions to a VA pharmacy with recordation of the prescription in the VA electronic health record, and to ensure that if a community provider's provider prescribing practices are in conflict OSI guidelines, that actions are taken to ensure the safety of the veteran.63

61Ibid.

62Ibid.

63Ibid.

The Committee believes that VA must take steps to ensure safe opioid prescribing practices are adhered to when a veteran is sent to the community for care. Accordingly, section 207 of the bill would require VA to provide OSI guidelines to community providers and certify that the community providers have reviewed the guidelines and to implement a process to ensure that community providers receive a veteran's relevant history including all medications. It would further require that opioid prescriptions be filled at a VA pharmacy, or at a community pharmacy only if prior authorization has been received (with an exception for certain urgent or emergent circumstances). Section 2017 would also require that opioid prescriptions be recorded in the electronic health record and that community providers whose prescribing practices are inconsistent with OSI requirements or violate licensing guidelines are removed from VA community care networks.

Section 208. Assessment of health care furnished by the Department to veterans who live in territories

Veterans in Puerto Rico, the U.S. Virgin Islands, the American Samoa, Guam, and the Northern Mariana Islands face a number of barriers to timely, accessible VA care and benefits. The principle barrier these veterans face is the lack of VA care at home, which often necessitates lengthy travel to VA medical centers and clinics in other areas. In light of the unique challenges that veterans residing in these territories face accessing VA services, section 208 of the bill would require VA to report on the care provided to veterans in Puerto Rico, the U.S. Virgin Islands, the American Samoa, Guam, and the Northern Mariana Islands and include whether it would be feasible for VA to establish a medical facility in any territory that does not contain such a facility.

Section 209. Oversight and accountability of financial processes of Department of Veterans Affairs

Since Choice was established in 2014, VA has returned to Congress several times seeking additional, "emergency" appropriations to keep the program operational in the face of funding shortfalls. Most recently, on December 12, 2017, Secretary Shulkin predicted without additional funding by the end of the year, veterans would see a "dramatic impact" on their overall healthcare.64 The Committee contends that these repeated requests for additional appropriations are outside the scope what would typically constitute an "emergency" designation and believe VA must improve its community care accounting, bringing all projections for care purchased from the community back into the standard budget request process. Section 209 of the bill would require VA to submit a justification to any request for supplemental appropriations, based upon sound actuarial analysis. It would require VA's Chief Financial Officer to certify the sufficiency, to the extent possible, of VA's annual budget submission to provide benefits and health services to veterans, as required by law.

64December 12, 2017. Letter from the Honorable David J. Shulkin M.D., Secretary of the U.S. Department of Veterans Affairs to the Honorable David P. Roe, Chairman of the Committee on Veterans' Affairs of the U.S. House of Representatives. https://veterans.house.gov/ uploadedfiles/roe.pdf.

Sec. 210. Authority for Department of Veterans Affairs Center for Innovation for Care and Payment

As a nationwide system, VA has struggled to maximize efficiency of payment and care in its clinics and hospitals. Some areas have seen improvement, while others have fallen behind. Section 210 of the bill would address this by amending subchapter I of chapter 17, as amended by section 122, by authorizing a "Center for Innovation for Care and Payment." Through this center, the Secretary could carry out pilot programs to develop innovative approaches to testing payment and service delivery models to reduce expenditures while preserving or improving the quality of care. The programs could be carried out in locations appropriate for the intended purpose of the programs, and no pilot shall last longer than five years. The Secretary would be required to obtain advice from the VA special Medical Advisory Group in the development and implementation of any pilot. In implementing the pilot programs, the Secretary would be authorized to waive any requirements under Title 38 only after submitting a report to Congress explaining the authorities to be waived and the reasons for such requirement. The Secretary would only be allowed to act upon any such waiver after Congress enacts a bill or joint resolution approving the action. The Secretary would be required to conduct an evaluation of each model tested and make such information public.

TITLE III--IMPROVEMENTS TO RECRUITMENT OF PHYSICIANS

Section 301--Designated scholarships for physicians and dentists under Department of Veterans Affairs Health Professional Scholarship Program

VA currently has several programs to address recruiting in its professional ranks. These programs include the Education Debt Repayment Program (EDRP) and the Health Professions Scholarship Program (HPSP). Physician remains the top position in VA's mission critical positions shortage despite these programs, with VA indicating a need to hire more than one thousand additional physicians in fiscal year 2017.65 VA's considerable recruitment and retention issues are worsened by an aging workforce that is becoming increasingly retirement- eligible.66

65United States Cong. House Committee on Veterans' Affairs. Oversight Hearing. March 22, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (Question for the Record response from the U.S. Department of Veterans Affairs.)

66United States Cong. House Committee on Veterans' Affairs. Legislative Hearing. March 16, 2016. 114th Cong. 2nd sess. Washingtoon: GPO, 2016. (Testimony from the Partnership for Public Service.)

To help alleviate the shortage of physicians and increases the number of young physicians working at VA, section 301 would provide scholarships to medical students in exchange for service to VA. A minimum of two to four year scholarships for medical and dental students would be required so long as the shortage of those positions exceed 500. Once the number falls below 500, the minimum number of scholarships provided annually would be at least ten percent of the number of positions deemed in shortage. The obligation requirement for the scholarship is successful completion of residency training leading to board eligibility in a specialty and 18 months of clinical service at a VA facility for each year of scholarship support. Section 301 would also authorize VA to provide preference to veterans and require VA to conduct annual advertising to educational institutions.

Section 302--Establishment of Department of Veterans Affairs Specialty Education Loan Re-payment Program

The average medical education debt is approximately $192,000 for a 2017 graduate.67 VA's current loan repayment program is offered just before a resident completes training or has completed training in exchange for service at a VA facility. The Veterans Integrated Service Network (VISN) determines how much EDRP funds are allotted to each facility and each facility director is authorized to offer up to $24,000 annually in exchange for service. The timing of the offer presents potential obstacles as VA is competing with other professional and financial opportunities for physicians. The salaries offered by other practices are competitive with VA, and the anticipated salary is high enough so that the burden of a loan payment may not appear onerous.68 Moreover, because of VHA human resource policies for hiring physicians, for example, firm offers cannot be made until physical examinations and credentialing are completed, the earliest of which are 120 days prior to starting a position, many senior resident physicians are offered positions earlier than VA69 thus obviating the ability to present the EDRP to potential hires. Lastly, the EDRP program is effectuated at the local level based on local needs, therefore does not have a mechanism for VA to direct funds to recognized needed specialties on a national level.

67AAMC Medical School Graduation Questionnaire. https:// www.aamc.org/download/481784/data/2017gqallschoolssummaryreport.pdf.

68Medscape Physician Compensation Report 2917. https:// www.medscape.com/slideshow/compensation-2017-overview-6008547#4.

69Darves, B, Physician Job-Search Timeline: Delayed Approach Not Advised; The New England Journal of Medicine, October 8, 2014.

Section 302 would establish a new loan repayment program for medical or osteopathic student educational loans for newly graduated medical students, or residents with at least 2 years of training remaining, who are training in specialties deemed by VA to be experiencing a shortage. The loan repayment would be $40,000 per year for a maximum of $160,000. In exchange for the loan repayment, the recipient would agree to obtain a license to practice medicine, complete training leading to board eligibility in a specialty, and to serve in clinical practice at a VA facility for a period of 12 months for each $40,000 of loan repayment with a minimum of 24 months of obligated service. Because resident salaries are much lower than salaries for fully trained clinicians, this would make the loan repayment is more economically meaningful and allow VA to fund specialty positions in shortage areas, develop a predictable future physician workforce, and ensure a cadre of young physicians are able to join VA's physician workforce.

Section 303--Veterans Healing Veterans Medical Access and Scholarship Program

In order to assist VA in recruiting veteran physicians, section 303 would establish a pilot program for supporting four years of medical school education costs for two veterans at each of the five Teague-Cranston Schools and the four traditional black medical schools. The covered medical schools would include Texas A&M; College of Medicine, Quillen College of Medicine at East Tennessee State University, Boonshoft School of Medicine at Wright State University, Edwards School Medicine at Marshall University, the University of South Carolina School of Medicine, Drew University of Medicine and Science, Howard University of Medicine, Meharry Medical College, and Morehouse School of Medicine. The medical schools that opt to participate in the program would be required to reserve two seats each in the class of 2019. Eligible veteran scholarship recipients would be those within ten years of military discharge who are not eligible for GI Bill benefits but who meet the minimum admission requirement for medical school and apply for the entering class of 2019. The scholarship recipients would agree to successfully complete medical school, obtain a license to practice medicine, complete post-graduate training leading to board eligibility in a specialty applicable to VA, and after training, serve in clinical practice at a VA facility for four years.

Continues with Part 2 of 3

TARGETED NEWS SERVICE: Myron Struck, editor; 703/304-1897; [email protected]; https://targetednews.com