Veterans Community Care Program: VA Took Action on Veterans’ Access to Care, but COVID-19 Highlighted Continued Scheduling Challenges

What GAO Found

During the COVID-19 pandemic, the Department of Veterans Affairs (VA) took action regarding veterans’ access to care through the Veterans Community Care Program (VCCP). For example, VA recommended that VA medical facility staff schedule telehealth appointments whenever possible in order to reduce veterans’ risk of exposure to COVID-19. VA also directed facility staff to prioritize appointment scheduling and monitor referrals. Nevertheless, for referrals created between January 2020 and January 2021, GAO’s analysis below shows that about 172,000 referrals (3 percent) remain unscheduled as of March 24, 2021.

Status of Veterans Community Care Program Referrals Created Between January 2020 and January 2021, as of March 24, 2021


Note: A referral is complete after the veteran attends the appointment and VA staff receive medical documentation from the provider. A canceled referral is returned to the ordering VA provider. A discontinued referral is no longer wanted or needed. Referral data from one VA facility were not reported after October 2020.
aThe number of unscheduled referrals created in January 2020 through May 2020 is too small to display in this figure.

Staff at six selected VA medical facilities told GAO they faced both new and previously identified challenges scheduling VCCP appointments during COVID-19. For example, staff from all six facilities stated that community care wait times increased during the pandemic. However, as VA lacks an overall wait-time measure for the VCCP, the effect of COVID-19 on appointment timeliness is unknown. GAO previously identified, and made recommendations to address, VA’s lack of wait-time measures under its previous community care programs in 2013 and 2018. Given that VA had not implemented these recommendations over the prior 7 years, in 2020 GAO recommended congressional action to require VA to establish a VCCP wait-time measure.

Staff from all six facilities said they also faced challenges with understaffed community care offices and increased referral volume as veterans returned to seek care. GAO previously recommended in 2020 that VA direct its medical facilities to assess community care staffing needs. VA has taken some action to address these concerns but has not yet implemented this recommendation.

Why GAO Did This Study

In June 2019, VA implemented a new community care program—the VCCP—under which eligible veterans can receive care from community providers. GAO has previously reported on challenges VA has faced regarding oversight of its community care programs, including the VCCP. VA’s ability to ensure veterans have timely access to care under the VCCP is especially important as VA continues to respond to the COVID-19 pandemic.

The CARES Act includes a provision for GAO to report on its ongoing monitoring and oversight efforts related to the COVID-19 pandemic. This report describes (1) VA’s response to the COVID-19 pandemic as it relates to the VCCP and (2) challenges selected VA medical facilities experienced scheduling VCCP appointments.

GAO reviewed VA documentation, such as guidance for VCCP appointment scheduling, and reviewed VCCP referral and appointment data. GAO interviewed officials from VA and its two third-party administrators, and community care management and staff from six VA medical facilities, which were selected, in part, based on complexity, rurality, and location.

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    Hospital outpatient departments perform a wide range of procedures, including diagnostic and surgical procedures, which may use drugs that Medicare considers to function as supplies. If the drug is new, and its cost is high relative to Medicare's payment for the procedure, then hospitals can receive a separate “pass-through” payment for the drug in addition to Medicare's payment for the procedure. These pass-through payments are in effect for 2 to 3 years. When the pass-through payments expire, Medicare no longer pays separately for the drug, and payment for the drug is “packaged” with the payment for the related procedure. The payment rate for the procedure does not vary by whether or not the drug is used. Medicare intends this payment rate to be an incentive for hospitals to furnish services efficiently, such as using the most cost-efficient items that meet the patient's needs. Examples of Types of Drugs that Medicare Considers to Function as Supplies GAO's analysis of Medicare data showed that higher payments were associated with six of seven selected drugs when they were eligible for pass-through payments versus when their payments were packaged. For example, one drug used in cataract removal procedures was eligible for pass-through payments in 2017. That year, Medicare paid $1,824 for the procedure and $463 for the drug pass-through payment—a total payment of $2,287. If a hospital performed the same cataract removal procedure when the drug was packaged the following year, there was no longer a separate payment for the drug. Instead, Medicare paid $1,921 for the procedure whether or not the hospital used the drug. Of the seven selected drugs, GAO also reviewed differences in use for four of them that did not have limitations on Medicare coverage during the time frame of GAO's analysis, such as coverage that was limited to certain clinical trials. GAO found that hospitals' use of three of the four drugs was lower when payments for the drugs were packaged. This was consistent with the financial incentives created by the payment system. In particular, given the lower total payment for the drug and procedure when the drug is packaged, hospitals may have a greater incentive to use a lower-cost alternative for the procedure. Hospitals' use of a fourth drug increased regardless of payment status. The financial incentives for that drug appeared minimal because the total payment for it and its related procedure was about the same when it was eligible for pass-through payments and when packaged. Other factors that can affect use of the drugs include the use of the drugs for certain populations and whether hospitals put the drugs on their formularies, which guide, in part, whether the drug is used at that hospital. The Department of Health and Human Services reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate. Medicare makes “pass-through” payments under Medicare Part B when hospital outpatient departments use certain new, high-cost drugs. These temporary payments are in addition to Medicare's payments for the procedures using the drugs. They may help make the new drugs accessible for beneficiaries and also allow Medicare to collect information on the drugs' use and costs. The Consolidated Appropriations Act, 2018 included a provision for GAO to review the effect of Medicare's policy for packaging high-cost drugs after their pass-through payments have expired. This report describes (1) the payments associated with selected high-cost drugs when eligible for pass-through payments versus when packaged, and (2) hospitals' use of those drugs when eligible for pass-through payments versus when packaged. GAO reviewed federal regulations on pass-through payments and Medicare payment files for all seven drugs whose pass-through payments expired in 2017 or 2018 and that were subsequently packaged. All of these drugs met Medicare's definition for having a high cost relative to Medicare's payment rate for the procedure using the drug. GAO also reviewed Medicare claims data on the use of the drugs for 2017 through 2019 (the most recent available). To supplement this information, GAO also interviewed Medicare officials, as well officials from 11 organizations representing hospitals, physicians, and drug manufacturers, about payment rates, use, reporting, and clinical context for the drugs. For more information, contact James Cosgrove at (202) 512-7114 or cosgrovej@gao.gov.
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  • Court Orders Toledo Pharmacy and Two Pharmacists to Stop Dispensing Dangerous Doses and Combinations of Opioids and Other Controlled Substances
    In Crime News
    A federal court in Ohio ordered a Toledo pharmacy and two of its pharmacists to pay a $375,000 civil penalty and imposed restrictions related to the dispensing of opioids and other controlled substances.
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  • Veterans Community Care Program: Improvements Needed to Help Ensure Timely Access to Care
    In U.S GAO News
    The Department of Veterans Affairs (VA) established an appointment scheduling process for the Veterans Community Care Program (VCCP) that allows up to 19 days to complete several steps from VA providers creating a referral to community care staff reviewing that referral. However, as the figure shows, VA has not specified the maximum amount of time veterans should have to wait to receive care through the program. GAO previously recommended in 2013 the need for an overall wait-time measure for veterans to receive care under a prior VA community care program. Subsequent to VA not implementing this recommendation, GAO again recommended in 2018 that VA establish an achievable wait-time goal as part of its new community care program (the VCCP). Potential Allowable Wait Time to Obtain Care through the Veterans Community Care Program Note: This figure illustrates potential allowable wait times in calendar days for eligible veterans who are referred to the VCCP through routine referrals (non-emergent), and have VA medical center staff—Referral Coordination Team (RCT) and community care staff (CC staff)—schedule the appointments on their behalf. VA has not yet implemented GAO's 2018 recommendation that VA establish an achievable wait-time goal. Under the VA MISSION Act, VA is assigned responsibility for ensuring that veterans' appointments are scheduled in a timely manner—an essential component of quality health care. Given VA's lack of action over the prior 7 years implementing wait-time goals for various community care programs, congressional action is warranted to help achieve timely health care for veterans. Regarding monitoring of the initial steps of the scheduling process, GAO found that VA is using metrics that are remnants from the previous community care program, which are inconsistent with the time frames established in the VCCP scheduling process. This limits VA's ability to determine the effectiveness of the VCCP and to identify areas for improvement. In June 2019, VA implemented its new community care program, the VCCP, as required by the VA MISSION Act of 2018. Under the VCCP, VAMC staff are responsible for community care appointment scheduling; their ability to execute this new responsibility has implications for veterans receiving community care in a timely manner. GAO was asked to review VCCP appointment scheduling. This report examines, among other issues, the VCCP appointment scheduling process VA established and VA's monitoring of that process. GAO reviewed documentation, such as scheduling policies, and referral data related to the VCCP and assessed VA's relevant processes. GAO conducted site visits to five VAMCs in the first region to transition to VA's new provider network, and interviewed VAMC staff and a non-generalizable sample of community providers receiving referrals from those VAMCs. GAO also interviewed VA and contractor officials. GAO recommends that Congress consider requiring VA to establish an overall wait-time measure for the VCCP. GAO is also making three recommendations to VA, including that it align its monitoring metrics with the VCCP appointment scheduling process. VA did not concur with one of GAO's recommendations related to aligning monitoring metrics to VCCP scheduling policy time frames. GAO continues to believe this recommendation is valid, as discussed in the report. For more information, contact Sharon M. Silas at (202) 512-7114 or silass@gao.gov.
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    In Crime Control and Security News
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