THE VA MISSION ACT

An update

By Craig Collins

When it was signed into law with overwhelming bipartisan support on June 6, 2018 – the 74th anniversary of D-Day – the VA MISSION Act was celebrated as a long-overdue expansion of the partnership between the Veterans Health Administration and the non-Veterans Affairs (VA) health care community. The new law promised to increase access to health care, both in VA facilities and in the community; reduce wait times; expand benefits for caregivers; and improve VA’s ability to recruit and retain quality medical professionals.

Historically, the VA has made considerable efforts to ensure veterans receive care in the community when VA cannot provide the care needed. Beginning in 1920, Congress authorized the VA to contract with community providers in “exceptional cases.” The series of laws passed over the ensuing decades – authorizing certain inpatient, outpatient, and urgent-care services to veterans with and without service-connected disabilities through non-VA community providers – resulted in a complicated network of programs, each with its own eligibility requirements.

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The Choice program, which allowed veterans to receive care outside the VA system under certain conditions (i.e., excessively long wait or drive times to receive care at VA facilities), along with other fee-based community care programs, was replaced by the provisions of the VA MISSION (Maintaining Internal Systems and Strengthening Integrated Outside Networks) Act, which establishes a permanent community care program and requires VA to build and administer a high-performing, integrated network of VA and non-VA providers that seamlessly provides high-quality care.

Above and below: The Department of Veterans Affairs’ Community Care Network comprises six regions that are managed by third-party administrators (TPAs). This graphic shows the TPAs for regions 1, 2, 3, and 4. The TPA for region 5, TriWest Healthcare Alliance, was announced in October 2020.

The VA MISSION Act also expanded veteran access to care in other ways, beyond a focus on community care: increasing support and assistance to family caregivers of disabled veterans; establishing a new urgent care benefit; and authorizing “anywhere to anywhere” telehealth visits across state lines.

VA leadership conducted in-person visits to facilities across the country in the lead-up to implementing the law’s provisions, and the regulations were finalized a year later. The rollout of the law’s provisions – beginning with its new Veterans Community Care Program – began on June 6, 2019, and extends out beyond 2030.

COMMUNITY CARE

The MISSION Act’s changes to VA community care have required completion of a considerable number of interrelated tasks. Community Care Program access is tied to a set of eligibility requirements based on a veteran’s place of residence and the availability of VA services in their region. Whether a veteran meets established drive-time and wait-time standards, they may be eligible to receive care under other conditions, all of which were set in the actual legislation: They may be eligible for the “grandfather” provision that, under the Choice Act, allowed them to receive care if they lived more than 40 miles from the nearest VA care facility. On a case-by-case basis, a veteran may be referred to a community health care provider when the patient and the referring doctor or agency agree it’s in the patient’s best interest.

These new eligibility criteria continue to depend, first and foremost, on a veteran’s individual needs or circumstances. A detailed overview of the law’s provisions and eligibility requirements can be accessed at www.missionact.va.gov.

According to Dr. Kameron Matthews, VA’s chief medical officer and Assistant Under Secretary for Health for Clinical Services, this new list of requirements is a combination of those explicitly legislated and others published through regulation. “We’ve used the sense of urgency and transformation that the MISSION Act promoted to update a lot of the business processes around community care,” she said.

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The community care contracts that will assist in the implementation of the requirements of the MISSION Act, Matthews said, resulted in a more veteran-centric arrangement, with the VA assuming a role of coordinator for patients receiving care at VA-approved providers within its Community Care Network (CCN), which comprises six regions managed by third-party administrators (TPAs). As of late 2020, TPAs for five of the six regions had been selected, expanding the CCN throughout the continental United States, Alaska, Hawaii, the U.S. Virgin Islands, and Puerto Rico.

Not all of these regional networks had been fully deployed by the fall of 2020, Matthews said – and the COVID-19 pandemic has caused minor local delays in the deployment schedule. As the pandemic worsened in the spring of 2020, the VA began reviewing referrals to community care providers on a case-by-case basis, weighing the clinical needs and safety of veteran patients with the risks of in-person visits. While the VA stayed open for all care that rose above the risk of COVID-19, both at VA facilities and in the community, this had the effect of temporarily decreasing in-person visits to community providers. In addition, community providers were decreasing services and negotiations with individual providers for enrollment in the network slowed. “We deployed facility by facility,” said Matthews, “and by the end of the fiscal year [2020], we’d fully deployed regions 1, 2, 3, and 4” – an area covering providers throughout the lower 48 United States and Hawaii.

The VA MISSION Act expands the Program of Comprehensive Assistance for Family Caregivers in two phases to support caregivers of Vietnam and older veterans injured in the line of duty on or before May 7, 1975 (the first phase, launched in October 2020), and caregivers of veterans injured in the line of duty between May 7, 1975, and Sept. 10, 2001 (the second phase, anticipated to launch in fall 2022).

The VA has been working closely with community providers to ensure a positive experience for veterans. By taking responsibility for coordinating community care appointments, the VA is making the process as seamless and trouble-free as possible. It has been working closely with community providers – providing training and education, for example, about the challenges confronted by veterans – to ensure a positive experience for veteran patients.

The MISSION Act directs the VA to establish rigorous quality standards for the Community Care Program, and to make comparative quality scores for the VA and community care available to both veterans and their providers.

URGENT CARE

One of the MISSION Act’s new provisions is the urgent (non-emergency) care benefit “for the treatment of minor injuries and illnesses, such as colds, sore throats and minor skin infections.” This benefit is offered in addition to the opportunity to receive same-day services from a VA primary care or mental health provider. Urgent care options are available from care providers that belong to the VA’s contracted network of community providers, without prior VA authorization.

The availability of same-day service at an urgent care or retail clinic (for uncomplicated illnesses, such as a sore throat, or for more pressing illnesses or injuries requiring splinting, casting, or wound treatment) has been a concern of several veterans service organizations (VSOs), including the American Legion, which argued for a more streamlined experience for veterans seeking urgent and emergency care.

The VA is continuing to expand its contracted urgent care network, so that most veterans will be within a 30-minute drive of an urgent care center – though veterans should verify that the center is an in-network facility before visiting. According to Katie Purswell, the American Legion’s deputy director of health policy, “You can call the VA and they’ll tell you: ‘You need to go to an urgent care center, and here’s a list of the closest ones to your area that accept VA payments.’ I know the VA is continuing to make those relationships. The partnership is best for everybody, especially the veterans who aren’t able to get the care they need without having to drive three hours to get to an emergency room.” A list of in-network urgent care providers – or of any VA or community providers – is also available online at www. va.gov/find-locations.

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For those unfamiliar with the language of health care insurance and claims, it’s important to distinguish between the terms “urgent care” – which is for nonlife-threatening illnesses or injuries – and “emergency care,” which is for an injury, illness, or symptom so severe that a “prudent layperson” (according to VA policy) reasonably believes a delay in seeking immediate medical attention would be a threat to the life or health of the patient.

Dr. Janeen Smith of the San Francisco VA Health Care System speaks with Navy veteran John Bartlett, who lives in Hawaii, using VA Video Connect. The “anywhere to anywhere” authority granted by the VA MISSION Act has made it possible for licensed health care providers to see patients using telemedicine regardless of their location.

The VA implemented a new business process in June 2020 that allows emergency room visits to providers in the VA’s third-party network to be covered by community care if certain conditions are met. These conditions are detailed online at https://www.va.gov/communitycare/programs/veterans/emergency_care.asp This process has streamlined the approval and claims submission process for emergency room visits.

CAREGIVER SUPPORT

Before passage of the MISSION Act, the VA offered general support for family caregivers of any veteran enrolled in VA health care: training, education, respite care services, a Caregiver Support Line, self-care courses, and other benefits. An augmented Program of Comprehensive Assistance for Family Caregivers (PCAFC) offered expanded benefits – including a monthly stipend, a beneficiary travel allowance, mental health counseling, and enhanced respite services – to caregivers of veterans injured in the line of duty on or after Sept. 11, 2001.

Nathan Naylor of Philips, left, and Dr. Neil Evans, chief officer for the VHA Office of Connected Care, demonstrate ATLAS to U.S. Sen. Shelley Capito, R-W.Va., in November 2019. The goal of ATLAS is to extend VA telehealth to rural and underserved veterans.

The VA MISSION Act expands eligibility for the PCAFC in two phases. After successfully installing and certifying a new information technology system to help administer the program, the VA launched the first phase – accepting applications from family caregivers of veterans who were injured in the line of duty on or before May 7, 1975 – in October 2020.

“We’ve expanded the program to include Vietnam and older veterans,” said Matthews. “And we, of course, will continue to support general caregiver resources and education for all veterans, but now the comprehensive assistance program provides more financial support for caregivers of older veterans.” The VA had accepted thousands of applications by the end of the first week of October.

A second phase of PCAFC expansion, to caregivers of veterans who were injured in the line of duty between May 7, 1975, and Sept. 10, 2001, is anticipated for the fall of 2022. According to Purswell, focusing first on caregivers of older veterans was the right move. “Knowing we have an aging veteran population, it’s really important to us to make sure they are getting quality care,” she said. “And supporting caregivers is the best way we can make sure that is happening – making sure they are getting the benefit, first of all, and then that they’re trained and they’re capable, and that we’re looking back in on them and making sure they are staying qualified and have all the tools they need.”

TELEHEALTH

One of the earliest and most conspicuous changes to veteran health care enabled by the MISSION Act was the expanded use of telemedicine. The law states that a covered and licensed health care professional may practice “at any location in any state,” regardless of where they or the patient are located, if they are using telemedicine.

“Typically telehealth is constrained by state lines,” explained Matthews. “The MISSION Act actually gave us, VA – a federal entity not restricted by state lines – what we call ‘anywhere to anywhere’ authority.” Matthews can now practice telemedicine anywhere in the VA network.

This “anywhere to anywhere” authority had an immediate effect: More than 900,000 patients used VA telemedicine services in fiscal year 2019, an increase of 17 percent. When the COVID-19 pandemic hit, said Matthews, and in-person visits presented health risks, VA’s telemedicine infrastructure was able to take up the slack. “Since the start of the COVID-19 pandemic, in a matter of months, we’ve increased the number of video visits by 1,800 percent,” Matthews said. “Through the MISSION Act, we have the capacity in our health system to support it.”

This capacity has been boosted further by partnerships – for example, a new program known as Project ATLAS, which is a collaboration between the VA, Philips Healthcare, T-Mobile, and two of the nation’s largest VSOs: the American Legion and Veterans of Foreign Wars (VFW), which have offered up their posts as hubs where veterans – whether they are members of that particular VSO or not – can access telehealth services. Project ATLAS (Accessing Telehealth through Local Area Stations) aims to improve access to care for the nation’s 20 million veterans – particularly the roughly 5 million who live in rural areas where health care access is limited.

The VA MISSION Act includes provisions aimed at recruiting and retaining high-quality health care providers, such as increased education debt reduction, increased numbers of medical residencies at VA and other federal health care facilities, and the recently launched Veterans Healing Veterans scholarship pilot program.

“I can only imagine, for some of our other rural veterans that are homebound or wheelchair-bound, how difficult it is for them to find a ride or drive themselves to these locations, for appointments that could have been done via telehealth,” she said. Veterans in rural areas often don’t have great internet access – and some may not even have access to a computer. “So to be able to allow veterans to go to a local post and see their medical provider and not have to worry about the bandwidth dropping out, or not to have video, or not to have someone there to be able to help them walk through the steps of doing a virtual appointment – we’re excited to make that available to veterans.”

LOOKING TO THE FUTURE OF VETERAN CARE

Expanded access to community care, urgent care, caregiver support, and telehealth are among the MISSION Act’s most significant provisions, but the law contains several others aimed at improving the quality of the VA for decades to come. It requires the VA to establish mobile deployment teams of medical personnel, for example, who will provide health care at underserved VA facilities.

As Matthews pointed out, it’s difficult for any health care organization to recruit staff clinicians in some parts of the United States, and the VA, despite its collaborations with other agencies, sometimes encounters resource and personnel constraints. So far, pilot deployments of mobile teams have been undertaken at three different sites to establish what Matthews called clinical resource hubs – outposts to supplement the care provided at these locations, both in-person and via telemedicine. To date, the VA’s mobile care teams at these pilot sites have provided more than 94,000 visits.

With provisions that extend out to 2034, the MISSION Act also looks to the future of veteran health care, giving the VA tools to recruit and retain the nation’s best health care providers. The law increases the amount of education debt reduction available to VA physicians, expands the number of medical residencies in the VA and other federal health care facilities, and establishes a pilot program for medical scribes – personal assistants who help physicians document and coordinate patient visits.

Under MISSION Act authority, the VA recently launched a scholarship pilot program, Veterans Healing Veterans, for veterans pursuing a medical education through historically black colleges and universities (HBCUs) and five other Teague-Cranston medical schools that were established in conjunction with VA medical centers. Eighteen veteran medical students were enrolled at nine medical schools through this program in 2020. The VA has stood up a new Innovation Center, intensified its focus on underserved facilities through programs such as the mobile teams pilot, and launched a veteran peer support program for primary care in VA medical centers.

These provisions of the MISSION Act will serve to nourish and reinforce the ongoing transformation of the VA’s efforts, drawing a growing number of quality health professionals into its ranks to help plot a course for the future of American health care – and above all, to provide veterans with the level of care a grateful nation has determined is their due.