Amanda Wirtz started her six-year Navy career in 1997. She served aboard a destroyer off Bosnia and during combat off Iraq in 1998.
When she developed a rare tumor, Wirtz, 37, was discharged in 2003 and began using the Department of Veterans Affairs Health System in San Diego. For the most part, she has been happy with her care.
Then last year, Wirtz began having headaches. When the VA couldn’t get her in to see a specialist, she said she was told she could see a neurologist outside the VA system, using the Veterans Choice program.
This was the type of situation Congress envisioned when it created the Veterans Choice program in August 2014, during the heat of the scandal over long wait times at the VA. If the VA couldn’t schedule a patient within 30 days, the veteran could go to a doctor outside the system.
Wirtz was referred to the program in November. She has a letter she eventually received from the company handling Veterans Choice.
“This is Feb. 23, for an appointment scheduled March 23. (In) January, I’m considering suicide because I’m in so much pain. I’m asking for relief, and the Choice program is giving me an appointment in March,” Wirtz said.
Overhauling the program
Veterans have reported numerous problems with the Veterans Choice program. Congress and VA officials are currently in the middle of overhauling the program, which many say has not delivered on the promises made to veterans when it was created.
Here are some of the problems cited:
• In February, the VA’s inspector general found that Colorado Springs, Colorado, veterans were waiting longer than 30 days for care because staff at the local VA hospital was not adding them to the list of patients eligible for the Choice program.
• In March, a General Accounting Office report showed that the Choice program was doing little to overcome the VA’s problem of getting veterans to see a primary care physician within 30 days.
• The VA recently set up a call center to help veterans who have issues with their credit because the Choice program hadn’t paid doctors on time.
• In May, the GAO showed that the VA was on a pace to pay out more money for interest on late claims than Medicare, which processes hundreds of billions of dollars more in claims.
• As of April, VA data shows the number of veterans waiting more than 30 days for an appointment was actually higher than when the Choice program began in November 2014.
In a letter to VA Secretary Robert McDonald, Sen. Susan Collins, R-Maine, called the rollout of Veterans Choice in her state “deeply flawed.”
The question is whether Congress or the VA should have anticipated the problems. Two years ago, Congress was hearing about the VA concealing wait times at hospitals and clinics. As chairman of the House Veterans Affairs Committee, Rep. Jeff Miller, R-Florida, was listening to accounts of veterans dying while they waited for care at the VA in Phoenix and elsewhere.
“If you don’t think, in 2014, that was the time to (start) up a program like Choice, I don’t know when you would find a time,” Miller said. “That’s the problem. They were causing veterans to wait. And by the way, veterans did die while they were on the waiting list.”
Confusion from the beginning
Congress worked at a frantic pace in 2014 to address the wait time issue. The House passed a bill June 10. The Senate passed its own version within days. By Aug. 7, President Barack Obama signed the Veterans Access, Choice and Accountability Act of 2014. It gave the VA $10 billion to allow more veterans to go to private doctors.
There was confusion from the start. The law required the VA to hand out 9 million Veterans Choice Cards to basically every vet receiving VA care as of August 2014. Sen John McCain, R-Arizona, explained the card at a news conference while lawmakers were crafting a final version.
“I always believed that veterans could choose and should choose, and that’s why I first proposed this in 2008, when I ran for the presidency of the United States,” McCain said. “Give these veterans a choice card so they can take that choice card and present it to the healthcare provider.”
When the program began, only a fraction of vets could actually use it. Basically, they were eligible if they were waiting longer than 30 days for a VA appointment or lived more than 40 miles from a VA medical center.
Impatient lawmakers gave the VA 90 days to set up the national program. With the clock ticking, the first decision that VA officials made was that they couldn’t run the program themselves.
“Could we set up the infrastructure to build the network to credential the network in 90 days?” said Dr. Baligh Yehia, assistant deputy under secretary for Community Care at the VA. He wasn’t with the VA when Congress mandated the Choice program. These days, he spends much of his time before Congress explaining the rollout.
“We couldn’t. We just didn’t have the resources, the tools available to us to do that,” Yehia said.
VA turned to two companies
So the VA shopped around. They invited 57 companies to a VA-sponsored event on Sept.17, 2014. Nearly all of the companies turned down the VA.
“Only four companies said they were interested in continuing some conversation,” Yehia said. “And then two of those companies made it crystal clear, that given a November, or a 90-day time frame, they’re not interested.”
So, when nearly everyone else said no, the VA turned to two companies it had under contract. TriWest Healthcare Alliance and Health Net had just begun running Patient Centered Community Care, or PC3. They were building a network of doctors and hospitals to help the VA manage a portion of the roughly $4 billion a year it was spending on outside providers.
RELATED: Despite $10B ‘Fix,’ Veterans Are Waiting Even Longer To See Doctors
Unfortunately, PC3 was getting off to its own rocky start. The VA’s inspector general found that in the summer of 2014, while Congress was debating the Choice program, VA administrators were scrambling to find appointments for hundreds of vets after TriWest and Health Net couldn’t find doctors for them in their networks.
In three months, TriWest returned 172 gastroenterology cases — 57 patients had to be seen immediately because they had symptoms of significant ailments like cancer. Several medical centers either curtailed their use of the contractors or stopped using them altogether.
In Las Vegas, TriWest was cited for sending cancer patients to providers who did not meet the VA's accreditation standards. For its part, the VA was taking on average 19 days to submit appointments to the contractors — the type of internal delay that would resurface under Choice.
They had only 90 days
Yehia stressed that PC3 was new, and it was smaller than Choice. So why did the VA give two companies that were already struggling an even larger contract? Bottom line, Yehia said, VA officials felt they had no choice. They had only 90 days to get something going under the law Congress passed.
So when no one else wanted the program, including staff inside the VA, the VA modified the contracts for TriWest and Health Net and gave them the keys to run PC3 and Choice.
“This car wasn’t designed to run this race,” Yehia said. “It had a very different purpose. It had a very different intention,” he said. “In fact, the PC3 contract, when it first rolled out, didn’t even have primary care. It was only a specialty care contract. It gives you the scope that this vehicle was not meant to deliver this vast program.”
Health Net did not respond to requests for an interview for this article. The company runs the Choice program in the eastern United States. TriWest covers 28 states in the western half of the country, including California. Once its VA contract was modified to include the Choice program, TriWest began setting up 10 call centers around the country, including one that opened in San Diego in September 2015. The company has hired more than 3,000 employees.
“Oh, my God, you expect us to build networks, have all these processes in place, all these contact centers,” said Frank "Mac" Maguire, chief medical officer for TriWest. “To be able to do all of these things, at a very, very abbreviated schedule, I think a lot of people said, ‘You are crazy.’ Were we crazy? In hindsight, maybe, yes, but we felt we were up to the challenge and we just want to be given an opportunity to show that it’s working.”
The company believes it finally has a network of doctors large enough to handle the patient load for Veterans Choice. TriWest officials concede creating a network was a struggle, in part because the VA did not always understand its own needs.
Company CEO David McIntire said TriWest built a huge network in Los Angeles, which has one of the largest concentrations of vets in the country.
“It turns out the need was in Bakersfield, which is a bedroom community of L.A.,” he said. “But if your population lives in Bakersfield, you shouldn’t have your network in L.A.”
The company had to start over. There were other problems. Originally the VA would not let TriWest’s contractors call veterans directly to schedule an appointment. The veteran had to call the company, a situation that sometimes left vets waiting by the phone.
“Many veterans were confused,” Maguire said. “Maybe it was a month since they've seen the VA. Why is my appointment not set up? And we'd say, unfortunately, we've been waiting for you to call us."
Answering veterans’ calls
TriWest officials believe they now have a handle on the problems. In San Diego, TriWest went from a ribbon-cutting in September 2015 to more than 300 employees answering veterans’ calls.
But the improvements may be too late. Less than a year-and-a-half into the Choice program, the VA is reconsidering whether it should have outsourced so much of the program — especially customer service.
Adrian Atizado with the Disabled Veterans of America said putting a contractor between the VA doctor and the outside physician may always cause problems.
“The third-party administrator will sometimes say the authorization is not very clear,” he said. “Exactly what kind of eye check do you need? Or what kind of MRI do you need? There are a lot of communication problems when you start handing things off to other people.”
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Congress is considering revamping and expanding the Choice program to cover most of what the VA spends on outside care. Because Veterans Choice was born out of a scandal involving VA scheduling, some in Congress are not eager to allow the VA to take on a greater role.
The General Accounting Office report released this month says the VA’s system for processing claims relies mainly on paper files. The VA ended the year with a backlog of 453,000 unprocessed claims. The backlog can add months to the time it takes for doctors to be paid. The backlog calls into question whether the VA was in the position to handle the load from the new Choice program.
Whatever the outcome, two years after Congress acted in response to the wait-time scandal, the pressure is still on to figure out how to get veterans the care they have been promised, without all of the confusion.
As for Navy veteran Amanda Wirtz, she did receive some medical attention, but her situation with the Choice program is still unresolved.