Understanding the Evolution of Veterans Community Care Program
The Veterans Health Administration (VHA), a cornerstone of the Department of Veterans Affairs (VA), is dedicated to providing comprehensive healthcare services to eligible veterans. This care is delivered through a network of VHA facilities and, increasingly, through community care networks. Historically, community care—referring veterans to non-VA providers—was an exception. However, significant legislative actions and VA policy shifts have broadened veterans’ access to community-based healthcare. The Veterans Community Care Program (VCCP) is a prime example, offering veterans the option to receive care from outside providers based on various criteria, including the availability of local VHA services and individual veteran circumstances. This article delves into the origins and evolution of community care within the VA, examining the key factors and legislative milestones that shaped the VCCP and its predecessors.
Between 2014 and 2019, approximately two million veterans, nearly a quarter of VHA enrollees, were authorized for community care under the Veterans Choice Program, VCCP’s precursor. The VA MISSION Act of 2018 marked a pivotal shift, formally establishing the VCCP and superseding the Veterans Choice Program along with numerous local agreements with private providers. This act signaled a departure from past VA policies that viewed community care as a last resort. Today, veterans meeting specific criteria can choose community care even when VHA facilities are accessible. The Congressional Budget Office (CBO) has analyzed these evolving policies, noting a rise in community care utilization, decreased wait times at VHA facilities (often below private sector averages), and a substantial increase in VHA’s community care expenditures, from $7.9 billion in 2014 to $17.6 billion in 2021.
Alt text: Timeline illustrating the evolution of Veterans Community Care Programs, starting from pre-2014 local agreements, moving through the Veterans Choice Program established in 2014, and culminating in the VA MISSION Act and the Veterans Community Care Program (VCCP) in 2018.
While expanded community care access offers benefits like reduced wait times, it also introduces complexities. Care coordination becomes more challenging outside VHA facilities, and quality control over community providers is limited. Furthermore, increased community care utilization may lead to underutilization of VHA facilities, potentially raising costs if these facilities cannot be efficiently consolidated.
The Veterans Community Care Program: An Overview
The VCCP empowers eligible veterans to seek healthcare from community providers, with the VHA covering the costs. While community care has always been part of the VA system to some extent, the VCCP consolidated pre-existing agreements and broadened eligibility, making community care a more accessible option for veterans.
VHA’s Direct Healthcare Services
The VHA operates a vast direct care network, encompassing 170 medical centers and over 1,000 outpatient clinics, rehabilitation centers, and nursing homes. Services span inpatient, outpatient, and specialized care, pharmaceuticals, and crucial social support programs for the homeless and caregiver stipends.
VHA’s service capacity is contingent on annual congressional appropriations. To manage resource allocation, VHA employs a priority group system. Veterans are assigned to eight priority groups (1 being the highest) based on factors like service-connected disabilities and income. Priority group assignment dictates cost-sharing responsibilities and, in some cases, enrollment eligibility. In 2020, out of 9.2 million enrolled veterans, approximately 6.2 million utilized VHA services, alongside 760,000 non-veteran patients. It’s important to note that many veterans have supplementary insurance, often through Medicare, and access healthcare from multiple sources. VHA projections estimated an average spending of $14,750 per veteran patient in 2021, with enrollment anticipated to remain stable until 2023.
The Historical Path to Community Care Expansion
The concept of community care for veterans dates back to World War I, with eligibility criteria evolving over decades. In the 1920s, as VA primarily offered inpatient services, Congress authorized contracts with external providers under specific circumstances, such as outpatient care for service-connected disabilities. Eligibility expanded in 1957 to include female veterans and veterans in U.S. territories, and in 1979 to veterans receiving VA pensions or those who were housebound. Community care was also authorized for specific services, such as dialysis and obstetrics, when VA facilities were geographically distant, over capacity, or lacked the specific service.
The establishment of the VHA in 1989, following a VA reorganization, formalized the administration of veteran healthcare, both within VA facilities and through community care when necessary. Initially, community care agreements were primarily local, operating on a fee-basis system where community providers billed local VHA facilities, and payments were processed centrally.
A significant expansion of community care access began in 2014. Public outcry regarding long wait times and management issues at several VA medical centers spurred legislative action. The Veterans Access, Choice, and Accountability Act of 2014, enacted in August 2014, established the Veterans Choice Program. This temporary program allowed eligible veterans to access non-VHA providers if they faced appointment wait times exceeding VA’s 30-day goal or lived over 40 miles from a VHA facility. Congress allocated $10 billion (nominal dollars) over three years for community care under this program and an additional $5 billion (nominal dollars) to enhance VHA’s in-house capacity through increased staffing and facility expansion. The mandate was to implement expanded community care access within 12 weeks of the Act’s enactment. Subsequent months into 2015 saw further clarifications and revisions to the Veterans Choice Program through VHA rule-making and additional congressional legislation.
Legislative and Policy Shifts Shaping Community Care
2017 marked a significant policy shift, moving away from community care as a last resort. The new approach, driven by a new Congress and Presidential Administration, allowed veterans meeting broad criteria to choose between VHA and community care. While VHA was developing a new program, lawmakers extended the Veterans Choice Program’s expiration and provided additional funding. VHA then focused on consolidating community care contracts and developing the program that would replace the Veterans Choice Program. The new eligibility criteria, emphasizing timely access and clinical need, broadened veterans’ options for seeking treatment outside VHA facilities.
The VA MISSION Act, enacted in June 2018, was a landmark piece of legislation. It created the VCCP as a permanent program for medical and long-term care services through non-VHA providers. This act fundamentally restructured the legal framework for local agreements and other community care programs. VHA now contracts with regional networks of community providers to deliver care to enrolled veterans. These community providers primarily include, but are not limited to, Medicare program participants.
VCCP Eligibility: Who Can Access Community Care?
VCCP eligibility is determined by a set of criteria based on a veteran’s circumstances or VHA’s service capabilities. New access standards for wait and drive times significantly increased the number of eligible veterans. In principle, under VCCP, any enrolled veteran could be eligible for community care under certain conditions.
Criteria for Community Care Access
The 2018 legislation outlined general conditions for community care provision, with the VA Secretary retaining discretion over specific criteria. As the VCCP is relatively new, its implementation is still evolving. As of 2021, veterans qualify for community care based on one or more of these six criteria:
- Lack of VHA Services: The required care or services are not available at VHA facilities.
- Geographic Inaccessibility: Residence in a state or territory without a full-service VHA medical facility (Alaska, Hawaii, portions of New Hampshire, Guam, American Samoa, Commonwealth of the Northern Mariana Islands, and the U.S. Virgin Islands).
- Prior Veterans Choice Program Eligibility: Previous qualification for community care under specific Veterans Choice Program provisions.
- Wait and Drive Time Standards Not Met: VHA facilities cannot provide care or services within VA-designated access standards for appointment wait times or facility drive times.
- Quality Standards Not Met: VHA facilities do not meet VA-designated quality standards for the required care or service.
- Best Interest Determination: Agreement between the veteran and VHA provider that community care is in the veteran’s best interest.
Community care authorization is typically for an “episode of care,” covering treatment for a specific medical issue within a defined period. This approval is condition-specific and doesn’t automatically extend to subsequent care. Generally, pre-approval from VHA staff is required for community care, except in emergencies and urgent care situations. Appointments with approved providers (Medicare/Medicaid participants and federal providers like the Department of Defense) can be scheduled by the veteran, VHA, or the contractors managing the community care networks. By 2020, approximately 1.7 million community providers had joined VHA’s regional networks, with most accepting Medicare rates.
Evolving Access Standards: Wait and Drive Times
The MISSION Act’s access standards for wait and drive times have significantly expanded VCCP eligibility, impacting the program’s scope and costs. The drive-time standards align with Tricare Prime, the Department of Defense’s HMO-style healthcare program, which has long relied on community providers. In contrast, VHA has traditionally provided most care directly.
While reduced wait and drive times were key drivers for community care expansion, community providers are not bound by VHA’s access standards. Although VA aims to ensure contractors build adequate networks with VHA-like access standards, VHA acknowledges limited control over community providers’ appointment wait times once veterans opt for community care. Consequently, there’s no specific maximum wait time goal for community care. Similarly, veterans can choose community providers farther away than closer VHA facilities.
Appointment Wait Times: The Veterans Choice Program aimed for a maximum 30-day wait for new appointments. VCCP shortened this to 20 days for primary care, mental health, and non-institutional extended care, and 28 days for specialty care. These standards are flexible if veterans agree to longer waits in consultation with their VHA provider.
Under the Veterans Choice Program, long VHA wait times were a primary eligibility factor for about half of community care users. However, improved VHA wait times since 2014 have lessened reliance on this criterion. VHA provides website resources for checking average wait times at specific facilities and publishes historical access data. Despite improvements, external audits have noted ongoing challenges in VHA wait time measurement and appointment scheduling.
Drive Time Standards: The Veterans Choice Program defined community care eligibility based on driving distances exceeding 40 miles to the nearest VHA facility. VCCP shifted to drive time, with eligibility triggered by average drive times exceeding 30 minutes to the nearest VHA facility for primary care, mental health, or non-institutional extended care, and 60 minutes for specialty care.
Unlike wait time criteria, drive time standards have not been systematically evaluated. Under the Veterans Choice Program, relatively few veterans (around 250,000) qualified based on driving distance. However, drive time is projected to become the most common VCCP eligibility condition. VHA data indicates that at least 2 million veterans (about a quarter of enrollees and one-third of patients) were drive-time eligible in 2020, predominantly in rural areas. VHA addresses rural veteran access through facility construction in underserved areas and the Office of Rural Health programs. However, remoteness in some areas means no providers, VA or community, can be reached within the 30-minute drive time standard.
Impact on Healthcare Access
Many veterans now experience improved healthcare access compared to 2014, driven by increased community care utilization and reduced VHA wait times.
Community care authorizations surged from 1.3 million veterans in 2014 to 2.3 million by 2020, a more than 75% increase. In contrast, VHA enrollment grew by only 2% during the same period. Long-term VHA patient load trends are downward, reflecting a decrease in the overall veteran population from 30 million in 1980 to under 20 million in 2021.
VHA facilities generally exhibit shorter average wait times than the private sector. Research indicates that VHA wait times for primary care and several specialties have improved since 2014, now matching or surpassing private sector wait times, both in urban and rural settings.
Studies also suggest that longer VHA wait times often correlate with regions experiencing longer community care waits, supported by VHA administrative data. For example, certain VHA facilities in the South and parts of Texas reflect private-sector provider scarcity, leading to greater VHA reliance. Even where private providers exist, their VCCP participation isn’t guaranteed.
The 2020-2021 pandemic saw temporary telehealth restrictions waived, enhancing veteran access to community providers during clinic closures. Telehealth utilization depended on community provider capabilities, veteran preferences, and the nature of care needed. VHA extensively utilized telehealth throughout much of 2020.
Shifting Expenditure on Community Care
VHA’s community care spending has risen sharply in recent years, both in absolute terms and as a percentage of VHA’s total budget. From $7.9 billion in 2014 (12% of VHA’s budget), community care costs more than doubled to $17.6 billion by 2021, representing approximately 20% of the budget. In 2021, VA’s medical care appropriation was $89.8 billion (a portion of direct clinical services), about 40% of the department’s total program funding.
Historical Spending Trends and Funding Requests
Community care spending growth can be divided into two periods: growth under the temporary Veterans Choice Program (2014-2019) and subsequent growth under VCCP (from 2020 onwards). The first period saw significant annual cost increases, starting with a 33% rise in 2015, the first year of the Veterans Choice Program. Cost growth moderated as the program matured, reaching a 14% increase by 2018. Long-term services and supports (primarily nursing home care) constituted about 30% of community care costs and experienced slower growth than healthcare costs.
Alt text: Table displaying VA’s costs for Veterans Community Care from fiscal years 2014 to 2023, showing a significant increase in spending over time, particularly after the implementation of the Veterans Choice Program and the Veterans Community Care Program.
The second period, beginning in 2020 with VCCP implementation, saw further cost jumps and increased future funding requests. VHA’s advance request for community care in 2023 is $23.9 billion (2021 dollars), triple the 2014 costs and double the 2018 figure. This growth contrasts sharply with VHA enrollment, which increased by only 3% between 2014 and 2021.
Future Community Care Expenditure
Congressional appropriations directly control future VHA spending. VHA budget requests will depend on veteran choices regarding community care and the costs of non-VHA providers. Increased spending pressures could lead to larger budget requests or resource reallocation from other VA programs to fund community care.
Spending pressure may arise from VHA’s limited near-term control over community care use once authorized and potentially higher costs of community care compared to VHA direct care. Cost comparisons are scarce and often outdated. However, recent studies confirm earlier findings that VHA care is less expensive and yields better health outcomes than comparable Medicare services.
Variations in practice patterns among community providers could also inflate spending. These differences might stem from cost control and incentive structures in VHA versus the private sector. VHA lacks control over the services veterans receive from community providers. VHA officials attributed higher-than-estimated spending in 2017-2018 partly to local practice patterns, such as increased MRI use over less costly alternatives.
Conversely, community care costs could be lower if community providers make fewer referrals for other healthcare or tertiary services than VHA providers. Private providers might also be more efficient or see more patients daily. Community provider utilization could also free up space in busy VHA facilities, potentially avoiding capital investments for expansion.
Increased VCCP spending pressure could challenge future VA budgets, especially given VA’s spending growth outpacing economy-wide inflation over the past two decades. Increased veteran reliance on VHA and community care choices could accelerate spending growth. If funding is insufficient, the VA Secretary could restrict community care access or rescind enrollment for lower priority groups to prioritize higher priority veterans, or Congress could legislate stricter access criteria or reduce funding for other programs.
Broader Effects of the Veterans Community Care Program
While VCCP has improved community care access, other outcomes are mixed. VA’s stated goal is “high-quality, timely, veteran-centric care” aligning with veteran preferences and clinical needs. However, inherent conflicts exist between quality, timeliness, patient preference, clinical needs, and cost. The MISSION Act introduced potentially conflicting requirements, some outside VA’s control. For example, onerous contract requirements for community providers, such as mental health screening, quality reporting, and record sharing, could deter participation. VCCP’s novelty means its full effects on utilization, cost, and other metrics are still unfolding. Research highlights the inherent difficulties in cross-system care coordination, the impracticality of monitoring every community provider’s quality, and the potential for VHA facility underutilization due to increased community care access.
Challenges in Care Coordination
Care coordination involves organizing patient care activities and information sharing among all providers for safer, more effective treatment, crucial for patients with chronic or multiple conditions, including veterans with conditions like cancer, COPD, PTSD, and suicide risk.
Care coordination between VHA and community providers has been inconsistent. As of June 2020, few community providers had adopted VHA’s software for referrals and information sharing. Both VHA and non-VHA providers have reported frustrations with communication, information sharing methods, and care delivery variations, issues also experienced under the Veterans Choice Program. Delayed payments have also been a source of provider frustration. These challenges have led to reluctance among community providers in some areas to participate in VCCP.
Poor care coordination risks include redundant tests, conflicting medical instructions, and disjointed transitions between providers. VHA offers optional training for community providers on veteran-specific healthcare needs, but awareness may be limited. Once a veteran is approved for community care, VHA may lose the ability to retain the patient for in-house treatment and coordinate care for optimal outcomes. Future care coordination may improve with increased community provider adoption of VHA electronic health records, new programs, and stronger relationships with local VHA facilities.
Quality Assurance of Community Care Providers
Community care providers in VHA’s network must meet credentialing standards (licensure, education, training verification), but the quality of many remains unknown. Healthcare quality encompasses various aspects of patient care, generally indicating how effectively medical services improve health outcomes. Extensive research consistently shows VHA delivers high-quality care, often as good as or better than community providers.
The MISSION Act mandates VHA to establish and monitor community provider quality. Healthcare systems measure multiple dimensions of care quality, but a unified national quality reporting system is lacking in the U.S., resulting in non-standardized measures for VHA. VHA network participants are not required to report VHA quality measures, and provider quality varies. Quality for discrete services like dialysis or cholesterol monitoring is likely consistent, while complex, clinician-intensive treatments like mental healthcare and occupational therapy may exhibit greater variation.
VHA has launched initiatives to assess community care quality. Accreditation, a process of setting standards and reviewing providers, is one approach. Medicare providers must be state-certified, but external accreditation is voluntary. VHA also provides a website for quality comparisons of its facilities and some non-VHA providers using data from the Centers for Medicare & Medicaid Services and others. Measurable metrics like mortality rates and safety protocol adherence are readily available. However, aspects like patient satisfaction are harder to assess and may not directly correlate with clinical quality. While VHA can promote its services and veteran-centric care, veterans may prioritize convenience over potentially higher quality VHA care.
VHA Facility Utilization
Geographic imbalances exist between VHA facilities and veteran populations. VHA anticipates that increased community care access will enhance capacity and efficiency in some medical centers and reduce the need for costly new facility construction. However, in other areas, increased community care access could reduce utilization of adequately capacitated VHA facilities, potentially raising per-veteran costs if facility consolidation is not feasible.
Improved Patient Flow in Under-Capacitated Areas: During the late 1990s and 2000s, VHA invested heavily in infrastructure, shifting towards outpatient and broad-based care. Many VHA hospitals and large clinics are located in historically veteran-dense states east of the Mississippi. However, veteran migration patterns have shifted, with many relocating to the Southeast and Southwest. This has led to facility imbalances, with some states having a higher facility-to-enrollee ratio than others. For example, New York and Florida have a similar number of facilities, but Florida has significantly more enrollees. While geographic region and wait times aren’t directly correlated, facility management practices are a significant factor.
Alt text: Chart comparing the number of VHA facilities to the number of veteran enrollees per state in fiscal year 2019, highlighting the variation in facility density relative to veteran population across different states.
Community care can help ensure timely care in areas with VHA capacity constraints. Furthermore, it could save VHA capital expenditure on new or expanded facilities, especially as the veteran population declines. This also applies to facilities experiencing seasonal appointment volume fluctuations. However, in areas with limited private providers, community care’s impact may be minimal.
Reduced VHA Facility Use in Sufficiently Capacitated Areas: Increased community care access could lead to fewer veterans seeking care at VHA facilities operating at or below capacity. This could increase per-patient costs due to fixed facility costs. Maintaining existing hospitals and tertiary facilities incurs high fixed costs regardless of utilization. Even with staff relocation, physical facilities remain. Under VCCP, veterans eligible for community care cannot be mandated to use VHA facilities.
The MISSION Act mandates VA to develop criteria for facility modernization or disposal to align with veteran healthcare needs, initiating an Asset and Infrastructure Review in 2022. However, if facility closure attempts are unsuccessful, increased community care utilization could result in VHA maintaining expensive, underutilized facilities. Modernizing these facilities, especially those experiencing declining use, could be difficult to justify and costly. Changes in veteran reliance on VHA or other factors could mitigate VHA facility underutilization.
This analysis provides a comprehensive overview of the Veterans Community Care Program, tracing its origins, evolution, and multifaceted impacts on veterans’ healthcare access, costs, and the broader VA healthcare system. The program represents a significant shift in how veteran healthcare is delivered, with ongoing implications for both veterans and the VA.
