Alaska VA makes progress after taking over Choice referrals

Wednesday, January 31, 2018 - 11:33
  • Alaska Veterans’ Affairs Director Dr. Timothy Ballard has been on the job since July 2016 and has helped add staff as well as overseen the local office in Anchorage take over referrals under the Veterans Choice Program. Alaska veterans once had to call Phoenix under the program, but now the local office handles about 1,000 referrals per week to non-VA providers. (Photo/Naomi Klouda/AJOC)

Alaska’s 72,000 veterans will continue to receive care under a program that the state office of the Department of Veterans’ Affairs took pains to reconfigure over the past 18 months.

The Veterans Choice Program received an additional $2.1 billion in December, just weeks prior to the three-day government shutdown on Capital Hill.

VA Secretary David Shulkin wrote a letter to Congress Dec. 12 warning that money for the program, which allows eligible veterans to receive health care from a community provider rather than waiting for a VA appointment or traveling to a VA facility, was running low.

Sen. Dan Sullivan, who helped push for the $2.1 billion in funding from his seat on the Senate Committee on Armed Services, announced Jan. 9 to Alaska’s veterans that his efforts continue to focus on devising new ways to overcome problems in achieving quality medical care.

In the meantime, Sullivan favors keeping the Choice program in place to pay doctor reimbursement bills and the December appropriation should last four to six months.

At 1 out of every 10 Alaskans, the state has the highest per capita population of veterans in the nation, according to the U.S. Census Bureau.

Alaska VA Healthcare System Director Dr. Timothy Ballard took his position in July 2016, the same month that Alaska’s congressional delegation decided they had heard enough complaints to justify an “Alaskanization” of the program that was created in 2014 amid the national scandal of long wait times and employee misconduct that even led to veterans dying while awaiting care at VA facilities.

Prior to Ballard’s Alaska appointment, he was the CEO and commander of the 88th Medical Group at Wright-Patterson Air Force Base in Ohio. There he oversaw a staff of 2,200 at 39 clinics, nine outpatient clinics and four inpatient units.

Alaska VA services include the Anchorage VA Outpatient Clinic; a 50-bed domiciliary for substance abuse; rehab treatment/homeless services for vets; a 10-bed intensive care unit and a 24-bed medical services unit at Joint Base Elmendorf Richardson; community clinics in Fairbanks, Kenai and the Mat-Su Valley; and outreach clinics in Homer and Juneau.

Short staffed

When Ballard moved into his Alaska office, he immediately saw that the VA here was understaffed with about 550 members.

Ballard found staff members that were filling three positions at a time, which led to part of Alaska’s problems in providing health care services.

Congress created the 2014 VA Choice program with a $10 billion fund to pay for medial services that went beyond what the local VA could provide or if it had wait times that were longer than those at other health care facilities.

Then came the problems. When the VA Choice Program was created, two call centers were contracted to handle veterans’ health care appointments and approve payment. In the west, it was the Phoenix-based TriWest; in the east, Health Net Federal Services.

Alaska vets were placed under TriWest’s services.

The program was supposed to ease the extremely long wait lists to get care by opening a network of non-VA providers when it “didn’t have capacity or capability to meet the need,” Ballard said.

“There were fairly immediate problems that mainly had to do with the fact most of their agents are out of state,” he said.

Alaska veterans would call TriWest to set up to seeing a specialist, as required for pre-approval. But TriWest’s medical specialists could be anywhere in Alaska and without knowing the state, the agents set up odd, long-distance appointments.

“(For example,) you need to be seen by an ophthalmologist,” Ballard said. “So we’re going to send you to Juneau to see an ophthalmologist there. The vet might protest, ‘but there’s no roads to Juneau, you know.’ And so veterans felt frustrated. They were sending them to towns that didn’t make sense.”

But in July 2016, the Alaska VA was granted permission to take back its referrals by setting up offices in-house at the VA Alaska headquarters on Muldoon Road in Anchorage. This pilot program coincided with Ballard’s arrival.

Instead of going through Arizona, the program shifted to oversight by Cynthia Massey, chief of the Integrated Care System for the Alaska VA Healthcare System.

Massey’s team now handles 1,000 referrals per week, Ballard said, a staggering amount for one of the country’s smaller VA systems.

“Other VAs have a staff of 3,000 – we had 555 when I came on the job last year,” he said.

He immediately requested more doctors and other position to gain about 100 new staff. So far, he’s received half of that number.

Some of the new staff were installed at the Anchorage referral office, which helped ease a significant frustration, Ballard said.

Ballard said he still needs to fill positions varying from physicians, nurses, budget people, maintenance crew and even police officers to help secure the facilities.

Referrals and reimbursements

Another big source of aggravation for veterans was the tug-of-war to get reimbursed for non-VA care. Their VA-approved referrals to primary care and other providers would be reimbursed in one of two ways: either through the Choice program or by Non-VA Coordinated Care, or NVCC.

Out of the 1,000 provider referrals per week from the Alaska VA, about half are reimbursed by NVCC and other half by Choice, Ballard said.

“But NVCC referrals have to be sent through the national payment center. Where there’s been problems is when the bill is sent to the wrong reimbursement center. A number of vets complained they were in collections because their provider hadn’t been paid,” Ballard said.

When bills ended up back in a veteran’s mailbox, they were simply marked “denied” without the explanation that they went to the wrong payment center.

If not dealt with, mounting medical bills went to collections and sometimes accumulated to staggering sums.

In addition to the referrals, Massey’s team untangles these disputed bills and clarifies which payment centers the doctor visit reimbursements need to be sent.

“It’s going very well,” Massey said of the referral program, now.

The Alaska private and federal healthcare network coordinates with the VA program so that Alaska veterans have a number of medical options.

One of those is to use Tribal medical facilities, such as the Alaska Native Medical Center in Anchorage or the Southcentral Foundation care providers. Even if the veteran is non-Native, a VA-Tribal sharing agreement allows vets to use any Indian Health Service medial facility in the state. Then the bill goes to the VA, Massey said.

Another 16 approved private doctors and health care providers are also available, vetted by TriWest and added to those approved for veteran referrals, Massey said.

These include whole health alternatives such as acupuncture, physical therapy, chiropractic, osteopathic manipulation and pain management.

One in four appointments are generated to these modalities, Ballard said, services that the VA doesn’t provide.

“We heavily rely on these community providers,” Ballard said.

Addressing opioids

Another big challenge is opioid addiction and treatment, also covered under the Choice program. The Comprehensive Addiction and Recovery Act, or CARA, signed in July 2016, included guidance on care for veterans that have been prescribed opioids. The official policy was to give veterans alternatives, said VA Chief of Integrated Care Services Cynthia Joe.

“The idea is to reduce opioid use and so we try to facilitate the stoppage,” Joe said. “There is no safe dosage of opioids. They run an increased risk of overdose with higher dosages given to them over time.”

Many veterans are frustrated with the push to take away a tool that helped manage pain, for some, over the course of many years.

“Some have used it for the past 20 years, and in their minds, successfully so. They question ‘why are you going to stop it now?’” Ballard said.

The CARA Act provided guidance but the relationship between physician and patient still may include opioid prescriptions, he added.

A number of providers hold Suboxone credentialing, a level that demands a special Drug Enforcement Administration licensure to treat opioid use disorder.

This drug is helping ease the addiction pains of getting off opioids. Paired with other therapies including massage, yoga and mindfulness techniques, the effort is on to help veterans find options to pain management, Joe said.

But unfunded mandates also press hard on the understaffed facility, Ballard has found. The CARA Act placed demands on VAs to help bring down the severely high suicide rate among veterans.

A program for mental health and substance abuse at the VA has small resources such as 15 designated beds at the U.S. Department of Veterans Affairs Domiciliary Care Program on C Street in Anchorage.

The facility offers 50 beds to cover all homeless vets, substance abuse residency and care for criminally related mental health behavior.

Between unfunded substance abuse mandates in the CARA Act, there’s also guidance on suicide prevention that requires better-staffed programs.

“These programs are required by law, an increase mostly in the policy initiatives but they amount to unfunded mandates,” Ballard said.

Other changes for improved care involve more direct access to physicians through registering online to talk with the doctor or fill a prescription, a system called My Healthy Vet. Regularly scheduling town halls to get direct communication also help, Ballard said.

The most recent one was Jan. 23 in Wasilla and another was to be held Feb. 1 in Fairbanks. More i1nformation is at alaska.va.gov.

Naomi Klouda can be reached at naomi.klouda@alaskajournal.com.

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