Veteran’s Choice

Reprinted from PN/Paraplegia News January 2015

As the Veterans Choice Program continues to roll out, paralyzed veterans have to decide: Is care outside the VA right for me?

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Robert Patty is a veteran with a spinal-cord injury (SCI) living in Murfreesboro, Tenn. The Paralyzed Veterans of America (PVA) member sees a primary care physician, an orthopedist and a pain management specialist, all outside of the Department of Veterans Affairs (VA) Health Care System. With the help of Tricare, Patty only utilizes the VA when he needs to.

Jerry Ellis is also a veteran with SCI and a PVA member. The Chipley, Fla., resident relies on three hospitals for his medical care, all VA centers, two of which have SCI clinics. When it comes to taking care of his SCI-related health, Ellis only uses the VA.

The pair have each been affected by problems exposed last year within the VA health care system and now have a decision to make concerning the Veterans Choice Program.

Change & Choice

The program was created as part of the changes being made under the Veterans Access, Choice, and Accountability Act of 2014 (VACAA). The law came about following an investigation of the entire VA Health Care System by the Veterans Health Administration (VHA), which exposed access problems in the form of deathly long wait times for appointments and secret waiting lists at some locations. Additionally, many veterans live too far from a clinic to receive adequate care.

The VACAA outlines several changes to be made by VHA, including giving the system $5 billion to hire more doctors and nurses and granting veterans the ability to access care outside the VA using a “choice card.”

Choice cards became effective Nov. 5, 2014, and are provided to veterans who live more than 40 miles away from the closest VA health care facility or have to wait more than 30 days from their preferred appointment date or the date chosen to be medically necessary by their physician.

These veterans have a choice to make: continue receiving care within the VA, or take their choice card to a hospital and/or physician in the private sector to receive care. Two private health care companies have signed contracts with VHA to provide this service.

On Nov.5, 2014, Department of Veterans Affairs (VA) Secretary Robert McDonald (top photo, center) held a roundtable meeting with veteran service organizations’ staffs, including Paralyzed Veterans of America, at the VA Central Office in Washington, D.C.

However, a big concern for some, including PVA, is the ability of private facilities to provide the specific type of care needed for veterans with spinal-cord injury or disease. It’s a concern Ellis has experienced first hand.

Choosing Excellence

When Ellis needed in-patient neck surgery, he used a private hospital near his home.

After the surgery, nurses brought him to his room where Ellis found an inaccessible bathroom. He couldn’t use the toilet or shower and when his nurses suggested using a potty chair by his bed, he checked himself out.

After that experience, Ellis won’t seek in-patient care or any health care related to his SCI outside of a VA SCI center, not even in a primary care VA hospital where there aren’t SCI specialists. He worries about issues a non-SCI doctor wouldn’t know about, like autonomic dysreflexia (AD) for example. Ellis once had symptoms of this from a bladder issue, but the doctor didn’t know what to do because he didn’t know what AD was.

“The problem you have living away from a spinal-cord injury center, the problem is in these clinics, rural clinics, smaller clinics, they don’t know anything about SCI,” Ellis says. “… I don’t think [the choice program is] a great idea for spinal cord because of the specialty involved … The general family type doctor you would have to be careful, but if you have something you need to see a specialist, like a surgeon or a cancer doctor or whatever, a specialty, that would be doable.”

Carolyn Clancy, MD, interim under secretary for health in the VA, agrees. For things related to SCI, especially annual physicals, Clancy says it’s her “hope, and frankly expectation” for veterans to choose to use the VA SCI centers. However, in cases of emergency or needed services outside of the SCI center, such as a scan or test that requires a long wait time, she believes the choice card is a great option for veterans with SCI.

“The SCI centers themselves ... are really centers of excellence for spinal-cord injury,” Clancy says. “ ... There will be some veterans who will choose not to use [the program] but live far enough away that for selective services, which may not have anything to do particularly with their spinal-cord injury, but they need some health care, it would be of help to them to get that closer to home.”

Navigating the Mess

Although there are many things to consider before deciding to seek care outside the VA, Patty is a prime example of how Clancy thinks this bill can work for someone with SCI.

He uses the VA for his annual physical at the SCI center, but even then, he dreads making the appointment. Last year, Patty tried to make his physical with his local VA center, but it doesn’t have an SCI center. Patty was told he would have to make a 200-mile trek.

“Getting an appointment for my physical in [the SCI center I use] is kind of a chore because they only want to do them on certain days and the person that schedules them … is real snippy and just flat out rude when you call up, and treats it like she’s doing you a favor by allowing you to schedule an appointment,” Patty says.

Ellis has an even longer trek to his preferred VA SCI center — about 600 miles. He says he’s never had a hard time with scheduling, but that’s because he doesn’t give them the choice.

“If it’s something where I needed to go right away, I just called them and told them I was coming,” Ellis says. “You know, I say, ‘This isn’t something I can wait weeks on.’”

Where Ellis has run into issues at his VA hospital is for any procedure ordered outside the SCI center, like an MRI, CT scan or surgery.

“To get an appointment at any of the other places, say MRI or surgery … it takes months,” says Ellis. “… Anything where you have to leave the spinal-cord [injury center] and go into the main hospital unit … is a mess.”

In situations like that, Patty is already using care from the private sector because of scheduling issues and long wait times he’s experienced within the VA as well as living more than 200 miles away from an SCI center.

“If it ever came down to it where it was either use the VA or pay for it out of pocket, I would still pay for it out of pocket,” Patty says.

This new law may give him the opportunity to get coverage for care of other ailments not related to his SCI outside of the VA, but Patty says he will continue to use the SCI center for his annual physical.

It’s Only the Beginning

Pro-VA or not, there is one thing Patty,

Ellis and Clancy all agree on: This law is only the beginning.

The VA is still rolling out the program and sending choice cards to veterans. This is just one of many possible solutions to a whole host of problems and there are still questions to be answered.

“Our goal isn’t only to fix this problem. Our goal is to make this the best system in the country. Because we really have all the components in place, including the SCI centers to achieve that goal,” Clancy says. “So, this is not fantasizing or daydreaming. This is actually what we are going to do by way of transforming the system.”


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