Resources and Capabilities of the Department of Veterans ... · medical supplies (J), construction and capital management (K), and leadership (L). VA engaged the Centers for Medicare

C O R P O R A T I O N

Research Report

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans

Appendixes C–G

RAND Health

Sponsored by the U.S. Department of Veterans Affairs

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RAND Corporation Assessment B

The views, opinions, and/or findings contained in this report are those of RAND Corporation should not be construed as an official government position, policy, or decision.

iii

Preface Congress enacted and President Barack Obama signed into law the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113-‐146) (“Veterans Choice Act”), as amended by the U.S. Department of Veterans Affairs (VA) Expiring Authorities Act of 2014 (Public Law 113-‐175), to improve access to timely, high-‐quality health care for Veterans. Under “Title II—Health Care Administrative Matters,” Section 201 called for an independent assessment of 12 facets of VA’s health care delivery systems and management processes (Assessments A–L): veteran demographics and health care needs (A), health care capabilities (B), authorities and mechanisms for purchasing care (C), access standards (D), appointment scheduling (E), inpatient clinical workflow (F), staffing and productivity (G), health information technology (H), business processes for purchased care (I), pharmaceuticals and medical supplies (J), construction and capital management (K), and leadership (L).

VA engaged the Centers for Medicare and Medicaid Services (CMS) Alliance to Modernize Healthcare (CAMH) to serve as the program integrator and as primary developer of 11 of the 12 independent assessments. CAMH carried out one assessment internally (H) and subcontracted with the RAND Corporation for three assessments (A, B, and C), Grant Thornton LLP for two assessments (G and I), and McKinsey & Company for five assessments (E, F, J, K, and L). VA separately engaged the Institute of Medicine of the National Academies to prepare an assessment of access standards (D). CAMH coordinated the assessments, prepared an integrated report for the overall study, and furnished the complete set of reports to the VA Secretary, the House and Senate Veterans Affairs Committees, and the President’s Commission on Care on September 1, 2015.

This report describes the results of an assessment of VA health care resources and capabilities (Assessment B), conducted by the RAND Corporation. Specifically, it examines VA’s current and projected health care resources and capabilities in five domains (fiscal, workforce and human resources, physical infrastructure, interorganizational relationships, and information technology), the level and nature of access to VA care, barriers and facilitators to access, the quality of care, and analysis of how selected policies could affect Veterans’ access to high-‐quality care.

This research was conducted by RAND Health, a RAND division, under subcontract to CAMH, a federally funded research and development center sponsored by CMS and operated by the MITRE Corporation. The analyses upon which this publication is based were performed under a Contract for the Department of Veterans Affairs. The content of this publication does not necessarily reflect the views or policies of the Department of Veterans Affairs, nor does the mention of trade names, commercial products, or organizations imply endorsement by the U. S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented.

Additional information RAND can be found at www.rand.org.

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v

Table of Contents

Appendix C Summary of Qualitative Interview Results .............................................. C-‐1

Appendix D Access ................................................................................................... D-‐1

Appendix E Quality .................................................................................................... E-‐1

Appendix F Projections .............................................................................................. F-‐1

Survey Data Tables and Participant Comments ..................................... G-‐1 Appendix G



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vii

List of Figures

Figure D-‐1. Responses to Access Questions on VA Survey of Enrollees, 2010–2014. .......................... D-‐163

Figure D-‐2 Maps of Wait Time Performance at VA Facilities across the United States, First Half FY2015 and Change from First Half FY2014 to First Half FY2015 .......................................... D-‐167

List of Tables

Table C-‐1. Fiscal resources domain: code count by facility-‐level interview .............................................. C-‐9

Table C-‐2. Workforce and human resources domain: code count by facility-‐level interview ................ C-‐33

Table C-‐3. Physical infrastructure resources domain: code count by facility-‐level interview ................ C-‐61

Table C-‐4. Types of Interview Questions by Interviewee Type ............................................................... C-‐73

Table D-‐1. Total and VISN Veteran Population by Enrollee and User Status ............................................ D-‐1

Table D-‐2 Geographic Access to VAMCs ................................................................................................... D-‐2

Table D-‐3 Geographic Access to VAMC Complexity Level 1 or 2 .............................................................. D-‐4

Table D-‐4. Geographic Access to VAMC Complexity Level 1A , 1B, OR 1C ............................................... D-‐7

Table D-‐5 Geographic Access to VAMC Complexity Level 1A or 1B ........................................................ D-‐10

Table D-‐6 Geographic Access to VAMC Complexity Level 1A ................................................................. D-‐13

Table D-‐7 Geographic Access to Health Care Centers ............................................................................ D-‐16

Table D-‐8 Geographic Access to Multi-‐specialty CBOCs ......................................................................... D-‐19

Table D-‐9 Geographic Access to Primary care CBOCs ............................................................................. D-‐21

Table D-‐10 Mapping of Clinical Inventory Profiles and Services to the Seven Clinical Conditions ......... D-‐25

Table D-‐11 Geographic Access to VA Facilities providing ED care .......................................................... D-‐27

Table D-‐12 Geographic Access to VA Facilities with a Coronary Care Unit ............................................. D-‐30

Table D-‐13 Geographic Access to VA Facilities with Telemetry .............................................................. D-‐33

Table D-‐14 Geographic Access to VA Facilities providing Non-‐invasive cardiology services .................. D-‐36



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Table D-‐15 Geographic Access to VA Facilities providing diagnostic cardiac catheterization ................ D-‐38

Table D-‐16 Geographic Access to VA Facilities providing interventional cardiology .............................. D-‐41

Table D-‐17 Geographic Access to VA Facilities providing cardiac surgery .............................................. D-‐44

Table D-‐18 Geographic Access to VA facilities providing primary care .................................................. D-‐46

Table D-‐19 Geographic Access to VA Facilities providing colonoscopy .................................................. D-‐49

Table D-‐20 Geographic Access to VA Facilities providing CT scans ........................................................ D-‐52

Table D-‐21 Geographic Access to VA Facilities providing Surgical Services ............................................ D-‐55

Table D-‐22 Geographic Access to VA Facilities providing Oncology Services ......................................... D-‐58

Table D-‐23 Geographic Access to VA Facilities providing Palliative/Hospice Care ................................. D-‐60

Table D-‐24 Geographic Access to VA Facilities with Primary Care ......................................................... D-‐63

Table D-‐25 Geographic Access to VA Facilities with a specialty or endocrinology clinic ........................ D-‐66

Table D-‐26 Geographic Access to VA Facilities with a podiatry clinic ..................................................... D-‐69

Table D-‐27 Geographic Access to VA Facilities with an ophthalmology clinic ........................................ D-‐71

Table D-‐28 Geographic Access to VA Facilities with a Polytrauma support clinic team ......................... D-‐74

Table D-‐29 Geographic Access to a hospital with a polytrauma network site ....................................... D-‐76

Table D-‐30 Geographic Access to VA Facilities with a Polytrauma rehabilitation center ....................... D-‐79

Table D-‐31 Geographic Access to VA Facilities providing TBI Specialty Care ......................................... D-‐82

Table D-‐32 Geographic Access to VA Facilities providing Domiciliary Mental Rehabilitative Treatment Program ................................................................................................................................ D-‐84

Table D-‐33 Geographic Access to VA Facilities providing Mental Health Services ................................. D-‐87

Table D-‐34 Geographic Access to VA Facilities providing psychotherapy .............................................. D-‐90

Table D-‐35 Geographic Access to VA Facilities providing Residential treatment for SUD ...................... D-‐94

Table D-‐36 Geographic Access to VA Facilities providing Methadone ................................................... D-‐96

Table D-‐37 Geographic Access to VA Facilities providing Outpatient specialty care for SUD ................ D-‐99

Table D-‐38 Geographic Access to VA Facilities providing Inpatient detoxification for SUD ................. D-‐102



ix

Table D-‐39 Geographic Access to VA Facilities providing Gynecological surgery services ................... D-‐105

Table D-‐40 Access to Any Non-‐VA Hospital .......................................................................................... D-‐108

Table D-‐41 Access to Teaching Hospitals .............................................................................................. D-‐111

Table D-‐42 Access to Academic Hospitals ............................................................................................ D-‐113

Table D-‐43 Distribution of enrollee-‐level drive time differences between VA vs. non-‐VA facilities .............................................................................................................................. D-‐115

Table D-‐44 Distribution of enrollee-‐level drive time differences between VA facilities with interventional cardiology vs. non-‐VA facilities with interventional cardiology ............................ D-‐117

Table D-‐45 Access to Emergency Department within 40 mile and 60 minute driving distances ......... D-‐119

Table D-‐46 Access to Interventional Cardiology (PCI) within 40 mile and 60 minute driving distances ................................................................................................................................... D-‐121

Table D-‐47 Access to Coronary Care Unit within 40 mile and 60 minute driving distances ................. D-‐124

Table D-‐48 Access to Diagnostic Cardiac Catheterization within 40 mile and 60 minute driving distances ................................................................................................................................... D-‐127

Table D-‐49 Access to Cardiac Surgery within 40 mile and 60 minute driving distances ....................... D-‐130

Table D-‐50 Access to Surgery within 40 mile and 60 minute driving distances ................................... D-‐132

Table D-‐51 Access to Chemotherapy within 40 mile and 60 minute driving distances ........................ D-‐136

Table D-‐52 Access to Oncology within 40 mile and 60 minute driving distances ................................. D-‐138

Table D-‐53 Access to Palliative care within 40 mile and 60 minute driving distances ......................... D-‐141

Table D-‐54 Access to Inpatient Palliative care within 40 mile and 60 minute driving distances .......... D-‐144

Table D-‐55 Access to Hospice care within 40 mile and 60 minute driving distances ........................... D-‐147

Table D-‐56 Access to Cardiologists ....................................................................................................... D-‐150

Table D-‐57 Access to Endocrinologists ................................................................................................. D-‐151

Table D-‐58 Access to Gastroenterologists ............................................................................................ D-‐152

Table D-‐59 Access to General Surgeons ............................................................................................... D-‐154

Table D-‐60 Access to Hematologists-‐Oncologists ................................................................................. D-‐155



x

Table D-‐61 Access to Mental Health Providers (Psychologists and Psychiatrists) ................................ D-‐156

Table D-‐62 Access to Neurosurgeons ................................................................................................... D-‐157

Table D-‐63 Access to Neurologists ....................................................................................................... D-‐158

Table D-‐64 Access to Obstetricians & Gynecologists ............................................................................ D-‐159

Table D-‐65 Access to Physical Medicine & Rehabilitation Specialists .................................................. D-‐160

Table D-‐66 Access to Primary Care Physicians ...................................................................................... D-‐161

Table D-‐67 Access to Thoracic Surgeons .............................................................................................. D-‐162

Table D-‐68 Number of Appointments Completed Within 0-‐14, 15-‐30, 31-‐60, and 61+ Days of Preferred Date, by Appointment Type, First Half FY2014 and First Half FY2015 ............................. D-‐165

Table D-‐69 Number of Days Waited at VA Facilities, by Appointment Type, First Half FY2015 ........... D-‐166

Table D-‐70 Performance on Patient-‐Reported SHEP PCMH Access Measures by VA Facility, FY2014. ................................................................................................................................................. D-‐173

Table D-‐71 Percent of Veterans in VA Facilities Responding that They “Always” Got Appointment for Routine or Urgent Care as Soon as Needed on SHEP PCMH FY2014, by Facility Performance on Wait Times in First Half FY2015. ...................................................................................................... D-‐175

Table E-‐1. Variation in VA Facility-‐Level Performance on Quality Measures for Outpatient Setting, FY2014 ....................................................................................................................................... E-‐25

Table E-‐2. Performance on Outpatient Quality Measures, VA Compared to Non-‐VA, 2013 .................. E-‐30

Table E-‐3. Variation in VA Facility-‐Level Performance on Quality Measures for Hospital Inpatient Setting, FY2014 ....................................................................................................................... E-‐32

Table E-‐4. Comparison of Mean Facility-‐Level Performance of VA and Matched Non-‐VA Facilities on Measures for Inpatient Setting, FY2014 ............................................................................................ E-‐38

Table E-‐5. Variation in Facility-‐Level Performance of Matched Non-‐VA Hospitals on Quality Measures for Hospital Inpatient Setting, FY2014 ................................................................................... E-‐42

Table E-‐6. Comparison of Mean Facility-‐Level Performance of VA and All Non-‐VA Facilities on Measures for Inpatient Setting, FY2014 ................................................................................................. E-‐47

Table F-‐1. Projected Demand and Supply in FY19, Under Supply Scenario Two, By Specialty ................. F-‐1

Table F-‐2 Projected Demand and Supply in FY19, Under Supply Scenario Two, By VISN and Specialty ............................................................................................................................................. F-‐1



xi

Table F-‐3. Projected Demand and Supply in FY19, Under Supply Scenario Three, By Specialty .............. F-‐4

Table F-‐4. Projected Demand and Supply in FY19, Under Supply Scenario Three, By VISN and Specialty ............................................................................................................................................. F-‐4

Table G-‐1. Chief of Staff: Question 1 ........................................................................................................ G-‐2





Table G-‐6. Chief of Staff: Question 6A ...................................................................................................... G-‐5


Table G-‐8. Chief of Staff: Question 6B ...................................................................................................... G-‐8


Table G-‐ 10. Chief of Staff: Question 9 ................................................................................................... G-‐11

Table G-‐11. Chief of Staff: Question 10 .................................................................................................. G-‐11

Table G-‐12. Chief of Staff: Question 10D ................................................................................................ G-‐11



Table G-‐15. Chief of Staff: Question 13A ................................................................................................ G-‐12

Table G-‐16. Chief of Staff: Question 13B ................................................................................................ G-‐13






Table G-‐22. Chief of Staff: Question 19/20 ............................................................................................. G-‐15



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Table G-‐28. Post-‐Traumatic Stress Disorder: Question 1 ....................................................................... G-‐18

Table G-‐29. Post-‐Traumatic Stress Disorder: Question 3A ..................................................................... G-‐19

Table G-‐30. Post-‐Traumatic Stress Disorder: Question 3B ..................................................................... G-‐20

Table G-‐31. Post-‐Traumatic Stress Disorder: Question 3C ..................................................................... G-‐21

Table G-‐32. Post-‐Traumatic Stress Disorder: Question 3D ..................................................................... G-‐22

Table G-‐33. Post-‐Traumatic Stress Disorder: Question 3E ..................................................................... G-‐23




Table G-‐37. Post-‐Traumatic Stress Disorder: Question 6C ..................................................................... G-‐27

Table G-‐38. Post-‐Traumatic Stress Disorder: Question 6D ..................................................................... G-‐28

Table G-‐39. Post-‐Traumatic Stress Disorder: Question 6E ..................................................................... G-‐29

Table G-‐40. Post-‐Traumatic Stress Disorder: Question 6G ..................................................................... G-‐30

Table G-‐41. Post-‐Traumatic Stress Disorder: Question 6H ..................................................................... G-‐31

Table G-‐42. Post-‐Traumatic Stress Disorder: Question 6I ...................................................................... G-‐32

Table G-‐43. Post-‐Traumatic Stress Disorder: Question 6J ...................................................................... G-‐33







xiii

Table G-‐48. Post-‐Traumatic Stress Disorder: Question 10 ..................................................................... G-‐37

Table G-‐49. Substance Use Disorders: Question 1 ................................................................................. G-‐38

Table G-‐50. Substance Use Disorders: Question 3A ............................................................................... G-‐39

Table G-‐51. Substance Use Disorders: Question 3B ............................................................................... G-‐40

Table G-‐52. Substance Use Disorders: Question 3C ............................................................................... G-‐41

Table G-‐53. Substance Use Disorders: Question 3D ............................................................................... G-‐42

Table G-‐54. Substance Use Disorders: Question 3E ............................................................................... G-‐43

Table G-‐55. Substance Use Disorders: Question 3F ................................................................................ G-‐44

Table G-‐56. Substance Use Disorders: Question 3G ............................................................................... G-‐45

Table G-‐57. Substance Use Disorders: Question 3H ............................................................................... G-‐46





Table G-‐62. Substance Use Disorders: Question 6G ............................................................................... G-‐53

Table G-‐63. Substance Use Disorders: Question 6H ............................................................................... G-‐54

Table G-‐64. Substance Use Disorders: Question 6I ................................................................................ G-‐55

Table G-‐65. Substance Use Disorders: Question 6J ................................................................................ G-‐56

Table G-‐66. Substance Use Disorders: Question 6M .............................................................................. G-‐57

Table G-‐67. Substance Use Disorders: Question 6N ............................................................................... G-‐58

Table G-‐68. Substance Use Disorders: Question 6O ............................................................................... G-‐59



Table G-‐71. Substance Use Disorders: Question 9B ............................................................................... G-‐62




xiv

Table G-‐73. Substance Use Disorders: Question 9D ............................................................................... G-‐64

Table G-‐74. Substance Use Disorders: Question 9E ............................................................................... G-‐65


Table G-‐76. Substance Use Disorders: Question 10 ............................................................................... G-‐67

Table G-‐77. Substance Use Disorders: Question 11A ............................................................................. G-‐68


Table G-‐79. Substance Use Disorders: Question 11B ............................................................................. G-‐70


Table G-‐81. Traumatic Brain Injury: Question 1 ..................................................................................... G-‐72

Table G-‐82.Traumatic Brain Injury: Question 2 ...................................................................................... G-‐72



Table G-‐85. Traumatic Brain Injury: Question 6A ................................................................................... G-‐75

Table G-‐86. Traumatic Brain Injury: Question 6B ................................................................................... G-‐76

Table G-‐87. Traumatic Brain Injury: Question 6C ................................................................................... G-‐77

Table G-‐88. Traumatic Brain Injury: Question 6D ................................................................................... G-‐78

Table G-‐89. Traumatic Brain Injury: Question 6E ................................................................................... G-‐79

Table G-‐90. Traumatic Brain Injury: Question 6F ................................................................................... G-‐80

Table G-‐91. Traumatic Brain Injury: Question 6G ................................................................................... G-‐81

Table G-‐92. Traumatic Brain Injury: Question 6H ................................................................................... G-‐82

Table G-‐93. Traumatic Brain Injury: Question 6I .................................................................................... G-‐83


Table G-‐95. Traumatic Brain Injury: Question 8/9 .................................................................................. G-‐84

Table G-‐96. Traumatic Brain Injury: Question 10 ................................................................................... G-‐84

Table G-‐97. Traumatic Brain Injury: Question 12A ................................................................................. G-‐86



xv

Table G-‐98. Traumatic Brain Injury: Question 12B ................................................................................. G-‐87

Table G-‐99. Traumatic Brain Injury: Question 12C ................................................................................. G-‐88

Table G-‐100. Traumatic Brain Injury: Question 12D ............................................................................... G-‐89

Table G-‐101. Traumatic Brain Injury: Question 12E ............................................................................... G-‐90

Table G-‐102. Traumatic Brain Injury: Question 12F ............................................................................... G-‐91

Table G-‐103. Traumatic Brain Injury: Question 12G ............................................................................... G-‐92

Table G-‐104. Traumatic Brain Injury: Question 12J ................................................................................ G-‐93

Table G-‐105. Traumatic Brain Injury: Question 13 ................................................................................. G-‐94

Table G-‐106. Traumatic Brain Injury: Question 14A ............................................................................... G-‐94


Table G-‐108. Traumatic Brain Injury: Question 14B ............................................................................... G-‐97


Table G-‐110. Acute Coronary Syndrome: Question 1 ............................................................................. G-‐99

Table G-‐111. Acute Coronary Syndrome: Question 3A ........................................................................ G-‐100

Table G-‐112. Acute Coronary Syndrome: Question 3B ......................................................................... G-‐101

Table G-‐113. Acute Coronary Syndrome: Question 3C ......................................................................... G-‐102

Table G-‐114. Acute Coronary Syndrome: Question 3E ......................................................................... G-‐103

Table G-‐115. Acute Coronary Syndrome: Question 4 ........................................................................... G-‐103




Table G-‐119. Acute Coronary Syndrome: Question 6D ........................................................................ G-‐107

Table G-‐120. Acute Coronary Syndrome: Question 6E ......................................................................... G-‐108

Table G-‐121. Acute Coronary Syndrome: Question 6F ......................................................................... G-‐109

Table G-‐122. Acute Coronary Syndrome: Question 7 ........................................................................... G-‐109



xvi




Table G-‐126. Acute Coronary Syndrome: Question 9D ........................................................................ G-‐113

Table G-‐127. Acute Coronary Syndrome: Question 10 ......................................................................... G-‐114

Table G-‐128. Acute Coronary Syndrome: Question 12A ...................................................................... G-‐115

Table G-‐129. Acute Coronary Syndrome: Question 12B ....................................................................... G-‐116

Table G-‐130. Acute Coronary Syndrome: Question 12C ....................................................................... G-‐117

Table G-‐131. Acute Coronary Syndrome: Question 12D ...................................................................... G-‐118

Table G-‐132. Acute Coronary Syndrome: Question 12E ....................................................................... G-‐119

Table G-‐133. Acute Coronary Syndrome: Question 12F ....................................................................... G-‐120






Table G-‐139. Acute Coronary Syndrome: Question 17C ....................................................................... G-‐125

Table G-‐140. Acute Coronary Syndrome: Question 17D ...................................................................... G-‐126

Table G-‐141. Acute Coronary Syndrome: Question 17E ....................................................................... G-‐127

Table G-‐142. Acute Coronary Syndrome: Question 17F ....................................................................... G-‐128








xvii

Table G-‐148. Colon Cancer: Question 1 ................................................................................................ G-‐133








Table G-‐156. Colon Cancer: Question 11A ........................................................................................... G-‐138

Table G-‐157. Colon Cancer: Question 11C ............................................................................................ G-‐139

Table G-‐158. Colon Cancer: Question 11D ........................................................................................... G-‐140

Table G-‐159. Colon Cancer: Question 11E ............................................................................................ G-‐141

Table G-‐160. Colon Cancer: Question 11F ............................................................................................ G-‐142

Table G 161. Colon Cancer: Question 11I ............................................................................................. G-‐144

Table G-‐162. Colon Cancer: Question 12 .............................................................................................. G-‐145





Table G-‐167. Type 2 Diabetes: Question 1 ........................................................................................... G-‐150

Table G-‐168. Type 2 Diabetes: Question 3A ......................................................................................... G-‐151

Table G-‐169. Type 2 Diabetes: Question 3B ......................................................................................... G-‐152

Table G-‐170. Type 2 Diabetes: Question 3C ......................................................................................... G-‐153

Table G-‐171. Type 2 Diabetes: Question 3D ......................................................................................... G-‐154

Table G-‐172. Type 2 Diabetes: Question 3E ......................................................................................... G-‐155



xviii

Table G-‐173. Type 2 Diabetes: Question 3F .......................................................................................... G-‐156

Table G-‐174. Type 2 Diabetes: Question 3G ......................................................................................... G-‐157

Table G-‐175. Type 2 Diabetes: Question 3H ......................................................................................... G-‐158




Table G-‐179. Type 2 Diabetes: Question 6C ......................................................................................... G-‐162

Table G-‐180. Type 2 Diabetes: Question 6D ......................................................................................... G-‐163

Table G-‐181. Type 2 Diabetes: Question 6E ......................................................................................... G-‐164





Table G-‐186. Type 2 Diabetes: Question 10 ......................................................................................... G-‐169

Table G-‐187. Gynecologic Surgery: Question 1 .................................................................................... G-‐170

Table G-‐188. Gynecologic Surgery: Question 2A .................................................................................. G-‐171

Table G-‐189. Gynecologic Surgery: Question 2B .................................................................................. G-‐172

Table G-‐190. Gynecologic Surgery: Question 2C .................................................................................. G-‐173


Table G-‐192. Gynecologic Surgery: Question 4A .................................................................................. G-‐175

Table G-‐193. Gynecologic Surgery: Question 4B .................................................................................. G-‐176

Table G-‐194. Gynecologic Surgery: Question 4C .................................................................................. G-‐177






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C-‐1

Summary of Qualitative Interview Results Appendix CThis appendix provides a descriptive summary of the results from the expert and facility-‐level interviews conducted as part of Assessment B. The methods used are described in Chapter Two and Appendix A. Below, we present a descriptive summary of the qualitative interview data for the following domains:

Fiscal and economic resources Workforce and human resources Physical infrastructure resources Information resources Access/quality Policy options

Results by Domain Appendix C.1

Fiscal and Economic Resources Appendix C.1.1In 11 qualitative interviews with VAMC leadership (Directors and Associate Directors), the questions for the fiscal and economic resources domain focused on the effects of decentralization on the ability to allocate resources at the facility level, potential drivers of costs, and perspectives on the process for contracting to outside providers. Table C-‐2 at the end of this section provides the code counts by interview for each fiscal and economic resources domain code.

Budget and Budget Process

VAMC administrators were asked whether there were disconnects between the projection model, which helps develop the budget submitted to Congress, and the VERA model, which allocates money from the VISN to facilities. Most respondents indicated that the VERA distribution model worked well at efficiently allocating resources from the VISN to the VAMC based on workload and population factors at the facility level. However, respondents noted different issues with the process, including time lags in the data used in the VERA model or delays in receiving the allocation itself (four facilities) and the need to document and code accurately to reflect actual workload (two facilities). Several respondents noted that after being initially underfunded through the VERA allocation process the VISN was able to supplement their budget to bridge the gap.

…there’s actually a two-‐year lag between what data that methodology looks at, so there can be some significant population and/or workload shifts that take place. [F-‐005]

In as far back as I can remember, we haven’t gotten a budget allocation for several months into the fiscal year. Sometimes we’ve gone till six months into the fiscal year before we have a budget, so that’s sort of a very difficult question to respond to when we’re dealing with such a vacuum of information.[F-‐064]

Probably about five years ago we started looking at a lot of the things that impact VERA to make sure that we were maximizing…or we were documenting correctly, we were coding correctly, we were getting everything completed within the amount of time to capture the appropriate workload. [F-‐061]



C-‐2

Respondents at five facilities also commented on whether the reallocation process was flexible enough to allow for redistribution based on changes in the patient population with some indicating the VISN had flexibility (four facilities) while others described constraints on the ability to redistribute funds (two facilities).

….so, again, you may have a base allocation that’s provided, but then as things change during the year there’s enough flexibility in that the funds both to the facility and then within the facility can be redistributed or reallocated without really going into a VA cost accounting. [F-‐005]

If the VISN holds a reserve, which they do, you’re halfway through the year and you see a big shift, then some money can shift with it out of the reserve. The problem is that, again, we have created rules that all of your reserve needs to be out—all of your projects need to be obligated in the first six months of the year, all of your equipment has to be purchased in the first six months of the year, which doesn’t leave you any room to have emergencies or make shifts as the environment shifts. [F-‐044]

Administrators at all facilities described different challenges to using allocated funds, including the time it takes to acquire new space (three facilities), mandates that have to be funded out of the allocation (three facilities), the inability to move funds between categories at the facility level (two facilities), and the burden of maintaining physical infrastructure no longer used for patient care (one facility).

Time to acquire new space

… that we are in a huge space crunch and so right now I’m being told that you’ve got to bring 150-‐some mental health staff onboard. And in order to do that we’re putting up modular buildings until once the space is available. Then we can start bringing the people onboard. But you can’t recruit until you have that space to accommodate that staff. So it works great when the money comes at the beginning of the fiscal year. You have time to plan well and you’ve got the space. But when it comes at a very restricted time or the timeline is very short it makes it a challenge. [F-‐084]

Mandates and special programs

I think it’s a lot of the mandates or all of the sudden something new comes from a program office that then it’s thrown back at you and you have to then fund it with the money that you’ve been allocated from the beginning. And then it becomes a challenge. [F-‐084]

Inability to move funds between categories

If we’re spending more than it was originally budgeted in a certain category, we would need to go to our network to try to get approval to move money from one account to another. Generally we’re not allowed to do that. [F-‐064]

In addition is all the special funding that comes out of central office. So they decide what your needs are, they decide that you need 15 mental health providers and say, “Here you go. You can only spend this money on this.” And then at the end of the year if you didn’t necessarily need that, you can’t use the money for different operations somewhere else. You would have to return that money to central office. [F-‐041]

Need to maintain physical infrastructure



C-‐3

The problem is that for this facility here, it’s a pretty significant bill that we pay every year that the funding methodology does not compensate for, to maintain these buildings and the grounds that are really no longer needed for healthcare. So that has an impact on our budget, a direct impact on our budget, because we still have to manage these buildings and maintain them and the infrastructure to support them, but it generates no revenue for us in workload or anything else. And so that puts us—is a handicap right away in our budget methodology. [F-‐024]

Respondents at most facilities offered suggestions for improving the allocation process, including using a long-‐term budgeting process, allowing flexibility to move funds between categories at the facility level, and developing a performance-‐based model that goes beyond assessing prior workload.

VA has been attempting to go more toward a planning-‐based or performance-‐based model that would, again, truly based on—and this would be more at the local or the market level—based on needs of the specific, unique population of the area and based on the capacity, not only in the VA but the capacity in the community resources, that those kind of be reconciled, to make sure that optimal treatment is given and services provided based on what is available in the budget. [F-‐005]

In terms of overall adequacy of the budget allocated through the VERA process, there was variation across facilities, with some starting out positively while others begin the fiscal year in a deficit. One administrator noted that the overall budget was constrained by centralized programs that required a lot of resources, while another commented that these centralized programs did not appear to be coordinated by the central office.

Currently and for the last several years has been a positive VERA in terms of—that our allocation is, at the onset, sufficient to take care of our operational needs. That is not the case with all of the medical centers in our network. Some of them start with a projected deficit with regard to what they've been allocated. [F-‐064]

Of course, we never have enough to go around everywhere. Actually this year we faced a pretty substantial projected budget deficit. So we had to take some steps locally to deal with that and delayed some funding of programs, that type of thing, to make sure we were going to close the year out—and we’ll do fine now. [F-‐024]

For instance, a lot of money comes out of the budget to support centralized programs both at the big VA level and at the VHA level and there’s been tremendous growth in those programs that take money – there’s only a fixed pot of money – that take money out – well, so there’s less to be distributed to the field to provide the care to the Veterans. [F-‐044]

then you have a lot of mandates, either…and from different program offices, that I believe in the sense throughout the organization is that a lot of these mandates that come from the different program offices are not coordinated through the leadership at central office. [F-‐084]

Hiring

Administrators at four facilities noted that there was discretion at the facility level to hire physicians, nurses, and other clinical staff as necessary to meet local demand.



C-‐4

We do have to ability to do that locally. That’s a local decision. Again, it is based on funding availability. And so the way we do it here, we have a physician management committee that looks at all new positions and recurring positions that have come open. And they go through the process of looking at that and looking at our budget projections and our supportable FTE levels, and then make recommendations to the director on which positions to fill or not fill. [F-‐024]

Purchasing

Respondents were asked about purchasing drugs and medical supplies. Generally, facilities had fairly good processes in place to meet their needs. One respondent, however, in describing the purchasing process in more detail, emphasized the layers of tasks and processes that needed to be accomplished despite centralized contracting.

We have the national contracts and the idea was originally that [those] would streamline the process, but since they don’t negotiate best pricing, that still has to be done at the regional or local level which then adds a substantial amount of lead time to the average procurement. So anything over $3,000, over the micropurchase threshold, still has to go through a fairly labor intensive and time consuming procurement process to validate [that] we’re getting best value. That has a major impact on your efficient supply distribution methodologies because then you have to build that procurement process or that best value analysis process into your lead time. And so when you're trying to go to a just-‐in-‐time model of supply support at your facilities so you're efficiently using space and people and everything else, that is counter to that. That causes major, major problems. [F-‐024]

Contracting to External Providers

Respondents were asked about how they developed budgets for and made the decision to refer to non-‐VA care. Several themes emerged about the infrastructure and processes for non-‐VA care.

Developing budgets for non-‐VA care

Respondents described budgeting for non-‐VA care as part of the annual budgeting process. Like other parts of the budget, services or segments of the facility are asked to estimate needs for the coming year and provide justification. Given the somewhat unpredictable nature of demand for non-‐VA services, and the variability in staffing and other resources that might affect the site’s ability to provide care in-‐house, respondents freely admitted that budgeting was only an “educated guess” at what they might need. When demand for non-‐VA care outstrips the budget, as was commonly true in one site, facilities need to go back to the VISN for more funds.

We do our budget call, each individual service, medical service, or surgery, or whatever else, they would analyze what they feel they need for fee or non-‐VA care, so that would be part of the annual budget call. They would try to project what that requirement would be and then of course adjustments are made throughout the year based on actual patient needs. But that is part of the budget call that we do annually with all the services. And it’s an educated guess, as things shift. [F-‐024]

[To determine the budget for non-‐VA care] You look at what you did last year…. I say [that] kind of tongue in cheek, but really a lot of it is based upon previous experience. [F-‐081]



C-‐5

It's a yearly cycle of being allocated a certain amount and knowing going in that you've executed more money the year before than you started out with the current year—you know you're going to have to go back in for more money. So that's the situation we face. [F-‐104]

Making referrals to purchased care

Respondents discussed the reasons that purchased care would be used. They emphasized that use of purchased care is based first on clinical need and what is best for the patient, not on cost.

Those decisions are primarily based on clinical need and we try to keep it that way, that we don’t—we try not to bias, if you will, the clinical decision due to funding. So if the need is there, the clinical need is there, we don’t have the specialty in-‐house, then yeah, they are free to fee that out. That is what drives that decision, not the money. [F-‐024]

You go through the third party administrator and, to be patient-‐friendly, you want to get that care as close to the Veteran’s home as you can. For instance, if they need PT three times a week for some rehab, you don’t want them coming all the way into [central city] for that. Then you’d just bring them to the medical center. You want to do that close to where they live. [F-‐044]

Here at the facility level, we can take individuals on an individual basis and kind of do some research on their particular situation and make an exception to that rule [of when to refer to non-‐VA care]. There is a clause written for the geographical burden; however, the parameters of that decision-‐making process can be left for very vague interpretation. So our philosophy here is to err on the side of the Veteran and that’s taking into account all the geographical barriers, the weather, the road conditions, all these factors that preclude them from being eligible and making an informed decision on that, and so that’s kind of given that population of Veterans some hope. [F-‐005]

Respondents also described the tension between the benefits of providing care through VA and the cases in which non-‐VA care makes more sense for Veterans. VAMC leadership were attentive to the need to analyze the business case for either model of care, and the importance of periodically re-‐evaluating to identify the best solution.

We would always prefer to have people working for us because we feel that provides better continuity of care, continuity of services, when somebody works for you, as opposed to a contract. However, sometimes a contract is better because we don’t do enough of that work in-‐house here to justify having our own staff to do it. Case in point, mammographies. We don’t have enough workload to justify the equipment and the personnel to run that equipment on a full-‐time basis, so we contract for that. And we have sufficient resources in the area to do that. [F-‐064]

I feel like we have the authority to look into the demand for health services, and for example, one of the initiatives we're looking at now is, we don't have magnetic resonance imaging or an MRI machine. In the past, they've had contracted services for a service provider could bring a tractor trailer that has the MRI for certain days a week or a certain number of days per month, and so pay a contract fee for imaging onsite. A couple of years ago, it was decided that that was no longer what management wanted to do—instead, they were going to fee out or purchase the MRI services in the local communities. So as we take a fresh look at it, it appears that there's probably a blended



C-‐6

approach that's more financially advantageous, so we're working on a contract to bring an MRI vehicle back to our central facility [F-‐104]

When we are looking to staff or send something out on contract or bring in a fee provider or somebody on an intermittent basis, we need to look at the workload, we need to make sure that we’re doing a make [or] buy analysis and do the best for the facility. So if we have the space and we’re bringing people in, that’s great. If we’ve got mammography and we know that we can’t take care of that and that that’s over at [academic partner]; great. But that workload has to be there. That data has to be there and that analysis is done appropriately. [F-‐041]

Use of contracts

Respondents commented on the challenges of using established third-‐party administrators (TPA) to refer patients to purchased care. Some facilities described the workflow required to interface with the TPA is duplicative and onerous. Respondents also complained about the limited networks of the TPA, how this affects patients, and how it creates more work for the sites, who must find an out-‐of-‐network fee provider when the TPA “fails.”

I can no longer just fee something to the dermatologist across the street unless it’s an affiliate, and we have all these other issues we have to jump through. We created this third party administrator that’s going to get all the providers for us and you know it sounds great on paper except they can’t perform, so I send people out on fee and I can’t get the work done because unless we go through this third party administrator. They fail and then I can send it out and get the care done, but I have to prove that the third party administrator can’t perform the service first and that is not good patient care and it certainly is not good for patient satisfaction. [F-‐044]

Choice Cards – Utilization and Challenges

Respondents reported generally low utilization of the Choice Act option for obtaining purchased care. When asked about low demand, respondents surmised that many patients preferred receiving care within VA, and that wait times for community facilities were similar or worse than at VA.

[The low utilization of the Choice Act is] for multiple different reasons. We could actually have an appointment that’s earlier than they can find in the community—which happens a lot. Most of our veterans really love the VA here. We have an inner city population, we’ve got a high homeless population, and they connect with the VA. They want to be here. They don’t want to go outside. … In addition, … for Choice the VA has also contracted with HealthNet. So the veterans just can’t go to anybody that they want to go to. They have to go to the HealthNet providers. And if they don’t have a good provider network, why are they going to go on the outside? [F-‐041]

I've been asking for hard numbers and I haven’t been able to get much information, much data yet. So I can only give you anecdotal data that yeah, we’re not seeing much use of the Choice Card. And an

Documents

Resources and Capabilities of the Department of Veterans ... · medical supplies (J), construction and capital management (K), and leadership (L). VA engaged the Centers for Medicare