How Congress And The VA Left Many Veterans Without A 'Choice'

May 17, 2016
Originally published on June 8, 2016 3:53 pm

NPR — together with member stations from across the country — has been reporting on troubles with the Veterans Choice program, a $10 billion plan created by Congress two years ago to squash long wait times veterans were encountering when going to see a doctor. But as we reported in March, this fix needs a fix.

Around the nation, our joint reporting project — called Back at Base — has found examples of these problems. Emily Siner of Nashville Public Radio reported on troubles with overcrowding in Tennessee. And Monday, we reported on hospitals and doctors not getting paid in Montana and veterans getting snarled in the phone systems trying to make appointments in North Carolina.

Congress and Department of Veterans Affairs officials are in the middle of overhauling the program. Here are some reasons:

  • The VA's most recent data show compared with last year, there are now 70,000 more appointments that kept a veteran waiting at least a month to get care.
  • A March General Accounting Office report shows the Choice program had little impact on getting veterans to see a primary care physician in 30 days.
  • Thousands of veterans referred to the program are returning to the VA for care — sometimes because the program couldn't find a doctor for them, and for 28,287 vets, because the private doctor they were told to see was too far away, according to data NPR obtained from the VA.
  • The VA's own inspector general found that Colorado Springs, Colo., veterans were waiting longer than 30 days for care because staff at the local VA hospital was not adding them to the list of patients eligible for the Choice program.
  • The VA recently set up a hotline to help veterans who have issues with their credit because the programs hadn't paid doctors on time.
  • The GAO tells NPR that the VA's claims process is so backed up that the VA could easily spend more money this year on interest for late payments than Medicare does, even though Medicare processes hundreds of billions of dollars more in claims.
  • Congress gave the VA only 90 days from the day it was signed into law to implement the Choice program. In a VA document justifying its decision not to open up the contract to bidders, the VA cited the "hyper-accelerated" pace imposed by Congress. Typically, a program of this size would take at least a year to create.

'I'm In So Much Pain. I'm Asking For Relief'

Amanda Wirtz, who was discharged from the Navy in 2003 after developing a rare tumor, began having headaches last November. When the VA couldn't get her in to see a specialist, it offered to send her to a neurologist in the community, using the new Veterans Choice program. This was the type of situation Congress envisioned when it created the program in 2014: If the VA couldn't schedule a patient within 30 days, or if the vet lived more than 40 miles from a VA clinic, the vet could see a nearby private doctor.

"This is Feb. 23, for an appointment scheduled March 23," Wirtz said, holding up a letter she received from the company handling the Choice program. "[In] January I'm considering suicide because I'm in so much pain. I'm asking for relief and the Choice program is giving me an appointment in March."

Her experience isn't new to government officials, but the question is whether Congress or the VA should have anticipated there would be problems.

Two years ago, Congress was hearing about the VA concealing wait times at VA hospitals and clinics, and about the veterans who were suffering as a result.

"If you don't think, in 2014, that was the time to stand up a program like Choice, I don't know when you would find a time," said Rep. Jeff Miller, R-Fla., the chairman of the House Veterans Affairs Committee. "That's the problem. They were causing veterans to wait. And by the way, veterans did die, while they were on the waiting list."

Congress worked at a frantic pace. The House passed a bill on June 10, 2014. The Senate passed its own version within days. By Aug. 7, President Obama had signed the Veterans Access, Choice and Accountability Act of 2014. It gave the VA $10 billion to set up a program that would give qualified veterans the option of seeing a private doctor.

There was confusion from the beginning. The law required the VA to distribute 9 million Veterans Choice Cards to vets receiving VA care as of August 2014, even though all vets who use the VA already have a VA card. Sen. John McCain, R-Ariz., explained the card at a press conference, while lawmakers crafted a final version:

"I always believed that veterans could choose and should choose and that's why I first proposed this in 2008, when I ran for the presidency of the United States," McCain said. "Give these veterans a Choice Card so they can take that Choice Card and present it to the health care provider."

How To Build A $10 Billion Program In 90 Days

Impatient lawmakers gave the VA only 90 days to set up the national program. The first decision that VA officials made was that they couldn't run the program themselves.

"Could we set up the infrastructure to build the network to credential the network in 90 days?" Baligh Yehia, assistant deputy undersecretary for community care at the VA, asked. "We couldn't. We just didn't have the resources, the tools available to us to do that."

So the VA shopped around. It invited 57 companies to a VA-sponsored event in September 2014 to gauge interest in possible bids. But nearly all of them turned down the VA.

"Only four companies said they were interested in continuing some conversation," Yehia, who wasn't with the VA when Congress mandated the Choice program, said. "And then two of those companies made it crystal clear that given a November, or a 90-day, time frame, they're not interested."

That left two companies the VA had under contract to help it manage a portion of the roughly $4 billion a year the agency was already spending on outside providers. TriWest and Health Net were building a program called Patient Centered Community Care, or PC3. The network of private doctors and hospitals was meant to help the VA streamline the relationships local VA medical centers had with community providers.

The VA decided to build the Veterans Choice program by building it on top of PC3.

But PC3 was having its own problems. The VA's inspector general found that in the summer of 2014, while Congress was debating the Choice program, VA administrators were scrambling to find appointments for hundreds of vets, after the companies couldn't find doctors for them in their networks.

Some of the problems that would emerge later with the Choice program were apparent in PC3. For example, within three months, TriWest returned referral authorizations of 172 out of 192 gastroenterology cases, and 57 of those patients had to be seen immediately because they had symptoms of significant ailments, such as cancer.

The VA was also making the process difficult because it was taking the agency an average of 19 days to submit appointments to the contractors, according to another VA inspector general report.

Yehia stressed that PC3 was new and smaller than Choice but also acknowledged that the VA didn't have any other alternatives.

"This car wasn't designed to run this race," Yehia said. "It had a very different purpose. It had a very different intention. In fact, the PC3 contract when it first rolled out didn't even have primary care. It was only a specialty care contract. It gives you the scope that this vehicle was not meant to deliver this vast program."

'Many Veterans Were Confused'

Health Net did not respond to requests to be interviewed. It runs the Choice program mostly in the Eastern portion of the United States. TriWest covers 28 states in the Western half of the country. TriWest created 10 call centers, including one in San Diego that opened in September. The company has hired more than 3,000 employees.

"Oh my God, you expect us to build networks, have all these processes in place, all these contact centers to be able to do all of these things, at a very, very abbreviated schedule," said Frank "Mac" Maguire, chief medical officer for TriWest. "I think a lot of people said, 'You are crazy.' Were we crazy? In hindsight, maybe yes, but we felt we were up to the challenge and we just want to be given an opportunity to show that it's working."

The company believes it finally has a network of doctors large enough to handle the patient load for Veterans Choice. It concedes creating a network was a struggle, in part because the VA did not always understand its needs.

Sometimes VA rules created obstacles. Until recently, the VA would not let the companies call veterans directly to schedule an appointment. The vet had to call them, which sometimes left vets waiting by the phone.

"Many veterans were confused," Maguire said. "Maybe it was a month since they've seen the VA. 'Why is my appointment not set up?' And we'd say, 'Unfortunately, we've been waiting for you to call us.' "

TriWest believes it has a handle on the problems. In San Diego, TriWest went from a ribbon-cutting in September to more than 300 employees answering veterans' calls.

But it may be too late. The VA is now reconsidering whether it should have outsourced so much of the program — especially customer service.

Adrian Atizado, with the Disabled Veterans of America, said putting a contractor between the VA doctor and the outside physician may always cause problems.

"The third-party administrator will sometimes say the authorization is not very clear," he said. "Exactly what kind of eye check do you need? Or what kind of MRI do you need? There are a lot of communication problems when you start handing things off to other people."

Congress is looking at revamping and expanding the Choice program to cover most of what the VA spends on outside care. Considering it was born out of a scandal involving VA scheduling, some in Congress are not eager to allow the VA to take on a greater role.

The GAO report released this month says the VA's system for processing claims relies mainly on paper files — a process that adds months to the amount of time it takes to pay doctors. Whatever the outcome, the pressure is on to figure out how to get veterans the care they've been promised, without all of the confusion.

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Veterans are still waiting too long to see a doctor. Back in 2014, we heard a lot about that. It became a national scandal and forced the VA to come up with a fix. Yesterday on this program, we heard how the fix is broken. And today, we'll hear why. And first, some context from NPR's Quil Lawrence, who covers veterans. Good morning, Quil.

QUIL LAWRENCE, BYLINE: Good morning, Renee.

MONTAGNE: Let's just briefly remind people - what was broken?

LAWRENCE: Well, the VA was overloaded. And Congress wanted to move quickly to get care for veterans who'd waited at least 30 days for an appointment or who lived more than 40 miles from a VA clinic. So Congress pushed through a $10 billion program to pay for vets to see a private doctor outside the VA system if they met those conditions. It's called the Veterans Choice Program.

MONTAGNE: A program that, look, if you get right down to it, those veterans needed timely care. It seemed to make sense at the time to try private doctors.

LAWRENCE: Right, that was the idea. The problem was Congress gave the VA just 90 days to set the program up. And this was something they knew would be very complicated. You're talking about setting up a whole new network for millions of veterans with all the right specialties - mental health care, acupuncture, physical therapy, everything. They had to set up a whole new system.

MONTAGNE: And NPR, in cooperation with member stations around the country, has been investigating that system for several months - and, Quil, I gather - finding that the VA plainly did not pull it off.

LAWRENCE: Exactly, this was supposed to be a simple solution. They even mailed out this card that made it seem like veterans could just take this card to any private doctor's office and just charge their care to the VA. But what really happened was the creation of a new layer of bureaucracy that health care providers didn't really understand and the VA didn't really know how to run. And the evidence is that the number of backlogged appointments has gotten worse.

Compared to this time last year, there are 70,000 more appointments that took over a month for a vet to get seen. So today, we're going to dig into how Veterans Choice may have been flawed from the beginning. And we'll start with one veteran's story, which we found is pretty typical.

MONTAGNE: And that story is brought to us by Steve Walsh as part of this month's long investigation. He's a reporter at member station KPBS in San Diego.

STEVE WALSH, BYLINE: Amanda Wirtz served in the Navy on a destroyer. She got out in 2003. She got sick - a rare tumor that makes it hard to swallow.

AMANDA WIRTZ: I'm dealing with pain on a daily basis. So much so - you know, interrupting our sleep, our quality of life, my ability to function.

WALSH: She goes to the VA in San Diego. But last fall when she began having severe headaches, the VA couldn't get her an appointment.

WIRTZ: So the neurology department said, no problem. Would you like to be referred out into the community to the Choice Program?

WALSH: The Choice Program, designed precisely for people in Wirtz's situation. Too long of a wait at the VA? Choice gets you to a private doctor. Except for Wirtz, it didn't work. After six weeks of migraines and still no appointment, she finally heard back from the Choice Program. She showed me the letter.

WIRTZ: This is Feb. 23 for an appointment scheduled March 23. January, I'm considering suicide because I'm in so much pain. I'm asking for relief. The Choice Program is giving me an appointment in March.

WALSH: The Vets Choice Program is broken. And the reason goes back to the beginning - how the VA implemented the program and how it was designed in Congress.


JEFF MILLER: Ma'am, veterans died. Get us the answers, please.

UNIDENTIFIED WOMAN #1: I understand that, Mr. Chairman.

WALSH: That's Chairman Jeff Miller, a Republican from Florida who heads the House Veterans Affairs Committee. He was grilling the VA back in May of 2014 about the long wait times at VA medical facilities. I spoke with Chairman Miller recently about what happened back then. I was trying to get a sense of why he and others in Congress were in such a hurry.

MILLER: You don't think, given the crisis that erupted in 2014 - was the appropriate time to stand up a program like Choice. I don't know when you'd find a better time. That's the problem. They were causing veterans to wait.

WALSH: Miller pushed the House of Representatives to get a bill through to help veterans waiting to see a doctor. In August 2014, Congress passed the Veterans Access, Choice and Accountability Act. Most of the money, $10 billion, went to pay for a plan to allow vets to go outside the VA to a private doctor or clinic.


PRESIDENT BARACK OBAMA: If you live more than 40 miles from a VA facility or if VA doctors can't see you within a reasonable amount of time, you'll have the chance to see a doctor outside the VA system.

WALSH: There was only one problem. The VA had only 90 days to figure out how to set up the system that would deliver on the president's promise. But there was confusion from the start. I called the VA to try to understand how the program was set up.

AUTOMATED RECORDING: Someone has entered the conference.

WALSH: Is anybody here yet? Can you hear me?

BALIGH YEHIA: Hi, this is Baligh.

WALSH: Hi, so we're looking at the timeframe of the roll out. How did Veterans Choice roll out the way it did?

YEHIA: Sure, so let me give you a little bit of background. So...

WALSH: That's Baligh Yehia. He runs the Choice Program for the VA. And how he runs it all hinges on decisions made in the 90 days after the law was passed. The first decision the VA faced...

YEHIA: Could we set up the infrastructure to build a network and credential the network in 90 days?

WALSH: Infrastructure - creating the network of private doctors, staffing call-in centers to set appointments, sending member cards to 9 million vets.

YEHIA: We couldn't. We didn't have the resources or the tools available to us to do that.

WALSH: So the VA turned to private contractors to do the job instead. Remember, the VA had only 90 days to get this done. And the clock had started. On Sept. 17, 2014, 41 days after the law passed, the VA hosted what it called an industry day. Fifty-seven companies showed up. The whole idea was to see who might run this new $10 billion program. Nearly all the companies said, no, count us out.

YEHIA: Only four companies said, hey, I'm interested in continuing some conversations. And then two of those companies made it crystal clear that given a 90-day implementation timeline that they're not interested.

WALSH: So when everyone else said, no, the VA turned to the two still standing, TriWest and Health Net. The two companies already had contracts with the VA for a program not too different from the one Congress had just created, a network of doctors and hospitals outside the VA called Patient-Centered Community Care or PC3. I asked Baligh Yehia of the VA about it.

I'm looking at a couple of different IG reports about PC3. And it was not going well. Their network was full of holes. Given that, I mean, how could the VA give them a bigger contract?

YEHIA: Well, I think you have to know the history of the PC3 contract. That PC3 contract wasn't even around for a year to even have the opportunity to reach its full potential before Choice came along.

WALSH: So on Oct. 1, the VA signed a contract with Health Net and TriWest, contractors the VA knew were struggling. Essentially, the VA decided to build a new $10 billion Choice Program on top of an untested model.

YEHIA: This car wasn't designed to run this race. It had a very different purpose. It had a very different intention. In fact, the PC3 contract when it was first rolled out, didn't even have primary care. It was only a specialty care contract. So it gives you the scope of this vehicle was not meant to deliver this vast program.

WALSH: The VA justified the new contract by saying it had to act on a, quote, "hyper-accelerated basis." The 90-day clock was ticking down. There was one month left to get the program up and running - everything from doctors to call centers.


UNIDENTIFIED MAN: You can also call the VA Choice Card Hotline. This hotline is exclusively for veterans and providers to access the Choice Program.

WALSH: TriWest began setting up call centers around the country.


UNIDENTIFIED MAN: The Department of Veterans Affairs wants to help you obtain the best healthcare anywhere.

WALSH: It was slow going. Health Net refused several requests for a taped interview. But TriWest invited me to the opening of a call center in San Diego back in September.

UNIDENTIFIED WOMAN #2: And we're very excited about the first day of our operations here in San Diego. And also Kansas City starts today as well.


WALSH: That was last fall. I went back a few months later to see how it was working. Frank Mac Maguire showed me around. He's the chief medical officer for TriWest.

FRANK MAGUIRE: Oh, my God, you expect us to build networks and to have all these processes in place, all these contact centers, be able to do all these things at a very, very abbreviated schedule. And I think a lot of people went, are you crazy?

WALSH: By March, TriWest was opening the last of its 10 call-in centers. TriWest says both the law and VA regulations made Veterans Choice a difficult program to launch. Maguire says the company believes it finally has a network of doctors large enough to handle the patient load for Veterans Choice.

MAGUIRE: Were we crazy? In hindsight, maybe yes. But we're also - we felt like we were up to the challenge. We just want to be given an opportunity to show that it's getting better and it's working.

WALSH: What we found and what internal VA investigations confirm, is that it hasn't worked as advertised. And there are a lot of reasons why. Wait times are actually up at the VA, a year and half after Veterans Choice was created. Thousands of vets referred to the Choice Program are returning to the VA for care, sometimes because the program can't find a doctor for them, and for 28,000 vets, because the private doctor they were told to see was too far away.

The very problem Vets Choice was designed to fix. There's more. VA regulations baffled vets, doctors, even the companies.

MAGUIRE: We had to wait for the veteran to call us.

WALSH: That's Frank Maguire again from TriWest. Until recently, the VA had a rule. The contractor couldn't call the vet.

MAGUIRE: And many veterans were confused. They'd say, why is my appointment not set up? And we'd say, well, unfortunately, we've been waiting for you to call us.

WALSH: TriWest says it's got it figured out now. But it may be too late. Congress and the VA are working to change the program dramatically. The VA might take over the customer service job from the companies, meaning those new call centers might go away after more than $3.5 billion has already been spent.

MONTAGNE: And that was Steve Walsh of NPR member station KPBS in San Diego. Transcript provided by NPR, Copyright NPR.