Defining the mission of the MISSION Act

Abstract

The Veterans Health Administration of the Department of Veterans Affairs (VA) is the largest integrated health system providing cancer services in the United States, with approximately 50,000 Veterans diagnosed and cared for each year. In June 2018, Congress passed the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act. The MISSION Act further expanded Veterans access to health care by revising wait time and travel criteria to obtain health care in the private sector, which the VA has termed “Community Care.” In 2020, $15.2 billion was allocated for Community Care, and this allocation will grow to $20.1 billion by fiscal year 2022. These funds are managed through two main private sector groups: OptumServe (a subsidiary of United Health Care Group) and Tri‐West Healthcare Alliance. Fiscal stewardship is essential if the goals of the Community Care Program are to be realized. To this end, we investigated how reimbursement for the VA s Community Care Program compares to Medicare using the VA Community Care fee schedule. The Table (Table 1) compares current Medicare reimbursement with average VA fees for fiscal year 2020 for eight common ambulatory procedures for benign or malignancy‐related concerns. We used the Medicare Procedure Price Look‐up tool to determine current national mean medicare reimbursements (i.e., physician, facility fees, and patient copays) for ambulatory procedures at both outpatient hospital and ambulatory surgery centers. Although mean reimbursements for Medicare do not provide descriptive measures of variability, those characteristics are calculable for the VA reimbursement schedule due to location‐based variation. The VA fee schedule also does not routinely distinguish between hospital outpatient and surgery center fees. For fiscal year 2020 we found substantial variations in negotiated fees that often exceed Medicare reimbursements irrespective of hospital or surgery center venue. For example, the VA average reimbursement for routine cataract surgery—one of the most commonly performed surgeries in the United States—is essentially 2.1‐fold higher than that of Medicare ($3235.00 vs. $1569.00). Similarly, colonoscopy was 2.8‐fold higher than the Medicare ambulatory surgical center reimbursement ($1628.00 vs. $578.00). The 2021 VA fee schedule has undergone a significant update and fees are now determined by the location where care is rendered rather than the location of the referring VA center. Due to this and other changes, VA negotiated reimbursement fees for many procedures appear to have decreased substantially for 2021 compared to 2020, and in some cases are now well below Medicare reimbursement. Whether these significant fee updates will affect the access to quality oncologic care in the community for Veterans is not yet known, and further studies are needed to determine the downstream consequences of these fee changes. The stakes are high as more funding for Community Care means less for expanding the VA s healthcare workforce or strengthening its infrastructure, which would also improve access to cancer care for Veterans. P.S. All authors are familiar with the contents of this report and agree to its publication. The views expressed in this article are those of