A detailed look at the PACT Act, the MISSION Act and what else is ahead for the biggest civilian agency with VA’s undersecretary for health

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Veterans Affairs has never been a static organization. In recent years, legislation has added external practitioners to augment health care available in VA’s own facilities. For a review of how this has gone so far, and a look ahead to 2023, the Federal Drive turned to VA’s undersecretary for health, Dr. Shereef Elnahal.

Interview transcript:

Tom Temin
And let’s begin with external care provided, enabled under the MISSION Act, give us a sense of what the uptake has been so far, do a lot of veterans use it? And do how do you measure how it’s going?

Shereef Elnahal
Absolutely. So we have infrastructure across the country, Tom, to be able to serve veterans, we have brick and mortar facilities in every state. And we really do try to cover as much of our veteran care need as possible within our system. But of course, we can’t cover all of our veterans’ needs. And in fact, the reliance of veterans on care in the community providers we partner with has increased over time. And so just to give you an idea of the volume, we’ve seen 37 million community care, outpatient appointments over the last fiscal year, representing about a third of all outpatient appointments that veterans received. And we also spent over $27 billion on community care last fiscal year. So we’re certainly using community care as veteran by veteran needs arise. And that will certainly continue into the future.

Tom Temin
So it sounds though is if while VA would love to provide all of the health care to everyone, that’s not really the veteran’s choice, they seem to be eagerly after the external provider.

Shereef Elnahal
Well, the MISSION Act affords six possible pathways for veterans to get community care, including whether or not we meet our access standards for care within our direct care system, whether clinicians determined that it’s in the best medical interest of the veteran to get care outside of the system for specific and complex conditions. For example, if we don’t have a full acute care hospital in any given state, any veteran in that state qualifies for community care. And there are a number of other pathways for veterans to get care, we are obligated to offer community care to veterans according to the MISSION Act, and we do so for every veteran who needs it.

Tom Temin
And what is the information channel that gets to the veterans so they know what their options are?

Shereef Elnahal
So this is part of the daily work that we do in our clinical settings. Tom, if we think that a veteran needs a referral to specialty care, for example, in our clinics, and we see that the veteran qualifies for the MISSION Act, we offer a veteran that option. Many times the veterans choose to stay within the system, because we have over 90% trust score in our care. And as I said, our quality and patient safety within the direct care system actually exceeds that of the community in a lot of cases, according to studies. Nevertheless, we do offer care in the community when it’s needed. And that is when we are in front of veterans in clinic, when veterans call our call centers seeking care and other opportunities.

Tom Temin
And that differential in quality, what are the measures of that? How do you go about ensuring at least that the community care providers are coming closer and closer to what VA’s standard is, it’s almost like company owned stores versus franchises.

Shereef Elnahal
We use a number of different standards to measure quality, including data that is regularly collected by CMS. And in fact, the MISSION Act calls for comparisons to care in the community for quality and performance for each region, where we serve veterans. And so that’s an ongoing assessment to see whether we are falling behind in any given clinical specialty in any region. And thankfully, we haven’t had to trip that wire, because our care standards are as high as they can be. And we’re, of course continuing to work on that. But of course, we are held accountable for our quality of care as we should be.

Tom Temin
Do you feel that perhaps affiliation with VA under that law, and therefore being paid by VA has raised the quality for those providers because they become VA providers?

Shereef Elnahal
I think it’s certainly an impetus for us to make sure that we’re meeting a certain standard. As I said, we are proud to have quality and patient safety scores measured in various ways exceed that of the community on average across the country. But of course facility to facility region to region, there may be a better opportunity for a veteran to get care in the community. And if that is the case, we will offer a veteran that care.

Tom Temin
But my question is do you think that community care is getting better by virtue of VA’s paying for it and demanding things of it?

Shereef Elnahal
Well, we do measure quality in various ways in our community care network. And our community providers know that we do that we have third party administrators that regularly collect that data, and we examine it and where we see issues, we certainly do reach out through our third party administrators and in some cases directly to those providers. And so I do hope that is an impetus for quality improvement for our community partners.

Tom Temin
We’re speaking with Dr. Shereef Elnahal, he’s undersecretary of health at the Veterans Affairs Department, you mentioned the idea of the best practice or the latest, most contemporary, most efficacious practice in different areas of medicine. And I imagine there’s hundreds or thousands of them. How do you know that at a given moment, the best practice is not in VA, but out there somewhere that you can bring on board to the VA? How do you know it’s best practice in a given domain?

Shereef Elnahal
Well, oftentimes, we rely on the judgment of our frontline clinicians, they know the veteran the best in terms of their care needs. And if they determine that it’s in the best medical interest of a veteran, to get care with a particularly community, particular community provider, they will indicate that and we will offer the veteran that appointment. But of course, we have different measures that we use more broadly, to compare ourselves to the community. And when we trip that, and if we trip that, that is a trigger to offer veterans care in the community for that specialty, until we improve. And so that is another accountability measure on us to make sure we’re meeting a certain standard.

Tom Temin
But if some large hospital somewhere that has an expertise, so I’m just making this up in a heart valve procedure or knee replacement procedure, that becomes a breakthrough. Wow, everybody in the medical community understands this is a breakthrough, it’s published somewhere, you have a manner of bringing that into VA. So VA can get that good also, is my question.

Shereef Elnahal
We’re constantly trying to make investments, Tom and care that we think veterans need on a population level, if we see that a certain type of care is purchased in the community frequently that is built into our efforts around infrastructure. And we do try to make investments and recruit the providers needed to do that service. But of course, that’s not always possible. And sometimes, whether it’s an academic medical center or a private sector institution, they simply have more expertise in a particular type of care, or procedure. And in those cases, we do offer the veteran the soonest and best care option, even if it’s in the community.

Tom Temin
In general, though those best practices tend to migrate throughout the medical community eventually, so that the baseline of care in a given area is higher than it was generation earlier.

Shereef Elnahal
That’s right. And we’re proud to have national experts in every domain of medicine, leading our specialty care offices that are nationwide in terms of their impact, and weighing in on clinical best practices, and innovations in different specialties. And so we are functioning as a system here, to be able to make sure that care standards are optimized everywhere, veterans baby getting care.

Tom Temin
What do they say about surgery? You see one, do one, teach one? Correct?

Shereef Elnahal
That’s right. That’s the old adage I heard since I was in medical training. But of course, we have a lot more rigorous training. And in fact, we do train, the majority of physicians that go through residency in the United States were a major part of the medical training infrastructure. And that is advantageous to us because of course, we want to hire as many of those new grads as possible consistent with this being our top priority and VA now.

Tom Temin
And let’s talk about 2023. What are your general plans? I mean, it’s a really big network that you oversee. But what are your general goals for the coming year or two. And now that there’s an appropriation congratulations, the Congress came through for everybody.

Shereef Elnahal
So I wake up and go to sleep thinking about how we have to prepare for the historic expansion of veterans benefits under the PACT Act. The president signed into law, this expansion of benefits, particularly for veterans who are exposed to toxins across different periods of deployment, whether it’s post 9/11 conflicts, the Gulf War, Vietnam, or otherwise. And now if you have a particular condition that is connected in the law, to these exposures, you are presumed to have been exposed just by being deployed. And as long as you have that condition, you now qualify for service connection to get benefits and VA. And so what that means is we’re going to see not only an increased reliance on our care for veterans are already enrolled in VA health care, which will mean more demand from our existing base of veterans. But we will also see a new cohort of veterans and welcome them into the system as well. And so we are trying to build capacity in every single way possible. That includes hiring 52,000 people a year to keep up with attrition and demand from the PACT Act, making sure that we expand our clinical space and our brick and mortar footprint to be able to accommodate our clinical teams and and overall making our clinics more efficient to be able to see more veterans per day and per scheduled time for clinicians. And so all of that is really what we’re gearing up for in this next year.

Tom Temin
And as a medical man yourself, do you expect say that this burn pit treatment plan, as you say, it’s gonna take a lot of effort, a lot of money to carry out the PACT Act. Is there new medical horizons? Is there new learnings from treating people with this particular affliction? Because it’s so specialized do you think?

Shereef Elnahal
Absolutely, and in fact, the PACT Act calls for a real investment in new research on the connection between different exposures and clinical conditions that are not yet considered presumptive. So we are participating in an interagency working group right now to determine the most impactful studies that we can do. And when we generate enough evidence that a new clinical condition should be added, and considered presumptive or a new toxin entirely should be considered in terms of its health effects. We will examine that and make sure that we use our regulatory process to add that as a new condition, and potentially a new exposure. And so the great thing about this law is that it affords us the opportunity to do that into the future.

Tom Temin
And regarding the brick and mortar question, which, unfortunately, VA just doesn’t have the freedom of action that other medical systems have with respect to tearing down old hospitals that are functionally obsolete, or serve a shrinking population, this kind of thing, as we learned in the whole back and forth. Now, you’re back to ground zero and planning the infrastructure footprint, what’s your sense, your sense of the state of VA facilities, as you look around, I mean, you know, you were trained in the most modern medical school there is, and you’ve been in some high end places. VA has some old places, and buildings themselves ceased to be functional medically, at some point, don’t they?

Shereef Elnahal
That’s right Tom. And unfortunately, we have an average age of our hospitals that far exceeds the private sector are approaching 50 years old, on average, especially when you consider the hospitals in New England and the Northeast, and also some of our older hospitals, built many, many years ago, we absolutely have to build new infrastructure, in order to accommodate modern medicine and modern technology. But also to create more space, especially in areas with high veteran growth, I actually have a lot of experience with this, I used to run a very old safety net hospital in Newark, New Jersey. And every few months, we had an infrastructure failure, whether it was a pipe that was bursting, that flooded some of our clinical areas, or otherwise, that forced us to close down those services for a period of time until we address them, of course, that impacts access to care. So our infrastructure agenda is absolutely imperative for us to execute on so that we can keep up with the demand for care for veterans.

Tom Temin
So in some sense, you might need a hospital in a given place, but you would have to replace in place almost. And that’s sometimes more difficult than building new in a greenfield area. And just tearing down, because you get into all of those labor Agreement issues and the pushback from so many parties.

Shereef Elnahal
Well, the good news is that the PACT Act actually expedites 31 new leases across the country, for us to move faster, and to create those spaces sooner than we otherwise would have. And so I do view that as an important opportunity for us to move faster than we otherwise would have. But yes, we have issues with being able to expand proximately in certain areas based on whether our facilities are landlocked. And that has created some issues. And so we’re trying to be as innovative as possible, and how about how we create more clinical space to serve veterans.

Tom Temin
And I always ask this of people that reach a certain managerial level in the career they have chosen. Do you ever walk the halls? Do you ever say put a stethoscope on a veteran yourself? You have that opportunity whatsoever?

Shereef Elnahal
I have a chance to meet veterans all the time when I travel to medical centers, I meet clinicians and I meet the leadership teams, at our hospitals and clinics. But I also do try to meet veterans and ask them how we’re doing with their care. That’s the most valuable type of feedback that I can get. Of course, we get data regularly on surveys questions that we ask veterans at a population level. But there’s nothing like meeting the heroes that we serve, and getting that feedback directly from them.

Tom Temin
And what are the first three numbers you look at every morning?

Shereef Elnahal
Right now, I’m looking at our success. With the PACT Act, I’m looking at the toxic exposure screenings that we are doing. I’m looking at wait times for care and survey data on how we’re doing with regard to veteran satisfaction with timeliness of care and I’m also looking at quality and patient safety data. If we are providing good access and good quality, while at the same time executing on this historic legislation, then I know we’re in a good place.

Tom Temin
And if you had a magic wand, what would you do about the electronic health care record situation?

Shereef Elnahal
Well, I think we’re starting to see some positive progress on that Tom. Right now, we are focused, of course, on making the system work better for the clinicians, and the employees using it at the five sites already in the system. And once we make substantial progress on that, I think we’ll be able to proceed to other facilities. So I actually wouldn’t wish for anything now other than for us to execute on our plans. And I think we’re well on our way to doing so.

Tom Temin
And you find the vendor’s generally responsive? I mean, since Oracle took over, is that been a big change? Do you think?

Shereef Elnahal
I think that relationship has improved since I even I’ve been here just this past July, when I arrived, and I think the company is understanding that, you know, the system needs to improve the episodes of downtime and lag time, need to go away. And ultimately, the system needs to be configured in a way that’s usable and intuitive for the frontline clinicians using it. I think we’re making progress on those friends.

Tom Temin
And just a final question when you go to medical meetings, and there are lots of big time administrators of hospital chains, and so forth, Mass General and Kaiser and all of these, how do they seem to regard you now as the undersecretary of health at VA?

Shereef Elnahal
I think most of my colleagues, reading private sector health care systems appreciate the mission that we have. And they know that they see many of the veterans we care for in their systems. And so it is a spirit of collaboration. And it really has to be in order for us to execute on the full scope of care that veterans need.

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