Field Hearing: Improving Access to Quality Healthcare for Rural Veterans

Saturday, April 21, 2012      

10:30amMST

Parmly Billings Library, 510 North Broadway, Billings, MT

Prepared Statement of Mark C. Rumans, MD, Physician in Chief, Billings Clinic, Billings, Montana

Madam Chairman and members of the Senate Committee on Veterans’ Affairs, thank you for providing me, on behalf of Billings Clinic, the opportunity to offer testimony on the very important topic of improving access to healthcare for rural veterans and Billings Clinic’s participation in Project ARCH. My name is Mark Rumans and I currently serve as Physician in Chief for Billings Clinic. 

First a little bit about Billings Clinic and the services we are able to provide to veterans in this community-based partnership with the Veterans Administration. Billings Clinic is an integrated, not for profit, community-governed health care organization providing services to a forty-three county area in eastern Montana and northern Wyoming. Billings Clinic employs more than 3,400 employees, including 238 physicians, 22 anesthesiologists who work with Billings Clinic by exclusive contract, and 81 mid-level practitioners, and operates a multi-specialty physician clinic; 272-bed acute care hospital; level II trauma center; a 90-bed long-term care facility; a clinical research center; and a variety of ambulatory, diagnostic and treatment services.

Billings Clinic operates primary and specialty care clinics in three Billings locations and in Bozeman, Miles City and Columbus, Montana and Cody, Wyoming. In addition, Billings Clinic has recently partnered with two facilities in Montana (Beartooth Billings Clinic and Stillwater Billings Clinic), formed from the integration of Billings Clinic-owned physician clinics with local critical access hospitals. Billings Clinic also provides contracted management services for a clinic and five other health care organizations in outlying communities in Montana and Wyoming. Billings Clinic also provides services to 22 rural communities through 93 specialty outreach clinics and a regional telemedicine network. 

Annually, Billings Clinic has about 15,000 inpatient cases, nearly 66,000 inpatient days and more than 39,000 patient visits to the emergency department and 900,000 patient encounters. 

PROJECT ARCH

My purpose is to share from Billings Clinic’s perspective how Project ARCH is improving access to quality healthcare for rural Montana veterans.  We are now six months into the pilot which officially began in Montana on August 29, 2011.  The report card will be based on the achievement of the goals for the initiative as set forth in the Department of Veterans’ Affairs news release announcing the pilot in September 2010; quoting now… 

The pilot program, Project ARCH (Access Received Closer to Home), intends to improve access for eligible Veterans by connecting them to health care services closer to their home. Under this program, Veterans will gain local convenience without sacrificing the quality of care VA provides Veterans within its system. VA will ensure that participating Veterans’ medical records are shared between participating providers and VA so Veterans in the program experience seamless, quality health care whether receiving that care in their community or at VA medical facilities. 

“Project ARCH intends to expand VA’s ability to serve our Veterans who live far from VA facilities,” VA Secretary Eric K. Shinseki said. “This pilot program will also provide critical information about the role of contracted care in the future of VA’s health care delivery system.” 

According to the law enacting Project ARCH, Veterans are eligible to participate in the program if they reside in a location where a pilot site is located and are enrolled for VA health care when the program starts. In addition the law requires Veterans meet any of the following criteria: 

Live more than 60 minutes drive time from the nearest VA health care facility providing primary care services, or 

Live more than 120 minutes drive time from the nearest VA health care facility providing acute hospital care, or 

Live more than 240 minutes drive time from the nearest VA health care facility providing tertiary care 

The contractor will provide acute inpatient care for medical and surgical specialties for those Veterans living in highly rural counties in Eastern Montana. With secondary care provided in Billings, Veterans in Eastern Montana will reduce their travel time significantly, up to four hours one way when compared to their current choice for VA hospitalization at Fort Harrison VAMC. This pilot will supplement VA Montana’s Intermediate Complexity Surgical Program, allowing Veterans access to providers experienced in complex surgical procedures without traveling to Salt Lake or Denver VAMCs. This pilot will meet the intent of Project ARCH by providing secondary care closer to Veterans from highly rural counties who meet the criteria outlined above. There are currently 7368 Veteran patients and 10,709 enrollees residing in the counties involved in this pilot…”  

It may help to explain how rural veterans are referred to community providers for care under Project ARCH.  Humana Veterans Healthcare Services (Human Veterans) of Lexington, Kentucky is the contractor with the VHA’s Office of Rural Health and the Montana Veterans Administration (MT VA) for the Billings, Montana pilot site. Humana Veterans’ role is the administrator of a network of providers in Montana, coordinating placement of veterans with providers who are able to meet the quality and access standards of the program, processing claims and payment after documented services are performed.  Operationally, the veteran’s primary care provider (PCP) is to identify the patient as eligible for the pilot and refer the veteran to the Project ARCH Care Coordinator at the MT VA.  The ARCH Care Coordinator obtains the veteran’s consent to participate in the pilot and then submits a request/referral to Humana Veterans who selects a provider from their list of “qualified” providers.  Humana Veterans has a vetting process that ensures all providers are credentialed, have submitted evidence of their authorization to prescribe controlled substances (Pharmacy Card) and completed their privacy training – more about that later.  Humana Veterans’ scheduling team contacts the veteran and coordinates an appointment, ideally on a three way call with the provider’s scheduler.  Once the appointment is scheduled, Humana Veterans sends an authorization and all available medical records from the MT VA system.  Humana Veterans also sends a confirmation of the appointment to the patient and follows with automated telephone reminders.  This scheduling process results in very few missed appointments, a positive for Humana Veterans’ processes.

There were challenges with this flow during the first 6-8 weeks of the pilot as the MT VA ARCH Care Coordinator was not hired, trained, and fully functional until 2 months after the contract start date.  It is the Coordinator’s role to help the veteran access care with the non-VA contracted providers. According to the brochure published by the MT VA the end of December 2011, there is also an ARCH Patient Advocate assigned to Humana Veterans, although this person has not been identified to us.  The Project ARCH Program Support Assistant (our first contact, hired the end of August 2011) did her best to work with us and Humana Veterans as orthopedic consults and surgeries were hurriedly scheduled before the end of September 2011 so that funds could be obligated. We all learned together and now our working relationships with both the team at the MT VA and at Humana Veterans is one that is able to focus on making the veterans’ access seamless and the administrative hurdles generally transparent to the veteran. 

In our large organization with nearly 50 specialties, we realized we needed to have a central point for scheduling and tracking the authorizations for services.  Initially we thought this was a simple matter of having appointment requests come through one person in our central appointment desk.  It wasn’t long before this person became a care navigator for the ARCH patients, not only making appointments, but tracking down test results and records, coordinating additional authorizations for non-ARCH covered services through the VA fee-based service or internally within the VA system.  We now have a full-time nurse in this role. This is an increased financial and administrative burden to our organization. 

Another significant time investment in the pilot is the VA requirement for all providers to complete the course “VA Privacy and Information Security Awareness and Rules of Behavior.”  The course is accessed on-line and takes 45-60 minutes to complete.  For the provider community this course is redundant as the same training is required by all health care providers and staff.  At Billings Clinic staff completes similar training annually as a requirement of their employment.  Coincidentally, we were notified by two of our new employed providers that attempted to complete the training that it is not accessible at the original website as of April 1, 2012. We have not received the new log-in instructions for this site from HVHS (who is waiting on direction from the VA) so we have not been able to “qualify” any new providers for referrals.

REPORT CARD:

Gain local convenience without sacrificing quality:  Since we accepted our first referral in early September 2011 we have seen over 200 veterans and currently have 85 veterans “actively” in treatment in specialties from orthopedics, neurology, rheumatology, cardiology, gynecology, oncology, and urology.  There is no primary care or emergency care authorized under the contract in VISN 19 (our pilot area).  One of the areas of greatest immediate need was orthopedics.  Our orthopedic specialists have seen over 70 referrals which resulted in over 40 inpatient and outpatient procedures.  Cardiology is second with 31 referrals to date.  We are one of several providers in the state:  Humana Veterans has contracted with a full range of providers in the Billings area, a critical access hospital in Anaconda and a provider group in Great Falls. 

Overwhelmingly, the veterans we have seen are extremely grateful to be able to have their medical needs met in their community.  Many orthopedic patients had been waiting for years for surgery and several have returned for their second knee or hip replacement.  One of our first orthopedic patients, Robert Wombolt, a 77 year old USAF Korean War veteran first told his story to the Billings Gazette in August 2011.  He had been on the waiting list for a hip replacement since 2009. In March 2011 he was told he his surgery was indefinitely postponed. After referral to Billings Clinic and confirmation that hip surgery was indicated, Mr. Wombolt had his surgery in October. Another Billings Clinic patient, David Richardson, 58, a paratrooper in the U.S. Army, also shared his story with the Gazette in October 2011. The severity of his pain made it nearly impossible to work. Through a series of appointments, X-rays and MRIs at the VA Clinic in Billings and the VA Medical Center in Sheridan, Wyo., Richardson knew he would need hip replacement surgery. It would likely be at the end of 2012 — and in Sheridan.  Under Project ARCH, Mr. Richardson had his hip surgery on September 9, 2011 at Billings Clinic. 

VA will ensure that participating Veterans’ medical records are shared between participating providers and VA so Veterans in the program experience seamless, quality health care whether receiving that care in their community or at VA medical facilities.  The sharing of medical records is one of the biggest initial challenges. Humana Veterans receives records with the VA referral and strives to make them available to the provider within 60 minutes of scheduling the appointment. After the first few appointments we realized that any gaps in documentation could be filled prior to the consultation. Gaps included missing diagnostic test results and digital images of MRIs, x-rays and other examinations. Humana Veterans coordinated discussions and education with the MT ARCH Care Coordinator who then passed expectations on to the MT VA PCPs for referral protocols for individual specialties: for example, cardiac clearance before surgery, MRIs of the impacted area within 6 months, lab tests within 30 days, documentation of all other previous treatments and their efficacy prior to neurosurgery referral.  Sharing these protocols allows us to partner with the MT VA to facilitate appropriate screening within the VA system prior to referral to our specialists.  

When a veteran receives care in the community that is not ordered by the MT VA (outside the VA system and paid by private insurance, i.e. Medicare, or by the veteran), those medical records may not have been provided to the MT VA and therefore are not in the MT VA system.  Our care navigator now asks every veteran, new to ARCH at the time of initial scheduling, if he or she has obtained care at a non-VA facility so that the veteran (or our staff) can obtain those records prior to the consult. 

Access to veterans who live far away from VA facilities: In addition to veterans who live in Eastern Montana (as far north as Havre), we have also seen patients from Western Montana, including Kalispell, Polson, Bozeman, Hamilton, Missoula and Great Falls. The determination of eligibility for the pilot is made by the MT VA Project ARCH Coordinator. 

This pilot program will also provide critical information about the role of contracted care in the future of VA’s health care delivery system.  Nationally, the VA has contracted with Altarum Institute to “provide a story of (y)our experiences with the development of Project ARCH.” A team conducted a “Project ARCH Evaluation Site Visit” at Billings Clinic on April 4, 2012 and will return again every 6 months to collect “Information related to project successes, challenges, and lessons learned (that) will be incorporated into a report that will be delivered to the Office of Rural Health.”  The information that follows was shared with that team. 

At Billings Clinic, as an integrated healthcare system, our mission is to provide continuity of care.  We have had to learn to work with Humana Veterans, and more specifically the MT VA, to partner in securing needed services that they are able to provide at the local Community Based Outpatient Clinic (CBOC).  With our dedicated care navigator who over time has developed her network of “go-to” people within the MT VA, we can make this happen. We still will have problems with communication flow until the MT VA providers are educated about the ARCH program and how it can meet the needs of their veteran patients.

One of the first things Billings Clinic’s ARCH team realized was that the menu of services in the contract that were authorized for our VISN lacked critical associated services that subsequently had to be authorized through the VA fee-based system or provided within the MT VA.  For example, the contract does not provide for post-discharge physical therapy for patients with hip and knee replacements, nor does it cover post-procedure placement in transitional care facilities. Coordinating the authorization for these services outside the ARCH contract has been one of our biggest obstacles.

Humana Veterans, MT VA and the providers have learned what is and is not covered by trial and error. When this occurs services appear fragmented and it reflects negatively on the provider. 

It can be challenging to track services referred back to the MT VA through Humana Veterans.  We are not sure when the patients are pulled back into the MT VA system, when and if they receive services and how to go about pulling them back into Billings Clinic with the accompanying records for our providers for continuity of care.  Humana Veterans establishes the initial relationship and, contractually, is the advocate for the veteran (reference HVHS Procedure Manual, “Customer Care”).  However, with our current process, the Billings Clinic care navigator takes on the advocate role.  We assist the veteran with guidance to get other VA services. An example of this would be a referral to VA-fee based services for physical therapy and durable medical equipment which are not covered under Project ARCH.

The MT VA has chosen to keep certain services, i.e. MRIs, in the VA system even though they are authorized under ARCH.  MRIs (with few exceptions) must be obtained at the VAMC in Sheridan, WY and transportation is by DAV van from Billings once per week.  Family members or care givers are not able to travel with the veteran on the DAV van to the appointments except in rare circumstances.  

Also, if the DAV van brings the patient to our facility for surgery or treatment from their home, it is difficult to ensure the patient has proper post-discharge supervision prior to and during the DAV van return trip because of the restrictions on who may ride in the van.  This is a challenge for our discharge planners. 

Every service is authorized by the MT VA through Humana Veterans.  In a standard care model, a provider frequently requires additional tests in order to confirm a diagnosis or to establish a treatment plan.  The requirement for specific authorization for each service hinders this process as providers and patients must wait for those additional tests to be authorized. Requests For Additional Services (RFAS) have to go back through Humana Veterans.  They are responsible for communicating with the MT VA.  We chase not only the authorizations, but also the denials.  The denials need to include next steps for the patient.  If denied through ARCH, are the services to be provided by the provider but billed to the VA?  Are they to be provided within the VA system, if so, when?  Are they denied completely and the patient must use alternate resources?  Denials are not always received in a timely manner and rarely written, just oral instructions after persistent follow-up.  We have also received RFAS denials for “no response from the VA within 30 days.”   To the credit of Humana Veterans, and to the extent possible by the ARCH Care Coordinator at the MT VA, emergent services identified at a consultation are almost always authorized by phone in a timely fashion. 

Until the end of January 2012, Billings Clinic was treating 22 veterans for cancer- related illnesses.  Oncology is a unique service line and Billings Clinic is interested in working with the MT VA to resume placements. There are challenges with making sure all the requests for additional services are in place for the multiple appointments and services provided in oncology, especially when treatment plans can change daily based on the patient’s condition. An additional hurdle is that some of the oncology services are covered by ARCH, while others are not.

Finally, a patient dissatisfier is the difficulty in obtaining medications prior to the trip home because veterans are required to use the CBOC pharmacy when it is open.  This includes the need for the CBOC provider to re-write the prescription.  The VA pharmacy is not allowed to fill a prescription written by a non-VA physician and so a CBOC provider must validate the medical necessity and write the prescription.  Under the Project ARCH contract, a process is in place for weekends and other non-CBOC operating hours that authorizes prescriptions through the Heritage Network, but weekday discharges can be a struggle for the patient or their caregiver to get to the CBOC and have the prescription authorized and filled prior to closing.  

The contractor will provide acute inpatient care for medical and surgical specialties for those Veterans living in highly rural counties in Eastern Montana.  As stated previously, veterans from all over the state have been referred to us, not just those living in rural Eastern Montana. 

The final contract included these services as described in the brochure published in December 2011: 

• Acute inpatient medical and surgical care including medical consultations and ancillaries

• Selected outpatient specialty consultation, including related diagnostic imaging and laboratory services.

The contract provides for consultation and procedures in the following specialties according to Humana Veterans: 

• General Medicine

• Cardiology

• Pulmonary Medicine

• Gastroenterology

• Oncology

• Infectious Disease

• Rheumatology

• Neurology

• Nephrology

• Endocrinology

• Geriatrics

• General Surgery

• Urology

• Cardiothoracic

• Vascular

• Gynecology

• Orthopedics

• Plastic Surgery

• Neurosurgery

We feel that the addition of the following services would enable better continuity of care when the veteran is referred to a community provider and also serve identified needs in our VISN: 

• Physical Therapy

• IV Therapy

• Infusions

• Behavioral Health

• Emergency Room

• Durable Medical Equipment

• Obstetrics

This pilot will supplement VA Montana’s Intermediate Complexity Surgical Program, allowing Veterans access to providers experienced in complex surgical procedures without traveling to Salt Lake or Denver VAMCs.

Billings Clinic and other community providers are certified to provide complex surgical procedures.  We have had three veterans referred to us for open heart cardiac procedures that were subsequently pulled back into the VA system requiring the veteran to travel to Denver or Salt Lake City.  We were told that “tertiary care” was not authorized under Project ARCH although this is clearly the intent of the pilot.  Humana Veterans attempted to obtain the MT VA definition of “tertiary care” and to date we have not been given that explanation.  Again, for continuity of care, we feel that the community provider needs to be able to partner with the MT VA to provide complete care for the veteran.  

Billings Clinic also has a nationally recognized Cancer Center.  It saddened and alarmed us that 22 of the oncology patients referred to us, including 13 in active treatment, were abruptly pulled back in to the MT VA system the end of January 2012 with no real explanation from Humana Veterans or from the MT VA, even with intervention by Senator Tester’s office.  Understanding that the MT VA decision was final, our only request was that our providers be able to discuss the veterans’ history and medical needs with the VA providers assuming their care.  We were told that this was impossible because the contract prohibited providers from speaking to anyone in the VA directly, that all communication concerning our patients had to go through Humana Veterans.  

CONCLUSION

Billings Clinic believes that a partnership between community providers and the MT VA healthcare system can indeed expand the Veteran Health Administration’s ability to provide quality health care for our nation’s veterans. Our providers and staff embraced the administrative requirements understanding that we had a unique opportunity to serve our veterans, many of which are family members and friends.  

From our perspective, a veteran might be better served if the MT VA staff could coordinate the needed services through all resources available, i.e. fee-based, Project ARCH, internal to the VA.  Our sense is that because of the structure of the Department, the process is siloed so that the VA PCP refers either to Project ARCH or to fee-based instead of to a team who looks at all available resources, taking into consideration convenience and best outcomes for the veteran and the total cost of care.  An additional benefit to this would allow the provider to coordinate services for patients on our end, helping the VA complement existing resources with the services that need to be placed in the community. 

Our desire is that the MT VA open direct dialog with Project ARCH providers, facilitated by Humana Veterans Healthcare Services, to identify opportunities and work through solutions.  Conversations between Project ARCH providers in the state and the other 4 VISN’s across the nation should be facilitated and encouraged.  The Altarum site visit reports should be shared with interested providers and at a minimum with the Project ARCH Care Coordinators in each VISN. 

Billings Clinic fully supports the goal of increasing access to quality care for our veterans closer to home and will continue to partner with the MT VA and Humana Veterans Healthcare Services for the benefit of rural Montana veterans.