The Veterans Community Care Program, established in 2019, allows eligible veterans to receive care from non-VA health care providers. The VA excludes providers from participating in the program who have been disciplined for poor quality care.
But VA's processes may not prevent excluded providers from participating. For example, the VA may not always verify whether providers have lost licenses over care quality. Also, while the VA excludes providers who have been removed from VA facilities over care quality, providers who were removed before 2019 may still participate.
We recommended ways to ensure credential policies are followed and more.
What GAO Found
The Department of Veterans Affairs (VA) has implemented contracts with Optum and TriWest to set up networks of community providers as part of the new Veterans Community Care Program (VCCP). However, the two contractors' processes for implementing eligibility restrictions established by the VA MISSION Act, as outlined in their policies and reflected in their contracts, may not consistently exclude all ineligible providers from participating in the VCCP. The VA MISSION Act prohibits providers from participating in the VCCP if they have lost a state medical license, for example, as a result of revocation or termination for cause or due to concerns about poor quality of care. However, VA's contracts with these contractors do not require the verification of providers' history of license sanctions, including a revoked license, in all states during credentialing. Only one of the two contractors has a process that includes verifying providers' licensure history in all states and neither has a sufficient process for continuously monitoring provider licenses.
Contractor Processes for Implementing VA MISSION Act Restrictions on Community Care Provider Eligibility
In May 2019, VA began tracking providers who do not meet the eligibility restrictions established by the VA MISSION Act. However, this tracking does not address providers removed from VA prior to this date. As of September 2020, VA had deactivated 136 ineligible VA providers from VCCP participation. GAO reviewed data going back to July 1, 2016 and identified an additional 227 providers that had been removed from VA employment and are potentially providing care in the VCCP. VA stated it has no plans to further review these providers. VA officials said these providers were eligible to participate in the VCCP because they were removed from VA employment before the VA MISSION Act restrictions were effective. Thus, there is a continued risk that former VA providers associated with quality of care concerns are participating in the VCCP.
Why GAO Did This Study
The VA MISSION Act of 2018 established a new community care program, the VCCP, aimed at providing care to veterans when it could not reasonably be delivered by providers at VA medical facilities. The act also requires VA to exclude from participation in the VCCP providers who lost a license for violating medical license requirements in any state or who VA removed from employment for quality of care concerns or otherwise suspended from VA employment.
The VA MISSION Act included provisions for GAO to report on the implementation of restrictions on certain health care providers' participation in the VCCP. This report examines, among other issues, VA and contractor processes to implement these eligibility restrictions on provider participation in the VCCP.
GAO reviewed VA's contracts and contractor policies related to VCCP provider credentialing, interviewed VA and contractor officials, and assessed the provider credentialing requirements and processes. In addition, GAO collected data on former VA providers and compared these data to the database of VCCP providers.
GAO is making three recommendations to VA, including that VA require its contractors to have credentialing and monitoring policies that ensure compliance with VA MISSION Act license restrictions and that it assess the risk to veterans when former VA providers with quality concerns continue to provide VCCP care. VA generally agreed with GAO's three recommendations.
Recommendations for Executive Action
|Department of Veterans Affairs||1. The Secretary of Veterans Affairs, in concert with the Undersecretary for Health, should require the Community Care Network contractors to amend their credentialing policies to ensure that providers who have violated the requirements of medical licenses that resulted in the loss of those medical licenses in any state are excluded from providing care to veterans through the Veterans Community Care Program. (Recommendation 1)|
|Department of Veterans Affairs||2. The Undersecretary for Health should ensure that Community Care Network contractors develop and implement a process for continuous monitoring of the eligibility requirements in section 108 of the VA MISSION Act, such as by using the National Pra titioner Data Bank's continuous query function. (Recommendation 2)|
|Department of Veterans Affairs||3. The Secretary of Veterans Affairs, in concert with the Undersecretary for Health, should identify, analyze, and respond to the risk to veterans when providers who have been removed from VA employment for failure to provide safe care are not prohibited from providing care to veterans in the community. For example, the Undersecretary for Health could direct VHA to review the list of terminated VA providers generated from our data analysis; determine whether these providers were removed from VA employment due to conduct that violated VA policy related to the delivery of safe and appropriate health care; and determine whether these providers should be allowed to provide care to veterans through the Community Care Net ork or a Veterans Care Agreement. (Recommendation 3)|