VA Mission Act: New Access to Care for Veterans

A new era of health care is in store for our nations veterans with the passage of the Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Outside Networks (MISSION) Act, the most comprehensive health care reform bill passed by Congress since the Affordable Care Act. The MISSION Act provides the largest access to care expansion for veterans in over 25 years, when the VA first decentralized into its current Veterans Integrated Service Network (VISN). Many consider the legislation a response to the $10 billion 2014 Choice Act, which failed to live up to its intended level of access improvement.

A GAO report issued last, year cited an average 51-day wait from initiation of the community access referrals to the veteran actually receiving care from private physicians. This was in part due to physician reimbursement delays under Choice, which ultimately discouraged community physicians from participating in the program altogether.

The MISSION Act design is based on the military’s Tricare Prime and the Medicare Advantage programs. A new streamlined community care program has replaced the Choice program (as of June 2019), which required veterans to drive more than 40 miles to a VA facility or wait longer than 30 days to see a private physician. Rules recently published in the Federal Register state that the VA will pay for veterans to see non-VA physicians if they have to wait longer than 20 days, or drive more than 30 minutes to a VA facility.  For specialty care, a “28 day or one-hour commute” is required. Other key access to care enhancements under the Act include:

  • An expansion of the number of walk-in and urgent care clinics
  • Timely reimbursements for community providers at Medicare rates and timeline standards
  • Visit co-payment rates will be maintained with community physicians (for the 26% of Veterans who currently have co-pays within the VA)
  • Improved access to medications prescribed by non-VA physicians
    • The VA will now pay for or fill prescription drug medications for urgent care (the VA will continue to require that routine medications be filled within the VA)
    • For urgent prescription medication of a 14 day or fewer supply, veterans can now use a contracted pharmacy within the VA network (utilization of non-contracted pharmacies will require the veteran to pay for the drug, and then file a claim with the VA for reimbursement)

Spillover Implications for Drug Manufacturers

In fiscal year 2018, 1.7 million veterans used some form of private community care, and that number is expected to increase significantly under the MISSION Act. Many expect that physicians providing veteran care will continue to be required to adhere to the VA National Formulary when prescribing medications, or be subject to a VA-managed exception process.
Drug manufacturers who are on the VA formulary may consider community physician exposure, and the influence this may have on prescribing patterns, meaningful spillover into the commercial segment.

Looking Ahead

Many have wondered if the MISSION Act reform is the first step in the VA adopting a Tricare model (two-thirds of military healthcare is provided in the community care setting), or, if the VA intends to privatize altogether.

The MISSION Act is expected to cause an increase in the number of veterans who use their VA benefit (of the 27 million veterans in our country, less than half are enrolled in the VA). The VA will need to balance this general beneficiary engagement with an aging Vietnam veteran population and those returning from Iraq and Afghanistan. The ultimate divide between the integrated portion of VA healthcare and that provided by private physicians may evolve, but full privatization is unlikely. It is important to remember that veterans have complicated service-connected disease states that require specialized, military specific care.

Cheryl Nagowski is the senior director for federal markets for D2 Consulting in Washington, D.C.