Little health care choice for veterans in shadow of Lebanon VA

Lebanon resident Arquelio Martinez was a staff sergeant in the National Guard, called into active duty during the Gulf War to repair electronics critical to the war effort, when his health took a negative turn.

Maybe he was bit by some creature, or maybe it was exposure to the harsh desert climate, but as soon as he returned to the United States, aches, bruising and fatigue increased.

“I was in top physical shape before I went,” said Martinez. “I came back, and I was not able to run a quarter mile.”

Over time, he developed more problems that he said were determined to the National Guard to be related to his military service, including swollen glands, neurological pain in his neck, and fibromyalgia.

In recent years, with VA payment approval being a lengthy and perhaps futile process, Martinez has opted to go ahead with private treatments. He knows the Veterans Choice program, designed to let veterans access private health care on the government's dime, isn't as simple as it seems.

About four months ago, for example, a VA doctor recommended he receive a Botox shot from a private neurologist in Ephrata to improve pain in his neck and shoulders. Martinez ordered the shot, only to receive a call from the private neurologist a week before the shots were to be administered telling him they were having great difficulty getting the VA to agree to pay for the visit.

He decided to have the shot anyway, and said it has reduced his pain and increased movement in his neck. But he still isn’t sure who will end up paying for it.

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Martinez wonders why he can’t work directly with Penn State Hershey Medical Center and other private doctors, then bill the VA for the cost.

If he lived in much of the country, Martinez would be able to take full advantage of the VA’s Veterans Choice Program, which recently received a funding boost from Congress and President Donald Trump.

For people living within 40 miles of a VA hospital, however, choice often remains an illusion - even when the Lebanon VA can't provide the needed treatment.

To Tennessee for treatment

U.S. Rep. Charlie Dent, R-15, remembers learning about one constituent who was asked to go to Tennessee at his own expense for bladder cancer treatments.

“I said, ‘Is this the best place in the world for bladder cancer treatments?’" Dent recalled. "(The VA nurse) said, ‘no, it’s just where the VA is that does this.’”

Many veterans have expressed their satisfaction with the Lebanon VA Medical Center to the Lebanon Daily News, and the facility is frequently rated as one of the best in the nation.

However, veterans living in the shadow of even a good VA facility often face a Catch-22.

On one hand, they live too close to the VA to qualify for the Veteran’s Choice program, passed in 2014 in response to scandals related to wait times at VA hospitals (the Lebanon VA was not implicated and the facility has scored comparatively well in analyses of VA wait times).

On the other hand, not all procedures can be performed at the local VA, meaning they are sometimes asked to travel hundreds of miles to other facilities.

“It is absurd that veterans who live in south-central Pennsylvania who might need certain types of specialized care are forced to travel to New York or Philadelphia for services that could easily be rendered at (WellSpan) Good Samaritan (Hospital) or Hershey Medical Center or elsewhere,” said Dent, who chairs an appropriations subcommittee that handles VA and medical bills.

VA discretion

The Veterans Choice Program allows veterans to automatically qualify for receiving care at a private facility if they:

Live more than 40 miles from the closest VA medical facility with a primary care physician

Cannot be seen by the local VA facility within 30 days of when the veteran’s physician determines they need to be seen

Would have to travel by air, boat or ferry to their nearest VA facility; or

Face an “unusual or excessive burden” in traveling to the VA facility.

However, the VA has discretionary allowances that permit it to approve care at outside facilities in certain situations, said Charles Dorrough, chief, office of care coordination at the Lebanon VA.

For example, if someone is receiving treatment for their back, the VA likely wouldn’t require them to make a lengthy drive that could be counterproductive to their treatment. Something inexpensive, like a flu shot, is also more likely to be approved for private treatment.

In other areas, their discretion is limited. All transplants, for example, must be approved by the National VA Transplant Agency before someone can go to a private facility outside of the VA.

With more expensive procedures, “obviously, it costs less to get it done at the Philadelphia VA than it does on the outside,” said Lebanon VA spokesman Doug Etter. “We have to be good stewards of the money that Congress provides.”

Overall, the Lebanon VA is making less transfers to other VAs than it used to, according to Dorrough. Several years ago, the facility would average about 300 such transfers per month. It’s now down to about 150.

'McDonalds mentality'

Some veterans provide pushback when the VA refuses to approve private medical treatment, Dorrough said.

Often, they have an incomplete understanding of the medical care they need, he said. Other veterans simply don’t understand the complexity of health care in America and have a "McDonalds mentality" – they want what they want, and they want it now.

Robert Kale, director of the Lebanon County Department of Veterans Affairs, said he believes most veterans are satisfied with the care they receive at the Lebanon VA Medical Center. The Philadelphia VA’s doctors – who often work in partnership with University of Pennsylvania doctors – also provide top-notch care, he said.

Still, Kale understands why some rural Lebanon County residents who rarely travel are reluctant to be treated at a VA center in the heart of Philadelphia.

When the Choice program is used, some veterans express confusion about the extent to which it will pay for outside care, he said. Sometimes, for example, the VA will authorize an outside surgery and a couple of follow-up doctor’s visits, but not outside physical therapy to help one recover from the surgery, he said.

More privatization?

Pending bills in both chambers of congress would eliminate the 40-mile barrier to accessing the Veterans Choice program, but attempts to expand the program have become ensnared in a debate over the fate of the VA system itself. Both Democrats and influential veterans groups worry that an expansion of Choice could come at the expense of adequate funding to VA hospitals.

It could also lessen the amount of veterans using the VA, reducing economies of scale that make the VA hospitals financially sustainable, they maintain.

“This choose your own adventure approach to health care also leads to veterans receiving fragmented health care that the Commission on Care determined leads to lower health care outcomes and endangers patient safety,” said Carlos Fuentes, director of the national legislative service of Veterans of Foreign Wars (VFW), in June during a Senate committee hearing. “Veterans deserve the highest quality health care possible, not fragmented care that fails to meet their health care needs.”

Dent, however, said the VA system should manage government-paid private care for veterans while VA hospitals focus on service-connected issues like post-traumatic stress disorder and prosthetic limbs. He opposed an effort to add OB-GYNs to VA hospitals, for example.

“The VA will never be any good at delivering babies, because they will never do enough of them,” he said. “You can’t develop a specialty in every area.”

Rep. Ryan Costello, R-6, also believes there is room for improvement in the area of choice for veterans.

“While this program took a significant step forward in improving access to health care for veterans, the program’s first years showed that several improvements needed to be made to strengthen the VCP. The House recently passed legislation, which was signed into law, to begin the process of making these changes,” Costello said in a written statement. “My office continues to assist veterans across the Congressional District with access to benefits and care, and I receive feedback from my staff and constituents on this issue on a regular basis.”