Kristie Chapman is a Registered Nurse, Healthcare Advocate, and gifted writer from Charlotte, North Carolina. She serves as our “resident expert” on all things related to Healthcare here at “The Thirsty Quill.” Kristie’s personal blog, “A Scarlet Stethoscope,” is loaded with additional information and resources, which you can find at http://rnadvocate.blogspot.com.

Most notably, Kristie has specifically been recruited to speak on Healthcare at many forums and town hall meetings over the past several weeks. As always, we appreciate Kristie’s contributions here at ‘The Quill.’ Feel free to contact her offline via email at kchapmanrn@gmail.com.

“Grading The V.A.: A Litmus Test For Government Healthcare”

By: Kristie Chapman, RN (Healthcare Consultant for “The Thirsty Quill”)

This is a little bit of an “aside” from the series of posts that I’ve been writing about healthcare reform – but – I think this is worth mentioning and opening for discussion. There have been recent changes to the VA program that has had a huge effect on healthcare providers that are not part of the VA system, and you have to wonder if maybe, just maybe, this is a picture of what is to come if we take on a “government option” for healthcare.

There is a summary, and also some specific details, at the Veterans Administration website, of changes to the VA program, including the changes to “Fee Basis” care that will be discussed here. http://www.va.gov/healtheligibility/library/pubs/healthcareoverview/#Eligibility. Specifically, this is what is listed regarding obtaining care from a non-VA facility:

“To qualify for routine care at non-VA facilities at VA expense (otherwise known as Fee Basis care), you must first be given written referral. Included among the factors in determining whether such care will be authorized is your medical condition and availability of VA services within your geographic area. VA copay may be applicable.”

Basically, what this means is that if a veteran requires care at a facility that is not affiliated with the VA, they must obtain authorization from the Fee Basis office. This change has been something that I have seen happen very recently, working in a private oncology practice. To my knowledge, there is not a VA oncology office locally here in Charlotte. A fee-basis office has just opened in the University area, but to my knowledge, there is not an oncologist on staff there – it is a primary care practice. (If there is anyone that has any further information or knows of VA oncologists that are closer to Charlotte than the main VA hospital in Salisbury, please let me know?)

So when a veteran needs to see an oncologist, they must have a referral from their (VA) primary care physician. At that point, the initial consultation is authorized by the Fee Basis office. However, the initial consultation, at least in oncology care, is just the beginning of a need to utilize many different specialties in order to give the best treatment.

A good example is someone with a “solid tumor” cancer – pick one – breast cancer, colon cancer, prostate cancer, etc. Beyond surgical approaches, chemotherapy and radiation are usually indicated for these types of cancers. So once the veteran sees the medical oncologist, they are then referred to a radiation oncologist to continue their treatment plan. Chemotherapy is sometimes given along with radiation, or given directly after radiation.

It is at that point where the oncology office must contact the Fee Basis office for authorization for further visits. In two separate cases this past week, I had to contact the Fee Basis office for authorizations. In one case, I was still sending faxes and making follow up calls FOUR DAYS after my initial request, and on the date of that patient’s appointment at the other clinic the patient needed to go to. Even then, I did not receive a “definite” authorization, just a reassurance that they were sure it was fine, they must have overlooked letting us know. I had to insist that someone please contact this patient to let them know what is going on.

In a different case of a blood cancer, special blood tests are required to “stage” the patient – to find out how involved the disease process is and how well a patient is responding to treatment. In our office, we have full capabilities to perform many of these blood tests, and contract with a reference labs for specialized testing that can be sent out and reported directly back to us – no middle man, no risk of the results not getting where they should be. Now, if we are giving a patient chemotherapy (which is something that is possible for a VA patient – WITH authorization), we are able to check basic blood counts to make sure that levels are adequate for the patient to tolerate chemotherapy…BUT…if the patient requires any other blood tests, they must go to a separate VA office to have that blood drawn, and the VA clinic gets the results and sends it back to our office.

Let it suffice to say that we’re still trying to get the results that we needed on one patient that had to have this outside labwork done.

Along with the topic of staging cancer patients: solid tumor cancers must be scanned on a routine basis to determine how well they have responded to treatment and to monitor for a recurrence. If we have these scans done at a “non-VA” facility, again, we go through the authorization process (every time – it’s not just a one time call for each patient – we call for each test, each scan, every time, and have to fax treatment plans), and we wait. And the patient waits. Now, I do not have cancer, so I can’t really “relate” to how it feels to have to wait. But I can only imagine – not only do you have to deal with the disease and all of the uncertainties that come with it – now, you have to deal with waiting for every treatment, every office visit, to be authorized, and wait for permission to have diagnostic testing to make sure that you are doing well.

Beyond that, for every office visit, the physician has to dictate a separate note to be sent to the VA Fee Basis office outlining whatever specific information they have requested, in addition to the routine office visit note that is done for each patient. These notes are faxed, and then we wait. And wait. Calls are returned, but thus far it has not been in a very timely manner.

This has all been in an effort marketed by the VA to “bring patients back” to VA-based care, to “provide for a better continuity of care”. From the perspective of someone that has had to fight this authorization process already, I have to wonder if this is really about continuity of care. It seems to be more about control than anything – control over who veterans can see for their care, control of when they can get this care, and control of how much care they can get. I’m not going to ‘reach’ and say that this is ‘rationing’ of care. I will say that it has added a HUGE bureaucratic hurdle that doctors and nurses are having to scale on a daily basis to try to advocate for their patients.

I cannot help but wonder if this is a premonition of what is to come if we embrace a “government option” for healthcare. When I read the 1,018 page bill, I see a process that now is relatively simple compared to what this bill is proposing (and the process now – without government intervention – the processes we go through for non-VA patients – is NOT fun) – becoming a bureaucratic nightmare for patients. The “flowsheet” that certain congressional representatives have presented (see picture on this blog) is confusing to the point of being ridiculous, and just another factor to keep doctors and nurses from doing what they went in to medicine to do – direct care of patients. I didn’t go into nursing to make phone calls and beg for every little aspect of someone’s care to be authorized. I can’t imagine anyone would want such a job. And I can’t imagine any American, if they really knew the barricades that are about to come up if this healthcare reform bill passes ‘as is”, would want such a program for themselves or their loved ones.

I am reading the bill. In all honesty, I have not finished reading it, but I am making it a personal mission to read this from beginning to end, not only for my patients, but for myself – I want to know what my representatives are trying to pass, and I will not sit by quietly while healthcare is destroyed by politicians. I strongly encourage you to take time to read as much of this bill as you are able to. Get the information you need, organize it, come up with some constructive ideas, and CONTACT YOUR CONGRESSIONAL REPRESENTATIVE – we do have a little more time as the debate has been “tabled” until after the August recess, but it is still precious little time. Please act soon, if you have not already, and if you have, remain persistent! Your elected officials know that in order to keep their jobs, they have to respond to the needs and opinions of their constituents. Do not be a silent majority in this issue – it is too important to ignore!

Resources:

The text of the healthcare reform bill, HR 3200 “America’s Affordable Health Choices Act”, can be found at: http://waysandmeans.house.gov/media/pdf/111/AAHCA09001xml.pdf

VA Healthcare Eligibility and Enrollment: http://www.va.gov/healtheligibility/library/pubs/healthcareoverview/#Eligibility

Healthcare Reform diagram can be found at: http://voices.washingtonpost.com/capitol-briefing/

Kristie Chapman is a Registered Nurse, Healthcare Advocate, and gifted writer from Charlotte, North Carolina. She serves as our “resident expert” on all things related to Healthcare here at “The Thirsty Quill.” Kristie’s personal blog, “A Scarlet Stethoscope,” is loaded with additional information and resources, which you can find at http://rnadvocate.blogspot.com.

Most notably, Kristie has specifically been recruited to speak on Healthcare at many forums and town hall meetings over the past several weeks. As always, we appreciate Kristie’s contributions here at ‘The Quill.’ Feel free to contact her offline via email at kchapmanrn@gmail.com.