Illustrative Case Study of the Growth and Capacity of a Fixed Budget Healthcare System

Background: The Veterans Access, Choice, and Accountability Act, a program enacted in 2014 encompassing the Veterans Choice Program (VCP), provided temporary funding for community care resources to meet the health care needs of veterans enrolled in the Veterans Health Administration (VHA) (VA Office of the Inspector General, 2017). Limited resources and increased demand for health care services are impacting access to care for veterans enrolled in the VHA and financial hardships for those participating in the VCP either as a provider or a recipient. Objective: The objectives of this study are to: 1) explore and describe the demand for community care within the VHA; 2) compare utilization, resources, and payment systems in the VHA; 3) identify ways for the VHA to manage the influx of invoices from the VCP, including an option for the VHA to function as a single payer insurance provider as opposed to a health care entity. Methods: Descriptive quantitative methods explore data sets from the Washington, D.C. VA Medical Center. The data set describes payment practices in relation to the VCP. The data highlights payment trends as well as peak invoice times and most common diagnosis codes for which payments are made. The analysis of the number of invoices received by community care providers provides insight into the number of invoices received as part of the VCP. Results: Upward trends in usage of the Veterans Choice Program in 2016 and 2017 show an increased need for VHA resources. Both the number of claims and total dollar amount are increasing annually. Invoice payment trends suggest that there are delays in payments and processing of invoices. Conclusion: The need for community health care for veterans is increasing and the utilization of community care made an upward and then a downward trend in relation to the Veterans Choice Program. These trends could be a reflection of funding for the Veterans Choice Program. Invoice payments that exceeded the number of received claims for 2017 and 2018 with dates of service as far back as 2014 suggest that there was, at least at one point over the past 3 years, a backlog of unpaid invoices and these unpaid invoices had financial implications for veterans who received care through the Veterans Choice Program. Third-party administrator performance is a significant factor in timely claim processing and payment to community care providers. Whether delayed payments are the result of third-party administrator or Veterans Health Administration performance, the payment data for the dates of service show that the Veterans Health Administration is not capable, with its current resources, to function as a single payer insurance entity in addition providing health care services to veterans. However, it is unlikely that budgetary factors played a large role in payment delays as the expenditures for both years in which data was provided fell below the allocated budget