Research published recently in the journal HSR, an official journal of AcademyHealth, sheds light on the ways VA might insure adequate access to high quality care via in its Community Care Network. One strategy, the establishment of network adequacy standards, is common in the commercial market, where states regulate commercial insurers provider network. The researchers sought to determine if, and how, such standards might work for the VA system.
Background: The 2014 CHOICE Act and 2018 MISSION Act attempted to address longstanding issues with timely access to care for Veterans receiving health care from the Department of Veterans Affairs (VA). In order to implement the requirements of the MISSION Act, including the establishment of a consolidated care network — the Community Care Network, or CCN — the Department has entered into contracts with two Third Party Administrators, companies that provide operational services such as claims processing and employee benefits management. The contract process offered the VA an opportunity to establish requirements for timely access to a sufficient number of “in-network” providers. These requirements are typically referred to as network adequacy standards.
This use of network standards is common in the commercial market, where states regulate commercial insurers provider network. However, the regulations vary from state to state and the VA is a national system. In addition, the VA is challenged to implement a comprehensive set of standards by virtue of its history and patient mix. Veterans have typically received the majority of their care within the VA system, and new standards defining acceptable wait times for appointments and drive times has increased the number of Veterans eligible for community care. Taken together, it’s difficult or impossible to estimate the demand for community-based care and, therefore, to define the minimum number of providers necessary to meet their needs. Finally, the VA is constrained to paying Medicare rates and therefore lacks the negotiating power of other major payers, who can adjust rates to incentivize participation and other behaviors by providers.
The process and findings: A group of VA researchers conducted a review of the existing research literature, convened an expert panel discussion, and facilitated a prioritization exercise to consider how the VA could implement network adequacy standards for community care in light of these challenges. Specifically, they sought to understand 1) whether it is possible for the VA to utilize network adequacy standards for its Community Care Network; 2) what considerations or challenges the VA might have in enforcing such standards, and; 3) how VA standards might be similar or different to those used in the private health insurance marketplace.
They found that network standards used by health care plans cannot be simply adapted by the VA health system, and that Congressional constraints on VA reimbursement to community providers was an impediment to developing and implementing network adequacy standards. Furthermore, much greater understanding of the demand for non-VA care among Veterans is needed to inform whether networks are potentially adequate. The researchers also found that priorities for Veterans were more likely to include the ability to access accurate and comprehensive provider directories and the provision of useful and understandable standards of quality.
Implications: This work provides important understanding of the challenges facing the VA as it moves to implement the MISSION Act and pursues contracts with community care providers, and calls for additional research to inform a comprehensive understanding of the demand for community care services.
For more information on this study, please contact Kristin Mattocks, Ph.D., M.P.H. at Kristin.Mattocks@va.gov.
As part of our mission to advance evidence to inform policy and practice, AcademyHealth works with HSR, one of our official journals, to develop and publish plain language summaries of selected articles from each issue. Articles are selected by HSR Editor-in-Chief Austin Frakt, Ph.D. and the summaries are prepared by AcademyHealth staff in partnership with article authors.