Veterans Community Care Program: immediate action needed to ensure health care providers associated with poor quality care are excluded

What the GAO found

The Department of Veterans Affairs (VA) has contracts in place with Optum and TriWest to set up networks of community providers under the new Veterans Community Care Program (VCCP). However, the two contractors’ processes for implementing the eligibility restrictions established by the VA MISSION Act, as stated in their policies and reflected in their contracts, may not systematically exclude all ineligible vendors from participation in the VCCP. The VA MISSION Act prohibits providers from participating in VCCP if they have lost a state medical license, for example, due to revocation or termination for cause or due to concerns about poor quality of care . However, VA contracts with these contractors do not require verification of vendor license sanction history, including a revoked license, in all states upon accreditation. Only one of the two contractors has a process that includes verifying vendor licensing history in all states and neither has a sufficient process to continuously monitor vendor licensing.

Contractor Process for Implementing VA MISSION Act Restrictions on Community Care Provider Eligibility

In May 2019, VA began tracking vendors who do not meet the eligibility restrictions established by the VA MISSION Act. However, this follow-up does not apply to suppliers removed from VA before this date. As of September 2020, VA has deactivated 136 ineligible VA providers from participation in VCCP. The GAO reviewed data going back to July 1, 2016, and identified 227 additional providers who had been removed from VA employment and who are potentially providing care in the VCCP. VA said it has no plans to investigate these vendors further. VA officials said these vendors were eligible to participate in VCCP because they were removed from VA employment before the VA MISSION Act restrictions came into effect. Thus, there is an ongoing risk that former VA providers associated with quality of care issues will participate in VCCP.

Why GAO Did This Study

The VA MISSION Act of 2018 established a new community care program, the VCCP, to provide care to veterans when it could not reasonably be provided by providers at VA medical facilities. The law also requires VA to exclude from participation in VCCP providers who have lost a license for violating medical licensing requirements in any state or who have been removed from employment by VA for product quality issues. care or otherwise suspended from VA employment.

The VA MISSION Act included provisions for the GAO to report on the implementation of restrictions on the participation of certain healthcare providers in the VCCP. This report examines, among other issues, the VA and contractor processes for implementing these eligibility restrictions for supplier participation in the VCCP.

GAO reviewed VA contractor contracts and policies related to VCCP vendor accreditation, interviewed VA and contractor managers, and assessed vendor accreditation requirements and processes. In addition, GAO collected data on former VA vendors and compared this data to VCCP’s vendor database.

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