For anyone who wishes to have what the VA hospital system claims to offer, you might think twice after learning about the ins and outs of dealing with the VA bureaucracy. It is an embarrassment to our veterans and a hazard to their safety. Several years ago the federal government decided that paying community hospitals to care for veterans was either too expensive or not part of the deal for vets who risk their lives for our country. So how does it work now? How do vets get the care they need since there isn't a VA hospital in every city of our country?
If a patient comes to the emergency room at thehospital and they are unstable, I am told the VA will pay for hospitalization and care up to the point that the patient is determined to be stable for transfer to VA hospital. So that's what we do. The nearest VA hospital in my neck of the woods is over an hour's interstate drive away. We stabilize and transfer. That's what we do, when there is actually a bed available.
One problem though. Unless the veteran meets certain service connection criteria, the VA system will not pay for the ambulance transfer. Sometimes this cost can run up to a thousand bucks or more depending on the level of ambulance care and the distance that must be traveled. You can see the dilemma here. If the ambulance wants their money up front or the patient doesn't want to pay a grand for an ambulance, how are they going to get to the VA? It's these little details that often throw giant wrenches into the medical evaluations of our VA patients.
So let me tell you a little story. I once took care of a veteran who presented with multiple episodes of passing out over a two month period. Three of the times he ignored them. The fourth time, his wife caught him. That's how he ended up in my hospital. After 24 hours of monitoring and based on the available data and work up to date, I made a clinical determination that he needed further cardiac work up to exclude an ongoing cardiac etiology for syncope. Certainly, while he wasn't unstable, he wasn't stable for direct discharge to home and I didn't feel compelled to begin a $50,000-$100,000 cardiac workup in my hospital when I knew very well he had the benefit of all the VA care our government could provide.
So I recommended he transfer to the VA hospital. One problem though, he was not service connected, as usual, and therefore the ambulance ride would have to be paid for out of his own pocket. The patient told me he couldn't afford an ambulance. What's a doctor to do? Should I just keep him here and risk the VA not paying for the rest of his cardiac care while he is immediately stable? I couldn't do that to him, his wife or his wallet. So I took a risk and recommended he go to the VA by private vehicle. I recommended discharge from my hospital and readmission to the VA as a direct admission. I took a risk that something could happen between here and there. But in my medical judgment, I didn't think the risk was immediate enough to risk harm during his transfer.
I did this in the interest of my patient's financial and economic health. I told him I thought he was stable enough over the last 24 hours to be discharged from my hospital and to have his wife drive him to the VA hospital to be admitted as a direct admission. All I needed was a VA doctor to be the accepting physician.
This kind of thing happens all the time at my hospital. We accept patients from small town hospitals from doctors who feel the patient is stable enough to discharge and travel by private vehicle for further inpatient care at my hospital. I have no problem with this. In fact, I think if the physician discharging the patient feels comfortable making that medical determination, then I have no place to question their clinical judgment since they are the ones who have done the face to face evaluation. If they don't feel an ambulance is necessary and the patient can come by private vehicle, that's up to the transferring physician to decide, not me.
In these situations, I accept the patient and the patient arrives to get the continued in-pateint evaluation and care they need, as a direct hospital admission. That's the way it should work. I speak with the physician, accept the patient and notify my admissions people of the direct admission. The whole process normally takes under five minutes.
Now, let me explain to you how it works with the VA. I notify my social worker that I have a VA patient that is clinically stable and needs further work up to be performed at the VA hospital as an in-patient. I then have to fill out a form describing the entire clinical history of the patient's admission. Then the social worker contacts the VA bed control people who let us know if there is a bed available or not. The form and any other paper work the VA desires gets faxed. Then a VA resident physician calls me for a physician to physician communication. The whole process can take an hour or more, but usually more.
In this case, I indicated on my form that I would be discharging the patient by private vehicle and they would be arriving by private vehicle to be readmitted to the VA hospital for further evaluation of his events as a direct admission. I was requesting a direct admission, much like it happens when a clinical patient arrives by private vehicle.
At this point I was notified, not by a physician, but by the VA bed control secretary that they would not accept the veteran, a patient who has every entitled right to be cared for by VA services. The reason I was given? The patient must come by ambulance. Yes, folks, the VA secretary is refusing to accept veterans to your VA hospitals without ever speaking with a physician. Their words?
If the patient is stable enough to come here by private vehicle, they are safe enough to go home. Either they come by ambulance, or they don't come at all.
Wow. I was stunned. So I called the VA secretary to ask them where they get their information from. Exactly what is the basis of this policy? They said it's always been like that, but couldn't give me a reason other than that's their policy. I said it was unacceptable. I explained that I was requesting a direct admission to a VA hospital for a patient whom I made a face to face evaluation and determined was stable for a direct admission by private vehicle so they could receive further in-patient care in the VA hospital.
After the secretary became frustrated by my persistence I was then told that a nurse manager of some sort would be calling me. They did. About an hour later I received a call from some lady who said she was in charge of assisting with issues related to transfer. She indicated the VA could not accept any patient from in-patient to in-patient that did not come by ambulance. I asked why. She couldn't tell me me. She said it was a patient safety issue. I said, I've already determined that the patient was safe enough to be discharged and directly admitted to the VA and arrive by private vehicle. She refused to accept that premise either.
We went around in circles for another 15 minutes. Then she offered to have me speak with the medical director of the VA. I said, fantastic. Get him on the line. About thirty minutes later I received a call from the medical director/officer of the day/ VA doctor in charge to discuss my issues.
Same story. He commended me for trying to do the right thing for the patient and save him some money, but again, he indicated they could not accept the patient as a direct admission unless they came by ambulance. I explained that I had no other option but to discharge the patient and force him to arrive at the VA emergency room and for him to tell the VA emergency room doctor he needs to be evaluated for episodes of passing out. The VA doctor tried to tell me that would be a HIPAA violation. I think he meant EMTALA, but I didn't have the heart to correct him.
However, I disagree. EMTALA regulations only apply to facilities that accept Medicare funds. VA hospitals are not bound by EMTALA rules since they do not receive funding from CMS. If I determine that the patient is stable for private vehicle transfer to a hospital the patient wishes to receive care from, especially the VA hospital that the patient routinely receives care from, the patient has a right to receive that care. By refusing to accept the patient as a direct admission the VA has given me no choice but to recommend they head to the ER as a route to be readmitted for further care.
The VA system is not funded my CMS and therefore not bound by EMTALA rules. Even if the VA was bound by EMTALA regulations there is nothing in the regulations that state a patient must travel by ambulance.
EMTALA's requirement for an "appropriate transfer" is determined by the circumstances. Not every transfer requires the same equipment and personnel. That decision is a medical decision that should be left up to the physician requesting the transfer. There are no EMTALA requirements that the accepting physician must refuse a transfer if it does not come by ambulance, even if EMTALA applied to VA hospitals, which I does not.
I told the doctors we could go around in circles but the fact remains I've evaluated the patient and made a clinical determination that they were clinically stable to be discharged from my hospital and be driven up by private vehicle to be further monitored and evaluated under VA benefits. If they don't want to accept a direct admission, what they are saying is they don't trust my clinical judgment. It has nothing to do with EMTALA or HIPAA and everything to do with ignorance.
The doctor told me my patient should just "suck it up" and pay for an ambulance. I said it wasn't medically necessary. In the end they wouldn't budge. The only way to get admitted to a VA hospital, it turns out, is to make the patient pay for an ambulance that the doctor, who has evaluated the patient, feels is not medically necessary or the VA won't accept the patient. And the only way to get an ambulance is for the doctor to lie about the medical necessity of an ambulance.
So. You think the VA is a great place to be cared for? Think again. With any other insurance or even for the uninsured, the transfer details and communication would take less than five minutes. With the VA, they won't even accept their own veterans after three hours of phone tag.
For all the great things the policy wonks always talk about with VA health care, they leave out the realities of what it's like for a patient and doctor to deliver medical care. In no other hospital system can I imagine a secretary making the decision to refuse a patient transfer. And they don't even know why they have policies, that I suspect don't even really exist. It's travesty I tell ya. You want a VA system? Heck, I'd rather be uninsured. At least I'll get cared for. Here's my experience immortalized with my original Hospitalist vs VA Doctor Patient Transfer Xtranormal Medical Video Production.