Letter to the VA to express our members' concerns about two ongoing issues they face in caring for America's veterans

The Honorable R. James Nicholson
Secretary of Veterans Affairs
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Secretary Nicholson:

I am writing on behalf of the American Academy of Family Physicians, which represents more than 94,000 family physicians and medical students nationwide. Specifically, I am writing to express our members’ concerns about two ongoing issues they face in caring for America’s veterans and to seek your help in addressing those issues for the benefit of our mutual patients.

The first issue concerns a lack of communication between Veterans Administration (VA) physicians and physicians practicing in the community. Family physicians provide comprehensive, coordinated, and continued care to all members of the family and serve as the patient’s advocate in the changing healthcare system. They also frequently serve as the coordinator of a patient’s care. This means family physicians must often interact with the VA health system and its physicians in the coordination of care for their patients who are veterans.

Unfortunately, our members have repeatedly expressed their frustration that as patients move within and out of the VA Clinic System, there is little, if any, communication from the VA health system and its physicians to community physicians who care for those patients. We, in turn, have noted that VHA Directive 2002-074, National Dual Care Policy, states:

VA providers are under no obligation to follow a treatment or medication plan recommended by community physicians. If they disagree with that plan or if that plan conflicts with national and local policies related to the prescription of non-formulated and restricted medications, the VA provider needs to communicate the rationale for the medication changes or refusal of medications to the veteran, and document this communication in the medical record.

Of note is that while the directive requires the VA physician to communicate with the veteran, it does not require the VA physician to communicate with the community physician. We believe such communication would result in better continuity and quality of care for the patient. For instance, when the community physician is unaware of changes the VA physician may have made to a patient’s medical regimen, the community physician may prescribe additional medication or treatment which is contraindicated, unnecessary or a duplication of existing treatment. Thus, failure to communicate creates an unnecessary risk for the patient as well as inefficiencies and added costs.

In prior correspondence with your department on this issue, we were advised that the VA is bound by strict adherence to the Privacy Act and Health Insurance Portability and Accountability Act (HIPAA) regulations. We were also advised that those laws do not allow you to communicate directly with the non-VA provider without prior written consent of the veteran. A copy of this prior correspondence is enclosed.

Family physicians are also strictly bound by HIPAA, and we respectfully disagree with your department’s interpretation of HIPAA in this instance. In the final modifications to the privacy rule, the Department of Health and Human Services stated:

Second, the final Rule makes the obtaining of consent to use and disclose protected health information for treatment, payment, or health care operations optional on the part of all covered entities, including providers with direct treatment relationships. A health care provider that has a direct treatment relationship with an individual is not required by the Privacy Rule to obtain an individual’s consent prior to using and disclosing information about him or her for treatment, payment, and health care operations. (Federal Register, Vol. 67, No. 157, Wednesday, August 14, 2002, Page 52311)

Thus, the HIPAA Privacy Rule permits VA physicians to disclose protected health information to another health care professional, such as a community physician, for treatment purposes.

We understand that in 2006, the VA plans to offer each veteran patient the freedom to access key portions of his or her electronic medical record online at any time through the “MyHealth-eVet” web site. To the extent veteran patients share the results of such access with their community physicians, it will facilitate access and in part address concerns regarding the availability of VA care plans and findings. However, it will not eliminate the need for VA physicians and community physicians to communicate with each other to the benefit of their mutual patients. Accordingly, we ask for your help in amending the VHA Directive referenced above, as well any other relevant VHA policy, to encourage, if not require, VA physicians in such situations to communicate with the community physician as well as the veteran.

The second issue concerns the VA’s inability to fill prescriptions written by non-VA providers except in very specific circumstances. As a result of this limitation, veterans who see a community physician and receive a prescription must subsequently make an appointment and see a VA physician to have the prescription re-written, so it will be honored by the VA pharmacy. This is an unnecessary hassle for the veteran and a waste of resources in the health care system.

We understand that this limitation is statutory in nature and that there are concerns about the cost to the VA system from honoring prescriptions from non-VA physicians, even when the drugs prescribed are on the VA formulary. To this latter point, we note that the Department of Defense allows prescriptions written by civilian providers to be honored by the military treatment facilities pharmacies, as long as the items are on the formulary and within the amount limits authorized by the Commanding Officer for the facility. Specifically, the Tri-Service Pharmacy Policy Guidance for Medical Treatment Facility commanders and pharmacies states, “Prescriptions for formulary drugs written by civilian practitioners for eligible beneficiaries will be honored.”

We believe it would be reasonable for the VA to have a policy similar to that of the Department of Defense, and we are working with key members of Congress to change the law in this regard. We hope that we can count on the VA for support in this regard. We believe such a change would ease the VA workload and benefit veterans.

I would like to suggest a meeting of representatives of the Academy and the Department of Veterans Affairs to explore these issues further and discuss potential solutions that would benefit the VA, veterans, and community physicians like our members. We would ask that a member of your staff contact Mr. Kevin Burke at the American Academy of Family Physicians at 1-888-794-7481 or kburke@aafp.org to arrange such a meeting in the near future.

Thank you for your time and consideration of this matter. We look forward to your response.

Sincerely,

Mary E. Frank, M.D., FAAFP
Board Chair

Enclosure

Cc: Kevin Burke