Are military veterans getting timely, high-quality care when they choose the option of care in the community rather than within the Department of Veterans Affairs (VA) health care system? For specialty services such as a type of dermatology microsurgery known as Mohs, the answers might not be all that positive for veterans.
UC Davis Health and VA physicians in Northern California reviewed the records of 273 veterans who had been referred for Mohs surgery. Mohs is the optimal procedure used to treat certain skin cancer to provide the best cancer outcomes with the least scarring.
The researchers found that 40% of patients who were referred outside of the VA were seen by non-VA providers who had not done the year-long fellowship training for the Mohs procedure. Some providers were not even dermatologists, and some were not physicians; they were physician assistants.
When patients were seen by non-VA providers, they were three times less likely to get the preferred specialized surgery than when they were referred to a Mohs-fellowship trained surgeon. Some veterans received no procedure at all when the non-VA provider opted to "observe."
Moreover, the average wait time between referrals for Mohs surgery and the procedure differed by just over three days for veterans getting their care in the private sector versus care at a VA facility.
The findings are published online in a letter to the editor in the Journal of the American Academy of Dermatology titled "Access to Mohs Surgery through the Choice program of the United States Department of Veterans Affairs."
"Our study raises serious questions about the efforts to privatize care for veterans," said R. Rivkah Isseroff, professor of dermatology at UC Davis School of Medicine and chief of the Dermatology Section at the VA Northern California Health Care System where the study was carried out. "The findings also call into question the levels of expertise veterans are actually getting when they are referred for Mohs surgery to a provider outside of the VA system."
Mohs surgery is the treatment of choice for skin cancers that are at high-risk for recurrence or are located near functionally important areas such as the eyes, ears, nose and mouth. The procedure is known to offer the highest cure rates with the best cosmetic results.
In 2014, Congress passed the Veterans Access, Choice and Accountability Act to address concerns about wait times and quality of care at some VA facilities. The law expanded non-VA treatment options for eligible veterans through what was commonly referred to as the Choice program, and is now known as the Veteran Community Care program.
David Siegel, professor emeritus of medicine at UC Davis, recently retired chief of medicine at VA Northern California and co-author of the study, noted that the cross-sectional observational study examined cases seen at the VA Medical Center in Sacramento over a three-year period. The cases involved patients with biopsy-proven skin cancers who, after being evaluated by a VA Mohs surgeon, and after a discussion of alternatives, were referred to the private sector for the surgery.
"What is concerning about our findings is that when veterans with known skin cancers were referred to community providers for this specialized Mohs surgery, that was recommended as the best treatment for their specific case, many did not receive it," said Siegel. "Some were treated by providers who were not dermatologists and, in some cases, were physician assistants. When patients were seen by these providers, they were three times less likely to get the preferred specialized surgery than when they were referred to fellowship-trained MOHS surgeons."
Equally concerning, added Siegel, is that some patients did not get a procedure at all "when the community provider opted, without a clear medical reason, to wait and simply observe the natural history of the cancer over multiple return visits. This puts the veteran at risk for extension of the cancer and a worse outcome."
Siegel and the other researchers found that in 22% of the cases, patients received treatments other than the specialized Mohs procedure for which they were originally referred. Another 17% of veterans received additional unauthorized treatments unrelated to the referral for which the VA was billed.
While the VA does not require its Mohs surgeons to be fellowship trained – a surgical training program that establishes a level of quality and competency in the procedure and can mean optimal outcomes for patients – 80% of VA Mohs surgeons have the added expertise of the fellowship.
The report noted that among the factors for establishing the VA's Choice program was the notion that veterans could receive better care from private providers outside the VA and be seen more quickly.
"Our report raises concerns about the delivery of quality and timely care for veterans through the Choice program," said Siegel. "When it comes to Mohs surgery for skin cancer, VA Mohs surgeons would have been able to offer superior expertise in nearly the same time as the private sector providers. Given our findings, it would be wise to evaluate other care offered through the Choice Program to determine if the goals of improved access and quality of care are met."
Isseroff and Siegel pointed out limitations in their analysis. They were unable to evaluate the long-term outcomes of patients treated either through the Choice program or within the VA. The study also was limited in that it looked at cases involving one VA patient population from Northern California.
In addition to Isseroff and Siegel, the study's co-authors were Jayne S. Joo, Rachel A. Cortez and Theresa A. Furlong.
