The VISN footprint covers 88,913 square miles in a four state area. The region comprises eight senatorial and 24 congressional districts. It is served by two Veterans Benefits Regional Offices. Currently eight medical centers and 27 peripheral facilities or CBOCs serve eligible Veterans in the region. The VISN is allocated funding through Congressional appropriation. The budget is approved two years prior to the operating annum.
Operating a system this size requires a considerable amount of funding. The current operating budget is approximately $2.75 billion. The size of the budget is based on activity at each of the facilities, and is forecast two years into the future. So, the amount of funding for a given year is based on the qualifiying attendance in the fiscal cycle two years’ prior.
Other considerations are also factored into the Congressionally approved, budget. As federal belts tighten, it is incumbent of VISN staff to increase vigilance in spending dollars efficiently, cutting costs where possible, without sacrificing service to Veterans. In fact, our goal is to improve care while reducing costs.
VISN 6 – North Carolina
FY 11 Budget $1.332 billion
- MF Dollars $38.2 million
- Minor Construction $19.6 million
FY 11 Sites of Care to open
- Robeson County CBOC, Goldsboro CBOC, Brunswick County Outreach Clinic, Elizabeth City CBOC, Fayetteville Clinical Annex, Community Dialysis Centers in Raleigh and Fayetteville
VISN 6 – Virginia
FY 11 Budget $877million
- MF Budget $19.9 million
- Minor Construction $19.4 million
FY 11 Sites of Care opened
- Wytheville and Staunton CBOCs, Richmond Polytrauma Center, Albemarle POC
VISN 6 – West Virginia
FY 11 Budget $107million
FY 11 Sites of Care opened
- Reduction in Non-VA Care
- Overall reduction in Non VA Care of $24 million
- Annually the process is reviewed from start to finish and control mechanisms are implemented for review of authorizations, obligations, disbursements, and timely clinical feedback.
- Reduction of dependence on Non-VA Providers
- Budget growth affected by an increase in direct care capability
Steadily, more Veterans are seeking VA health care. We experienced an overall increase in the number of unique patients of two percent, to 320,000. Growth in most staffing areas has grown by about one percent. Although physicians number about 960, an increase of just one percent, the number of non-physician providers jumped seven percent to 610, which combined with Registered nurses and physicians amounts to a force of 4,268 care providers who can affect the health outcomes of our Veterans.
One of the greatest single expense categories in the region involves the referral of care to providers outside VA. This can happen for a variety of reasons. A Veteran might require the care of a specialist not in the VA system. The frequency, proximity or VA’s capacity to provide needed care within a reasonable time frame are all factors that may dictate whether a Veteran is seen by a care provider in the community. Ultimately, this represents about 10% of the VISNs cash flow, directly affecting medical center operations.
A process exists to pay for services according to an established fee schedule. Whenever Veterans are referred to community providers, the provider must set the billing to the schedule, which is averaged, so, although there may be some variance according to geography, the fee is a fair market value across the country.
Still, paying for community provider services is more expensive than performing the procedures in-house. Therefore efforts are made to perform as much within VA as possible, to include possible patient transfer to a facility with greater capacity or expertise within the network or elsewhere in VA. Our goal is to minimize the number of procedures or treatments that are conducted in the community.
Memorandums of understanding are established between the facilities for services provided in the VISN resulting in workload leveling and appropriate capacity generation.
Medical Center tracking systems by clinical service were developed to track progress. Areas showing greatest levels of capacity were reviewed for capacity, referral patterns, and available resources to best determine true availability of services without impacting wait times in Primary Care or Specialty areas.
Building an internal dialysis capacity (infrastructure, staff, equipment) to provide high quality, safe dialysis service to Veterans in free-standing units has enabled VISN 6 to increase internal capacity for provision of dialysis, optimizing care for Veterans through improved continuity of care and validated proof of the concept. The VISN will continue to measure and analyze data from this pilot and initiate refinements for greater quality and value.
This vigilance has resulted in annual savings of $24 million.
Increasing Cash Flow
Almost ten percent of VISN 6 revenue is captured in Veteran health services covered by third party carriers, or insurance. If paid completely and on time, this would not present a problem. But collections usually falter and the operating budget in each facility often meets a shortfall as a result. In fiscal year 2011 VISN collections stood $3.6 million short of its $189 million goal.
The impact on patient care services and other operation and budgetary plans result in insufficient funding for ongoing operations. The VISN has diverted funds from other planned expenditures in the past, to ensure solvency for the medical centers.
This is also being handled for future mitigation through additional audits, coder training and point of service coding, and more frequent monitoring meetings.