[Senate Hearing 114-274]
[From the U.S. Government Publishing Office]
S. Hrg. 114-274
EXPLORING THE IMPLEMENTATION AND FUTURE OF THE VETERANS CHOICE PROGRAM
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
MAY 12, 2015
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas Richard Blumenthal, Connecticut,
John Boozman, Arkansas Ranking Member
Dean Heller, Nevada Patty Murray, Washington
Bill Cassidy, Louisiana Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota Sherrod Brown, Ohio
Thom Tillis, North Carolina Jon Tester, Montana
Dan Sullivan, Alaska Mazie K. Hirono, Hawaii
Joe Manchin III, West Virginia
Tom Bowman, Staff Director
John Kruse, Democratic Staff Director
C O N T E N T S
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May 12, 2015
SENATORS
Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........ 1
Blumenthal, Hon. Richard, Ranking Member, U.S. Senator from
Connecticut.................................................... 3
Moran, Hon. Jerry, U.S. Senator from Kansas...................... 33
Sanders, Hon. Bernard, U.S. Senator from Vermont................. 35
Rounds, Hon. Mike, U.S. Senator from South Dakota................ 37
Manchin, Hon. Joe, U.S. Senator from West Virginia............... 39
Tillis, Hon. Thom, U.S. Senator from North Carolina.............. 45
Hirono, Hon. Mazie, U.S. Senator from Hawaii..................... 47
Boozman, Hon. John, U.S. Senator from Arkansas................... 52
Tester, Hon. Jon, U.S. Senator from Montana...................... 53
WITNESSES
Gibson, Hon. Sloan, Deputy Secretary, U.S. Department of Veterans
Affairs; accompanied by James Tuchschmidt, M.D., Acting
Principal Deputy Under Secretary for Health.................... 5
Prepared statement........................................... 7
Response to requests arising during the hearing by:
Hon. Joe Manchin........................................... 39,42
Hon. Mazie Hirono.......................................... 49
Response to posthearing questions submitted by:
Hon. Patty Murray.......................................... 56
Hon. Bill Cassidy.......................................... 57
McIntyre, David J., Jr., President and Chief Executive Officer,
TriWest Healthcare Alliance.................................... 12
Prepared statement........................................... 14
Response to posthearing questions submitted by:
Hon. Patty Murray.......................................... 58
Hon. Bill Cassidy.......................................... 59
Hoffmeier, Donna, Vice President and Program Officer, VA
Services, Health Net Federal Services.......................... 22
Prepared statement........................................... 24
Response to posthearing questions submitted by Hon. Patty
Murray..................................................... 60
Butler, Roscoe G., Deputy Director, Health Care, Veterans Affairs
and Rehabilitation Division, The American Legion............... 60
Prepared statement........................................... 62
Selnick, Darin, Senior Veterans Affairs Advisor, Concerned
Veterans for America (CVA)..................................... 65
Prepared statement........................................... 67
Violante, Joseph A., National Legislative Director, Disabled
American Veterans (DAV)........................................ 70
Prepared statement........................................... 71
Rausch, Bill, Political Director, Iraq and Afghanistan Veterans
of America (IAVA).............................................. 77
Prepared statement........................................... 79
Fuentes, Carlos, Senior Legislative Associate, National
Legislative Service, Veterans of Foreign Wars of the United
States (VFW)................................................... 80
Prepared statement........................................... 82
APPENDIX
Murray, Hon. Patty, U.S. Senator from Washington; prepared
statement...................................................... 93
Second Report on Veterans Choice Program Submitted by the
Veterans of Foreign Wars of the United States (VFW); report.... 94
EXPLORING THE IMPLEMENTATION AND FUTURE OF THE VETERANS CHOICE PROGRAM
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TUESDAY, MAY 12, 2015
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:45 p.m., in
room 418, Russell Senate Office Building, Hon. Johnny Isakson,
Chairman of the Committee, presiding.
Present: Senators Isakson, Moran, Boozman, Cassidy, Rounds,
Tillis, Blumenthal, Sanders, Tester, Hirono, and Manchin.
OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, U.S.
SENATOR FROM GEORGIA
Chairman Isakson. I call the Committee to order. We have a
vote on the floor which should be over in the next 10 minutes.
I passed Ranking Member Blumenthal going in as I was leaving.
He supposedly is on the way, so I will talk a little bit and
tell you what I want you to know by the opening statement. If
he is not here, I want to start with the testimony from Deputy
Secretary Sloan Gibson. If he is here, we will hear from the
Ranking Member. Is that fair enough? Is that OK?
[Sen. Blumenthal's staff nodding affirmatively.]
Make a note that his staff said that was OK. [Laughter.]
I hate to get people in trouble.
I want to take a little extra time on this, anyway, because
this is a very important hearing for the VA and it is a very
important hearing for us.
Last year, culminating in August with the passage of the
Veterans Choice bill in the U.S. House and Senate, the VA--
every morning I got up, it was bad news: veterans dying in
Phoenix, problems in Raleigh, problems in Denver, problems in
Orlando, and answers that were incomplete at best--for
understandable reasons, because an awful lot of the personnel
at the VA were new.
I am the first person to recognize that Robert McDonald had
just gotten there. I am the first person to recognize that
Deputy Secretary Petzel just had left VA. Secretary Shinseki
was gone as well, so there was a transition.
But, to my way of thinking, there is no excuse for the
plethora of problems the VA was having, and the transition
should have been much better but was not.
The VA demonstrated to me in the last hearing we had on
Veterans Choice that they finally were listening. All I was
hearing on the 40-mile rule in terms of as-the-crow-flies
versus how far the car drives was nothing but stonewalls until
finally Sloan walked into that hearing, reached in his pocket,
and pulled out a new ruling on the 40-mile rule to make the
number of miles driven be the governing factor. I think
everybody on this Committee appreciated and agreed with and was
happy that VA found a way to do it. I believe we are
satisfactorily working toward ``the care you need'' definition
being defined statutorily in such a way to make that change,
which will not happen today but will happen in the very near
future. I want to commend Deputy Secretary Gibson, Secretary
McDonald, and the others for the work they have done on that.
To the VSOs who are in the room, I know some of you do not
like the Veterans Choice bill because they fear it will be a
replacement for the Veterans Administration. We are not going
to replace the Veterans Administration. It will always be
there. But you can empower the Veterans Administration, you can
empower the veteran by seeing to it they have access to world-
class care, in close proximity to where they live, in an
affordable amount and a manageable amount, whether it is from
the private sector or whether it is from the Government.
In fact, if anything--and this is going to sound harsh, and
it should sound harsh--the VA has demonstrated it cannot build
a hospital by running over 100 percent, 200 percent, 300
percent, or 400 percent. Every time we can have private sector
help given to veterans without having to build a hospital to
put the people in, it is saving the VA money, it is saving the
United States money, and it is giving the veterans far better
services.
What we need is a partnership between the private sector
and the Veterans Administration to deliver the ultimate goal,
which is to see to it that our veterans get world-class health
care and they get it in a timely way. That is my only goal.
However we do that, the most important way to do it is to get
it done. I think Veterans Choice is the way to do it.
Now, we have had some bumps since Veterans Choice was
rolled out. We have had some bumps. I have met with some of our
private contractors, and, by the way, I appreciated those
meetings and their confidence in the job that we can do. I
appreciate the fact that VA is now cooperating I think in ways
that it might not have been cooperating before to see to it the
two are working seamlessly. If they cannot work seamlessly, it
will never work.
The private contractors have to understand their contracts
are not just subject to their performance for the veteran, but
also their willingness to work cooperatively with the VA. The
VA needs to understand that the veteran's health care drives
the decision and nothing else.
There are some in VA health care who do not like the non-VA
health care provisions anyway. I understand that. But they are
going to have to get used to it, because we are going to make
this thing work. We are not going to put a square peg in a
round hole. We are going to match the round peg with the round
hole and make this work for our veterans.
Today's hearing is important to hear a report from the VA
and the contractors and then later from the VSOs, understanding
that as we talk today, remember, the first person we are here
to serve is our veteran. They risk their lives for each and
every one of us to be here today. We can expect no less of
ourselves to see to it they get the best world-class health
care as accessible and affordable as possible from our country
and the taxpayer.
With that said, I will turn to the Ranking Member, Senator
Blumenthal.
STATEMENT OF HON. RICHARD BLUMENTHAL, RANKING MEMBER, U.S.
SENATOR FROM CONNECTICUT
Senator Blumenthal. Thank you, Mr. Chairman, and thank you
for having this hearing. Thank you to each of you for being
here today.
We went through a terrible tragedy and debacle not long ago
that prompted the Veterans Access, Choice, and Accountability
Act, which sought to relieve some of the problems and
underlying issues, including deceit and fraud, that caused
delays and misreporting within the VA system.
The discussion today is centered on the remaining flaws and
failings in the VA health care program, particularly the
Veterans Choice Program. As much as this program was
established to deal with the immediate crisis of access to care
in the short term with an investment of $10 billion to provide
direct care services in the community and $5 billion to provide
the Choice Program, there is still a lot to be done.
The program was just a downpayment, just a first step, and
I believe that it has to be improved even further. There
remains, for example, underutilization of the Choice Program.
The reasons for it have yet to be determined or discovered. The
underutilization may well be the result of a failure to
sufficiently publicize or make veterans aware. It may be the
result of other more fundamental issues within the program, and
I share the Chairman's view that changing the 40-mile rule was
certainly a welcome step.
The most important fact that brings us here today--and we
cannot lose sight of it--is that we still have not solved the
crisis that led to this program. Veterans still wait too long
for health care. Health care delayed, in effect, is health care
denied for veterans who suffer from health conditions that
require immediate treatment.
The VA's most recent data release of May 1 indicates that
wait list numbers have increased significantly since the same
time last month. In its an April 2 release, 377,300 veterans
had appointments scheduled in more than 30 days from the
preferred date. As of the May 1st release, that number had
jumped by approximately 56,000 to nearly 434,000.
Anybody who believes that this crisis has been solved is
living in an alternate universe. It is not the universe that
our veterans inhabit.
These delays have real-life consequences. They cannot be
tolerated. Too many veterans are still waiting too long for
appointments, and I am glad that the VA is finally going out to
the facilities with long wait times trying to determine why
exactly they are not utilizing non-VA care options. I notice
that a lot of the testimony today talks about further changes
to the geographic criteria.
Every time there is an additional change to the 40-mile
criteria, more of the $10 billion allocated for the Choice
Program will be devoted to paying for access. This money is
owed to our veterans because better health care is due them.
I will close on this note. We still do not have
accountability for the delays. The Inspector General still has
not completed his work. We still have no reports on action, and
I mean effective disciplinary action for the delays that were
intolerable and still are unacceptable. Accountability is
absolutely necessary, and I believe that the Inspector General
needs more resources to effectively implement accountability. I
will continue to press for the reports and for action by the
Inspector General that will send a message to the health care
apparatus and professionals in the VA that we really mean what
we say when ``accountability'' is our watch word.
Thank you, Mr. Chairman.
Chairman Isakson. Thank you, Senator Blumenthal.
Our first panel will be made up of the following
individuals:
First of all, Hon. Sloan Gibson. We have become new best
friends over the last 4 or 5 months, and I want to thank him
publicly in this introduction for his willingness to take on
some tough situations. He inherited some tough situations, and
I appreciate the fact that he is approaching them in a very
positive way. We have got a few more tough ones coming up, so I
hope you will maintain that attitude all the way through. I am
very appreciative of the cooperation.
To reiterate for those who are present, including the
press, Secretary McDonald and Deputiy Secretary Gibson invited
the Ranking Member, myself, the House Ranking Member, and the
House Chairman to the VA for what they call a ``standup,''
which was in February. We have been invited to come back in
June, and I believe the invite is for the entire Committee if
they want to come. I think I heard that this morning, so, as
many Members who want to go, I want to make sure they are
invited to see the way in which the VA is benchmarking itself
against itself, so to speak, to try and find better ways to do
things and flush out the problems in advance and get them
solved earlier. We are looking forward to doing that, and we
have got some big problems to solve in the next few months,
which will be a testimony or a test, one way or another, to our
willingness to work together.
Dr. Tuchschmidt, we appreciate you being here to assist
Sloan in any way he needs. I am sure if he gets a tough
question, he will defer to you, so we appreciate you being here
very much.
To our private providers: Mr. McIntyre, I enjoyed our
meeting earlier this week. I appreciate the insights that you
gave me. Ms. Hoffmeier, I appreciate your being here today. We
look forward to hearing first from Sloan Gibson.
STATEMENT OF HON. SLOAN GIBSON, DEPUTY SECRETARY, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JAMES
TUCHSCHMIDT, M.D., ACTING PRINCIPAL DEPUTY UNDER SECRETARY FOR
HEALTH
Mr. Gibson. Thank you, Mr. Chairman. Chairman Isakson,
Ranking Member Blumenthal, and Members of the Committee, we are
committed to making the Choice Program work and to providing
veterans timely and geographically accessible quality care,
using care in the community whenever necessary. I will talk
shortly about what we are doing and the help that we need from
Congress to make all that happen. First I want to talk very
briefly about access to care.
Most mornings at 9 a.m. for the last year, senior leaders
from across the Department gather to focus on improving
veterans' access to care. We have concentrated on key drivers
of access, including increasing medical center staffing by
11,000, adding space, boosting care during extended hours and
weekends by 10 percent, and increasing staff productivity. The
result: 2.5 million more completed appointments inside VA this
year than last. Relative value units, a common measure of care
delivered across--used to measure care delivered across the
industry are also up 9 percent.
Another focus area for us in improving access has been
increasing the use of care in the community. In 2014, VA issued
2.1 million authorizations for care in the community, which
resulted in more than 16 million appointments completed. Year
to date in 2015, authorizations are up 44 percent, which will
result in millions of additional appointments for community
care.
Veterans are responding to this improved access. More are
enrolling for care at VA. Among those who are enrolled, more
are actually using VA for care, and those using VA are
increasing their reliance on VA care. This is especially the
case where we have been investing most heavily due to long wait
times.
In Phoenix, for example, where we have added hundreds of
additional staff, we have increased completed appointments 20
percent this year. I should also note that we have increased
care in the community 127 percent in Phoenix over the last
year, largely due to the extraordinary effort of TriWest in
that particular community.
However, wait times are not down. Wait times are not down
in Phoenix because of the surge in additional veterans coming
to VA for care plus the veterans that are there asking for more
care from VA.
In Las Vegas, we have got a 17-percent increase in veterans
receiving care since we opened the new medical center there
less than 2 years ago.
In Denver, we have opened outpatient clinics and added more
than 500 additional staff. Veterans using VA for care there are
up 9 percent.
In Fayetteville, NC, where wait times continue to be a
problem, we have increased appointments 13 percent, relative
value units up 19 percent, and veterans using VA for care are
up 10 percent.
In all of these locations, we have had dramatic increases
in care in the community.
As Secretary McDonald has testified during budget hearings,
the primary reason for increasing demand are an aging veteran
population, increases in the number of medical conditions
veterans claim, and a rise in the degree of disability, and as
we can see here, improving access to care.
As I mentioned at the outset, community care is critical
for improving access. We use it and have for years in programs
other than Choice. In fiscal year 2013, we spent approximately
$7.9 billion on community care other than Choice. In 2014, that
rose to $8.5 billion, and we estimate that at the current rate
of growth, VA will spend $9.9 billion, including Choice, a 25-
percent increase in care in the community in just 2 years.
At the same time, we have had a large increase in care in
the community, but Choice is not working as intended. Here are
some things we are doing to fix it.
On April 24, we changed the measure from straight line to
driving distance using the fastest route. This roughly doubles
the number of veterans eligible for the 40-mile program under
Choice.
There is much more to do. A follow-on mailing to all
eligible veterans is about to go out. We have just launched a
major change in internal processes to make Choice the default
option for care in the community: additional staff training and
communication, extensive provider communications, improvement
to the Web site and ramped-up social networking, new mechanisms
to gather timely feedback directly from both veterans as well
as from front-line staff. These are all already in place or
about to launch.
In the longer term, we must rationalize community care into
a single channel. The different programs with different rules
and reimbursement rates, methods of payment, and funding routes
are too complicated. They are too complicated for veterans, for
providers, and for VA employees who coordinate care. I am
confident we will need your help on that.
Next, let me touch on the other 40-mile issue. We have
completed in-depth analysis using patient-level data to
estimate the cost of a legislative change to provide Choice to
all veterans more than 40 miles from where they can get the
care they need. We have shared that analysis with some Members
of the Committee, with staff, and with the CBO. It confirms the
extraordinary cost that had been estimated previously.
We have also briefed the staff on a broad range of other
options and believe there are one or more options worthy of
discussion and careful consideration.
While we are working together on an intermediate-term
solution, we are requesting Congress grant VA greater
flexibility to expand the hardship criteria in Choice beyond
just geographic barriers. This authority would allow us to
mitigate the impact of distance and other hardships for many
veterans.
We also request greater flexibility around some
requirements that preclude us from using Choice for services
such as obstetrics, dentistry, and long-term care.
As described above, we accelerated access to care in the
community this year, anticipating that a substantial portion
would be funded through Choice. For various reasons, most
touched on previously, we will be unable to sustain that pace
without greater program flexibility and flexibility to utilize
at least some portion of Choice Program funds to cover the cost
of other care in the community. We are requesting some measure
of funding flexibility to support this care for veterans.
On May 1, VA sent to Congress a legislative proposal
providing major improvements to VA's authority to use provider
agreements for the purchase of community care. We request your
support.
Last, we are requesting flexibility in one other area of
veteran care: hepatitis C treatment. You are all familiar with
the miraculous impact of this new generation of drugs. Veterans
that have been hepatitis C positive for years now have a cure
within reach, with minimal side effects. Because of the newness
of these drugs, there was no funding provided in our 2015
budget request or appropriation. We moved $688 million from
care in the community, anticipating the shift in cost to
Choice, to fund treatment for veterans with these new drugs. It
was the right thing to do, but it was not enough. We are
requesting flexibility to use a limited amount of Choice
Program dollars to make this cure available to veterans between
now and the end of the fiscal year.
We are improving access to care, notwithstanding the
reported wait times that you see. That means we have still got
work to do on wait times, but we are improving access to care.
We are committed to making Choice work and have very
specific actions underway to do just that, and we need some
help, especially additional flexibility to allow us to meet the
health care needs of our veterans.
We look forward to your questions.
[The prepared statement of Mr. Gibson follows:]
Prepared Statement of Hon. Sloan Gibson, Deputy Secretary,
U.S. Department of Veterans Affairs
Good afternoon. Chairman Isakson, Ranking Member Blumenthal, and
Members of the Committee. Thank you for the opportunity to participate
in this hearing and to discuss the progress of the Department of
Veterans Affairs' (VA) implementation of the Veterans Access, Choice,
and Accountability Act of 2014 (Veterans Choice Act). I am accompanied
today by Doctor James Tuchschmidt, Interim Principal Deputy Under
Secretary for Health.
implementing the veterans choice program
The Veterans Choice Program is helping VA to meet the demand for
Veterans healthcare in the short-term. VA is focusing on ensuring the
program is implemented correctly and seamlessly as well as on creating
the most positive experience for all Veterans.
VA's goal is always to provide Veterans with timely and high-
quality care with the utmost dignity, respect, and excellence. For the
Veteran who needs care today, VA's goal will always be to provide
timely access to clinically appropriate care in every case possible.
However, as we have shared with staff for the Senate and House
Committees' on Veterans Affairs, users of the Veterans Choice Program
have identified aspects of the law that are challenging. We are working
diligently to address these challenges and to turn them into
opportunities to improve VA care and services. My testimony addresses
the progress we have made thus far.
Eligibility for the Veterans Choice Program
President Obama signed the Veterans Choice Act into law on
August 7, 2014. Technical revisions to Veterans Choice Act were made on
September 26, 2014, when the President signed into law the Department
of Veterans Affairs Expiring Authorities Act of 2014, and on
December 16, 2014, when the President signed the Consolidated and
Further Continuing Appropriations Act, 2015. On November 5, 2014, VA
published an interim final rulemaking that implemented section 101 of
Veterans Choice Act.
The Veterans Choice Program, established by section 101 of Veterans
Choice Act, requires VA to expand the availability of hospital care and
medical services for eligible Veterans through agreements with eligible
non-VA entities and providers. Under section 101, some Veterans are
eligible for the Choice Program based on the distance from their place
of residence to the nearest VA medical facility. The Choice Act does
not state how distance should be calculated for purposes of determining
eligibility based on place of residence. The most common methodologies
for calculating the distance between two places are by using a
straight-line and by following the actual driving path between the two
points. In the initial interim final rulemaking, VA adopted a straight-
line measure of distance to determine eligibility based on residence,
consistent with certain statements in the legislative history.
During the public comment process for the rulemaking, VA received
many comments questioning the use of the straight-line distance instead
of driving distance. By contrast, VA received no comments in support of
the use of straight-line distance. After considering extensive
feedback, VA decided to amend the interim final rule to change the
method used to determine the distance between a Veteran's residence and
the nearest VA medical facility from a straight-line distance to
driving distance. The general intent of the Choice Act is to expand
access to health care for veterans, and the use of driving distance
allows more veterans to participate in the program and receive care
closer to home. Moreover, from the standpoint of a veteran, the most
relevant question is how far he or she must actually travel to receive
care, not the length of a straight-line route.
I am happy to report that on April 24, 2015, VA published a second
interim final rule adopting this change, effective immediately. VA
estimates that this change almost doubles the number of Veterans
eligible for the Veterans Choice Program based on place of residence.
We understand one frustration for Veterans is that according to the
Choice Act, the Veteran is eligible for hospital care and medical
services if the Veteran resides more than 40 miles from the medical
facility of the Department, including a Community-Based Outpatient
Clinic (CBOC), that is closest to the residence of the Veteran. This
criterion bases eligibility on the proximity of the nearest facility,
regardless of the availability of the needed care at that site. VA is a
regionalized system; so we recognize that every CBOC does not deliver
the services needed by every Veteran. We acknowledge this is
problematic and have carefully studied the issue and potential
solutions, recognizing the constraints of VA's authorities in the
program under current law and the significant budgetary impact that
would accompany the potential solutions, which could range from $4
billion to $34 billion per year.
We have presented our analysis of the issue to the Congressional
Budget Office and staff of the Senate and House Committees' on Veterans
Affairs, and we are continuing to work with Congress to find an
economically sound solution.
Revisions to the Beneficiary Travel Program
Based on Veterans' feedback, we are using the fastest route by time
calculation to determine eligibility for the Veterans Choice Program.
This is different from the method that had been previously used by the
Veterans Health Administration (VHA) Beneficiary Travel Program, which
determined mileage reimbursement based on the shortest route. This
route determination method may not have been a ``common'' route
traveled by our Veterans to their healthcare appointments. However, we
now believe the Beneficiary Travel Program standard should be altered
as well to reflect the fastest route by time calculation and ensure
consistency between both programs.
To reduce variation in mileage calculation between the two
programs, VA will now calculate mileage reimbursements under both
programs based on the fastest route by time. In most cases, the change
will provide equal or greater mileage reimbursements to Veterans.
Veterans Choice Program Outreach Efforts
We understand that the Choice Program is not working as well for
Veterans as it should, in part because Veterans, VA employees, and
community providers do not understand how the program works. We
continue our outreach efforts to increase Veterans' awareness of the
program. With VA now determining eligibility for the Veterans Choice
Program based on driving distance to the nearest VA medical facility,
to include CBOCs, more Veterans are now eligible for the Veterans
Choice Program. Beginning April 25, 2015, these newly eligible Veterans
were sent a letter informing them that based on their place of
residence, they are eligible to immediately participate in the Veterans
Choice Program. The letter also provides guidance to the Veterans on
how to verify their eligibility and access care.
When we initially launched the Veterans Choice Program, we mailed
explanatory letters to over eight million Veterans, with their Choice
Cards. This month, we are planning to send a mailer regarding the
Veterans Choice Program to the same group of Veterans. The mailer
assists Veterans in determining if they are eligible for the Veterans
Choice Program and provides guidance on how to confirm their
eligibility and schedule their next appointment.
We will continue to focus on outreach and communicating with
Veterans to ensure they understand the Choice Program, to include:
establishing a reoccurring Veterans survey to measure their knowledge
of the program; strengthening and expanding our social media strategy
for Veterans, families, and caregivers; and, conducting program-related
town halls at VAMCs.
Veteran Choice Program Employee Training and Education
We acknowledge that there are gaps in understanding the Veterans
Choice Program and related business processes among VHA staff. We
continue our outreach to VA facility leadership to improve employees'
understanding of the Choice Program and to address any reluctance our
staff may have to send patients into the community to use the Choice
Program. Our staff are more familiar and comfortable with assisting
Veterans with existing VA community care programs. We must ensure they
are adept with the Choice Program, as well.
It is important that our staff understand and use the program
properly. To date, VHA has conducted a variety of training including,
but not limited to, in-person training, webinars, virtual training,
teleconference, and other means. We, at VA, will continue to reiterate
the distance standard rule change. On April 24, 2015, Interim
Undersecretary Clancy sent a message about the Veterans Choice Program
to all employees and included a reference called the Five Questions
About the Veterans Choice Program, further explaining recent updates
and how to assist Veterans in accessing the program. In addition to the
Interim Under Secretary's message, the Network Directors and Medical
Center Directors will be sending their own messages to their employees,
and Service Line Chiefs will be meeting with their employees in person
to further discuss the program and to ensure that all employees
understand the program.
As I mentioned in testimony to the Senate Veterans' Affairs
Committee on March 24, 2015, we are sending teams of experts, including
staff from our Third Party Administrators (TPA), Health Net and
TriWest, as well as VA leadership, to 15 facilities in each of their
catchment areas. These facilities were selected based on the high
number of Veterans waiting for care and low utilization of the Veterans
Choice Program. The experts will hold discussion sessions regarding
needs of the medical centers, and the Third-Party Administrators (TPA)
network's capacity to provide care. During this time, we will review
data regarding needs and utilization, and identify gaps in TPA provider
networks. An action plan will follow each visit.
Educating Third Party Providers on Veterans Choice Program
As we work to solve Veterans' issues, we must also ensure non-VA
providers are informed about the program and how to best serve
Veterans. We use a variety of means to conduct outreach and to educate
and inform community healthcare providers about how to participate in
the Veterans Choice Program. Since the Choice Program started,
Secretary McDonald has met with national health care organizations,
such as the American Medical Association and the American Association
of Medical Colleges to discuss the Choice Program as well as other
aspects of VHA's transformation.
In November 2014, VA established the Choice Web site as a
clearinghouse for public information. Veterans and Veterans Service
Organizations are the primary audience for the Choice Web site, but
care providers also utilize the site's resources. VA expanded the
existing VA Community Care Provider Web site to include new information
on the Veterans Choice Program, as well as how to become a Veterans
Choice Program provider. Additionally, community provider training is a
contractual requirement of VA's TPAs, Health Net, and TriWest, which
have provider pages that they use to engage in targeted outreach to
non-VA healthcare providers and to deliver training and information as
they build their networks.
Recognizing that the Veterans Choice Program is connecting
community care providers with Veterans to a greater extent than ever
before, VHA is providing broad access to Veteran-relevant training and
information for providers who may not be familiar with military
culture. Recently, VA established VHA TRAIN (TrainingFinder Real-time
Affiliate-Integrated Network), an external learning management system
to provide valuable, Veteran-focused, accredited, continuing medical
education at no cost to community healthcare providers. Since the
launch of VHA TRAIN on April 1, 2015, more than 1,520 people have
created an account or subscribed to VHA content through a previously
established account. The first course offerings, four modules of
Military Culture: Core Competencies for Health Care Professionals, have
already seen over 347 registrations and 179 course completions. VA will
add dozens of Veteran-care training courses to VHA TRAIN throughout
2015.
Rationalizing All VA Community Care Programs
Beyond the Veterans Choice Program, VA has, for years, utilized
various authorities and programs in order to provide care to Veterans
more quickly and closer to home. In fact, the Department spent over
$7.012 billion on VA community care in Fiscal Year 2014 to help deliver
care to eligible Veterans where and when they want it. In Fiscal Year
2014, Veterans completed 55.04 million appointments inside VA, and 16.2
million appointments in the community.
We recognize though, that the number and different types of VA
community care programs and authorities may be confusing to Veterans,
our stakeholders, and our employees. Navigating these programs to
determine the best fit for a Veteran may be challenging. Therefore, we
are currently working to streamline channels of care, billing
practices, mechanisms for authorizations, etc., with the goal of
creating a more unified approach to community care.
Refining Business Processes
We are also focused on looking internally at the business rules and
internal processes that govern the Veterans Choice Program. It is our
hope that stepping back to revise our own practices and focus on long-
term work plans will create more efficient processes that will engender
better and timelier care experiences for Veterans as well as better
business relationships with our VA community care providers. Managing
the Veterans Choice Program effectively requires us to have broad
visibility of data. We are refining our data analytics to develop more
thorough management and oversight of the TPA performance. In order to
support the VA community care providers that treat our Veterans, we are
refining the oversight of payments for services provided. We are also
continually working with the TPAs to help them develop their healthcare
networks to support Veterans' healthcare needs.
Pilot programs in VISN's 8 and 17 are beginning to send clinical
documentation only when a Veteran contacts the TPA for an appointment.
The TPA then requests information from the VA site and VA provides that
information within 24 hours. There is very little wasted effort and the
TPA is assured of getting the proper information. With the current
practice, VA sends clinical documentation to the TPA on every Veteran
regardless of whether they intend to use the Veterans Choice Program.
This creates a tremendous burden on both the facility, who must compile
and send the material, and the TPA who must store all of this data.
Currently, the pilot is doing well, and we look forward to rolling this
process out across the Nation.
More broadly, VA sent to the Congress on May 1 an Administration
legislative proposal entitled the ``Department of Veterans Affairs
Purchased Health Care Streamlining and Modernization Act.'' This bill
would make critical improvements to the Department's authorities to use
provider agreements for the purchase of VA community medical care--in
order to streamline and speed the business process for purchasing care
for Veterans when necessary care cannot be purchased through existing
contracts or sharing agreements. We urge your consideration of this
bill, which will provide VA the right legal foundation on which to
reform its purchased care program. And, that is critical for Veterans'
access to health care.
choice act: funding
We are thankful for the Veterans Choice Act's funding to help us
overcome our access issue. As of April 30, 2015, of Section 801's $5
billion for enhancements to VA staffing and facilities, we have
obligated almost $304 million to increase access to care for Veterans
at our VA medical centers. The $304 million includes an estimated $143
million obligated for hiring medical staff. In addition, we have
obligated more than $145 million for infrastructure improvements. These
improvements include legionella mitigation, non-recurring maintenance,
minor construction and information technology improvements. Of Section
802's $10 billion dedicated to the Veterans Choice Program, VHA has
obligated more than $500 million for healthcare, Beneficiary Travel,
pharmacy, prosthetics, and implementation costs. As we implement the
improvements described above, we expect these obligations to grow.
vha staffing
VHA is in the process of hiring more than 10,000 medical
professionals and support staff, leveraging the funds provided by
Congress in the Choice Act. These healthcare professionals will augment
the current baseline of employees already providing care to Veterans--
with the goal of further improving timely access to care. As reported
in the Veterans Choice Act Section 801 Spending Plan provided to the
House and Senate Committees on Veterans' Affairs on December 3, 2014,
VHA expects to complete these hires by the end of Fiscal Year 2016. VHA
is making good progress, with roughly 25 percent of the more than
10,000 staff now on-board. Using the resources provided by the Veterans
Choice Act, VHA will continue to aggressively market, recruit, hire and
credential medical professionals and support staff to ensure we make
full use of this opportunity to deliver quality care to Veterans.
Additionally, the Department appreciates the changes to the
Education Debt Reduction Program authorized by Section 302 in the
Choice Act. This Program provides a valuable tool for the Department to
recruit and retain eligible, high-quality staff to VA.
sections 105 and 106: paying va community medical care providers
The Department understands the importance of complying with
requirements of the ``Prompt Payment Act'' and making timely payments
to VA community medical care providers. The organizational changes
implemented in Section 106 that consolidated payment of claims under
centralized authority serve as the basis for further improvements in
the prompt payments.
Section 106 of the Veterans Choice Act required the Department to
transfer authority to pay for healthcare and the associated budget to
the Chief Business Office no later than October 1, 2014. In seven
weeks, we re-aligned more than 2,000 positions and over $5 billion
dollars in healthcare funding to the Chief Business Office from the
VISNs and VA medical centers. This realignment established a single,
unified shared services organization responsible for payment functions
and implemented centralized management which will allow us to leverage
business process efficiencies going forward. We are in the process of
refining and implementing standard processes and performance targets,
and monitoring to ensure processing activities are performed and
measured consistently across VA. This will enable us to deliver
exceptional customer service to Veterans and VA community medical care
providers. In addition, Choice Program claims processing and payment
was centralized to ensure efficiency of processing and accuracy of
payments.
We acknowledge that claims processing timeliness must improve. To
date, our efforts include expediting hiring, maximizing the use of
contract staff, implementation of involuntary overtime, and
implementing tiger teams to maximize efficiencies with people,
processes, and technology. Our current standard is to have at least 80
percent of our inventory under 30 days old.
section 201: independent assessments
Section 201 of the Veterans Choice Act requires VA to enter into
one or more contracts with a private sector entity or entities to
conduct an independent assessment of the hospital care, medical
services, and other healthcare furnished by VA, specifically assessing
areas such as staffing, training, facilities, business processes, and
leadership. Our work on Section 201 Independent Assessments resulted in
completion of the first legislative milestone on November 5, 2014, by
awarding a contract to the Centers for Medicare and Medicaid Services'
Alliance to Modernize Healthcare (CAMH) to serve as Program Integrator
for the independent assessments. The program is now progressing toward
the second legislative milestone--completing the independent
assessments by July 3, 2015. CAMH, supported by the Institute of
Medicine and a diverse team of assessment subcontractors, are currently
in the Discovery and Analysis phase.
To date, the teams have interviewed hundreds of VA and VHA staff as
well as assessed over 80 medical facilities across 30 states,
Washington D.C., and Puerto Rico. The teams have completed a landmark
``Organizational Health Index'' Survey to capture the perspectives of
VHA employees nationwide, and VA has provided access to its data,
systems, and records by sharing over 1,000 data sets, reports, and
other critical documentation.
A Blue Ribbon Panel of 16 healthcare experts, with substantial
executive-level experience, has held two meetings and will continue to
do so to regularly advise CAMH on the independent assessment. This
panel, along with CAMH and their sub-contractors, will ensure that the
recommendations resulting from Section 201 meet the needs of Veterans
and establish a foundation for transforming VA into the preeminent
21st-century model for improving health and well-being.
new residency program positions
The Veterans Choice Act provided VA the opportunity to expand
physician residency positions by up to 1,500 positions over five years.
The law gives priority to the disciplines of primary care and mental
health and to sites new to Graduate Medical Education (GME), in health
professional shortage areas, or with high concentrations of Veterans.
VHA has conducted extensive outreach to the academic community to
ensure we generated interest in these new residency positions. The
first Request for Proposals (RFP), released in the fall of 2014,
resulted in 204 positions being awarded to VA sites and their academic
affiliates. These first residents will start July 1, 2015. The process
for distribution of the Veterans Choice Act positions continues, with
the second of five annual RFPs anticipated for release in late spring/
early summer 2015. VA plans to award between 200-325 positions each
year for the next four years.
As part of the Veterans Choice Act expansion, facilities new to GME
(or with extremely small residency programs) were offered funds for
infrastructure support. These funds will offset specific administrative
or clinical costs incurred in running a residency program and will
enable these smaller facilities to become more successful in hosting
residency programs. Last, in order to encourage small VA facilities to
engage in residency education, VA will issue planning grants to
incentivize the formation of new affiliation relationships.
conclusion
We are grateful for the close working relationship with Congress as
we make progress in implementing the Veterans Choice Program. Mr.
Chairman, we will continue to work with Veterans, Congress--especially
this Committee--VA community care providers, VSOs, and our own
employees to ensure the Choice Program is working well and delivering
great healthcare outcomes for Veterans.
I again thank the Committee for your support and assistance, and we
look forward to working with you in improving the lives of America's
Veterans.
Chairman Isakson. Mr. McIntyre.
STATEMENT OF DAVID J. McINTYRE, JR., PRESIDENT AND CHIEF
EXECUTIVE OFFICER, TRIWEST HEALTHCARE ALLIANCE
Mr. McIntyre. Mr. Chairman, Ranking Member Blumenthal, and
members of the distinguished Committee, I am grateful for the
opportunity to appear before you this afternoon on behalf of
our company's employees and its nonprofit owners to discuss
TriWest Healthcare Alliance's work which we are privileged to
do in support of the Department of Veterans Affairs.
I would like to focus my oral testimony on three topics:
the realities of this program's implementation, the process of
identifying and resolving gaps and those which remain to be
resolved, and what I believe to be the art of the possible path
going forward.
Mr. Chairman, before the Veterans Choice Program, there was
PC3, Patient-Centered Community Care. As you know and as
Secretary Gibson has said, purchasing care in the community
from community providers has been a long practice of the VA. In
fact, in September 2013, after 2 years of planning, VA sought
to change that with the awarding to the patient-centered
community care contracts to us and Health Net. That contract
was designed to have a consolidated, integrated delivery system
built in the community to undergird the VA facilities across
the 28 States and the Pacific that we are privileged to serve,
and make sure at the end of the day that we were not there to
replace the VA, that we were there to supplement it.
In fact, it worked as intended. When the furnace lit off in
our home town of Phoenix, AZ, 6,300 providers under contract
under PC3 leaned forward at the site of the VA medical center
to assist them in eliminating the backlog, and by August,
14,000 veterans had moved through that process.
Around the same time, we got a modification to add primary
care to those contracts, and within 90 days we stood up a
network of primary care providers. We now have over 100,000
providers across 28 States and the Pacific under contract,
along with 4,500 facilities, and we are not finished. The
reason why we are not finished is that we need to make sure
that the networks are tailored to match the demand that exists
in a particular market that is not able to be met by the VA
facilities itself.
The fact of the matter is that it was a complicated program
to set up. It was done under very short order. But it was
training, if you will, for what was to come next, because on
November 5, after 30 days of work, we were to stand up in
support of VA the Choice Program. We had to partner with VA to
receive a list of all eligible veterans. We had to design and
produce a card and put it out with a personalized letter from
the Secretary. We had to stand up a contact center to handle
all of the calls coming in. After 2 weeks of design and 2 weeks
of hiring and training of 850 people, no one went into 3-hour
waits; the phones were answered; but the work had only begun.
We have been on a pathway since to try and mature the
operations.
The Secretary talked about the 40-mile issue. There are
additional refinements that may well be needed and desired in
that area, and if so, we stand prepared to support what those
might look like. There are some other changes that may well be
needed to the program as we go forward.
Second, we need to aggressively identify and resolve our
gaps and fix our operational performance, and we are in the
process of doing that together. We are modernizing our IT
systems, rolling out after Memorial Day, after a 24/7 build, a
new portal system that will serve all of the facilities and our
own staff as we seek to move the veteran information back and
forth between the two facilities as care is rendered downtown.
We are in the process of tailoring networks to match the demand
that exists in each market across our area.
The Choice Program is up, it is operational, and there are
refinements still need. I believe that because of the
collaborative work that has been underway between all of us
that are engaged in this, we are refining the pieces that need
to be refined, we are identifying the policy gaps that need to
work, and those things, as the Secretary said, are getting
attended to.
I think there are a couple of policy issues, though, that
remain the jurisdiction of this particular Committee. One is I
would encourage a relook at the 60-day authorization limitation
that has been applied. Second, I would respectfully submit that
there needs to be harmonization between the two programs and
between all of the facets of how the VA buys its care
currently, as well as how the VA operates itself in engagement
with us in order to make this work right.
At the end of the day, I believe the art of the possible
which you sought is truly within our grasp. I would like to
point to Dallas, Texas, for a second, if you will permit me to
do so. We are under the engaged leadership of the VISN 17
Director. A couple of weeks ago, we sat with the VA medical
center Director and the entire staff there, including
behavioral health staff, and looked at the full demand that
exists for veterans in that market. We then took out and looked
at what is the network that is constructed to stand at its
side, which is the base on which Choice rides. In other words,
if there is not a network provider, you can set up an
engagement with an individual provider to deliver services
under Choice.
We then designed a network map that we are now in the
process of constructing together, and over the next 90 days,
from behavioral health to primary care to specialty care, we
will rack and stack the network to meet the demands that
otherwise cannot be met by the VA medical center in Dallas.
That is being repeated across our entire 28 State area and the
Pacific as we seek to do our part to mature the operations of
Choice.
It is a privilege to serve in support of those that served
this country. It is an honor to serve the veterans from the
States that are represented by half of the Members of this
Committee, and, Mr. Chairman, I look forward to taking
questions after my colleague Donna Hoffmeier is finished with
her remarks.
Thank you.
[The prepared statement of Mr. McIntyre follows:]
Prepared Statement of David J. McIntyre, Jr., President and CEO,
TriWest Healthcare Alliance
Good afternoon Mr. Chairman, Ranking Member Blumenthal, and members
of this distinguished Committee. I am grateful for the opportunity to
appear before you this afternoon on behalf of our company's non-profit
owners and employees to discuss TriWest Healthcare Alliance's work in
implementing the Veterans Choice Program (VCP). More importantly, I
look forward to discussing our ability to achieve our collective
potential in meeting the needs of those who deserve our very best * * *
our Nation's Veterans.
our background
TriWest is intentionally in business only to serve those who serve;
which has been the case for nearly 20 years. And during our entire
history, the company I was fortunate to help found with a group of non-
profit health plans and University Hospital Systems, and have been
privileged to lead since, has focused exclusively on providing access
to needed care when it is not able to be provided by the Federal
systems on which those in uniform rely. Our first 17 years were spent
helping the Department of Defense (DOD) stand-up and operate the
TRICARE program. And while we no longer support the DOD in that line of
work, I'm proud of the work that we did to assist DOD in making TRICARE
the most popular health plan in the country and meet the needs of
millions across 21 states who relied on us for that support. And, as
those of us who were around at the time can attest, we know it was
neither an easy nor painless road. Now, working together with VA, I
believe we can achieve the same results for the Veterans who look to VA
for their health care needs.
pc3 performance
Mr. Chairman, before VCP, there was PC3.
In September 2013, TriWest was awarded a contract to stand-up and
implement the brand new Patient Centered Community Care (PC3) program
across 28 states and the Pacific. Initial access to specialty care from
network providers began in January 2014, with the rest of the program
coming online over the months that followed.
PC3 was intended to be a nationwide program giving VA medical
centers (VAMC) an efficient and consistent way to provide access to
care for Veterans from a network of credentialed providers in the
community. We are pleased to be sharing this work in support of VA with
our long-time colleagues in the TRICARE work, Health Net. And, I want
to assure this Committee that we are working together very
collaboratively to leverage our collective knowledge so that VA
benefits from it as they and you seek to fashion strategies that will
optimize VA's direct delivery system and supplement that care with
access to care in the private sector when and where it is needed.
Important to the success of PC3 was that the cost to VA, quality,
and processes would be consistent all across the country. Community
providers, VA staff, and Veterans would know how the program works.
Congress and VA health care executives could more accurately budget for
non-VA care costs. The facilities could turn to consolidated networks,
tailored to their needs just like DOD did with TRICARE, versus
inconsistently buying on their own. And, claims payment challenges for
providers would be a thing of the past.
The promise of that vision is still there today.
However, the implementation of PC3 was not without challenges. And,
overcoming those challenges has been a huge focus for TriWest and our
VA partners during the first year of its operations.
For those of us at TriWest, a big challenge at the outset was the
absence of data showing the VAMC's needs and historical purchasing
patterns. As you might expect, it is very difficult to build a network
of providers when you don't know the volume, configuration or location
of demand. This led to some initial mismatches in our network and
significant unexpected cost as we had to recalibrate the network once
we received the needed information. Put simply, we had more of some
services than VA would ever need in some places. But, we also had less
of some services in other places than it turns out VA needs in order to
ensure that care is both in sufficient supply to meet the need and
reasonably close to where the Veterans reside. I want to compliment our
contracting officer, Mara Wild, for tirelessly staying on the pursuit
of this critical information over the course of nine months * * *
information that we are putting to good use in our efforts to optimally
calibrate the networks to meet the need.
Being able to effectively project volumes based on solid
information not only assists with making sure that networks are
tailored properly to support each VAMC and Community-Based Outpatient
Clinic (CBOC), and the Veterans who rely on them for care, it also
ensures that we have the staff necessary to administer the program and
meet the tight performance specifications. The PC3 contract is designed
to pay us only after care is ordered, appointments are made, the
medical documentation is returned to VA to be inserted in the Veteran's
consolidated medical record, and we have paid the provider. That means
staffing levels are all at risk to us. If we hire too many staff and VA
does not use the program, we lose money * * * effectively paying the
government for the privilege of doing the work. But, if we hire too
few, it can lead to delays in the receipt of care as we struggle to
meet demand. So obviously, getting this as close to right as possible
is very important.
There are few programs structured this way, as even TRICARE,
Medicare plans, and private insurance have premiums being paid in
advance to cover both the anticipated administrative costs and the
projected health care risk.
Yet another challenge has been voluntary utilization of the PC3
program by each VA medical facility. As noted above, my colleagues and
I at TriWest and our owners who call most of the communities in our
area of operation home, built a network of providers based in part on
estimates derived from historical fee basis care purchasing. However,
much to our surprise, we've painfully discovered that many facilities
have simply continued to use, almost exclusively, their historical non-
VA care program to buy care from community providers * * * even when we
had network providers. In fact, some of our network providers were the
same providers from whom they continued to buy directly. While some
VAMCs have largely abandoned this practice, we have had a very
difficult time understanding why this practice has been allowed to
continue such that only about 15% of total purchased care has been
bought through this mechanism and VCP, in spite of all the money and
man hours that have been spent in constructing these networks.
Beyond that, we see provider confusion as we attempt to convince
them to join a network when they are already seeing Veterans through
the legacy programs. Even worse, when a provider does join the TriWest
network but continues to receive referrals for services from both VA
and TriWest, they quickly notice that the requirements, rates, and
claims processes are often completely different. And yet, to the
provider, it is a Veteran being referred for care by VA.
Voluntary utilization of PC3 at the local level has also
exacerbated the challenges with staffing because even when utilization
data is available, we cannot assume such workload will come through the
contract. We have to consider how much volume each local medical
facility will move through the networks, and its related processes, as
we determine how much staff is needed to do the work. And, as you might
expect, those projections are extremely difficult to make with any
accuracy * * * even with the talented and experienced staff we have
attending to that task.
There is, however, hope. I would like to compliment my fellow panel
member, Dr. Jim Tuchschmidt, for the direction that he and the rest of
VA's leadership have given to the team at VA that this practice is to
come to a halt. Instead, their direction is that the networks that were
constructed to support them and programs, such as VCP, which extend
options further for Veterans, are to be used rather than resorting to
direct purchasing of care.
Mr. Chairman, fortunately, the first year of PC3 operations has
also had a lot of successes. In fact, I'd say that in spite of the
challenges I've just noted, we have made some amazing progress together
in a very short span of time.
The most important element of that progress is that more workload
is coming through this contract than when it started. In January 2014,
the first month of operations for PC3, TriWest received approximately
2,500 requests for care. This past April, we received over 21,000. As I
just noted, whether to use the contract is still seen as voluntary
throughout the system. So, when more care comes through the contract,
it is evidence that more VAMCs see the benefits of using consistent
processes, rates, and network to obtain needed, quality care for
Veterans. In the long run, when these programs are the vehicle for the
vast majority of care purchased outside of VA, the consistency will
benefit the entirety of the non-VA care program.
Concurrent with, and certainly not unrelated to the growth in
utilization, the partnership between VA and TriWest has matured
substantially over the past year. And that maturity has helped us to
focus on better matching the needs of local Veterans with the providers
in the network, and ensuring those providers are in the right
communities served by the VAMC. For example, while it is important to
know that the Topeka VAMC purchased 500 MRIs from community providers
in a given month, it is critical to know if they purchased 200 in
Manhattan, 100 in Hays, and 200 from Salina * * * as they are all
considered to be in the catchment area of the VAMC. However, as I am
sure Senator Moran can attest to, the Topeka Kansas VAMC has a big
catchment area in a huge state. Without that second layer of data,
TriWest would almost assuredly build network in the wrong places.
The work we are doing at each other's side, and the appreciation of
what is needed for us to execute with reasonable effectiveness for VA
in support of Veterans is allowing us to grow the provider network
smartly. One year ago, there were just over 50,000 network providers
serving VAMCs in Regions 3, 5, and 6. Today, we've crossed the
threshold of 100,000 providers in the network devoted to caring for
Veterans in need of services from providers in their community. More of
those providers are in more communities where the needs exist. And we
aren't done yet, which I will talk about in a few minutes.
It is also important to make sure when you ask a provider to render
care that they get paid on time and accurately for their work. Not only
is it proper, but that is the way to ensure they are likely to agree to
serve another Veteran when the need arises. As we all know, when you
have to spend time chasing the bill payer, it adds to expense and makes
the work less attractive. And, we want this work to be attractive * * *
just as it was with TRICARE when we worked to help the DOD reengineer
claims processing at the start of the program which put us on a path to
becoming the fastest and most accurate payer with which most of our
provider network dealt.
Any new program has challenges with aspects of implementation and
operation. And, unfortunately, at the outset of PC3, we were not paying
our claims as quickly as we would like. In fact, I think we were
averaging close to 90 days in June 2014. That simply isn't the case any
longer. Experience, focus, and refinements have successfully brought us
to a place where our average clean claim is now being paid in fewer
than 30 days. Providers who render quality care to our Veterans deserve
timely payment of their claims. And we are committed to honoring their
service at our side by doing just that.
On the way to improving the PC3 experience for Veterans, VA, and
providers, it turns out that we also were just getting warmed up in
preparation for the ultimate program implementation run which came in
October 2014 with the first indication that the new VCP would become a
modification to the PC3 contract. And, the intensity was about to pick
up several-fold.
implementing the veterans choice program
To be exact, we would ultimately have one month for the
implementation of this massive new program that would ``go live'' on
November 5, 2014.
I recall vividly that during one of the initial discussion sessions
VA had with potential industry partners in mid-September 2014, it was
said by some in the room that 12-18 months was the needed timeframe in
which to stand up a program of this magnitude. And while there
certainly were imperfections on Day 1, and we continue to refine
operational processes internally at TriWest and between VA and us, I'm
very proud of what we all accomplished in such a short timeframe. And I
would like to focus for a moment on what went right, before I share
with the Committee what remains a challenge and what I hope we all can
focus on for the future as we seek to achieve an effective and
efficient program for those we are all privileged to serve.
As this Committee is aware, the law mandated that all Veterans
enrolled for care with the VA Health Care system as of August 1, 2014
receive a Veterans Choice Card. At its core, this required printing
those cards and mailing them off to Veterans. But, in reality, it
involved so much more.
First, we had to partner with VA to receive a list of all Veterans
eligible to receive the card. We were informed early on that the list
would contain nearly nine million names. Of course, in order to ensure
that a list of that size can be used for its intended purpose,
formatting is crucial. Working together with VA and our colleagues at
Health Net, we agreed on a template of the fields that would be
provided to us. We then made that template available to the card
printer we selected once the design was available to us because they
had a week to get the first batch of cards printed, stuffed, and into
the mail.
At the same time, we worked with our colleagues at Health Net to
parse out all of that data and break it up so that each of us would
have the right list of Veterans for each area served. After completing
that project, we knew there were just under four million Veterans
eligible in the area of our responsibility.
Just knowing who was to receive a card was not enough. We also had
to load all of that data into our customer relations management (CRM)
system so that when those cards arrived in the mail and Veterans called
the number on the back, we knew who those Veterans were when we
answered the phone. And I'm proud to say that we had that system up and
operational in advance of ``go live'' day.
While we are on the topic of phones, at the same time all of the
data loading and print work were occurring, we were also standing up a
call center infrastructure big enough to serve the outreach from all of
those who would receive the cards as well as providers and others in
the general public who learned about the new benefit and had questions.
To accomplish this task, we worked directly with Verizon and our
call center partner to establish a cloud-based system that would
support a single, public-facing phone number (866-606-8198) where a
Veteran; a provider; or a VA staff member encountered a message from
the Secretary about the program and then was routed to the appropriate
agent representing us based on their zip code to receive supportive
services. Again, in fewer than 30 days, we designed and stood this up
and it was staffed with nearly 800 people by November 4, 2014 so that
we would be ready to serve Veterans in need.
I would submit that our most important accomplishment is what did
not happen. No computers crashed. No busy signals occurred. In fact,
there were no long waits for the phone to be answered by a live person.
In less than 30 days, working together with VA and other partners, we
stood-up a contact center that worked.
In those first 30 days, we also had to work with VA to develop a
means of learning who was eligible for VCP at any given time. As you
know, the law created two distinct types of eligible Veterans: those
waiting longer than 30 days to receive needed care; and those residing
more than 40 miles from the closest medical facility of the department.
TriWest would need to know which Veterans qualified under which
category of eligibility because the range of services available differs
greatly.
Those residing more than 40 miles from the closest VA medical
facility are eligible to receive through VCP any needed medical care
covered by VA. TriWest is delegated responsibility to make
determinations of medical necessity. As such, our only issues in
serving this population are whether the care is medically needed, and
whether there is a provider close-by who agrees to provide that
service. As many Members of this Committee know, if you live more than
40 miles from the closest VA medical facility, it is likely you live in
a rural or highly rural area. As such, it is often not only VA that is
far away, but it can be difficult to locate some types of specialty and
subspecialty providers due to their scarce supply.
For the 30-day waitlist population, the task proved much more
difficult because it was not only necessary to know that you were on
the eligibility list, but we needed to understand what service(s) the
Veteran needed. For this, we would need clinical information (known as
a ``clinical consult'') from the referring VA provider.
In an effort to expedite the provision of that clinical
information, given the very short time in which to stand this up, an
initial decision was made by VA leaders to send us all clinical
consults related to any Veteran on the Veterans Choice List (VCL). The
initial waitlist alone contained information on over 34,009 Veterans.
For each of those names, we would also receive via fax information
documenting their respective clinical need. Then, we had to match that
clinical information with the registry created by the card-mailing file
and the updates created by the eligibility file so that we could help
Veterans in need of service when they called. This process has proven
to cause the most challenges in operation of VCP.
Nevertheless, in the six months the program has been operational,
TriWest has processed over 40,000 authorizations for care. And we have
seen growth in the use of the program every month with the exception of
a slight drop between January and February of this year. In
November 2014, we processed approximately 2,600 authorizations (more
than the first month of operation under PC3). By April 2015, the number
was 10,600; growth of nearly 400%.
As I mentioned earlier, while we certainly had many successes about
which I am proud, I am by no means suggesting that all went right in
our implementation. And I think it is very important that we outline
what went wrong if for no other reason than because Veterans and their
representatives in Congress deserve to know and understand our
challenges. After all, at the end of the day, we are ever mindful that
we are all spending taxpayer money.
First, and foremost, we suffered from a lack of training time. We
had less than two weeks to hire and train hundreds of people just to
answer phone calls from Veterans and describe or explain a complex new
program. It is no understatement to say that most who worked to get VCP
up and operational worked 100 hour weeks during that 30-day period * *
* in order to understand what was envisioned by the law and then design
the approach and stand-up operations. Given the brief amount of time to
do all that was required, one of the greatest challenges was to gain a
solid base of understanding of this valuable new benefit, and get the
operation design set so that we could sufficiently explain both to
others. And, we were not alone in that challenge. Among those most
impacted, beyond the Veterans we were all aiming to serve, were the new
staff in the call centers, as they only had five to seven days in which
to grasp the information versus the typical two to three week period
one ought to provide. I am sure others, including VA, struggled with
the same.
Obviously, the lack of training led to less than optimal customer
experiences. Information provided to Veterans was at times inaccurate
or confusing. And some Veterans were left frustrated. I want to
apologize for that. But, in apologizing, I also want to assure this
Committee that we did everything in our power to train and educate this
new team in the very short period of time we were allotted. In the end,
it was simply not enough time. And, we are doing our best to stay on
top of making sure that our staff has the right knowledge base of the
program in order to provide solid customer service * * * even as this
program continues to be refined, creating a need for re-training.
The training of our staff was not the only challenge that impacted
the customer service experienced by Veterans who called the Choice
line. As noted above, there are many areas where cooperation and
collaboration between VA and TriWest needs to occur every day to ensure
solid performance of VCP. I think it is fair to say that as hard as it
was for TriWest to train hundreds of new staff, it is vastly more
complicated for VA's leadership to train thousands--maybe even tens of
thousands--of administrative and scheduling staff all across the United
States so that their engagement with Veterans would be informed. Not
only that, but this challenge left us in a place where our staff and
Veterans struggled with the impact of encounters with insufficiently
trained personnel on whom they had to rely for information in order to
achieve a positive customer experience.
Another challenge in early implementation of VCP was the timely
receipt of the eligibility file. As I mentioned earlier, VA worked with
us to create a template that would allow their team in the Eligibility
Office to push regular information to us about which Veterans were
eligible for VCP. But, the Eligibility Office also needed to obtain
that information every day from clinics all across the country. It was
always the goal to provide a new file every night so that when a
Veteran called us the next day, we knew of their eligibility. In
reality, even to this day, there is at least a five-day lag in between
when a Veteran is told there is a wait time in the clinic that provides
them eligibility for VCP and when that information can be used by
TriWest to serve the Veteran.
There are many reasons for this delay. But, none of them are
related to a lack of hard work. In fact, I would like to publicly
acknowledge the incredible work done by Laura Prietula and her team in
the Eligibility Office. She is a dedicated public servant who seeks to
deliver outstanding work every day and from our experience many nights
she is there too. And, there are many others like her in VA working
tirelessly in an attempt to get this benefit to where we all want it to
be. The hope is that some level of automation is coming to this program
and to this area in particular. But, it was not available on Day 1 and
that has led to some challenges and frustration.
Still another challenge has been the receipt of the clinical
consultation information from VA which, as noted earlier, is necessary
to schedule an appointment with a provider. For those eligible for VCP
by virtue of their inclusion on the 30-day waitlist, TriWest must have
a clinical consult for use when helping to make an appointment. The
information in the consult tells the provider in the community why the
Veteran is being referred to them for services. Providing this
information is standard practice and good clinical care. And for some
services, it is even required by Medicare, insurance policies or other
accrediting organizations. For example, no imaging center will provide
an MRI, CT, or other sophisticated imaging study without a physician
order. This order would be in the clinical consult.
Because this information comes from hundreds of different clinics
all across the VA system, receipt of that information in a consistent
fashion has been a challenge. Without it, however, we are left with no
alternative but to tell a Veteran who calls the Choice line that we are
waiting on clinical information from VA. Needless to say, when we tell
a Veteran we know they are eligible, and yet we still cannot help them,
the frustration is enormous.
As I noted above, the consult is supposed to come to TriWest
automatically for every Veteran who is placed on the VCL.
Unfortunately, we only know what we don't have when a Veteran calls for
an appointment and can't receive one. I also do not want to lay all of
the challenges in this area at VA's feet. The fact is, many times when
we call for consults that we do not believe we have, we are told by VA
staff that they were already sent. This no doubt frustrates VA staff
too.
The good news is that recently we implemented a pilot program in
VISN 17 in collaboration with the Dallas VAMC which is testing whether
a process of requesting on our end can be met with a response on VA's
end within 24 hours. Initial data suggests that it is working well. If
the evidence continues to show promise, it will mean that Veterans all
across the country can expect a consistent customer experience under
which we can all assure them that we will have the information
necessary to make an appointment within 24 hours of them calling us.
And no longer will VA be responsible for sending thousands of clinical
consults every day for Veterans who may not use VCP. I would submit
that this is a win-win.
This looming success in addressing one of our collective challenges
flows from the collaborative work in which we, Health Net and VA have
been engaged since the beginning of the year. Just a little over 60
days from the start of VCP, we began to sit down together to map the
gaps in process and customer service and blueprint how to resolve them.
The focus of this work is to identify the components of our individual
and collective work, or the policies and approaches that underlie them,
that are in need of re-engineering or refinement to ensure that
Veterans receive the access to care that was envisioned with the
enactment of VCP.
This work is highly collaborative and involves leadership at all
levels of the three organizations. In fact, just last week we all met
for a day-long summit on Clinical Issues where we identified problems,
discussed solutions and made the changes that will close gaps. This was
on the heels of our regular, monthly day-long summit during which we
focus on needed administrative process changes or refinements. Those
issues are brought to the table by a myriad of integrated topical
workgroups that meet in many cases several times a week.
It is intense and focused, just as should be * * * as we are trying
to quickly address the processes we all know need attention in order to
improve this critical program and meet the intended objective of VCP.
I would submit that this approach is yielding effective change and
refinement at great speed for a program of this magnitude that was
stood up very quickly and across a vast geographic expanse. And, I want
to offer that the focus and intensity on the part of those involved and
the collaboration present is unlike anything I have ever seen in my 30
years of engagement in this space.
For our part, not only are we engaged at a macro level, but we are
operating in this same fashion within our company * * * which is how we
have accomplished successful and quick refinement and improvement since
the early days of TRICARE nearly 20 years ago. We have also engaged our
long-time partner in such work, the world-renowned Customer Service
Institute at Arizona State University, to conduct customer service
gapping and blueprinting with the Phoenix VA and within our own
organization.
The very early indications are that this time-tested approach,
mirroring that of the most highly regarded customer service brands in
America, is beginning to yield results that matter.
The customer experience under VCP is getting better with each
passing day. Information provided by TriWest staff is more consistent
and more accurate; providers are more familiar with the program; and we
have recently begun an initiative that allows any provider in our
region to register online with us to be a VCP provider. Knowing who is
willing to treat a Veteran under VCP, even if they are not already a
TriWest network provider, will go a long way toward speeding up the
appointing process.
Additionally, we are updating our entire CRM system so that our
staff and all of the VA staff across our regions who interact with us
in the IT environment will have more information about each Veteran
right at their fingertips. Construction of these brand new tools was
conceived of through the collaborative process of which I just spoke.
We have condensed design and testing of these new systems to weeks and
are using a 24/7 build strategy in order to rollout the new tools just
after Memorial Day rather than waiting until next year, which would be
the case using normal construction schedules.
It has been my experience that many customer service failures are
due to the fact that line staff (those on the phone or on the ground)
simply do not have access to the information needed to help a customer.
When information is available, resolution of problems is possible. This
new effort and these new tools will lead us down that road.
That said, there are many improvements needed that will require
longer-term planning, collaboration, and perhaps even legislative
change to what you passed last Summer. And I would like to take a
moment to discuss a few of those and how, if they are pursued, VCP and
PC3 can help bring an entirely better experience to the Veteran in need
of health care services.
refining the veterans choice program for the future
One area I would respectfully suggest is in need of review is the
60-day authorization limitation in the VACAA statute. While we
understand there were reasons to include the time duration limitation,
I would respectfully suggest that it is leading to an increasing number
of circumstances where quality and continuity of care are not the
ultimate determining factors in the treatment of a Veteran. As a quick
example, under the strictures of the statute, a Veteran sent through
VCP for radiation oncology services because the local VA could not see
him or her within 30 days, could have that service ``recaptured'' by VA
after the first 60 days in the community if the local VA now has
capacity. I am not a clinician. But, my Chief Medical Officer tells me
that only under extreme circumstances should you change radiation
oncology services in the middle of treatment. Yet, we understand that
the statute leaves no alternative to continue that care through VCP.
The same circumstance would apply to maternity care. If the initial
appointment was more than 30 days out, a female Veteran could be sent
through VCP to a community OB/GYN. However, after 60 days, VA would
have to reassess their capacity and could recapture the care, requiring
the Veteran to change provider mid-pregnancy. Again, I know there were
reasons for the requirement. However, I would respectfully suggest a
revaluation to allow for some flexibility when it is in the best
interests of the patient.
Additionally, I would respectfully suggest that there is a need to
harmonize all of the disparate programs that now exist to provide non-
VA (or community) services to Veterans. I noted earlier that voluntary
use of the PC3 contract made it difficult to predict with any
reasonable accuracy how much network would be needed for certain
services and where that network was needed. It is also true that even
if I can accurately predict network needs, it is difficult to convince
providers to join a network when they already receive work directly
from VA at better rates with fewer requirements. It sounds odd to say,
but in some instances we're competing against VA to provide services to
VA. Harmonizing the programs in some manner would help alleviate this
challenge.
I also mentioned that without knowing, generally, the overall
volume of services VA will need from my company, it is difficult to
staff accurately for workload. But, again, it is difficult to predict
workload when local facilities simply have options every day on the
program through which they intend to purchase services.
I think the net result of both of these challenges that stem in
some manner from multiple different programs come through loud and
clear in the recent IG report which found a lack of savings under the
initial year of the PC3 program. The IG noted that there were instances
in which timely appointing wasn't available through TriWest or network
providers were not close by. While I do not know the exact cases the IG
reviewed, I know it is true that when workload exceeds our imperfect
projections we find ourselves with inadequate network and a lack of
staff. And that will lead to delays in appointing and difficulties
finding providers. As an aside, I might note in response to another
aspect of the IG report, that measuring first year savings of the PC3
program against implementation fees designed to cover five years of
operations is a little bit of apples-to-oranges comparison.
Nevertheless, I am pleased to say that I understand VA intends to
take some steps to create a hierarchy of options that local non-VA care
staff will be expected to follow. This will go a long way toward
providing everyone: VA staff, Veterans, community clinicians, and my
team with the information we all need to bring timely care to Veterans
using a consistent process with predictable rates.
This new effort on VA's part does lead me to one additional
observation on what is needed for the long-term health of these
programs. We must focus on a better collaborative planning process when
changes are needed.
I've noted at length the challenges we experienced in implementing
VCP; partly due to the short implementation schedule. Yet, just in the
last few weeks, we saw an implementation of VA's new determination on
eligibility under the 40-mile rule. I want to be clear and say that
this is a tremendous change for Veterans. It is absolutely true that
one of the most frequent complaints to our call center was the ``crow
flies'' determination. However, there were only three weeks between the
time it was determined that the rule would change and when VA sent out
letters to just over 128,000 Veterans in our three regions notifying
them of this change.
In just the first week following the letter, workload to our call
center for VCP more than doubled. And, we understand that there are
likely additional changes coming as well that VA is working on.
The challenge will be to synchronize them effectively so that we
have the best chance to make sure that sufficient staff are hired and
trained to meet the increased demand, or to agree among all effected
that the change needs to be made quicker and that it is acceptable for
capacity to catch up to demand.
Regardless, we are ``All In''!
One of the areas I know that is being worked diligently within VA
is how to ensure that the networks we are constructing and the
providers who want to serve at our side in support of Veterans are
being utilized. And, that is to be applauded.
the art of the possible
At the ground level, I am thrilled at the strong collaboration that
is emerging all across our geographic area of responsibility. It is
being supported by one of the superstars from our area, Joe Dalpiaz, as
he is taking his time to completely engage at the side of his
colleagues and me to fashion the ``art of the possible.''
We started with one of the largest facilities in the VA system,
which is under his engaged and watchful eye, and sat down with the
Director and non-VA care team to look at all of the demand they have
for community services and where the VA's needs are. Then, we produced
an assessment of whether the network we have built is sufficient to
meet VA's full demand. Where a bit more service is needed, we are
discussing the optimal strategy to bring it to a fully tailored state
so that Veterans in that community will have exactly what they need,
when they need it * * * whether it is from a VA medical facility or
with a community provider. Of course, a Veteran will also be free to
select a provider of their choice to the degree that one does not exist
within VA or the network.
This effort includes primary care and specialty care, to include
behavioral health. And, I am confident of the success that will come
from this completely engaged and collaborative effort, which will have
each leader within VA knowing what they have at their disposal inside
VA and in the community to meet the access needs of Veterans * * *.
My confidence in this process is bolstered by the fact that this is
exactly what we did together with DOD in TRICARE that led to phenomenal
success in our area of responsibility and it is what we have now
accomplished together with the VA leaders in Phoenix and Hawaii * * *
where networks are now completely tailored to demand. These early
successes were the result of the great collaborative effort involving
not only the local leaders and staff, but the tireless work of several
in VA: Sheila Cain, Greg Frias and Tommy Driskill.
We have prioritized the areas in which we will begin this work in
collaboration with the VA leaders that Joe and I have met with over the
last five weeks. This ensures that we can quickly move the needle once
VA communicates its intention to the provider community that VCP is the
pathway, and ensures its own staff on the ground is lined up behind the
objective of this being the purchasing tool for care when it is
unavailable in VA, or from a nearby DOD facility or academic affiliate.
For the purpose of illustration, I would like to highlight what
will come from this as it relates to one of the biggest needs at the
moment * * * timely and convenient access to behavioral health care.
To be sure, VA is the gold standard in understanding the behavioral
health needs of our Veterans. But, there are many instances in which we
may be able to help them free up space in VA for their most acute
patients by working with providers in the community.
Next, I am matching that demand (both behavioral health and all
other services) against the network we have in the catchment area of
the VAMC. And I am doing that in a fully transparent way right in front
of the VAMC Director. Where I have what he needs, he will know it. And
he will also know what I am missing.
Next, the VAMC Director will begin notifying local providers that
he will be sending all of his community care through PC3 and VCP and
there will no longer be (with few exceptions) local, direct contracts.
Then, my team will set out on an aggressive schedule to build the
network that can fill in the gaps identified by the ``map-and-gap''
analysis. Community providers will know that VA's future purchasing
will be through the consolidated network. We will provide regular
updates to the team at the VAMC. And as network growth occurs, so too
will workload, which means I can plan for the hiring and training of
staff on a timeline to deliver.
In the very long run, VAMCs can use this process to analyze ``make/
buy'' decisions. Obviously, there is a tremendous need for many
services at VA medical facilities. But, there are also many exigent
circumstances that VA must confront in every community. Internal VA
expansion may be desirable and justifiable. However, perhaps the
physical space does not exist; the facility may be landlocked; or, most
commonly, the community itself has a shortage of the type of providers
VA requires to meet the needs of Veterans, which makes direct hiring
difficult.
In those instances, it is my hope that they will find a robust
network to be an asset they can use in planning and delivering. Perhaps
the marginal use of time from a dozen community providers can better
meet the needs of the Veterans than hiring one internally because of
some challenges I've just mentioned. And, perhaps hiring directly is
the right thing to do. That decision should always rest with VA and
Congress.
To be clear, I am not suggesting in any way that PC3 or VCP should
replace the direct care provided by the VA health care system. But, I
do believe that greater knowledge of what is available locally from a
network of providers could help VA in the long run plan for and deliver
quality health care in a more timely fashion.
I believe that is what you envisioned in the passage of VCP * * *
and, I believe the successful fulfillment of that vision in support of
those who have borne a high cost in defense of freedom is very much the
``art of the possible.'' We look forward to doing our part as you
refine and modify policies and authorities to give us the final tools
that will be needed to accomplish the success that we all desire.
conclusion
Mr. Chairman and Members of the Committee, my colleagues and I at
TriWest truly believe that if we are transparent about the needs and
the shortcomings, collaborate together with VA to fill the gaps, and
then implement them as quickly as possible, we will earn the trust of
Veterans and collectively meet their needs. And believe me, I know we
must earn this trust.
Supporting the care needs of America's Veterans is a tremendous
honor and privilege for me, all of the employees of TriWest, our non-
profit owners, and most importantly the providers in our markets that
have leaned forward at our side to say we will serve a few of our
fellow citizens when they have needs that are unable to be met by VA
directly. We are humbled by the service and sacrifice of America's
Veterans and their example reminds us constantly of the high cost of
freedom. We take our responsibility very seriously and VA, Veterans,
and this Committee can be sure that our entire focus is on ensuring
that our work in support of VA and the Veterans who rely on them for
their care is fitting of the sacrifices of our heroes and is worthy of
their trust.
This concludes my formal testimony. I'd be happy to answer any
questions you might have.
Chairman Isakson. Thank you, Mr. McIntyre.
Ms. Hoffmeier.
STATEMENT OF DONNA HOFFMEIER, VICE PRESIDENT AND PROGRAM
OFFICER, VA SERVICES, HEALTH NET FEDERAL SERVICES
Ms. Hoffmeier. Chairman Isakson, Ranking Member Blumenthal,
and Members of the Committee, I appreciate the opportunity to
testify on Health Net's administration of the Veterans Choice
Program.
Health Net is proud to be one of the longest-serving health
care administrators of Government programs for the military and
veterans communities. We are dedicated to ensuring our Nation's
veterans have prompt access to needed health care services and
believe there is great potential for the Choice Program to help
VA deliver timely, coordinated, and convenient care to
veterans.
In September 2013, Health Net was awarded a contract for
three of the six PC3 regions. We implemented PC3 across our
regions on a 6-month implementation schedule, completing
implementation at the beginning of April 2014. Then in October,
after Congress passed and the President signed the Veterans
Access, Choice, and Accountability Act of 2014, VA amended our
PC3 contract to include several components of the Choice
Program. With less than a month to implement Choice, as Dave
just mentioned, we literally hit the decks running--I am a Navy
veteran, to use a Navy phrase--and we have not slowed down
since.
To meet the required start date of November 5, we worked
very closely with VA and with TriWest to develop an aggressive
implementation schedule and timelines. The ambitious schedule
required us to hire and train staff quickly and to reconfigure
our systems for the new program.
Despite this very aggressive implementation schedule, on
November 5, veterans started to receive their Choice cards, and
they were able to call in to the toll-free Choice number to
speak directly with a customer service representative about
their questions on the Choice program or to request an
appointment for services.
Having said that, there certainly have been challenges that
have resulted in veteran frustration as well as frustration on
the part of VA and, to be honest, even our own staff, including
call center and appointing staff. With such an aggressive
implementation schedule, there was little time to finalize
process flows and make system changes. We literally had less
than a week from the date we signed a contract modification
with VA to the actual go-live date.
While the cooperation with VA since the start of the Choice
Program has been good, there still is considerable work that
needs to be done to reach a state of stability where the
program is operating smoothly and the veteran experience is
consistent and gratifying. We appreciate the opportunity to
offer our thoughts on the future of the Choice Program. The
Choice Program is a new program that was implemented in record
time. As a result, there are a number of policy and process
decisions and issues that are either unresolved or
undocumented. If Choice is to succeed, these items might be
addressed quickly.
As I mentioned earlier, we have been working very closely
with VA to address these issues. Many of the items simply could
not have been anticipated before the start of the Choice
Program. Others, however, should have been addressed before the
program started, but the implementation timeline did not
provide adequate time to do so.
The identification of policy and operational issues and
concerns has been occurring very quickly. As a result, we have
struggled to keep up with developments and to adequately train
our staff with the most up-to-date and accurate information.
This situation is not ideal. Based on these dynamics, we have
one overall recommendation for moving Choice forward.
We recommend VA develop a comprehensive, coordinated
operational strategy for Choice that clearly defines the
program requirements, the process flows, and rules of
engagement. This strategy should provide a clear road map for
all of us to follow, one that is communicated to all the
stakeholders: VA leadership, VISN Medical Center leadership and
staff, both contractors, Congress, and, most importantly, the
veterans.
While the strategy needs to identify key initiatives and
reasonable timelines for implementing those initiatives, it
also needs to contain the flexibility to address issues as they
arise and make necessary course corrections. The strategy must
include resolution of outstanding policy and process issues;
development of policy and operational guides that are mandated
across the program; comprehensive training of both VA and
contractor staff using consistent process flows, operational
guides, and scripting; and a clear and responsive process for
resolving legitimate issues and challenges.
In closing, I would like to thank the Committee for its
leadership in ensuring our Nation's veterans have prompt access
to needed health care services. We believe there is great
potential for the Choice Program to help VA deliver
appropriate, coordinated, and convenient care to veterans. We
are committed to collaborating with VA to ensure the Choice
Program succeeds. Working together with the leadership of this
Committee, we are confident that Choice will deliver on our
obligation to this country's veterans.
Thank you. I look forward to your questions.
[The prepared statement of Ms. Hoffmeier follows:]
Prepared Statement of Donna Hoffmeier, Program Officer, VA Services,
Health Net Federal Services
Chairman Isakson, Ranking Member Blumenthal, and Members of the
Committee, I appreciate the opportunity to testify on Health Net's
implementation and administration to date of the Department of Veterans
Affairs' (VA) Patient-Centered Community Care (PC3) and Veterans Choice
programs.
a history of partnership
Health Net Federal Services is proud to be one of the largest and
longest serving health care administrators of government and military
health care programs for the Department of Defense (DOD) and Department
of Veterans Affairs (VA). Health Net's health plans and government
contracts subsidiaries provide health benefits to more than five
million eligible individuals across the country through group,
individual, Medicare, Medicaid, TRICARE, and VA programs.
For over 25 years, in partnership with DOD, Health Net has served
as a Managed Care Support Contractor in the TRICARE Program. Currently,
as the TRICARE North Region contractor, we provide health care and
administrative support services for three million active-duty family
members, military retirees and their dependents in 23 states. We also
deliver a broad range of customized behavioral health and wellness
services to military servicemembers and their families, including
Guardsmen and reservists. These services include the worldwide Military
and Family Life Counseling (MFLC) program providing non-medical, short-
term, problem solving counseling, rapid-response counseling to
deploying units, victim advocacy services, and reintegration
counseling.
As an established partner of VA, Health Net has collaborated in
supporting Veterans' physical and behavioral health care needs through
Community Based Outpatient Clinics (CBOCs) and the Rural Mental Health
Program. We also have supported VA by applying sound business practices
to achieve greater efficiency in claims auditing and recovery, and
previously through claims re-pricing. It is from this long-standing
commitment to supporting the military and Veterans community that we
offer our thoughts on the role of PC3 and Choice in augmenting VA's
ability to provide eligible Veterans with timely access to needed
health care services.
the evolution of pc3 and choice
The Department of Veterans Affairs developed Patient-Centered
Community Care (PC3) to provide eligible Veterans access to health care
through a comprehensive network of community-based, non-VA medical
professionals. Care is available through PC3 when local VA medical
centers cannot readily provide the needed care to Veterans due to
limited capacity, geographic inaccessibility or other limiting factors.
Services available through PC3 include primary care, inpatient
specialty care, outpatient specialty care, mental health care, limited
emergency care, limited newborn care for enrolled female Veterans
following delivery, skilled home health care, and home infusion
therapy.
In September 2013, Health Net was awarded a contract for three of
the six PC3 regions. These regions include 13 of 21 VISNs; 90 VA
medical centers in all or part of 37 states; Washington, DC; Puerto
Rico; and the Virgin Islands.
Figure 1: Health Net Federal Services' Contracted PC3 Regions 1, 2 and
4
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Region 1: VISNs 1, 2, 3, and 4
Region 2: VISNs 5, 6, 7, and 8
Region 4: VISNs 10, 11, 12, 19, and 23
Health Net phased in implementation of PC3 across our regions
during a six month implementation period, with services starting for
the first VA medical centers on January 6, 2014. We completed
implementation of all remaining VA medical centers by April 1, 2014.
Originally covering only specialty care, the PC3 program was expanded
to include primary care in August 2014.
In August 2014, with the leadership of this Committee, Congress
passed and the President signed into law the Veterans Access, Choice,
and Accountability Act of 2014 (VACAA, Public Law 113-146, ``Choice
Act''), which directed the establishment of a new program to better
meet the health care needs of Veterans. The law directs the
establishment of a Veterans Choice Card benefit that allows eligible
Veterans who are unable to get a VA appointment within 30 days of their
preferred date or the date medically determined by their physician;
reside more than 40 miles from the closest VA healthcare facility
(there are different mileage rules for some states, such as New
Hampshire and Hawaii); or face other specific geographic burdens in
traveling to a VA facility to obtain approved care in their community
instead.
In October, VA amended our PC3 contract to include several
components in support of the Choice Act such as production and
distribution of Choice Cards; establishment of a Choice call center to
answer Veteran's questions about the Choice program and to verify
eligibility for it; appointing services for eligible Veterans with
Choice-eligible community providers; and claims processing. Since VACAA
required implementation by November 5, 2014, we worked collaboratively
with VA and TriWest (the contractor for the other three PC3 regions) to
develop an implementation strategy with extremely aggressive timelines.
This ambitious schedule allowed for minimal time to hire and train
staff and to reconfigure our systems for the new program, which
contains many requirements that differ from PC3 and therefore have to
be tracked and recorded separately. Despite the fast-paced
implementation schedule, on November 5th, Veterans started to receive
their Choice Cards and were able to call in to the toll-free Choice
telephone number and speak directly with a customer service
representative about the Choice program.
engaging collaboratively
From the start of discussions on implementation of VACAA, the VA
Chief Business Office, Contracting Office, and senior VHA officials
have worked closely with both contractors to establish priorities,
provide policy guidance and develop process flows. As Choice
implementation progressed, more policy and process items were
identified. We collectively agreed to establish a Steering Committee
and several Work Groups to address these items and to provide an
effective forum for VA to provide clear policy decisions and program
requirements.
This approach has been valuable in identifying policy and process
gaps, facilitating decisionmaking designed to resolve any issues, and
ensuring consistency across all regions. We have committed to making
the appearance of the programs seamless for Veterans across the
country, regardless of where they reside or which contractor provides
service.
A key component to the success of both PC3 and Choice is acceptance
by community providers. To accomplish our goal of providing Veterans
with timely access to care in the communities in which they reside,
Health Net proactively recruits providers to both PC3 and Choice. This
is another area of collaboration with VA. In addition to public-facing,
self-service information found on the Health Net Web site, we have
attended community conferences to educate and engage providers.
A specific example of collaboration between VA and the Choice
contractors to educate and engage providers is the effort to integrate
federally Qualified Health Centers (FQHCs).We are working very closely
with VHA's Office of Rural Health on this effort, and participated with
VA at the National Rural Health Association annual conference and
National Association of Community Health Centers webinar. In addition,
we have been very successful in working with the Virginia Primary Care
Association to contract 26 FQHCs as VA Choice providers; our approach
to outreach in Virginia has become a model we will pursue in other
states. This collaborative effort has been invaluable in engaging the
FQHCs--to date, we have recruited a total of 115 FQHCs to participate
in Choice (27 FQHCs) or join our PC3 network (88 FQHCs).
results to date
Under PC3, from program inception in January 2014 through April 13,
2015, VA has provided Health Net with over 150,000 authorizations for
care in 75 specialty areas and primary care. The top six areas of
specialty care, comprising about 50 percent of authorizations include:
optometry, physical therapy, podiatry, primary care, orthopedics, and
colonoscopy. To meet demand, Health Net's network presently includes
almost 76,600 providers. Since the beginning of April 2015, Health Net
has successfully recruited over 4,200 additional providers, including
27 hospitals.
Since the inception of the Choice program in November through the
beginning of May, 2015, we have answered about 550,000 calls, with the
vast majority of those calls coming from Veterans seeking information
on Choice or requesting an authorization for care. About 30,000
Veterans have opted-in to the Choice Program with almost two-thirds
eligible based on wait time. About 16,500 authorizations have been made
for wait list eligible Veterans and nearly 10,000 authorizations have
been issued for mileage-eligible Veterans. With the recent change in
eligibility criteria based on driving distance, we expect a significant
increase in demand for care for mileage eligible Veterans.
moving forward
Implementation of any new program is challenging, particularly when
the change is significant and the implementation period is condensed
into a very short timeframe. Working collaboratively with VA and our
colleagues at TriWest, we were able to effectively stand up the Choice
Program by November 5th, as required by the statute. In achieving this
milestone, Choice cards were mailed out to all Veterans identified as
eligible by VA, calls to the Choice 866 number were answered promptly,
and Veterans have been able to exercise the option of obtaining care
within their local community when the VA capacity is limited or the VA
facility is far from the Veteran's home. Having said that, we know
there have been bumps in the road with the accelerated rollout of
Choice--delays in eligibility information being available, confusion
over program details, and incorrect or sometimes conflicting
information provided to Veterans. These bumps have understandably
caused a level of Veteran frustration.
While the collaboration with VA since the start of the Choice
program has been solid, there still is considerable work that needs to
be done to resolve outstanding policy and process questions, adequately
ensure appropriate staff training, conduct provider outreach, and
enhance Veteran education. To that end, we would like to offer a few
key recommendations for enhancing Choice we believe will facilitate
achieving a state where the program effectively optimizes VA capacity
and enables VA to provide all eligible Veterans with access to the care
they need in a consistent and gratifying manner.
1. Consolidate non-VA programs
Currently, there are multiple options for non-VA care, including
Choice, PC3, local agreements/direct contracts and individual
authorizations (``Fee''). Each option has different reimbursement
levels, different requirements for community providers (requirements
for return of medical documentation, credentialing, etc.), and
different ``administrators'' (VA Medical Center non-VA care staff, VA
contracting staff, PC3/Choice contractors). These various options
create enormous confusion with non-VA (community) providers, Veterans,
VA Medical Center staff and contractor staff. Reducing the number of
non-VA care options would help to reduce confusion.
We understand VA is about to address this issue. We commend VA for
its efforts to resolve the challenges created by these multiple options
for delivering care to Veterans when VA lacks the capability or
capacity to provide it directly. VA has informed us of a number of key
initiatives being planned to streamline non-VA care and to ensure
Veterans have access to Choice. We fully support these efforts.
To ensure success as we move forward in support of Choice, we
recommend VA develop a coordinated implementation strategy that clearly
defines each initiative and lays out an execution schedule that is both
aggressive and achievable. Currently, we receive around 10 percent of
the non-VA care volume through PC3 and Choice. Moving from 10 percent
to 100 percent requires a well-defined road map that is communicated to
all key stakeholders--VISN and VA Medical Center leadership and staff,
both contractors, Congress and most importantly, Veterans. As this
effort moves forward, it is critical that certain steps be taken:
Outstanding policy and process issues must be
resolved
Comprehensive training of VA and contractor staff
must be conducted using consistent process flows and scripting
Policy and operational documents and/or manuals
should be developed and provided for use by VA facilities and
both contractors
2. Eliminate unnecessary impediments to community provider
participation
Consolidating options into one approach that also minimizes VA-
unique requirements for community providers would have a very positive
impact on the willingness of community providers to participate in
Choice. Specific community provider challenges and impediments to
participation include:
Medical documentation requirements that are not
consistent with commercial/community standards. VA requirements
for medical documentation are often more detailed than accepted
standard of practice in commercial health care. For example,
PC3 and Choice require specific elements, short timelines, and
provider signatures. VA asks for more documentation and more
specific detail, such as provider social security numbers, than
is typically provided in private sector health care. In
addition, many of these requirements are not present in other
non-VA care options.
Delays in payment of medical claims due to return of
medical documentation. Providers are not paid until medical
documentation is returned and accepted by VA. This delays
payments to providers who have already legitimately provided
the services and complied with the requirements to return
medical documentation. Continued delays in payment will result
in dwindling community provider participation and access
problems could return.
High level of appointment no-shows in the community.
Currently, we are required to schedule appointments for
Veterans we are unable to reach by phone, and then notify these
Veterans of their appointment by mail. This process increases
Veteran no-show rates and causes frustration with community
providers. Community providers have no ability to bill VA for
these no-shows, nor can providers bill the Veteran a fee. This
process also creates frustration for VA Medical Center staff
because Veterans show up for VA appointments that may have been
canceled due to their scheduled community appointment. More
importantly, it means Veterans may not receive needed care in a
timely manner. We think a modification to this process would
reduce community provider reluctance to participate.
Confusion on where to send documentation and claims.
This issue is largely related to multiple non-VA care options
and would be substantially aided by a more coherent (and
smaller) set of options in non-VA care programs.
Lack of timely follow-up for authorizations on
needed additional services requested by provider for
appropriate clinical care. PC3 and Choice services are
authorized for ``episodes of care.'' Once an episode of care is
complete, additional authorizations are necessary, even for
follow-on care that is normally considered standard of
practice. This issue currently is being addressed by VA and
much progress has been made already to ensure timely approval
of requests for additional services. We appreciate VA working
collaboratively with us to address this challenge.
Primary care in 60 day increments for 30 day wait
list eligible Veterans is difficult for primary care providers
outside of urgent care settings.
The 60-day limit on an episode of care under the
Choice program creates challenges in certain clinical areas,
such as chemotherapy, radiation oncology, and complicated
obstetrics. With these types of care, it could be harmful to
bring the patient back to VA part way through a course of
treatment because the VA has availability at the 60 day point
and the patient is no longer wait list eligible. There is
similar risk if the patient changes address during a course of
treatment but is still close enough to receive care from the
Choice provider but is no longer eligible by distance criteria.
Some flexibility to support continuity of care when it is
important to veteran outcome would be very helpful.
committed to veterans' choice
In closing, I would like to thank the Committee for its leadership
in ensuring our Nation's Veterans have prompt access to needed health
care services. We believe there is great potential for the Choice
program to help VA deliver appropriate, coordinated, and convenient
care to Veterans. We are committed to continuing our collaboration with
VA and TriWest to ensure Choice succeeds in providing Veterans with
timely access to care when VA is unable to provide it. Working
together, and with the support and leadership of this Committee, we are
confident that the Choice Program will deliver on our obligation to
this country's Veterans.
Chairman Isakson. Well, thank you all very much. I had all
these preplanned questions, but after listening to your
testimony, I have canceled all of them. I am going to ask the
ones you have raised in your testimony, starting with you, Mr.
McIntyre.
It was quick, so I want to make sure I got it. You were
encouraging us to look at the 60-day authorization of what?
Mr. McIntyre. I would look at the limitation on 60 days for
authorized care under Choice. It puts people who have cancer in
a position where we need to move them back and forth between
the VA medical center. It takes a person who might be with us
under Choice because of a pregnancy and does the same. I do not
think that was intended. I think it was intentional that there
were parameters drafted around it, but the notion that certain
types of care would have to move back and forth between the VA
medical center and downtown is neither efficient nor effective
in the delivery of care.
Chairman Isakson. All right. I do not want to spend too
much time on this, but this is very important, I think, from
listening to your testimony and watching everybody's heads bob.
You want to expand the 60-day authorization to a longer period
of time?
Mr. McIntyre. I think I would leave it to the clinicians in
the Department of----
Chairman Isakson. No, you are not getting off with that.
Mr. McIntyre. OK. I will not get off with that. [Laughter.]
I got it, sir. What I would do is to evaluate which types
of care need authorizations that would last more than 60 days.
And----
Chairman Isakson. So, what you are saying is the 60-day
limitation causes things like some cancer treatments, a
pregnancy, for example, and things like that, for the patient
to have to go back and forth between private and VA health care
because of the 60-day limitation?
Mr. McIntyre. The administrative process requires us to go
back and forth in support of that veteran when it is probably
unnecessary, is what I would submit.
Chairman Isakson. That is like Medicare's two-night rule in
the hospital.
Mr. McIntyre. Yes, sir.
Chairman Isakson. It is one of those unintended
consequences.
Mr. McIntyre. Yes, sir.
Chairman Isakson. Is there any reason we cannot fix that?
Mr. Gibson. We are going to work on it, and we will come
back to you with a proposal. We think----
Chairman Isakson. It seems to me it would be more cost-
effective to the VA to do it, to fix it, rather than go back
and forth, because there has got to be money involved every
time you are doing that. Is that right?
Mr. Gibson. Yes, sir. There is a fee that is paid for each
authorization, but the bigger concern is the potential
disruption to the veteran.
Chairman Isakson. Efficiency is always less expensive, and
that is more efficient, it seems like to me.
Mr. McIntyre. Yes.
Chairman Isakson. I appreciate your raising that in your
testimony.
Mr. McIntyre. You are welcome, sir.
Chairman Isakson. Ms. Hoffmeier, do you have any credit
cards? [Laughter.]
I do not want them. I just want to know if you have got----
Senator Blumenthal. You have the right to remain silent.
[Laughter.]
Ms. Hoffmeier. I am trying to think, which ones do I
acknowledge? Yes, sir, I do.
Chairman Isakson. OK. Let me ask: do you ever get the
annual mailing of the required Government notification of
security? It is about four pages long, and the print is so
small you cannot read it, and you do not read it anyway.
Ms. Hoffmeier. I think that goes right in the recycle bin,
Mr. Chairman.
Chairman Isakson. OK. In your testimony I heard from you a
clear statement that we needed to simplify and coordinate the
instructions, the rules, and the processes under which Veteran
Choice works. Is that right?
Ms. Hoffmeier. It is, Mr. Chairman.
Chairman Isakson. I--go ahead.
Ms. Hoffmeier. As I said in both my written statement and
opening remarks, everything has been moving very, very quickly,
and as a result, there are a number of things that maybe have
not been addressed as completely, as ideally, as we would all
like to see, which makes it really difficult. I mean, it is
hard for us--you know, we talk about this at our level--to keep
up with everything. You are talking about call center
representatives and appointing clerks that are trying to keep
up with all of the developments. Somehow we have to find a way
to make it easy, not for us to understand, but for the people
that are working closely with veterans to make this program
work. They need to understand it.
Chairman Isakson. That goes a little bit further than just
to you all. I think the veteran needs to have it simpler to
understand, too. All the stuff that I did as a businessman, we
served people with college degrees and master's degrees, but we
wrote everything to an eighth-grade level, which is what the
newspapers do as well, because that is the way you can
communicate to the majority of the American people. Some of
these things--I have not read any medical instructions, but
some of these things I read on drug notices when I get my
drugs, you know, my regular drugs, the real ones----
[Laughter.]
Chairman Isakson [continuing]. Prescriptions. You read all
these things you are not supposed to do or you are supposed to
watch out for. It is so long and so cumbersome I cannot
understand it, so I do not do the right thing sometimes. I
think that could be our veterans as well on the instructions
they are getting.
Deputy Gibson, I would hope what all of you would do is
work together to find some ways to simplify the communication
mechanism to the beneficiary, which is the veteran, and the
provider, which is the local provider, in Veterans Choice. I
know it is complicated and I am not trying to oversimplify, but
sometimes out of fear of--or out of a desire to make sure we
have covered everything, we cover so much that we do not
accomplish the goals. I appreciate both of you raising that in
testimony.
My last question is going to be of Mr. Gibson until we come
back for a second round, if we do. You kept talking about you
wanted us to give you more flexibility.
Mr. Gibson. Yes, sir.
Chairman Isakson. Put some meat on that bone. Flexibility
on what?
Mr. Gibson. Well, I would say at the very top of the list
is flexibility around the determination of hardship for
veterans to be able to have access to Choice care. The way the
law is written today, it is restricted to geographic barriers,
I think is the language that is in the bill. We want to open
that aperture, which would give us much more flexibility to be
able to extend care under Choice to veterans.
Chairman Isakson. Open that aperture, to be a type of
illness?
Mr. Gibson. It could be a type of illness; it could be
distance. There could be an instance where a veteran lives
within 40 miles of a VA facility that does not deliver the
case, and we want to be able to refer the care into the
community while we are working on the intermediate term----
Chairman Isakson. In other words--my time is up, so I am
going to interrupt you, and I apologize.
Mr. Gibson. Yes, sir.
Chairman Isakson. In other words, you want the ability to
exercise judgment----
Mr. Gibson. Yes, sir.
Chairman Isakson [continuing]. In what you do in terms of
hardships.
Mr. Gibson. Yes, sir.
Chairman Isakson. You want the chance to exercise judgment
in terms of the 60-day authorization. Is that right?
Mr. Gibson. Yes, sir.
Chairman Isakson. OK. There ought to be ways that we can
accomplish both of those things.
Mr. Gibson. Yes, sir.
Chairman Isakson. I think in raising those things, Dr.
Tuchschmidt is really excited about that answer, or either he
needs to leave, one or the other. I do not know. [Laughter.]
Chairman Isakson. Whatever the case is, you can help us
write that? Because you think those are both determinations we
ought to be able to do. Your flexibility on the 60-day
authorization sounds to me more cost-effective and less
expensive. Yours probably raises some cost questions like are
raised anytime you do things like that. In the end, again, we
have got to remember the person we want to serve is the
veteran.
Dr. Tuchschmidt. Yes.
Mr. Gibson. Yes.
Chairman Isakson. Denying them service because of a
misapplied hardship is not the right thing to do.
Mr. Gibson. Yes.
Chairman Isakson. Ranking Member Blumenthal.
Senator Blumenthal. Thanks, Mr. Chairman.
Just at the outset, let me say that you will be asked
shortly by Senator Sanders, I believe, about the letter that he
has written to Secretary McDonald urging that he use his
authority as Secretary of Veterans Affairs to break patents on
hepatitis C medications for the treatment of veterans suffering
from that disease. I would strongly urge that you consider
using your authority under 28 U.S. Code Section 1498 to take
that action that will make this medication more widely
available to veterans who need and deserve it, especially since
the VA was involved through one of its employees in the
research that undertook this initiative and successfully
reached the result.
I want to focus for the moment on the VA's proposal to fund
construction costs at the Denver facility, specifically the $1
billion cost overruns out of the Choice Program's provisions
for long-deferred maintenance and facility capacity issues in
the VA system. These funds were very specifically designated
and intended by Congress to improve veterans' health care.
Veterans in my State who are aware of this proposal are
absolutely outraged that their health care, specifically the
primary care upgrade at the West Haven facility, would be
indefinitely deferred because of $1 billion cost overruns in
Aurora, CO. I suspect the same reaction will be felt equally
deeply by veterans at the more than 220 other facilities whose
health care will be compromised as a result of the proposed
redesignation of these funds.
I would like assurance from you, Secretary Gibson, since we
are talking here about Choice Program funds and we are talking
about not just a few dollars here or there but actually one-
fifth of all the funds in that $1 billion pot, that you are
considering alternatives to that action.
Mr. Gibson. Senator, we have sent a letter earlier today to
this Committee, to the House Committee, and to the
Appropriations Committee requesting the increase in the
authorization to be able to complete that facility as well as
requesting the use of $730 million of those $5 billion to be
used to complete the Denver facility. We have identify $100
million----
Senator Blumenthal. Well, I just want to interrupt you
because--and I apologize--for me that alternative is a
nonstarter. It is just unacceptable, and I have expressed that
view to appropriate administration officials. I realize that
you are dealing the hand you were dealt. I am simply urging you
to consider alternatives. There are alternatives, in my view,
responsible and available alternatives that do not involve
deferring health care improvements through construction and
maintenance at those facilities across the country, whether in
Connecticut or Georgia or Montana or Louisiana or Vermont, and
all the other States represented on this Committee, as well as
many who are not.
Mr. Gibson. Senator, in years past I would tell you it is
very likely that if VA had gone looking for that kind of money,
there is a pretty good chance that we could have found it. But
because of the work that we have been doing over the past year
to accelerate access to care, to make hepatitis C care
available to veterans, under the circumstances, we do not have
$700 million sitting on the sideline. There are no easy answers
here.
Senator Blumenthal. I am not asking you to find $1 billion
sitting on the sideline. But this Nation is capable of doing
better for its veterans, and a supplemental appropriation, for
example, might be an alternative. I am asking you to go back to
the drawing board and use different pencils, not necessarily
sharpened pencils but different alternatives to compensate for
the absolutely unacceptable cost overruns and delays in Aurora.
The project should be completed, but not at the sacrifice of
health care for other veterans around the country. What I say
to you today is not personal to you or to Secretary McDonald,
and we have talked at great length about this issue. We have
visited that facility together along with the Chairman. I have
seen that vast hulking shell of a campus that is a mockery of
Government contracting.
We need to address this situation to complete the project,
but it cannot be done in effect at the sacrifice of other
veterans.
My time has expired. I apologize for interrupting you, and
I thank the witnesses for being here today.
Chairman Isakson. I would not ordinarily do this, but in
light of the question that was raised and for the benefit of
everybody at the Committee just to know--and I do not want this
to limit anything anybody says, but I think we all have an
obligation to ourselves to make out-of-the-box suggestions on
what we do about the cost overruns at Denver, particularly
those of us that have been there and seen it. I have taken a
couple of actions which I will share with the Committee leading
up to a meeting we are going to have tomorrow where I have got
the Democrats and the Republican leaders coming together to
say, ``OK, what are we going to do with this?'' Which I hope
the VA people are back in their offices saying, ``What are we
going to do with this, too?'' not just saying there is nothing
we can do.
I have ordered GAO to do a study of surplus property and
that which would be liquidatable to try and find a way to raise
money to go to Veterans Choice to offset what might be borrowed
from it, which you are dealing with a situation where you have
got until about May 20, is about as much time as we have got
right now. We need to get at least to July 15, and we have a
way to do that. It is going to take an action of this
Committee, but getting us to July 15 only gets us time to
determine how close to $700 million it is we need, first of
all, with the Corps and the Veterans Administration working
together to do that.
In that time period, we are going to have to have some
interim bridges, which I am working on to present to the
Committee tomorrow. But if everybody on the Committee would
think outside the box, if it was your problem, if you were in
Secretary McDonald's place or Deputy Gibson's place and you had
inherited a $700 million shortfall and ran an agency that is
the second biggest in the Government, where would you go
looking?
I want Sloan to revisit the two places I mentioned to him
in Denver, because it seems like to me if we are going to take
you out of the construction business, which we are--and that is
going to happen, at least to a certain major extent--there are
going to be savings in that appropriation unit within your
department, and also look at the 77 FTEs you are asking for an
increase in the current budget, maybe those FTEs are not as
necessary as helping to build that hospital in Denver. I think
if everybody is making a contribution like that--it is like
that movie, ``Dave,'' when the guy became President, he was a
fill-in for somebody. He called the Cabinet in, they got a
yellow pad out, and they started working on solutions. We need
to get the yellow pad out and start working on solutions and
find a way to do it, because not building the hospital is
unacceptable, and just saying we are going to borrow funds from
the veterans health care benefit, I agree with Mr. Blumenthal,
is not the right way to do it.
I apologize for interjecting that, but I wanted everybody
to----
Senator Blumenthal. I want to thank the Chairman because he
and I have worked together. I am not speaking for the Chairman,
obviously, but I have some alternative suggestions as well. I
have no pride of authorship--I do not think any of us does--in
meeting the needs of completing that facility, but doing it
without sacrificing these other projects. So, I will have some
specific ideas and proposals tomorrow, as well.
Chairman Isakson. My apologies to all the Members of the
Committee for taking a little time, and I will turn now to
Senator Moran.
HON. JERRY MORAN, U.S. SENATOR FROM KANSAS
Senator Moran. Mr. Chairman, thank you, and Senator
Blumenthal, for your comments and for conducting this hearing.
Mr. Secretary and others, welcome to the Committee.
I hope to ask a series of questions, but the time on the
clock will run quickly. I want to start with a story that I
have told before about a Vietnam veteran named Larry. Larry
McIntyre lived in Florida and indicates that he is a Vietnam
veteran, a swift boat Navy veteran. He indicates while he was
in Florida he received excellent care from the VA; moved to
rural Kansas, became my constituent; lives about 25 miles from
a CBOC and about 3 hours from a hospital. I started this story
or this story began in July 2014 when Larry, this Vietnam
veteran, needed a cortisone shot. The VA's instructions were,
``Come to Wichita,'' so a 3-hour drive each way to get a
cortisone shot.
We raised this topic with Secretary McDonald at a hearing
here on September 9. Larry had contacted us and said, ``I do
not care how it comes, the Choice Act or any other way that the
VA can provide this service.'' We raised this topic with the
Secretary in September of last year. Then shortly thereafter,
the VISN Director in Kansas City took this issue to heart and
at least solved the problem but, unfortunately, temporarily.
In December, Larry was granted an appointment in Hays, the
place where the CBOC exists--I should say the CBOC that does
not offer cortisone shots, but he got care in the private
sector in December of last year.
The doctor who treated him, who provided the colonoscopy,
then asked to treat him again and to follow up. The VA denied
that request and sent him back to Wichita. They denied that
request because he was not eligible for Choice. The CBOC exists
within the 40 miles of his home.
He is back to Wichita. Ultimately he then needed--instead
of a cortisone shot--a colonoscopy. Same series of events. The
outpatient clinic does not provide colonoscopies, and he is
trapped in this system of no one telling him what he can do or
what he qualifies, except he does not qualify for Choice, go to
Wichita. He has done that, but then just recently, last week,
he received a letter from the VA approving him for Choice. He
then calls TriWest, and TriWest says, ``You are not eligible.
We do not have you on our list.'' ``But I got this letter.'' He
indicates that he talked to four different operators at
TriWest, all who gave him a different answer than anyone else,
than the three other operators.
He called the 866 number and was told he was not eligible,
got the four different answers, and now we are back to the
question of what happens to Larry. My point here is, one, it
ought not be Larry's problem to solve what happens to Larry;
but even from the beginning, if he was not eligible for Choice,
and even if he is not eligible today because the CBOC is there,
even though it does not provide the colonoscopy or the
cortisone shot, why is someone not at TriWest or the VA telling
him, ``Oh, we have these other authorities; this would work for
you,'' as compared to just leaving Larry hanging about whether
he is eligible and what he should do? How do we solve that
problem? I do not think it is totally unique. I hope it is, but
I doubt that Larry is the only veteran that experiences this
circumstance.
Mr. Gibson. I doubt that the problem is unique. I suspect
there are other veterans that are having similar experiences.
As I described in my opening statement, we are asking for
additional flexibility which would give us some more authority
to be able to handle that kind of situation inside Choice. We
actually handle many of those situations through other VA care
in the community routinely, which is why we have incurred so
much expense on a year-to-date basis. But we find ourselves
running out of resources in order to be able to sustain that.
We wind up making suboptimal decisions.
I would tell you, you have just given two great examples.
The Chairman asked earlier about whether or not we would be
using judgment around the nature of the procedure. The answer
is yes. I would tell you, for someone that has a routine
requirement like a cortisone shot, there is no reason to travel
150 miles to go do that. That is something that ought to be
getting done--we ought to be getting done locally.
For the veteran that has to go get a colonoscopy, I got to
tell you, I am not going to drive 150 miles to go get a
colonoscopy. That is not going to happen. That is something
else that needs to be provided for inside the community.
Now, if a veteran needed a knee replacement, I might say,
you know, ``OK, under the circumstances make the trip.'' But
for the therapy that has to follow up after that, no, I do not
want the veteran traveling 150 miles each time he needs to go
to physical therapy.
The challenge that we have is 40 miles from where you can
get the care. We keep running the numbers, and the tab is
horrendous. It is huge. What we have got to do is find a way to
be able to manage this in such a way that we are doing the
right thing for veterans at the same time we are being the best
stewards we can of the taxpayer dollar.
Senator Moran. Mr. Secretary, as you know, you and I have
had a number of conversations on this topic, and today I am not
arguing--I would argue, given the chance, but I will not argue
today about whether or not--or how the 40 miles should be
interpreted. My point on this episode, one, is the uncertainty
and the burden lying in the wrong place. It ought to lie with
the VA or TriWest, not the veteran. My second point is that if
you have these other authorities, whether or not Larry
qualifies for the Choice Act ought not matter in the answer he
gets.
Mr. Gibson. I agree completely.
Senator Moran. Thank you.
Chairman Isakson. Thank you, Senator Moran.
Senator Sanders?
Senator Sanders. Senator Manchin has kindly yielded to me
because I have got to run out the door.
Chairman Isakson. To the gentleman that has got to run out
the door, Senator Sanders.
STATEMENT OF HON. BERNARD SANDERS,
U.S. SENATOR FROM VERMONT
Senator Sanders. Thank you, Mr. Chairman. Thank you for the
work that you have been doing and for your maintaining the
bipartisan spirit of this Committee. Congratulations for all
you are doing.
Chairman Isakson. Thank you.
Senator Sanders. I want to just make two points.
First of all, I want to thank Deputy Secretary Gibson and
his boss, Secretary McDonald, for the very impressive work they
are doing. I understand, as the former chair of this Committee,
how easy it is to beat up on the VA, running 151 medical
centers, 900 CBOCs, and there is a problem every single day.
But, you know what? In a Nation which has a dysfunctional
health care system, the private sector also has one or two
problems. I will not go into them, but I think we should
recognize that when you talk to the major veterans
organizations--the American Legion, the VFW, the DAV, the
Paralyzed Veterans of America--you know what they say? You have
heard this, Mr. Chairman. They say that when people walk into
the VA, the quality of care they get is pretty good. I want to
thank you for trying to improve that care. I personally will
fight vigorously those who want to privatize the VA or
dismember the VA. I think our goal is to strengthen the VA. I
think our goal is to be creative in terms of using the new
program that we have developed so that people can get care in
their community locally. That is a good mix. I will oppose
efforts to privatize the VA, which is serving our veterans so
very well.
I wanted to get to another issue, and Senator Blumenthal
touched on it. Today I wrote a letter to Secretary McDonald
about an issue that has concerned me for a while, and that is
the high cost of the drug Sovaldi, which is a miracle drug, so
to speak, which is now treating the veterans of our country who
have very high rates of hepatitis C.
Mr. Chairman, to me it is an outrage that you have a
company whose profits have soared in the last few years. Their
revenues have doubled, I believe, in the last year. They have
come up with a drug. They are charging the general public
$1,000 a pill for that drug. They are charging, I believe, the
VA--I do not know if this is a great secret, but I will tell it
anyhow--something like $540 for the drug. Is that right? No
comment. All right. That is because the VA negotiates drug
prices. But you are running out of money, and we have several
hundred thousand veterans today who are suffering with
hepatitis C, which can be a fatal disease, and you do not have
any money to treat them. Frankly, I think that it is time to
talk to Gilead, the manufacturer of Sovaldi, and basically ask
them if they are currently being very generous in providing
these drugs, hepatitis C drugs, to countries like India and the
Republic of Georgia for free. Very generous, for whatever
reasons they are doing that. Maybe at a time when their profits
are soaring, maybe they might want to respect the veterans of
this country who might die or become much sicker because they
do not have access to this wonderful product. As Senator
Blumenthal mentioned, if they are not prepared to come to the
table--and I know you think you have done very well by getting
their prices down by half. I am not impressed that you are
paying $540 per pill for people who put their lives on the line
to defend our country.
I would suggest to them you sit down again with them and
tell them that you are prepared to utilize Federal law,
specifically 28 U.S.C. 1498, to break the patents on these
drugs unless they are prepared to come down significantly lower
than they are right now. It is not a question of taking money--
I know you have requested to take money out of the Choice
Program. Maybe that is a good idea. It is a better idea to have
them treat the veterans of this country with respect and charge
the VA a reasonable price rather than ripping off the VA as
they currently are.
With that, I would yield.
Chairman Isakson. Thank you, Senator Sanders.
Whomever is operating the clock, fell asleep a minute ago,
so turn that clock on when they start talking, if you would.
We have Senator Rounds, followed by Senators Manchin,
Cassidy, Hirono, Tillis, and Tester.
Senator Rounds?
HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA
Senator Rounds. Thank you, Mr. Chairman, and I appreciate
your work and also the Ranking Member's work with regard to the
issues on the hospital in Aurora. I agree that it should not
come out of the Choice Program as the alternative.
Mr. Gibson, I was looking back at the notes I have taken
here, and you gave some very encouraging notes with regard to
some of the stats about some of the areas of the country with
regard to some additional care being provided, and that is
encouraging. I am just curious. Do you believe that those stats
are consistent across the country? Are you finding evidence of
that across the rest of----
Mr. Gibson. Actually, that is--I always worry when people
quote averages to me, and what you find is wide disparity
across the country in terms of the length of wait times, and,
therefore, in terms of the specific areas where we are making
the most intensive investments. What I would tell you is where
we have been making consequential investments, you pretty
consistently see a material improvement in access measured by
completed appointments, measured by growth in relative value
unit. What we are not seeing pretty consistently is a material
improvement in wait times.
When you look behind that you realize that what is
happening is as we improve access to care, either more veterans
are coming or veterans that are already there are making
additional utilization of VA care.
Senator Rounds. I am just curious. It sounds almost like we
have--and I think Senator Sanders had suggested this in a way,
but I really think we have to have the discussion about how we
deliver care long term for our veterans. I would love to be
able to allow the veterans to make that decision themselves as
to how we deliver the care to them. I think the Choice Act
allows that to begin. I understand that right now we have got a
significant investment, if we have over 150 health care
communities--or health care centers and 900 CBOCs right now.
What do you see as the answer here? One of the comments was
made that we are looking at providing the Choice opportunity
there if the care cannot be met by the VA itself. It sounds to
me like what we are saying is that the VA should be making the
decision about whether or not they are delivering the care or
whether or not the veteran should be making that decision. It
sounds to me like maybe we ought to take the other approach
here and say if we gave that choice to the veterans, I would
suspect that a number of them who have very great care being
delivered to them by VA facilities might very well want to
continue that on. There are others that I suspect would say,
``Look, I am not near a facility, and I do not expect you to
build a new hospital near me.''
You have looked at asking for the ability to have
flexibility to make that choice. What would happen if we took
as an alternative and said--and, once again, I think we are
talking about dollars and cents now as being the deciding
factor in this case. What would happen if we allowed the
veterans to decide for themselves whether they wanted to have
the care through a VA facility or through utilizing the Choice
Program more fully and skip all of the extra stuff that you
have talked about here in terms of the 40-mile rule or whether
or not they have already had care and now they have got to go
back in after 60 days and so forth? It is still the VA making
the decision. Why not--and share with me your thoughts. I am
sure this is not a new thought. Share with me your reasoning
and logic and why you are where you are at in terms of not
allowing the veterans to make that choice themselves.
Mr. Gibson. Sure, not at all a new thought, and we have
spent a great deal of time talking about it and alluded to some
options that we briefed the staff on.
One of the things first to keep in mind, 81 percent of all
the veterans that we provide care for have either Medicare,
Medicaid, TRICARE, or some form of private health insurance.
Often, what you see today--you mentioned the fact earlier that
veterans, if given the option for Choice, some would elect to
stay in. And, in fact, that is precisely what happens today.
Roughly half, 40 to 50 percent, somewhere in that neighborhood,
depending on whose survey you are listening to. I would tell
you my perspective, part of those are deciding to stay because
they want to stay, because they are getting great care, they
enjoy the camaraderie with other veterans, they have continuity
of care there because they have been receiving care for a long
time. Others come there because they have an economic incentive
to come there, because if they go out to Medicare, they have a
20-percent co-pay for a procedure. You look at that colonoscopy
or whatever it happens to be, or the knee replacement, which is
an example that we use oftentimes, and the veteran can go get
it with Medicare, but he is going to wind up with a $7,500 bill
to foot.
I think part of the answer comes--and it is one of the
options that we have talked about here--is that we step back
and we look at some of the economic distortion that exists
today and find ways to eliminate that.
For example, what if Medicare, Medicaid, TRICARE, and other
providers became the primary payer and VA indemnified the
veteran against a 20-percent co-pay? Then you really are
providing the veteran with choice. Then you have really--and
you wind up--the taxpayer does not wind up paying twice for the
same care.
I think therein lies kind of the answer. This is not about
protecting the turf. All we are about is doing the right thing
for veterans and being good stewards of taxpayer resources.
Wherever that leads us, that is where we are ready to go.
Senator Rounds. Mr. Chairman, my time is up, but I think
that is something that we should seriously consider on this
Committee. Thank you, sir.
Chairman Isakson. Thank you, Senator Rounds.
Senator Manchin?
HON. JOE MANCHIN, U.S. SENATOR FROM WEST VIRGINIA
Senator Manchin. Mr. Chairman, thank you very much, and I
thank all of you for being here today.
Let me just say that, needless to say, the VA has a lot of
problems or has had a lot of problems that you all have been
dealt. Some of you have been there longer than others. Some of
you have had careers at it. Some of you have come from the
private sector.
I have got problems in West Virginia, like every other
State. Nobody has problems like Colorado has right now with
what is happening there, but let me just say I need to get this
on record. I have a situation in Beckley VA medical center. I
do not know if it had been brought to your attention or not, if
it has got that far up the ladder. Last month, the Office of
Special Counsel released a report with substantial allegations
of switching anti-psychotic drugs based solely on cost. The
providers and doctors said this is what our veteran needs.
Then, they made an executive decision that it was too cost
prohibitive, cut the medicine, and did not get the right
application.
I was told there is a new policy in place that regulates
dispensing of these drugs, and I have not been able to obtain a
copy of that. At the same time, I am also told that there is a
follow-on investigation into the matter. I have not heard much
about that.
At the same Beckley VA, the Greenbrier clinic, which
operates under Beckley, has been closed three times because of
air quality. I am having a horrendous time, because we have a
very rural State, trying to get our veterans the care they
need.
The only thing I can ask, if it has not gotten to your
level, if you can get me an answer back as quickly as you can.
Mr. Gibson. One, we will get you the regulation.
[The information referred to follows:]
Response to Request Arising During the Hearing by Hon. Joe Manchin to
U.S. Department of Veterans Affairs
visn 6 beckley vamc congressional update
current as of september 15, 2015
* Greenbrier County CBOC (Closure of Maxwelton Location)--
June 1, 2015:
The alternative for long-term options for providing care to
affected Veterans is continuing to be evaluated. Beckley VAMC's first
action focused on deactivating the current clinic in our systems to
enable area Veterans to be eligible to use Veterans' Choice benefits
that include authorization to receive care by local providers. Other
current actions include investigating the viability of long-term care
options to maintain clinical services for the regions' Veterans.
The primary option being pursued at this time is to contract with
area providers for services. This option has become more challenging
with the recent Choice Act guidance, which `prohibits new contracts for
care except in urgent circumstances as determined by the DUSHOM.' This
updated guidance is dated May 12, 2015. VISN 6 drafted a request for
Exception to this Policy and forwarded the request to the DUSHOM's
office for consideration on May 26, 2015.
Another option being considered is to find replacement space to
reestablish the CBOC. A newspaper ad for lease space up to 5,000 usable
square feet of outpatient space was or is to be published in the
Mountain Messenger (5/22 and 5/29); Valley Ranger (5/24, 5/27, 5/31, 6/
3); and Daily News (M-F, X 2 weeks starting 5/25). In order to procure
a new lease to replace the Greenbrier CBOC, VA would need to validate
the need for the new lease through the Strategic Capital Investment
Planning process, and obtain a lease delegation from General Services
Administration.
June 15, 2015:
Beckley VAMC is continuing to work with the VISN and VA Contracting
to investigate the viability of long-term care options for providing
access to care to the Veterans in the Greenbrier Valley. Currently the
medical center is working with VA Contracting on parallel paths:
1. The marketing study for lease space ended at 4:30 p.m. on
June 12, 2015.
Thirteen interested offerors made contact with the Contract
Specialist.
2. The VA is now working on a newspaper ad to seek information on
the availability of potential sources with board-certified providers of
Primary Care and basic Mental Health in Lewisburg, Rainelle, and
Alderson who are interested in a multiyear contractual arrangement. A
supplemental email with details of the ad will be provided prior to
publication.
July 1, 2015:
The newspaper ad seeking information from sources interested in
providing primary care and mental health outpatient services in the
Lewisburg, Rainelle, and Alderson (WV) catchment area was or is to be
published in the Mountain Messenger (7/3 & 7/10); Valley Ranger (6/28,
7/1, 7/5, & 7/8); and Daily News (M-F, X 2 weeks starting 6/29-7/8).
Interested sources are asked to contact Marchelle Peyton no later than
5:00 p.m. on July 10 at [email protected]. The ad information was
provided to our Congressional partners via email on June 26.
The medical center is preparing a business plan to be submitted to
the VISN that will provide an analysis of the need based on access,
workload, and comparison of the various options for providing care
noted above.
July 10, 2015 (Interim Email Update):
A local (Beckley VAMC) Review Committee has been established. On
July 14, this Committee along with VA Contracting will begin the site
survey process of assessing the identified 13 potential ``ready to
occupy'' spaces. VA Contracting is in the process of scheduling these
site visits.
July 15, 2015:
DUSHOM approved the waiver for new contracts for care on June 2,
2105.
The community care solicitation resulted in three (3) interested
sources. These sources will now be evaluated as to whether they are
good community based options in which to provide services to our
Veterans.
The marketing analysis and preparation of a business plan is
ongoing.
SecVA scheduled to speak with Senator Manchin on July 16.
July 24, 2015 (Interim Email Update):
A final newspaper ad for lease space up to 5,000 usable square feet
of outpatient space is to be published in the Mountain Messenger (8/1);
Valley Ranger (7/26 and 7/29); and Daily News (M-F, 7/27 to 7/31). Any
new interested parties should submit an official response to VA
Contracting by 4:30 pm EST on August 3, 2015, no other properties will
be accepted after this date. This will conclude the market research and
a solicitation will be sent to those properties that meet the
Department of Veteran Affairs requirements.
August 1, 2015:
Follow-up to the Congressional conference call held on July 30:
The marketing analysis determined that VA contracted community care
is not a viable option at this time.
The focus is on the re-location site for a VA staffed CBOC. The
selection of the site is on-going and thoroughly being pursued.
Anticipated timeframe for the reopening of the Greenbrier County CBOC
is up to 12 months.
Note: The Greenbrier Valley Economic Development Corporation (Mr.
Steve Weir) was notified of the VA's intent to not renew the lease on
the CBOC (Maxwelton) in writing by the Lease Contracting Officer on
April 30, 2015 and May 5, 2015.
The Director will host a Town Hall for the Veterans in the
Greenbrier Valley on Thursday, August 6, 2015, at 6:00 p.m. at the West
Virginia School of Osteopathic Medicine, Roland Sharp Alumni Center,
400 North Lee Street, Lewisburg. Announcement will be made via media
outlets.
August 10, 2015 (Interim Email Update):
The final marketing study for lease space ended at 4:30 p.m. on
August 3, 2015. An additional nine interested offerors made contact
with the Contract Specialist. VA Contracting is in the process of
scheduling site visits for the local (Beckley VAMC) Review Committee to
assess the additional nine spaces this week. This will conclude the
market research and a solicitation will be sent to those properties
that meet the Department of Veteran Affairs requirements.
Note: Local media coverage of the Town Hall held on Thursday,
August 6, 2015, seems to be somewhat misleading often with erroneous
information on the process for relocation of the CBOC.
August 15, 2015:
The Beckley VAMC Review Committee completed the assessment of the
additional nine spaces on August 14. The reviews for all 22 sites will
be collated and a prioritized list provided to VA Contracting by
Wednesday, August 19. The solicitation process will begin.
September 1, 2015:
Beckley VAMC provided the list of acceptable properties to VA
Contracting as planned. The VA Contracting process will be consolidated
and given priority consideration with an anticipated award date of
December 2015.
On August 18, Beckley VAMC received an Interim Letter dated
August 17, 2015, from the National Institute for Occupational Safety
and Health (NIOSH) which provides the results from the analyses for
volatile organic compounds (VOCs) and isocyanates from air sampling
collected on March 26, 2015 (Attached below) from the Maxwelton
location. Also attached for continuity is the Interim Letter dated
April 24, 2015 which provides the air sampling results for formaldehyde
and carbon monoxide (CO).
September 15, 2015:
The National Contracting Office 6 is continuing to aggressively
work on the process for awarding a contract for a relocation site for
the CBOC.
* Office of the Medical Inspector Report to the Office of Special
Counsel OSC File Number Dl-14-3389, dated November 3, 2014--closed
April 22, 2015 (Pending supplemental report)
June 1, 2015:
On April 28-April 30, the Office Medical Inspector conducted a
supplemental site visit at Beckley VAMC. Beckley VAMC has not received
the final report. On May 27-May 28, VA Office of Accountability Review
conducted an administrative investigation as part of the follow-up
actions to this pharmacy review conducted by the Office of the Medical
Inspector. The final report is pending.
June 15, 2015:
Beckley VAMC has not received the final reports on these visits;
however, the embedded letter has been sent from the Acting Under
Secretary of Health to Senator Capito.
July 1, 2015:
No new information. Beckley VAMC has not received the final reports
nor are they listed on the Office of Special Counsel's Web site.
July 15, 2015:
No new information.
August 1, 2015:
No new information.
August 15, 2015:
No new information.
September 1, 2015:
No new information.
September 15, 2015:
The reports from the Office of the Medical Inspector's supplemental
review and the VA Office of Accountability Review are pending.
* Intensive Care Unit (ICU) Relocation--
June 1, 2015:
On May 27, 2015, the ICU unit was temporarily relocated to Ward 3A
pending floor repair and replacement. Estimated time for relocation is
September 2015.
July 15, 2015:
Nothing new to report.
August 1, 2015:
Renovations are approximately 75% complete and are on target for
completion in September 2015.
August 15, 2015:
This project remains on target for completion in September 2015.
September 1, 2015
This project remains on target for completion by the end of
September 2015.
September 15, 2015:
The flooring project has been completed and the ICU unit is up and
running in its permanent location as of September 10, 2015. This topic
is now closed.
* Princeton VA Clinic--
September 15, 2015:
Since the June 8, 2015 opening, there has been a net increase of
200+ Veterans enrolling to receive care or transferring their care to
the Princeton VA Clinic in addition to the more than 400 Veterans whose
care was transferred from the mobile unit that was parked in Bluefield,
WV. The clinic has the capacity to care for 1,200 Veterans.
* Adult Day Health Care Unit--
September 15, 2015:
The medical center is currently in the process of relocating the
Adult Day Health Care program into their new site--the new building
located on the left and attached to the medical center. The program
will now have the capacity to grow and offer care for more Veterans on
a daily basis.
Mr. Gibson. Two, I believe the follow-on investigation that
is referred to here is oftentimes--well, routinely, when the
Office of Special Counsel has a finding that substantiates a
whistleblower allegation, then if it is medical care, it is
turned over to the Office of the Medical Inspector, and we have
a team of physicians----
Senator Manchin. You all----
Mr. Gibson. We do. They really bore it out; they come and
determine exactly what happened, where the accountability was,
and then those oftentimes will come to me.
Senator Manchin. Sure. I have already heard that it is at
that level now, it has been there. I have been trying to get an
answer back.
Mr. Gibson. We will get you an answer.
Senator Manchin. If you can help me, I would appreciate it
very much.
Mr. Gibson. We will do that, sir.
[The information referred to follows:]
Response to Request Arising During the Hearing by Hon. Joe Manchin to
U.S. Department of Veterans Affairs
Date: September 24, 2015
Source: Jon Coen, OCLA
Inquiry from: Sen Manchin
Context of Inquiry: Please provide an update on whistleblower
allegations concerning the Pharmacy Service at the Beckley VAMC
Response (excerpt from June 9, 2015, Sen Capito Letter attached):
In response to OSC's referral of whistleblower allegations concerning
the Pharmacy Service at the Beckley VAMC, the Department investigated
the allegations and submitted its report to OSC on January 5, 2015. As
reported, VA substantiated that the Beckley VAMC Pharmacy and
Therapeutics (P&T) Committee encouraged its providers to switch
established Beckley VAMC Veterans from aripiprazole or ziprasidone
prescribed by Beckley VAMC providers to medications with similar
indications. VA also substantiated the allegation that Beckley VAMC
management did not communicate the opioid performance measure to
Primary Care physicians within 90 days of the beginning of the FY as
required by Veterans Health Administration (VHA) policy. The report set
forth specific recommendations for corrective and follow-up actions to
be taken by Beckley VAMC. Beckley VAMC has fully implemented all of the
recommendations.
Beckley VAMC conducted clinical reviews of the condition and
medical records of all Veteran patients who were discontinued from
aripiprazole and ziprasidone to determine whether any adverse patient
outcomes had resulted. Clinical reviews of 137 patients who had been
receiving aripiprazole and 45 patients who had been receiving
ziprasidone up until that time were completed on November 18, 2014, and
January 21, 2015, respectively. Of these 137 Veteran patients, 66
Veteran patients previously on aripiprazole and 19 Veteran patients
previously on ziprasidone were changed to other medications with
similar indications. There were no patients receiving aripiprazole and
ziprasidone concurrently before or after the reviews. As previously
stated, the review, validated by the Chief, Mental Health Service Line,
found no adverse outcomes as a result of the change in medications.
It is also important to note that based on current information,
aside from national guidance (evidence-based prescribing criteria,
treatment algorithms, clinical practice guidelines, etc.), there are no
``blanket restrictions'' for any drugs or treatments for acute medical
conditions in place at Beckley VAMC. As a result of the investigation,
VA instructed Beckley VAMC to ``stop the practice of automatically
removing patients from aripiprazole or ziprasidone without a legitimate
clinical need.'' As stated earlier, Beckley encouraged providers to
switch Veterans from aripiprazole or ziprasidone to medications with
similar indications; however, at no time did they ``automatically''
remove patients from those therapies as reported. Providers may request
any medication, even medications not listed on the VA's National
Formulary, through a Special Drug Request (SOR) process when a
medication is clinically indicated for an acute or chronic medical
condition. Additionally, Beckley VAMC management has formally clarified
to staff, via email and in face-to-face meetings, that aripiprazole and
ziprasidone are, in fact, available for physicians to prescribe when
clinically needed.
With respect to VA's recommendation that Beckley VAMC management
take steps to improve the education of its leadership and the P&T
Committee on the policy and procedure requirements outlined in VHA
Handbook 1108.05, Outpatient Services, and VHA Handbook 1108.08, VHA
Formulary Management Process, Beckley VAMC management has taken the
following actions:
On January 25, 2015, during the Medical Staff meeting,
providers were educated on the policy and procedure requirements
outlined in VHA Handbook 1108.05, Outpatient Pharmacy Services, and
1108.08, VHA Formulary Management Process;
On March 12, 2015, Medical Center leadership, (including
the Chief of Staff, the Medical Center Director, and the Chief of
Pharmacy), and members of the P& T Committee were educated about the
same information. Additionally, the Veterans Integrated Service Network
(VISN) 6 Pharmacy Executive participated (via teleconference) in a
Beckley VAMC P&T Committee meeting and during the meeting covered the
salient elements of VHA Handbook 1108.08 and 1108.05, especially those
related to continuation of therapy; and
On March 17, 2015, the VISN 6 Pharmacist Executive
reinforced the key points of VHA Handbook 1108.05 and 1108.08 to all
VISN 6 Chiefs of Pharmacy (or their designee) during a conference call.
VA also recommended that VHA take action to reinforce to all
Medical Centers the policy and procedural requirements outlined in VHA
Handbook 1108.05 and VHA Handbook 1108.08 related to the processing of
formulary medications. This was accomplished on March 13, 2015, when
VHA issued such guidance to the field. Notably, this same information
was provided to all VISN Chief Medical Officers, VISN Pharmacist
Executives, Chiefs of Staff, and other internal stakeholder groups.
With respect to the status of VA's recommendation that, if and as
warranted, appropriate action be taken against VAMC leadership and the
P&T Committee for approving actions that were inconsistent with
applicable VHA policy on prescribing drugs, the Beckley VAMC Director
is currently working with VA's Office of Accountability Review, a
multidisciplinary body which reports to the Secretary through the
General Counsel, to determine the need for any such action.
To ensure staffs are able to report suspected violations of policy
or law and that such reports are investigated promptly, Beckley VAMC
has appointed a full-time Compliance Officer who is available (both in-
person and via a telephone hotline number) to receive confidential
reports by staff of suspected policy violations. When a complaint is
received, the Compliance Officer will notify the Beckley VAMC Director
of the complaint and enter the matter into a web-based reporting system
where it is to be monitored until satisfactorily closed. As part of the
process, the Compliance Officer conducts a fact-finding exercise and
presents the findings to the Director, who may take whatever action is
deemed appropriate. The manner in which complaints are to be handled
and/or resolved will depend upon the nature and facts of each
complaint. For instance, the Director may convene an Administrative
Board of Investigation to investigate the types of matters covered by
VA Handbook 0700. Please note that with respect to suspected criminal
activity, VA employees, not only the Compliance Officer, are obligated
to report suspected criminal activity to the appropriate law
enforcement officials in accordance with 38 CFR Sec. Sec. 1.200-1.205.
Beckley VAMC maintains posters for the Office of the Inspector
General and Joint Commission displayed throughout the facility
informing staff, Veterans, and visitors about how to make complaints of
suspected waste, fraud, or abuse. Additionally, suggestion boxes can be
found throughout the facility making it easy for any person to
anonymously submit questions or concerns to the Compliance Officer.
The remaining allegation substantiated by VA was the medical
center's failure to communicate the opioid performance measure to all
primary care physicians within 90 days of the beginning of the fiscal
year. VA recommended the facility take steps to ensure performance
measures are communicated to physicians in a timely manner, in
accordance with VHA policy (VA Handbook 5007, Pay Administration). On
January 21, 2015, Beckley VAMC's Office of Human Resources implemented
a standard operating procedure (SOP) requiring service lines to
develop, communicate, and implement physician performance pay goals
(which are the performance measures plan) based upon the Executive
Career Field plan and opportunity for improvement identified by Beckley
VAMC. The SOP includes calendar reminders for this action and requires
confirmation of completion by each service line before the 90-day
deadline.
[June 9, 2015, Senator Capito Letter intentionally omitted.]
Senator Manchin. Really what it comes down to, this leads
up to everything that we have talked about here, and I think as
Senator Sanders says, you know, privatization, this and that. I
just truly want--I just care about the veterans. There are
going to be an awful lot of them coming back who will need a
lot of care. My generation coming out of Vietnam, 40 years
later still have tremendous need.
With that being said, do you believe--you come from the
private sector. You come from the private sector. You are
public. You are public.
Dr. Tuchschmidt. She is private sector.
Senator Manchin. Private? Oh, I read here you had 15 years
in Government. Those who have more public--more private
exposure, would understand. Do you believe we can give better
care to our veterans through the private sector? I mean that in
the case of the quality of care, the time, and also the cost. I
am not saying we are going to shut the VA down. But before we
expand, I do not think we are going to build another hospital.
I do not think we are going to build anything else. We are
going to have to maintain what we have and give better care for
more people.
Mr. Gibson. Sir, I would tell you, no, I do not believe
that that is the case. If you look at the typical----
Senator Manchin. Tell me why.
Mr. Gibson. If you look at the typical veteran that we
provide care for, they are older, they are sicker, and they are
poor. We have a highly fragmented health care system in
America, and that is precisely the person that I do not think
fares best when turned loose in that fragmented system. If you
go talk to veterans, to a large number of veterans,
consistently what you are going to hear, are there instances
where they had to wait too long for care? Are there instances
where we made a mistakes? Yes, there absolutely are. Fifty-five
million outpatient appointments a year.
Senator Manchin. Use Alaska as an example. We used Alaska
for the Choice. Alaska is the basis for with Choice. We used
Alaska and how they were given so much better quality of care
and quicker wait times than anywhere else. They do not even
have a VA hospital. Who wants to take that one?
Mr. Gibson. You know that market very well.
Mr. McIntyre. If I might, I know Alaska a fair bit, and
about a decade of public service experience. I would offer the
following: I think it takes both.
Senator Manchin. OK.
Mr. McIntyre. I think the real question at the end of the
day is: Which things fundamentally are done best by the VA
directly? Which things have enough demand where it justifies
building it? Which things ought to be supplemented by the
private sector? Because it is either there is not enough demand
to justify a build or where it makes sense to spread the supply
simply because of the amount of resourcing that is needed to
deliver services. I think that has always been true. I think
that is true in the DOD system. That is why you see TRICARE
constructed the way it is. Alaska has a joint-use facility in
Anchorage. But when you get outside of Anchorage, most of the
footprint tends to either be public in the DOD, public through
the Indian Health Service, or private. It is those two pieces
working together that are ultimately going to deliver what
needs to be done.
Senator Manchin. Well, I can talk to you all day, but my
time is running out, but the thing on drugs, the drug
dispensing to our veterans is almost criminal, what we are
doing to them. The concoction of drugs we are giving them
without proper guidance, and when you look at high unemployment
rates in our veterans and look to it as drug addiction, we have
got to do something there. Prescription drug abuse is the
biggest killer I have in my State of West Virginia, and it is
everywhere. It is horrific. But in the ranks of our military
and our veterans, it is just absolutely off the charts.
We are putting a prescription drug abuse caucus together,
Democrats and Republicans working together. We are going to
need your help because this is where we can----
Mr. Gibson. We would love to participate. We agree with
you. We recognize it as a national problem, and it is a problem
inside VA.
Senator Manchin. Thank you.
Chairman Isakson. It is a problem in general society. Thank
you, Senator Manchin.
Senator Tillis, then Senator Hirono, followed by Senator
Boozman and Senator Tester.
HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA
Senator Tillis. Thank you, Mr. Chair. Thank you all for
being here.
Just a couple of things. One is based on a comment made
here earlier about the idea of completely privatizing the VA. I
honestly have not had a single serious discussion with any
member that saw that as an end state. If they did, if anyone
here did, all they need to do is spend some time in the VA to
understand the unique nature of what the VA has to offer. There
is no other more welcoming place for a veteran than the VA. Not
that there are not opportunities for private care. There
clearly are already. The non-VA care is a very significant part
of what you all do every day, long before Choice was ever
implemented. Choice is just another safety valve.
I realize in these Committee meetings sometimes our words
carry more weight than perhaps they should. But I do not think
anybody should leave this Committee meeting thinking that
anybody here has any serious goal or objective to privatize the
entire VA.
I want to go back to the point that Senator Blumenthal
mentioned. I also have concerns about the overrun in the Denver
hospital. I completely understand your predicament. You have
got to figure out a way to get it built out. Can you give me an
idea of what the thought process was? Because presumably, if
you were going to shift that money over for the short-term need
to fund the buildout of the Aurora facility, what would that
cause in terms of delay or ramping down of what we would be
doing with Choice over the period of time that that money would
not be available?
Mr. Gibson. What we basically did is in identifying the
non-recurring maintenance and minor construction projects, we
have a capital planning process that actually builds a
prioritized list that is years long based upon the pace of
funding that we normally expect to get. When we looked at the
$5 billion in Choice funds, we basically reached into that skip
list and pulled a segment out to put into that priority bucket.
What happens now is the substantial portion of those, if we
were permitted to do this, in all likelihood would wind up in
the 2017 budget because they then would fall back into that
prioritized queue.
Senator Tillis. That is why I was asking the question,
because you could infer from some of the discussion that there
is a $700 million hit and care not being provided versus taking
a look at how that money was spent over time to build the ramp-
out of the Choice Program. That is why I was asking. It sounds
like there is some leveling assumptions you were making about
having the money when you need it.
Mr. Gibson. That is exactly right. Our commitment has been
that we would work this back into the funding stream as quickly
as we could. There are hundreds of----
Senator Tillis. I think that that is critical in order for
what you have requested in the letter that you sent us to have
any prayer of serious consideration, you need to map out how we
would have assurances that it does not really materially affect
it because of the way that you would plan to spend that money
anyway.
Mr. Gibson. Thank you. Thank you for raising the issue.
Senator Tillis. Because, otherwise, I would tend to go back
to the well-articulated position of the Ranking Member.
The other question that I had or the thing that I think is
very important is we need to get a 5-year, 10-year, 20-year
picture of what Choice non-VA care means, to get some
parameters set about it, because that is critically important
for you to go back and review your capital improvement plan to
figure out how to do it. The answer is going to be different
depending upon where you are.
Senator Sullivan will rightly say that his State has a
higher per capita veterans population of any State in the
Nation. I have a veterans population that exceeds the
population of several States. The capital planning requirements
in North Carolina will be necessarily different than non-VA
care, and the Choice mix in Alaska will be necessarily
different. We have to come up with that long-term vision so we
can relook at the current capital improvement plans based on
what appears to be the interest of the Senate to continue down
that multipronged path so that you are taking pressure off of
capital requirements in some areas and maybe redoubling them in
other areas. That is a very important thing that I think this
Committee needs to see, but then we need to be very specific
about what we want beyond just brick and mortar VA presence in
the form of non-VA care and Choice are to get this right.
Mr. Gibson. If I can make two quick observations. I think
you are absolutely spot on. First of all, we have to force
ourselves to make certain decisions about what care can be most
efficiently delivered in the community. We have talked before,
my example the Chairman remembers, optometry. Why would we send
a veteran 100 miles to go get his eyes checked and get some
glasses? You can do that anywhere. Why would we not be
routinely referring that out into the community unless a
veteran really wanted to come to VA?
The other issue that we are trying to get at--and we are
learning right now, again, working to manage toward
requirements rather than just a budget number. What we are
seeing is every time we improve access to care with a new
facility, with additional staff, demand changes. Part of what
we are trying to understand is what are the dynamics.
For example, you look in Phoenix where we know we are
underpenetrated in the veteran market. We improve access to
care, and we get a disproportionate response back. We have got
to understand that market penetration phenomenon because it
will affect our capital planning.
I have already talked with the folks in Phoenix about
getting beyond looking over the horizon as it relates to demand
for care among veterans in Phoenix. We cannot keep
incrementally doing this because we are just going to stay
behind. We have got to get ahead of that demand. Your points
are excellent.
Senator Tillis. Thank you.
Thank you, Mr. Chair.
Chairman Isakson. Thank you, Senator Tillis.
Senator Hirono?
HON. MAZIE HIRONO, U.S. SENATOR FROM HAWAII
Senator Hirono. Thank you.
There is a shortage of medical personnel in the VA, and I
note in your testimony, Secretary Gibson, that you are going to
be creating some 1,500 new residency positions, and this is a
matter that I have discussed with our VA person in Hawaii,
because if we can create residency positions in the State, it
is more likely that those folks will be able to practice in the
State.
How will these residency spots be allocated? By region? By
capacity? Are there any you are planning to increase for Hawaii
medical students?
Dr. Tuchschmidt. I do not have the list with me today
specifically of where the slots are going.
Senator Hirono. Have you already determined where the
residency slots are going?
Dr. Tuchschmidt. Not all 1,500. That is a multiyear plan to
deploy the 1,500, and the first round of those started this
fiscal year. I, quite frankly, did not think our Office of
Academic Affiliations would be able to do it, but they went out
and sought applications. There are very specific criteria in
the law about them going to underresourced communities and
specialties. They went out and specifically sought those. We
have awarded several hundred for this first round this year,
not as many as we had thought maybe, but a lot more than I
anticipated they would be able to award. I can get you
specifically where those----
Senator Hirono. Certainly, because Hawaii has a lot of
rural areas on the neighbor islands that are underserved in the
VA. Thank you. You can send me the information, or the
comparative effectiveness.
Dr. Tuchschmidt. Yes.
[The information referred to follows:]
Response to Request Arising During the Hearing by Hon. Mazie K. Hirono
to U.S. Department of Veterans Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Hirono. As we look at the request of Secretary
Gibson to pay for the Denver facility and we are looking--I
think that it is really difficult for us to accept that you
want to take money from the Choice Program to do that. I would
like to ask you this: When a veteran goes to the VA to get care
for a non-service-connected matter and this veteran has private
insurance, do you have the authority to get reimbursed from the
private insurance company for the care that the VA provides?
Dr. Tuchschmidt. If the patient goes out into the community
in our normal purchased care program and has insurance, we will
bill that insurance company and collect to offset the cost of
the care we provided.
Under Choice, we are actually the secondary payer, so under
the Choice Program, the way the law was written, if the patient
has commercial insurance, the commercial insurance is the
primary payer, and then we will make the provider whole up to
the Medicare rate.
Senator Hirono. All right. Under the Choice Program that is
good because VA becomes the secondary payer. My understanding
is that in the first instance, where the veteran goes to the VA
and gets the treatment, then often there is no reimbursement
from his or her private insurance company. You are telling me
otherwise.
Dr. Tuchschmidt. We will bill the private insurance company
if the patient has insurance.
Senator Hirono. Yes. And do they reimburse you?
Dr. Tuchschmidt. Yes, we get paid from them. A lot of the
patients that have insurance have Medigap insurance, and
without a Medicare EOB oftentimes those insurance companies
will not pay for the care because it is not Medicare--the
insurance is specifically Medicare gap coverage. We will not
oftentimes get paid by those insurers.
Senator Hirono. You are reassuring me that the VA goes
after every dime from the private insurance carriers that you
can get your hands on.
Dr. Tuchschmidt. I can assure you we go after every dime we
can collect.
Senator Hirono. That is reassuring.
Dr. Tuchschmidt. About $3 billion a year, yes.
Senator Hirono. There are some questions about the outreach
on the Choice Card Program. There is still confusion out there
and whether you found all of the veterans who would qualify for
the Choice Card. What are the outreach efforts that you have
engaged in? Do you think that you are succeeding in explaining
the Choice Program? And, also, to VA employees and community
health care providers who need to get training on how to
explain the program.
Dr. Tuchschmidt. We originally mailed--we know who the
people are who are eligible to get a Choice Card, and we mailed
the letter to every one of those people back when the program
started in November.
Senator Hirono. I have talked to veterans, and they found
that letter to be rather confusing.
Dr. Tuchschmidt. Yes. We are about to mail a second letter
to all of them. Hopefully it is a lot simpler to understand. We
have actually tested that with veterans before we put it in the
envelope.
Senator Hirono. Good idea.
Dr. Tuchschmidt. We have made a lot of phone calls and
outreach to people. There is no question that I think we can do
more to reach veterans through our Web site, through mobile
technology, through mailings, and other forms of communication.
We need to do a better job of educating them.
Senator Hirono. Good.
Mr. Gibson. We do need to do a much better job. One of the
things we have got to remind ourselves of is there is no
parallel to this out there. It is not like an insurance card
where you just walk into your doctor's office and present your
insurance card. There is no frame of reference for people to
understand how it works. You know, do I have a benefit or do I
not have a benefit? That is one of the reasons it is hard for
us to explain and why we have to keep trying.
Senator Hirono. If giving you feedback from my veterans,
for example, could help you all do a better job, I would be
happy to pass that on.
Mr. Gibson. We would love it, yes.
Senator Hirono. Thank you.
Thank you, Mr. Chairman.
Chairman Isakson. Thank you, Senator Hirono.
Senator Boozman, followed by Senator Tester.
HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS
Senator Boozman. Thank you, Mr. Chairman.
Very briefly I would like to ask a question of efficiency.
I understand that the third-party administrators (TPAs),
TriWest and Health Net, have raised the issue of how much
clinical documentation is being sent to them by the VA.
Apparently VA is sending the clinical documentation of every
veteran who was approved due to having a wait time in excess of
30 days, which presumably is overwhelming the TPAs. You now
have a pilot program in VISNs 8 and 17 to only send the
clinical information of veterans who choose to participate in
the Choice Program. I guess the question is: are the pilots
proving successful? Then, Mr. McIntyre and Ms. Hoffmeier, if
you would like to comment from your standpoint as to what is
going on.
Dr. Tuchschmidt. When we first set up the program, we gave
every patient in the system an appointment in our system and
put them on the Choice list so that they could decide at any
point in time which direction they wanted to go. We have
learned through experience over the last 6 months that that
does not work. It does not help the veteran. It does not help
us. Quite frankly, it is not cost-effective.
We have the pilots. We have just started these pilots to
see how this goes and how we can improve those business
processes. But we are moving, quite frankly, in the direction
of at the point of service offering the veteran--finding out
what is the appointment that we can provide in the VA, offering
the veteran that appointment or offering them the opportunity
to go outside through the Choice Program. At that time, if the
veteran chooses to go out, then our staff, much like they do
outside of Choice for all of our other purchased care
appointments, will work directly with TriWest and Health Net to
get that patient an appointment through the Choice Program. At
that time, we hope we have learned from our pilots in 8 and 17
how to do this smarter and better so that we will greatly
reduce the volume of people that we are referring to the TPA
and are only providing medical record documentation for those
patients who actually choose to go outside the system.
Senator Boozman. That sounds excellent. Do you----
Mr. McIntyre. The pilot is a very good idea. Sitting at the
table in the initial design, when we were getting ready to
launch, we had 2 days to make a decision. The question was, how
do you make sure that all the right information is in the right
place to be able to serve people on the front end? The back-end
consequences are now obvious, and making the change makes a lot
of sense, and we are looking forward to supporting it.
Senator Boozman. OK. Ms. Hoffmeier?
Ms. Hoffmeier. The pilot has been going exceptionally well
in our area, and, in fact, we just approved a schedule with VA
to move forward with implementing the concept across all of our
regions here very soon. We are getting the consults in less
than 24 hours on the veterans we need. It is very effective.
Senator Boozman. OK. That is excellent. I know that it is
kind of a rocky road as you are working through these things,
but it is encouraging that you are working through.
Thank you, Mr. Chairman.
Chairman Isakson. Thank you, Senator Boozman.
The Patience of the Year Award goes to Senator Tester.
Senator Tester?
HON. JON TESTER, U.S. SENATOR FROM MONTANA
Senator Tester. It is just because you have a very, very
good Committee meeting here, Mr. Chairman.
Chairman Isakson. We got good testimony.
Senator Tester. I want to thank you and the Ranking Member
for having you guys, and thank you for your work.
I just really do not know where to start, quite frankly.
First of all, you guys do do a good job. I think the private
sector does a good job. You have your fallibilities. Do not
think that the private sector does not have their
fallibilities, too. They are short on nurses, they are short on
docs, they are short on mental health professionals, they are
short on facilities, just like you guys are. In the bookkeeping
nightmare that may come with this, let me give you an example.
Just say I was a vet. I live 50 miles from a CBOC. My nearest
hospital is 12 miles away. But that nearest hospital does not
have a doctor in it. It is staffed by a nurse practitioner.
Then the questions become: one, is that somewhere you want
to have an appointment; and, two, if I do not, guess where the
nearest hospital is? In the same town where that CBOC is. I
mean, the bookkeeping here is just amazing. I know we are all
here trying to do the right thing, and I know you are trying to
do the right thing. Still, sometimes even if you do the right
thing, people are mad because they think it is the wrong thing.
I thank you for that.
Mr. Gibson, you talked about the 40-mile thing as far as
not offering the service several times, and you talked about
how it does not make any sense if a guy is going to have a set
of glasses, why ship them halfway across the country. When you
did your analysis, did you also include the savings that would
accrue to the VA by not shipping them a long ways away? Because
I think that is really important. If I was a veteran and had to
do it over again, I probably would have signed up just for this
benefit. But, the truth is that if you are talking about what
it costs to ship them to the private sector, it also is a
savings if just in mileage alone. Did you include that in the
overall net dollar figure?
Dr. Tuchschmidt. No. We actually do not in the analysis. We
have worked through several options from what 40 miles from the
care you need might look like.
Senator Tester. Yes.
Dr. Tuchschmidt. We have not taken into account a lot of
savings.
Senator Tester. OK.
Dr. Tuchschmidt. We were modeling this for the Choice
Program. In the short run, our cost structure is highly fixed;
90 percent of our costs are fixed. There are variable costs,
which is mostly the eyeglasses that you do not prescribe, but
the rest of the infrastructure, the building, a lot of the
people, et cetera, do not go away.
Senator Tester. Yeah, but the mileage is also not a fixed
cost, and if you have to put them up in a room, that is not a
fixed cost.
Dr. Tuchschmidt. We have not specifically looked at the
bene travel, and then there are two aspects of the bene travel.
There is the true cost savings and there is the cost avoided
because you have not made them travel.
Senator Tester. That is correct.
Dr. Tuchschmidt. But, that is not a real savings. That is a
cost that you did not realize.
Senator Tester. Yes, but really? I mean, come on. That
sounds like CBO talk here, truthfully. I do not want to debate
this, but the fact is that if you are doing the actual cost
analysis and you would have spent the money if they went to a
facility of yours, you have to include that in the savings.
Truthfully, if we are going to deal with honest figures, that
savings has to be included, even if it did not accrue.
Mr. Gibson. Clearly it does have to be included.
Senator Tester. OK. Right.
Mr. Gibson. Even though the level of analysis today is
orders of magnitude better than what we had initially, all the
way down to the individual patient level, we have not picked up
some of those incidental costs.
Senator Tester. Mr. McIntyre, you talked about
harmonization, which I have talked with Sloan about regarding
the ARCH program, PC3, and Choice. I am assuming you are for
harmonization. I read it in your testimony. Just nod your head
if that is correct.
Mr. McIntyre. Yes, sir.
Senator Tester. Deputy Gibson, you are for harmonization of
those programs. Could you give us some language on how we can
harmonize those programs? I do not want to be the micromanager
here, but if you guys need language to be able to harmonize
those programs, I think it is a reasonable thing to do.
Mr. Gibson. We need to do that. I think part of that
picture is how do we manage the 40-mile issue.
Senator Tester. Yes.
Mr. Gibson. I think we need to think through this. Are we
going to look at VA becoming a secondary provider to those that
have other insurance alternatives? Because it changes the
nature of the work.
Senator Tester. OK. Well----
Mr. Gibson. It is wrapped up in that. It needs to be a very
near-term exercise.
Senator Tester. Yes, let us deal with that, because I think
it is confusing right now, and I think there is a little
manipulation going on.
Mr. McIntyre. Well, and if I might, one of the issues I was
attempting to address and allude to is the fact that we built a
network out now I our area that has got 100,000 providers in
it.
Senator Tester. Yes.
Mr. McIntyre. The requirements are more extensive than
those under Choice if you are a participating provider. Those
things need to be blended together so that we do not have
disincentive to participate in one program versus another.
Senator Tester. Fair enough.
Mr. Gibson. And the reimbursement rates need to be the
same.
Senator Tester. That is exactly right. Hepatitis C, you
want some additional dollars, I think $700 million transferred?
$400 million?
Mr. Gibson. Not transferred. If we are allowed to be
flexible----
Senator Tester. Be able to tap it. I do not have a problem
with that, by the way. The question I have is if this is a
miracle drug, when do you anticipate those costs or hepatitis C
to flatten out so you are not going to need those kind of
dollars?
Mr. Gibson. I think the conversation that needs to be held
with this Committee, with the House Committee, and with the
appropriators has to do with the requirement that we manage
toward. I would tell you VA's thought is we should be talking
about a requirement where veterans that are hepatitis C
positive, we manage that number to functional zero by the end
of 2018. That is what I think the requirement should be. So,
what we need to do is step back from that and lay out a plan
that says this is what would be required----
Senator Tester. I agree with that.
Mr. Gibson [continuing]. In order to manage to that
requirement, so we are not back and forth about--because the
first time we deny a veteran access to the treatment who is
hepatitis C positive because he does not have advanced liver
disease, everybody thinks we are depriving a veteran of care.
We need to reach agreement on what the requirement is.
Senator Tester. One last question, if I might, since I get
the award for being patient. You talked about residency slots,
which I think is great and I support and will do everything we
can. I believe residencies are 3 years?
Dr. Tuchschmidt. It varies depending upon what the
specialty is.
Senator Tester. How about for internists? How long is that?
Dr. Tuchschmidt. That is 3 years.
Senator Tester. 3 years. That is what we are short on,
right?
Dr. Tuchschmidt. Yes.
Senator Tester. The question I have is this place changes
every 2 years, and to have 3 years in a residency, you have got
to have the money for that residency.
Dr. Tuchschmidt. Yes.
Senator Tester. Talk to me about how this works, because
you have got a 2-year--you have got forward funding, but you do
not have forward funding for 3 years. What do you do if
Congress does something irresponsible--and that has been known
to happen a time or two--and does not fund you.
Dr. Tuchschmidt. I think this is actually one of our
concerns. These residents all have tales. When we start a new
residency slot, all of those slots have to be funded for the
duration of that residency training.
Senator Tester. In that budget.
Dr. Tuchschmidt. Yes.
Senator Tester. OK.
Dr. Tuchschmidt. Exactly, and that is not the case today.
Senator Tester. OK. That is important to know as we move
forward. When are you going to start the residency program? Is
it going to start in this fiscal year?
Dr. Tuchschmidt. Well, we actually do not own the residency
slots. They are owned by the Academic Centers.
Senator Tester. Yes.
Dr. Tuchschmidt. We pay for trainees, offset their salary.
The additional slots that we added started this academic yes.
Senator Tester. This fiscal year.
Dr. Tuchschmidt. The academic year that will start this
coming July.
Senator Tester. In this budget we are dealing with this?
Dr. Tuchschmidt. Yes.
Senator Tester. So, if your budget comes in a little short,
this may be a program that goes bye-bye.
Dr. Tuchschmidt. I doubt it, because we have made
commitments at this point.
Senator Tester. I appreciate it. Thank you, guys, for your
work.
I appreciate your flexibility, Mr. Chairman.
Chairman Isakson. Thank you, Senator Tester. Thanks to all
the Members, and thanks to our witnesses. It has been a long
and I think very productive hearing. We are on the path to
solving some problems and recognizing a few that we need to
solve. I appreciate everybody's time and effort very much.
We will take a 2-minute break while we shift nameplates and
go to panel two.
Mr. Gibson. We appreciate the collaborative working
relationship, Mr. Chairman. Thank you.
Chairman Isakson. That is the only way to do it.
Mr. Gibson. Yes.
[Pause.]
Response to Posthearing Questions Submitted by Hon. Patty Murray to
Hon. Sloan Gibson, Deputy Secretary, U.S. Department of Veterans
Affairs
Question 1. Non-VA Care Programs
The Choice Program was created as an emergency fix to help bring
down serious wait times that were keeping veterans from care they
needed, but that program is a temporary authority and will expire in a
few years. VA now has at least 4 different major authorities to get
veterans into non-VA care and they all have different procedures,
eligibility requirements, reimbursements, and reimbursement rates. This
is inefficient and confusing to providers, VA employees, and veterans
alike. VA should be preparing now to create one non-VA care program
that is effective and efficient, and complements the care provided by
the Department. Please describe the key features and requirements
needed for such a future program.
Response. VA agrees that the existence of four programs, with
separate statutory and regulatory authorities to access care in the
community is confusing for VA employees, providers and ultimately
Veterans. While each program serves a specific purpose, VA agrees that
the rationalization of these programs would be a welcomed
simplification for all. In May, 2015, the Department proposed
legislation through the Department of Veterans Affairs Streamlining and
Modernization Act which would allow the development of an established
network of approved non-VA medical care providers, expanding Veteran
access to care. In addition to this Act, rationalization of non-VA care
programs is necessary, and should focus on consistency, simplification
of processes, and robust technology, to include:
Consistent eligibility requirements for all care in the
community (or non-VA medical care).
Eligibility requirements that are written in easy-to-
understand verbiage that VA employees can quickly and concisely
articulate to providers and Veterans.
A dynamic provider network that allows VA medical
facilities the opportunity to continue to cultivate relationships
within their community.
Simple, consistent payment methodology for all non-VA
care.
Electronic submission of Vendor claims 100% of the time.
Automation of payments.
Clearly defined reporting requirements prior to program
implementation.
Robust reporting system that captures national and
facility-level data.
Ultimately, the future of care in the community is dependent on
developing an approach that is driven by Veteran satisfaction and
industry-leading cost-effective care.
Question 2. Denver
Two construction projects in Washington state were among those that
were allocated funding from the Choice Act. VA has now asked to
reprogram $24.7 million dollars away from those projects to pay for the
outrageous cost overruns at the Denver facility. The $5 billion
provided in the Choice Act was provided to increase access to care by
addressing critical problems at facilities around the country, not to
cover the Department's shocking mismanagement of the Denver hospital.
These two construction projects in Washington are greatly in need of
this funding, and any request to take away from those projects is
deeply concerning. Where else can the Department find the money to
address the problem in Denver besides taking the funds meant to address
critical issues at other facilities? In responding please provide a
detailed accounting of such funds and a plan to mitigate the serious
deficiencies in the Department's management of major construction.
Response. On June 5, 2015, VA released a comprehensive proposal to
the House and Senate Veterans' Affairs Committees. The plan details
specific reforms VA has instituted to improve our construction program
outcomes and prevent mistakes moving forward. The funding plan for
completion of the Denver facility presents options from a Veteran-
centric focus that we believe deploys resources efficiently while
addressing the emerging needs of VA facilities in a fiscally
responsible, budget-neutral manner. For your convenience, the full text
of the plan documents is available for download:
1. Letter to Congress
2. Plan for Completion of the Denver Replacement Medical Center
3. Cost Benefit Analysis--Denver VAMC (April 2015)
4. Photos of Denver Replacement Facility
5. VA Accountability Fact Sheet (June 2015)
6. VA Making Progress to Improve Service for Veterans Fact Sheet
(June 2015)
7. MyVA Transformational Plan (June 2015)
______
Response to Posthearing Questions Submitted by Hon. Bill Cassidy to
Hon. Sloan Gibson, Deputy Secretary, U.S. Department of Veterans
Affairs
Question 3. Mr. Gibson, I would like to take this opportunity to
address the importance of timely claims processing and outstanding
medical claims for non-VA facilities. As of Feb 9, 2015 the VA had
$43.7 million in unpaid medical invoices to non-VA facilities in
Louisiana alone. One single healthcare system covering Texas,
Louisiana, and New Mexico is owed almost $5.5 million. This is
unacceptable, we cannot expect private institutions to render care to
veterans if they know that VA will either only pay the claims at 33% or
not pay the claims at all.
a. When does the VA expect to eliminate the backlog of claims
(older than 30 days) to non-VA facilities?
b. My constituents are still reporting claims assistance hold times
ranging from 1-4 hours, what is being done to address this situation as
a whole within the VA?
c. When will the VA stop mishandling veterans' paper medical
records and allow electronic submission of these claims--in the same
way Medicare and virtually all other payers do now?
d. In November and in April, the Chief Business Office said it had
reopened a large group of claims VISN 16 had inappropriately denied for
lack of medical records after VA employees failed manually scan these
records into the system. Chief Business Office leaders have not been
willing to report how many of these claim denials were overturned. When
will the VA develop metrics that demonstrate the accurate payment of
claims in VISN 16 and other poorly performing areas?
VA Response:
a. Purchased Care has developed a specific plan to address backlog
elimination and process improvement. The goal is to eliminate the
backlog and have only current claims in inventory by December 31, 2015.
b. Due to higher than normal volumes of calls and claim
submissions, telephone wait times had increased. However, Purchased
Care has implemented several strategies to address the increase and
provide customer service to include providing claim status updates via
email or paper mail, setting up routine follow-up conference calls with
providers, taking voice mails and returning calls in order to alleviate
holding times, and the realignment of the V16 call center to Program
Administration Directorate to pilot a possible national roll out of
call center support if successful. Subsequent to the implementation of
the call center pilot in VISN 16 the average waiting time for VISN 16
callers is 15 minutes. Please provide the constituents' names and we
will reach out to them to isolate the date called to determine if there
were any issues associated with the call center systems.
VA acknowledges there have been instances where clinical
documentation was misrouted. Internal controls have been established to
ensure clinical documents are scanned correctly at the VISN 16
centralized payment center. A pilot to track clinical documentation has
proven to be successful at another location. This pilot reduced
customer service wait times and abandonment rates. We have also
completed technical site visits to evaluate how well the current
software design is meeting business needs in order to implement
corrective actions.
c. VA will be expanding that project through VISN 16 in the near
future. Providers may also submit medical documentation via CD or DVD
and VA staff can upload those digital files. Unfortunately VHA will be
unable to accept electronic submission of supporting clinical
documentation until upgrades are completed to the Electronic Data
Interchange submission systems. That upgrade is anticipated to occur in
approximately two years.
d. There were a large number of claims that were reopened and
processed during November and April 2014 in VISN 16. VA staff are
unable to distinguish the reason why claims were closed during those
timeframes. However, VA's Purchased Care office does have a department
responsible for Audits and Internal Controls and monitors payment
accuracy and addresses specific claims processing errors. In addition
VA has established claims processing measures to monitor status of
claims at all payment locations. Claims timeliness is monitored daily
with weekly conference calls with all payment locations to monitor the
status of claims processing and implementation of corrective actions.
______
Response to Posthearing Questions Submitted by Hon. Patty Murray to
David J. McIntyre, Jr., President and Chief Executive Officer, TriWest
Healthcare Alliance
Question 1. Private Providers and Non-VA Care
TriWest and Health Net both play major roles in both the Choice
Program and in the Patient Centered Community Care Program. Some very
important controls were put into the PCCC program, including
requirements to coordinate health care and more oversight of the
quality of care. As major contractors administering PCCC regions, each
company made certain assumptions about workload and other factors in
setting up business plans and provider networks for the PCCC program.
How is management of the PCCC contracts affected with large portions of
the workload going through the Choice Program instead?
Response. Overall, the biggest challenge we have is explaining some
of the billing differences between the PC3 and Choice programs to
providers in our network. For the PC3 program, our contract is explicit
in its prohibition on providers collecting any funds from the Veteran.
One hundred percent of the bill is paid by TriWest on behalf of VA.
When that same Veteran is seeking care under the Choice program, the
law requires that his or her private insurance provide first dollar
coverage if the care is for the treatment of a non-service-connected
condition. That creates provider confusion and it is one of the reasons
I advocated, what I called ``harmonization'' of the programs in my
opening statement.
Additionally, while we received very little from VA in the way of
anticipated volumes for the PC3 program, we were generally assured that
referrals for care made to TriWest from VA would result in a patient
visit. In that sense, we were able to predict with some level of
certainty the staffing we needed to deliver timely service. With the
Choice Program, at the outset it was not uncommon that only 15-20% of
the eligible patients would ever call us to use the program to receive
services in the community. However, we are never really sure from one
day to the next what the ``uptake'' rate will be from the Choice-
eligible population. That creates substantial challenges in
appropriately staffing for needed services on a daily and weekly basis.
Obviously, it is our hope that as we continue to partner with VA
and educate Veterans about the benefit of the program, some stability
in expected utilization will occur. But, for now, it is a constant
challenge to monitor over or under staffing for needed services.
The only other issue is the multiple different reporting
requirements that have us segmenting out workload by program. We
certainly understand that it is important to track activity in ways
that assure accurate accounting and program utilization. However, at
times, the segmentation can present a picture of individual programs in
isolation of the entirety of the efforts to provide care and service to
Veterans.
______
Response to Posthearing Questions Submitted by Hon. Bill Cassidy to
David J. McIntyre, Jr., President and Chief Executive Officer, TriWest
Healthcare Alliance
Question 2. Mr. McIntyre, After listing the challenges in your
testimony that TriWest confronted in implementing a Patient Centered
Community Care (PC3) across 28 States to give VA medical centers a
consistent way to provide veterans access to care from a network of
providers, you described a pilot done in the collaboration with the
Dallas VAMC. At what point, was it decided to implement a pilot? If you
are finding the pilot successful, why wasn't that a strategy before
implementation in 28 states to avoid some of the challenges you listed?
Response. The pilot program in Dallas was specifically targeted at
a challenge brought about by implementation of the Choice program; not
the PC3 program. When the Choice program was first implemented, a major
issue that was identified was the fact that providers in the community
would need clinical consults (medical notes that also include the
recommended or suggested specialty service needed) prior to providing
services. There were only two ways for VA to provide that information
to TriWest so that we could, in turn, hand it to community providers:
provide it all up front or provide it only when needed following
outreach from a Veteran.
The second option certainly seemed to be a more efficient and
effective way to provide the information. However, given the short
timeframe of 90 days to stand up the program in its entirety and the
backlog of patients on wait lists when the program went live, we all
were rightly concerned that VA had no personnel operations or processes
through which it could receive requests for those records and turn them
around in a timely fashion. While we all wished it was not the case, we
were forced to deal with the reality that attempting this at the outset
could very well lead to more delays, not fewer.
As such, we started the program with a system whereby VA sent a
consult for every Veteran deemed eligible for care under the Choice
program rules outlined by Congress regardless of whether the Veteran
reached out to TriWest for care. It was our hope that this would ensure
that TriWest would have all of the necessary information to help the
Veteran as soon as he or she decided to reach out to the Choice program
for assistance in obtaining a community care appointment. As the
program grew, the number of clinical consults sent to TriWest grew
right along with it. Yet, it was still the case that fewer than half of
those eligible patients were reaching out to the Choice program for
appointments.
At this point, TriWest and VA realized that there were more than
enough staff processing consults that we could comfortably begin to
implement the more efficient and effective solution we all wanted to
attempt initially. And we started to test that operationally in Dallas,
Texas in the form of a pilot program.
______
Response to Posthearing Questions Submitted by Hon. Patty Murray to
Donna Hoffmeier, Vice President and Program Officer, VA Services,
Health Net Federal Services
private providers and non-va care
Question. TriWest and HealthNet both play major roles in both the
Choice Program and in the Patient Centered Community Care Program. Some
very important controls were put into the PCCC program, including
requirements to coordinate health care and more oversight of the
quality of care. As major contractors administering PCCC regions, each
company made certain assumptions about workload and other factors in
setting up business plans and provider networks for the PCCC program.
How is management of the PCCC contracts affected with large portions of
the workload going through the Choice Program instead?
Response. Both PCCC and Choice support providing eligible Veterans
with access to health care through a comprehensive network of
community-based, non-VA medical professionals and facilities. The PCCC
contract, awarded to Health Net in September 2013, was phased in over a
six month period, with services beginning in January 2014. In
October 2014, VA amended the PCCC contract to include several
components of the Choice Act (such as production and distribution of
Choice Cards, establishment of a call center, and other administrative
functions) and required very fast implementation in one month.
PCCC and Choice are designed to achieve the same objective of
enabling VA to provide all eligible Veterans with access to the care
they need in the local community. In support of PCCC and Choice
contract requirements, we have developed policies and processes to meet
requirements to coordinate Veterans' healthcare and provide oversight
of quality. For example, in building provider networks, we tailor the
network to meet the Veteran's health care needs, as identified by the
VA Medical Center that is submitting authorizations while meeting the
specific requirements of PCCC and Choice. Choice Program participation
requirements make it easier for providers to participate, and as a
result we are able to get Choice providers on-board more quickly, which
enhances Veterans' access to community care.
Currently, the range of options (e.g., PCCC, Choice, affiliate
agreements/direct contracts, individual authorizations) for non-VA fee
care is confusing for Veterans, providers, and VA staff. As VA
discusses options to streamline the programs for non-VA care through
greater use of PCCC and Choice, we would anticipate greater efficiency
in care delivery.
Chairman Isakson. All right. Welcome back to the Senate
Veterans' Affairs Committee. It was a good first panel. I
apologize to our second panelist that it took so long, but I
think it was beneficial, and from the participation you all
were illustrating by the looks on your faces, I am sure you
enjoyed it, too. Thank you very much.
For our second panel we have Mr. Roscoe Butler, the Deputy
Director for Health Care for The American Legion. Roscoe, good
to have you.
Darin Selnick, Senior Veterans Affairs Advisor for
Concerned Veterans for America.
Joseph Violante, National Legislative Director, Disabled
American Veterans.
Mr. Bill Rausch--who is missing in action right now, or
AWOL--Political Director for Iraq and Afghanistan Veterans of
America.
And Carlos Fuentes, Senior Legislative Associate of the
Veterans of Foreign Wars.
We welcome all of you for being here today, and we will
start with you, Mr. Butler.
STATEMENT OF ROSCOE G. BUTLER, DEPUTY DIRECTOR, HEALTH CARE,
VETERANS AFFAIRS AND REHABILITATION DIVISION, THE AMERICAN
LEGION
Mr. Butler. Chairman Isakson, Ranking Member Blumenthal,
and distinguished Members of the Committee, on behalf of our
national commander, Michael Helm, and the 2.3 million members
of The American Legion, we thank you for this opportunity to
testify regarding The American Legion's views of the progress
of the Veterans Choice Program.
The American Legion supported the Veterans Access, Choice,
and Accountability Act of 2014 as a means of addressing
emerging problems within the Department of Veterans Affairs. VA
wait times for outpatient medical care had reached an
unacceptable level nationwide as veterans struggled to receive
access to timely health care within the VA health care system.
It was clear that swift changes were needed to ensure veterans
could access health care in a timely manner. As a result, The
American Legion immediately took charge by setting up veterans
benefits centers (VBCs) in large and small cities across the
country to assist veterans in need and their families as a
result of the systemic scheduling crisis facing the VA.
The American Legion VBCs' charge is to work firsthand with
veterans experiencing difficulties in obtaining health care or
having difficulties in receiving their benefits.
On November 5, 2014, VA rolled out the Veterans Choice Card
Program, and after 6 months, it is clear the program fell short
of the initial projections from the CBO. According to the VA
latest Daily Choice Metrics dated November 30, 2014, there were
approximately 51,000 authorizations issued for non-VA care
since implementation of the Choice Program, with about 49,000
appointments scheduled. When you compare these numbers to the
over 8 million Choice Cards issued, one would ask: Why did VA
issue so many Choice Cards? Nevertheless, The American Legion
is optimistic that the recent rule change by eliminating the
straight-line rule and using the actual driving distance will
allow more veterans access to health care under the Choice
Program.
The American Legion also believes that if VA were to move
forward with the 40-mile rule change to only include a VA
medical facility that can provide the needed medical care or
services, everyone would see increases in utilization and
access to non-VA health care.
The American Legion applauds the Senate for unanimously
passing an amendment reminding the Department of Veterans
Affairs they have the obligation to provide non-VA care when it
cannot offer the same treatment at one of its own facilities
that is within the 40-mile driving distance from the veteran's
home. We now call upon the House to take up H.R. 572, the
Veterans Access to Community Care Act, and ensure its swift
passage. Let us get these bills to the President's desk and
make sure we are taking care of our rural veterans.
During a recent visit last month to examine the health care
system in Puerto Rico, The American Legion learned that VA
staff had been mistakenly telling veterans that no one on the
island is eligible for health care under the Veterans Choice
Card Program because there is no medical facility that is
further than 40 miles from anywhere anyone lives on the island.
The American Legion is concerned that as a result of inadequate
training, there could be staff at many health care facilities
who failed to receive proper training as a result of bad
communications and providing incorrect information to veterans.
Recently, The American Legion learned that the VA contract
with Health Net and TriWest required these third-party
administrators to report Daily Choice Metrics. However, this
contractor requirement has now expired, and the TPAs are no
longer required to report these daily metrics. The last report
VA provided to VSOs was dated March 31, 2015. The American
Legion is concerned that since the TPAs are no longer required
to provide these daily metrics, VA can easily lose track of the
numbers.
The American Legion calls on Congress to require VHA to
continue reporting these daily metrics throughout the duration
of the contract or explain how they will continue to track this
information. In fiscal year 2014, VA spent over $7 billion on
non-VA health care. Many of the non-VA purchased care programs
are managed by different program officers in VA's central
office, and some of these services are handled outside of VA's
fee-basis claim processing system. VA should streamline its
current purchased care model to incorporate all of VA's non-VA
care programs into a single integrated purchased care model.
Congress should also look into streamlining the VA's non-VA
care statutory authorities. Once Congress gets a better sense
of how the Choice Program will play out over the next couple of
years, VA's non-VA care statutory authorities should be
consolidated and rationalized incorporating lessons learned
from the VA Choice Program.
Thank you, and, again, Mr. Chairman, Ranking Member
Blumenthal, I appreciate the opportunity to present The
American Legion's views and look forward to answering any
questions you may have.
[The prepared statement of Mr. Butler follows:]
Prepared Statement of Roscoe G. Butler, Deputy Director, Health Care,
Veterans Affairs and Rehabilitation Division, The American Legion
Chairman Isakson, Ranking Member Blumenthal, and distinguished
Members of the Committee, On behalf of our National Commander, Michael
Helm, and the 2.3 million members of The American Legion, we thank you
for this opportunity to testify regarding The American Legion's views
of the progress of the Department of Veterans Affairs veterans choice
program.
background
The American Legion supported the passage of H.R. 3320, the
``Veterans Access, Choice, and Accountability Act (VACAA) of 2014''
that was signed into law on August 7, 2014 as Public Law (PL) 113-146;
as a means of addressing emerging problems within the Department of
Veterans Affairs (VA). VA's wait time for outpatient medical care had
reached an unacceptable level nationwide and veterans were struggling
to receive access to care within the VA healthcare system. It was clear
that swift changes were needed to ensure veterans could access health
care in a timely manner. Congress implemented this law to ensure when
VA could not provide access to timely, high-quality health care inside
the VA health care system; eligible veterans could elect to receive
needed health care outside the VA health care system as a temporary
measure until VA corrected its wait-time problem. The law authorizes
veterans who were enrolled as of August 1, 2014, current eligible, or
recently discharged combat veterans, the ability to be seen outside the
VA by an approved non-VA health care provider if they are unable to
schedule an appointment within 30 days of their preferred date,
clinically appropriate date, or live more than 40 miles from a VA
medical facility.\1\
---------------------------------------------------------------------------
\1\ Public Law 113-146--August 7, 2014: Veterans Access, Choice,
and Accountability Act of 2014: http://www.gpo.gov/fdsys/pkg/PLAW-
113publ146/pdf/PLAW-113publ146.pdf
---------------------------------------------------------------------------
assessment of the choice program to date
On November 5, 2014, The Department of Veterans Affairs Veterans
Health Administration (VHA) started the Veterans Choice program in
three stages of implementation. The initial step VHA took was to mail
320,000 choice cards to enrolled veterans who reside more than 40 miles
from any type of VA medical facility. On November 17, 2014, VHA
initiated the second stage by mailing the choice card to those veterans
who were currently waiting for an appointment longer than 30 days from
their preferred date or the date determined to be medically necessary
by their physician. The third and final stage was to mail choice cards
and letters to the remainder of all veterans enrolled in the VA health
care who may be eligible for the Choice Program in the future. The card
mailings included a letter explaining how to verify eligibility and use
the choice card. As of February 2, 2015, according to the latest Daily
Choice Metrics obtained from VA Health Net, one of the third-party
administrators (TPAs) authorized 16,644 veterans to be seen outside the
VA healthcare system under the Choice Program, of which 13,733
appointments were scheduled. Similarly, TriWest, another TPA issued
34,909 authorizations, and scheduled 34,909 appointments. Based on this
information, the authorizations totaled 50,936 and appointments
scheduled totaled 48,642. When you compare the number of authorizations
and appointments scheduled to the 8,671,993 Veterans Choice Cards
issued, one can easily arrive at a conclusion that the program is off
to a slow start. However, The American Legion is optimistic that the
recent changes used to calculate the distance between a veteran's
residence and the nearest VA medical facility, moving from a straight-
line distance to actual driving distance, will allow more veterans
access to care under the Veterans Choice program.
Recently, The American Legion learned that the portion of VHA's
Veterans Choice contract with Health Net and TriWest, which requires
the TPA's to report Daily Choice metrics, has expired and the TPA's
will no longer be reporting this information to VA. The American Legion
is concerned that if the TPA's are no longer required to provide this
type of information the number can be easily manipulated and may become
an issue in the future. The American Legion calls upon Congress to
require VHA to continue reporting these daily metrics throughout the
duration of the contract, or explain how they will continue to track
this information. One of the critical functions of the original
legislation was to provide metrics on how and where the program was
being used as a bellwether to indicate where VA needed to improve
capacity in their system or efficiency of care delivery. By examining
where the Choice program is used most heavily, stakeholders should be
able to determine where improvements are needed in VA's overall care
network.
actions needed to eliminate impediments to greater veteran and
physician participation
On February 25, 2015, American Legion National Commander Michael D.
Helm stated during his congressional testimony before the Senate and
House Veterans' Affairs Committees that one of the biggest challenges
he has seen with the implementation of the Veterans Choice Card Program
is the confusion over VA's definition of a VA medical facility.
On November 5, 2014, VA published a regulation which defines a ``VA
medical facility'' as a VA hospital, a VA community-based outpatient
clinic (CBOC), or a VA health care center. VA further stated that they
``* * * included these types of VA facilities because they provide
medical care or hospital services that may be provided as part of the
program.'' \2\ However, there is no consideration as to whether the VA
medical facility can provide veterans the needed medical services. In
many cases, veterans are being referred from a CBOC to the parent VA
medical center which can be over 150 miles further away without taking
into account travel times and road conditions. This can significantly
impact veterans' ability to maintain their appointments, which directly
impact VA's appointment cancellation and no-show rates.
---------------------------------------------------------------------------
\2\ Federal Register, 79 FR 65571: https://www.Federalregister.gov/
articles/2014/11/05/2014-26316/expanded-access-to-non-va-care-through-
the-veterans-choice-program
---------------------------------------------------------------------------
During The American Legion's Commander's testimony, Senator Moran
(KS) emphasized the importance of providing non-VA health care to
veterans. Senator Moran calculated the distance from Helm's home in
Norcatur, Kansas to the nearest VA medical facilities.
``It's 267 miles to Denver, 287 miles to Wichita, 287 miles
to Omaha, and 100 miles to the nearest Community Based
Outpatient Center (CBOC). I appreciate the perspective that
this commander will bring about caring for all veterans
regardless of where they live in the United States.'' \3\
---------------------------------------------------------------------------
\3\ Commander to Congress: We face `historic opportunities'-
February 26, 2015: http://www.legion.org/washingtonconference/226220/
commander-congress-we-face-%E2%80%98historic-opportunities%E2%80%99
On March 27, 2015, American Legion National Commander Mike D. Helm
praised the Senate for unanimously passing an amendment to remind the
Department of Veterans Affairs that they have the obligation to provide
non-VA care when it cannot offer that same treatment at one of its own
facilities that is within 40-miles driving distance from a veteran's
home. According to Commander Helm, the call to VA to clarify its stance
was embodied in an amendment, offered by Senator Jerry Moran, R-Kansas,
to Senate's budget Resolution 11.\4\
---------------------------------------------------------------------------
\4\ Congress.gov: https://www.Congress.gov/bill/114th-congress/
senate-concurrent-resolution/11
``This bill simply calls on VA to do what it already had the
authority to do,'' National Commander Michael D. Helm said.
``Intent is everything. When Congress passed the Veterans
Access, Choice and Accountability Act last year, it once again
gave VA this authority. I say `once again' because VA had this
authority on a fee-basis long before the Choice act. Despite
this authority, VA was trying to find loopholes by denying
people who were near VA clinics that did not offer the needed
services the right to use an alternative provider.''
``We applaud Senator Jerry Moran for writing this amendment,
even though it's a shame that such a common sense measure needs
to be spelled out repeatedly for VA. We call on the House to
pass this measure quickly and send an unmistakable message to
VA.''
efforts to ensure adequate training of va staff regarding
the choice program
The American Legion is concerned that due to improper training,
some VA medical centers are not offering Choice access to their
veterans at all. On a recent visit last month to examine the healthcare
system in Puerto Rico, The American Legion discovered VHA staff had
been mistakenly telling veterans that no one on the island is eligible
because there is no medical facility that is further than 40 miles from
anywhere on the island. The American Legion also heard scattered
reports of similarly confusing directives about the program from some
other medical facilities, in contradiction to what was being expressed
by VA Central Office directives. This can only occur when employees are
not adequately trained, which can result in miscommunication. Better
understanding of programs and communication between VA and the veterans
they serve is essential to the success of any VA program.
In a recent Senate Veterans Affairs hearing, Debra Draper Director
of Health Care Issues Government Accountability Office (GAO) stated:
``the veterans health care system was added to the high-risk
list due to ambiguous policies and inconsistent processes;
inadequate oversight and accountability; information technology
challenges (such as outdated systems that lack
interoperability); inadequate training for VA staff; and
unclear resource needs and allocation priorities.'' \5\
---------------------------------------------------------------------------
\5\ GAO Testimony: Veterans Affairs Health Care, Addition to GAO's
High Risk List and Actions Needed for Removal, GAO-15-580T http://
www.gao.gov/assets/670/669927.pdf
Since the implementation of the Veterans Choice Program, The
American Legion has seen and heard from veterans Nation-wide, that
there was a complete lack of training and knowledgeable staff regarding
the program requirements, rules and regulations. The American Legion is
concerned when the Veterans Choice program was rolled out, VA did not
issue an official national policy to its health care facilities
outlining VA's policy, procedures and program requirements. However,
---------------------------------------------------------------------------
VHA Directive 6330, ``Directives Management System'' (DMS), states:
``It is VHA policy that VHA Central Office, VHA Veterans
Integrated Service Networks (VISNs) and their field facilities
establish and maintain a DMS, in accordance with this VHA
Directive and corresponding Handbooks, regarding ``directive''
and ``non-directive'' media. Directive documents contain
mandatory policies, procedures, and, as indicated, oversight
monitoring requirements.''
This directive establishes mandatory VHA policies for VHA
Programs.\6\ According to VHA Directive 6330, VHA can issue two types
of policy Directives, a VHA DMS Directive or a VHA Temporary Directive.
---------------------------------------------------------------------------
\6\ Department of Veterans Affairs VHA Directive 6330- December 15,
2008: http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1814
---------------------------------------------------------------------------
A VHA DMS directive establishes mandatory VHA policies for VHA
Programs. These Directives must be recertified every 5 years. A VHA
Temporary Directive defines policy that has a limited time span or new
program policies that will be incorporated in DMS Handbooks at a later
date. A Temporary Directive carries an expiration date and is not
issued for longer than 5 years. If the policies prescribe short-term
requests for reports, data collection or implement special short-term
programs, they are issued as temporary directives with a 5-year (or
less) expiration date specified.
The lack of VHA policies and procedures outlining the Veteran
Choice program requirements and procedural guidance for VHA field
facilities staff to follow has significantly undermined VA's ability to
educate and provide appropriate guidance to its employees. These
policies and procedures when implemented are often used by VA staff to
properly train employees throughout the health care system.
The American Legion believes when a new law is passed implementing
new program requirements or changes, VHA should be required to provide
Veterans Service Organizations and Congress a detail communication plan
outlining it plans to implement the changes required by the law to
include plans for staff training. In additional to this information,
VHA should include the timeframe for issuing any VHA Directives and
Handbooks.
increasing access to care by streamlining va's multiple non-va care
programs into a single integrated purchased care model
VA spent over $5.5 billion on Non-VA care in Fiscal Year 2014. Many
of VA's non-VA purchase care programs are managed by different program
offices within VHA, and purchases for Contract Nursing Home, VA's State
Home, Home Health, Dental and Bowel and Bladder services are handled
outside of VA's Fee-Basis Claims Processing System. VA needs to
streamline its current purchase care model to incorporate all of VA's
non-VA care programs into a single integrated purchase care model.
Congress should also look into streamlining VA's non-VA care
statutory authorities. Currently, there are eight statutory
authorities, including the new Choice Act. Once Congress gets a better
sense of how the Choice Program will play out over the next couple of
years, the eight statutory authorities should be consolidated and
rationalized incorporating lessons learned from the Choice Program.
conclusion
As always, The American Legion thanks this subcommittee for the
opportunity to explain the position of the 2.3 million veteran members
of this organization.
For additional information regarding this testimony, please contact
Mr. Warren J. Goldstein at The American Legion's Legislative Division
at (202) 861-2700 or [email protected].
Chairman Isakson. We appreciate the Legion's willingness to
follow up and come to all our hearings and give us the
testimony we need. Thank you, Roscoe.
Darin Selnick, senior veterans affairs advisor for the
Concerned Veterans of America.
STATEMENT OF DARIN SELNICK, SENIOR VETERANS AFFAIRS ADVISOR,
CONCERNED VETERANS FOR AMERICA
Mr. Selnick. Chairman Isakson, Ranking Member Blumenthal,
and Members of the Committee, I appreciate the opportunity to
testify at today's hearing on the implementation and future of
the Veterans Choice Program, and thank you for your leadership
in ensuring that veterans get the quality health care they
deserve.
Today true choice in veterans health care remains out of
reach for most veterans: like a mirage in the desert, as you
move closer it recedes into the horizon. Our assessment is that
the Choice Program has been unsuccessful and is not a long-term
solution. As such, we have developed recommendations for
comprehensive reform through the Fixing Veterans Health Care
Taskforce.
The current rules pertaining to choice do not represent
real choice. Instead they require veterans to obtain approval
from VA before they are able to make a choice. Veterans should
not have to ask for permission to select their health care
provider.
The VA implementation of the Choice Program has been a
failure. For example, the Associated Press reported, ``GAO says
Veterans' Health Care Costs a `High Risk' for Taxpayers....The
number of medical appointments that take longer than 90 days to
complete has nearly doubled,'' and that only 37,000 medical
appointments have been made through April 11.
Last fall, CVA commissioned a national poll of veterans.
The results showed that 90 percent favored efforts to reform
veterans health care, 88 percent said eligible veterans should
be given the choice to receive medical care from any source
they choose, and 77 percent said they want more choices even if
it involved higher out-of-pocket costs.
Choice and competition are the bedrock of today's health
care system. We choose our health care insurance, provider, and
primary care physician. Health care organizations provide
quality and convenient care because they know if they do not,
they will lose their patients to someone else. In order to fix
the VA health care system, both choice and competition must be
injected into the system.
VA recognized this when they said ``evaluate options for a
potential reorganization that puts the veteran in control of
how, when, and where they wish to be served.'' Unfortunately,
veterans do not have that control and will not under the
current VA health care system.
VA needs to have a 2015 health care system. We believe the
Veterans Independence Act is the road map and solution to do
just that. This road map was developed by the Fixing Veterans
Health Care Task Force, co-chaired by Dr. Bill Frist, former
Senate Majority Leader; Jim Marshall former Congressman from
Georgia; Avik Roy of the Manhattan Institute; and Dr. Mike
Kussman, former VHA Under Secretary.
We developed ten veteran-centric core principles that serve
as the guiding foundation. These ten principles included: the
veteran must come first, not the VA; veterans should be able to
choose where to get their health care; refocus on, and
prioritize, veterans with service-connected disabilities and
specialized needs; VA should be improved, and thereby
preserved; grandfather current enrollees; and VHA needs
accountability.
To implement these principles, we laid out three major
categories of reform and nine policy recommendations.
First, restructure the VHA as an independent, Government-
chartered nonprofit corporation, empowered to make decisions on
personnel, IT, facilities, partnerships, and other priorities.
Second, give veterans the option to seek private health
care coverage with their VA funds.
Third, refocus veterans' health care on those with service-
connected injuries--VA's original mission.
The key policy recommendations included: separate the VA's
payer and provider functions into separate institutions;
establish the Veterans Health Insurance Program as a program
office in VHA; establish the Veterans Accountable Care
Organization, VACO, as a nonprofit Government corporation fully
separate from VA; preserve the traditional VA health benefit
for enrollees who prefer it, while offering an option to seek
coverage from the private sector through three plan choices:
VetsCare Federal: Full access to the VACO integrated
health care system with no changes to benefits or cost
sharing;
VetsCare Choice: Select any private health care
insurance plan legally available in their State,
financed through premium support payments; and
VetsCare Senior: Medicare-eligible veterans can use
their VA funds to defray the costs of Medicare premiums
and supplemental coverage.
Last, create a VetsCare Implementation Commission, to
implement the Veterans Independence Act.
We retained the services of HSI to conduct a fiscal
analysis. HSI determined a properly designed version of these
policy recommendations is likely to be deficit neutral.
In order to fix veterans health care, we must always keep
in mind what General Omar Bradley said in 1947: ``We are
dealing with veterans, not procedures; with their problems, not
ours.''
That is why we urge you to use the Veterans Independence
Act road map to develop the legislative blueprint that will fix
and be the future of veterans health care. Veterans must be
assured that they will be able get the access, choice, and
quality health care they deserve. In this mission, failure is
not an option.
We are committed to overcoming all and any obstacles that
stand in the way of achieving this important mission, and we
look forward to working with the Chairman, Ranking Member, and
all Members of this Committee to achieve this shared mission.
Thank you.
[The prepared statement of Mr. Selnick follows:]
Prepared Statement of Darin Selnick, Senior Veterans Affairs Advisor,
Concerned Veterans for America
Thank you Chairman Isakson, Ranking Member Blumenthal, and Members
of the Committee. I appreciate the opportunity to testify at today's
hearing on the implementation and future of the veterans choice program
and your leadership in ensuring that veterans get timely and convenient
access to the quality health care they deserve.
Nearly as we approach the one year anniversary of the passage of
the Veterans Access, Choice and Accountability Act of 2014, true choice
in veteran's health care remains out of reach for most veterans: like a
mirage in the desert, as you move closer it recedes into the horizon.
Our assessment is that the choice program has been unsuccessful and is
not a tenable long-term solution. As such, we have developed
recommendations for comprehensive reform through the Fixing Veterans
Health Care Taskforce.
The current rules pertaining to choice do not represent real
choice. Instead they require veterans to obtain approval from VA before
they are able to make a choice. Veterans should not have to ask for
permission to select their health care provider.
The VA implementation of the choice program has been a failure. For
example, the Associated Press has reported that ``GAO says Veterans'
Health Care Costs a ``High Risk'' for Taxpayers'' \1\ and that ``The
number of medical appointments that take longer than 90 days to
complete has nearly doubled.'' \2\ They have also noted that ``only
37,648 medical appointments have been made through April 11.'' \3\
---------------------------------------------------------------------------
\1\ Associated Press. ``GAO: Veterans' Health Care Cost a 'High
Risk' for Taxpayers'' New York Times Online. ABC News Online, 11 Feb.
2015. Web. 11 Feb. 2015.
\2\ Associated Press. ``VA Makes Little Headway in Fight to Shorten
Waits for Care'' ABC News Online. ABC News, 09 April 2015. Web.
09 April 2015.
\3\ Associated Press. ''$10B Veterans Choice program more underused
than previously thought'' Stars and Stripes Online. Starr and Stripes,
23 April 2015. Web. 23 April 2015.
---------------------------------------------------------------------------
Last fall, Concerned Veterans for America commissioned a national
poll of veterans. The results of that poll showed that 90% favored
efforts to reform veteran health care, 88% said eligible veterans
should be given the choice to receive medical care from any source they
choose and 77% said give veterans more choices even if it involved
higher out-of-pocket costs.
Choice and competition are the bedrock of today's health care
system. We choose our health care insurance, provider and primary care
physician. Health care organizations provide quality, timely and
convenient care, because they know if they don't, they will lose their
patients to someone else. In order to fix the VA health care system,
both choice and competition must be injected into system.
Secretary Bob McDonald's VA has recognized this in a fact sheet
wherein they promise to ``evaluate options for a potential
reorganization that puts the Veteran in control of how, when, and where
they wish to be served.''\4\ Unfortunately veterans do not have that
control and will not under the current VA health care system.
---------------------------------------------------------------------------
\4\ ``The Road to Veterans Day 2014 Fact Sheet'' http://
www.blogs.va.gov/VAntage/wp-content/uploads/2014/09/
RoadToVeteransDay_FactSheet_Final.pdf, accessed May 5, 2015.
---------------------------------------------------------------------------
The outmoded VA health care system that currently exists needs to
become a 2015 health care system. We believe the Veterans Independence
Act is the roadmap and solution to do just that. This roadmap is part
of the Fixing Veterans Health Care report developed by a Bi-Partisan
Policy Taskforce co-chaired by Dr. Bill Frist, former Senate Majority
Leader, Jim Marshall former Congressman from Georgia, Avik Roy of the
Manhattan Institute and Dr. Mike Kussman, former VHA Under Secretary.
The solutions and actions recommended are designed to provide
concrete reforms to dramatically improve the delivery of health care to
the 5.9 million unique veteran patients served by the VA.
We first developed ten veteran-centric core principles that serve
as the guiding foundation. These ten principles are:
1. The veteran must come first, not the VA
2. Veterans should be able to choose where to get their health
care
3. Refocus on, and prioritize, veterans with service-connected
disabilities and specialized needs
4. VHA should be improved, and thereby preserved
5. Grandfather current enrollees
6. Veterans health care reform should not be driven by the budget
7. Address veterans' demographic inevitabilities
8. Break VHA's cycle of ``reform and failure.''
9. Implementing reform will require bipartisan vision, courage and
commitment
10. VHA needs accountability
In order to implement these principles, we laid out three major
categories of reform and proposed nine policy recommendations.
First, restructure the VHA as an independent, government-
chartered non-profit corporation, fully empowered to make
difficult decisions on personnel, I.T., facilities,
partnerships, and other priorities.
Second, give veterans the option to seek private health
coverage with their VA funds.
Third, refocus veterans' health care on those with service-
connected injuries--which was the VA's original mission.
These reforms are carried out by nine policy recommendations:
1. Separate the VA's payor and provider functions into separate
institutions, the Veterans Health Insurance Program (VHIP) and the
Veterans Accountable Care Organization (VACO).
2. Establish the Veterans Health Insurance Program (VHIP) as a
program office in the Veterans Health Administration.
3. Establish the Veterans Accountable Care Organization (VACO) as a
non-profit government corporation fully separate from Department of
Veterans Affairs.
4. Institute a VA Medical Center realignment procedure (MRAC)
modeled after the Defense Base Realignment and Closure Act of 1990
(BRAC).
5. Require the VHA to report publicly on all aspects of its
operation, including quality, safety, patient experience, timeliness,
and cost-effectiveness.
6. Preserve the traditional VA health benefit for current enrollees
who prefer it, while offering an option to seek coverage from the
private sector through three plan choices.
VetsCare Federal: Full access to the VACO integrated health
system with no changes to benefits or cost-sharing
VetsCare Choice: Select any private health insurance plan
legally available in their state, financed through premium
support payments.
VetsCare Senior: Medicare-eligible veterans can use their VA
funds to defray the costs of Medicare premiums and supplemental
coverage (``Medigap'').
7. Reform health insurance coverage for future veterans.
8. Offer veterans' access to the Federal Long Term Care Insurance
Program.
9. Create a VetsCare Implementation Commission, to implement the
Veterans Independence Act.
To understand the fiscal impact of these policy recommendations, we
retained the services of Health Systems Innovation Network to conduct a
fiscal analysis. HSI determined a properly designed version of these
policy recommendations is likely to be deficit neutral.
In order to fix veterans health care we must always keep in mind
what General Omar Bradley said in 1947: ``We are dealing with veterans,
not procedures; with their problems, not ours.''
That is why we urge you to use the Veterans Independence Act road
map to develop the legislative blueprint that will fix and be the
future of veterans health care. Veterans must be assured that they will
be able get the access, choice and quality health care they deserve. In
this mission, failure is not an option.
CVA and the co-chairs of the taskforce are committed to overcoming
any and all obstacles that stand in the way of achieving this important
mission. We look forward to working with the chairman, ranking member,
and all Members of this Committee to achieve this shared mission.
Chairman Isakson. Thank you, Mr. Selnick.
Let me just interject at this point. I have read--and I am
sure Sen. Blumenthal has, too--the Fixing Veterans Health Care
Report that your organization did, which is an outstanding
report. I think it basically could be called ``Ultimate
Choice,'' if I am not mistaken. Wouldn't that be a good name
for it?
Mr. Selnick. Yeah, that would be a good name.
Chairman Isakson. Your representation of the changes are
probably far more broad than some on the panel might look for
us to do in terms of preserving what VA does without giving
choice, but I want to commend you on that and let you know we
are watching what you recommended. We are taking a look at it.
We are trying to make sure--Senator Blumenthal and I have one
underlying principle: we are going to make Veterans Choice
work. It is not an option that it might work; if it does not
work, we will think of something else. We are going to make it
work. How it works is going to take the very best ideas and
input, and your organization's report is one of those that is
going to help us a lot, as is each stakeholders' input. This is
going to be a process of evolution as we go, but one thing is
for sure: we are not just hoping it is going to be over one
day. We are going to make it happen one way or another.
Mr. Selnick. Thank you.
Chairman Isakson. Mr. Violante.
STATEMENT OF JOSEPH A. VIOLANTE, NATIONAL LEGISLATIVE DIRECTOR,
DISABLED AMERICAN VETERANS
Mr. Violante. Chairman Isakson, Ranking Member Blumenthal,
and Members of the Committee, on behalf of the DAV and our 1.2
million members, all of whom were wounded, injured, or made ill
from their wartime service, thank you for the opportunity to
testify on the temporary Choice Program. While it is too early
to reach conclusions about this program, we are beginning to
see some lessons.
As of last week, almost 54,000 Choice authorizations have
been made and 43,000 appointments have been scheduled. By
comparison, about 6 million appointments are completed monthly
inside VA and another 1.3 million appointments are completed
outside VA using non-VA care programs other than Choice.
A number of reasons likely contributed to this lower than
expected utilization of the Choice Program. Since last spring,
VA has used every available resource to increase its capacity
to provide timely care that may have shifted some of the demand
away from Choice.
VA was slow in rolling out Choice cards and in educating
its staff. We also have high-risk troubling reports of a
significant lag time between when a VA clinician determines a
veteran is eligible for Choice and third-party administrators
can see this authorization in their system.
Finally, some veterans simply prefer to go to VA. The
bottom line is we do not have adequate information today and
need to take steps to gather sufficient data before making any
permanent changes. We must study private sector wait times and
access standards, coordination of care, patient satisfaction,
and health outcomes for those who use the Choice Program.
Mr. Chairman, recently DAV, VFW, the Legion, IAVA, and
others wrote to congressional leaders to extend the mandate of
the Commission on Care to allow at least 12 months for its
interim report and at least an additional 6 months for the
final report. We called on Congress to refrain from making any
permanent, systemic changes until after the Commission
submitted its recommendations and then allowed sufficient
opportunity for stakeholders and Congress to engage in a debate
worthy of the men and women who served.
For more than 150 years, going back to President Lincoln's
solemn vow--``to care for him who shall have borne the
battle''--the VA health care system has been the embodiment of
our national promise, yet today some are proposing to make it
just another choice among health care providers, while others
are calling for the VA to be downsized or eliminated. But for
millions of veterans wounded, injured, or ill from their
service, there is only one choice for receiving the specialized
care they need, and that is a healthy and robust VA.
Although the VA provides comprehensive medical care to more
than 6 million veterans, the VA's primary mission is to meet
the unique, specialized health care needs of the Nation's 3.8
million service-connected disabled veterans. If VA was
downsized or eliminated, the private health care system would
be unable to provide timely access to the specialized care they
require. Even if all disabled veterans were dispersed into
private care, they would only be 1.5 percent of the total adult
population. Does anyone truly believe that a market-based
civilian health care system would provide the focus and
resources necessary for this small minority in the way VA does?
Mr. Chairman, while it is far too soon to settle on how to
reform the VA health care system and integrate non-VA care, we
can at least outline a framework for rebuilding, restructuring,
restructuring, realigning, and reforming the VA health care
system.
First, rebuild and sustain VA's capacity by recruiting,
hiring, and retaining sufficient clinical staff, and by funding
a long-term strategy to repair and maintain VA facilities.
Second, restructure the many non-VA care programs into a
single integrated extended care network which incorporates the
best features of fee-based, ARCH, PC3, and other purchased care
programs and provide this program with a separate and
guaranteed funding source.
Third, realign and expand VA health care to meet the
diverse needs of future generations of veterans, including
women veterans. This should include new urgent-care nationwide
with extended operating hours.
Fourth, reform VA management by redesigning its performance
and accountability report and restructuring its budget process
by implementing a PPBE system, which stands for planning,
programming, budgeting, and execution.
Mr. Chairman, this framework is not intended to be a final
or detailed plan, nor could it be part of one at this point.
But it offers a new pathway toward a future that truly fulfills
Lincoln's promise.
That concludes my testimony, and I would be happy to answer
any questions.
[The prepared statement of Mr. Violante follows:]
Prepared Statement of Joseph A. Violante, National Legislative
Director, Disabled American Veterans
Chairman Isakson, Ranking Member Blumenthal, and Members of the
Committee: On behalf of the DAV and our 1.2 million members, all of
whom were wounded, injured or made ill from their wartime service,
thank you for the opportunity to testify before the Committee today to
discuss the implementation of the temporary ``choice'' program
authorized by the Veterans Access, Choice and Accountability Act of
2014 (VACAA), and how it fits into the larger issue of providing high-
quality, timely care to America's veterans.
It has been just over a year since the waiting list scandal
exploded in Phoenix; nine months since passage of the VACAA; six months
since the first ``choice `` cards were mailed out; and just over three
months since the mailing of nearly 9 million ``choice'' cards was
substantially completed. While it is still far too early to reach
significant conclusions about whether this program will achieve its
intended purpose, we are now beginning to see the outlines of early
lessons from this grand experiment.
Today's hearing is an appropriate opportunity to examine the
challenges VA has faced in implementing this unprecedented, temporary
program, to explore some of the reasons for the lower-than-expected
usage, and to consider changes and improvements to the program so that
it can achieve its short-term goal of providing timely and convenient
access for veterans seeking health care, and to start the discussion
about how best to reform the VA health care system so that we never
face this kind of access crisis again.
origins of the va health care access crisis
Mr. Chairman, in order to evaluate the success of the ``choice''
program, it is important to understand the underlying causes of the
access crisis that precipitated enactment of VACAA. While the scandal
that enveloped VA last year certainly involved mismanagement in Phoenix
and at other VA sites, we have no doubt that that principle reason
veterans were put on waiting lists was the mismatch between funding
available to VA and demand for health care from VA by veterans, a
phenomenon that is hardly new. In fact, this mismatch has been
regularly reported to Congress by DAV, our partners in the Independent
Budget (IB), and others for more than a decade.
In May 2003, the bipartisan Presidential Task Force to Improve
Health Care for Our Nation's Veterans examined chronic VA funding
shortages in the wake of growing waiting lists at VA, which had
resulted in the suspension of new enrollments for nonservice-connected
veterans. At that time, 236,000 enrolled veterans were already waiting
more than six months without any appointments--a much higher number
than during last year's crisis. However, despite clear evidence of
inadequate funding, successive Administrations and Congresses failed to
adequately increase VA funding to address the heart of the mismatch, or
to end the moratorium on new enrollment. Unfortunately, that mismatch
continues today.
Mr. Chairman, over the past decade, the IB has recommended billions
of dollars to support VA health care that the Administration did not
request and Congress never appropriated. Over that period, we and our
partner veterans service organizations have presented testimony to this
Committee and others detailing shortfalls in VA's medical care and
infrastructure budgets. In fact, in the prior 10 VA budgets, the amount
of funding for medical care requested by the Administration and
ultimately provided to VA by Congress was more than $7.8 billion less
than the amounts we recommended. Over the past five budgets, the IB
recommended $4 billion more than VA requested and Congress approved.
For this fiscal year, FY 2015, the IB had recommended over $2 billion
more than VA requested or Congress appropriated.
The other major contributor to VA's access crisis is the lack of
sufficient physical space to examine and treat all veterans in need of
care. Over the past decade, the amount of funding requested by VA for
major and minor construction to sustain its medical centers and
clinics, compared to the amount appropriated by Congress, has been more
than $9 billion less than what the IB estimated was needed to provide
VA sufficient space to deliver timely, high-quality care. Over the past
five years alone, that shortfall was more than $6.6 billion, and for
this year the VA budget request is more than $2.5 billion less than the
IB recommendation.
Mr. Chairman, we are all aware that funding levels for VA have
risen every year for more than a decade, and we appreciate that fact.
However, the demand--as measured not only by enrollees and users, but
more importantly by the number of appointments--has risen even faster.
In addition, the cost of care is rising not just due to medical
inflation, but also because of the increased cost of specialized care
provided to so many veterans being treated for traumatic physical and
mental injuries, many from the ongoing wars in Iraq and Afghanistan.
When VA does not have enough physicians, nurses and other clinical
staff, and when VA's facilities are not being properly maintained,
repaired, replaced or constructed, veterans will be required to wait
for care. It was under these circumstances that DAV and many others
supported the emergency VACAA legislation last year, but our support
was predicated on a number of very important conditions and principles.
background of the temporary choice program
First, DAV and all major veterans organizations agreed that the
most important priority was to ensure that any veteran waiting for
necessary medical care was taken care of, whether that care was
provided inside VA or in some form of care in the community. Second, in
setting up the new ``choice'' program, Congress established a separate
and mandatory funding source to ensure that VA would not need to make a
choice between providing care to veterans who chose to receive their
care at VA and paying for those who chose to access care through the
non-VA ``choice'' program. In fact, one of the primary reasons that
VA's purchased care program had struggled to meet veterans' needs was
the fact that it lacked a separate, mandated funding stream. Going
forward, Congress and VA must ensure that funding for non-VA extended
health care, however that program might be reformed, remains separate
from funding for the VA health care system.
Another principle that was central to our support for the
``choice'' program was the coordination of care, which is vital to
quality. Care coordination helps ensure that the veteran's needs and
preferences for health services and information sharing are met in a
timely manner. VA's use of third party administrator (TPA) networks
helps to assure that medical records are returned to VA, that quality
controls are in place on clinical providers, and that neither VA nor
veterans are improperly invoiced for these services. VA's use of the
TPA structure has many similarities with VA's Patient Centered
Community Care (PC3) program. Through PC3, VA obtains standardized
health care quality measurements, timely documentation of care, cost-
avoidance with fixed rates for services across the board, guaranteed
access to care, and enhanced tracking and reporting of VA expenditures.
While the use of TPAs for non-VA care does not guarantee that
coordination of care and health outcomes will meet the same standard as
an integrated VA health care system, it remains an important component
of how non-VA care should be provided in the future.
Finally, and most importantly, while the VACAA established a
temporary ``choice'' program to address an immediate need for expanded
access, it also included a significant infusion of new resources to
rebuild VA's capacity to provide timely health care. As we have
testified to this Committee and others, the underlying reason for VA's
access crisis last year was a long-term, systemic lack of resources to
hire enough physicians, nurses and other clinical professionals, along
with a lack of usable treatment space to meet the demand for care by
patients. Regardless of how both VA and non-VA care health care
programs are reformed in the future, unless adequate--and separate--
funding is provided for both, veterans will likely continue to have
unacceptable access problems.
challenges facing the choice program
According to VA, as of last week, 53,828 Choice authorizations for
care had been made to date by the TPAs and 43,044 actual appointments
for care had been scheduled. By comparison, according to VA, about 6.4
million appointments are completed each month inside the VA health care
system, and another 1.3 million appointments are completed outside VA
each month using non-VA care programs other than the ``choice''
program, including the fee-basis, contract care, PC3, ARCH and other
programs.
A number of reasons likely contributed to this lower than expected
utilization of the ``choice'' program. On the positive side, since the
most recent access crisis gained attention last spring, the VA has used
every available resource to increase its capacity to provide timely
care at facilities across the Nation. VA health care facilities
expanded their days and hours of operation; mobile health units were
deployed to areas with higher-than-average demand; and VA made greater
use of existing non-VA care authorities. VA's ability to expand its
capacity on a temporary basis may have shifted some of the demand away
from ``choice.''
It is also very clear that VA was slow in rolling out ``choice''
cards and in educating its own staff about how and when the ``choice''
program could be utilized. In part this was due to the extremely
aggressive implementation schedule in the law. However, even today we
are hearing reports of VA personnel who do not understand the
``choice'' program or its role among non-VA care authorities. As a
result, some veterans who are eligible for ``choice'' are not being
properly referred to the program, and some veterans who are eligible
for non-VA care programs, such as PC3, are inappropriately being
referred to ``choice.'' Both of these factors may have deterred some
veterans from exploring their eligibility for the ``choice'' program.
VA must do a better job of ensuring that all VA employees understand
the proper role and relationship of all non-VA care programs, including
``choice.''
We also continue to hear troubling reports of a significant lag
time between when a VA clinician determines a veteran is eligible for
``choice'' and the time that the TPA receives this authorization in its
system. In some cases, we have been told up to 30 days or more could be
required. VA must determine the cause of such unacceptable delays,
whether IT related or not, and ensure that there is a rapid and
seamless handoff from VA to the appropriate TPA. Such delays certainly
might dampen veteran interest in using the ``choice'' program.
Another possible contributing factor for the low utilization is the
restrictive manner in which the 40-mile distance criterion mandated by
VACAA was implemented. The bill established two primary access
standards to determine when and which veterans would be authorized to
use the new ``choice'' program: those who would have to wait longer
than 30 days or travel more than 40 miles for VA care. Unfortunately,
due to cost and scoring implications, the 40-mile standard was crafted,
interpreted and implemented in a way that was more restrictive than
logic and common sense would dictate, although VA has now revised that
criterion in part.
As was clearly stated in the report accompanying the law, the
determination of whether a veteran resided more than 40 miles from the
nearest VA medical facility was based on a geodesic measurement,
essentially the distance in a straight line from point-to-point, or
``as the crow flies.'' Fortunately, following further discussions
between VA and Congress, this distance has been revised so that the
calculation of 40 miles is now done by the shortest driving distance in
road miles. This change has expanded the number of veterans eligible
under the distance standard and could lead to some increase in
utilization.
The second inequity in the distance criteria is that the
measurement is taken from the veteran's residence to the nearest VA
medical facility regardless if that facility can actually provide the
service required by the veteran. As has been acknowledged by the law's
primary sponsors, these restrictive standards for measuring 40 miles
were due to the high cost estimates received from the Congressional
Budget Office (CBO) during the bill's consideration, and a need to
lower that projected cost. As we have testified previously, such a
measurement makes no logical sense and should be changed in the
temporary ``choice'' program.
However, it is important to note that creating a system that will
allow VA to immediately determine whether a service is or is not
available at a VA and/or private facility, or will be available within
a 30-day window, could be very difficult. Furthermore, VA has indicated
that the number of veterans who may live farther than 40 miles from a
VA medical center, where most VA specialty care is delivered, could
rise to as high as 3.9 million, which could significantly expand the
utilization of the program.
Finally, another reason so few veterans have used the ``choice''
program may be because they simply prefer to go to the VA. Even with
the ``choice'' card, some veterans with non-urgent medical needs may
prefer the VA physician, treatment team, or facility they know, rather
than look for a new, unknown provider in the private sector. The bottom
line is that we simply do not have sufficient data to determine exactly
which factors are behind the low utilization rates at this point.
Therefore, it is absolutely essential to take steps now so that we have
sufficient data and analysis before it is the appropriate time to
consider permanent changes to the VA health care system.
learning from the choice program
The ``choice'' program is an unprecedented experiment, launched
during a crisis in order to address a short-term emergency need.
Therefore, it is incumbent upon us to ensure that the proper
measurements and metrics are in place in order to evaluate the success
of the program and learn the appropriate lessons. Unfortunately, a
number of important questions and metrics at present are not being
studied.
The ``choice'' program was principally intended to address the
unacceptable waiting times facing veterans to receive care within the
VA by allowing them to choose private care providers. As such, it is
imperative that VA measure the time that veterans wait for
appointments, including follow-up appointments, when authorized to go
outside the VA. It is also necessary to understand what the waiting
times, or access standards, are for the private sector, both in general
and in detail. After all, the waiting time for a routine dermatology
appointment should not be the same as that for a serious cardiac
condition.
One of the key questions, and one of the primary contributing
factors to the waiting list scandals, was unrealistic access standards
in place at VA, which were subsequently repealed. It is important for
VA to develop new and realistic standards, regardless of the future
structure of non-VA care, not only for waiting times, but also for
travel distances. As we and others have pointed out in prior hearings,
the distance that is reasonable to expect a younger veteran in
relatively good health to travel may be significantly different from
what a 90-year old World War II veteran with serious physical
disabilities would be required to travel. Furthermore, these standards
must be clinically based to ensure the best health outcomes, not
randomly set for financial or political reasons.
Mr. Chairman, given the importance of determining appropriate
access standards, we would recommend that Congress authorize a
comprehensive and independent study be performed to review the access
standards used in the private sector, and to make recommendations for
such standards for the VA health care system.
In order to properly evaluate the ``choice'' program, VA must also
collect, study and analyze data on patient satisfaction and health
outcomes for those who use private providers through the ``choice''
program. VA needs to establish baseline data from which it can compare
satisfaction for those who use ``choice,'' those who use other non-VA
care programs, and those who use VA care. Measuring health outcomes may
prove more challenging, given that it takes many years before true
outcomes are known; however, since this is the ultimate measure of
success, VA must begin to explore appropriate research, analysis and
metrics that could be implemented now in order to help with such
analysis in the future.
Another key area that must be evaluated is the coordination of care
for veterans who go outside the VA, both through the ``choice'' program
and other non-VA care authorities. Over the next couple of years,
veterans may find themselves receiving care inside VA as well as
outside, and VA must be able to determine how well that care is
coordinated through the various programs. It is imperative that VA
carefully monitor how and what kind of medical information is
transmitted back and forth between VA and non-VA providers.
the congressionally-mandated ``commission on care''
In addition to the temporary three-year ``choice'' program and the
investment of new resources in the VA health care system, the VACAA
also requires the creation of a ``Commission on Care'' to study and
make recommendations for long-term improvements to best deliver timely
and high quality health care to veterans over the next two decades.
Specifically, the law requires that members of this Commission be
appointed not later than one year after the date of enactment of Public
Law 113-146, which would be no later than August 7, 2015. The
President, Majority and Minority Leaders of the Senate, Speaker and
Minority Leader of the House, will each appoint three members of the
Commission, with the President designating the Chairman.
Under the law, once a majority of appointments is made, the
Commission must hold its first meeting within 15 days, and then it is
provided only 90 days to produce an interim report with both findings
and recommendations for legislative or administrative actions, and then
only 90 additional days to submit a final report.
Mr. Chairman, last month, DAV, PVA, VFW, The American Legion, IAVA
and a number of other VSOs wrote to Senate and House leaders to call
for extending the mandate of this Commission to allow at least 12
months before the interim report is due, and at least six additional
months before the final report is presented to Congress. In our jointly
signed letter, we argued that, ``* * * 90 days does not provide nearly
sufficient time for a newly constituted Commission of 15 individuals--
each with their own unique background, experience and understanding of
the current VA health care system--to comprehensively examine all of
the issues involved, to conduct and review sufficient research and
analysis, and to discuss, debate and reach agreement on specific
findings and recommendations that could change how health care will be
delivered to millions of veterans over the next twenty years.''
In addition, we called on Congress to refrain from taking any, ``*
* * permanent, systemic changes * * * until after the Commission has
had sufficient opportunity to consider how best to deliver health care
to veterans for the next two decades, submitted its recommendations,
and then allowed sufficient opportunity for other stakeholders and
Congress to engage in a debate worthy of the men and women who
served.''
By gathering essential data and performing crucial research over
the next year or so, the Commission, Congress and other stakeholders
would be able to work together to ensure that veterans receive the
health care they have earned. However, it is also important that before
we engage in a debate about how to structure both VA and non-VA care
programs, we gain a consensus about the proper role and responsibility
of the VA.
the principle mission of va health care
One hundred and fifty years ago, only a month before the Civil War
ended, President Abraham Lincoln stood on the East Front of the U.S.
Capitol to make his Second Inaugural Address, in which he made a solemn
promise on behalf of the Nation ``* * * to care for him who shall have
borne the battle, for his widow, and his orphan * * *'' Those words
which are engraved on the entrance of the Department's building here in
Washington, DC, were spoken just one day after Lincoln signed
legislation to create the very first Federal facility devoted
exclusively to the care of war veterans, which ultimately evolved into
today's VA health care system.
Since that date, leaders of Congress and Presidents of all parties
have been united in their bipartisan support of a robust Federal health
system to care for veterans. But after a very difficult year filled
with a waiting list scandal and a health care access crisis--which
resulted in the resignation of a sitting VA Secretary--there is now
discussion about how and whether to keep that promise to the men and
women who served. While we certainly agree that change and reform are
needed at the VA, we have a sacred obligation to ensure that America
never abandons Lincoln's promise.
While the VA health care system has long been the embodiment of our
national promise, some are now proposing to make it just another
``choice'' among all health care providers, while others are calling
for VA to be downsized or eliminated altogether. For millions of
veterans wounded, injured or made ill from their service, their only
``choice'' for receiving the specialized care they need is a robust VA.
Although the VA today provides comprehensive medical care to more
than 6.5 million veterans each year, the VA system's primary mission is
to meet the unique, specialized health care needs of service-connected
disabled veterans. To accomplish this mission, VA health care is
integrated with a clinical research program and academic affiliation
with well over 100 of the world's most prominent schools of health
professions to ensure veterans have access to the most advanced
treatments in the world.
Furthermore, in order to achieve the best health outcomes, it is
necessary to treat the whole veteran, and that is exactly what the VA
is organized to do. VA provides comprehensive, holistic and
preventative care that results in demonstrably improved quality, higher
patient satisfaction and better health outcomes for the veterans it
serves. For those veterans who rely on VA for care, those who have
suffered amputations, paralysis, burns and other injuries and
illnesses, we believe they deserve the ``choice'' to receive all or
most of their care from the VA.
If the VA health care system ends up being downsized as a result of
allowing all veterans to leave VA through expanded ``choice'' programs,
and certainly if VA is eliminated outright, some or all of the 3.8
million service-connected disabled veterans who rely on VA for their
health care today would no longer have a ``choice.'' Instead, they
would end up with fractured care, receiving care through a combination
of VA and non-VA providers.
And if VA care was no longer an option for seriously disabled
veterans, would the private health care system be able to provide
timely access to the specialized care they require? While the private
sector also treats many of the same conditions that VA specializes in--
including amputations, paralysis, severe burns, blindness, Traumatic
Brain Injury (TBI) and even Post Traumatic Stress Disorder (PTSD)--
there is simply no comparison with the frequency, severity and
comorbidities routinely seen by VA physicians. Even if all 3.8 million
disabled veterans were dispersed into private care, they would still
make up just 1.5% of the adult patient population. Does anyone truly
believe that a market-based civilian health system would provide the
focus and resources necessary to advance the level of care for this
small minority in the way that a dedicated, Federal VA system would?
setting a new framework for reforming va health care
While it is far too soon to settle on how to reform the VA health
care system and integrate non-VA care, we must begin to establish at
least a road map to guide us. We propose a new framework to meet the
needs of the next generation of America's veterans based on rebuilding,
restructuring, realigning and reforming the VA health care system.
First, we must rebuild and sustain VA's capacity to provide timely,
high quality care. That must begin with a long-term strategy to
recruit, hire and maintain sufficient clinical staff at all VA
facilities. In addition, VA must gain the commitment and funding to
implement a long-term strategy to repair, maintain and expand as
necessary, usable treatment space to maximize access points where
veterans receive their care. VA must buildupon its temporary access
initiatives implemented last year by permanently extending hours of
operations around the country at CBOCs and other VA treatment
facilities to increase access for veterans outside traditional working
hours. To provide the highest quality care, we must strengthen VA's
clinical research programs to prepare for veterans' future health care
needs. In addition, we must sustain VA's academic affiliations to
support the teaching and research programs and to help support future
staffing recruitment efforts.
Second, VA must restructure its non-VA care program into a single
integrated extended care network. This will require that VA first
complete the research and analysis related to the ``choice'' program
discussed above, and allow the Commission on Care to complete its work.
Then based on research and data, VA must develop an integrated VA
Extended Care Network which incorporates the best features of fee-
basis, contract care, ARCH, PC3, ``choice,'' and other purchased care
programs. Congress must provide a single, separate and guaranteed
funding mechanism for this VA Extended Care program. To make this
program effective, VA must complete the research discussed above
related to private sector access standards in order to establish new
clinically-based access policy that is informed, objective and based on
rigorously established objective evidence. In addition, VA must develop
an appropriate and effective decision mechanism that ensures that
veterans are able to access VA's Extended Care Network whenever
necessary. In addition, there must be a new, transparent, and dedicated
review and appeal process capable of making rapid decisions to ensure
veterans have timely access based on their medical needs.
Third, we must realign and expand VA health care services to meet
the diverse needs of future generations of veterans, beginning with VA
expanding urgent care clinics with extended operating hours. These
services would be delivered by dedicated doctors and nurses in existing
VA facilities, or smaller urgent care clinics strategically located in
new locations around the country, such as in shopping malls. The VA,
like any large health care system should provide walk-in capability for
urgent care needs of eligible veterans. In addition, VA must extend
access to care further through enhanced web-based and tele-medicine
options to reach even the most remote and rural veterans. And with
veteran demographics continuing to change, VA must eliminate barriers
and expand services to ensure that women veterans have equal access to
high quality, gender-specific, holistic, preventative health care. VA
must also rebalance its long-term supports and services to provide
greater access to home- and community-based services to meet current
and future needs, including expanding support for caregivers of
veterans from all generations.
Fourth, VA must reform its management of the health care system by
increasing efficiency, transparency and accountability in order to
become a veteran-centric organization. VA can begin by developing a new
patient-driven scheduling system, including web and app-based programs
that allow veterans to self-schedule health care appointments. To
support responsible organizational behavior, VA should redesign its
Performance and Accountability Report (PAR) to establish new metrics
that are focused on veteran-centric outcomes with clear transparency
and accountability mechanisms. VA's budgeting process would benefit by
implementing a more transparent and accountable system known as PPBE,
which stands for planning, programming, budgeting and execution. This
approach is already working for the Departments of Defense and Homeland
Security, and there is legislation pending to bring the same to VA.
Finally, VA must hold all of its employees--from the Secretary to
receptionists--to the highest standards, while always balancing the
need to make the VA an employer of choice among Federal agencies and
the private sector.
Mr. Chairman, the framework outlined here certainly is not intended
to be a final or detailed plan for reforming VA, nor could it be at
this point with so much unknown, but it offers a new pathway that could
lead toward a future that would truly fulfill Lincoln's promise. DAV is
convinced that the VA health care system has been, can be and must be
the centerpiece of how our Nation delivers health care to America's
wounded, injured and ill veterans.
While the VA faces serious challenges, the answer is not to abandon
it, or to destroy it. Instead, we must honor the service and sacrifices
of our Nation's heroes by creating a modern, high-quality, accessible
and accountable VA health care system. Anything less breaks Lincoln's
promise, ignores our sacred national obligation, and leaves our
veterans to fend for themselves in a private sector health system ill
prepared to care for them.
That concludes my testimony and I would be pleased to address
questions from you or other Members of the Committee.
Chairman Isakson. Thank you very much.
Mr. Rausch?
STATEMENT OF BILL RAUSCH, POLITICAL DIRECTOR, IRAQ AND
AFGHANISTAN VETERANS OF AMERICA
Mr. Rausch. Chairman Isakson, Ranking Member Blumenthal, on
behalf of Iraq and Afghanistan Veterans of America and our
nearly 400,000 members and supporters, thank you for the
opportunity to share our views with you at today's hearing.
As you know, IAVA was one of the leading veterans
organizations involved in the early negotiations on the
Veterans Access to Choice and Accountability Act as it was
being drafted and the breadth of its final language was being
debated. It is a highly complex law that the Department is
working hard to effectively implement in order to ensure
veterans are not left waiting for unacceptable lengths of time
to receive health care services.
My remarks will focus on the experiences of utilizing the
VA Choice Program IAVA members have recently reported to us by
way of survey research. Additionally, I will provide
recommendations Congress and the Secretary must consider in
order to get this program operating at the height of its
potential. These recommendations include: legislative
clarification of the eligibility criteria for accessing the
Choice Program, strengthening training guidelines for VA
schedulers charged to explain the eligibility criteria to
veterans, and continued active engagement with veterans
organizations to more broadly identify a comprehensive strategy
and plan for delivering non-VA care in the community moving
forward.
In examining the current criteria for determining which
veterans are eligible to use the Choice Program--those who must
wait longer than 30 days for an appointment and those who live
more than 40 miles from a VA medical facility--more statutory
clarity is required.
Veterans are all too frequently reporting they are unsure
if they are eligible for Choice, and VA in some cases has been
inconsistent in communicating whether or not a veteran can
access it in individual cases.
Based on our most recent survey data, over one-third of our
members have reported they do not know how to access the Choice
Program. This is compounded by reports that in some cases VA
schedulers are not explaining eligibility for Choice while
offering appointments outside the 30-day window. The Secretary
and VA senior leadership must continue to engage VA front-
facing scheduling personnel with ongoing and evolving training
standards, so when veterans call the VA they receive consistent
and clear understanding of their eligibility for the choice
program. The VA has improved in this area, but with so many
veterans still confused about eligibility, training criteria
must be strengthened and maintained.
Congress should aid in the Department's implementation
efforts by clarifying in law that the 40-mile criteria must
relate specifically to the VA facility in which the needed
medical care will be provided. This frustrating example that
continues to surface is one of a veteran that requires
specialized care in a VA facility outside the 40 miles, but
through strict interpretation of the current VACAA law is
ineligible because a local CBOC or other facility may be
geographically near the veteran's address, notwithstanding that
facility cannot provide the required care.
One of our members illustrated this recently by stating,
``Because there is a CBOC in my area, I was denied. The clinic
does not provide any service or treatment I need for my primary
service-connected disability. The nearest medical center in my
network is 153 miles away.''
Congress must provide needed clarity and work with VA--and
it sounds like you are--to eliminate cases like those just
described.
There have been encouraging developments related to the
implementation of the Choice Program, specifically VA's action
to step up and fix the initial ineffectiveness of the 40-mile
rule calculations, as it related to the geodesic distance
versus driving distance. That regulatory correction was much
needed, and as a result there are hundreds of thousands of new
veterans who are now eligible for the Choice Program. On behalf
of our members, we applaud Secretary Bob McDonald and Deputy
Secretary Sloan Gibson for their leadership in listening to
their customers, our veterans, to make that change happen.
VHA's statistics on Choice utilization among the veteran
population as of this month state there have been nearly 59,000
authorizations for care and nearly 47,000 appointments. This
data verifies that veterans out there are using the program,
and the VA has been making progress to implement what is
clearly a complex yet important program.
IAVA is committed to remaining actively engaged with the
veterans making use of the Choice Program so we can keep
current on the veteran experience. We are mindful that with
thousands of appointments being concluded, there will
inevitably be thousands of unique experiences, and we want to
gauge those levels of satisfaction with our members for this
program. The satisfaction of veterans utilizing Choice, the
cost of the care purchased outside of VA facilities, and
understanding issues that come up along the way will allow us
to better realize a veteran-focused strategy and plan for non-
VA care in the community moving forward.
We appreciate the hard work of this Congress, the VA, and
the veteran community and recognize we have to stay focused on
improving veteran health care delivery in the short and long
term. Robust discussion on the scope and cost of maintaining
health care networks is complicated and multilayered, which is
why our last recommendation is simple and something we have
touched on before: We must continue to work together and keep
communication active between all relevant stakeholders.
Mr. Chairman, we sincerely appreciate your Committee's hard
work in this area, your invitation to allow me to testify
again, and we want you to know we stand ready to assist this
Congress and our Secretary to achieve the best results for the
Choice Program now and in the future. We look forward to taking
your questions.
Thank you.
[The prepared statement of Mr. Rausch follows:]
Prepared Statement of Bill Rausch, Political Director, Iraq and
Afghanistan Veterans of America
Chairman Isakson, Ranking Member Blumenthal, and Distinguished
Members of the Committee: On behalf of Iraq and Afghanistan Veterans of
America (IAVA) and our nearly 400,000 members and supporters, thank you
for the opportunity to share our views with you at today's hearing
Assessing the Promise and Progress of the Choice Program.
IAVA was one of the leading veterans organizations involved in the
early negotiations on the Veterans Access to Choice and Accountability
Act (VACAA), as it was being drafted and the breadth of its final
language was debated. This is a highly complex law that the Department
is working hard to effectively implement in order to ensure veterans
are not left waiting for unacceptable lengths of time to receive health
care services.
My remarks will focus on the experiences of utilizing the VA Choice
Program IAVA members have recently reported by way of survey research.
Additionally, I will provide recommendations Congress and the Secretary
must consider in order to get this program operating at the height of
its potential. These recommendations include: legislative clarification
of the eligibility criteria for accessing the Choice program,
strengthening training guidelines for VA schedulers charged to explain
the eligibility criteria to veterans, and continued active engagement
with veteran organizations to more broadly identify a comprehensive
strategy and plan for delivering Non-VA care in the community moving
forward into the future.
In examining the current criteria for determining which veterans
are eligible to use the Choice Program, those who must wait longer than
30 days for an appointment and those who live more than 40 miles from a
VA medical facility, more statutory clarity is required. Veterans are
all too frequently reporting they are unsure if they are eligible for
choice and VA has, in some cases, been inconsistent in communicating
whether or not a veteran can access it in individual cases.
Based on our most recent survey, over 1/3rd of IAVA members have
reported they do not know how to access the Choice program. This is
compounded by reports that in some cases VA scheduling personnel are
not explaining eligibility for choice to veterans and are then offering
appointments ``off the grid'' of the 30 day standard--sometimes much
later.
The Secretary and VA Senior Leadership must continue to engage VA
front-facing scheduling personnel with ongoing and evolving training
standards, so when veterans call the VA, they receive consistent and
clear understanding of their eligibility for the Choice program. The VA
has improved in this area but with so many veterans still confused
about choice eligibility--nearly 7 months after the program's birth--
training criteria must be strengthened and maintained.
Congress should aid in the Department's implementation efforts by
clarifying in law that the 40-mile criteria must relate specifically to
the VA facility in which the needed medical care will be provided. The
frustrating example that continues to surface is one of a veteran that
requires specialized care in a VA facility outside of 40 miles, but
through strict interpretation of the current VACAA law, is ineligible
for participation because a local CBOC or other facility may be
geographically near the veteran's address, notwithstanding that
facility cannot provide the required care. One of our members
illustrated one of these cases with the following statement: ``Because
there is a CBOC in my area I was denied. The clinic doesn't provide any
service or treatment I need for my primary service-connected
disability. [The] nearest medical center in my network is 153 miles
away.'' Congress must provide much-needed clarity and work with VA to
eliminate cases like those just described.
There have been encouraging developments related to the
implementation of the Choice Program, specifically, the VA's action to
step up and fix the initial ineffectiveness of the 40mile rule
calculations under regulation, as it related to geodesic distance vs.
driving distance. That regulatory correction was much needed and as a
result there are hundreds of thousands of new veterans eligible for the
Choice program. On behalf of our members we applaud Secretary Bob
McDonald's leadership for listening to his customers, our veterans, to
make that change happen.
VHA's statistics on choice utilization among the veteran population
as of this month state there have been nearly 58,863 authorizations for
care and nearly 47,000 appointments. This data verifies that veterans
out there are using the program and the VA has been making progress to
implement what is clearly a complex and historic mandate relating to
the furnishment of veteran health care now and in years to come.
IAVA is committed to remaining actively engaged with the veterans
making use of Choice care so we can keep current on the veteran
experience. We are mindful that with thousands of appointments for care
being concluded, there will inevitably be thousands of unique
experiences we want to know about to gauge the satisfaction with this
program. The satisfaction of the veteran utilizing Choice, the cost of
the care purchased outside of VA facilities and understanding issues
that come up along the way, will allow us to better identify the scope
and role the concept of choice plays in the future.
We appreciate the hard work of Congress, the VA, and the veteran
community and recognize we have to stay focused on improving veteran
healthcare delivery in the short and long-term. Robust discussion on
the scope and cost of maintaining healthcare networks is complicated
and multi-layered, which is why our last recommendation is simple: we
must continue to work together and keep communication active between
all relevant stakeholders.
Mr. Chairman, we sincerely appreciate your Committee's hard work in
this area, your invitation to allow me to testify before you again, and
we want you to know we stand ready to assist Congress and Secretary Bob
McDonald to achieve the best results for the Choice program now and in
the future.
I am happy to answer any questions you may have.
Chairman Isakson. Thank you very much.
Mr. Fuentes?
STATEMENT OF CARLOS FUENTES, SENIOR LEGISLATIVE ASSOCIATE,
NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE
UNITED STATES
Mr. Fuentes. Chairman Isakson, Ranking Member Blumenthal,
on behalf of the men and women of the VFW and our Auxiliaries,
I would like to thank you for the opportunity to present our
views on the Veterans Choice Program.
Before I begin, I just want to say that VFW opposes VA's
change to the way veterans choose to use the Veterans Choice
Program. Veterans must have the opportunity to explore their
private sector options before rejecting their VA appointments.
This change is a bureaucratic convenience that will negatively
affect veterans' experiences.
The VFW continues to play an integral part in identifying
new issues the Veterans Choice Program faces and recommending
reasonable solutions. Yesterday, we published our second report
evaluating this important program, which made 13
recommendations on how to ensure it accomplished its intended
goal of expanding access to health care for America's veterans.
Our initial report identified a gap between the number of
veterans who were eligible for the program and those who were
given the opportunity to participate.
Our second report has found that VA has made progress in
addressing this gap. Thirty-five percent of second survey
participants who believed they were eligible were given the
opportunity to participate. That is a 60-percent increase from
our initial survey.
For 30-dayers, participation hinges on VA schedulers
informing them of their eligibility. The lack of systemwide
training for front-line staff has resulted in veterans
receiving dated or misleading information. VA must continue to
improve its processes and training to ensure that all veterans
who are eligible for the program are given the opportunity to
participate.
Our second report also found a decrease in patient
satisfaction among veterans who received non-VA care. This has
been a direct result of veterans not being able to find viable
options in the private sector.
The 40-mile standard used to establish geographic-based
eligibility for the Veterans Choice Program was based on
eligibility for TRICARE Prime. However, there is a distinct
difference between the veterans population and the military
population. Thirty-six percent of veterans enrolled in VA
health care live in rural areas. Thus, measuring the distance
servicemembers travel to military treatment facilities and
using that same standard to measure distance traveled by
veterans to VA medical facilities does not appropriately
account for the diversity of the veterans population.
Our second report found that a commute-time standard based
on population densities would more appropriately reflect the
travel burden veterans face when accessing VA health care.
Regardless, Congress and VA must commission a study to
determine the most appropriate geographic-based standard for
health care furnished by VA.
As the future of the VA health care system and its
purchased care model are evaluated, it is important to
recognize that the quality of care veterans receive from VA is
significantly better than what is available in the private
sector.
Moreover, many of VA's capabilities cannot be duplicated or
properly supplemented by private sector health care--especially
for combat-related mental health, blast injuries, or service-
related toxic exposures, just to name a few. With this in mind,
VA must continue to serve as the initial touch point and
guarantor of care for all enrolled veterans. Although
enrollment in the VA health care system is not mandatory, and
despite more than 75 percent of veterans having other forms of
health care coverage, more than 6.5 million of them choose to
rely on their earned VA health care benefits and are by and
large satisfied with the care they receive.
Moving forward, the lessons learned from the Veterans
Choice Program should be incorporated into a single systemwide
non-VA care program with veteran-centric and clinically driven
access standards, which afford veterans the opportunity to
receive private sector health care if VA is unable to meet
those standards. More importantly, non-VA care must supplement
the care that veterans receive from VA medical facilities, not
replace it.
Ideally, VA would have the capacity to provide timely
access to direct care for all the veterans it serves. We know,
however, that VA medical facilities continue to operate at 115
percent capacity and may never be able to build enough capacity
to provide direct care to all the veterans that they serve.
VA must continue to expand capacity based on staffing
models for each health care specialty and patient density
thresholds. However, VA cannot rely on building new facilities
alone. When thresholds are exceeded, VA must use leasing and
sharing agreements with other health care systems and
affiliated hospitals when possible and purchase care when it
must.
Mr. Chairman, this concludes my testimony. I am prepared to
answer any questions you may have.
[The prepared statement of Mr. Fuentes follows:]
Prepared Statement of Carlos Fuentes, Senior Legislative Associate,
National Legislative Service, Veterans of Foreign Wars of The United
States
Chairman Isakson, Ranking Member Blumenthal and Members of the
Committee, on behalf of the men and women of the Veterans of Foreign
Wars of the United States (VFW) and our Auxiliaries, I thank you for
the opportunity to present the VFW's thoughts on the current state of
the Veterans Choice Program.
More than a year ago, whistleblowers in Phoenix, Arizona, exposed
rampant wrong-doing at their local Department of Veterans Affairs (VA)
hospital through which veterans were alleged to have died waiting for
care, while VA employees manipulated waiting lists and hid the truth.
In the months that followed, similar problems were exposed across the
country, and the ensuing crisis forced the Secretary of Veterans
Affairs and many top Veterans Health Administration (VHA) deputies to
resign.
As the crisis unfolded, the VFW intervened by offering direct
assistance to veterans receiving VA health care; publishing a detailed
report, ``Hurry up and Wait,'' which made 11 recommendations on ways to
improve VA's health care system; working with Congress to pass
significant reforms; and working directly with VA to implement reforms.
In August 2014, Congress passed and the President signed into law
the Veterans Access, Choice, and Accountability Act of 2014 (VACAA)
with the support and insight of the VFW. This critical law commissioned
the Veterans Choice Program, which now offers critical non-VA health
care options to veterans who are unable to receive VA health care
appointments in a timely manner (30-dayers) or who live more than 40
miles from the nearest VA medical facility (40-milers).
In an effort to gauge veterans' experiences and evaluate how the
program was performing, the VFW commissioned a series of surveys and
compiled an initial report on how the program performed during the
first three months of its implementation. The VFW's initial report
included six specific recommendations regarding participation, wait
time standard, geographic eligibility, and non-VA care issues that
needed to be addressed. Fortunately, the Veterans Choice Program has
been a top priority for VA and Congress. As a result, several issues
that accompanied the roll-out have been resolved.
The VFW continues to play an integral part in identifying new
issues the Veterans Choice Program faces and recommending reasonable
solutions to such issues. Yesterday, we published the second report on
the implementation of the Veterans Choice Program. All our reports can
be found on our VA Health Care Watch Website, www.vfw.org/VAWatch. Our
second Veterans Choice Program report found that the implementation of
the program has improved. However, more works remains. The second
report includes 12 recommendations regarding several issues that must
be addressed to ensure the program accomplishes its intended goal of
improving access to high quality health care for America's veterans.
participation gap
The VFW's initial report identified a gap between the number of
veterans who were eligible for the Veterans Choice Program and those
afforded the opportunity to receive non-VA care. Our report found that
VA has made progress in addressing this gap. However VA must continue
to improve its processes and training to ensure all veterans who are
eligible for the Veterans Choice Program are given the opportunity to
receive timely access to health care in their communities.
Thirty-eight percent of second survey participants who believed
they were eligible for the program were offered the opportunity to
receive non-VA care. This is a 12 percent increase from our initial
survey. Yet, the VFW continues to hear from veterans who report that
the schedulers they speak to are unaware of the program or are unsure
how it works.
For 30-dayers, participation continues to hinge on VA schedulers
informing veterans that they are eligible for the program. The lack of
system wide training for schedulers and frontline staff has led to a
reliance on local facility driven training, which VA admits has
resulted in inconsistent training. To mitigate this issue, VA has
developed system wide training for all VHA staff, which it intends to
implement later this month. VA will also conduct specialized training
for scheduling staff to ensure they are familiar with the Veterans
Choice Program's business processes and know how to properly serve
eligible veterans.
The VFW applauds such efforts, but we are concerned that training
will not have the desired outcome if VA fails to implement proper
quality assurance processes. For example, the program's contractors,
Health Net and TriWest, monitor their call center representatives to
ensure they provide accurate information about the program. Doing so
allows them to identify call center representatives who need remedial
training. They also utilize quality assurance mechanisms to improve
training to ensure veterans receive high quality customer service. VA
can benefit from adopting similar processes to ensure VA staff provide
high quality customer service and adhere to training objectives.
The VFW acknowledges that the participation gap will not be
eliminated with training alone. Regardless of how well VA trains its
staff, human error will lead to veterans not being properly informed of
their opportunity to receive health care in their communities. To
address this issue, VA implemented the Veterans Choice Program Outreach
Campaign to contact more than 100,000 veterans who were initially
eligible for the Veterans Choice Program as 30-dayers. The program
concluded in February and resulted in VA staff transferring
approximately 30 percent of the veterans it contacted to the Veterans
Choice Program call centers. VA would benefit from implementing an
automated letter or robocall system that would continue the work of the
Veterans Choice Program Outreach Campaign.
The VFW's second Veterans Choice Program report also found a
decrease in patient satisfaction among veterans who received non-VA
care through the Veterans Choice Program. Feedback from veterans shows
that the primary reason for the decline in satisfaction has been a
direct result of their inability to find viable private sector health
care options. Many veterans have reported that they chose to keep their
VA appointments because they were unable to find private sector
providers closer than their VA medical facilities, or their
appointments at VA were earlier than what they were able to obtain in
the private sector.
Health Net and TriWest have candidly acknowledged that scheduling
veterans within 30 days is unattainable in certain instances. The
reasons differ case by case, but are generally associated with a lack
of availability in the private sector or a delay in receiving the VA
medical documentation needed to schedule an appointment. For example,
TriWest reports that in many communities wait times for a new
dermatology patient are often 60 or even 90 days out. This indicates
that health care in the private sector is not widely available for all
specialties, especially when veterans seek veteran-specific care that
does not exist in the private sector, such as spinal cord injury and
disorder care, polytrauma treatment and services, and specialized
mental health care. For example, a veteran from Elko, Nevada, who is
eligible for the Veterans Choice Program as a 40-miler told us she
wanted to explore mental health care options in her community, but was
unable to find a mental health care provider able to treat veterans, so
she decided it was best to continue receiving telemental health care
from VA.
The VFW is concerned that local facilities may also contribute to
the delay or inability to schedule non-VA care appointments through the
Veterans Choice Program. Our report found that some local VA medical
facilities were slow to provide the medical documentation needed to
schedule appointments through the program. We also found that some VA
medical facilities were slow to process requests for follow-up
treatment through the program. For example, a veteran in
Fredericksburg, Virginia, was authorized to receive back surgery
through the program, but his appointment was delayed because the
Richmond VA Medical Center had not sent the medical documentation his
private sector doctor needed to schedule his surgery. After receiving
surgery, the veteran was prescribed postoperative physical therapy.
Unfortunately, he was unable to schedule his physical therapy
appointments until the Richmond VA Medical Center approved the
treatment. It took nearly a month for his non-VA physical therapy to be
approved.
Furthermore, the VFW is concerned with the lack of private sector
providers opting to participate in the program. Due to reimbursement
rates and requirements to return medical documentation, some private
sector providers have been reluctant to participate in the Veterans
Choice Program network when they have a preexisting agreement with a VA
medical facility. Such agreements often allow for higher reimbursement
rates or do not require the non-VA provider to return medical
documentation. The VFW is concerned that the reliance on local
agreements has limited Health Net's and TriWest's ability to build
capacity by expanding their Choice networks. VA must issues clear
directives on how to properly utilize purchase care programs and
authorities to ensure local medical facilities do not prevent the
Veterans Choice Program's contractors from expanding their networks to
better serve veterans.
wait time standard
The VFW's initial report highlighted several flaws in the way VA
calculates wait times. Unfortunately, our second report found that this
flawed metric is still being used. VA's wait time standard still
requires veterans to wait unreasonably long and remains susceptible to
data manipulation.
VA's current wait time standard requires a veteran to wait at least
30 days beyond the date a veteran's provider deems clinically
necessary, or clinically indicated date, before being considered
eligible for the Veterans Choice Program. This means that a veteran who
is told by his or her VA doctor that he or she needs to be seen within
60 days is only eligible for the Veterans Choice Program if he or she
is scheduled for an appointment that is more than 90 days out, or more
than 30 days after the doctor's recommendation. The VFW remains
concerned that veterans' health may be at risk if they are not offered
the ability to receive care within the timeframe their VA providers
deem necessary, regardless of whether the care is received through a VA
medical facility or the Veterans Choice Program.
Furthermore, VA's wait time standard is not aligned with the
realities of waiting for a VA health care appointment. Forty-five
percent of the 1,464 survey respondents who have scheduled an
appointment since November 5, 2014 reported waiting more than 30 days
for their appointment. Yet, VA data on more than 70.8 million pending
appointments between November 1, 2014 and April 15, 2015 shows that
fewer than seven percent of such appointments were scheduled beyond 30
days of a veteran's preferred date.
VA's preferred date metric is a figure determined subjectively by
VA schedulers when veterans call to make an appointment. The VFW has
long disputed the validity of this figure, which we outlined in detail
in our initial report. Our second Veterans Choice Program report found
that veterans who perceive they wait longer than 30 days for care,
regardless of how long VA says they wait, are more likely to be
dissatisfied than veterans who perceive that VA has offered them care
in a timely manner. Patient satisfaction is fundamental to the delivery
of health care. Ultimately, satisfaction is based on how long veterans
perceive they wait, not how VA estimates wait times. VA must take
veterans' perceptions into account when establishing standards to
measure how long veterans wait for their care.
The VFW and our Independent Budget (IB) partners have continued to
call for VA to develop reasonable wait time standards based on acuity
of care and specialty. Arbitrary system-wide deadlines do not fully
account for the difference between the types and acuity of care
veterans receive from VA. Waiting too long for health care can be the
difference between life and death for veterans with urgent medical
conditions. For example, a veteran with severe Post Traumatic Stress
Disorder should not be required to wait 30 days for treatment.
As part of the 12 independent assessments being conducted by the
MITRE Corporation, et al., which were mandated by section 201 of VACAA,
the Institute of Medicine (IOM) is currently evaluating if VA's wait
time standard is an appropriate system wide access standard. The VFW
will monitor IOM's work to ensure its recommendations serve the best
interest of veterans.
geographic eligibility
On March 24, 2015, VA announced the most significant change that
has occurred since the Veterans Choice Program was created. VA listened
to the concerns of countless veterans and changed the way it calculated
distance for the Veterans Choice Program from straight-line distance to
driving distance. The change went into effect on April 24, 2015 and
gave nearly 300,000 additional veterans the opportunity to choose
whether to receive their health care through private sector providers
or travel to a VA medical facility. The VFW applauds VA for taking the
initiative and fixing an issue that confused veterans and caused
frustration.
However, this change did not address another significant flaw in
eligibility for the Veterans Choice Program. The VFW continues to hear
from veterans who report that their local Community-Based Outpatient
Clinics are unable to provide them the care they need, so VA requires
them to travel long distances to a VA medical center. In order to
properly account for the travel burden veterans face when accessing VA
health care, geographic eligibility for the Veterans Choice Program
should be based on the calculated distance to facilities that provide
the care they need, not facilities that are unable to serve them.
The 40 mile standard was based on eligibility for TRICARE Prime.
However, there is a distinct difference between the military population
and the veteran population. According to VA's Office of Rural Health,
youths from sparsely populated areas are more likely to join the
military than those from urban areas. During their service, they are
likely to live near military installations, which often have military
treatment facilities. However, when they leave military service, 36
percent of veterans who enroll in the VA health care system return to
rural areas. Although VA has made an attempt to expand capacity to
deliver care where veterans live, it has not been able to, nor should
it in some instances, expand its facilities to cover all veterans.
Thus, using the same standard to measure distance that servicemembers
and their families travel to military treatment facilities to measure
distance traveled by veterans to VA medical facilities, does not
properly account for the diversity of the veteran population.
Feedback we have received from veterans indicates that a commute
time standard based on population density (urban, rural, highly-rural)
would more appropriately reflect the travel burden veterans face when
accessing VA health care. However, the VFW recognizes that any
established standard will be imperfect. Thus, VA must have the
authority to make clinically based exceptions. Regardless, a study must
be commissioned to determine the most appropriate geographic
eligibility standard for health care furnished by the VA health care
system. IOM is currently evaluating the way VA calculates wait times,
yet no one has been asked to evaluate whether the 40-mile standard is
appropriate.
While changes are made to the Veterans Choice Program, VA must
fully utilize all of its purchased care programs and authorities, such
as the Patient-Centered Community Care Program, to ensure veterans have
timely access to high quality care. The VFW continues to believe that
veterans should be afforded the opportunity to obtain care closer to
home if VA care is not readily available, especially when veterans have
an urgent medical need.
va's purchased care model
The Veterans Choice Program was intended to address the
inconsistent use of VA's decentralized non-VA care programs and
evaluate whether national standards for access to non-VA care would
improve access. The VFW is committed to ensuring such standards serve
the best interest of veterans who rely on VA for their health care
needs. Fortunately, the Veterans Choice Program is succeeding in
improving access to care for thousands of veterans. The problem remains
that many veterans who are eligible for the program have yet to be
given the opportunity to receive non-VA care.
As the future of the Veterans Choice Program and VA's purchased
care model are evaluated, the VFW believes it is important to recognize
that the quality of care veterans receive from VA is significantly
better than what is available in the private sector. In fact, studies
conducted by the RAND Corporation and other independent entities have
consistently concluded that the VA health care system delivers higher
quality health care than private sector hospitals.\1\ Additionally,
independent studies have also found that delivering VA health care
services through private sector providers is more costly.\2\
---------------------------------------------------------------------------
\1\ ``Socialized or Not, We Can Learn from the VA,'' Arthur
L.Kellermannhttp, RAND Corporation. August 8, 2012, www.rand.org/blog/
2012/08/socialized-or-not-we-can-learn-from-the-va.html.
\2\ ``Comparing the Costs of the Veterans' Health Care System with
Private-Sector Costs,'' Congressional Budget Office. December 10, 2014,
https://www.cbo.gov/publication/49763.
---------------------------------------------------------------------------
Moreover, many of VA's capabilities cannot be readily duplicated or
properly supplemented by private sector health care systems--especially
for issues like combat-related mental health conditions, blast
injuries, or service-related toxic exposures. With this in mind, the
VFW believes that VA must continue to serve as the initial touch point
and guarantor of care for all enrolled veterans. As advocates for the
creation and continued improvement of the VA health care system, the
VFW understands that enrollment in the VA health care system is not
mandatory. Yet, more than 9 million veterans have chosen to enroll and
6.5 million of them choose to rely on VA for their care, despite 75
percent of them having other forms of health care coverage.
Additionally, veterans who have chosen to utilize their earned VA
health care benefits are by and large satisfied with the care they
receive.
The VFW believes that veterans should continue to request a VA
appointment prior to becoming eligible for non-VA care. This will
ensure that VA upholds its obligation as the guarantor and coordinator
of care for enrolled veterans, which includes ensuring the care
veterans receive from non-VA providers meets department and industry
safety and quality standards. Doing so allows VA to provide a continuum
of care that is unmatched by any private sector health care system.
Moving forward, the lessons learned from this important program
should be incorporated into a single, system-wide, non-VA care program
with veteran-centric and clinically driven access standards, which will
afford veterans the option to receive care from private sector health
care providers when VA is unable to meet such standards. Such a program
must also include a reliable case management mechanism to ensure
veterans receive proper and timely care and a robust quality assurance
mechanism to ensure system wide directives and standards are met.
Non-VA care must supplement the care veterans receive at VA medical
facilities, not replace it. Ideally, VA would have the capacity to
provide timely access to direct care for all the veterans it serves. We
know, however, that VA medical facilities continue to operate at 119
percent capacity, and may never have the resources needed to build
enough capacity to provide direct care to the growing number of
veterans who rely on VA for their health care needs.
VA must continue to expand capacity based on staffing models for
each health care specialty and patient density thresholds. However, the
VFW recognizes that in the 21st century, VA cannot rely on building new
facilities alone. When thresholds are exceeded, VA must use leasing and
sharing agreements with other health care systems, such as military
treatment facilities, Indian Health Service facilities, federally-
qualified health centers, and affiliated hospitals when possible and
purchase care when it cannot.
To ensure the VA health care system provides veterans the timely
access to high quality health care they have earned and deserve, VA
must conduct recurring assessments and future years planning to quickly
address access, safety, and utilization gaps. The VFW recognizes that
these improvements will not happen overnight, but veterans cannot be
allowed to suffer in the meantime. Non-VA care must continue to serve
as a reliable bridge between full access to direct care and where we
are now.
The VFW is committed to working with Congress, VA, our veterans
service organization partners and other stakeholders to continue
monitoring changes to the Veterans Choice Program and VA's purchased
care model; evaluate what is working; identify shortcomings; and work
toward reasonable solutions.
A copy of the VFW's second Veterans Choice Program report has been
sent to the Committee and I kindly request it be included in the
record.
Mr. Chairman, this concludes my testimony. I am prepared to take
any questions you or the Committee Members may have.
Chairman Isakson. Mr. Fuentes, at the beginning of your
testimony, you said VA must immediately address--and I could
not write fast enough to put it down, but I could not find it
in the printed testimony. What was that very first, right in
your first two or three sentences?
Mr. Fuentes. My first statement was regarding the change
that Dr. Tuchschmidt actually just announced on how veterans
elect to use the Choice Program. Right now they are scheduled
an appointment at VA, and if that appointment is beyond 30
days, then they keep that appointment, and they call TriWest or
Health Net and explore what their options are in the private
sector. That means that they are making an informed decision
when they decide to essentially reject their VA appointment.
If you change that to having the veteran make the election
before exploring their private sector options, it is not an
informed decision and actually leads to veterans, if they go to
the private sector, having to go to the back of the line and
restart their VA scheduling process all over again.
Chairman Isakson. OK. I want to make sure we understand or
I understand this. I am a veteran that lives more than 40 miles
from a clinic, so I am eligible for Veterans Choice. You are
saying I should make the private appointment through TriWest
and make a VA appointment anyway, and then choose which one I
want? I should not automatically go to the private provider?
Mr. Fuentes. For 40-milers, they currently do and I believe
they should continue to just contact TriWest and Health Net.
However, for 30-dayers, if VA cannot schedule an appointment
within 30 days, then they refer me to TriWest. But from talking
to TriWest for dermatology for example, the average appointment
is 60 to 90 days. So, now I am choosing between waiting 60 days
in VA to waiting 90 days in the private sector. I should know
that the wait time in the private sector is 90 days before
making that choice.
Chairman Isakson. OK. Well, Deputy Gibson, will you answer
this question. If I am a veteran and I am more than 40 miles
from a clinic and I have got my card, can I automatically call
TriWest and make an appointment?
Mr. Gibson. If you are more than 40 miles, yes, sir, you
can. The example that he is citing is where it is 30 days' wait
time, and the proposed process would truncate--we were talking
before, Senator Boozman mentioned about all of the
administrative material, the clinical information that is being
sent over. What we are trying to do is to streamline that part
of the process.
You know, in this particular case, if the veteran is not
pleased with the appointment, that process happens within a
couple of days, and they should be able to come back to VA to
say, ``I was not able to get a timely appointment,'' or the TPA
refers the authorization back.
But it is a consequence of making the change, rather than
booking the appointment in VA and referring the veteran over to
the third-party administrator.
Mr. Fuentes. Mr. Chairman, just to be clear, there are two
distinct processes--one for 30-dayers and one for 40-milers,
and I think one of the issues that the proposed change is
looking to address is no-shows and cancellations. So, when the
veteran accepts an appointment in the private sector, TriWest
or Health Net, then tells the local facility this veteran has
chosen Choice, cancel that appointment; however, currently a VA
scheduler or a VA staff member has to go and manually cancel
the appointments. This will prevent that. However, this will
come at the cost of the veteran's experience.
Chairman Isakson. That is what I was getting to, because I
was hearing a potential problem there with two appointments
being made, one of them not kept, but nobody letting each other
know which is happening first.
Mr. Fuentes. There are better ways to address that issue. I
feel that an automated process could work. Develop a more
seamless way for TriWest and Health Net to notify VA that the
veteran has accepted a private sector appointment.
Chairman Isakson. Now I am going to open a hornet's nest,
but I am going to go ahead and do it anyway. I had to pay a $30
penalty for not keeping an appointment back in Atlanta for some
health care I was getting. I think we cannot put everything on
the shoulder of TriWest or the VA. If somebody does not do
their job by letting VA and TRICARE know which appointment they
are going to keep, I would be the first person to say there
ought to be a penalty to that person for not keeping the
appointment, assuming the communication was complete. I know
there are going to be some people who are not going to like
that idea, sounding like a co-payment, but practically, it gets
everybody's attention. If we are going to be more efficient, I
think everybody has got to be part of the efficiency, including
the veteran who is getting the benefit. I just wanted to put
that in there--not to shake a hornet's nest. I thank you for
raising that issue because that is very helpful.
Senator Blumenthal?
Senator Blumenthal. Thanks, Mr. Chairman. You know, we have
been talking a little bit about how to pay for the Denver cost
overrun, and----
Chairman Isakson. We just figured it out. [Laughter.]
Senator Blumenthal. The Chairman has told me that we just
figured it out. Now this has been a more productive afternoon
than you could ever have hoped. [Laughter.]
I want to thank all of you for thinking through these
issues in such a constructive and positive way. I was taught as
a trial lawyer, ``Never ask a question if you do not know what
the answer is going to be;'' however, I want to ask a kind of
open-ended question. Given that the Choice Program and the
Choice and Accountability Act creates this fund of $15 billion,
my view is that the potential raid on this money and the effort
to use it as a kind of slush fund to pay for cost overruns in
Aurora and Orlando and New Orleans and Las Vegas where, in
fact, in total there have been $2.5 billion in cost overruns is
a real threat to veterans health care. We can debate how much
private care should be provided and how much it should be
through VA facilities, but there is no question, in my mind at
least, that VA facilities are an essential part of the health
care mix of opportunities that we provide to our veterans.
Therefore, to say we are going to defer projects and delay
construction on those facilities all around the country to pay
for cost overruns in those medical facilities under new
construction is a very dangerous threat.
Let me make that statement and throw it out to you for
comment.
Mr. Butler. I would say that our national commander has
gone on record to state his position that he opposes taking
money from the Choice Program and using that funding to support
other means. I have heard a lot of interesting conversations
today about exploring other options, thinking outside of the
box. I think that Members of Congress and VA need to do just
that. They need to put their hats on and to think about what is
best for veterans. How can we come to a resolution that would
serve veterans best without taking money from a program that is
early in its infant stage and then utilizing that funding for
other means or purposes? If that is an option, that should be
the last option after you have explored all the other options.
Mr. Selnick. Let me just chime in. I would agree with him
in what you are saying in that we do not want that money
raided. I worked at the VA from 2001 to 2009. I worked in VHA
for 3 years. Every time there was a management failure, $300
million IT program, a failure and they scrapped it, there was
not accountability, and it was just ``Give me more money, give
me more money.''
It is like an alcoholic. You cannot give them more alcohol
if they are failing. You have got to fix it in other ways.
I always liked, having been in the VA, that you should do
an audit of the books, because I saw lots of money put off the
table. Now, maybe that money is not off the table anymore, off
to the sidelines, but I would sure love to see an audit to see
what is really there and what is really not.
Mr. Fuentes. Veterans should not suffer because VA is
unable to get its house in order. The VA must atone for its
gross mismanagement. It should find cost savings in this
program and in other programs in any way it can. Ultimately,
Congress does have an obligation to ensure VA has the resources
it needs to complete this project. Additionally, further delay
and funding uncertainty will only lead to higher cost overruns.
Mr. Violante. There is no easy answer, and I believe that
the facilities are necessary and must be completed. Where that
money comes from is another question, but I think it was said
it is about veterans, and veterans need to be cared for.
Congress needs to find the money somewhere to continue these.
It should never happen again. I think VA should get out of the
business of building hospitals.
Mr. Rausch. We would agree in regard to the construction,
and just more broadly, any and all cost overruns at VA provide
a high risk of not providing the highest-quality care to
veterans. That is the bottom lime, whether it is for
construction or anything else. IAVA supports the Secretary's
budget request. We also support his request for greater
flexibility. As I said in front of this Committee in the
previous hearing, in theory, without greater flexibility to
move money within those 72-plus line items, in theory, it would
allow him to move more money back into Choice. We support his
request for that, but more broadly, we believe Choice is an
opportunity to better understand how veterans and where
veterans want to receive the health care that they deserve.
That, frankly, ties into what I think everyone is talking
about, which is a strategic plan for coordinated care in the
community. Care in the community, again, Mr. Chairman, I think
that was a phrase you used in the previous hearing, and we have
started to use that because ultimately we believe that whether
Choice stays in its current form or fashion, we think it is an
opportunity to better understand the customer, our members, so
the VA can move forward with a strategic plan to provide the
best services possible.
Thank you.
Senator Blumenthal. Well, I appreciate all of your answers,
which confirm my views, and the Chairman and I have stated
those views. The Chairman has stated and I have as well that we
have alternatives, different options, that we think absolutely
have to be explored. We look forward to working with you on
those options and also on this concept of accountability, which
all of you have mentioned. You heard me talk about it earlier,
which is includes looking backward, holding people accountable
who, in effect, are responsible for this nightmarish debacle,
and also looking forward. I might mention, Mr. Violante, in
your written testimony you discuss the VA's need to redesign
its performance and accountability report. You make reference
to the Department of Homeland Security's similar regiment known
as planning, programming, budgeting, and execution, PPBE, as a
possible model. I am sure there are other models as well.
To your point, Mr. Rausch, I have said that the VA ought to
be out of the business of construction, that it should be the
Corps of Engineers or some other agency that takes over this
function. No disrespect to the VA, but it is not within their
job description to manage these mammoth, multimillion-dollar,
in fact, billion-dollar projects on which the future of VA
health care depends.
You know, when you and I go to build a house, ordinarily we
are not our own contractors. Maybe some of you are, but we try
to get a little professional help to do it. That may be an
inexact analogy, but for all the Government agencies, not just
the VA, this should be some professional center of management
that maximizes resources, reduces costs, makes it energy
efficient, decides what materials and designs should be
incorporated.
I think we have a lot to discuss going forward. I welcome
your participation, and I thank the Chairman for this hearing.
Thank you all.
Chairman Isakson. Thank you, Senator Blumenthal.
Let me just echo everything that Senator Blumenthal said
and point out a couple of things.
Originally, in our first hearings, the VA people who
testified told us on the 40-mile rule in terms of distance
driven versus crow flying, that that was going to expand the
number of people being eligible for VA Choice and was going to
cost more money.
Now that we have talked about the care you need and that
definition, which we are working on, one of the estimates is it
is going to cost more money than we planned.
We understand that to go from Point A, which was a disaster
in Phoenix that led to all the problems that caused Veterans
Choice, to where we want to go is going to take time, it is
going to take money, and it is going to take coordination,
which is where the coordination work comes from. There are
savings in coordination once you accept a few principles.
Principle one is that if you use the private sector well and
the veterans like it and it is an alternative to make the
veteran system work--it is not a substitute, but in certain
cases at times it is an alternative--then you are saving the VA
money in cost; you are getting the private sector investment,
and you are getting better health care to the veteran.
I am willing to look at this in a macro sense. We just did
a budget in the Congress. It is a 10-year budget that balances
in the tenth year. VA has got some problems. It is going to
probably take 10 years to financially solve it, but you have
got to begin that at some point in time.
Hopefully, as we work through this problem on Denver and
get the resolution on who builds what and when they build it,
we also look at it in a macro sense for how we find the savings
to pay for the changes we need to make. Eventually, we are
going to have a delivery system that is probably less costly
than building the bricks and mortar. It is going to take us a
while to get there.
With that said, I want to thank all of you for being here.
Thank you for your service to America, and I appreciate the
time everybody has given us today.
[Whereupon, at 5:07 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Patty Murray,
U.S. Senator from Washington
Mr. Chairman, Thank you for holding this hearing. As the daughter
of a World War II veteran, I believe making sure our country keeps the
promises we've made to our Nation's heroes should be at the top of our
list of priorities, all of the time. Taking care of our veterans when
they come home is a fundamental part of who we are as a nation and we
must make sure that the Department of Veterans' Affairs (VA) has the
tools and resources it needs to provide critical care and support. It
is part of the cost of going to war.
Ensuring that all veterans receive quality care in a timely manner
remains a critical issue. The Department must work quickly resolve
challenges associated with the implementation of the Veterans Access,
Choice, and Accountability Act. I continue to hear from veterans about
delays and confusion in getting care through the Choice Program--and
delays in filling positions created by this legislation. This is very
concerning to me.
No doubt, the $5 billion we gave to build and strengthen VA for the
long-term is making a difference in some areas, but there is much more
to be done. In my home state of Washington, we are seeing some positive
effects of this legislation in addressing critical shortages, as
several VA medical centers have already announced they will hire
hundreds of new medical care staff. They will also be able to upgrade
and expand many of the facilities in Washington.
It is critical that VA uses that $5 billion as it was intended by
Congress: to hire more providers, create more usable clinical space,
and improve access to care for veterans. The Department should not be
diverting this money from those serious needs to make up for the
failures in constructing the Denver hospital.
Despite this, low utilization of the Choice Program and increasing
delays make it clear that it's time to start planning now for what the
future of non-VA care will look like. The Choice Program was a
temporary, emergency authority. When it expires, VA needs to have one
reformed program in place to help veterans access care outside VA in a
way that complements services provided by VA, provides coordinated care
with strict quality of care requirements, has consistent processes and
eligibility rules, and is cost effective. I look forward to working
with all of you on this important task.
Finally, I would also like to thank both panels of witnesses for
testifying at this hearing. Your hard work is very important for us as
we work to make sure there are adequate resources to provide veterans
the benefits and care they have earned.
______
Second Report on Veterans Choice Program Submitted by the Veterans of
Foreign Wars of the United States
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