Good morning, everyone. The committee will come to order. I welcome our witnesses in person and those that are appearing distancely. We look forward to their testimony and getting a better understanding of where the department of Veterans Affairs and the Third Party Administrators are in administering the mission act. Im also very interested in hearing more today about the caregivers implementation, as well. Almost every member of our committee, though not physically present at the moment, some are joining us in person and others will be joining us, almost every member of our committee will be participating and is expected in todays hearing. The focus of todays hearing is the implementation of title 1 under the mission act by the department of Veterans Affairs related to Veterans Community care programs and the program of comprehensive assistance to family caregivers. I scheduled this hearing because of my dissatisfaction with the pace of mission implementation. While va officials were invited to participate in todays hearing to discuss the critical programs they oversee, the department chose to decline that invitation. This committee and the va shared a common goal to pass the mission act in 2018 to better serve veterans and their families and we continue to Work Together to address important issues for our nations veterans. I would expect them to be here for this conversation to share all theyve accomplished since the va was transformed with this legislation and to discuss what needs to be done to meet improvements. The va is an integral part of this dialogue, which is why i discuss title one implementation. I would be remiss not to discuss it during the covid19 pandemic. The va staff require our recognition for fulfilling the vas mission. The va has struggled to uphold the mig acts requimissions acts requirements. My staff and i continue to hear complaints from veterans and providers regarding poor communication and lapses to inadequacies. Third pf party, are valued in essential partners in the care through the Community Care network. You play and they play an Important Role in a robust and resilient care network which provide veterans timely access to care and make search they receive prompt payment for the care ask services they provide. When the va released stringent access standards for Community Care, i was encouraged to see more veterans would finally be able to access timely, quality care closer to home. However, once again, my staff and i have since learned that the vas contracts with Third Party Administrators use a completely different set of standards to determine how veterans access care. Under contract terms, rural and highly rural veterans can be forced to drive up to three hours for care which is completely, totally unacceptable and contradicts the spirit of mission. Ive discussed this glaring inconsistency with the va officials with months and despite vas assurances privately and publicly it is uncertain whether the va has modified the terms of the contract. It appears to me that its possible now for veterans to have a different access for care certainly than the law and the mission act requires different than the regulations of the va and perhaps different from vision to vision based upon the contract terms based upon third pf party administrates and we hope to learn more about it today and it is central to the transform the va into an innovative and responsive 21st century system capable of addressing what veterans face today under the law. As such i want to make sure that vision act succeeds and the Communications Network is accurately accounted for because there are a sufficient of number of local providers for veterans to utilize. Much has changed in our country since the Committee Held a hearing on implementation and the Community Care Network Earlier this year and the intent and goal of the mission act has not changed and theyre able to get that care without unnecessarily scheduling delays for Community Providers and that those providers are pait paid in a timely manner. Congress has the responsibility to execute the laws to serve veterans and i take and this Committee Takes its responsibilities seriously. I believe some of the vas most Senior Leaders agree with me that while progress may be under way it must move fast tore enable Community Care networks to serve veterans as we all envisioned. I want to know how the va is make being progress to working with thirdparty administrators to offer veterans access to the health care they deserve. Another essential component of the mission act is the family caregivers to all generations of veterans, many caregivers have been providing essential services for their loved ones without support for years and in some cases, decades. As veteran caregivers are often the main care takers for their loved ones, many can experience depression, anxiety and other Mental Health decisions in part or solely to the stress of care giving. The stress associated with caring for a spouse or Family Member with the set of complex healthcare needs is a real and present concern for veteran caregivers. It is essential that the va support for caregivers these Mental Health challenges be addressed effectively. Mission outlined a twofaced process to expand the resources with the anticipated start date of october 1, 2018. For phase one. Phase one implementation only just began october 1 of this year, two years behind schedule. This delayed rollout will result in caregivers needing to wait longer to be a part of the vital support program. Forward to hea testimony from everyone about the issues that you face in your work to help care for and serve veterans and steps that the va can take to make certain both of these programs are functional and able to deliver good results and outcomes for veteran caregivers. My Opening Statement is longer than my usual practice, but i had sufficient desire to say a few things this morning as we begin this hearing and i want to yield to the Ranking Member and author, senator tester. Thank you, mr. Chairman. I want to thank you for holding todays hearing. And im looking forward to the discussion among our panelist witnesses. But i, like you, am disappointed the administration chose not to participate in this dialogue. I do not know why something as important as implementation of the mission act doesnt rise to that importance in the va. Hopefully its not because theyre out campaigning across the country. This committee has serious issues with the administration on the imp indicatilication of mission act and its unfortunate they couldnt be here to participate to finding solutions for those problems. When congress creates programs to benefit veterans and their families, the expectation the administration will implement those programs as congress intended. The legislative branch isnt here just as a nuance. We actually do things and have expectations. So the executive branch ought to be sending folks here. With the creation of the va missions act, congress sought to provide veterans with greater options for Community Care when the department could not provide care in a timely manner. The latest data we have from the va shows that it made more than 4. 1 million referrals into the community from the beginning of fiscal year 2020 to june. Nationally, they took va nearly 22 days to Schedule Health Care Services in the community after a request is made. Thats not acceptable. Its a problem. Veterans should have shouldnt have to wait for the va to navigate a bureaucratic process before their appointments are scheduled. Veterans wait an average of 20 days for their appointments after theyve been scheduled. Thats that doesnt work, man. That dog doesnt hunt. If the va was here, i would tell them to find a way to reduce the red tape. The Administration Needs to explain how it plans to bring down the number of days it takes to get veterans to the point where they get scheduled for care in the community. And the last year, theres not been much improvement in this timeline. Rather than sticking with this broken process, the Administration Needs to figure out a better path forward. I have a bill, the accountability and department of Veterans Affair scheduling and consult managing act which passed last august. It would help the va do just that, it would require the va to take a hard look at its scheduling process and then report how long it takes to get through that process. It would also require scheduling audits and review of scheduling because too often personnel leave these jobs for better opportunities. My bill would help veterans make better informed decisions on where they can get care because they would have the information they need to make those decisions. It would also help congress exercise oversight of va scheduling to make sure the program is working as we intended. Another area of scrutiny is the Caregivers Program. While it has the potential to vastly improve the lives of veterans and their caregivers, many of whom have waited years to receive the same stipends, straining and Mental Health services that have been available to post9 11 veterans, im concerned that the administration wrote the rules on eligibility. Modifications that tighten eligibility for the current and expanded program are not mission act driven and were undertaken by the administration in an effort to limit eligibility for this program and for the veterans that it impacts. Im also concerned that the administration is in a rush to meet a new selfimposed deadline after missing the mark by a year causing on fusion when causing confusion when it actually did. I want to thank the Elizabeth Dole foundation for being here today so we can make sure this program is functioning well for veterans and their caregivers. Thank you, mr. Chairman, for calling this very important hearing. Let me introduce our witnesses. Dave mcentire is the ceo of triwest, steve that wschwab fro elizabeth both foundation. Thank you for providing testimony so we can understand the circumstances by which we may help you accomplish your goals of meeting the needs of veterans of yoour country. Were begin with Lieutenant General horoho. Thank you for being here and thank you for the conversation that we had for nearly an hour on sunday evening. On behalf of the 25,000 health care employees, were honored to support the commission to ensure our nations heroes live the healthiest lives. Can you hear now . Im sorry. Would you like me to start over . Do you want me to start over . Okay, good. I had to dig deep into my military voice there. After 33 years of uniformed service, the mission is personal to me and our entire organization. Were veterans. My Leadership Team has a total of 350 years of service in uniform. Many of us or our Family Members receive care from the Va Health System or the community. Since i last appeared before the committee, optum serve completed our implementation across regions. Our responsibility is to build and manage a highquality provider network. Were managing a network of 830,000 providers across 1. 6 million sites of care. We intentionally built a Large Network so veterans could have their choice from a wide variety of timely care options. To date, the va has issued more than 1. 5 million referrals for care to our Network Connected individual veterans with a highquality provider, one veteran at a time. 100 of our network is fully accredited and credentialed. In addition, as compared to the 15 benchmarks set by the va, 54 of providers assessed are designated as highperforming providers. The success of our network goes beyond the data. Underlying the data are hundreds of thousands of individual connections made between care providers and veterans. We understand that health care is local and the choice of a provider is personal. Our network is dynamic, highly reliable, and responds quickly to the needs on the ground. Recently the leadership at the Lexington Va Medical Center expressed gratitude for our assistance in ensuring a veteran who was battling cancer could be treated by the same provider as his wife. We know that caring for our nations heroes is more than signing a provider contract or paying a claim. It means caring about the women and the men who have worn the cloth of our nation and doing whatever it takes to help them heal. Every day we work side by side to advance veteran care, review successes, develop action plans, address challenges, and share best practices. These relationships are critical when the unexpected happens. This occurred in august when hurricane laura left 200,000 without water and a million without power in louisiana. Many hospitals were forced to close and my team jumped into action, leveraging relationships with the louisiana hospital association. We ensured they had uptodate information on hospitals where they could safely serve veterans. Our network is not a national entity. Its a collection of regional care, ecosystems, designed to be responsive and convenient to veterans. Working with each group, we have prioritized the credentialing of highquality providers with a history of serving verpts in te the community. Weve partnered with providers and 93 of academic affiliates including duke and the university of kansas. And for the first time in the vas history, a providing care in the community, optum partnered with the va to bring the mayo clinic into the network. While managing our network is a dynamic process, our restlessness keeps the veteran at the center of everything we do. This month we learned that a veteran was matched with a lifesaving heart. More quickly than expected. This evoked our warrior ethos of never leaving a fallen comrade behind. Within 24 hours, this West Virginia veteran received a new heart. Over the last few weeks, we began facilitating dozens of lifesaving organ transplants. This is the power of one, one organization working one on one with va staff, vsos, congress, caregivers and many others to advance the health and wellbeing of one veteran at the time. Mr. Chairman, Ranking Member tester and members of the committee, thank you for the opportunity to appear before you today as a veteran, former army surgeon general, wife of a veteran, daughter of a veteran, and the proud mother of an airborne infantry lieutenant, ensuring veterans has a network that meets their needs is important to me and our entire organization. Thank you for your testimony and thank you to you and your family for your service to our nation. Mr. Mcentire, welcome. Mr. Chairman, Ranking Member tester and distinguished members of the Senate Committee on Veterans Affairs, on behalf of all those associated with triwest, its an honor to appear before you today. Weve been serving the military and veterans population for nearly 25 years now. Were privileged to have partnered with va for the past seven years and helping them respond to the Health Care Needs of veterans from pc3 to the choice act to expansion and replacing of health net its been quite a journey. Weve tried to remain nimble and focused on one objective, to support, not compete with, the va in providing timely, quality care for veterans. Through the use of our proven demand capacity process and leveraging the footprint of our nonprofit owners, weve tailored highquality networks in collaboration with va to match the unique demands of each of their enrolled veterans. It will contain all academics for region 4 and delivered more than 42 million medical appointments. This included everything from urgent care within 30 minutes of a Veterans Home to eye appointments, to primary care, to urology, to womens services, to Behavioral Health and just this past weekend, a triple organ transplant to safe the life of a hero. We have collaborated in administering the benefit for hundreds of couples who cannot otherwise have children because of their combatrelated wounds. We have customized a network for each one of the couples, their unique circumstances, and lots of babies and proud and grateful parents are the result. Im pleased to report that due to the team effort between us and va, were processing and paying clean claims, professional institutional alike within two weeks to a level of accuracy and access of 98 . And it will please you, im sure, mr. Chairman, to know that the va is reimbursing us on a timely basis as well. Along with these successes have come some challenges. Especially in the delivery of timely appointments. As you know, early in the year, our nation was hit with covid, a challenge unprecedented in our lifetime they reduced the Available Services as they made changes to keep their staffs and patients safe and preserve capacity for those fighting the virus. It was a daunting situation. But soon and since july of this year, weve been scheduling appointments within five days for 90 of all veterans needing primary care appointments and theyre seen within 26 days from the receipt of the referral. Mental health within 27, and specialty until 28. Theres still a bit of work to do, but were close. And only 1 of the care requests that weve been given have returned been returned for no network provided. Getting here has been challenging, but were close and we will not rest until were delivering on our collective commitment to timely and convenient care. With the implementation of ccn, va takes over care coordination and appointing, but the vas request, we begun supporting the first six vampcys and we expect that to be spread to other medical centers. We look forward to doing the same in alaska. Not to replace va, but to enhance it and provide the elasticity needed so they can serve veterans as you and they believe should be served. Veterans deserve no less. We applaud your continued leadership, mr. Chairman, and members of the committee and direction as we work towards a common goal that we all are united by, providing timely, quality access to health care for our nations veterans. Thank you. I recognize mr. Shwab for his testimony. Members of the committee, the Elizabeth Dole foundation is pleased to testify today on the mission act and the expansion of the va program of comprehensive assistance for family caregivers. Hundreds of thousands of military caregivers are counting on us to get this expansion right as are the generations of veterans who depend on their care. The original legislation establishing this program unfairly drew an artificial line between the caregivers of those who served before september 11th, 2001, and those who followed them. Our nation must continue to swiftly act to end this disparity and caregiver benefits. Pre9 11 caregivers provided a service to our country. They have been suffering in the shadowing for decades tending to war wounds, compounded by age, and now confronting additional debilitating conditions such as als, alzheimers, cancer, mobility issues and so much more. In twou2014 a study found that of pre9 11 caregivers spend more than 40 hours providing care. A quarter have taken unpaid off time from work or temporarily stopped working because of their caregiving. More than 13 have dropped out of the workforce entirely. And the most common pre9 11 caregiver is a grown child of the veteran, many of these caregivers fall in the sandwich generation, who simultaneously care for their parent and their children. These Hidden Heroes are contributing nearly 15 billion in care every year. The vast majority of which is provide by pre9 11 caregivers. Experts agree that a wellsupported caregiver is the most important factor to the wellbeing of a veteran. Correcting the inequity was one of your foundations first and urgent authorities. We applaud congress for responding to our call and were grateful that secretary Robert Wilkie and the u. S. Department of Veterans Affairs have carried out this legislation as part of the vas continued investment in caregivers. Unfortunately, however, implementation of the expansion has been marred by ambiguities and delays that have led to widespread frustration and confusion all across the caregiver population. Our chief concern is the pace of implementation. After more than a year of delays, the va still intends to roll out benefits in protracted phases, requiring those caring for veterans who served before may 7th, 1975, to wait two more years for eligibility, thats two years. We understand the faced approach is specified by law, but these prolonged delays are further straining caregivers. The veterans, families, caregivers and survivors, federal advisory committee, chaired by my boss, senator Elizabeth Dole, recently recommended that congress provide legislative relief to expedite this timeline. Mr. Chairman, senator tester, members of the committee, senator dole hopes action is taken on this very important legislative reform. And even more important, our pre9 11 caregivers who are being forced to wait even longer to receive their benefits hope you will take action immediately. Our Foundation Also strongly urges the va to standardize the expansions implementation. The largest source of caregiver anxiety and dissatisfaction has always been the inconsistencies between va centers. Among the areas open to interpretation is the requirement for annual assessments. Some medical centers choose to evaluate caregivers multiple times each year. That causes undue stress among the caregivers over the possibility that they will be dropped from the program. Key language about how caregivers are evaluated lacks clarity. We are particularly concerned about the reliance on activities of daily living as the marker for how much care a veteran requires. Mandating that caregivers assist with adls on a daily basis will likely disqualify those for caring for veterans with post Traumatic Stress and traumatic brain injury. The ability for veterans with cognitive injuries can vary over time, even hour by hour. We cannot leave their caregivers unsupported. At the core of the implementations challenges is a critical lack of communication. Caregivers have largely learned that the program was officially expanding benefits on october 1st, secondhand. Through social media or through word of mouth. However, large percentages of the caregiver population do not use social media or participate in online communities. Furthermore, those who do participate in these communities are vulnerable to inaccurate information. The va must invest in a proactive comprehensive campaign and engagement with msos like ourselves to ensure all caregivers receive the benefits and communications that they need and deserve. Finally, our foundation calls on the va to create a permanent head of the va support program and classify the position as an ses. Currently the position is interim and that is s unacceptable. It requires an established position of Senior Leadership. While we strongly encourage the va to respond to the recommendations we have presented today, we also praise the department for its commitment to implementing this historic legislation. We know and we recognize a lot of hard work has been done. Its a tremendous task. The Elizabeth Dole foundation and our coalition of partners are standing by and ready to assist in promoting and implementing this program. Thank you, again, mr. Chairman, Ranking Member tester, and Committee Members for this opportunity to appear before you today. We look forward to continuing our Work Together. We look forward to your questions today and to supporting our nations veteran caregivers. Thank you for your presence here today. Thank you for the work that the Dole Foundation does and accomplishes. Please give our best wishes and gratitude to the caregivers. As a kansan, but as an american, give my regards to both senator doles for their work in congress and their retirement from congress, the work theyve done since then, on behalf of veterans in america. Let me turn to your colleague, ms. Beller. Chairman, Ranking Member, members of the committee, thank you for inviting me to share my story as you assess the expansion of benefits under the Va Mission Act of 2018. I appear before you today as the caregiver of a veteran. Im also a national advocate for military caregivers with the Elizabeth Dole foundation and a lawyer who served as a Deputy Attorney general for the state of indiana. More than 45 years ago, my husband was exposed to agent orange while deployed during the vietnam war. That exposure caused diabetes and the diabetes triggered a major stroke. For almost ten years, hes required 24hour care. The stroke caused paralysis on the right side of his body so i assist him with all activities of daily living. Every day begins with me helping him out of bed, moving him into his chair and getting him dressed. I prepare breakfast, assist with eating, and administer insulin and other medications. Our biggest challenge is chucks inability to communicate. His intelligence and memory are intact. However, he can go longer read or write. He understands about 60 of what is said and his speech is completely garbled. It is my job to help him understand what is going on in any given situation and moiake sure he feels hes been heard, especially at medical appointments. For my first five years as chucks caregiver, i did my best to hold my life together. I was entering some of the most professionally fulfilling years of my life, not to mention the highest earning years. I leaned on the family medical leave act to help me stay employed. But with that assistance, i barely had time to sleep. I was devastated by the neverending cycle of work and caregiving. Considering the sacrifices i was making as a caregiver, i could not understand why va benefits were denied to me and millions of other pre9 11 caregivers, just as i do not understand why caregivers must deal with drawnout time lines. The va must find ways to streamline the evaluation process. For example, the va has a decade of medical files demonstrating that my husband needs assistance and that im his primary caregiver. Yet to apply for these benefits, a va representative is required to interview me and my husband for 2 1 2 hours. This lengthy process can add stress and anxiety to the veteran and the caregiver. It is imperative that interviews accommodate veterans who may not be communicative or who may not be able to sit still for a full interview. Im happy to say, however, that the caregiver support coordinator in indianapolis was very accommodating for chuck and the concern is, we cant see that through the rest of the va system. The va should also enforce consistency in the evaluation process. Caregivers sharing their application stories in online communities are revealing significant variances between va locations and between the application instructions and how it is applied. The most concerning of these inconsistencies is the overreliance on activities of daily living as a measure of care. Caregivers assisting someone with invisible wounds are struggling to prove the value of their care and i assure you, their care is saving their veterans lives. Resolving these issues is critical because caregivers are counting on these benefits. The vas Financial Assistance is not insignificant to caregivers who have to choose between caring for their veteran or paying the bills. I loved my career, but i would have died if i continued working while caregiving for chuck. And then chuck would have died shortly thereafter. However, its not just the Financial Assistance that is invaluable. If allowed into this program, i will have someone who is available to help me during my caregiver journey. These benefits are lifelines to the caregivers and without the love and support from a Family Member of a veteran may not survive. This is how important caregivers are to their veterans. And that is why allocating these benefits as quickly as possible is so vital. Despite the damages i outlined today, i would like to commend both congress and the u. S. Department of Veterans Affairs for remaining committed to correcting the inequity in va caregiver benefits. For many years, veteran caregivers have felt voiceless. Today we finally feel heard. Thank you very much for your testimony and thank you for your husbands service and your care and concern for him and for other veterans and their caregivers. I think now we are ready to begin the questions. Before i do that, i i wanted to highlight something that i failed to say in any opening remarks. Since we met last, the president has signed into law legislation passed by the house and senate, the Health Care Improvement act. And i want to express my gratitude for helping with that. Let me begin with a couple of questions for both the general and mr. Mcentire. Has the va reached out to your companies to discuss modifications related to access standards . We have been implementing a series of changes to our contracts since we started the implication of region four. That follows the work that was done originally with optum. And to this point, there is no modification currently being negotiated formally as to the access standards. Ill come to you maybe its easier if i ask a series of questions directed to both of you. Is there youre making progress in improving i think what youre saying, the access, the timeliness, the access standards. Why are you doing so if its not included in your contract . We sought from day one to build a network that was in keeping with the access standards that are envisioned in the mission act. And the award of region four was done in such a way that it predated the opportunity for the va to make an adjustment to the contract before award. So i thought it made most sense for us to start a trajectory line with that in mind. The region five contract that just got awarded for alaska to our company includes the mission act standards. And when covid hit, we suspended a bit our work to more broadly build the network in favor of making sure that we protected the base that needed to be built and were now getting back to closing out the work on the mission act standards as well as refining the dental network which has been, as senator tester and others from region four know, a little bit more complicated than was initially anticipated. Is my concern that veterans have different access standards depending upon what thirdparty administers contract says and what that thirdparty administer is doing . What you indicated is in the most recent negotiations, the mission act standards are included, but in other contracts, they are not. Therefore, depending upon what region you live in, youre operating under a different standard. The mission act standards were included in five because that was most recently awarded. That gave the va enough time to modify that contract before award. That was not the case in region four and so therefore were stretching ourselves voluntarily in the direction of the mission act standards for the Network Build for region four. General, your response to those questions. Thank you, senator. So we when we received our contracts for regions one, two, and three, it was before the mission act went into law and so six months after we had that award, it went into law. Those sparta those standards were not part of the contract. When we looking at the contract, we looked at it through three different lens, one to have a bigger network, two, to have a bigger chance for availability, and, three, to have bigger veteran choice. And so we intentionally went and overbuilt the network, we realized that theres more than 10,000 veterans that leave the military every year and so we didnt want to build a network just where veterans are today but we wanted to have a robust enough network that we have capability and providers in the right place at the right time for the veterans for the future. And so we are not in active conversations with the va on modification but that hasnt stopped us from wanting to make sure that we have the most Robust Network available. So we kind of look at it through three two lens, one is a retrospective lens where we look at the referrals and through the claims process and we look to see how long it took for a veteran to be able to get an appointment and then we look within that area to make sure that were in access standards. We look prospectively and look at geo mapping, where the veteran lives and where the providers are to make sure that we have really robust drive times as well as availability for care. And so internally we have monitored ourselves on what the secretary wilkie had put out for the access standards of 30 minutes for primary care and Behavioral Health and then 60 minutes for specialty care. So internally, we monitor that and were actually very close to meeting that standard across all primary care Behavioral Health and specialty except for the area of dental where we have were probably about 79 with dental. But everything else, were close to 90 or higher. Your contracts, the ones that were negotiated before the mission act took effect and do not include the mission act standards last for how long . The contract length before theyre renegotiated is how long . Eight years. And you have no indication that the va let me ask a more neutral question. Do you have any indication one way or the other whether the va is interested in implementing a contract modifying your contracts to meet those standards, to include the standards . Senator, we have given them all of our data and information that they would need for them to make that decision and right now were not in active discussions. And now, i may be editorializing, correct me if im wrong, if you both are working in the direction, both your thirdparty administers are working to meet the standards of the mission act, what is the reason for those not to be included in the contract and in the absence of the contract, the reason we have standards is so that a veteran regardless of where he or she lives operates under the same rules . So in area five, theres a different standard for a veteran than a veteran in region three. Does that is there any reason that makes any sense . Maybe if i can frame it in how were operating every single day. And so one of the things that weve realized is health care is local. And so we work every single day with each local area on the ground to identify where they have gaps in care, and ensuring that we have a robust enough network to support each one of those vamcys. I think im in agreement with you, and we believe that the intent is more veterans to get care where they need it, when they need it is part of why were driving to the most Robust Network. Thank you for that answer. I would say that i agree with you, general, that care is local. I believe that, but a threehour drive is a threehour drive wherever you live in this country. Mr. Mcentire . We have sought to understand what the footprint of the veteran is and what the footprint of the Va Medical Center is and their capacity and not just their capability and we seek to build the elasticity that they are going to need. With regard to your question about modifications, weve done 100 modifications since we started this space. And i think there will be a day when it makes sense for the va to modify our contracts, the ones we currently have, to layer in the standards so that we can measure appropriately between us how were doing in meeting those standards. And i was refreshed to see that the mission act standards are layered into the region five contract and i think thats probably an indication of where va intends to go but have not asked them that question. Thank you very much. Thank you both. I apologize to my colleagues for running over time significantly. Ill try to make up for it. I dont know whether senator tester has returned from another committee meeting, if so, i recognize him im here. Im here. Thank you, mr. Chairman. Its okay if you run over time, once in a while. Youve been very gracious. I want to thank you everything for testifying. Im going to start with you because youre a big deal and i want to talk a little bit about dental Network Rates and access to preferred dental providers is a concern that i hear consistently from veterans across the state. So my state staff tells me that calls and emails from veterans concern that regular dental provide providers not in the network have eclipsed those without eligibility through the va. The chief concern appears to be that dentists believe the Network Rates are too low. So what i would like to have you do, dave, is walk me through how you and the va establish dental rates in region four and the adequate adequate si of the dentists in montana. Does that make sense . Great question, senator tester. Its good to see you. We are building the network in montana. As i said, its been a little more complicated that we initially expected. The reason for that in part is there is no fee schedule thats national for dental services for the va. They were local fee schedules. In some cases they varied substantially market to market. And what were asked by va to do in the dental space was to attempt to put together that reflected the market rates in those environments. We sought to involve our dental subcontractor, delta dental, which has a wide foot fingerprint across the geographic expanse of montana and the rest of region four to leverage their engagement in the marketplace and to convert over to a fee schedule that is consistent and to build out that network. In some cases, the market rate that theyre paying for dental services is different than what the va was paying historically and thats where part of it occurred and we are collaborating market by market to make sure that we are able to make appropriate adjustments and complete the network. So i just want you to add onto that. In what circumstances would you pay more than the rates are right now . More than the rates in the market or more than more than the rates lets assume for a second that the problem is in fact that the Network Rates are too low. Lets make that assumption. What circumstances would cause you to race those curreise thos rates . If a higher rate was necessary to make sure that we could build a complete dental network in their state. Okay. I appreciate that. Do you feel at this point in time that the rates have not been a limiting factor on you building that network . I think that its been a bit of a challenge, but its one that were working through to attempt to respond to the local conditions in the market to make sure that we can build a sufficient network that the veterans need to be able to rely on. Okay. General, could you like to add anything to this topic . Yes, sir, i would. So when you look at dental the challenge is in a couple areas. One, 12 of the veteran population is eligible for dental. But that data isnt readily available and so you really have to build the dental network to support the 6 million veterans that are there. And each of them actually, its a fee for service. Its different than the managed cares support contracts that are out there. And so the rates are by cdt codes. Each dentist, theres different rates for the subspecialty, versus general dentistry. What we have found is that weve had to pay up to 150 for some of our contracts to be able to ensure that we can have a robust enough dental capability within that within that marketplace. So when we look across our three regions for wait times, region one, its about 27 days, region two, 21 days, and region three, about 13 days. Its a negotiation market by market. I want to thank you both for your explanation and i want to point out to the chairman, i only went 25 seconds over. I yield. Thank you, mr. Chairman. Thank you, senator tester. I know recognize senator cassidy. Doctor . You got me now. I think you do. Yes, sir. Great. Thank you. Thank you, both. One of the issues that im sure youve heard of is the timely and accurate claims processing and so theres a system back home that says that from about june of 2019 to about june of 2020 theres just a whole batch of claims that they have not been compensated on. Now, subsequent to that, its going okay. But there are these claims there. I say that because were all aware of the impact that covid has had upon hospitals cash flow. Obviously, theyre still in business. But nonetheless, part of what keeps them in business is paying attention to stuff like this. And so can you give us some perspective on how tpas are going to handle this. And if you addressed this in your opening remarks, i apologize. Ill take that, patty, if thats okay. Because i feel the breach our company did before you arrived in louisiana, and there is a requirement currently that providers file claims within 180 days up to service. Thats half the time given for medicare and half the time given for tricare and most other programs. Whats happened to them is further complicated because of the fact because sometimes va ordered the works, sometimes health net ordered the work, and staoimts sometimes we ordered the work. Theres been a complication on the part of providers of where to file. The va and we have worked extensively over the last couple of months to put a process in place thats going to allow every provider that falls into the gap that you so articulately identified, senator, that will allow them to refile the claims, have them processed and paid. And we have the resources to do that on the dollar side and the va will reimburse us. And this just started at the beginning of october. Theres been common outreach between us and va of that fact. And theres now a 1367 claims that have been refiled that otherwise were denied for timely payment in the last couple of weeks. So we look forward to working with you. Va and ourselves. To make sure that your constituents are aware of what to do and how the process will work so that they can get reimbursed for the services that they delivered. We can follow up directly with you, should there be a continued concern or a problem on their side. Of course, they think they filed correctly. And so, mr. Chairman, i cant see the clock. You tell me when im out of time. Let me address this to optum. The mission act authorized the new care benefit for veterans which ive supportive of because it expanded options for care and made sure that folks who get urgent care where they needed it. The tricare established a nationwide network of 7,200 urgent care providers serving 92 of enrolled veterans. Optum is the tpa for region three and is in my state of louisiana. So i gather that optums Urgent Care Network is not as robust and since obviously i care about this, i was the one who sponsored the legislation, what steps is optum taking to ensure a Robust Network of providers comparable to triwest. Thank you, senator. We established urgent care and we did that in the midst of covid. We actually have 6,600 Urgent Care Centers across all three regions. And so across those regions, in region one, 98 accessibility and availability, 91 in region two, and 95 in region three. And we have seen where those have been utilized during covid because we also had some of them that used telecapability, where those that wanted to access care were able to do that remotely as well. Okay. So what ive been informed is your network is as robust and for whatever reason, as Humphrey Bogart once said, i was misinformed. Thats good news. Im told that the providers are unaware of a process to resubmit those claims. So the degree to which you can publicize that would benefit not just my folks but others. With that, i yield back. If i might mr. Mcintyre. I will reach out to every office thats on this committee to inform you of the communications that va and us have put together and to help you understand the information for that might be used to outreach to providers in your state and make patty aware of same things because our commitment before we fully leave, the errors that she stood up, is that all of the claims are paid even those that were not otherwise done in our on our watch but might have been done in the health space. Mr. Chairman, if i could just add to that so we get a complete scenario on it. What weve done internally as well, were paying claims 11. 9 days. When we get claims that are triwest or if it was, you know, health net at that time, weve got an internal code so we just dont deny them. We put the code on it so that it gets routed back and we work closely with triwest to make sure that works well, as well as working with the va. So we try to take away the friction with our providers. Dr. Cassidy, thank you for raising these topics. I now recognize senator murray. Thank you very much. I appreciate it. Thank you for your incredibly important testimony and your recommendations today. I really want to thank the Elizabeth Dole foundation for their dedication to our veteran caregivers. And mrs. Beller, thank you for all you do, both as an advocate and a caregiver. Im so grateful to my colleagues for their support in passing the caregivers legislation as part of the Va Mission Act to finally expand the program to veterans of all eras. But now weve got to get this expansion right and make sure that current participants are not getting unfairly pushed out of the program. Back in may, i joined senator tester in a Public Comment letter to the va regarding the agencys proposed changes to the Caregivers Program which would restrict eligibility and potentially remove some veterans from the programs. In the law, we set the criteria to include eligibility for veterans who need assistance with at least one activity of daily living. And we included other Eligibility Criteria such as supervision, protection or instruction to make sure those with the invisible wounds of war who need assistance can get it. However, vas new rule goes beyond congressionals intent to further limit eligibility. So i wanted to ask you, do you believe that the va is defines eligibility too narrowly when compared to the eligibility specifications outlined in our law, and how will those new limitations on eligibility to veterans rated at 70 service could affect our veterans . Senator murray, thank you for the question. And thank you for your leadership going back years on advocating for the expansion of this program. You are among the first members of congress, certainly, to be with us at the foundation and calling for the expansion of the program and youve worked hard on it. We appreciate that. Your question is superimportant and something i highlighted in my testimony. The program even before expansion was inconsistent at best in integrating, including, and caring for folks who are caring for a veteran with emotional mental and Emotional Health care wounds and injuries. Yeah, we yes, we do believe that the va has gone has gone beyond the interruption in the ways that its implementing eligibility with for folks who are caring for mental and emotional wounds. I think that my colleague if i could refer to her, senator, could expound on this point as well. Molly . Yes, thank you so much, steven and senator murray, for everything that you do for our caregivers and with the Elizabeth Dole foundation. As steve mentioned, we believe that the va has gone a little further than the intention of what was put into both the initial caregiver bill and the Va Mission Act. Were hopeful that they treat invisible wounds, such as ptsd or other neurological Mental Illnesses or wounds like the physical assistance with adls. Weve been told that the va will look into make sure the are weighing safety and supervision as equally as the physical assistance with activities of daily living each time. However, some caregivers that we have in our network and were working with have excessed concerns of that. You bring up a good point, also, of the 70 requirement. That was something that we were surprised to see in the initial Impact Analysis that the va provided. They did try to assure the community that 95 of what theyre considering legacy participants as well as members or veterans who are already receiving care under the Va Health System, would meet that qualification. However, that is possibly the lower bar of eligibility requirements. There is those functional assessment needs and as jenny beller so eloquently put, the twohour interview process, those are the higher parts of the eligibility requirements that were concerned with. Thank you. And mrs. Beller, thank you for your testimony today and let me just say, weve got to get this right and im not going to give up. Thank you for your recommendations and i look forward to working with you. Weve got to keep working on this. I very much appreciate it. I just have a few seconds left and i wanted to ask about ivf to mr. Mcentire. This is important to me, that veterans have the smoothest experience possible in connecting with the ivf provider that best matching their familys needs and i continue to have concerns about approvals from the va being delayed and im troubling by how it will effect the scheduling process for these families. To that end, ive heard that the va will soon be assuming full responsibility for scheduling appointments with the Community Providers as opposed to the network administers. I just want to ask quickly, what have you found to be most important in getting this done in a customized way that fits each couple . Senator, thank you for that question and your leadership with this important topic. It is true that the va is going to be taking over the functions related to ivf. It is, as you say, it has to be done very customized. And we anticipate that they are ramping up to do that. We will continue to do the Network Piece which is customized fully for the needs of the couple when we come to understand what their authorization is and what theyre circumstances are and at this point, the vas planning to do the scheduling of them. But Washington State is one of the areas that we expect the va to look to us for elasticity on appointing. If we can be helpful with the appointee on the ivf side to assist them, we certainly will do so. Okay. Mr. Chairman, i have additional questions that i want to submit to the record and i appreciate you allowing me to go over time. Without objection. Thank you. I want to thank you for having the hearing. I cant imagine anything more important than about increasing the quality of care and maintaining the quality of care that we have, and again, going forward. And also access to care, which is really what this is all about. So i know that we have had a really significant backlog regarding reimbersment in the past. We have worked hard to get that down. General, recognizing that the mission act changed the reimbursement plan for providers, placing a heavier burden up front, can you provide the committee an update on how the v. A. Is reimbursing Community Providers around are there any challengers we can be helpful with . I think thats the bottom line. Youre not going to have provider it is they dont get paid. Could not agree more. One of the significant areas of getting providers into the network was because of the challenges of the past. I can report to you today that i think were in a very good place. We are pay progress individualers first, which is a change, and were paying them 11. 9 days, almost 99 of the time. And then the v. A. Is actually rebir reimbursing us in around seven days. So that system is working now and we keep a close eye on it is, because it is how we retain high quality providers. Very good. Again, optum now is in arkansas, which is great. Theres concern about people that are under other providers that have had, you know, longterm relationship with them. For a veteran whose current provider is not in the network, what does this transition look like . How can we, how can you help provide continuous care for veterans you believed the s und circumstances . Continuity of care is so very important and health care is very personal relationship with your provider. One of the things that we have done is we have asked the v. A. To prospectively identify those individuals that do have a relationship that theres ongoing authorizations. And then the analysis to see whether or not there is a gap in the provider being in our network. And where there is, we can look to evaluate does that provider meet the new standards of being a fully credentialed provider, meeting all the standards than were able to bring them into the network. So when we meet every single month, we talk about gaps in care, we talk about, you know, where they need us, we talk about veterans concerns and so thats another place where that can come in. And then actually, the v. A. Has given us their priority providers, as well for us to bring those into the network. Very good. We understand that it takes time to build Community Care networks to best serve veterans, based on your testimony, general, it appears that optum serve has been able to quickly create a network that serves almost all regions in region three, and its commendable. You stated for region three, 95 of veterans are able to reach an innetwork urgent care facility within a 30minute average drive time. This is partially a credit to optums ability to Credit Health care providers as part of your network. In terms of the process, what is the average timeline for a Health Care Provider to receive accreditation by optum service . Is this something that can be improved on . Is there anything that we can do as a committee to help in that regard . So thank you, senator. Early on, when we were first standing up region one, we had a challenge in that area, because we were bringing on hundreds of thousands of providers. And so it was a large volume going through our system. Were now in a much better shape, having fully operationalized region one, two, three. Is our averages are between 5 to 15 days, sometimes theres some specialty like visions that may take 20 to 30 days. But that process is actually working extremely well right now. So i dont think theres any assistance we need from congress. Thank you very much. And now we will go to senator blumenthal. I think. Okay. Well, we are going to go to senator rounse. Thank you, mr. Chairman. Since optum is actually handling the processes within south dakota, i would like to address most of my questions to the general. First of all, i would like to thank you for your service to our country. Thank you. And i appreciate your continued service as your work with optum. There seems to be a little bit of a disconnect between what you have shared with us today regarding the working environment that you find yourself in with the v. A. Who have decided unfortunately not to participate in this hearing, and also with regard to what our folks on the ground and in south dakota have been sharing with us about the availability of the networks that you have been building. And the networks that were there prior to your participation. And i want to visit a little bit about this disconnect that im hearing today. Ive heard from both large and small providers that they literally have been extremely frustrated with the amount of bureaucracy that it takes to get into the network, and once in the network, to actually get paid. On at least three occasions, a veterans local v. A. Medical center has referred them, unfortunately, to a triwest Network Providers who had been there with years of service, but theyre being denied then once theyve been there. It appears to simply be administrative delays in getting them moved into the network. In this particular case, those veterans were denied access to care by those providers because they were not in the network any more, and that most certainly is something that as you indicated earlier and as we had discussion here today, is something simply not acceptable, and that continuity of care is critical. So what im going to ask is, i think we have got to have an analysis of whether or not what were seeing on the ground in terms of ground truth, versus having perhaps a 90 or 95 success rate, thats leaving out those critical numbers in the middle that somehow suggest that there are people that are getting left behind. It appears to be a bureaucracy problem. What i would like to do is to discuss, at least hear from you, what youre saying in terms of what is stopping or perhaps is the most frustrating part for you. Im sure there are frustrating parts about your working with the v. A. And trying to get through with your team these these former providers, to get them in. And finally, and ill let you answer, i would like to know what it is that are the guidelines and are they published for being an acceptable provider in your network that might have excluded those from the previous network. Thanks. Yeah. Thank you, senator. And i will absolutely myself and the team will come and meet with you and lay out the data for your area so that we can have a further in depth conversation with it. But if i can kind of address some of the concerns that you raised. Ill address first what it takes to become in the network. So when we started to roll out Community Care, what we went forward with is not trying to replicate the network that was pc3 choice, because Community Care changed the standards and made it a mandate to ensure that the entire network was fully credentialed. So not only did they have to be licensed, but we had to do prime source verification on the National Practitioner data bank. We had to look at their education, licensing, we made sure there werent any challenges and issues, either from any agency that was out there. If they meet those requirements, and there is and so, thats been the standard and thats what it takes to get into that network. The other piece that i want to bring out so some of the frustration that you have raised is we, if regions one, two, three, we dont do the scheduling. The scheduling is done by the v. A. And so when they go into the data bank, the First Priority is to look at those practitioners that are part of regions one, two, and three, to be able to schedule those appointments. So part of the transition we just finished going live in june of this year with all three of the regions. So some of that frustration may have been when there were the overlap, which we did all the right reasons with the for the veteran, is when we went live, we did a 30day overlap with triwest to ensure that there was no gap in care during that transition. But that also allowed the v. A. To look into the system and see the current optum providers, as well as the triwest. And they may have scheduled one or the other, which then tied into claims being put into the system that could have caused some of the confusion. But we can do a deep dive with you on all of your data thats there. Thank you. And look, i think what youre pointing out here is that we do have a problem with this transition, and i think the folks that are holding the bag on this are veterans that very well may have been denied care, and i dont think its been a once in a while issue. I think its happened on several different occasions, and i think were going to have to go the extra step to cut through that bureaucratic red tape, and i like the idea that triwest is going to go back in and allow for a revisit on those claims that are over 180 days old. I would like for your commitment as well that youll do the same thing, because were going to have that problem. Weve got folks out there that have claims over that time period. They provided the services. And so it looks to me like this transition has not been super clean, and nor would we expect it to necessarily be super clean. But i dont want those providers holding the bag, and i most certain hi dont want our veterans on the short end of being able to get services with the individuals that have been appropriately providing them with services in the past. And i think that means that as you transition into this, i do think youre going to have to go the extra mile, and with focus on those veterans. I would sure like your commitment that youll look at that 180day rule the same as triwest and make sure the veterans have the continuity of care where we have a problem. If you can give me that commitment, i think we can move forward. Senator, i can already tell you that were doing that right now. Every claim that gets denied, we look to see what was the reason before it goes back to the provider. We have been doing an internal code to make sure its routed appropriately. That didnt happen in the very beginning. But when we realized the confusion occurring with triwest, realized the confusion that was occurring when you had multiple Third Party Administrators in one market until it was fully transitioned. So we have made that commitment and we are doing that. So youve got my commitment that it will continue. Im assuming has that changed just occurred in the last week or so . That has no, we have been doing that actually probably for the last several months. Thank you, senator. And, again, that really again, that really is an important point. Senator blumenthal . Thanks, mr. Chairman, thanks to being here. Im disappointed as senator moran and tester have expressed, that the v. A. Is not here. Im also disappointed that the v. A. Has apparently declined to answer a number of the questions that we have asked you regarding the Racial Disparities in the impact of covid19 on our veterans. Seven months into this devastating pandemic, 3,667 v. A. Patients have died, which is a devastating average of about 17 veterans every day. Right now, we are apparently at the beginning of another surge. Theres been a 50 increase in active cases at the v. A. , compared to last month. I will say that im proud of the v. A. Facility in west haven, because they have done prompt testing with rapid results using the pcr process. It can be a model for the whole country. And the infection rate at our v. A. Facility has been much lower than the National Average and i want to point out that there is some good news, even amidst some of the more discouraging facts. But the results of a recent v. A. Study have shown that black and hispanic veterans are twice as likely as white veterans to test positive for covid at the v. A. My guess is that not only infection rates but also death rates. That show the same disparities. The v. A. Has refused to communicate with congress about this issue. Questions sent to the v. A. In june were completely ignored, as was a followup letter sent by the committee in august. I join my colleagues in expressing grave dissatisfaction with this refusal to answer our questions. The v. A. Does a tremendous disservice to veterans when it refuses to communicate with members of congress who represent them and have a responsibility for oversight. And then refuse to come to hearings, as it has done today. So i would like to ask all of you, but particularly the general, how the covid19 pandemic has affected your operations in particular at the facilities in your network, have they had adequate access to covid19 tests, reliable tests, and with prompt results and personal protective equipment . Thank you, senator. If i could take one second before i answer that and just talk about health despaisparitd because that has been so important. So one of the things that optum serve, my company is actually a Data Analytics Consulting Health service and technology company. We developed a Health Disparity data analytical tool that we have been using since covid started that we can go down to the zip code level and identify those americans that are disadvantaged or at high risk for covid19 based on their health disparities. And then we have done stop covid, where our company has done philanthropic work where we have provided that testing for free. We have also reached out to the v. A. And offed that capability to be able to utilize that, as well. I agree its a population that is extremely, extremely vulnerable. And to answer your other question, a couple things that we did as an enterprise when we looked at our network being so tied to our Enterprise Network and making sure that providers are one financially stable enough to keep their operations going was important. And so we have accelerated over 2 billion in patients to doctors and hospitals that are also serving veterans so we made sure that financially they were stable. We donated over 100 million to support covid19 impacted atrisk communities. And then we worked in partn partnership with hhs to help disburse over 100 billion of the c. A. R. E. S. Act relief. We did that because we knew this Robust Network of 830,000 practitioners are providing care not just for veterans but for americans. We wanted to make sure that was stable. What were seeing is we utilized and lef ranned a lot of telehealth prior to covid. Only about 12 to 16 actually used telehealth as referrals. And then now were up to 12,000 a month. So most of those were Behavioral Health, about 31 . And were starting to see the systems really coming back to normal and being able to improve access. Thank you very much. Thank you. Thank you, senator blumenthal. On behalf of the chairman, senator blackburn. Senator blackburn . Im coming. There we go. All right. Thank you all so much. I appreciate your coming for the hearing, and i really want to thank the Elizabeth Dole partnership on caregiver advocacy. This is something from our vet raps we hear a good bit about. So we thank you for that. Optum serve began managing the Community Care network in tennessee earlier this year. And let me say right now, i really agree with chairman morans statement that were disappointed the v. A. Declined to participate in this. And look at the process that we have had with this network. I will tell you, i am optimistic that we are going to be able to expand care to our veterans, especially those in the rural areas that are qualifying for care, and were seeing an increasing number of those that retire out from ft. Campbell, they choose to stay in tennessee because of its geographic location. Also because no state income tax. And the Community Care is something that is vital for them. And i want to focus today on the caregivers and we know in the past, and we have had some problems in tennessee with the v. A. Booting veterans and their caregivers from the program without justification and without them knowing why they got kicked off the program and senator peters and i have team care gagivers act that would pu into law some guidelines and bring some specificity to this program to be sure it doesnt continue to happen. We think those standards are going to be vital. It also takes steps to recognize the caregivers to a veterans their access to the veterans Electronic Health record. Mr. Schwab, in your testimony, you mentioned that caregivers are Hidden Heroes. And we know that they are heroes, but i will tell you, they ought not to be hidden. Certainly when it comes to having access to that veterans medical records, because this is one of the issues that we have in having that precise, timely coverage. Lets Work Together and be sure that they are not going to be Hidden Heroes. Let me ask you a question, mr. Schwab. In tennessee, with our Caregiver Program, what we see is we have many that are there because of ptsd and traumatic brain injury. And really what we term invisible wounds. And lets talk about the activities of daily living criteria that have been set by the v. A. And talk to me how that can negatively impact veterans eligibility for the Caregiver Program. Thank you for the question, senator blackburn, and thank you for the work your recent legislative call for consistency, access to Health Records is vital. Ill echo something i said in my testimony, in that we responded with in our answer earlier. The definitions that have been established with respect to mental and emotional wounds, care of those across veterans, its causing inconsistency around eligibility. Im going to ask my colleague, molly, to expand on this point for your purposes, as well. But standardization of those excuse me of those conditions is really important. Were going to continue to see people being booted excuse me. People being booted in and out of the program as youve been seeing in tennessee. So molly, do you want to add to that . Yes, absolutely. Thank you, senator black burn, for that wonderful question. We, with the requirement of assistance of daily living, each time that that definitely focuses more on the physical needs of the veteran as well as safety and supervision on a daily basis. We know caregivers and veterans who that assistance each time on a daily basis, you could go a couple of days where your veteran is able to remember that to not tou being put into the microwave. Theyre able to do that some days, but maybe not on a wednesday, just because thats how ptsd can work. And also there are instances where someone may be able to transfer themselves from their wheelchair to say to use the restroom or to the chair or to their bed. But thiere may be sometimes whee theyre not able to do that. So each time we understand can be limiting, and i think it would be great if the v. A. Could clarify, especially to the caregivers, because to them that seems a gray area, especially with the fluctuation of assistance they deal with every day, and especially for the ptsd and other neurological and emotional caregivers monitoring triggers every single day is something that many of our caregivers do. And its not the safety and supervision necessarily, but theyre able to function, be able to be home for families, be able to be parents or grand parents, just be able to be a good spouse or friend. So those are the things that we are hearing from caregivers within our network. And, again, we look forward to working with your office. We whole heartedly support the legislation with you. Well, thank you. I think you can see, senator murray, with her questions, that lack of standardization and the lack of the caregiver to understand why there are these ambiguous reasons, and a veteran can be rated 100 disabled, and then still be moved out of the Caregiver Program and it is just its very frustrating. Its going to be important that we get these straightened out. I know there are others to ask questions. Ms. Beller, first of all, thank you for your husbands service and for your dedication and service to our country. I appreciate how you go through the daily routine as you gave your testimony. What i would like to hear from you very quickly talk to me about what has changed for you sense you became a caregiver, appropriately recognized and then talk about your the uncertainties that exist with the program and your fear or concerns with the program, and youve got about a minute. Okay. For me, my life is drastically changed. I left my career, and that changed a whole lot of just the way i like operated. But his care required that. In my situation in attempting to enter the program, i have applied, ive been interviewed. Chets situation is such that hes almost exclusively all he needs a lot of care. Were a very obvious situation. What is so concerning is the people that i mentioned correctly, that have the invisible wounds, that are literally, their protection of the veteran and maintaining trigger levels and keeping things calm are keeping that veteran alive in preventing the spirals that can lead to suicide and keeping that veteran safe. And im hearing on social Media Networks is exactly what you said, that people are being dropped, people theyre not communicating. Its as if their work is not valued. And thats very concerning. Because their value is as dprat great as what i do for my husband if not greater. Thank you. Senator blackburn, if i could just add one point, because you brought up a very important motion earlier. A really Large Program that were advocating for across the v. A. Is called the campaign for inclusive care. And one of the very fundamental issues that caregivers like jenny face is an inconsistent set of protocols that clinicians use to enter fact with caregivers. Molly mentioned when a veteran goes through a disability rating interview, that veteran may be having a particularly good day on that interview. And caregivers are not always let in the room with those questions are being rendered, when those answers are dependant on the level of benefits theyre going to receive. Our campaign and protocols call for caregivers always being included in the room. That means when a husband or a wife feels like theyre having a good day, their spouse is by their side to say, you know what jim, you know what, suzy, youve been having a couple of bad weeks before today. Last week, you had one of your episodes, its really important for the v. A. To be aware of. So thats why your bill and legislation like you have put forward is so important, to create fundamental levels of consistencies in the way that the v. A. Is interacting with veterans and caregivers. We appreciate your continued leadership on this issue. Thank you. I appreciate that. And my apologies for my time running over. Thank you, mr. Chairman. Senator blackburn, thank you. The bill you were discussing cleared on the hotline just yesterday or today. So progress in that regard, as well. I think senator brown is next, and then that may be, other than my ability to wrap up, the concluding questioning. Senator brown . Thank you, senator moran and Ranking Member tester. I appreciate you calling this hearing. I have some important questions i would like to ask the department. Its too bad they declined to attend. It seems a little bit too much par for the course. Mr. Schwab, i appreciate what you said about caregivers being in the room. I had not thought that the way through the way you said it. My first question, thanks for your testimony, expanding the caregiver support program. Its been a Committee Priority since really for a decade. During roundtable discussions and meetings throughout ohio, i do a number of round tables with veterans. My staff does more than what i do. Wives and children caring for 18 Family Members, know that this kind of help is immensely helpful to them. The program is already a year behind schedule. Veterans who served after 1975 and before 9 11 will have to wait another two years. This shouldnt be the case. The v. A. Should be here to answer our questions about the delays and implementation. So my question for each of you, mr. Schwab, and ms. Beller, in your testimony, mr. Schwab, you discuss the need for greater communication between the v. A. And the Veterans Community it serves. My understanding is the v. A. With input from that community, before finalizing the new rule to expand the Caregiver Program. In addition to the adl threshold, what is the one thing that you wish v. A. Had included in the final rule, mr. Schwab . Senator brown, thats a great question. And thank you for it. Thank you for the work youve been doing across your state to listen to veterans and caregivers. Its really appreciated. I would suggest that evaluation and consistency around evaluating eligibility is probably our number one concern. I addressed in an ongoing concern with the implementation of the mission act. As i addressed in my testimony, senator, and we have loved your support on this, my boss, senator Elizabeth Dole, your former colleague, former member of the senate, has put forward a recommendation in her work chairing a group of leaders at the v. A. To introduce legislation to speed up this expansion. The mission act called for a phased expansion of caregiver benefits. As you rightly noted, that expansion is way behind, which means the lot of veterans being left out right now, we would love a legislative solution and just include everybody in the expansion in the next phase. Thank you. Ms. Beller, i want to make a comment to you. First, thank you to your years of service to our country and to chuck. You have waited far too long, as others have said, for that additional assistance and support. I appreciate your testimony where you outlined the stress that caregivers and veterans go through during the application process. Mr. Schwabs insight into that also, the additional meetings and interviews, when the medical records illustrate the support needed. So thank you for your speaking out and the courage you have shown and the service you have given. We appreciate the testimony of all four of you. Thanks so much. Thank you, mr. Chairman. Senator brown, thank you. Theres no other senators . I have a few questions for our witnesses. Let me start with caregivers. Mr. Schwab, i have seen the rand report that was commissioned by the Elizabeth Dole foundation. Supporting Research Studies in regard to caregiver Mental Health concerns. It was published back in 2014. I also know that this topic was discussed during the fifth annual National Convention that you held last week. Maybe this week, earlier this week. And im just asking for a direction. What is it that you would ask of this committee in regard to the Mental Health and wellbeing of caregivers . What more needs to be done . Is it just related to implementation of the act or is there something thats missing . I would highlight that this committee has indicated, and i think is attempting to fill our stated priority of Mental Health and Suicide Prevention for veterans and your testimony, your presence today is a reminder to me at least that we need to make certain that when we talk about Mental Health, Suicide Prevention, certainly for veterans, we also ought to include in our thought process and policy deliberations, the caregivers that are helpful to them. What would you like for me to know . Mr. Chairman, thank you for that question. I would say three things in response. First, i would ask the committee again to consider legislative removal of the phased expansion of the mission act, so that all caregivers, all pre9 11 caregivers receive their benefits right away. Around your question on Mental Health, as you noted we commissioned and published a study in 2014 that is almost six, seven years old but the data still rings true. One of the things the study called for was more robust Longitudinal Research and data on the situation facing caregivers. We dont have a great deal in fact, we have zero longitudinal data on the effects of military caregivers, spouses, family, friends, siblings and others providing this free athome care. And the new civic and patriotic response it that will be here forever. And we need to invest this committee needs to invest in understanding the implementation implications of that care and service on those loved ones. Mr. Chairman, something you said that i want to put an exclamation point on around suicide is that caregivers are the last line of defense in preventing veteran suicide. We believe at the Elizabeth Dole foundation enough is not being done to understand the unique roles caregivers can play in prevention. And so we would welcome wider dialogue, perhaps a round table with this committee, and a number of caregivers and other organizations to talk about ways that the v. A. , the d. O. D. Can more directly support the Mental Health needles of caregivers. One way to do that right away is to embrace and expand upon the campaign for inclusive care that i mentioned earlier, where were working with v. A. To implement now system wide a series of rainings and protocols that will encourage clinicians to engage with and support caregivers throughout the care process. Right now its a very disjointed engagement. I apologize. So those are the three things, mr. Chairman, that i would suggest are important to consider. I wasnt sure whose phone that was. I was going to scowl at one of my colleagues, but if its you, its just fine. Thank you for your testimony. Thank you for your three suggestions. Let me ask mrs. Beller a similar question about Mental Health and Suicide Prevention in regard to caregivers. You heard what mr. Schwab said. Weac one of the challenges i think we face is lack of professionals. The john hannon ask gets resources to Community Providers. Stands what would you ask of me to be of help in regard to the Mental Health and wellbeing, Suicide Prevention not only of a veteran the caregiver. Providing more resources of Mental Health issues. I have been to counseling a couple times. I am capable and healthy of taking care of my veterans and that is so critical because there are studies or indications caregivers can develop ptsd especially in situations dealing with tbi and ptsd so these are very real. I know of caregivers who committed suicide because it is very isolating and lonely occupation but with organizations like the foundation helping to raise awareness and alleviate the struggles. Thank you for that answer, you are very articulate and compelling witness and i appreciate your presence with us. Thank you for testifying before our committee. Let me return to the network issues. Neither one of you indicate you have any knowledge whether the va will move in the effort to modify their contract. If i misunderstood or you have additional information, what you told me, the va has decided not to modify their contract. I would then ask this question, perhaps this argument, the va testified they have sufficient Budget Resources to modify the contracts. It is not a budget issue. This is a fair summary, your networks are expanding voluntarily to meet those standards. What would you say a justification for not having uniform standard as suggested by the mission act. What am i missing here . General . Just to share some of the conversation, not to speak for the va but to share a conversation, some of their concerns when you look at the shortage of providers in geographical areas and look at veterans choice because some veterans are willing to drive a distance to see either a particular provider, one that is part of the va or Community Care, there is a perception that it would be overbuilding by some of the stringent drive times in some geographical areas and that is part of the hesitancy for moving in that direction. Weve looked at it through the lens, what we spoke about, wanting to ensure, in a geographical area utilize utilization data to tailor it to where veterans are living. That is part of the concerns they raised, i cant speak to other concerns but i can share that one. Retrospective look at demand, enabling enhanced access makes it very hard to accurately predict what people like to do with their decisions if they are given the opportunity. So as general horowitz said we were developing a network that matched what we believe based on analytics in a 7 year journey with the va. What likely will be sufficient to make sure there is enhanced access and availability, probably the best example of the collective success, birth between congress, the va and the community rests in texas. You used to have to drive 7 hours for care. Four Community Hospitals and all the providers in the Community Side with that. And and every kind of care, in its surrounding area and more than 400,000 appointments have been done in the valley in texas in that comprehensive network. Thank you for outlining what the goalies and indicating it can be achieved. Perhaps it appears i am carping just on insisting that the va comply with the mission act. And that is not my point here, the concern is if we dont build to those standards, veterans, some veterans will become discouraged not able to get the care they need. The mission act, successor to the choice act, for their benefit, doesnt discourage anyone from using choice, the two of you, your networks indicated youre going to build those standards demonstrate to me there is value of having standards. If you didnt have those words, you are building to what the va insists under the contract, further serve veterans who live role or have a particular reason closer to home. The va has indicated in their testimony and situations with me, they are pursuing this but more recent stories indicated the va is not interested in increasing the standards, the contracts, the provisions of the mission act, is more about caring for veterans and making certain they have confidence the mission act is fulfilling the needs of those veterans the when they didnt see it with choice in other circumstances. In kansas and across the country veterans know that we have them in a position in which they can access the care they need, in reality and image we are doing a disservice. One more thing to distrust they say i have a benefit but dont feel it or see it. Theres a real consequence to us not meeting the needs of veterans, a third or fourth id iteration of Community Care. It does matter. We have this dialogue. Center tester has returned. I have one more question but let me turn to center test there and wrap up as indicated earlier. I talked too long and the Ranking Member returned in time to have more conversations. I was told you would ask every question about longdistance Passenger Rail service that i asked. I was seen as an annoyance because you and i had the same line of questioning and you were feeling in here in the committee as chairing todays hearing, that immediately cause me to lose interest in the Commerce Committee and rushed back in case you were thinking this was a more longterm circumstance than i am hoping. I would never think that. It scares me to think you and i are on the same page when it comes to asking questions. I appreciate the opportunity to ask and make this as painless as possible. I appreciate the witnesses for being here today. This deals with covid19 and it goes to mister mcintyre. My understanding is that referrals and Community Care are on their way back up and month after the start of this pandemic. Would you either confirm that . Is that right or wrong . Are they on their way back up . I can provide the stats, with geographic territory, prior to covid19, we were receiving 7300, in the last week pulled the data and receiving over 7800 authorizations for care on a daily basis. There was, during the height of use, phase i of covid19. Some tamping down on the requests, but for the most part the things we touched minus 10 , to be rescheduled and readjusted so the veterans ultimately got their needs met. And it is a permanent picture. We have 72,000 referrals today. That leads to my next question. How has the pandemic affected the availability of networks . Mister mcintyre, talk about it generally or specifically. Providers have been immune from the impact, to make sure there was sufficient supply of services, up to treat covid19 patients and to protect, they tamp down on most volunteer services, that has now changed. Most providers now open back up for business and have been for months. It is true, the rest of the economy, we are finding by and large people are wanting to see patients. In the great state of montana. Similar trends, one thing we saw was an increased use of telehealth capability 31 of that was for Behavioral Health and a little surprising the second was for Pain Management and physical therapy, what we saw during covid19, the impact it did have across the Healthcare System but did cause a rapid change from facetoface delivery of care, which we rapidly transition to and that made a big difference. The other piece i am testifying to was the large influx of cash, accelerating payment, supporting the financial status to keep their practice because that was one of the big challenges as well. Last question, and answer second on this one. It deals with telehealth, we learned from this pandemic, is critically important, we need better Broadband Service in a rural state like montana or other areas. The Community Cares capacity, to provide telehealth servers and provide facetoface instances, in this pandemic. They do it through telehealth, that capacity, are you feeling some limiting forces in your network . I appreciate that because tele capability is one of the things that came out of this pandemic that has been a good thing. Celebrated the use of it and one of my concerns, we have been so reliant as a nation on the Authorities Congress gave to actually have transportability of licensing across state lines, waiver for interstate licensing, allowing practice at the top of your license and those of already is to leverage a network, not bound by that, made a huge difference in the affordability of the Healthcare Network being able to leverage tele capabilities. That is one of the things you didnt specifically ask but it is something, to make those authorities permanent would make a big difference in the ability for communities to provide that. Thanks for that. Im sure the chairman is taking notes and crafting a bill. The availability for the network. At the same time it is important for certain types of Services Telehealth levers for Behavioral Health, to make sure that service and the servicing provider is as close to perfection as possible because when they need to make a physical visit it is important that they see that person they have been seeing on the screen. We tried to put our focus on making sure we are enabling the existing providers within their own states to have that capacity. We all remember or we may remember telehealth was born out of alaska and hawaii and prior colleagues, senator stevens had a lot to do with that, access to the villages of hawaii and remote islands, the villages in alaska and remote islands, it is good to see it expanding but the challenge is access to broadband, and hopefully one of the things the federal government will be focused accelerating the access to broadband in rural areas so they could use telehealth as robustly as across the great state i would close by saying i agree with both of you to increase capacity across the board and both of you and others can be tremendous help to Congress Without allocating dollars for broadband and challenges you are facing and healthcare communities, it is all areas. Thank you for being here and i will turn it back to you. Let me wrap up with a few quick comments, senator chester went down the path whether providers in networks, i heard your answers, i will highlight for you the indication by the va that a significant number of providers in your network were no longer in business and are unwilling or incapable of caring for patients. It was not my experience in kansas, providers could not understand why they were being denied referrals. I would be interested in knowing, if that was your experience, you couldnt find providers during covid19 or the va made a decision to bring those appointments and referrals inhouse which i think probably the best place we could have our veteran patients is in their communities compared to traveling to a va center. Was there a real circumstance in which providers said we arent or wont, cant provide service . Reporter we found your network remain a Viable Network in the middle of this pandemic, went live to two other regions and the accessibility standards in the high to low 90s. We had providers signing up. We had them available. As an enterprise rollout, protect well which was a mechanism to ensure Healthcare Providers front lines were checking every day on their help and if they had symptoms they were not coming to work so we have a Healthy Network both from the clinicians being able were come to work. So we had a very Healthy Network. It goes from the clinicians being able to provide at Committee Practices and remaining open. Thank you. Anything to add . Much the same. We have the unique opportunity to do appointing during that time in support of the va. While a few providers were limiting the capacity, or in furlough, we were able to find keir for almost all of the patients that were placed in our hands for the purpose of care in the community at also highlight for you the issue there is veterans in the place of their choosing. But its also detrimental to our networks or to u. S. Providers if youre not getting referrals, just the financial strain that could come from that, having to keep you viable yourselves. Let me ask the general question. It occurred to me. Who came up with the hundred 80 mile highly rural standard . Is that something that optimum created or the department of veteran affairs . Optimum didnt create that and i will go back to find out exactly who. Okay, thank you very much. In regard to optimum which im becoming more familiar with, i would just highlight the please continue to pursue more opportunities for specialized care. Particularly, chiropractic care. We need more Network Providers closer to home than what we have. I also would compliment you both have experience with both companies. Both Third Party Administrators in kansas. And you are very good about helping me and my staff in regard to what we call casework. Veteran calls a race. A Family Member tells us that theres a problem and weve been able to come to you and you have helped us solve those problems. The goal for all of us ought to be that it ought not be a burden upon the veteran to bring a problem. I hate seeing this. The way it might sound. Were not at all complaining about the work that the veterans provides to help meet their needs. But we need a system that works in which its not the responsibility of a veteran to call a member of congress to Say Something isnt working here. Can you help me . The ultimate goal, thank you for the efforts that have undertaken to meet the needs of veterans as we bring those needs to, you and they are what those concerns, those complaints, those problems are with informs me and my staff so know what we should be doing, and advocating not just for those veterans, but for the system in which they are beneficiaries of health care. So we look forward to working with both of you. Your colleagues at work, try to make certain, also the department of veteran affairs to try to make certain that its not a issue of who do i complain to about something. Is it happening as it should . How does the system make sure that the provided to begin with . So those are counted we will all face. Thanks for helping us care for individual veterans. We need to adjust a system to help meet their needs as well. Mister chairman, your focus in that space, and that of the Ranking Member, and other members of this committee, is invaluable. And some people find that a nuisance. The reality of whats president in each of those cases allows us if we choose, in working the case, to find whats the real gaps are in making this work. And if we focus on that, and we adjust the processes and the tools to address those gaps, pretty soon there arent many more gaps. Well said mr. Mcintyre. As you are speaking, i was thinking theres not usually a veteran that has a unique issue. If a veteran has the issue with the way things are working there others who do as well. They may not be people whoever contact me or my staff for help. So we dont let anybody slip through the cracks. We need to fix the problem for the veteran who raises the issue. We need to fix the problem for everybody else who may not have said anything about it. I think im done. I would give all of our witnesses a chance as is my practice to say anything that they feel like they need to correct, or things that they wish they were asked that they dont get a chance to comment on. Is there anything that anybody would like to know before i adjourned this hearing . Anyone online, on zoom, on webex it just didnt say anything further. Just to thank you to you mister chairman and the folks who testified, i really appreciate their sunder thank you, again thanks for participating today. Thanks for the many members and their interest in this as we try to make certain we implement title i of the mission act appropriately. I appreciate hearing from each of you, as thirdparty administrators i am pleased to hear more about caregivers. The testimony that i heard today is very useful, and i appreciate the child that was given to us here. The things that need to be done. I would now ask that members have five legislative days to extend their remarks include extraneous material. We submit any questions to you please answer them as quickly as possible. Theres a couple of things that were said that you will get back with information, and we welcome that, and encourage that. With that, the hearing is now adjourned. Thank you. [inaudible conversations] [inaudible conversations] somebody who knows what they are talking about. [inaudible conversations] i dont think it is. Weeknights this month, were featuring American History tv programs as a preview of whats available every weekend on cspan 3. Tonight, caroline wouldnt you haul for Virginia Center for luck saudis discusses black prisoners in war in the confederacy. She talks about the treatment of the prisoners and how many were in sleeved including those born free in the north. Watch tonight 8 pm eastern. Enjoy American History tv every weekend on cspan 3. Women lawmakers talked about politics and gender equity issues. The conversation was hosted by the hill. Hello and welcome. Im steve comments, editor of the hill. Thanks for joining us to a ve
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