[inaudible conversations] the committee will come to order. Good evening and thank you all for being here and joining us. Its a somewhat unusual for the committee to meet in the evening hours. Tonights topic is one worth staying up late for. I want to keep our work this evening laser focused on the future on how we can all Work Together to create a better, brighter, healthier one for our veterans and for the Health Care System that weve built to serve. Rather than rehashing the mistakes we made long ago. As we begin to move forward this evening we mustnt lose sight of where we started. Three years ago next month in this very room, the Committee Heard testimony from a veteran who spoke about waiting almost a year for care from the department of Veterans Affairs medical facility in south carolina. When he was finally seen long after he should have been, he was diagnosed with stage four colon cancer that had spread to his liver and his lungs. He passed away in january last year. It was his story and accompanying allegations that for the veteran patients died while waiting to receive care from the Va Medical Center in arizona that kicked off a nationwide access and accountability scandal the likes of which the va had never seen. Ever seen. It also led directly to the creation of a Choice Program and the allocation of billions more taxpayer dollars to increase access to care for veteran patients. In the three years since then, more than 2 million authorizations for care has been approved in over 1 million veterans have been able to get the care that otherwise might not have been readily available. However all of us continue to hear from veterans day after day experiencing lengthy and frustrating delays when attempting to schedule appointments using choice. In fact i was contacted by a veteran with a story much like this. The veteran was diagnosed with cancer last fall and referred to choice for treatment. While im relieved to say he is receiving the care that he needs from the provider of his choice he suffered three weeks of doubt due to mishaps and miscommunications between the va, the thirdparty administrator managing choice in this particular region and the Community Provider who had agreed to treat him. It appears three years after his testimony, a lot has changed but too much has stayed the same. Whats more, recent work performed in the Government Accountability office illustrate very clearly the choice isnt set up to succeed at its primary mission providing timely care to veterans who cannot access the care put in the va because it isnt offered or available in a reasonable amount of time or it would entail a veteran traveling a great distance. For example, they are going to testify this evening that veterans could potentially lead up to 81 calendar days before receiving care due to the bureaucratic process the va and post on choice. That is unacceptable to me and im sure everyone in this room. Ive been a practice for over 30 years and i assure you it doesnt have to be this complicated and should not and should most certainly not take this long. Luckily the choices in the same program today as it was when it was reviewed in the last year and certainly it is in the program that it was on when it s first created. Through the legislative changes in the contract modifications and counting its been continuously improved on and made stronger but it remains far from perfect and in far too many cases it fails the veterans was created to serve. Im working to wichit double geh the Ranking Member and secretary and Senior Leaders and our Senate Colleagues and with our Veterans ServiceOrganization Partners to chart a path forward for choice and all Community Care programs in short order. I hope to have language to share in the coming weeks and have a Health Care Reform bill on the president s desk this year. However the first step to reforming the choice is making sure there is a smooth transition to lead the way. This is why it is critical the Committee Act tomorrow to mark up 369 though i introduced earlier to remove current threeyear sunset dates from the Choice Program. Absent legislation choice will begin shutting down in just a matter of the end will the and y in five short months from today. Cutting off the access at a time when veterans are seeking care more than ever before and critically at a time when the non Choice Community care account is not able to observe additional demand of care the va is already facing a 3. 4 billion deficit in the Community Care account next fiscal year that the leaders have told the Committee Staff would require additional appropriations to address. By removing the sunset date we are not endorsing the program in its current state but we are ensuring that emergency Funds Congress made available for the veterans care are used for that purpose until they are extended. Community care appointments increased by 61 overall in the choice was created in the last year 30 of all appointments were held in the community rather than medical facilities. The future relies on not only a strong Healthcare System but one that is inextricably linked with Community Resources to fill the gaps and meet the need of the veterans when and where they are. We must get this right and learn from the mistakes, miscommunication, undue bureaucratic process since its inception. Not only for those that depend on the system today but also for generations of american heroes to come. That is what i am committing to once again this evening. With that i will yield to the Ranking Member for any Opening Statement he may have. Thank you for holding the hearing and to senator mccain. It is a pleasure to have you over here in a special thank you to the secretary again that sounds very good and we appreciate you being here and also the Inspector General as well as the Committee Members are here all have the same mission and goal and in the most timely manner for our veterans so im grateful to each and everyone of you last congress we heard from policy experts including veteran service organizations, independent Assessment Panel about how we should shape the va in the future. Now it is time to get to Work Together to make positions and pass legislation to ensure they receive the health care they deserve. One of the highest priorities is to ensure they receive the highest quality healthcare in a timely manner and a safe environment that includes care aof the medical facilities and through Community Health care providers. From listening to the constituents are waiting too long to see care, we need to make changes in the program. The witnesses, Inspector General and the gao will testify to survey data to back up constituents have been telling all of us, the veterans are waiting too long for Community Care and in many cases theyve been forced to manage care on their own. It should never take 80 days to get an appointment in the community. Veterans in need of Mental Health care shouldnt be struggling to make their own appointments and coordinate complex care. The decisions should be made between the doctor and the veteran and the va should be there to make sure they get a timely appointment and make sure the doctor has a record to treat the veteran and the veteran isnt stuck with a huge medical bill after seeing the doctor. As they move forward in the consolidation plan, i hope we can take some of the lessons we learned from choice. We need strong leaders at the hospital to those committed to putting the plan in place. The facilities were responsible for filling in inadequate Community Care networks and providing the staff to support this new program. They should be involved in this new Community Plan every step of the way. We need technology to support our providers and Community Providers. This requires them to have Electronic Health records and an id system to reduce the time it takes to coordinate care and process claims. The Current System or the lack of to support care coordination are contributing to th the delas an increasing workload for staff were manually processing them. To get the plan right it will cost a significant amount of money. The president said hes committed to increasing funding for the veterans but this doesnt mean they get a blank check to continue programs that are not working or that it should go to Community Care when veterans need the care and coordination that only the va can and should provide. It also means they must be able to forecast the resources and staff it to provide the care and facilities through the network of Community Providers. Tomorrotomorrow well be marking legislation that will allow the remaining Program Funds to be spent in along with this weve come to a bipartisan agreement that the va should be build first before a veteran is built for receiving care and the Community Providers should be able to have access to the medical records. This was a bipartisan agreement working with the experts and i applaud them for making this happen. I hope he can continue working together to make decisions that move forward and improve healthcare. Thank you and i yield back. It is my pleasure to welcome a fellow veteran and our colleague from across the capital, the honorable john mccain the senator from the sene great state of arizona. On behalf of our service members, veterans and their families i appreciate your willingness to be with us this evening to talk about a topic i know its a personal and passionate one for you and all of us. You are recognized for five minutes. Thank you for your kind words mr. Chairman. I am one of those whose members of landings dont match the number of takeoffs. Thank you for allowing me to be here. I would like to set up my full statement for the record and i wont try to be brief since it is past my bedtime. [laughter] i would also like to comment on my strong support for doctor shulkin as the head of the va and we all have Great Respect for his work. Yesterday the front page of the republic reported there was a 2. 5 million settlement to an individual and army veteran of 18 years. He waited almost two years before seeing a doctor at the phoenix va and by the time he received care from his routine appointment turned into a diagnosis of terminal cancer. Everyone in this room has heard a similar story. Its not acceptable, it needs to be stopped. I want to thank every member of the committee for their dedication to our veterans and to make sure that never again is there another steve cooper served his country with honor and then because of the failure to get an appointment, hes terminally ill. In 2014 the country was shocked to learn he was one of 15,000 veterans standing in line for care, 3,300 of whom were urology patients and this served as a catalyst for the access choice accountability act and created a program that is an enabled program to receive their program needs. More than 7 million appointments for the providers with everything from diagnostic urology screenings to lifesaving heart and Cancer Treatment has been a result. Theres been significant progress in improving healthcare and we have a long way to go to change the status quo and thats why i know none of us will bend on our efforts to provide choice and flexibility and why we must continue the hard work of refining and improving the veterans care Choice Program. As you mentioned, we authorize the veterans Choice Program which is set to expire in a few short months. We let the Program Lapse hundreds of thousands of veterans lose their ability to visit a provider and apple once again become overwhelmed. I come from a rural state. I dont want to have to have a veteran drive for 50 miles or 40 miles when he can go to a local healthcare provider. It isnt more complicated than that. Can i say the choice authorization operation is approaching end of the va has already begun limiting care under the veterans Trace Program whose treatments extend beyond august 7, 2017. I think that lends urgency to your action. I am concerned veterans nationwide may encounter significant lapses in care if we dont act quickly. The outcome is not only unavoidable but it is unacceptable and in congress we must ask on the place for snobs reside to take a critical step forward by joining the senate veterans, johnny isakson, the Ranking Member john tester and others to introduce the Choice Program improvement act . You and the members of the committee, let me be clear no one is advocating if we privatize many veterans are satisfied knowing for providing specialized treatment in areas of Mental Health, post Traumatic Stress disorder and traumatic brain injury and at the same time we cant afford to go back to the days when a bureaucrat had the final say on when and where a veteran received care so that is what resulted in nearly 15,000 veterans standing in line for care. I know this committee agrees as does the secretary and i look forward to working with all of you and my colleagues in the senate to extend the program and continue to keep faith with our nations veterans. My dear friends, the world is in turmoil, and i believe that we will be sending our young men and women into harms way in a lot of places in the world for years to come and they will be veterans and they will come home someday and i believe the work you are doing is the lords work and because you are committed as all americans are giving the veterans t the care that they nd and deserve i thank you for allowing me to appear before you. God bless. [applause] [applause] i was going to thank senator mccain that he got two quick. Veterans affairs will be testifying for the first time. We certainly enjoyed the Ranking Member being at the white house for the swearing in with your lovely family. Thank you for being here and congratulations once again on your confirmation. 100zip, i might add. I look forward to working with you. The secretary is accompanied tonight by the deputy undersecretary for health communicator. Thank you for being here. Also, we are joined by the honorable va Inspector General and Randy Williams and health care directohealthcare directore Government Accountability office. Thank you for joining us tonight. We begin with you and you are recognized for five minutes. Good evening, chairman, Ranking Member, members of the committee it for the opportunity to discuss Community Care. I also did want to thank senator mccain that he ran out so quick for his leadership. I couldnt agree more we have to act now to ensure veterans have timely access to the care they need and i want to offer my condolences to the family of a World War Ii Navy veteran and father of modern transplantation who worked in the va and with veterans for over 50 years and conducted the first liver transplant at the va in 1963. As you know the va provided Community Care to veterans for over 70 years. Since august, 2014 we also provided care through the veterans Choice Program and we appreciate your support and providing the legislation and funding to better serve our veterans. As directed in the law o for pa implemented the program and in 90 days nationwide that is unprecedented for a program of this scope and complexity. Because of the design and the law and this implementation we did run into challenges many of which will be identified in the evaluations by the gao and the Inspector General. But since then, the Choice Program has evolved. We worked with members of congress on different amendments and with contractors on 70 different modifications to improve access and efficiency and as a result of these shortcomings identified in both be ig report are now outdated. Choice isnt a program it once was that these are valuations were released. I call it a living and growing program. Since the start of the program over 1. 2 million have received some Community Care. A million appointments in fiscal year 2015 now have increased to 5. 5 million in 2016. Even with these increases we have much more work to do. We are not satisfied with it. Our overarching concern is veterans have access when they needed regardless whether it is in the va facility where their communities. The goal is to deliver a program that is easy to understand, simple to administer and meets needs. We know we are not there right now. The Community Care are critical and veterans rely on both despite the large increases only about 5,000 veterans use the Choice Program as their healthcare provider. The overwhelming use both va and choice and many prefer only to use the va. The va looks forward to continuing to partner with congress to address the requested budget and legislative change including provider agreements making the va the primary coordinator of benefits and reporting obligations to the payment. We worked with veterans, Community Providers and other stakeholders in the past and we will continue to seek their input moving forward however we do need your help to Choice Program is going to expire in less than six months but the needs will not expire. This looming expiration is a cause for concern among veterans providers and staff and we need help in eliminating the excavation data august 7, 2017 sleek and utilize the remaining choice funds without congressional action veterans will have to face longer why did you cut waiting times we need your help in modernizing and consolidating. Veterans deserve better and now its time to get this right. We believe a modernized Community Care program must have seven elements. First maintain a high performing network that includes federal partners academic affiliates and Community Provider providers an, increased choice for all veterans starting with serviceconnected conditions. Third ensure that they get the care they need closer to the home when appropriate. Fourth, optimize coordination in the benefits of Health Insurance thats a better and already has. This, maintain affordability of Health Care Options from the lowest income. Sixth, assisting coordination of care for veterans served by multiple providers and the last apply industry standards for performance quality Patient Satisfaction and healt healthcae outcomes. We look forward to working with congress and other stakeholders to enact changes for veterans and within six months, we hope to present a plan although we are still early in developing this we are seeking input from veteran advocates and continue to do so as we move forward. We know our number one priority is to provide access to the high quality care they have earned and in the facility or as close to home as possible in the communities where they and their families live, thank you for the opportunity to be there for you today and i look forward to any questions. You are recognized for five minutes. Mr. Chairman and members of the committee, thank you for the opportunity to discuss the office of Inspector Generals work concerning the Choice Program and the future of the Community Care program. My written statement includes details of our extensive work in this area and i would invite your attention to those matters. For years theyve relied on programs to help it carry out its mission of providing medical care. Today the Purchase Care Program includes patient centered Community Care, individual authorization and other non va care programs. We have reported in the Office Reviews and healthcare inspections and hearings the challenges that are faced in administering these programs. In october of 2015, the va provided congress with a plan to consolidate all Purchase Care Programs into the Community Care program. Under consolidation, they continue to have problems determining eligibility for care, authorizing care, making accurate payments, providing timely payments to providers and ensuring the necessary coordination of care provided to veterans outside of the va Healthcare System. With that improvement in these areas, these issues will continue to be obstacles to ensure veterans receive timely access to quality care. To increase the programs overall effectiveness, the va and Congress Must understand the historical barriers and control weaknesses that have plagued the Purchase Care Programs and ensure they are adequately addressed in future Purchase Care Programs. With respect to the veterans Choice Program, we have recently completed audits and reviews concerning the Choice Program anand finding some substantiatie problemfindings have substantiag and scheduling appointments, consult management, Network Adequacy and timeliness of payments to providers. The hotline has received contacts and most o of the spred of complaints, scheduling, referrals, authorizations and consults. We also identify issues and the patient centered Community Care program. The pc three program that provides eligible veterans access through healthcare contracts to certain medical and Mental Health services. Its used at the medical facility and exhaust other options for purchase care and when the local medical facilities cannot readily provide the needed care to eligible veterans due to the lack of available specialists on wait times, accessibility and other factors. We published the report in 2015 and 16 and reported the Program Prior to including the veterans Choice Program didnt achieve its estimated cost savings and provide timely access to care or ensure contractors provided documentation and reported critical findings as specified in the performance requirements. In addition, we reported that the amount of Provider Network contributed significantly to the medical Facilities Limited use into that pc thre the pc three e not developed and awarded. What was clear and the work is that the clinical and support staff were dissatisfied in such areas as authorizing care, scheduling appointments and veterans waiting for care. These are some of the same issues we hear today about the Choice Program and in summary, our audits reviews and actions have highlighted theyve had a history of challenges in administering the Purchase Care Programs. Veterans access to care, proper expenditure of funds, timely payment of providers and necessary coordination of care are at risk to the extent they lack the adequate process to manage funds and oversee Program Execution while purchasing healthealthcare services from Community Providers the flexibility providing expanded access to care and services that are not readily available in the services facilities. It also poses a significant risk when adequate controls are not in place. We will continue to provide significant oversight of the Community Care programs. This concludes my statement and i would be happy to answer any questions you were members of the committee may have. You are recognized for five minutes. Ranking members of the committee in 2014, Choice Legislation was enact it for the express purpose of providing more Timely Healthcare access for eligible veterans. Correctly, however they have established a bureaucratic choice appointment scheduling process that sometimes does not provide Timely Healthcare access for veterans. This allows up to 81 days for them to receive routine care from the time the provider determined the veteran needs care but in many cases documented by the gao, the office of the Inspector General and the press wait times have been even longer for those that have opted into the Choice Program. For example, one of the centers we visited referred a veteran to the Choice Program for maternity care. Since the Medical Center doesnt offer this care. They confirmed her pregnancy at six weeks but waited almost a month and a half before sending an urgent referral to the thirdparty contractor who was responsible for making a prenatal appointment for her. It took another two weeks to attempt to make an appointment for her. At this point she was 15 weeks pregnant and when she was the teen weeks finally almost halfway through her pregnancy and still without an appointment she made her own appointment with a provider. There was no way to know whether this case or cases like these are typical because they have no reliable data to measure how long the entire process takes. The Current Program slated to sunset in august of 2017 and the congress is considering proposals to reauthorize what has been referred to as choice 2. 0, they face daunting challenges that must be addressed. One major challenge involves 3 million print appointment processes. Both Va Medical Center staff and thirdparty contractors are involved in this process but in the Choice Program, they are now considering they would perform all the scheduling and build Provider Networks. The key to achieving a streamlined appointment scheduling process is having an up to date userfriendly capability to help process the millions of choice referrals linked with Community Providers and schedule appointments to connect with both providers and contractors to transfer medical records and process claims. Its in an early stage of such a system. This will be a complex undertaking, one that could likely take years, not months to become fully operational. Another challenge is establishing the Robust Network of Community Providers who could offer the services they need. This has been somewhat problematic in that Current Programs almost threeyear implementation especially in rural areas. Finally, substantial resources would likely be needed to carry out. Resources needed to fund upgrades into their applications are largely unknown but could be costly. The changes in the eligibility requirements such as the 30 day or 40mile eligibility could potentially greatly increasing number of veterans seeking care through Community Providers and drive costs up considerably. Also with Medical Center staff began scheduling all appointments under the choice as the va envisions hiring more staff will likely be costly and slow. Already since it was establish established, the Medical Center staff devoted to helping veterans access care increased threefold or more at many locations. They havent fully analyzed the cost or the feasibility of increasing the Medical Centers to schedule the choice appointment. They are proceeding down the path towards its addition and as it does so, it needs to do so thoughtfully and carefully with goals that anybody timely access for veterans to quality care and in the community at a reasonable cost. Achieving these goals would require a clear approach to the datadriven analysis of the benefits and cost of the proposals in the comprehensive action plan and roadmap for successfully implementing the choice and including specific time frames and resources needed and a robust system to measure performance including three times that can be used to identify Program Improvements and hold the staff accountable for delivering Timely Services to veterans. This concludes my statement. Thank you mr. Williamson. I will now yield to mr. Bilirakis for five minutes. Thank you mr. Chairman and mr. Secretary. Appreciate the panel for testifying this evening. I look forward to working with you and im hopeful we can find the right balance. Weve spoken about credentialing private providers desire to see the va patients as providers in the community. How can we best equip them to provide the nature of those that occur during military service and how do we protect private providers interested in providing service for veterans through the choice that are not qualified in the Va Health Network . Thank you, congressman. This is a challenge for us. The studies show among the Community Providers it is quite significant. In the case of Mental Health providers we found only 13 of community Mental Health providers have inadequate sense of military competency to perform the right type of psychosocial counseling. The va is active in trying to work with its providers and that is why we are trying to develop a network of providers so we can go out and provide education. We do it facetoface, academic details. We believe our federal partners, federal health car healthcare s and academic partners in particular are very eager to increase these relationships and have the military competency that we know we need. How do you speed up the process . We advertise the Choice Program when we talk to constituents and in a lot of cases it isnt working. The wait times are too long and they kind of get disgusted and they deserve the best healthca healthcare. So whats going wrong and how can we fix it . I know we talked about the thirdparty administrators but i hear this on a daily basis and it is unacceptable to me. I hear it, too. I get letters from all of you and veterans directly. We are now marking them to make sure we have a good comprehensive sense of what they believe that solutions are so we can design a system that works for them and we are eager to continue the dialogue with all of you to get your ideas that heres what we do know. The system was too complex and difficult to maneuver so thats why we have 70 contract modifications and weve issued 23 letters of corrections and weve come back four times that we have more that we need to happen. Weve had four specific changes in the program that we need now but we hope will be considered including flexibility in funding and ability to obligate the funds when we use them and to coordinate other Health Insurance in a way that makes sense so they are not finding themselves getting billed inappropriately so we want to work with you to get this right and we believe right now we have to extend the Choice Program because veterans are getting caught in the middle that we want to come back and get the program so it works well. It was founded some cases clinically the dates were changed by the va staff. As you all know the falsification is what led to the 2014 access accountability act. Through your investigative work and interviews by words o ordere dates changed by the staff, what reason did they give and what response did you receive when you brought this to their attention . A that is an excellent point and one i find quite disturbing because out of the 196 we sampled an hundred 96 cases and out of that come in 60 cases the indicated they changed. We are trying to get to the bottom of finding out why but we couldnt. One can only surmise what happened. As you know the policy only allows the provider who cursed sets that to change it and its not supposed to be changed because they couldnt deliver the care in 30 days so we dont know but it is a good question. Thank you mr. Chairman and all of you for being here. The commitment we have to make this work. You talked about the complexity of the program and certainly stepping up to the Provider Networks and all that. If your assessment was the complexity of implementation thn between the va and thirdparty providers. I think there is enough blame to go around. But no ones intent was to do that. We try to make it go there. Do you still comfortable we are all working together and we are clear on our intent and how we want it to be delivered . We have learned a great deal. He wouldnt have designed a system quite as complex but if you remember the managed Care Industry that developed the last two or three decades was extremely complex and not userfriendly in the pre authorizations and all that. We had 90 days to do this. We know the system is working better today than it was when it started in 2015 so we have all the knowledge together we can go back and make the system work im confident we can do that. Are you concerned i think the Technology Interface piece is going to be critical and if it hasnt stood up when you try to stand up your communitybased coordination, that seems to me we are setting up for failure again. We are putting 3 35 schedules in the system in a position where they have to make judgments about how to record their appointments. That system doesnt work and we will have to do it through technology. The new scheduling system that is being rolled out records this technologically and in automated ways with takes the scheduler to make those decisions. What do you think the best thing to come out of choice was . A we hope a lot of veterans. I applaud congress for doing this. I think it was a National Emergency and it was the right thing to do and try to get it as soon as we possibly could and we felt 7 million appointment appos scheduled into those are veterans who needed that care and should be waitin shouldnt i think it was essential we were discussing some of the positives on this and one of the things you mentioned is we got a more honest transparent look at the times they were no longer hidden. One of the things that surprised us even when we began to use choice, the wait times were longer and with that said as there was a demand from the countrys Veterans Services we were not adequately addressing or meeting and i think it is exactly that which it showed us what the real demand is and that gave us a look into this now. I dont know if that can be extrapolated to all. Do you concur with that increased care in addition to it being complex . What we saw was limited that it is not inconsistent with what we saw. What can they do right now to get off the high risk list . I think early step are to have a detailed action plan to talk about time frames and resources needed and so on. It isnt a simple matter of addressing the gao recommendations. There are different criteria which i think the da has bought into. That has been my experience and accountability that talks about Personnel Accountability whether it be acquisition accountability and all the things that go with that, but i would encourage and i know wha it is your desire, to help us restore and expand that care we all have the same mission and i think this initiative is going to be critical for what the va is going to look like in the future. I just want to add last week i brought my team over to meet with the head of the gao. He and his team were very open and it was my commitment to make the ticket progress to get us off that list and that is my commitment. You are recognized for five minutes. To the representative, in 2014 we had the scandal that passed the choice act. Im sorry . In 2014, we had the appointment of a time act because at that level in terms of those who were responsible for the appointments essentially they cooked the books to receive cash bonuses and left a member of veterans without treatment. We found it in other parts of the system and so i now understand the objective is to give the procesget the process e employees. How did that make sense . I really dont know on that one. It is a very difficult situation to deal with i think. We have a choice and this is one we are seeking feedback on. We knew we had a lot of problems with it so what we have done in 54 of the Medical Centers is we brought the staff back in so whether it is a combination of inside or outside people or the va staff under new leadership and new policies, no incentives to cook the books as you said and strong oversight which is what they are recommending, we believe the most important thing is to meet the veterans needs and that is what we are committed to doing. So they couldnt manage their own employees. Im not sure we are making progress. The best solution is to let them schedule of themselves with the self scheduling applications we are working on that as well. My feeling is, and i share your concern i do not want to go backward on this, so we have to approach this in multiple avenues and ultimately make sure that we get the most direct way for veterans to get an appointment. I was talking to some of my healthcare providers. Com coming into these agreements came up where theyve had the ability to have direct negotiations with providers and arrive at an agreement to refer veterans directly to those facilities. Every agreement is negotiated separately and it takes a very long time to negotiate them. It does seem like a boiler plae frame or for that. Yet, we have the medicare system with its wellestablished reimbursement rate. Why dont we use that in these provider agreements . One of the areas we have had Great Success on is getting the providers into the network. Today it is over 480,000 providers, 180,000 in their network and because of the choice of law, we use medicare rates with some exceptions in rural areas so i think we are trying to simplify this and we have been successful building the network. We dont do a lot of negotiation because of the way that it was written. But why dont we use medicare rates . We should. We want to move towards one set of rules maintaining two different systems with two different fee schedules adding to the complexity, confusing providers. Im all in favor of moving towards a simplified single system. Do you need legislation for that . We do. Weve called it funding flexibility but maybe that isnt a good thing. For thbut as theythat is a ce you raised and that is separate. What we are talking about here is do you have the authority, i would assume you do if you have the ability to negotiate structure with each particular entity i would assume you do have the ability to say this is what we are going to do, medicare reimbursement, period. Underrate issue i agree. The rules to manage the programs we do need legislation, but there is flexibility like you are saying yes, sir. Thank you mr. Chairman. Ive long said that the lack of continuity is a challenge to the organization and im glad we are joined by the secretary tonight and many of the other familiar faces at the table. We need the Institutional Knowledge that the secretary and his team have provided to make the longlasting improvements at the va. As we heard tonight, the Choice Program was a temporary fix to improve the veterans access to care. Unfortunately as we also heard tonight it resulted in long wait times, confusion about payment and administrative headaches for veterans and staff. It is our task now to come up with a longterm solution that gives veterans to care they deserve and strikes a balance between the care of the va and in the community and keeps the central role to improve care coordination. I would like to first turn my attention to the Staffing Levels and how that has impacted the program. The ig found that the workload increased over 200 since the implementation of choic the chod that it didnt provide sufficient staff to meet the work requirements causing authorization delays and its efficient oversight of the contract with a Third Party Administrator. Are these positions exempt from the federal hiring freeze and has there been more hired staff . This was one of those unintended consequences do we learn. We thought if we outsource all of our care to a Third Party Administrator workload would go down. With our workload went up because we had to make more calls and chase down veterans is so we were then in catchup mode adding to the status. The clinical staffs are exempt. We made that request and that was granted. Business staff wouldnt be at this point so we would have to set our duty to separate the two functions and we are developing staffing guidelines to be able to make sure that we are staffing up to meet the veterans needs but you are right a this caught us by surprise. But that is complicating your ability to do your job am i not correct . We made the request to the white house 37,000 clinical staff and support staff that we think are essential for Patient Safety that has been granted. We are closely looking at the additional 8,000 staff as we look at almost every week to see if they are impacting our ability to deliver care and when we do find that they are impacting our delivery of care than we make those additional requests and we just made some additional requests. Are those hiring more staff to reason to be to reduce processing time . Im going to let you answer that. We are seeing an increase in staff across the country but i dont want to miss the key point. The gao report both show our traditional Program Works much better so it doesnt make sense to keep putting staff in a system that needs to be fixed. We need to make it simpler to administer than it is today. They have a central role to play in the care coordination that improves Patient Outcomes under the plan to consolidate how does the plan to address the fragmentation of care in the Community Providers . Care coordination is critical. The more integrated we become the more we have to integrate care. We are testing across the country that allow doctors to access your medical records completely. We want to make sure they take care of the veterans in the communities we are front and center focus on this. The veterans are being seen in two Different Health systems, the va and the care and community face risks from the dual System Healthcare that shouldnt be ignored. What do you have to say about that . Thats why we want to give access to the medical records so they do not repeat or order drugs that should not be ordered. Mr. Secretary, congratulations and welcome back if you will. You mentioned the providers and thats important in certain areas you mentioned Mental Health as it relates to ptsd and i can think of other areas. Whatever medical categories have you identified where there is a strong need for this level of competency . A primary care provider has to understand the comprehensive nature of what it takes to. The response is the sort of lose vote of confidence and trust so we think that is important. Would you be in favor of the system or you may need to see an ophthalmologist but one that specializes in glaucoma so just because they have an ophthalmologist doesnt mean that is the best one for you to see. As long as i have a primary care provider yes i do support. It is never a good idea. I spent my life trying to get paid by insurance companies, so im a firm believer. Today we are at 83 of payments within 30 days and that is a lot better than we were. We are making progress but we still have more to go. We are also looking at other options including if it could be done better outside we are looking at those options in the process. Thats all i have, thank you. I also want to say congratulations im delighted that you are at the helm of the va. I think the gao report identified very well where the choke points are in the process and we keep talking about how it is too complicated and where we need to improve upon, lack of controls and all that. But the underlining issue to all of this to me is the it systems still feels like when youre driving a model t. Down the highway trying to keep up with the tesla and bmw. Then i see this report even one step saying if we dont reach the veteran by telephone will send a letter its mindboggling we are in this bureaucratic maze that is just prolonging up to ten days int and that is a nobrainer why cant we fix it like now. So the area i have the least confidence in is all the automation and it that has to take place. So how do you alleviate my fears that we will always be as slow as an an automated process will be and how will you give away my fears that are on this and that they are going to get it right . I dont want you to stop worrying until we give you confidence we have this right. Many have shared concerns about promises made in the failure to deliver. Ive come to the conclusion that building their own Software Products isnt a good way to pursue this. If somebody can explain why they benefit from the Software Developer then maybe id change my mind that we should focus on the things veterans need us to focus on but i dont want you to stop worrying about it until we show you we can do it differently. Thank you very much for that. Do you have a comment to make with regards to the statement i just made and where the points are in the program . Even with that they have to integrate the systems