Transcripts For CSPAN3 Hearing On Consolidation Of Non-VA Health Care Programs 20151203

Front line defenders on the war on sexual assault, ill say. They report to me overwhelmingly that they think were making progress on all fronts but one. And here comes the hardest of all, i think. Were definitely not satisfied. And that is the issue of retaliation. So, retaliation, by the way, can be if you report sexual assault, the boss takes some action against you, which is or feels like retaliation. Ill call that official retaliati retaliation. The other form is just when your peers in the unit kind of find out whats happened or what allegedly happened and they take sides and maybe they treat you differently or maybe people who are your friends now shun you. Ill call that unofficial retaliation. Our piggest problem is on that unofficial part, people who rush to swrujudgment to and take si who is going to replace dr. La plant as acquisition czar . Rich lombardi is now in the acting capacity. Thats dr. La plants deputy, who has floeeted up to the actig role. Beyond that well have to work our way through it and see who the permanent person will be. Is that your call or does the white house make that call . Ultimately all of these positions are president ial appointments. I have some housekeeping. National press club is the worlds leading professional organization for journalists and we fight for a free press worldwide. To learn more about the club, go to our website press. Org. To donate, visit press. Org institute. I would like to remind you about upcoming events. Friday, december 4th, prince ali al husse nichlt, fifa president ial hopeful and son of king hussein of jordan will address a National Press club luncheon. Also on friday at 7 00 am, the press club will publicly read articles by Washington Post reporter jason rezion for 24 consecutive hours to draw attention to the 500 days he has been unjust ly detained in an iranian prison. And on tuesday, december 8th, the new secretary of the Smithsonian Institution will address a press club luncheon. I would now like to present our guest with the most valuable and sought after National Press club mug. All right very cool. Thank you. Very close to air force colors. Well just say thats air force blue today. Excellent. Final question, you were recently spotted at the air force Navy Football game in annapolis and you were wearing an air force jersey with the number 23 on it. I assume the 23rd because you are the 23rd secretary. Right. So thats your number on the jersey. So we would like your assessment right from the top how is the air force Football Team looking . Whats the future looking for this team . Is there hope . Give your assessment from the very top level on that Football Team. My top level assessment is we are going all the way. And dont believe any statistics or any talk to the contrary. That is my favorite team. Youre right, my jersey is 23. Im lucky 23 because im the 23rd secretary of the air force. All the way weve had the commander in chief trophy for two years and even if the navy takes it away from us we may have misplaced it. Im not even sure where it is. How about a round of applause for our speaker . [ applause ] i would also like to thank the National Press club staff, including journalism of institute and Broadcast Center for organizing todays event. If you would like a copy of todays program or to learn more about the National Press club, visit our website, press. Org. Thank you. We are adjourned. On the next washington journal, congressman darin lahood on the deal reached on transportation funding. After that, congressman brad sherman of california on the u. S. Military effort against isis, iraq and syria. Congressional debate over syrian refugees. Washington journal, live every morning at 7 00 am eastern on cspan. And you can join the conversation with your calls and comments on facebook and twitter. Federal reserve chair swrja yellen will testify on the hill thursday morning. Watch it live at 10 00 am eastern here on cspan 3. Attorney general loretta lirc lynch will meet with muslim advocates. Well have it for you live 8 30 eastern on cspan. In an effort to improve veterans access to treatment and increase their Health Care Services, Veterans Affairs Department Plans to consolidatity Health Care Programs. They met to review the plan today. Deputy va secretary Sloane Gibson and va undersecretary for health dr. David schulkin. They were joined by advocacy groups who gave their recommendations on the plans. This is just over 2 1 2 hours. Call this meeting to order. Welcome, everybody. Hope yall had a great thanksgiving and hope everybody has a wonderful Holiday Season coming up. This is a very important hearing for the United States senate. On november 4th, if my memory is correct, we had a meeting at the va. Sloane gibson, dr. Schulkin and some others were in the room. In terms of Va Health Service delivery to our veterans, veterans choice, consolid dms ating programs, reimbursement rates so there wasnt any preference over another. A reality in our lifetime and in their lifetime. This will not be the first time i heard most of this information. We had that meeting before. It will be the first time a lot of people have heard it. This is a critical there are a critical number of decisions we will have to make to make my va work. The new veterans choice work and make sure that va does what it does best well but doesnt get itself into things it has proven in the past it doesnt do very well. Information technology and Network Building i specifically want to ask. As someone who ran a Company Every time you Start Talking about Information Technology or Start Talking about building networks, you talk about inf infrastructure and costs, raising management people and take an agency that already has 314,000. If you grow that some more youre probably making a big mistake. Ill be very interested in the testimony of what all of you have to say on those particular points. Were delighted that with the progress we made at the va im symptomed all the time in georgia and they say youre the chairman of the va committee, arent you . Are you frustrated with how screwed up the va is . I said the problem is that we see every day the successes weve made, weve got a good secretary, good team, making Good Progress on veterans choice and for all the bad storyies yo hear about, theyre mostly stories that happened in the past that were trying to correct, not things that are happening today. This is to address a number of previous shortcoming of the Va Health Care system to improve it for the veteran in terms of access and coordination of their care and va in terms of the delivery of the system. But to ensure that we magnify choice and not minimize choice so we can deal with the challenges of the 21st century. I recognize Ranking Member senator blumenthal. Thank you. Welcome to our witnesses and thank you for your good work on behalf of our nation. This task of consolidating and reorganizing community in the care and patchwork of programs we have now is certainly an urge enter one and apparently a very expensive one, 1. 9 billion is a lot of money to spend on organization. I want to know how that money is necessary and what specifically it will be used to do. I also want to know about Consumer Rights. How do we protect Consumer Rights and educate both providers and individual patients, your consumers as to their rights and responsibilities. And i want to make sure that this plan for care and community is implemented as well as possible. I know thats your goal, too. Thank you for being here. We have two panels today. First panel will be made up of honorable Sloane Gibson, secretary of the Veterans Affairs. Accompanied by david schulkin, who i want to commend this committee on the rapid approval to his confirmation to take over a job that will help him. Doctor im going to mess this up. No, no, dont cheat. Dr. Joe dapias. Yall can correct me. No doctor. No doctor . Take it if you can get it. And with that well your testimony keep it within five minutes if you can. If you go a little bit over as long as its factual, important and relevant, were happy to hear from you. Sloane, thank you for being here. The program is yours. Thank you, mr. Chairman. Ill offer a bit more elaborate introduction. David has been at va for all of four months now. He comes to us from a career in the Health Sector managing systems. Dr. Valleu, brilliant young Infectious Disease doctor. And with va for over 30 years, Medical Center director and he has spent most of the past several months working with this team on this report and addressing Community Care issues. Were facing an extraordinary opportunity by consolidating and streamlining means of providing care in the community. Veterans get the best possible care no matter where they receive it. Were determined to seize that opportunity and make the most of it. Va is already in the midst of an enterprise you alluded to. Our proposal to consolidate Community Care programs is part of that overall effort. Care in the community has been and will always be a vital component for health care for veterans. When they live too far from a va facility, when they need care only in the community and when increasing command for care. Were saddled with the confusing array of programs, authorities and mechanisms that greatly complicate the task of ensuring veterans get the care they need, when and how they need it. Project arch, pc 3, choice, two different plans for emergency care, affiliations. Each has different requirements, eligibility rules, different methods of payment. Its all too complicated, for veterans, Community Providers and va staff as well. It will improve the process and make it easier for veterans to use. Providers will be encouraged to participate and provide Higher Quality care and va employees will be able to serve both better while being good stewards of taxpayer resources. Veterans, independent assessment, va employees, federal stakeholders, best practice of the private sector and we proesh many discussion s weve had with your staff. Single set of Eligibility Criteria based on distance to va provider, wait time for care and availability of services with va with expanded access to emergency and urgent care. Streamlined rules to simplify the process. Third, highperforming network. Partnering with federal and comunity to offer a network that will allow va to better monitor Health Care Quality and utilization. Fourth, better information. And fifth, prompt payment, improving billing, claims. Allowing faster more accurate payment. These efforts wont just improve the way we do Community Care. They will make Community Care part of the fabric of va care, making va truly an integrated Health Care System. Getting there will take time. Even as we work toward the longer time, were improving veterans experience of care in the community. Provider base by including providers based on medicaid. Weve eliminated enrollment date and combat eligibility indicators as factors limiting choice availability. Several new changes were announced yesterday to the productsf our collaboration with this committee and house counterparts for which we are very appreciative. Veterans are now eligible if theres not a va facility within 40 miles if a veteran just needs a flu shot or if they need a round of chemotherapy every two weeks or so they may now qualify for choice no matter where they live. Those are just a few ways were making Community Care for accessible to veterans even while working toward the longer term goal of consolidation. A number of close end consolidation objectives. Standardization of our partnerships with dod and academic affiliates. Critical make versus buy decisions on Information Technology, in contractor support. Successful application of my systems to Community Care coordination. These objectives will be the work of a Community Care Team Dedicated full time to improving and consolidating Community Care, led by a new deputy undersecretary of health for Community Care. Were eager to move forward but it must be a collaborative effort with congress. Like many of the improvements weve already made is only possible for your support. We need congress to provide ÷u required funding. I know costs are an issue. Critical cost issue right now is the 421 million. We expect to spend this fiscal year on systems redesign and business solutions. Absolutely essential if were to move forward with consolidation and improving critical care. To cover other possible aspects, such as increased demand and expanding emergency and urgent care. We also expect some cost savings from consolidation as well. Weve detailed our specific legislationive proposals in the report, and were happy to work with any member on these items. Finally, mr. Chairman, a word about provider agreements. We need congress to act on the proposal we submitted may 1st and uncertainty about care thats outside the Choice Program and our other Community Care programs. This is especially critical for veterans in longterm care. Were already seeing Nursing Homes not renew their agreements with us, which means veterans will have to find new homes. Thank you for the support youve already shown. We look forward to integrating care in the Community Within the Health Care System. Thank you, secretary gibson. Appreciate your testimony. I want a short answer on this question. You said you made two changes, announced two changes yesterday regarding the 40mile rule and the services a veteran needed to expand choice access. Steps long away to consolidation, i think thats what you said. Yes, sir. In one sentence, describe what that longterm goal is. The longterm goal of consolidation of care is to improve the veterans Care Experience and deliver that at the best possible value to taxpayer taxpayers. In that case when we had the field hearing in gainesville, and i dont think you were there. Secretary mcdonald was kind enough to come. The choice provider for the east coast, i cant remember their name right now. Health net. And a discussion ensued about issue of eligibility of a veteran to get services outside va through choice and it was an arduous process of which meant file after file going to a Third Party Provider before they could determine getting veteran the service. Is that still going on with the Third Party Provider . One of the things we want to see is easy access for the veteran, wherever it comes from, you or the private provider. This eligibility situation you used eligibility in your testimony a lot. Its evidently more cumbersome in practice than it is in words. What are you doing to streamline that process for a veteran to know if they are el inlgble and that it doesnt take a philadelphia lawyer to find out if they are. The way that a veteran can actually access care in the community, there are two of the fundational elements of the report. The process of consolidation is to help streamline eligibility. There are not multiple programs each with different criteria in order to access Community Care. Thats what we outline here, develop a set of criteria easy for the veteran to understand and easy for our Community Providers to also be able to administer and for our employees to deliver that care. So, thats from the eligibility standpoint. When we talk about referrals and authorization, that process is very cumbersome, as you described, mr. Chairman. There is a number of steps that our employees have to go through in terms of transposing information, uploading information, sending that over it our third party contractor, steps that they go through before we can actually make an appointment for the veteran. Thats too long. What were proposing here in the plan is to streamline that so theres less redundancy. We are more automated to accomplish that. What we have done in the meantime, mr. Chairman, is we have modified the contract with both the Third Party Administrators which now allows us to almost immediately send an authorization document to the Third Party Administrator that triggers a call from the administrator to the veteran. Instead of the veteran having to call the administrator, waiting several days before doing that, and getting bounced back and forth between va and the Third Party Administrator, the burden falls on the Third Party Administrator to reach out and make contact with the veteran to get the appointment scheduled. Designed to simplify the experience and streamline the experience from the veterans perspective. All right. Im going to try to phrase this question properly so i am expressing it properly. Veteran had a choice to go to the doctor to provide the veteran with the service they need whether theyre a va provider va hospital facility or a private provider in the community. When you refer to consolidating your private providers, are you talking about a network of i vd that the veteran can go to . Mr. Chairman, i think the name choice was deliberate on your part. That is the way that we intend to do this. The first issue in this plan is to build a network of providers in the community, as you said, based upon high quality criteria, to ensure that veterans are getting the best care available anywhere in america. Then to allow that information to be transparent so that people have information on quality and metrics to make educated choices. Thats the intent of the program. This program doesnt specify that how we do that because this year, the first phase of it would be planning and designing how that system work. How is very important. Im going over a little bit and i apologize. Well be generous with time for everybody. But if youre one, i have a health care plan. And i know which doctors in my community are eligible and ones arent. I call them up, make an appointment and i go. Its a Pretty Simple process because they all is that what youre looking at doing . That is the intent, identifying the high Priority Network and allowing veterans to have the choice in which providers they select. Its not only the criteria that defines the interaction with the patient and physician, its actually the personal interaction. And that is very variable, depending upon how the veteran experiences the physician. So we want to help guide veterans with right information, let them see it and allow them to make the choice. Last extension of my time. And i wont ask any more. Do you ultimately envision the third party conduit they have to go through going away because you have an approved list of doctors and the veteran makes the appointment themselves and they go . You eliminate that middleman . What we call phase one of the contract is to evaluate how do we simplify the process to allow this to be veteran centric, something were far way from because theres too many hoops to jump through. And were going to be doing a build by decision. Whats the best thing for a veteran and for taxpayers . The role of outside organizations helping us is still uncertain. Is it better to build and eliminate processes or is it better to seek external help . One of the things we recognized is that va doesnt always do this internally that well. We are open to the answer being that we need help to do this. But were going through every step. Thank you. I apologize for going over. Senator blumenthal . Thanks, mr. Chairman. I would like to pursue the question i raised in my opening remarks about protecting consumers and patients. What will be in place to assure that protection . Thats an excellent point. What we are proposing in the plan is the first step to get to Consumer Protection is to actually have the necessary information on the providers in the network, their performance so that we can make sure that consumers or patients have the information they need to make important decisions. Right now thats actually critically missing. We might have local information at the Medical Center level. Regionally and nationally, we dont have the necessitata to determine the quality of care or the health care utilization. Where do you get that data . Thats exactly what were asking for in some of the 421 million in phase one, to build a network where we can gain that sort of information. And what kinds of mechanisms will you put in place to assure that theres education of those patient patients . And, number two, that there is a way for them to bring complaints to bear. Ill answer that in two parts. Whats articulated in the plan is a Robust Customer service function. We want to make sure were able to get complaints or compliments or issues raised. Not only from veterans but also from Community Providers. So, health plans that function very well have a beneficiary arm as well as a provider engagement arm. We want to make sure that there are avenues to be able to communicate twoway between our customers, our patients as well as our Community Providers that serve them. In terms of the specific details were starting the process now of developing implementation plans and milestones and working out those details. The Veterans Experience Office that will be a center point or core function . The veteran experience office is, department wide, critically part of our team rolling this out. Yes, there is a role for that. Were welcome and open to discussing with you and your staff other opportunities that we can have to make sure there are safeguards for our patients in the network. I would want to pursue that. Lot of subjects to cover here, so i cant do it right now. I do want to pursue that set of issues. I was struck to learn that va data shows a loss rate of nearly 9 for physicians and 8 for nurses in the fiscal years 2014 and 2015. In each of those years the va lost about 6,000 physicians and nurses combined. Presumably, many of them would have played a key role in the coordination in care in the community. What can be done to keep those people within the va so that that care is, in fact, provided by the va . The majority of staff losses for physicians and nurses for fiscal years 20142015 were due to staff who quit. I also was struck to learn th that that the va has under has about 336 buildings that are vacant or less than 50 occupied. Given that the va trains about 70 of our physicians nationa y nationally, an impressive number, 70 nationwide, dont we run the risk of not being able to train enough medical professionals to work in both the private sector and the va . Were losing staff. Were under utilizing buildings. Can we continue to provide quality care within the va and can we continue to train . Senator, a lot in this question. Ill try to be brief in my answer. You can speed limit t i ecognize this forum is only kind of an introductory means to answering some very profoundly important questions. I appreciate that. We will take you up on that. Your issue about Consumer Rights, very important issue. Very, very big in health care. I would just very briefly say the rest of health care, the private sector is dealing with this by no longer trying to be paternalistic, you make Information Available and let people decide whats best for them. Senator isaacson was also talking about this as well. On the issue of losses, the 6,000 physicians and nurses and other staff that we lose, each one of those people that leave the organization that shouldnt is painful for us. We have to figure out ways to retain people. Morale is lower than we want in the organization. And we albsolutely have to address it. Thats one of my priorities, to address that issue. Its not all bad news. Between august of 2014 and october 31st of 2015, this period youre talking about, we had a net increase of 1,692 physicians and a net increase of 3,508 nurses. So while we are losing and we have to address that, we are actually hiring more and have a net increase, helping us deliver care. On the issue of training, the role of medical education, nursing education, va is critical for american medicine. We cannot lose that mission. We cannot lose that role. So we have to be able to keep a strong clinical environment to train americas professionals. We do have vacant space. And part of our plan identifies savings, another issue you had talked about in your opening statement, the costs. Some of the savings will come from right sizing some of the space we dont need. Its not going to be at the expense of us training Americas Health care professionals. I really appreciate those answers, and the answers that you have given. I really think this area is critical training our nations physicians is one of the premiere Public Service functions of our va system. And its a pillar of american medicine. And the talk around here is often of accountability and cracking down on bureaucrats who may be incompetent or corrupt. We also need to focus on keeping the good people, good docs and nurses and pharmacists and clinicians in the va. Because theyll be critical to american medicine in training but also in caring for our veterans. Senator moran. Thank you for holding this hearing and thank you to our panelists for joining us. Undersecretary schulkin, is it your responsibility to implement the choice act . First of all, welcome to the va. Thank you for congratulations on your confirmation. And glad to have somebody rowing the boat. But choice act becomes your responsibility or is . Yes, it is. Secretary deputy secretary Sloane Gibson and i have had a history on this topic. Im going to try a fresh face and go at this again. I have had a goal at seeing that the choice act is, in my view, appropriately implemented. Part of my interest in this certainly comes from the demographics, the geography of kansas. Lots of territory, lots of distances. Choice can be a significant asset of great value to veterans across our state. My greatest concern was this issue of whether it mattered if the cbot provided the service that the veteran needed. If it doesnt, does it count as a facility under the choice act . Weve had this ongoing discussion. I offered legislation that passed the senate that said if the veteran cant get the service he or she needs at the cbot, it doesnt count. That legislation is pending in the house of representatives. I was encouraged, perhaps convinced by my colleagues in house and perhaps here in this committee that there was another approach. That was to define what a facility is paced upon the fulltime nature of the staff there. In particular, a physician. Legislation now in law. So, a law says that it requires for a facility to be counted under choice that there be a fulltime physician at that clinic. I was always worried about whether or not the va would interpret that in in some way contrary to what common understanding would be. At least my common understanding. I had assurances from va personnel and staff, certainly on the House Committee that a physician would be required to be at a facility on a fulltime basis, 40 hours. Even as recently as two weeks ago it was confirmed to me by two of the panelists in a meeting with my staff in senator kings office. And then yesterday you report different language about what this now means. So, i feel i mean, what came out yesterday is that the interpretation is completely different than what i was assured it would be and it says multiple physicians, not one. I think the language is clear. It doesnt say physicians. Its not plural. I would like to hear how we got to the point that we now appear to be at and to see if theres something we can do about that. Let me bring this back to kansas. Secretary gibson and i have had long before secretary gibson weve been trying to recruit a physician to cbot in kansas liberal part of our state, unsuccessful in doing so in years. Secretary gibson in an effort to solve that problem, determined in a letter to me in july of this year that that cbot would no count as a facility and veterans receiving care there could have community services. This is the issue we continue to face. In part based upon how you define what a fulltime physician is. But also why dont the veterans who live in areas other than liberal get the same kind of standard as to whether or not the cbot counts or not . Emporia, kansas, in the flint hills of our state. 25,000 kansans. Its open one day a week. It counts as a facility. Seneca is opened one day a month. It counts. In fact, its now closing seneca cbot so it no longer counts. The reality is that it shouldnt count in the first place if its open one day a month. Is this just confusion in the va or is there a solution so that the veterans who get benefit of out Patient Services at liberal, its true regardless of where you live in kansas or across the country. Okay. Well, thank you. Senator, first of all, i hope that this is that there is not there shouldnt be a difference between what you want and what the va wants. First of all, not to take away liberals benefits to make that come true. No. Right. Okay. We want the same thing. Which is particularly in rural areas where there is a severe shortage of providers in general. We want to have as much access to care as possible. Thats the goal. I think this difference of interpretation, which you learned about a short time ago, myself as well this difference of interpretation is really a wellmeaning difference that i believe we can work out. Our belief is the way we were interpreting this, or ill speak for myself, is that we want to have a fulltime physician, a provider in rural areas, in particular, we find its easier to recruit parttime physicians rather than fulltime physicians. So two parttime physicians keeping that open at 36 hours a week is in the veterans best interest. 25 of physicians in this country work part time. For women physicians, its actually higher, up closer to 35 . So, we are trying to staff these clinics in the best way possible. Thats our intent, to provide the office open 36 hours in whatever setting. In terms of the clinics that are open one day a week, that shall not count. If theyre not open with a provider for 36 hours, that does not count. And they dont count. If i may, the cboc, you have to provide a certain volume of primary care and Mental Health care. There has to actually be open daily and they have to be able to provide that level of service. Theres a number of categori categorizations for clinics that are only open one day a month or couple of days a week. Those are not used in the calculation of the 40mile criteria. I actually have a listing from liberal, seneca and emporia that you mentioned are not used to judge the 40mile geographical criteria. Time has expired. Thats interesting, because cboc in seneca is being closed for the stated purpose of making certain it doesnt count as a facility under the choice act. The seneca as this was recently presented to me because i dont like closing facilities that serve rural areas. I think thats of concern. The seneca example is that there was such a small number of veterans, like 100 veterans, that our doctors coming from the larger Medical Center were spending a day traveling there and potentially they werent practicing during that time. We thought we could better serve kansas veterans by actually potentially closing that one clinic and using Community Providers. I only raise seneca as an example as where the va has determined, as i understand from the folks at home, that has to be closed so those veterans can access care in the community. Dr. Schulikin, maybe youre right about how were going to have to track physicians and theyll mover likely be part time than full time and fill that gap in rural places thats necessary, but i would again make the point that the law says what it says. And the conversations that weve had over a long period of time confirm that. And so whether youre right or wrong, whether veterans can get better care by a different definition, i think thats a matter that Congress Needs to deal with. Its outside your Rulemaking Authority to go beyond what the law says. Thank you. This is a very important point. Im going to follow up with a question on this. You made two changes you announced in the Choice Program. Would you read the second one again, your testimony . You said you announced two change changes of veterans choice eligibilit eligibility. Second when qualifying veterans for the Choice Program, we are now taking into consideration the nature of the care they need, how often they need it and whether they need someone to accompany them. So if a veteran just needs a flu shot or if they need a round of chemotherapy every two weeks or so, they may now qualify for choice no matter where they live. Here is my followup question on seneca and liberal. Seneca is part time. Liberal is semi staffed. Is that right . No physician. No physician. You have a kansas veteran who needs Health Care Service and cant get it at either one of those facilities, why arent they eligible now to go to a private doctor . They are already, from both locations. They already are. So what am i missing . I think youre missing that youre not missing anything, mr. Chairman. Excuse me for suggesting that you are. Thats not the way its being implemented. Well, thats what im referring to. Im a Pretty Simple guy. When you read what you read it told me if i it told me if i was a kansas veteran and i needed chemochairperson or i needed a regularscheduled twoweek therapy, i ought to have a choice, accessible me, to go to a private doctor heres what i would like to do to get clarification here. What we will do is go to the 40 mile roster. The list of veterans that are eligible for care under the 40 mile rule. Well look specifically at seneca and liberal and where ever else you want us to look. And well print you the list of the names of the veterans that show up on that 40 mile list. We know whos eligible for care under 40 miles. We know that, already, today, now. Well do that and provide it to you. And then we can figure out whether or not those vet ere rans are actually accessing care in the community. Im going to get rid of this in one more second because im slow. In the case that we just talked about, 40 miles is irrelevant. If you cant get the service that they need, they ought to have choice. If the clinic is not open, they ought to be able to go they ought to have choice, as well. Period. End of sentence. And that is the interpretation that we have applied on parttime clinics sips we watched choice. But well go print out the list of veterans on the 40 mile list and well look for those from seneca and whatever else youd like us to look for and determine whos actually using thats the way it works today. Not tomorrow, but today and yesterday. Mr. Chairman, there are nine c box that do not have a full time position that are still being listed as facilities. Veterans are being told that theyre too close to facility to access. Whether its hartford, connecticut, macon, georgia or kansas, if they cant get the choice from the va, they ought to be able to choose without having to get a philadelphia lawyer to negotiate. And they dont have to go through anybody to do that. I mean, they work, they get their appointments in. Mr. Secretary, your letter to me of june or july was very appreciated and, in fact, reinforced how i thought choice should be interpreted in the first place. Your ability to do that in liberal is just what we have the able to do every place else. And what youre telling me is thats now the case. That is now the case, yes, sir. And if were not executing that way, shame on us. Bad on us. Ive taken the additional time because the senator was out of the room and he would have been asking those questions. I wanted to make sure that people from kansas and montana and connecticut and georgia and Washington State and efb knew. We all believed that the choice was a veteran, could not get service from the va facility. Period. End of sentence. Without problems and definitions and things like that. If were talking about consolidation to revive choice to make it meaningful for our veterans, that ought to be where we go. Thank you, i thought i was hearing wrong. I was thinking on a political continue um. But, obviously, thats not what were talking about. Im looking at your testimony, secretary gibson. And i would like to make sure that i understand your testimony. So, in looking at page three, you say that this consolidation plan with a new vcp will center on five functional areas. And then, going onto page 5 of your testimony, you say that i assume that, again, were talking about the same five vcp. Is that how your testimony is to be read . It is a little bit confusing. The way that its presented is through these five foundations. We start with eligibility, go to referral and optimization, the providers that they see in the network, how they coordinate care and then go in the back office function of claim. We use whats called a system of Systems Approach. One is Customer Service which is how to approve Customer Service for veterans and Community Care providers. One is for care coordination, including how do we do better care. One is administration. That deals a little bit with referablety. The next one is the network, which is how do you actually build a network of providers that deliver care to veterans. And the last one is how do you implement it. That gets into the government structure nationally and locally. How do we get data to make sure that we are tracking and monitoring things creatively. They are very creative. They dont overlap a hundred percent. One is a foundation and Building Blocks the other is a system that we use to implement the plan. We know when were talking about the v. A. System, were talking about a vast system. Its all very complicated. From the individual veteran to navigate his or her way through the system is really a challenge. So while it sounds really good the way its described, each of these systems that you seek to enhance could take a whole lot of effort to even figure out how to do it. So im wondering what your time frame is. You asked for over 4 420 millio just to what . Design what youre going to do with these one, two, three, four, five enhancement systems that youre really focusing on is the outcomes. Thats a whole, huge system that you have to devise to see that were getting the best bang for the buck. Part of your testimony says this would not be possible without approval of requested legislative changes. I was looking at your testimony to see if you have some very specific legislative changes. Is it in your testimony . The legislative changes righthand turn incorporated into the testimony. They are incorporated into the planned document. And theyve been briefed and discussed with senate staff. Id hate for us to appropriate 421 million for you to develop a system and it cant ever be itch leapted because these other changes that you say are intragal dont have them. And ill give you an example. For example, when secretary gates said they were committed to making sure that the medical records of these the active duty and the veterans would become integrated and, after a billion dollars plus, we still dont have it. And so that raises, in my mind, some concerns i have about this undertaking and what kind of resources its really going to take for us to itch leapt it. But i think what are going to be working very closely with you to make sure this happens. And i dont know will this is biting too much, you know. What would priorities be within the area that youre designating. Thank you, senator. I just wanted to clarify, when were talking about systems, theyre not necessarily e. T. Systems. There may be a combination of improvements to existing systems, enhancements that ones exist. So the word systems is just a term to describe, for example, like Customer Service or care coordination. It doesnt necessarily mean that theres a platform. Its just the actual area of work. I would just add to be very specific, senator, the 421 million that were requesting from 802 funds, not new, additional moneys, would be to fix the problems that kurntsly exist in the Choice Program. This is to make the veteran experience better that we know is not working well for veterans. The biggest part of that 300 million of the 421 million is to build what we call a veteran portal. Get the information, have it coordinated with care from the private sector in the v. A. The plan that weve delivered to you of how were going to work better with the private sector needs to have the information exchange. Thats really the majority of the 421 million. I think we just want all of this to actually happen. Thank you, mr. Chairman. Thank you, mr. Chairman. Id like to follow up on what the senator from hawaii is speaking about with regard to the portal it and the plan on how you would implement it. Im curious, are you planning on using internal resources to accomplish this . Or will you be using a third party to actually create the enhancements to existing software . How do you plan on doing this . The first part of the plan, senator, is to identify the system that is we want and make it about building all the systems ourselves is not always the best. Well be very open because time is of the essence and intellectual is more important. Health information exchanges, another word for portals, are very, very robust now. I think im asking today is that the primary position . I would tell you, with our new chief Information Officer who came to us from johnson johnson, her bias on every system is to go commercial off the self. And so that is for us, thats the default position that we take until we have determined that we are unable to do that. Very kwood. How about with regard to the discussion about the providers and the provider net works that are out there right now. Currently, i believe in your earlier testimony, i believe you said medicaid . Individuals were provided services through medicaid. Is that correct . One of the changes that Congress Passed recently at our request was to allow us that the original choice act allowed us to only use medicare qualified providers. If you stop and think about it, theres some say obstetrics for example, youre not going to find any medicare providers in that space. So we asked to include medicaid providers to allow us to reach into some of those other specials. So, now, not only medicare, but medicaid to all be currently eligible to be qualified providers under your guidelines . So those providers, if youre a medicare provider or a medicaid provider, you meet that standard and then you would have to join the network. You would have to use the network providers. If you have an individual who is identified through medicare or medicaid, than the option becomes theirs with a decision to join your network and not a matter of stepping through another hoop provided by the va for determination of eligibility. It would be the providers decision. So the way it would work is lets say theres a doctor that takes medicare or medicaid in the community but theyre not part of the network, they can go to our contractor and say i want doctor smith. Our contractor will give them a premium to sign and that veter ran can go to that doctor. 14 months ago, there was a concern that you were using outside vendors for those networks. Today, youre looking serious doing your own network itself. Why would you find or why wow you now have the expertise to do its yourself if 14 months ago, you did not. I dont think weve made that decision, senator. I think this is another example of were going to look to whats available in the private sector to help us with that. And were going to look if we cant get that, then we would have to look internally, but we would not have made that decision. Do you intend that the net works also include optometrists . Yes. So that would be a major change over what it is today . We have optometrists in our network. I understand. But in many cases, you have licensed optometrists and communities where, at this stage of the game, they have not been found eligible until they have been approved by some sort of va termination up front. Ive had veterans go into their own optometrists and theyre told you dont have a qualifying optometrist giving you your information. What im curious about is is there an opportunity for this same category of provider sns medicare, medicaid eligible . I dont know the situation that youre referring to. It took us six months to get a pair of glasses. And that shouldnt happen. But we do need to have a contractual relationship for us to be able to Exchange Money for them. In this case, they wouldnt accept the prips from that optometrist. You would see in as going away. Once youre accepted to the network, you want all of those paper Work Authorizations to be minimized. Veterans got his prescription, he wants to come to the va to get his prescription filled. You ought to be able to do that right this minute thats right. No reason why. And that wouldnt work, either. Im happy to hear that it sounds like youre on the right track and hopefully, well get this resolved. Thank you. Senator murray . Well, thank you very much, mr. Chairman. Thank you for having this hearing. Secretary gibson, i wanted to ask you, some of the proposals out there would have the Va Health System provide only some ft socalled va personties and get the v a x out of the business of doing some things like primary care and rely just on the private sector for that type of care. Can you talk with us about taking away some of the fundamental lines of care . At the very heart, what we must preserve is primary care. I would tell you theres no other organization that integrates Mental Health care into primary care the way v. A. Does. So primary care will always be a mainstay of Va Health Care. I think as we get into other situations, weve talked about optometry, for example. You can get eyeglasses everywhere. Theres an optometrist everywhere. At some point, at some location, were going to have to make a decision. Are we better off continuing to use our scarce space and scarce resources to deliver basic Optometry Services or do we refer that into the community where vetter rans can get a good service at a good value thats going to be convenient for them. I dont see any of those cord injuries. Pol polly trauma. Oh, i have to tell you, we were in tampa a couple of months ago, and the former Surgeon General of the United States who saw what we were doing in polly trauma there said do you realize this is world class. This isnt just best in class in america. Theres nobody in the world thats doing what v. A. Is doing in polly from r trauma. Were not going to sacrifice that. Its really important that this program be more per misive in allows to use emergency care. Im kind of amazed that we would ask our veterans to pay for serviceconnected conditions. Thats a major reversal. We deny a third of er claims. And as a result of that blaif i dont recall right now, a lot of veterans end up defer iring to yard care and thats really creating an adverse incentive. And what were trying to do is be able to spongsblely address the manager. So what we propose is that were moving all of those restrixs so that a veteran feels comfortable when they go to the e. R. , they will get seen and im able to pay the bill. We dont want everyone to go to the e. R. If they have the sniffles. Even if theyre service connected, though . Well, i think its regardless of serviceconnected or nonservice connected. If you only have a little cold, you want to expedite that. Theres many different way that is we can do it. If we remove that cost share, many i think would say that is up for discussion. The actual kogs of that program would be well more than what weve outlined in this plan. I think we have always told our veterans we would care for them for serviceconnected issues. So this would be a major reverse in policy and charging them copay for emergency visits. Even for a serviceconnected con kigs, they get stuck with a very large bill and ambulance bills. So we were trying to find a way to sustainablely manage and address that issue. How are you going to make sure that the care of veterans receive in the private sector is high quality, timely and coordinated. How do you oversight of that. This is where were going to have a comprehensive set to be able to measure. And the advances in outcomes quality measuring is actually my area of training has become so sophisticated that va has data sets that are unparalleled to anywhere in the country. Im sorry, im out of time so ill follow up with you separately. If you want to have an integrated system i accept that. Fine. Okay. Fine. And when the chair asked you earlier, i think it was he, he spoke so long, it could have been he. As regards to metrics, you mentioned, as well, some qualitative measure of how the patient interacts with the physician. Well, we do do surveys. But what i was referring to, chairman, this is like dating. You dont know that attraction and that magic is i accept you need a certain end. So its going to be a robust data set. Yes. Now, at the risk of just sounding like a sour lemon, i had asked for data before on the va on data that was specific to the new orleans v. A. And i was told that you could not segregate it from the aggregate. Not true. And i apologize. We will get you whatever data you need. We have row brus metrics. Secondly, i went recently to a very wellrun ipa, which is what you are aspiring to but much smaller and much more able to bring every physician and counsel. It gives me pause that you can achieve that when a much smaller organization has been able to do so with the more home mo gene yous set of providers. Any comments on that . First off, i would very much appreciate being put in touch with them. But as you in, my speempbs is from the private sector. These are not perfect metrics. And, you know, im not suggesting that they are. They get better every year and they will continue to get better. And ill believe v. A. Has capableties to ablg which youly lead in this in american med sip. But for the data to with worth anything, then the physician who has seen the patient would have to spend a significant amount of time drafting with the melt rikings. A certain bulk of patients would have to be va patients in order to make it worth their while. You see where im going with this . If you unvolve your clinicians and data gathering, absolute absolutely understand thats not what our intent is. The advancement has come off of Administrative Systems merging with the clinical reco. We have more Clinical Data you can extract. So then let me ask this. Again, at the risk of just because were here, as secretary gibson once said about the veteran. I was in a conversation with a very highprofile medical system director. If i had mentioned who he was, we would all know who he is. So im just channelling right now. But the point is if the va has so far to go on quality according to this gentle man, superior care within the v. Amt. , again, it seems a little bit like the judges go to. Any thoughts on that . Yes. First off, there is data on this. The data actually show that va does as well or better in almost every quality metric study done. Ive just reviewed nine additional studies showing vas quality is better. Be glad to share that with you. Just came an hour before the meeting with all of these researchers and have the data to approve that. We all v the concerns of the va. That seems to be our problem in rural West Virginia and i know in rural america. And that situation happens. We dont have the experts, as you could imagine. And then theres a time lapse that goes on before they can get to the proper care they need. That is precisely the objective. And i think we all have it, dont we . All of us have it. And this takes effect when . Im sorry . When . The new plan . What you see in the plan here is been describing as an area process. What we do is we start going through and improving the veterans Care Experience as we have the cameblety to be able to do that. I was saying rural West Virginia u if you want to start and find out if it works or not, that would be the place to come. That ice wroo the greatest challenges are from. And they might have the Family Member to go and get topnotch expert. They dont have that opportunity. Thats just not right. Its just not fair. And i know thats what you want. We dont have to re that ice what this plan accomplishes. There are specific legislative requests that will help us do that. Two quick comments. I really shudder at the comment that va care is bad. Variability of access. So part of our challenge is to diminish variability. There are references in the fact that you actually find even in a wider variability in Health Care Outcomes than you find in the va system. Thats point number one. Point number two, as i mentioned in my testimony, the community is going to be there for the long haul. The challenge were in right now is we have seven different programs out there. If we dont streamline and simplify all of that so that we can make it we were in where were we . Charles ton. We saturday and we watched what our staff was going through. So what weve got here is we got this patchwork kwilt. What weve got to do is go through, streamline this and make sure its working for the veteran, the taxpayer and the community provider, as well. Thats where you get the kind of seemless care that were talking about delivering here. What are you able to do without us sn. If youre counting on us to get something done quickly, it doesnt work that way here. Theres certain things in the plan that were executing now. The choice of today is very different than the choice an year ago. And were continuing to build on that. And so theres a couple teams a couple items in the control that we want to start working on now. We want to call these our quick wins. Thats circumstance certain things that we really want to leverage my va Customer Service training for folks in the community so that when a veteran about Community Care, we can answer them. And then, for our core network, those spechx relationships that we have with dod and academic teaching partners, they really form the foundation of Community Care. We want to make shurt that the way we partner with them is as simple as possible. So those just a couple of things that are within nbas control. Get on, just finish up here quick my time is running out. But in states such as wech wf which is less than 2 Million People . This is a proportionately high v. A. Pop youlation. With that being said, youre growing to find any small, royal states. If you will youre looking for something to work and trying to come into something in rural areas, well get you feedback immediately. Im going to ask that you defer. Oh, okay. Thank you, senator. I think you guys probably know where im coming from. I am a big fan of yours. I really appreciate you coming up to alaska. You talk about quick wins, i thought we were going to have a quick win in mexico. You came up to the us and said hey, i know you guys are frustrated, this you didnt create the problem. Youre here to fix the problem. But i need i need to tell you that now im the one getting perpetrate perpetrated because its been a hundred days since youve been up there. Iit every day. I said oh, no, a plane coming down here. Veter rans in a circle of on the airplane. And im telling them, hey, dont worry. The v. A. Has a pilot program. Its going to have a quick win from alaska and then, my staff gets told today that what youve committed to is not going to happen now. You guys are asking for 13 billion to fix the choice act and you cant even fix it in my state where you know it is a disaster. Im trying to be measured here for months. You saw the way we op rated. Were not making this up. When are you going to fix the problem in alaska that you committed to in august . It was made here publicly. So what is going on. Senator, first off, you have been consistent. A hundred per credibility consistent. You were absolutely correct about how the veterans felt in alaska. I understand that. Youve been a tireless advocate. My staff, who i bet is watching this right now, who is listening when i say i made a commitment to you and the veterans, and were going to see this through. Now, heres whats been done. Number one, a Virtual Call Center was established. Remember, you said you were going to get people in alaska. One of the biggest problems that you saw was people down in whatever that was. I want people in alaska scheduling. Its a bigger deal than i knew when i came into the government. We are committed to doing that. That is going to be in place. The contract modification happened november 2nd. Triwest is now, now that that modification has been hiring, they believe it will be in place in six weeks. Secondly, the vvmt a. Alaska staff have taken their own people and signed them to be choice people. They have va alaska staff that is there. It is big gun now to help veterans. Youre right to be impatient. Yes. You came up with a plan, supposedly, to fix it. And now, we are being told by your staff that theyre going to work on the National Issues before they get to alaska. The whole. According to our three days spending together was to fix this, look at it as a template. Now youre talking about the national approach. Thats exactly the opposite of what you committed to me on. No, i do not want any of my staff to believe that alaska is not a priority and that we are not going to do it. We have embedded staff in one prior place, but its because it got implemented sooner in new orleans s. Mr. Chairman, if im going to commit to you and you, mr. Secretary on continuing to implement my team to imp lemt what youve already committed to me. We cant wait in the idea of you guys pushing this back. I know the deputy secretary and i have talk bd about this. You have never dooefuated from this. Were not deviating from it. It is taking longer. But thats why our staff in alaska are doing what they can to help veterans right now. Its not enough. I dont want to be getting excuses. I dont want to fix the problem in alaska. Were going to stick at it. I appreciate your active engagement and your sticking to it. Im going to recognize the senator in one second, but i want to leave the gavel to senator martin from kansas. And then i will return later on. Do you see an increase in the overall ratio of vetter rans being referred to nonva care . I think its highly likely that there will be. I think were fwieng to to see a disproportionate inskrees in caring for the community in 2015. I think were going to see a disproportionate increase during 2016, as well. We dont talk about money enough in this committee, but do you think that this is going to end up costing more . I think were to the point where were looking with a business eye. In different markets and different situations. We can buy it or get quality care at better value. Made more efficient use of the space and resources to deliver care that we cant buy in the market place. Once the plan is implemented, do you anticipate it costing more money, the same or less . I need to rephrase. Because we can prove access to care. So i cant really say that per veteran. But the point that youre making, if we dont become more productive through all of this, then i would say that weve exceeded. I eej going to go to another point and i have a very similar dance with no docs. It could actually save the va because of the mileage different. I am a big fan of va health departmentcare. I think that five years in monotan that, your guys on watches, you do a pretty dam good job. So the question that i have for you is were building in the private sector. Are we going to continue to build capacity within the v action . And how are you going to make those dirt nations of where the ball needs to be in the big part of that has to do with where we have Critical Mass. So where we have a Critical Mass of veter rans to serve which means that, you know, that we could deliver better care and better value. But where we have that business decision. In another year, you guys are probably going to be gone. Are you laying into process so that assuming whoever takes your back would see it seemless . Absolutely. Looking at ways that we can institutionalize, what were talking about doing, here. I would say that one of the important roam statistic committees could play is to be a source of continuity about some of these operational. So youve got what, six or 6 art views out there. Can you give me a kwit kmn on how that we took a lot of question as being built this plank. Theres a lot of foul and the note of care came from marening. A lot of listens learn how to work with Community Providers, mow to make sure that theres a direct connection between va and Community Providers. And from the business side, having one pot of money for care. I think what we tried to do in the plan was create these el jiblt criteria that if uz. So for the most part, a rovt of the back one, well with able to use to care. There may be some folks that would have to change providers. In in those transitions, you want to make sure that theres a transition lamp. What i just want to point out is actually, the kans kaps is are know what youve got is warm. It aint going to happen. So i hope that in case she tilters all the way through middlemanagement to the ground. The last thing, if i might, mr. Chairman, in fact, there were so many efforts underway that within about six months, maybe less, able to provide veterans the ability to skip an aappointment for primary Mental Health care through a mobile app. The second light of this effort is where weve taken and modified the actually put a graphic kal user interface on top of the old 1980s scheduling system so it actually looks like a 21st century app and works like one. And thats happening within the next six months or so. The longer term is this kovrp rehencive placement. And were going to have to do that in a very deliberate kind of way. Were about to deliver the field a substantial improvement scheduling functionality. Folks in the field that have seen this thing working are all strike. This is vista scheduling enhancement. They said that if im a veteran and i schedule at the va and its december and i schedule on the 20th and i get in on the 20th, theres no wait time. If that appointment was delayed until the 25, thats a fivehour wait. Is that real . We want that schedule to be clinically relevant or relevant to the designs of the ved i recall ran. If my doctor says i want to see you in 90 days. Was it scheduled coins dent, but im going to be travlging for the next three weeks. When can i get in . Afterthat . And we schedule that veteran in 24 days. Whats my wait time. So what were trying to do here is make it relevant to when the veteran wanted to be seen. If there is no relevance, its just the create date. But a large majority of our appointments are return. So youll see all kind of examples of people waiting 180 days for an poimt. When, in fact, thats exactly when they were supposed to come in. Youre right. 5 00 september if fact that i am sorry, mr. Chairman. I know weve been down this road. I took my granddaughter to the emergency room the other day and i spent five hours in that waiting room. They maybe looked at her for 20 minutes. I still spent five hours. How are we to know which is which . That pern has a pain in his heart and needs to get off of it for three days chlts quite frankly, while this is important, and i dont mean to be critical, why this is important is we had a real bad hearing here on phoenix. It was horrible. How are we going to know the metric. The question is how do we know and do the oversight . I gotchya. I understand. We published that data every two weeks. Well take this up offline. I mean, this is doesnt work so good. All right, thanks. Thank you. I appreciate your flexibility. Senator, i never get tired of hearing your questions. You havent been here long enough. I want to shift gears to really get back to really tap on what senator tester was getting at earlier in terms of institutionalizing this so that were not all of the sudden restarting in 2017. You all said a couple things to give me hope and a couple things to get me concerned. I like the idea of a graphical user. On the one hand, its a good, short term fix. On the other hand, it adds a layer of complexity. I like that plan. What we call them is lipstick on a pig. So it makes it easier. There the process of doing that, you probably not only aggregated data, you probably added data which adds another layer of complexity. So we have to be very careful not to go after some short term priorities that may be voiced from us or others at the expense of creating a long term, sustainable, economically viable fix. Thats more of a direction than, i would think or i would agree with that. I would be false nated if any of you didnt. Now, you know, one thing that i think we need to do, i sometimes think that we need to have hearings here where the only thing that is at the witness stand is a really big plate glass window. A part of what we need to do is the cio in this counsel till is topnotch. Cio, ms. Counsel is topnotch. She has great experience suppfoe job shes been assigned. Just be absolutely certain that youre buying what creating a best practice and not necessarily creating a franken system where you start out with a buy. It looks freighgreat, but then y this congressional mandate requires this measure. Or this required by this senator it requires so many things that theres no resemblance to what you were trying to attain. We had a hearing where senator brown and i have moved a bill thats going to provide a benefit, and i think slone that you were in that hearing, but i said its a shame that a benefit that over ten years will equate to about 6. 2 million is going to require 5. 1 million in system changes before you can start providing the benefit. So, sooner or later, we need to make sure that yall can come back. I want to associate myself with the comments made by most of the members, and i share the frustration of senator sullivan. Im mott going to get into the episodic issues with fayet fayetteville or anything else. Thats why well have discussions outside of the hearing. But at some point there needs to be a cost associated with a shift of priority that comes from the directions youre receiving from this committee. I will take at face value that the value provided to the states that youre prioritizing, like senator sullivans is worth it over the distraction and the die version of resources. But weve got to start getting very serious and have everyone understand what the distraction possibly costs us in terms of shortening the time to benefit t for the overall time to transformation. We also need you very quickly to be able to articulate in a way that we can understand with the time limits that we have in the va committee, why, what i may be asking you to do may move us further to the right in getting the transformation done. And the way youre going to do that is to create a plan that we can communicate before this committee on a state by state basis, what the footprint looks like. What is the mix of va nonva choice. What are the things that we can expect on a fairly immediate basis so that each one of us can feel like we have that information and then we can determine whether or not it needs to be juggled or whether or not its appropriate. We havent had that. And i think thats one of the reasons why we get more of the episodic discussions that we have in a lot of these hearings, but i would encourage you very quickly. The list of legislative programs, its concerning to me that we have to spend this much on a portal. I know we have a hairball of systems that we have to connect to. Its not the website, but its disturbing to me that, again, if we do these shortterm things, were adding complexity and time to the longterm, integrated solution. And we have to roach a point where like all largescale transformationthere has to be a freeze but for emergencies so that you can start getting to work on what were all wanting here sooner rather than later. I think you need to go back and you need to make a more critical look at the things that youre having to accept as a given that congress has mandated that you believe no longer have a place in the transformed va. And it needs to go far beyond what youve probably thought about in terms of the enabling legislation for this particular program. If you dont do that, then youre building the transformed system on outdated policies that may or hey not have ever appropriate. They just happened to get through congress and you have to live up to them because theyve been mandated to you. Im not going to get into a lot of questions except that the reason i continue to have this flavor to my discussion is i want to help you establish a plan that transcends your tenure and your positions. So do we. That continues when we get another president. That needs to be articulated. And we need people in the va to put the mirror back on us, saying youre asking me to do this thats shifting away from the other thing you asked me to do. If we do at that, and you put the mirror in, its our problem. If we make a request, and you dont reflect back on us, its your problem. And i want to make this our problem so that we can help facilitate the transformation. Last things that ill just mention, and we can speak first off, i appreciate the secretary and his staff. Its important. I also want to reenforce what senator murray said. Anytime ive heard it brought up. Ive spoken with hundreds, probably at this point been in the presence of thousands of veterans over the last 11 months since ive been senator. I have yet to hear a single veteran whos received care from the va say that they want purely a private choice. They want the optimum mix. They want veterans serving veterans. We want the best possible health care. We know we have world class practices out there. So we want to make sure that the people who come to us and say privatize it they almost all have one thing in common. Theyre not a veteran. And i want to listen to the veterans voices and make sure we do a better job of providing the best care for them. Which it includes choice. It includes nonva and includes it in different proportions based on the state. There are seven states who have one of the highest per capita of veterans per population. I have a state that has more veterans than those states have total people. We all have unique needs, and we need to solve them. But i hope you all will go back and come back with a larger list of things saying that a part of the complexity is because youve told me to do things that are not best practice and not necessary for me to produce the best clinical outcomes, so please relieve me of this burden. If you start doing that, your jobs going to be a lot simpler, and what we do for the veterans is going to be a lot better. If i may, just 15 seconds. I cant tell you how much i appreciate that perspective, the willingness. I like to think that bob and i have done more of that kind of challenging over the last year and a half or so than has been done in a long time, but what youre describing is a real paradigm shift for the department, and it i an extraordinary opportunity, and well do our best to seize it. Senator, thank you for your commentary and analysis, very valuable. In the absence of the chairman, there is no second round, but i have a question. And it is in response, its a question that follows, in fact, a question that you asked, i think, secretary gibson of me. As i understand it, my take away from this hearing as far as the choice act is that it no longer matters. If you live within 40 miles of a facility that doesnt provide the service that you need, you qualify to have services at home . No. I thought thats what you said in response to chairman isakson. No, if you live within 25 miles of a cbac, it doesnt provide the service that you need, what happens . So first of all, the definition of cbac kind of going back, it has to be 25 milds om a facility or cbac that has a primary, that provides primary, Mental Health care. Not the oneof. If its 25 miles from that you dont qualify under the geography criteria, however, you might, the cbac might not refer people to ct surgery and all those services are provided in the community. I think a lot of times people get fixated on the geography. Theres more than one way that people can access the care. They just dont access that local referral in the cbac. So veterans to live closer than 40 miles to a cbac that has a Fulltime Position have a different standard than those who live further than 40 miles, is that true . Thats correct. So the veteran that lives 25 miles from the cbac who has a fulltime physician, needs an optometrist, there is no optics at the cbac would be told to travel the 200 miles to wichita . Thats what weve described in here, the nature of the service that i read to the chairman. In the past, i think thats exactly what would often times happen and what were saying is we dont want that to happen. So it makes absolutely no sense for a veteran to drive 200 miles to get his eyes checked. Thats the kind of care that we should be referring to the community under choice. But to be very clear, and i think you realize this. If the app tour is opened all the way to where you can get the care, the cost goes through the roof. And we simply do not have the resources to be able to deliver that. Thats why were trying to do this in a very deliberate fashion. So your plan described to us today is intended to resolve those kind of issues . No . The way we resolve those issues is it avalancllows the l physician to make that determination. So we have geography, wait time and availability of services, but there in was one thing passed by the hill that allows nuance. When i see patients, and i see that physical therapy, you should not be driving 100 miles to get pt, we can make that decision together. Do you make that decision in the office. Together today regardless of what happens with your plan for the future. Thats already available to that veteran . It is now, based upon what we put in place effective yesterday. So today is a new day. It is a new day, yes. And many of the concerns and complaints that ive rayed ovisa long period of time are resolved in your mind by what happened yesterday at the va. You asked me where, you indicate that where do i get my concern. Emporia shouldnt qualify, and it does. Its people bringing us issues, and the veteran who lives 25 miles from the cbacc who cant get his eye glasses adjusted cant do that and has to drive to wichita. I checked with my staff. Just this week weve had ten new cases in kansas related to the choice act and the distance necessary to travel. It is an ongoing would you share those with us so that we can go do a deep dive and understand thats where we can help identify the defects in the system, to understand where things arent working. It would be great. If i could add one other thing, some of the 421 million requesting have to do be education and training. Theres a big chunk of that. We didnt talk about that today. But what youre experiencing and what were getting is if that information flow doesnt occur at every efrlevel of the organization theres a problem. Thats some of the costs is to improve the communication channels. Ive asked this question previously. Theres something called an abandonment rate. And that is described to me as those who apply for choice and conclude its not worth it. Those youve even perhaps reached out to, and they actually make a request to use choice and conclude to walk away. That could be a good thing, because they want to use the va in its traditional sense. It could be a bad thing, because eyve hit the breick wall. Theyve hit the bureaucracy. I have no standing to deny the senator another question. Thank you. Thank you, chairman moran. The Caring Community and generally nonva medical services involve payments. And there have been various efforts over the years to make sure that those payments are validly made. The va authorized a Recovery Audit Program in the 112th congress, i believe. And the inspector general, as you well know, recently found, i believe, 311 million for fy 2014 in quotes, improper payments for the nonmedical va payment plan. I would like to know what progress theres been made in the Recovery Audit Program. Understand there is a request for proposal or that that program is in the works. Could you update me . This Recovery Audit Program i am not immediately familiar with. Im familiar with the efforts that were doing to expedite and improve the processes around prompt payment. I mow thknow that some of the ps had to do with the fact that they were done under individual authorizations instead of being done under provider agreements, which is one of the reasons were anxious to have provider authority. Well get you some information on the recovery effort and because i am not conversant on that at all. I would appreciate you getting me any information you can and hopefully in the near future. I will. Its gone from 50,000 foot to the ground level. Doctor, you mentioned when we were talking about for doctors who may go into the Choice Program that if theyre already certified to provide medicare or medicaid coverage that you provide that doctor or provider an agreement to allow them to provide va care. What is that provider agreement like . So the way that it works right now is we have these contractors, health net and tri west. Theyre the ones that contract or work with the providers. The provider agreement is like two pages. Its actually a very simple process. If a veteran wants to, like i was describing, see someone in fayetteville, North Carolina and theyre not part of the network, its the responsibility of our contractor to reach out to that provider. But its not a twopage agreement with 75 attachments . No. Its a simple agreement. The ability to share medical information, things like that. Do you have any idea what the rejection rates are on, acceptance or rejection rates are on these agreements . I dont know. Do you have any information on how well were doing with reimbursements for people who come under that versus a medicare or medicaid provider in terms of timeline to reimbursement, those sorts of things . Yeah. In the Choice Program through our contractors, they are close to 1100 within 30 days. In the nonva, we are in a 79 within 30 days. Is the 79 relatively simple care versus complex care so you get an idea of the dollars outstanding, not just the no, our care in the community can be very complex care as well. And thats what i was referring to. So is there any potential 80 20 rule . So that its 80 of the dollars outstanding . The common met wreric that t use is claims that are not clean claims. They dont distinguish them by clinical criteria. Theyre no longer telling me its very, very difficult to do and tyre not getting paid on a timely basis. Providers sometimes dont differentiate choice from va. So youre going to hear both things. They should be getting their payments 100 of the time within 30 days through choice. And thats because it would be a nonva provider by contract and a choice provider by episode. Exactly. Right. Thank you, mr. Chair. Youre welcome. Gentlemen, thank you very much. Doctor, thank you. I ask the next panel to join us at the table. We should be joined by mr. Roscoe butler, the Deputy Director of the Veterans Affairs and Rehabilitation Division of the American Legion. Mr. Darren sell nick, for concerned veterans of america. Mr. Bill roush, political directdirect director for iraq and afghanistan veterans. And while youre taking your seats, i want to apologize that i have another commitment. I didnt realize that this hearing would last as long as it has. And so i may have to depart before youre done with your testimony, if that happens, i apologize and ill leave the hearing in your hands, mr. Chairman. You have no alternative. Thank you, senator blumenthal. Gentleman and maam, thank you for joining us. I cant see the nametag, but i think its m. Butler. Please proceed. Thank you, acting chairman moran. Ranking meer blumenthal and members of the commit e the American Legion believes in a robust veterans Health Care System designed to treat those who have worn the uniform. However, in the best of circumstances, there are situations where the system cannot meet the needs of the veteran. And the veteran must seek care in the community. I am privileged to be here today and to speak on behalf of American Legion, our National Commander dale burnett and more than 2 million members in over 14,000 posts across the country that make up the backbone of the nations largest wartime veterans association. The American Legion recognizes that the Choice Program was an emergency measure to make Health Care Accessible to veterans where va was struggling with care. In recognition of a system, the American Legion believes va needs to develop a welltee fined and consistent nonva Coordination Program that includes a patient strategy and takes their unique illnesses and injuries as well as travel and distance into consideration. The va purpose care Program Dates back to 1945 when the chief medical director of the Veterans Administration implemented vas hometown program. General hollee recognized that they could be treated before they needed hospitalization. As a result, general holly instituted a program for Hometown Medical and dental care at government expenses for veterans with serviceconnected ailments. Under the hometown program, eligible veterans could be treated in their community by a doctor or dentist of their choice. Fast forward 70 years. Vas implemented a number of programs for nonva programs. Like fee basis, patient arch and the veterans Choice Program were implemented to ensure eligible veterans could be referred outside the va for health care if needed. Va states that their Community Care program would streamline the programs by transitioning them into a Single Community Health Care Program that is seless and transparent to veterans. While these goals sound positive, the American Legion believes by resolution that a proper plan must include the following elements. Ensure all newspaperva Community Care contract provides complete military cultural awareness and evidencebased training. Provide all nonva providers with full access to vas computerized records system. Ensure va continues to improve its nonva coordination through the coordination office. Ensure va provides collection of information into the veterans medical record. Ensure va develops a National Tracking system to avoid local contracts from lapsing, and an automated claims Processing System that fully automates the authorization and payment process. We are pleased to see that vas plan incorporates many elements of our resolution. If approved by congress, the plan would be rolled out using a threephase approach. It would be implemented gradually, much like tri care by providing and streamlining business processes. It calls for cultivating a Provider Network to serve veterans utilizing federal Health Care Providers, academic affiliates and Community Providers. The American Legion believes va has not yet demonstrated it has the expertise or experience for large Provider Networks. So far this year it has relied on Third Party Plan tis pants such as health net to fulfill these requirements. It does not specify whether it would continue using thirdparty contracts if the plan is approved. Serious thoughts need it to be given to this. We have concerned about. Have vas ability to implement the plan. Va has rolled out numerous products in previous years that require dramatic system information and technology changes. They are concerned that their plan will not result in similar failures such as like corps fls, scheduling redesign, a veterans lifetime Electronic Health record, or the initial rollout of the Choice Program to name just a few. Veterans are calling on v. A. To get it right, and on their first attempt and not continually waste taxpayers dollars. In summary, if va can address the american lee swrons concerns, we are cautiously opt mits particular that va planning for moving forward may work and could represent an important step toward a truly interfreighted model for developing Veterans Health care. I thank the committee for their hard work and consideration for this legislation as well as your dedication for finding solutions for problems that stand in the way of delivery of Veterans Health care, and im happy to answer any questions. Thank you very much. Mr. Celnick. I appreciate the opportunity to testify at todays hearing and the recent of programs. In the interest of full sis closure, i am the commissioner. My testimony reflects cva and my own observations. Cva agrees there needs to be one veterans Choice Program that deals with root problems and is fiscally responsible. To meet the veteran how, when, and where theyd like to be served. After careful review, it is our opinion that this plan does not meet the criteria listed above. Instead, it continues the va status quo, cherry picks the status assessment. The plan will fail, costing taxpayers billions. Instead of a simple program, va has developed a grandiose plan. Nor is in line with the doctores comments. The aim is expanding into areas it does not have expertise in. We identified five key flaws in the plan. First, implementation requires an institution such as the cleveland clinic, the hva is using an antiquated hmo staff model focussing on a high degree of control. Solving these problems would demand farreaching and complex changes that taken together the number of issues va faces is appears overwhelming. Vas in the midst of a leadership crisis, and its in danger of becoming obsolete. Last year, vha made 85 million appointments, but only completed 55 million appointments. Lapses in care and reports suggest va is not up to the task. Second, they have a plan that has lofty goals but is not grounded in reality of the way veterans access their care. They are acting on the false premise that it is the medical home for the veterans they serve. As the assessment states, veteran patients reliance on va support amounts to 25 to 30 . It cherry picks recommendations and rejects others. Fourth, veterans want real choice in private health care. According to an october 2015 poll, 91 of veterans want more health care choices. Instead, va takes greater control over their access. They would be eligible if theyre over 40 miles away from a pcp. With wait times, vas gaming the system by having undefined wait times for every service and leaving it up to the provider for the necessary time frame. Accessing the highperformance network is another example. Vas undetermined referral process which could take months for each step, first is the network, then standard tiers all controlled by va, fifth, the plan is remature, especially in light of the charge Congress Gave to examine how best to deliver health care to veterans. Va could short circuit this char charge. Cva proposes consolidation. Should be done in consultation with the commission on care. Two, va should refine phases two and three of the program in consultation with the system on care. Operations and leadership reforms. Three,va should finalize stages two and three only after the commission on care provides findings and recommendations to the president and congress. Although it is attempting to move too quickly on consolidating the nonva program, you should concentrate on not having the failures. As Theodore Roosevelt says, a man who is good enough to shed his blood for the country is good enough to have a square deal afterwards. We look forward to working with the chairman, Ranking Member and all the members of this committee. Thank you. Mr. Roush . Acting careman mohairman mor. In our 425,000 members and supporters, thank you for our opportunity to share our views. Iava is proud to have previously testified before this committee recognizing the need for consolidation. And we applaud congress for requiring va to put forward a plan tor consolidation. We also want to recognize senior leaderes at va who are still with us here today for acknowledging the need for consolidation and providing an approach and process that was inclusive, transparent and veteran sen trick. Last year, the act was being implemented, it became apparent that the new law was confusing and added to a series of previous plans. 43 of respondents stated the main reason for not utilizing choice was simply because they did not know how. While 28 of our members who utilized the program said their experience using choice was extremely negative. Although necessary to address the scandal in phoenix, it quickly became an example of what was and what was not working for veterans, physicians and va employees when it came to accessible, and high quality care in the community. Iava has conducted polls and focus groups to understand what was needed in order to have a successful consolidation of care in the community. Weve attended over 25 formal meetings with other vsos and staff to share what our members are experiencing at the local level and have had dozens of informational calls and meetings to provide direct feedback from post 9 11 veterans. We brief any plan must be simple to understand. It must be consistent across the country and place the needs of veterans above all else. The plan put forward by va meets the above criteria and should be the framework and provide improved and seamless access to care for veterans. Despite the progress thats been made by congress and va, we have three han concerns. Congress drafting and enacting the required legislation to consolidate care, vas ability to implement the new laws designed to consolidate care, and three, a continued focus on access without outcome to veterans, we have seen provider whose have not historically served the veteran community. This committee has been a Strong Partner with iava as the program was being implemented. Unfortunately, some members of congress continued to put forward incomplete oneof plans and legislation that did not include feedback for veterans, vsos or va. As they move forward to simplify a very confusing process for veterans, iava highly recommends congress uses vas framework and avoid proposals that are one of or misinformed. Inefficiencies resulted in a need to consolidate care. We believe congress should be mindful of these lessons. Our second concern centers around vas ability to effectively implement a plan to consolidate care across the enterprise that avoids many of the mistakes made in the implementation of choice and puts the veteran at the center of every discussion. During a recent discussion with post9 11 veterans, there seems to be significant inconsistencies across va, and although ive had some good experiences, there are too many who have had bad experiences. They want to call all stakeholders to put the Veterans First and change the culture of va across the country. Given shortcomings on the implementation of choice and Customer Service generally, the va should also continue its efforts with my va and ensure employees are properly and consistently trained on any change in care. It includes everyone, congress, va and everyone to place importance on the quality of care veterans are receiving, especially, especially as new providers join networks in the community. We need to pay special attention to the care that veterans receive to ensure its consistent with the high quality of care provided by va and that private providers are trained to treat veterans. A recent report suggests community ibuprofen providers me equipped. In closing, iava would again like to thank this committee for your leadership and continued commitment to our entire community of veterans. Its important to testify in front of this committee today and we reaffirm our commitment to you and working with all of congress. Va and vso partners to ensure veterans have the access to the highest quality of care and that our country fulfills its obligation. We believe theres a real opportunity, a real opportunity to transform the va for todays veterans through a oneteam, onefight approach. Thank you, and id be happy to field any questions. Mr. Rausch, thank you very much. Thank you for the opportunity to testify today. The partners strongly believe veterans deserve accessible and veteran sen trick care. In most instances, va is the best option, but va cannot provide all services to all veterans in all locations at all times. That is why they must have other public Health Care Systems to expand viable options. We are pleased that many aspects of the vas plan are closely aligned. We support vas concept of consolidating va care into a Single Program that would combine the capabilities of Va Health Care system with other public and private Health Care Providers in the community wherever necessary. As part of the consolidation, several Community Care programs would be allowed to sunset, while allowing these programs to sunset is a natural part of the program, allowing them to expire without knowing that the current plan can carry the case load is unacceptable. We cannot support an across the board copayment for these services. The idea of charging veterans who are serviceconnected for care is unacceptable. In order to make sure that they access it appropriately, they suggest the establishment of a nurse advice line. While they must do a better job of collecting thirdparty payments we adamantly oppose withholding health care for veterans for not providing private insurance. The ivs framework builds on vas plan. Our fourpronged approach framework looks beyond the division between va care and Community Care to create a blend and seamless system that will restructure the Veterans Health care delivery system, redesign the system and the systems that facilitate access to health care, realign resources to reflect its mission and reform vas culture with workforce initiatives and accountability. Similar to vas plan, the iv framework would combine the strengths and capabilities of va and other public and prooit providers, but be a managed care program regardless of where they live. We recommend they move away from the standard. It would be clinically based decisions made between veterans and his or her doctor or health care professional. They would be able to schedule appointments most convenient to them. The iv calls for significant changes to vas skip process by including private Public Partnership options and blending replacement options to better leverage federal and local resources. We also have called for the establishment of a quadrennial review process to align vas Strategic Mission with its budget and operational plans and help provide continuity across all administrationsing the iv framework would establish an audit of vas budget terry accounts to identify programs for waste, fraud and abuse. Veterans experience officers would advocate for the needs of individual veterans who encounter problems obtaining va services. They would also be responsible for ensuring the health care protected, protected under title xxxviii are enforced. As proposals that provide veterans with vouchers. It makes private and Public Resources complementary instead of in competition with each other. Mr. Chairman, this concludes my testimony. And me and my partners look forward to any questions you may have. Senator blumenthal . I appreciate your courtesy in let being me ask a few brief questions first. Mr. Sellnick, let me ask you. Your recommendation is that the va should finalize its Choice Program, longterm new veterans program, only after the commission on care provides findings and recommendations to the congress and president and they decide which recommendations are feasible and advisable. Do you have a time frame as to when those recommendations will be made . As of right now, based on the legislation, we are due at the end of february. In february. That is as of right now thats when were due. So you would advise waiting until sometime this spring or later when there is feedback from the president and congress before the va finalizes its Choice Program . Yes, i think the vas program has some merits to it. Im speaking for myself, not for the commission or anything, but personally, i feel that it can be a more collaborative process. And as part of that collaborative process, lets have a process where we have a really integrated Systems Approach where we come up with a comprehensive solution. The Choice Program is not a solution on its own. It has to be integrated with the rest of the Health Care System. So coming up with a program on your own that may be in conflict with other recommendations would just cause more confusion. Mr. Rausch . I would just like to add although we have different views and opinions about this specific plan, i would challenge anyone to suggest that the process hasnt been collaborative, and in contrast to say two years ago in working with the va, i dont think this process would have taken place. And based off a lot of the discussion between members of this committee, it seems your experiences have also changed with va, so i would also like to highlight as i did in my testimony, the numerous, almost 35, it was daunting, frankly, so i would emphasize its been transparent, collaborative and unprecedented from the federal government from our perspective. Thank you. Senator, in full disclosure, i think it would be fair to say that the commission on care, weve met with their professional staff, and s our understanding that theyre hoping to extend their charge until next summer, so that means it would be put off to june, july or august at the earliest. I think that would be unfortunate for the va. This plan that the vas put forward is a good idea. Its a very good concept. If we just put it off for fo another potentially 12 months, where will we be then . I am heartened and encouraged by the feeling that i think is generally shared among this panel, that the process has been collaborative, and, to that end, i am going to invite, in fact request that the va react to some of the excellent ideas that have been suggested by this panel if they havent done so. I would ask that the va, who are still present, let the record show that all of the witnesses on the prior panel are still here and can hear me make this request. I would ask that they react to these proposals, because these ideas are very promising and important, and i think collaboration is the keyword here. The vsos have been extraordinarily and profoundly important in this process, and i want to thank all of you, gentlemen and lady, for the excellent ideas that youve offered today and throughout this process. Those who are represented here and others who are not on this panel. So thank you very much, and i look forward to additional collaboration. I think thats the operative word. Thank you. Senator moran . Mr. Chairman, thank you very much. I think it was mr. Rausch who had statistics about experiences with the Choice Program, access to care and communities, but let me ask all of you. Youre all involved in helping your members helping veterans access care. Whats been the experience with the choice act for each of you, each of your organizations members . Obviously, for the American Legion, weve had experiences where veterans have had positive experiences. As well as not so positive experiences. It all depends upon the type of relationship the va has within the community. And with the health net and tri west. Were still getting calls from veterans where their claims have been turned over to collection, because theyre not being processed and paid in a timely manner. When we get those types of issues and concerns, and we turn them over to our vso liaison and central office, and after they check into that, then we get an affirmative answer as to what was the break down and an easy solution to fix it. But then the question then becomes how come, when did we get to that point, how come it wasnt appropriately addressed in the beginning . For our members, its been mostly a nightmare. The number one thing that they say is, you know, literally the few that have been able to get choice is because theyve had a congressman or is that thor interfere on their behalf. And they say why does it take a congressman or senator to get some help . The whole process, for our members and you can go online and see the facebook posts. As just been a continual struggle and battle. And one of the number one questions we get is, look, if im within 20 miles of a va hospital and the heart surgeon is 100 miles, why cant i get that choice . Why does tri care offer a simple system of specialty and primary care metrics and the va has this convoluted process. Thank you, and to repeat those numbers, currently, 43 of our respondents say the reason for not using it was for confusion. 28 said they had a negative experience. What weve seen from our polling data, weve seen it increase, all be it generally, its still been a negative experience. Its increased exponentially. You mentioned kansas. I spent some time at ft. Leavenworth because i was assigned there by choice. And i was looking at a map recently that the tri west had showed me today or last month, excuse me, versus a year ago, the providers and the network that they built in kansas specifically has been tremendous. And so what weve seen is not a linear increase but an exponential increase in number of providers, veterans who understand it better, the va who prankly were the worst performing. Theyve improved significantly. So although its been a challenge, weve seen it start to steadily uptick, which is why we mention in our testimony that there are positive things and lessons from choice but also negative things weve learned. On the broader concept of choice about the different plans that have been floated. And one of the reasons we support this framework and reject some of the one of plans, there are some plans that want to take primary care out of the va. Well, as someone who actually had my primary Health Care Appointment this morning at the va, and i have choice because i have private health care as well, that would be remofing choice for me. Theres some that completely eliminate choice by pulling those resources out of va, which is why we think this collaborative choice that has been taken is a clear path forward. Thank you very much, and appreciate your patience in waiting for the opportunity to testify and to be here to ask questions which gives me the opportunity also to tell the va how appreciative i am in their patience in staying to listen to the testimony. And i apologize for having to go to the floor and make a brief speech, so ive missed almost all of your testimony. I have a couple quick questions, and i know its been a long time. I thank you for staying, and i thank the va representatives for staying and listening as well. Mr. Sellnick, you heard the exchange with senator moran and myself about the problems in liberal, kansas and the ease or difficulty of that program. You made a comment a minute agatha you werent sure those providing services at the local level and the va at the washington level understood how the program was actually working our Something Like that. Did i hear you right . Well, i mentioned a number of different challenges with the program, its staff, its process e the call center, the whole thing has been a problem. I think, and i think youre right. And i dont blame anybody for this. But i think there is a misunderstanding up and down the chain of command in terms of what the intent of choice was, and i hope as we implement these two changes yall rolled out yesterday, youll make sure that the people at the local level and the medical facilities understand what that really means in terms of veterans access. Those are two remarkable changes that will make choice better for every single veteran tomorrow,