We have a vote on the floor which should be over in the next ten minutes. I will talk a little bit and tell you what i want you to know. I will start with testimony from sloan gibson. Make the note that his staff said that was okay. I want to take extra time because this is an important hearing. Last year culminating with the passage of the veterans choice bill problems in raleigh, denver come orlando and answers that were in completed for understandable reasons. Just left about a year early. Gone as well. There was a transition. There is no excuse for the plethora of problems, and the transition should have been much better, but was not. Va demonstrated that they were finally listening. All i was hearing was nothing but stonewall until finally sloan walked into the hearing, pulled out a new rule to make the number of miles driven which i think everyone in this committee appreciates and agrees with. I believe we are satisfactorily working toward the care you need. It will happen in the near future. I no some of you do not like the veterans choice bill because they fear it will be a replacement for the Veterans Administration. Administration. You will not replace the Veterans Administration, you can empower it and the veteran by saying they have access to worldclass care in close proximity to where they live, and affordable and manageable amount. The va has demonstrated it cannot build a hospital without running over several hundred percent. Every time we can provide healthcare without having to build a hospital what we need is a partnership between the private sector and Veterans Administration to deliver the ultimate goal which is to see to it that veterans get worldclass healthcare in a timely way. We have had some bumps. I met with private contractors. With va is cooperating in ways it may not have been before the see to it that the two are working seamlessly. Private contractors have to understand it is contingent upon there willingness to cooperate with the va. There are some who do not like the non va healthcare provisions anyway but they will have to get used to it because we will make this work. We will make this work for veterans. The hearing is important. Understanding that as we talk the 1st person we are here to serve as our veterans. We can expect no less of ourselves to see to it they get the best worldclass healthcare. With that said, i turned to the Ranking Member. Thank you, mr. Chairman. Thank you for having this hearing. We went through a terrible tragedy and debacle not long ago that prompted the veterans access choice and accountability act which sought to relieve some of the problems and underlying issues including deceit and fraud that caused delays and misreporting within the va system. The discussion today is centered on the remaining flaws and failings in the Va Healthcare Program particularly the veterans Choice Program. And as much as this program was established to deal with the immediate crisis of access to care in the short term with an investment of 10 billion to 10 billion to provide direct Care Services in the community and 5 billion to provide a Choice Program, there is still a lot to be done the program was just a down payment, just a 1st step. I believe that it has to be improved even further. There remains underutilization of the Choice Program. The underutilization may well be the result of the failure to sufficiently publicize or make aware veterans. It may it may be the result of other more fundamental issues within the program and i share the chairmans view that changing the 40mile rule was certainly a welcome step. The most important fact that brings us here today that we cannot lose sight of is we still have not solved the crisis that led to this Program Veterans still way too long for appointments healthcare delayed in effect is healthcare denied for veterans who suffer from healthcare conditions that require immediate treatment. The va most recent data as of may 1 1st indicates weightless numbers have increased significantly since the same time last month. As of april 2 300,000 veterans 2nd 300,000 veterans had appointment scheduled more than 30 days from the preferred date. As of the may 1 release that number jumped to nearly 434,000. Anyone believes this crisis has resolved is living in an alternate universe. It is not the universe that our veterans and have it. Reallife consequences that cannot be tolerated. Too many veterans are waiting too long for appointments command i am glad that the va is finally going out to facilities with long wait times trying to determine why exactly they are not utilizing non va care options. I notice a lot of the testimony today talked about further changes to geographic criteria. Every time there is an additional change more of the 10 billion allocated will be devoted to paying for access but this money is due to our veterans because better healthcare is due to them. I we will i will close on this note we still do not have accountability. The Inspector General has not completed his work. We have no reports on disciplinary action for delays that or intolerable and still are unacceptable. Accountability is absolutely necessary and i believe the Inspector General needs more resources to effectively implement accountability. I will continue to press reports and for action by the Inspector General that will send a message to the healthcare apparatus and professionals that we mean what we say when accountability is our launch word. Thank you, mr. Chairman. Thank you, senator blumenthal. Our 1st panel is made up of the following individuals. Sloan gibson. I want to thank him for his willingness to take on tough situations. I appreciate the fact he is approaching it in a positive way. I hope you will maintain that attitude. To reiterate secretary mcdonald and undersecretary gibson invited the Ranking Member and myself for what they call a standup which we did in february and have been invited to come back in june. As many members as want to come i will make sure they are invited. Benchmark itself against itself to try to find better ways to do things to flesh out problems in advance and get themselves earlier. We have big problems to solve. We appreciate you being here to assist. I am sure that everyone appreciate you being here. Providers, mr. Mcintyre, i enjoyed our meeting earlier this week. I appreciate your being here today. Thank you, mr. Chairman. Chairman, Ranking Member members of the community we are committed to making the program work and provide veterans timely and geographically accessible quality care using care in the community whenever necessary. I we will talk i will talk shortly about what were doing and the help we need to make it happen. First i want to talk about access to care. Most mornings at 9 00 a. M. For the last years Senior Leaders from across the department gather to focus on improving veterans access to care. We concentrate on we concentrate on key drivers of access including increasing Medical Center staffing by 11,000 adding space, boosting care during extended hours and weekends and increasing staff productivity. The result, 2. 5 million more completed appointments inside the va this year than last. Of relative value units to make common measure of care used to measure care delivered across the industry is also up 9 percent. Another another focus area and improving access has been increasingly use of care in the committee. Va issued 2. 1 million which resulted in more than 16 million appointments completed. Here today authorizations are up 44 percent which will result in millions of additional appointments for Community Care. Veterans are responding to this improved access. Among those enrolled more are using va for care and those using va are increasing their reliance. This is especially the case where we have been investing most heavily. In phoenix we have invested hundreds of additional staff i should note that we have increased care in the committee 127 percent in phoenix over the last year largely due to the extraordinary effort of tri west in a particular community. Wait times are not down. The surge and in addition to five the surgeon additional veterans coming in those there asking for more care. In las vegas we have a 17 percent increase in veterans receiving care. In denver we have opened Outpatient Clinics and that it more than 500 additional staff. Veterans are using va for care there up 9 percent. In North Carolina were wait times continue to be a problem we have increased appointments 13 percent to my relative value units up 19 percent command veterans using va for care up 10 percent. In all these locations we have had dramatic increases in care for the committee. The primary reason for increasing demand increases in the number of medical conditions and a rise in the degree of disability and improving access to care. Community care is critical for improving access. We use it and have for years and programs other than choice. We spent approximately 7. 9 billion on committee care other than choice. In 2014 that row state and a half billion command reestimate at the current rate of growth va will spend 9. 9 billion at the same time we have had a large increase. It has not worked as intended. Here are some things we are doing to fix it. We changed the measure using the fastest route. Roughly doubles the number of veterans eligible. There is much more to do. Follow on mailing will go out. We Just Launched a major change to make choice the default option for care. Additional additional staff training and communication to make sense of provider communication improvement improvement to the website and ramped up social networking, knew mechanisms to gather feedback from veterans as well as frontline staff. These are all in place or are about to launch. In the longterm we must rationalize Community Care into a single channel. The Different Programs with different rules and reimbursement rates methods of payment and funding routes are too complicated too complicated for veterans providers, and for employees who coordinate care. We will need your help. Let me touch on the other issue. We have completed and that indepth analysis to provide choice to all veterans more than 40 miles from where they can get the care that they need. We have sure that analysis. It confirms the extraordinary costs that have been estimated previously. We have briefed the staff on a broad range of other options and believe there are one or more worthy of discussion and careful consideration. While we are working together on an intermediate Term Solution we are requesting greater flexibility to expand hardship criteria and choice beyond geographic barriers. This would allow us to mitigate the impact of distance and hardship. We request greater flexibility around requirements that preclude us from using choice for services such as obstetrics dentistry command longterm care. As described above, we accelerated access to care in the committee anticipating that a substantial portion would be funded through choice. For various reasons for various reasons most touched on previously we will be unable to sustain that pace without greater Program Flexibility and flexibility to utilize at least some portion of Program Funds to cover the cost of care in the committee. We are requesting some measure of funding flexibility to support this care. On may 1 the va sent a legislative proposal. We request your support. Lastly, we are requesting flexibility in one other area hepatitis c treatment. You are familiar with the miraculous impact of this new generation of drugs veterans that have been have see positive for years now have a cure within reach with minimal side effects. There is no funding provided in our 2015 budget request or appropriation. Remove 688 billion from care in the community anticipating the shift in cost to choice to Fund Treatment for veterans with these new drugs. Was the right thing to do but it was not enough. We are requesting flexibility to use a limited amount of dollars to make this available to veterans between now and the end of the fiscal year. So we are improving access to care. Now a standing airport of great times the we still have work to do but we are improving access to care. Were committed to making choice work. We need help especially additional flexibility to allow us to make the healthcare needs of our veterans met. We look forward to your questions. Mr. Chairman, Ranking Member, members of the community i am grateful for the opportunity to appear before you on behalf of our companys employees and its nonprofit owners to discuss the work which we are privileged to do in support of the department of Veterans Affairs. I would like to focus my testimony on three topics the reality of this programs implementation process of identifying and resolving gaps and those which remain to be solved and what i believe to be the art of the possible. As you know and as secretary gibson has said purchasing care in the community has been a lot of practice. In fact, in september of 2013 after two years of planning va sought to change that. That that contract was designed to have a consolidated, integrated Delivery System built in the committee to undergird the facilities across the 28 states. Make sure at the end of the day they were not there to replace the va but supplement. It worked as intended. When the furnace went off in our hometown 6300 providers under contract Going Forward at the side of the Medical Center to assist them in eliminating the backlog. By august 14000 veterans moved through that process. Around the same time we are modification that we had primary care. We now have over a hundred thousand providers across 28 states under contract along with 4500 facilities. The reason why is we need to make sure networks are tailored to match demand that exists in a particular market that is not able to be met by the facility itself. That was a complicated program to set up done in short order, but it was training for what was to come next. On november 5 after 30 days of work we were to stand up and support of Va Choice Program partner to receive a list of eligible veterans, design and produce a card and put it out with a personalized letter from the secretary and stand up a Contact Center to handle the calls coming in. After two weeks of design and hiring and training of 850 people. No one went into threehour waits. Phones were answered, but the work and only begun. We have been on a pathway sense to try to secure the operation. There is additional refinements that may well be needed and desired command if so we stand prepared to support what they might look like. There are there are other changes that may well be needed to the program as we go forward. Secondly, we need to aggressively identify and resolve gaps and fix Operational Performance command we are in the process of doing that together. Dot modernizing it systems after a 247 build a new system that will serve all facilities and our own staff as we seek to move the veteran information back and forth between facilities as care is rendered and we are in the process of tailoring networks to match the demand that exists in each market across our area. The program is up Operational Command there are refinements needed. I believe that because of the collaborative work that has been underway between all of us engaged in this we are refining the pieces that need to be refined identifying policy gaps and those things, as the secretary said, are getting attended to. There are a there are a couple of policy issues that remain the jurisdiction of this particular committee. I encourage a relook at the 60 day authorization limitation that has been applied. Secondly,. Secondly, i respectively submit that there needs to be harmonization between the two programs and between all of the facets of how the va buys its care currently as well as how the va operates itself in engagement with us at the end of the day i believe the art of the possible is truly within our grasp. I would like to. To dallas texas a couple of weeks ago we sat with the director and entire staff and looked at the full demand that exists for veterans in that market. We then we then took out and looked at the network constructed to stand aside. If there is not a Network Provider you can set up in engagement with an individual provider to deliver services under choice and then designed a network map and over the next 90 days from Behavioral Health to primary care to Specialty Care we will rack and stacked the network to meet the demands that otherwise cannot be met by the va Medical Center in dallas. That is being repeated across our entire 28 state area and the pacific as we seek to do our part to mature the operations of choice. It is a privilege to serve in support of those who serve this country, an honor to serve the veterans from the states represented by half the members of this committee, and i would forward to taking questions after my colleague is finished with the remarks. Thank you. I appreciate the opportunity to testify on the administration of the veterans Choice Program. One of the longestserving administrators. Dedicated dedicated to ensuring nations veterans have prompt access to needed healthCare Services and believe there is Great Potential to help va deliver timely, coordinated, and quality care. Awarded care. Awarded a contract for three to six regions. We implemented pc three. At the beginning of april 2014. In october after Congress Passed and the president signed the veterans access choice and accountability act we amended our contract includes several components. With less than a month we literally hit the deck running and have not slowed down sense. To meet the required start date we work closely to develop an aggressive implementation schedule and timeline. The ambitious schedule required us to hire and train staff quickly and to reconfigure our systems. Despite this aggressive implementation schedule for veterans started to receive their choice and were able to follow in calling to speak directly with a Customer Service representative about the questions or to request an appointment for services. Having said that there are challenges that have resulted in veteran frustration as well as on the part of va and our own staff including call centers with such an aggressive schedule there is little time to finalize process loads and make system changes. We we literally had less than one week from the date we signed to the actual go live date. The collaboration has been good but there is still considerable work that must be done. The program is operating smoothly and the veteran experiences consistent and gratifying. We appreciate the opportunity to offer our thoughts. It is a knew program. There are a number of policy and process decisions and issues that are either unresolved for undocumented. If it is to succeed, these items must be addressed quickly. We have been working closely to address these issues. Many items simply could not have been anticipated. Others should have been addressed before the program started but the implementation timeline did not provide adequate time to do so. The identification policy and operational issues and concerns as a result we are to keep up with development and adequately train our staff. The situation is not ideal. Based upon these dynamics we have one overall recommendation. We recommend a comprehensive coordinated operation strategy that clearly defines program requirements. The strategy should provide a clear roadmap for all of us to follow one that is communicated. Va leadership medical leadership and staff contractors, congress, and veterans. The strategy needs to identify key initiatives and timelines and needs to contain flexibility to address issues as they arise and make necessary course corrections. The strategy must improve process issues development of policy and operational guides mandated across the program, comprehensive training using consistent process loads operational guides command scripting. A clear and responsive process. I would like to thank the committee for its leadership we believe there is Great Potential for the program to help va deliver care to veterans and are committed to cooperating to ensure the program succeeds working together where confident. Thank you and i look forward to your questions. Thank you very much. I had all of these preplanned questions. It was quick, so i want to make sure i got it. You are encouraging the authorization of what . The limitation on 60 days for authorized care. It puts people who have cancer in a position where we need to move them back and forth. It takes a person who might be with us under choice and does the same command i do not think that was intended. I think it was intentional that there were parameters drafted, but the notion that certain types of care would have to move back and forth is not neither efficient or effective. I dont want to spend too much time on this but this is important i think. Tell me you want to expand that to a longer timeframe. I would leave it to the clinicians. I got it. What i would do is evaluate which types of care either needed authorization is that would last more than 60 days in other words what you are saying is the limitation causes things for that patient to have to go back and forth because of the limitation. The administrative process requires us to go back and forth in support of that veteran when it is probably unnecessary is what i would submit. [inaudible] yes, sir. Is there any reason we cannot fix that . We will work on it and come back with a proposal. Just listening it seems like it would be more Cost Effective to fix it rather than go back and forth. There has got to be money involved every time. There is a fee a fee for each authorization, but the bigger concern is the potential disruption. Always less expensive and that is more efficient. I efficient. I appreciate you raising that in your testimony. You are welcome. Do you have any credit cards . [laughter] i dont want them. I just want to know if you have them. You have the right to remain silent. Am trying to think. Do you get the annual mailing out the required notification of security about four pages long and the print is so small. It goes right in therecycling bin. In your testimony i heard a clear statement that we need to simplify and coordinate the instructions rules, and processes. Thats right, mr. Chairman. I think as i said everything has been moving quickly. As a result there are number of things that maybe of not been addressed as completely as ideally we would all like to see and it makes it difficult. It is hard for us. You are talking about Call Center Representatives trying to and clerks trying to keep up with the development and somehow we have to find a way to make it easy for not us that the people working closely with veterans to make the program work. They need to understand it. A little bit further. The veteran needs to understand. All of the stuff i did as a businessman we serve people with College Degrees but wrote everything that an 8th grade level. That is the way you communicate to the majority of the american people. Some of these things i read. [laughter] you read all of these things your not supposed to do. So long and cumbersome. I do not do the right thing sometimes. That can be our veterans as well. I hope you would Work Together to find ways to simplify the communication mechanism to the beneficiary, which is the veteran and the provider, which is the local provider. I no it is complicated. Sometimes out of fear we cover so much that we do not accomplish the goal. I appreciate you raising that testimony in my last question will be of sloan. You talking about you wanted more flexibility. Yes, sir. Put some meat on that poem. At the top of the list is flexibility around the determination of hardship for veterans to be able to have access to choice care. The way the law is written it is restricted to geographic barriers i believe is the language that is in the bill. We want to open that aperture giving us more flexibility to extend care. Open that to be a type of illness. A type of illness distance. There could be an instance where veteran delivers lives within 40 miles of the center that does not deliver the care. I will interrupt you, and i apologize. You want the ability to exercise judgment. Yes, sir. The chance to exercise judgment in terms of the 60 day authorization. Yes, sir. There ought to be ways we can accomplish those things. Yes, sir. Excited about that answer whatever the case. I recognize your flexibility sounds to be more Cost Effective and less expensive it probably raises cost questions but in the end were got to remember the person we want to serve as the veteran. Yes, sir. Thank you, mr. Chairman. Let me say that you will be asked shortly by senator sanders urging that he uses authority to break patents on hepatitis c medication for the treatment of veterans. I strongly urge you consider using your authority to take that action that will make this medication more widely available to veterans who need and deserve especially the research that undertook this initiative and successfully reach the result. I want to focus for the moment on the va proposal to Fund Construction cost at the denver facility specifically the one billiondollar cost overrun out of the Choice Program provision for long deferred maintenance and facility capacity issues. These funds were specifically designated and intended by congress to improve Veterans Health care veterans in my state who are aware of this proposal are absolutely outraged that their healthcare specifically the primary care upgrade would be indefinitely deferred because of one billiondollar cost overruns and aurora colorado. I suspect the same reaction will be felt equally deeply by veterans at the more than 220 other facilities whose healthcare will be compromised as a result of the proposed redesignation. I would like assurance from you since we are talking about choice Program Funds that you are considering alternatives to that action. Senator we sent a letter earlier today to this committee, to the House Committee command the Appropriations Committee requesting the increase in authorization to complete that facility as well as requesting the use of 700 30 million of those 5 billion to be used to complete the denver facility i want to interrupt you because and i apologize. For me that alternative is a nonstarter. It is just unacceptable command i expressed that i expressed that view to appropriate administration officials. I realize youre doing a hand youre dealt. I am urging you to consider alternatives. There are alternatives responsible and available alternatives that do not involve deferring healthcare improvement through construction at those facilities across the country whether in connecticut or georgia montana or louisiana of vermont and all the other states represented on this committee as well as many youre not. Sen. , senator, in years past i would tell you it is likely that fda had gone looking for that type of money there is a good chance we could have found it. Because of the work we have been doing over the past year to make hepatitis c care available to veterans under the circumstances we dont have 700 million sitting on the sidelines. There are no easy answers. I am not asking you to find a billion dollars but this nation is capable of doing better for its veterans. A supplemental appropriation for example might be an alternative. I am asking you to go back to the drawing board and use different pencils not necessarily sharpened pencil, but different alternatives to compensate for the absolutely unacceptable cost overruns and delays in aurora. The project should be completed but not at the sacrifice of healthcare for other veterans around the country. What i say to you today is not personal to you were secretary mcdonald command we have talked at great length about this issue. We have visited that facility together along with the chairman command i have seen that vast halting shell of the campus that is a mockery of government contracts. We need to address this situation to complete the project but it cannot be done at the sacrifice of other veterans. My time has expired. I apologize for interrupting you and i think the witnesses for being here today. I i would not ordinarily do this, but in light of the question raised and for the benefit of us to know i think we all have an obligation to ourselves to make suggestions on what we do, the cost overruns. Everyone on the committee command i have taken a couple of actions. A meeting tomorrow. Democrats and Republican Leaders come together. I hope the i hope the va people are back in their office saying what are we going to do. I have ordered gal to do a study of Surplus Property to try to raise money to go to veterans choice. You are dealing with a situation where you have until about may the 20th. We need to get at least until july 15. We have a way to do that. It only gives us time to determine how close it is we need. There are going to have to have interim bridges which i am working on but if everyone on the committee would think outside the box if it was your problem and you inherited a 700 million shortfall where would you go looking . I once loan to revisit the two places i mentioned because it seems like if we will take you out of the construction business, that we will happen to a major extent. There will be savings. And also and also look at the 77 ftes you are asking for an increase. Maybe they are not as necessary is helping to build that hospital in denver. If everyone is making a contribution despite that movie the american president we need to get the yellow pad out and work on solutions and find a way to do it. It is a nonstarter. I agree that it is not the right way and i apologize for injecting that. And i want to thank the chairman. He and i have worked together. I am not speaking for the chairman obviously but i have alternative suggestions as well. I have no pride of authorship in meeting the needs of completing the facility but doing it without sacrificing other projects and i will have specific ideas and puzzles. My apologies to the members of the community and i turn to senator murray and. Thank you. Your comments and connecting this hearing. I hope to ask a series of questions. I want to start with a story i have told before about a vietnam veteran named larry. He lived in florida and indicates that he is a vietnam veteran, a navy veteran indicates violent florida he received excellent care moved to rural kansas, became my constituent, lives about 25 miles from sealock and three hours from a hospital. I started the story or the story began in july of 2014 when larry, this vietnam veteran needed a cortisone shot. The va instructions were come to wichita. We raised this topic with secretary mcdonald hearing on september the 9th. Larry contacted us and said i dont care how it comes. We raised this topic with the secretary in september of last year. Shortly thereafter the director in kansas city took this issue to heart and has solved the problem temporarily. In december he was granted an appointment. I should say it does not offer cortisone shots, but he got care and the private sector. The dr. Who treated him then asked to treat him again and to follow up. The va denied that request and send them back to wichita. They denied the request because he was not eligible for choice. So he is back to wichita. Ultimately he then needed a colonoscopy same series of events. The outpatient public does not provide colonoscopies command he is trapped in the system of no one telling him what he can do. He has gone to wichita but recently last week he received a letter from the va approving and for choice. He then calls try west. Try west says, you are not eligible. But i got this letter. He indicates he talked to four different operators come all who gave him a different answer than the three others. He called the 866 number and was told he was not eligible to my got the four different answers and now were back to the question what happens to larry. Even from the beginning if he was not eligible and even if he is not eligible because the sealock is there why is someone not at try west or the va telling him we have these other authorities that would work for you as compared to just leaving them hanging. I doubt very is the only veteran experiencing this circumstance. I doubt that the problem is unique. I suspect there are other veterans with similar experiences. As i described in my opening statement, we are asking for additional flexibility which would give us more authority to be able to handle that kind of situation. We handle we actually handle many situations through other va care in the committee routinely which is why we have incurred so much expense on a yeartodate basis, but we find ourselves running out of resources in order to be able to sustain that. So we wind up making sub optimal decisions. Given two great examples the chairman asked whether or not we would be using judgment. The answer is yes but for someone with a routine requirement there is no reason the travel hundred and 50 miles. That is something that ought to be done locally. For the veteran that has to get a colonoscopy, im not going to drive hundred and 50 miles to get a colonoscopy. That is Something Else that must be provided. If a veteran needed a Knee Replacement i might say, okay, under the circumstances make the trip, but for therapy that must follow up, i do not want the veteran traveling 150 miles each time for physical therapy. The challenge we have is 40 miles from where you get the care. We keep running the numbers command the tab is renders. We have got to find a way to manage this in such a way that we are doing the right thing for veterans and at the same time being the best stewards we can of the taxpayer dollars. We had a number of conversations on this topic. I would argue i would argue given the chance, but i want today about whether or not how the 40 miles should be interpreted. The uncertainty and the burden lying in the wrong place. It ought to lie with the live with the va or try west. My 2nd. Is that if you have other authorities, whether or not he qualifies ought not matter in the answer he gets. I agree completely. Thank you. Senator kindly yielding to me. The gentleman that has to run out the door. Thank you. And thank you for the work you have been doing and maintaining the bipartisan spirit of this committee. I want to make two points. I want to thank sloan gibson for the impressive work that they are doing. I understand how easy it is to beat up on the va. 151 Medical Centers, 900 see box, problem everyday but in a nation with a dysfunctional Healthcare System the private sector also has one or two problems we should recognize that when you talk to the major veterans organizations American Legion you know what they say . And you have heard this this, when people walk in the quality of care that they get is pretty good. I want to thank you for trying to improve that care. I will fight vigorously those want to privatize. Our goal is to strengthen be creative in terms of using the knew program that we have developed so that people can get care locally. I will oppose efforts to privatize the va. I wanted to get to another issue. The senator touched upon it. I wrote a i wrote a letter to secretary mcdonald about an issue that has concerned me for a while the high cost of the drugs of all the which is a very a miracle drug so to speak treating the veterans of our country who have high rates of habitat is see. Mr. Chairman, to me it is an outrage that you have a companys profits have soared revenues have doubled. They have come up with the drug charging the general public a thousand dollars a pill, charging the va Something Like 540. No. No comment. But that is because the va negotiate strike prices. But you are but you are running out of money and we have several hundred thousand veterans suffering with hepatitis c which can be fatal without money to treat them. Frankly, it is time to talk to the manufacturer and basically ask them if they are currently being generous in providing these drugs hepatitis c drugs for free. Very generous. But maybe at a time when profits are soaring they might want to respect veterans of this country who might die or become sick because they do not have access to this wonderful product. As the senator mentioned if they are not prepared to come to the table, and i no you think you have done well i am not impressed. So i would you sit down again and tell them you up. To utilize federal law to break the patents on these drugs unless they are prepared to come down significantly lower than they are now. It is not a question of taking money. Maybe that is is a good idea, but it is a better idea to have them treat veterans with respect and charge a reasonable price rather than ripping off the va. [inaudible conversations] turn that clock on when they start talking. Thank you, mr. Chairman. I appreciate your work and the Ranking Members work. I agree that it should not come out of the Choice Program. Mr. Gibson, i was looking back at the notes i have taken. You gave encouraging notes with regard to statistics about the areas of the country with regard to additional care being provided which is encouraging. Do you believe they are consistent across the country . Are you finding evidence . Actually, i always worry when people quote averages to me. What you find is wide disparity across the country in terms of the length of wait times and therefore in terms of the specific areas where we are making the most intensive investments. What i would tell you is where we have been making consequential investment you consistently see a material improvement in access measured by completed appointments, growth and relative value units, but what we are not seeing consistently is material improvement in wait time. You look behind that and realize what is happening is as we improve access to care are more veterans are coming or veterans that are already there are making additional utilization of va care. It sounds like the va should be making the decision about whether or not they are delivering the care or whether veterans should he making that decision. It sounds to me like maybe we should take the other approach and say if we gave that toys to the veterans i would suspect that a number of them who have very great care of being delivered might very well might want to continue that out. But there are others that would suspect that would say i dont expect you to build a new hospital near me. You have looked at asking for the ability to have flexibility to make that choice. What happened if we took it as an alternative and once again we are talking about dollars and cents. What if we let them decide for themselves whether they want to have cured through a va facility or utilizing the Choice Program more fully and skip all of the extra stuff that you have talked about or whether or not they have already had care and now they have to go back in after 60 days. It is still the va making the decision. Im sure that this is not a new thought. So explain your logic in terms of not allowing them to make that choice than elves. We have spent a great deal of time talking about this. One of the things for us to keep in mind is that 81 of the veterans we provide care for have Medicare Medicaid or some form of private Health Insurance. Oftentimes what you see today, you mention this fact earlier that the veterans have given the option for toys and somewhat elect to stay in and that is precisely what happens today. Roughly half of 40 to 50 depending on whos the survey you are listening to. I would tell you my perspective part of those are deciding to stay because they are getting great care and they enjoy the camaraderie with other veterans, they have continuity of care because they have been receiving care for a long time and others come there because they have an economic and others come there. So they have 20 copay for a procedure and you look at that colonoscopy or whatever it happens to be where the Knee Replacement which is an example that we use oftentimes in the veterans can go get it with medicare but he is going to wind up with a 7500dollar bill that he has to foot. Part of the answer comes and its one of the options that we have talked about is that we step back and we look at some of the economic distortion. So what other providers become the primary payer and the va then defines a veteran against a 20 copay. Then you really are providing the veteran with choice. And they dont wind up paying twice for the same care. So this isnt about protecting their turf, all we are about doing is being good stewards of taxpayer resources. Where ever that leaves us thats where we are. Thank you sir. Thank you very much. Take you all for being here today and let me just say that the va has had a lot of problems as you have all talked about. Some of you have been there longer than others and some of you have had private sector. I have problems like every other state and nobody has problems like colorado has with what is happening there. But let me just say that i need to get this on record and i have a situation, i dont know if its been brought to your attention and its gone far up the ladder. Last month the office of special counsel talked about switching antipsychotic drugs based solely on cost. The providers say this is what the veterans need and they made an executive decision. And i was told there is a new policy in place dispensing these drugs and we have not been able to obtain a copy of that. At the time im also told that there is a wallop investigation into the matter and we havent heard much about that. At the same clinic which operates it has been close three times because of quality and i have a horrendous time because we are trying to get our veterans the care that they need. If you could give you an me an answer back as quickly as you can. I believe that once referred to here is oftentimes routinely when the office of special counsel has a finding that substantiate the whistleblower allegation we have positions that really bored out and determine exactly what happened and where the accountability was an oftentimes that is part of it. It has been there and i have been trying to get an answer back. We will do that, sir. Really believe that everything that we have talked about here my generation having tremendous need. That being said do you believe this you come from the private sector. Okay, already. Those that have more public and more private would understand. You believe that we give better care to our veterans and i mean that in the case of quality of care in the time and the cost. And im not saying that we are going to shut the va down. Dont think we are going to build everything else. I would tell you that we do not believe that that is the case. If you look at the typical veteran that we provide care for they are older and sicker and poorer, we have a highly Fragmented Health Care in america and that is precisely the person that i dont think there is the best one turned into that system. If you go talk to veterans to a large number of veterans consistently what you are going to hear is are there instances where they had to wait too long for care or are we have made a mistake. Yes, there are 55 million outpatient appointments. We used alaska and how they were given so much better quality of care and quicker. And they dont even have a va hospital. If i might, i know alaska a fair bit. And i would offer the following. I think that the real question at the end of the day is which things are fundamentally done best by the va directly in which things have enough demand where it justifies building it and which things should be supplemented by the private sector because its either not enough demand for where it makes sense to spread this applies simply because of the amount of resource and that is needed to deliver services and i think the band has always been true and i think that that is true in the dod system and that is why you see tricare constructed the way that it is. Alaska has destroyed facility most of the footprint tends to be public in the dod through the Indian Health service or private. Its those two pieces working together that are ultimately going to deliver what needs to be done. The drug dispensary to our veterans is almost criminal. Without proper guidance, you look at the high unemployment rates in our veterans and you look towards drug addiction. We have to do something. Because drug abuse is one of the biggest killers that we have. Our military and our veterans is absolutely off the charts. We are putting a drug, Prescription Drug abuse caucus together democrats and republicans working together. We agree with you and we recognize it as a National Problem and it is a problem inside the va. Its a problem it in the general society. Thank you, senator. Thank you mr. Chair, thank you all for being here. Just a couple of things and one is based on a comment earlier about some in the senate that are thinking that we should privatize this. I have not had a serious single discussion with anyone that has seen that in that way and if anyone here dead, all they need to do is spend some time to understand the unique nature of what they have to offer. There is no other more welcoming place in the va. Not that there arent opportunities for private care there really are already. The nonva care is already a big part of what you do long before choices implemented and so you know i realize in these Committee Meetings sometimes our words carry more weight than they should but i dont think anyone should leave this Committee Meeting thinking that anyone has any serious goal or objective to privatize the entire va. Going back to the point that the senator mentioned and i also have concerns about the denver hospital and i completely understand your predicament is you have to have a way to build it up. Can you give me an idea about what the thought process was. And so what would that cause in terms of delay or ramping down what we would be doing with choice over the time that that money would not be available . In identifying the nonrecurring maintenance and Construction Projects we had a Capital Planning process it actually builds a prioritized list of his years long based upon the pace of funding that we normally expect to give. So when we look at the 5 billion in funds we basically have reached into that list and pulled a segment out to put into that priority bucket. You know, what happens now is a substantial portion if we were permitted to do this, it would wind up in the 2017 budget because theyve been that would fall back into the prioritized piece. That is why i was asking the question because you could infer from some of the discussion that there was a 700 milliondollar hit the care nothing provided versus taking a look at how that was going to return out of the Choice Program and that is how i was asking. It sounds like theres leveling assumptions. That is exactly right, the movement has been that we would work it back to the funding stream as quickly as we could. I think that in order for what you have requested in a letter that you have and to to have any prayer of serious consideration, you need to map out hollywood have assurances that it doesnt materially affect it because of the way that you would plan to spend that money anyway. Thank you for raising the issue is. Otherwise i would tend to go back to the well articulated position of the Ranking Member. The other question that i have and the thing that i think is important is that we need to get a fiveyear or tenure or twentyyear picture of what choice care and that its critically important for you going back and relooking at the Capital Improvement trying to figure out how to do it, the answer is going to be different depending on where you are. The senator will rightly say that they have a higher per capita veterans population i have one that exceeds the population of several states. This would be necessarily different and the nonva care and the choice would be necessarily different but we have to come up with that longterm visit and based on what it appears to be the interest of the senate to continue down that multipronged path so that you are taking pressure off of capital arm and in some areas and maybe redoubling them in some areas and that the variant one thing this Committee Meets to see and then we need to be very specific about what we want beyond rick and mortar presence in the form of nonva care to get this right. If i could make two quick observations, your absolute spot on. First of all, we have is ourselves to make certain decisions on what can be made for the community. We have talked before my example of the chairman remembers optometry. Why would we send a veteran to get his eyes checked and classes. Why would we not be routinely referring to that unless a veteran really wanted to come to the va. The other issue that were trying to get at what we are learning what we are saying is that every time demand changes in part of what were trying to understand when you look in phoenix where we know that we are under penetrated and the veteran market and improve access to care and we get a disproportionate response and we have to understand that the penetration phenomenon will affect the Capital Planning and i will talk with the folks about getting beyond that, looking over the horizon. We cant keep incrementally doing this because were just where to stay behind and we are going to get ahead of this. Thank you, mr. Terry. Tank you, senator. There is a shorter personnel in the testimony and a noted that youre going to be creating his residency positions in this is a matter that i have discussed with the va person in hawaii. And its more likely that the folks will be able to practice in the state. So how will these residencies allocated by capacity are there any increasing for medical students of hawaii raiment. I dont have a list with me today specifically aware this is going. Have you determined where this is a matter. That is a multitier type of plan to deploy the 1500. The first round of those started this fiscal year and we actually went out, i frankly i did not think that our office would be able to do it but they went out and they sought applications and there are very specific criteria and a lot about them going to under resourced communities, they went out and saw those and we have awarded several hundred for this first round this year. Not as many as we had had thought maybe but more than we anticipated they would be able to award and specifically where they are as well. Hawaii has a lot of rural areas that are underserved with by the va. And we thank you for the information. Looking at the request to pay for the facility and its very difficult for us to accept that you want to take money from the Choice Program to do that. So i would like to ask you this. When a veteran goes to the va to get care for a nonservice can read matter in this veteran has private insurance, do you have the authority to get reimbursed from the private Insurance Company for the care that the va provides . As it goes we will build them and collect to offset the cost of the care that we provided. Under choice we are actually the secondary payers and under the Choice Program with the way the law was written to patient has commercial insurance, the commercial insurance is the primary payer. And then we will make the provider up to the medicare rate. My understanding is that in the first instance are the veterans goes to the va and gets the treatment, often there is no reimbursement from his or her private Insurance Company. Are you telling me otherwise . We will build a private Insurance Company if the patient has insurance. Do they reimburse you . Yes we get paid from them. A lot of the patients have insurance and have medigap insurance. Oftentimes they will not pay for this because of this gap coverage. Oftentimes he will not get paid by those insurers. Your reassuring me that they go after every dime from the private insurance . I can assure you that we go after every dime we can collect which is about 3 billion per year. Or western about the outreach and the program, there is confusion out there and whether you find the veterans that have all five. My question goes to order the outreach efforts and you think you are succeeding in explaining the Choice Program and also to have Community Providers to get training on how to explain the program. Know who the people are that are eligible to get a choice card and we mailed a letter to everyone of those people in the program started in november. Many found it confusing. Hopefully it is a lot simpler to understand we have actually tested that with veterans for we put it in the envelope. We have made a lot of phone calls and theres no question that i think that we can do more to be able to reach the veterans through website and mobile technology and mailings and other forms of communication and we need to do a better job of educating. We do need to do of her job. One of the things that we have to remind ourselves of is that there is no parallel to this its not like an insurance card where you walk into your Doctors Office and present your insurance card, there is no frame of reference for people to understand how it works. Why have a benefit, do i not have a benefit its hard for us to explain was why we have to keep trying. We would love that. Thank you. Thank you mr. Chairman. Briefly i would like to ask a question. I understand that the thirdparty administrators raised the issue of how much clinical documentation is being sent by the va many due to having a wait time of 30 days which presumably is overwhelming and you now have a Pilot Program to only send the clinical information and i guess the question is is it proving successful and also if you would like to comment from your standpoint as what is going on. When we first set up the program we gave every patient in the system an appointment and put them on the choice list so that they could decide at any point in time which direction they wanted to go. We have learned to experience over the last months this but it doesnt always work. It doesnt help the veteran rs quite frankly its not Cost Effective. So we have the pilots and we have just learned this to see how it goes and how it can improve the business processes. A quite agree we are moving in the direction that the point of service finding out what we can provide or offering them the opportunity to go outside to the choice of ram if they choose to go up and our staff much like they do outside of choice for all of our other appointments, we worked directly to get that part of the Choice Program. At that time we hope we have learned how to do this smarter and better so that we will greatly reduce the volume of people that we are referring to and are only providing medical record documentations for the patients who choose to go outside of the system. That sounds excellent. Is a very good idea and eating at the table in the initial design and we are getting ready to launch we had two days to make a decision. The question was heavy make sure that all the right informations and place to be able to serve people on the front and. The back and consequences are obvious and making the change makes a lot of sense and were looking forward to supporting it. This has been going exceptionally well in our area and we just approved is a dual to move forward with this across all of the regions and we are getting this in less than 24 hours and its very effective. It is kind of a rocky road as youre working through these things but it sounds like this is encouraging. Thank you, mr. Chairman. Senator, just because you have a very good Committee Meeting here. We thank you. And thank you for your work. And quite frankly i dont know where to start, you guys do a good job in the private sector does a good job dont think that the pirates sector doesnt have their fallibility is just like you guys are. And in the bookkeeping nightmare that could come with this, i lived 50 miles and my nearest hospital is 12 miles away. And its staffed by a nurse practitioner. So the question becomes is that somewhere you want to go to heaven of them in and if i dont, guess where the nearest hospital is. And the bookkeeping here is just amazing and i just i know that we are trying to do the right thing and that you are trying to do the right thing, people are mad because they think it is the wrong thing. But you talked about the 40 mouthing as far as not offering service. You talked about how it doesnt make any sense of the guy has no glasses, why should them halfway across the country. When you did your analysis did you include the savings that would occur to the va by not shipping them a long way away rematch because i think thats really important. If i was a veteran i probably wouldve signed up for just this benefit. But the truth is that if youre talking about what it costs, its also a savings just in mileage alone. Did you include that in the overall net dollar figure . We actually do not we have worked through several options with what it might look like. We have not taken into account a great many savings. In the short run we were modeling this. In the short run our structure is 90 of costs are fixed. Mostly the rest of the of the structure and the building dont go away. The mileage is also not a fixed cost. If you have to put them up in a room that is not a fixed cost. There are two aspects of the travel under is the true cost savings and there is the cost avoided and that is not a real savings, that is a cost that you did not realize. Correct. Come on, that sounds like that out there. Truthfully. I mean the fact is that if you are doing the actual cost analysis and you wouldve spent the money, you have to include that in the savings. By no means do i think this, but truthfully if we are going to deal with honest figures this has to be included. Clearly it does have to be included. Even if the level of analysis is better than what we had initially lay down to the individual patient and we havent picked up some of those incidents. It changes the nature of it. Its wrapped up in that and it needs to be a nearterm exercise. With steel with that because i think its confusing right now. I think there is a little manipulation going on. And if i might one of the issues i was attempting to address is the fact that we built a network in our area that has 100,000 providers. The requirements are more extensive than those under choice. If you are participating providers. Those things need to be blended together so that we dont have disincentive to participate in one program versus another. Fair enough. And the reimbursement rates need to be the same. 700 million transferred 400 million. I dont have a problem with that by the way. The questions i have is this is a miracle drug. When you anticipate those costs to flatten out so you arent going to need those kinds of dollars . I think the conversation that needs to be held at this House Committee and the appropriators has to do with the requirement that we managed great i would tell you our thought, the vas thought is we should be talking about a requirement where veterans that are hep c positively manage that number two functional zero by the end of 2018. That is what i think the requirement should the. So what we need to do with step back from that and lay out a plan that says this is what would be required in order to manage that requirement so we are not backandforth. The first time we deny a veteran access to treatment to his hep c positive because he doesnt have advanced Liver Disease everybody thinks we are depriving a veteran of care. We need to Reach Agreement on what the requirement is. One last question. You talked about residency slots and i think that is great and i would support it but i believe residencies or three years. It depends on what the specialty is. What about for internists . Three years. And that is what we are short on right . The question i have is this place changes every two years and to have three years in a residency you have to have the money for that residency. Talk to me about how this works because you have forward funding but you dont have forward funding for three years. So what do you do if congress does something irresponsible. That has been known to happen a time or two. I think this is one of our concerns. When we started new residency slot all of those slots have to be funded for the duration. That is not the case today. Thats important to know as we move forward. And when he are going to start the Residency Program . And will it start this fiscal year . We actually dont own the residency slots. They are owned by the academic centers. We pay for trainees to offset their salary. Additional slots that we added started this academic. So this fiscal year. The Academic Year that will start this coming july. So this budget we are dealing with this. If your budget comes in short this may be a program that goes i doubt it because we have made commitments at this point. Thank you guys for your work. Appreciate your flexibility mr. Chairman pang. Thank you to all the members and thanks for i appreciate every time and effort very much. We will take a twominute break. We appreciate the collaborative working relationship mr. Chairman. Its the only way to do it. [inaudible conversations] [inaudible conversations] sydney it was a good first panel. I apologize to our second panel is that it took so long but the participation you were illustrating by the looks on your face im sure you enjoyed it too so thank you very much. The welcome back to the Senate Veterans affairs committee. Darren selnick advisor for concern veterans for america. Joseph violante director of disabled American Veterans mr. Bill rausch who is missing in action right now for awol. Political director for iraq and afghanistan veterans of america. Carlos field taste of the veterans of foreign wars and we welcome all of you and we will start with you mr. Butler. Chairman nye six and Ranking Member blumenthal and distinguished members of the committee on behalf of our National Commander michael hamm in the 2. 3 million members of the American Legion we thank you for this opportunity to testify regarding the American Legion steel of the progress of the veterans Choice Program. The American Legion supported the access to choice and accountability act of 2014 as a means of addressing emerging problems than the department of Veterans Affairs. V8 waits for medical care have reached an unacceptable level as veteran struggled to reset access to Timely Health care within the Va Health Care system. It was clear this with changes were needed to ensure that veterans have access to Health Canada timely matter. As a result the American Legion to charge by setting up Veterans Benefits centers in big and small cities across the country to assist veterans in need and their families as a result of the systemic scheduling crisis facing the va. The American Legion dbc charges work firsthand with veterans experiencing difficulty in obtaining health care are having difficulty in receiving their benefits. On november the fifth, 2014 va world of the Veterans Choice Card Program and after six months is clear the Program Fell Short of initial projections from cbo. According to the va metrics dated november 31, 2015 there were approximately 51,000 authorizations issued for nonva care since implementation of the program with about 49,000 appointment schedule. When you compare these numbers to the opera 8 million cards issued one would ask why to be a issue so many choice cards . Nevertheless the American Legion is optimistic that the recent rule change by eliminating the straightline rule and using the actual driving distance will allow more veterans access to health care under the chase Choice Program. The American Legion believes if va were to move forward with the rule change to include the va medical facility that can provide the needed medical care or Services Everyone would see increases in minimization and access to nonVa Health Care. The American Legion applauds the senate for unanimously reminding the department of Veterans Affairs they have the obligation to provide nonva care where they cannot offer the same treatment as one of its own facilities within the 40mile driving distance from the veterans homes. We now call upon the house to take up h. R. 572 the veterans access to Community Care act and ensured its swift passage. Lets get these bills to the president s desk and make sure we have taking care of our veterans. During a recent visit last month to examine the Health Care System in puerto rico the American Legion learned that the va staff had mistakenly telling veterans that no one on the island was eligible for health care and to the chase card program because there is no medical facility further than 40 miles from anywhere anyone lived. The American Legion is concerned that as a result of inadequate training there could the staff in Many Health Care facilities in vail to receive proper training of the result of bad indications and providing Incorrect Information to veterans. Recently the American Legion learned to be a contract required these thirdparty administrators to report daily choice metrics however these contracts have now expired in the tba are no longer required to report these daily metrics. The last report b. A. Provided was dated march 31, to 2015. The American Legion is concerned that since the tba is no longer required to provide these metrics va can lose track of the numbers. The American Legion calls on congress to require va to report these daily metrics throughout the duration of the contract or explain how they will continue to track this information. In fiscal year 2014 va spent over 7 billion on nonVa Health Care. Many of the nonva purchased care programs managed by Different Program officers and Va Central Office in some of these services are handled outside of processing systems. V8 current purchase models incorporate all of vas nonva care programs into a single integrated purchased care model. Congress should look into streamlining nonva care statutory authority. One gets a better sense of how the Choice Program of play out over the next couple of years. V8 90 care statutory should be consolidated and rationalize incorporated Lessons Learned from the Va Choice Program. Thank you and again mr. Chairman Ranking Member blumenthal i appreciate the opportunity to present the American Legions views and look forward to the answers to questions you may have. We appreciate your willingness to follow up and come to all the hearings. Thank you roscoe. Darren selnick with concern veterans of america. Members of the committee i appreciate the opportunity to testify at todays hearing on implementation future of the present Choice Program and thank you for your leadership in ensuring veterans get the Quality Health care they deserve. Free Choice Health care remains remains like a moraitis in the desert move closer. The Choice Program is unsuccessful and longTerm Solutions. Current rules pertaining to choice not present real choice. They require veterans to obtain obtain prefer there will to make a choice. Instead they require veterans to to va. Veteran should not access permission to select health care provider. Be implementation against a Choice Program is that a failure. For example the associate press reported gao says Veterans Health care costs are highrisk for taxpayers the number of medical claimants to take longer than 90 days to complete his nearly doubled 37 medical claimants have been major at 11. Last fall cpa commissioned poll veterans. The results showed 90 favored efforts to reform Veterans Health care 88 said eligible veteran should be given a choice to receive medical care from any source they choose 77 said they want more choices involved in higher out of park it pocket costs. We choose a Health Care Insurance provider primary care physician. Health Care Organizations provide quality can be any care because if they dont they will lose their patience to summon up in order to fix the Va Health Care system both choice and competition must be injected into the system. Va recognizes the value it options for potential organization that put the veteran and control how when and where they observe. And enforcement veteran should not have the control and will not under the current Va Health Care system. Va needs to have a 2015 Health Care System but we believe the veterans roadmap and solution can do just that. This roadmap was developed by the Veterans Health care task force chaired by dr. Bill Frist Jim Marshall from a congressman from georgia the Manhattan Institute and dr. Mike bhas undersecretary could we develop 10 veterans or patrols a service for guiding foundation. These principles included the veteran Must Come First and not the va. Veteran should be it would choose where to get their health care focus on prior to tis Service Connected disabilities and specialized needs. Va should be improved and preserved. Current enrollees in bha needs of the company. Implement these principles we laid out three categories a reform in nine policy recommendations. First an independent government chartered nonprofit corporation. The power to make decisions on personnel i. T. Facilities partnerships and priorities. Second give veterans the option to see private Health Care Coverage with va funds. Third, refocus Veterans Health care of those with Service Connected injuries. Key policy recommendations including provider function to separate institutions established the Health Insurance program is a Program Office in bha. Establish Accountable Care organization the nonprofit Government Corporation separate from b. A. Preserve the traditional va Health Benefits for raleighs preferred and see coverage from private sector to three plan choices. Full access to the m. At grated grated integrated Health Care System Health Care Choice elected a private Health Care Insurance plan legally available in the state finance premium support payments and medicare veterans can you use their va funds to defray the cost of premiums and supplemental coverage. Lastly create an Implementation Commission to implement the independence that. Between the services the hsi to properly design policy recommendations likely to be deficitneutral. In order to fix the Veterans Health care we must i keep in mind general omar bradley said. We are dealing with veterans not procedures. With their problems not ours. This is why we are sure to use the veterans in the panasonic roadmap to fix and be the future Veterans Health care. Veterans must be sure they will be able to get the access choice and Quality Health care they deserve in this Mission Failure is not an option. We are committed to overcoming all obstacles to stand in the way of achieving this mission and the court to work and the chairman or Ranking Member and members of this committee to achieve this shared mission. Thank you. Thank you mr. Selnick. Let me just interject at this point. I have read and im sure richard s. Too the fixing Veterans Health care report that the organization did which is not standing report you think it is called ultimate choice if im not mistaken. With that mistaken. Without they could import . That would be a good name. In a representation of the changes are far more broadband some on the panel might look for us to do in terms of preserving what va does but i want to commend you on that and let you know we are watching what you have recommended and we are taking a look at it. Richard and i have one underlying principle. We are going to make veterans choice work and is not an option that my work and if it doesnt work and we will think of Something Else. How are works will take the best ideas and input and you are report is one that will help. This is going to be a process and evolution as we go through but one thing is for sure we are not just hoping its going to be over one day. We are going to make it happen one way or another. Iq. Mr. Sim six. Chairman isakson Ranking Member blumenthal members the committee on behalf of the va and the 1. 2 million members all of them are wounded injured or made ill from their Wartime Service thank you for the opportunity to testify on temporary Choice Program. While it is too early to reach a conclusion about this program we are beginning to see lessons. As of last week almost 64,000 choice authorizations have been made and 43,000 appointments have been scheduled. By comparison about 6 million appointments are completed monthly inside the egg and another 1. 3 million appointments completed outside va using nonva care programs other than choice. A number of reasons like to contribute to lower than expected utilization of the Choice Program. Since lets bring va has used every available resource to increase its capacity to provide timely care that may have shifted some of the demand away from choice. Ea was low in rolling out choice cards and in educating its staff. We also hear troubling reports of a significant lag time between when the va clinician determines the veteran is eligible for choice and a thirdparty administrator can see this authorization in their system. Finally some veterans refer to go to va. The bottom line is we do not have adequate information today and need to take steps to gather sufficient data before making any permanent changes greatly must study private sector wait times and access standards coordination of care, Patient Satisfaction and Health Outcomes to those who use the Choice Program. Mr. Chairman recently dav vfw the legion road to congressional leaders to extend the mandate of the commission on care to allow at least 12 months for its interim report and at least additional six months for the final report. He called on congress to refrain from taking any permanent systemic changes until after the commission submitted its recommendations and then allowed sufficient opportunity for stakeholders and congress to engage in a debate worthy of the men and women who serve. For more than 150 years going back to president lincolns solemn vow to care for him who shall have war and the battle the Va Health Care system has been an embodiment of our National Promise yet today some are proposing to make it just another choice among Health Care Providers while others are calling for the va to be downsized or eliminated. But for millions of veterans wounded injured or ill from their service there is only one choice for receiving a specialized care they need and that is a healthy and robust va. Although the va provides comprehensive medical care to more than 6 million veterans the vas primary mission is to meet the unique Specialized Health care needs of the nations 3. 8 million Service Connected disabled veterans. The va was downsized or eliminated it would the private Health Care System would be unable to provide timely access to the specialized care they require even if all disabled veterans were dispersed into private care there would only be 1. 5 of the total adult population. Does anyone truly believe that a marketbased civilian Health Care System would provide the focus and resources necessary for the small minority and the way va does. Mr. Chairman while far too soon to settle on how to reform the Va Health Care system and integrate nonva care we can at least outline a framework to rebuild, restructure realign and reforming the Va Health Care system. First rebuild and sustain the its capacity by recruiting hiring and retaining sufficient clinical staff and by funding a longterm strategy to repair and maintain va facilities. Second restructure the many nonva care programs into a single integrated extended care network which incorporates the best features of feebased pc3 and other purchase care programs and provide this program with a separate and guaranteed funding source. Third realign and expand the ehealth there are to meet the diverse needs of future generations of veterans including women veterans. This should include networking care nationwide with extended operating hours. Fourth a foreign va management by redesigning its performance and accountability report in restructuring its budget process by implementing a system which stands for planning programming budget and execution. Mr. Chairman this framework is not intended to be a final or detailed plan nor could it be part of one at this point but it offers a new pathway to a future that truly fulfills lincolns promise and that concludes my testimony. Id be happy to answer the questions. Thank you very much mr. Rausch. Chairman nye singson Ranking Member blumenthal Ranking Member blumenthal thank you for the opportunity to share these views with you at todays hearing. As has been drafted and it has final language being debated. Its a highly complex lob but the department is working hard to implement to ensure veterans are not left waiting for an acceptable length of time to receive health Care Services. My remarks will focus on the experiences of utilizing the va trace program. Members have reported to us by way of survey research. Ishmael provide recommendations to congress and the secretary must consider not to get the Program Operating at the height of its potential. These recommendations include legislative clarification of the Eligibility Criteria for access in the Choice Program, strengthening trading guidelines for va schedules charged with explaining criteria to veterans and continued active engagement with veterans organizations to broadly identified the conference of strategy and plan for delivering nonva care in the community moving forward. In examining the current criteria for determining which veterans are eligible to use the Choice Program those who must wait longer than 30 days for employment and those who have more than 40 miles to the va medical cysts facility more clarity is required to veterans are all to bring the reporting they are unsure of their eligible for choice and va has been inconsistent in communicating whether veteran can access in individual cases. Based on her most recent survey data over one third of our members have reported they dont know how to access the Choice Program. This is compounded by reports by in some cases be a schedules are not explaining eligibility for choice. The secretary and lucia must continue to engage scheduling personnel of ongoing evolving trading standards so an im veterans call the va they receive consistent and clear understanding of their eligibility for the Choice Program. The va has improved in this area but with so many veterans confused about eligibility training criteria must be strengthened and maintain. Congress should aid in the apartment implementation by clarifying bob at the 40mile criteria must relate specifically to the va facility in which the needed medical care will be provided. This frustrating example that continues to surface is specialized care to va facility outside the 40 miles but through strict interpretation of their current is ineligible because of facilities may be geographically and they veterans address. One of our members illustrated this recently by saying quote because there is a city block in my area i was tonight. The clinic doesnt provide the treatment need for my primary Service Connected disability. The nearest Medical Center in my network is 153 miles away and quote. Congress must provide needed clarity and work with va and it sounds like you are too limine cases like those described. Thereve been encouraging developments relating to implementation of the Choice Program specifically vas actions to step up and fix the effectiveness of the 40mile rule calculations related to the driving distance. That revelatory correction was much needed and as a result there are hundreds of thousands of new veterans eligible for the Choice Program. We applaud secretary of mcdonald and deputy secretary sloan gibson for their leadership in listening to their customers to make that change happen. The statistics on choice utilization among among veteran populations as of this months date thereve been 59,000 authorizations and nearly 47,000 appointees. This data verifies veterans are using the program and va has been making progress to implement a complex and important program. We are committed to remaining actively engaged with the veterans making use of the Choice Program so we can keep current on the veteran experience. We are mindful that thousands of appointments being conducted there will be thousands of unique experiences and we want to engage those levels of satisfaction with our members through this program. The satisfaction the cost of care purchased outside of va facilities in understanding issues come up will allow us to better realize that veterans book focused strategy and plan for nonva care in the can into forward. Appreciate the hard work of this congress the va and the veteran community and recognize its stay focused on improving veteran Health Care Delivery in the short and longterm. Robust discussion on the scope and cost of maintaining Health Care Networks is contemplated which is wireless recommendation is simple and something we have touched on before. We must continue to Work Together to keep communication active between all relevant stakeholders. Mr. Chairman we sincerely appreciate your committees hard work in this area and we wanted to know know we stand ready to assist this congress and their secretary to achieve the best results for the Choice Program now and future and we look forward to taking your questions. Thank you very much. Mr. Violante. Is that close enough . Chairman nye six and Ranking Member blumenthal the vfw and the artillery thank you for opportunity prisoner views on the Choice Program. Before they can i want to say the vfw opposes the vas change the way veterans choose to use the veterans Choice Program. The veterans must have the opportunity to explore their private sector options before rejecting the va appointments. This changes the bureaucratic convenience that will negatively affect identify new issues this Choice Program faces and recommending reasonable solutions. Yesterday we gave her a second report evaluating this program was made 13 recommendations on how to ensure the intended goal of expanding access to health care for americans veterans. Our initial report identified a gap between a the number of veterans who are eligible for the program and those who were given the opportunity to participate. Our second report has found that the va has made progress in addressing this gap. 35 of second survey participants who believe they are eligible were given the opportunity to participate. Thats a 16 increase for her initial survey. For 30day years participation hinges on va sche
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