Transcripts For CSPAN2 Senate Veterans Affairs Hearing On VA Community Care Program 20240712

Under Veterans Mission act, program of assistance to family caregivers. I scheduled this hearing because of my dissatisfaction with the pace. While officials were invited to discuss the critical programs they oversee, the department chose to decline that invitation. This committee and the va shared a common goal to pass the mission act in 2018 to better serve veterans and their families and we continue to Work Together to address important issues for our nations veterans. I would expect them to be here with this to share all theyve accomplished since the va was transformed with this legislation and discuss what needs to be done to make improvements. The va is an integral part of in dialog, which is why i planned a whole subsequent engagements with the va officials to discuss title 1 implementation. Id be remiss not to recognize the unprecedented challenges this have year due to the covid19 pandemic. The dedicated staff on the v as front line deserve our thanks for fulfilling the Fourth Mission however at a time when accessing health care is of utmost importance the va struggled to uphold the mission acts requirements of providing veterans access to Community Care. My staff and i continue to hear complaints from veterans and providers regarding poor communications, lapse of continuity of care and network inadequacy. Third party like tri west and optimum are for the Veterans Community care network. They play, you play an Important Role in building a robust and Community Care network thats able to provide veterans timely access to care and to make Certain Community procedure vieders receive prompt payment for the care and services they provide. When the va released stringent access standards for Community Care, i was encouraged to see more veterans would finally be able to access timely, quality care closer to home. However, once again, my staff and i have since learned that the vas contracts with Third Party Administrators use a completely different set of standards to determine how veterans access care. Under contract terms, rural and highly rural veterans could be forced to drive up to three hours for care which is totally unacceptable and contradicts the spirit of mission. Ive discussed this glaring inconsistency, but despite assurance rns publicly and privately its uncertain whether the va mod fight the terms of the contract. It appears that its possible for veterans to have a different access to care certainly than the law, the mission act requires, different than the regulations of the va, and perhaps different from visit to visit based on the contract terms of the third party contractors. We hope to learn more today. The Community Network is aimed at mission act to transform va care into responsive 21st Century Health care system capable of addressing the challenges veterans face today and access to the care veterans deserve under the law. As such i want to ensure that that mission act succeeds and mission of Community Care network is accurately accounted for because there are sufficient number of providers for veterans to utilize. Much mass changed since the Committee Held earlier this year. We remain commit today making certain that veterans who qualify for care in the community are able to get that care without unnecessarily scheduling delays through a mature and network that those providers are paid in timely manners. Congress has a responsibility to oversee vas execution of the law that governs the responsibility to serve veterans ai take and this Committee Takes the responsibility seriously. I believe that some of the va Senior Leaders may agree with me, while its underway it needs to move faster to serve as we envisioned. I want to know how the va is making progress working with Third Party Administrators to transform the va and offer veterans access to the health care they deserve. Another essential component of the mission act is the expansion and eligibility for program of comprehensive assistance for family carefwifrs caregivers. As veteran caregivers are for their loved ones, many can have stress associated with caring for a spouse or Family Member with a complex health care with a set of complex Health Care Needs is a real and present concern, concern for veteran caregivers. Its essential that the va support for caregivers these Mental Health challenges be addressed effectively. Mission outlined a twophased prospect with an anticipated start date of october 1st, 2018. For phase one. Phase one implementation only just began october 1 of this year. Two years behind schedule. This delayed rollout will result in caregivers needing to wait longer to be a part of the program. I look forward to testimony from everyone taking part in the hearing what you face in your work and steps that va can take steps to make sure these are functional and able to deliver good results and outcomes for veteran caregivers. I apologize my Opening Statement is longer than my issue practice, but i had sufficient desire to say a few things this morning as we begin this hearing and i now want to yield to the Ranking Member and author senator tester. Thank you, mr. Chairman. I want to have you for holding this and look forward to the panel of witnesses. I, like you, am very disappointed they have not chosen to be in this dialog. I dont know why something as important as implementation of the mission act doesnt rise to that importance in the va. Hopefully its not because theyre out campaigning across the country. The fact is, is this committee has serious issues with the administration on the implementation of the Va Mission Act and its important, its unfortunate the va couldnt be here to finding solutions for those programs. When congress creates programs to benefit their veterans and families, and its important to implementation and congress intended. Were not here as a nuisance, we do things and have expectations. So the executive branch sent folks here with the creation of the Va Mission Act, congress sought to provide better and greater options for Community Care when the department could not provide care in a timely manner or when veterans were forced to travel long distances to the va facilities. The latest data from the va, made 4. 1 referrals in the beginning of fiscal year 020 to june. Nationally, it took va nearly 22 days to Schedule Health Care Services after a request was made. Thats not acceptable. Thats a problem. Veterans should have shouldnt have to wait for the va to navigate a bureaucratic process before their appointments are scheduled. Then veterans wait an average of 20 days for their appointments after theyre scheduled. That doesnt work. That dog doesnt hunt. If the va was here find a way to reduce the red tape. They need to explain how to get down the number of days veterans get scheduled for care in the community and the last year, theres not been much improvement in this timeline. Rather than speaking with this broken process, the Administration Needs to find out a better path forward. I have a bill, the accountability and department of Veterans Affair scheduling consult Management Act passed out of Committee Last august. It would help the va to do just that. It would require the va to take a hard look at scheduling process and then report how long it takes to get through that process. It would also require scheduling honest and review of rating of physicians involved in scheduling because too often personnel leave these for better communities elsewhere. My bill would also help veterans make better informed decisions where they can get care because they would have the information they need to make those decisions. It would also help congress exercise oversight of va scheduling to make sure its working the way we intend. Another is the newly looked program. And caregivers many of whom waited for years for the same stipends for post 9 11 veterans and caregivers, im concerned the administration too narrowly wrote the rules. And tightened eligibility for the Current Program are not mission act driven and were undertaken solely by the administration in an effort to limit eligibility for the program and the veteran it impacts. Im concerned that the administration was in rush to meet a new selfimposed deadline after missing the mark for a while and prepared little time preparing stakeholders for when the program would go live causing confusion when it actually did. I do want to thank the Elizabeth Dole foundation for being here today to shed light on issues to make sure this program a functioning well for veterans and caregivers. With that, mr. Chairman, i want to thank you again for calling this important hearing. Senator tester, thank you. Now let me introduce our witnesses. Dave macintyre is the ceo. Trisha, the ceo of optimum. And steve is of the liz both Dole Foundation. And molly from the Elizabeth Dole foundation. And jenny, caregiver and liz bo both Elizabeth Dole foundation. Thank you for being here so we can understand your goals of meeting the needs of veterans of our country. Well now begin the hearing with our first witness, lieutenant general, youre now recognized for five minutes to deliver your testimony. Thank you for being here and thank you for the conversation we had nor nearly an hour on sunday evening. [inaudible] on behalf of the [inaudible] can you hear it now . Im sorry. Would you like me to start over . Do you want me to start over . Okay. Good. I had to dig deep into my military voice there, sorry. After 33 years of Uniformed Service the mission is personal to me and our entire organization, were veterans. My Leadership Team has a total of 350 years of service in uniform. Many of us or our Family Members received care from the Va Health System or the community. Since i last appeared before the committee across regions one two and three, our responsibility is to build and manage a high quality Provider Network. Were managing a network of 830,000 providers across 1. 6 million sites of care. We intentionally built a Large Network so veterans could have their choice from a wide variety of timely care options. To date the va has issued more than 1. 5 million referrals for care to our network connecting individual veterans with a high quality provider, one veteran at a time. 100 of our network is fully accredited and credentialed. In addition, as compared to the 15 benchmark set by the va, 54 of providers assessed are designated as high performing providers. The success of our Provider Network goes beyond the data. Underlying the data are hundreds of thousands of individual connections made between care providers and veterans. We understand that health care is local and the choice of a provider is personal. Our network is dynamic, highly reliable, and responds quickly to the needs on the ground. Recently, the leadership at the Lexington Va Medical Center expressed gratitude for our assistance in ensuring a veteran who is battling cancer could be treated by the same provider as his wife. We know that caring for our nations heroes is more than a contractor providing a claim. It means caring about the women and men who have worn the cloth of our nation and doing whatever it takes to help them heal. Every day we work side by side, to advance veterans care and review successes and address challenges and share best practices. These relationships are critical when the unexpected happens. This occurred in august when hurricane laura left 200,000 without water and a million without power in louisiana. Many hospitals were forced to close and my team jumped into action leveraging relationships with the louisiana hospital association. We ensured they had uptodate information on hospitals where they could safely serve veterans. Our network is not a national entity. Its a collection of regional care eco systems designed to be responsive and convenient to veterans. Working with each we have prioritized the credentialing of high quality providers with a history of serving veterans in the community. As a result, weve partnered with 92 of priority providers identified by the va. And 93 of academic affiliates including duke and the university of kansas and for the first time in the vas history, a provider care in the community, partnered with the va to bring the mayo clinic into the care network. While its a dynamic, our restlessness keeps our veterans at the center of everything we do. This year we learned that a veteran was matched with a lifesaving heart more quickly than expected this evoked our warrior ethos of never leaving a fallen comrade behind. Within 24 hours this West Virginia veteran received a new heart. Over the last few weeks, we began fill facilitating dozens of life saving transplants. This is a power of one, one organization working oneonone with va staff, congress, caregivers, vsos and many others to advance the health and wellbeing of one veteran at a time. Mr. Chairman, Ranking Member tester and members of the committee thank you for the ability to appear for you today. As a veteran, Army Sergeant general, wife of a veteran, daughter of a veteran, the proud mother after airborne infantry lieutenant, ensuring veterans have a high quality Credentials Network that meets their needs is important to me and our entire organization. I look forward to your questions. Thank you. General, thank you for your testimony and thank you to you and your family for your service to our nation. Mr. Mcintyre, welcome. Mr. Chairman, Ranking Member tester and the members of the Senate Committee on Veterans Affairs its an honor to appear before you today and pleased to do so with patty and those from the bob and Elizabeth Dole foundation. Weve been serving the military and veterans population for nearly 25 years now. We are privileged helping them respond to the Health Care Needs veterans from pc3 to replacing the health net, its been quite a journey. Weve tried to remain nimble and one objective to support with not compete with the v hamilton for providing timely care for veterans. Through the use of capacity process and leveraging the footprint of our nonprofit owners weve tailored highly, high Quality Networks in collaboration with va to patch the unique demands of each and veterans. Our network will soon contain all academic affiliates for region four has now delivered more than 32 million medical appointments in support of va to give them needed elasticity. This has included everything from merging care within 30 minutes of a Veterans Home to eye appointments, to primary care, to yurology, to womens services, to Behavioral Health and just this past weekend, a triple organ transplant to save the life of a hero. We in va have collaborated in administering the ibf benefit for hundreds of couples who could otherwise not have children because of battle wounds. Weve a network for each one of the couples, unique circumstances and lots of babies and proud and grateful parents as a result. Im pleased to result that due to the team effort between us and va, we are now processing and paying claims and professional and institutional alike within two weeks to a level of accuracy in excess of 98 percent. It will please you, im sure, mr. Chairman. That the va is reimbursing us on a timely basis as well. Along with successes have come some challenges, especially in the delivery of timely appointments. As you know, early in the year, our nation was hit with covid, a challenge unprecedented in our lifetimes. Community providers and va alike reduced the Available Services as they made changes to keep their staffs and patients safe and preserved capacity for those fighting the virus. It was a daunting situation. But soon and since the live this year, weve been scheduling appointments within five days for 90 of all veterans needing primary care appointments and theyre seen within 26 days from the receipt of the referral. Mental health within 27 and specialty until 28th. Theres all who are urgent and emergent in their needs are seen within the mission act standards. Theres still a bit of work to do, but were close and only one percent of the care requests that weve been given have been returned for no network provider. Getting here has been challenging. But we are close and we will not rest until we in va and four are delivering on our collective commitment to timely and convenient care. With the implementation of ccn, va takes over care coordination and appointing, but vas request, we have begun supporting within region four and services and expect that elasticity soon to be spread to other va medical centers. With the recent award of the ccn contract for region five. We look forward to doing the same in alaska. Not to replace va, but to enhance it and to provide the elasticity needed so they can serve veterans as you and they believe should be served. Veterans deserve no less. We applaud your continued leadership, mr. Chairman and members of the committee, and direction as we work towards a common goal that we all are united by, providing timely quality access to health care for our nations veterans, thank you. Mr. Mcintyre, thank you. I now recognize mr. Schwab for his testimony. [inaudible] members of the committee, Elizabeth Dole foundation is pleased to testify on va and family caregivers. Hundreds of thousands are counting on us to get this expansion right as are the generations of veterans who depend on their care. The original legislation establishing this program unfairly drew an artificial line between the caregivers of those who served before september 11th, 2001, and those who followed them. Our nation must continue to swiftly act to end this disparate in caregiver benefits. Pre9 11 caregivers, its exacted a toll on their lives, standing in the shadow with war wound, compounded by age and suffering debilitating conditions such as als, alzheimers, cancer, mobility issues and so much more. The Elizabeth Dole foundation a study by the rand corporation, pre9 11 caregivers, a quarter have taken unpaid time off from work or temporarily cropped working because of their care giving. More than 13 have dropped out of the work force entirely. And the most coming pre 911 caregiver is the grown child of the veteran. And most fall in the Sandwich Generation who simultaneously care for their parents and their children. These Hidden Heroes are an unpaid work force contributing nearly 15 billion in care every year, the vast majority of which is provided by pre 9 11 caregivers and experts korea well supported caregiver is the most important factor. And its one of the first and urgent priorities. We applaud congress to responding to our call and that Robert Wilkie and u. S. Department of Veterans Affairs has carried this out as part of the va continued investment in caregivers, unfortunately, however, implementation has been marred by ambiguities and delays, and confusion across the caregiver population. Our chief concern is the pace of implementation. After more than a year of delays the va intend to roll out in protracted phases, before may 7th, 1975 to wait two more years for eligibility. Mr. Chairman, senator tester, members of the committee, senator dole hopes actions taken on this very important legislative reform. And even more important, our pre9 11 caregivers who are being forced to wait even longer to receive their benefits hope you will take action immediately. Our Foundation Also strongly urges the v. A. To standardize expansions implementation. The largest source of caregiver anxiety and dissatisfaction with the pcs the as always been the inconsistencies tween v. A. Centers. Among the areas open to interpretation is the requirement for annual assessment. Some medical centers to three by what caregivers multiple times each year. That causes undue stress among the caregivers over the possibility that there they wie dropped from the program. Additionally, key language about how caregivers are evaluated lacks clarity. We are particularly concerned about the reliance on activities of daily living as the marker from which care a veteran requires. Mandating that caregivers assist with adl on a daily basis or each time they are performed will likely disqualify those for caring for veterans with posttraumatic stress and traumatic brain injury. The abilities of veterans with cognitive injuries can vary over time, even hour by hour. We cannot leave their caregivers unsupported. At the core of the implementation challenges is a critical lack of communication your caregivers have learned the program was sufficiently and benefits on october 1, secondhand, through social media through wordofmouth. However, large percentages of the caregiver population do not use social media or participate in online communities. Furthermore, those do participate in these communities are vulnerable to inaccurate information. The v. A. Must invest in a in a proactive comprehensive Communications Campaign at engagement to ensure that all caregivers receive the benefit and communication that they critically need and deserve. Finally, our foundation calls on the day to create a permanent head of the v. A. Support program and classify the position. Currently the positions interim and that is unacceptable. A program of such imports requires an established position of Senior Leadership. While we strongly encourage the view to respond to the recommendations we presented today, we also praised the department for its commitment to implement this historic legislation. We know and we recognize a lot of hard work has been done. Its a tremendous task. The Elizabeth Dole foundation at our Coalition Partners are standing by and ready to assist in promoting and defending this program. Thank you again, try to Ranking Member tester and Committee Members for this opportunity to appear before you today. We look for to continue our Work Together. We look for to questions today at the sporting our nations better caregivers. Mr. Schwab, thank you for your present your today. Thank you for the work the Dole Foundation does and accomplishes. Please give our best wishes and gratitude to the caregivers. And as a kansan but as an american please give my regards to both senator doles for their work in congress and the retirement from congress, the work theyve done since then on behalf of veterans and america. Let me now turn to your colleague, ms. Beller. Chairman moran, Ranking Member tester and members of the committee, thank you for inviting me to share my story. As you assess the expansion of caregiver benefits under the v. A. Mission act of 2018. I appear before you today as the caregiver of a veteran, at the same time also a national advocate for military caregivers with the Elizabeth Dole foundation, and a lawyer who served as a Deputy Attorney general for the state of indiana. More than 45 years ago my husband was exposed to agent orange while deployed during the vietnam war. That exposure cause diabetes and the diabetes triggered a major stroke. For almost ten years he was required 24 hour care. Stroke cause paralysis on right side of his body so i assisted with all activities of daily living. Every day begins with me helping him out of bed, moving them into his chair and getting him dress. I prefer breakfast, assist with feeding added minister his insulin and other medication. And so it goes for the day. Our biggest challenge is his inability to communicate. His intelligence in memory are intact. However, he can no longer read or write. He understands about 60 of what he said, and the speech is completely garbled. As his caregiver it is my job to help him understand what is going on in any given situation, and to make sure he feels he has been heard, especially at medical appointment. For my first five years since his caregiver i did my best to hold my own life together. I was entering some of the most professionally fulfilling years of my life, not to mention the highest earning years. I lean on medical leave act to help stay employed, but even without assistance i barely had time to sleep. Emotionally i was devastated by the never ending cycle of work and caregiving. Considering the sacrifices i was making as caregiver, i could not understand why v. A. Benefits were denied me and millions of other pre9 11 caregivers. Just as i do not understand now why caregivers must endure delays and drawn out timelines. The v. A. Must find ways to streamline the evaluation process. For example, the v. A. Has a decade of medical files demonstrating that my husband needs assistance, and that i am his primary caregiver. Yet to apply for this benefits, a rep is required to interview me and my husband who can barely communicate for two and a half hours. This lengthy process can add stress and anxiety to both the veteran in the caregiver. I understand the v. A. Is trying to gather as much information as possible but it is imperative that any views accommodate veterans who may not be communicative, like my husband, or whom may not be able to sit still for for a full interview. Im happy to say that the Caregivers Work coordinator in indianapolis was very accommodating for chuck, and the concert is we cant see that through the rest of the v. A. System. The v. A. Should also enforce consistency in the evaluation process. Caregivers sharing the application stories in online communities are revealing significant variances between the locations and between application instructions and how it is applied. The most concern of these inconsistencies is the overreliance on activities that daily living as a measure of required care. Caregivers assisting summer with invisible wounds are struggling to prove the value of that care, and i assure you there care is saving their veterans life. Resolving these issues is critical because caregivers are counting on these benefits. The v. A. Financial assistance is not insignificant to caregivers who have to choose between caring for the veterans or paying the bills. I loved my career, but it wouldve died if i continued working while caregiving for chuck, and then shot wouldve died shortly thereafter. However, its not just the Financial Assistance that is invaluable. I will have someone there who is available to help me during my caregiver journey. These benefits are lifelines to the caregivers, and without the love and support from a Family Member a veteran may not survive. This is how important caregivers are to their veteran, and that is why allocating benefits as quickly as possible is so vital. Despite the challenges outlined today, i would like to commend both congress and the u. S. Department of Veterans Affairs for remaining committed to correcting the inequity in v. A. Caregiver benefits. For many years that an caregivers have felt voiceless. Today, we finally feel heard. Thank you very much for your testimony, and thank you for your husbands service and your care and concern for him, and for other veterans and their caregivers. I think now we are ready to begin the questions. Before i do that, i wanted to highlight something i feel to say in my opening remarks. Since we met last the president has signed into law legislation passed by the house, passed by the senate. Our own john scott hannan veterans Mental Health improvement act, to my colleagues on the committee for your help in encompassing that goal, i want to express my gratitude. He began with a couple of questions for both the general and mr. Mcintyre. Has the v. A. Reached out to your companies to discuss modifications related to access standards . Mr. Mcintyre . We have been implementing a series of changes to our contracts since we started the implementation in region four. That follows the work that was done originally. And to this point there is no modification currently in negotiated formally as to the access standards. General, maybe its easier to ask a series of questions to directed to both of you. You are making progress, improving i think what youre saying is the access, the timeliness, the access standards. Why are you doing so if its not included in your contract . We saw it from day one to build a network that was in keeping with the access standards that are envision in the mission act. And the award of region four was done in such a way that it predated the opportunity for the v. A. To make an adjustment to our contract. Before award. So i thought it made the most sense for us to start on trajectory line with that in mind. The region five contract that just got awarded for alaska to our company includes the mission act standards. And when covid hit resuspended the bid we suspended the bid to more probably build the network in favor of making sure that we protected the base that need to be built, and we are w getting back to closing out the work on the mission act standards as well as refining the dental network, which has been as senator tester and others from region four no, a little bit more complicated than was initially anticipated. Is my concern that veterans have different access standards depending upon what thirdparty administrators contract says and what that thirdparty administrator is doing . Which indicated is in the most recent negotiations, the mission act standards are included but in other contracts that are not. Therefore, to bring on what region you live in your operating under a different standard . The mission act standards were included in five, because that was most recently awarded. It gave the v. A. Enough time to modify that contract before award. That was not the case in region four, and so, therefore, we are stretching ourselves voluntarily in the direction of mission act standards for the Network Build for region four. General, your response to those questions. Thank you, senator. When we received our contract for regions 12 and three it was before the mission act went into law and so six months after we had that award it when he to loss of the standards were not part of the contract. However, when look at the contract we can look at it through three different lenses. One come to the bigger network, two, to have a bigger bigger chance for availability, and three, to a bigger bedroom choice. And so we intentionally went and overbilled the network. We realize that theres more than 10,000 veterans that leave the military every year, and so we didnt want to build a network just where veterans are today, but we wanted to have a robust enough network that we have capability and providers in the right place at the right time for the veterans for the future. We are not in active conversations with the v. A. On modification, but that hasnt stopped us from wanted to make sure that we have the most Robust Network available. So it kind of look at it through two lenses. One is a retrospective lens when we look at the referrals and through the claims process, and would look to see how long it took for for a better to be abo get an appointment and then we looked within that area to make sure that were in access standards. We didnt look prospectively and look at geo mapping, where the better lives and whether providers are to make sure that we have really robust drive times as well as availability for care. And so internally we have monitored ourselves on what the secretary wilkie had put up for the access standards of 30 minutes for primary care and Behavioral Health and then 60 minutes for specialty care. So internally we monitor that and we are actually very close to meeting that standard across all primary care Behavioral Health and specialty, except the area of dental what we have, were probably 79 with dental. But Everything Else where close to 90 or higher. Your contracts that the once over negotiated before the mission act took effect and, therefore, do not include a mission act standards last for how long . The contract before their renegotiated is how long . Eight years. And your no indication that the v. A. Let me ask it, and more neutral question. Do you have any indication when we or the other whether the v. A. Is interested in implementing contract modifying your contracts to meet those standards, to include the standard . Senator, weve given them all of our data and information that they would need for them to make that decision, and right now were not in active discussion. And now i may be editorializing but correct me if im wrong, so if you both are working in the direction, both thirdparty administrators are working to meet the standards of the mission act. What is a reason for those not to be included in the contract . And absence of the contract, the reason we are standards so that if a better regardless of where he or she lives operates under the same rules. So in vision five theres a different standard for a better than a veteran in region or vision three. Is there any reason that makes any sense . Maybe if i can frame it in how were operating every single day, and so one of the things that we have realized this healthcare is local. And so we work every single day with each local on the ground to identify with it got gaps in care, whether having access to care issues and ensuring that we have a robust enough network to be able to support the demands of each one of those. Consistency from a a veterans perspective i think is very important. So i think im in agreement with you. We believe that the intent is for veterans to be able to get care where they need it when they need it, which is part of why we are driving to the most Robust Network. Thank you for the answer. I what mr. Mcintyre to respond here i would say i agree with you, general, that care is local. I believe that but but a threer drive is a threehour drive wherever you live in this country. Esther mcintyre. The networks that we built, we have sought to understand both with the footprint of the veteran is and with the footprint of the v. A. Medical center is, and their capacity not just their capability. And then we seek to build the elasticity in that they are going to need. With regard to your question about modifications, we have done 100 modifications since we started this base. I think there will probably be a day when it makes sense for v. A. To modify our contracts, the ones we currently have, to layer in the standards so that we can measure appropriately between us how we are doing in meeting those standards. And i was refreshed to see that the mission act standards are layered into the region five contract. And i think that is probably an indication of where v. A. Intends to go, but i have not asked them that question. Thank you very much. Thank you both. I apologize to my colleagues are running overtime significantly. I will try to make up for it. I dont know whether senator tester has returned from another committee meeting. If so i recognize it. If not i recognize i am here. Senator tester. Thank you, mr. Chairman. Its okay if you run overtime once in a while. You have been very gracious. I want to thank everybody for testifying and i appreciate your testimony. Im going to start with you, mre a big deal in montana and want to talk about dental Network Rates and access to preferred dental providers, is a concern i hear consistently from veterans across the state. So my state staff tells me calls and emails from veterans concerned that regular dental providers is not in the Triwest Network, have eclipsed those about eligibility for dental care to the v. A. The chief concern appears to be that dentists believe the Network Rates are too low. What id like to add you do is walk me through how you and the established in the region four and the adequacy of those out of the dental network in montana in particular. Of the rates montana is saying that you pay in more urban areas but that might be more general dentists and specialist . And doesnt make sense . Great question, senator tester. Its good to see you. We are building the network in montana. As i said its been a little more complicated than we initially expected. The reason for that in part is there is no fee schedule that is national for dental services for the v. A. They were local fee schedules, here in some cases they varied substantially, market to market. And what we were asked by v. A. To do in the dental space was to attempt to put together a network that reflected market rates in those environments. So what we sought to do was to involve our dental subcontractor, delta dental, which has a wide footprint across the geographic expanse of montana, and the rest of region four, to leverage their engagement in the marketplace and to convert over to fee schedule that is consistent and to build out that network. In some cases the market rate that they are paying for dental services is different than what the v. A. Was paying historically, thats what part of the problems occurred and we in v. A. Are collaborating market by market to make sure that we are able to make appropriate adjustments and complete the network. I just want you to add onto that, in what circumstances would you pay more than the rates are right now . More than the rates in the market, or more speakers so lets assume lets assume for a second the problem is, in fact, the Network Rates are too low. Lets make that assumption. What circumstances would cause you to raise those current rate . Is a high rate were necessary to make sure that we could build a complete dental network in your state. Okay. I appreciate that. Do you feel at this point in time that the rates have not been a limiting factor on you building that network . I think that it has been a bit of a challenge, but it is one that we and v. A. Are working through to attempt to respond to the local conditions in the market to make sure that can build sufficient network that the veterans need to be able to rely on. Okay. General horoho, would you like to add anything to this topic . Yes, sir, i would. When you look at dental, the challenge is in a couple areas. One, 12 of the veteran population is eligible for dental, but that date it isnt readily available and so you really have to build the dental network to support the 6 million veterans that are there. And each of them actually, is a feeforservice was very different from the managed care support contracts that are out there. So the rates are by the codes. So each dentist, theres different rates for the subspecialty versus general dentistry and so what we have found is that weve had to pay up to 150 for some of our contracts to be able to ensure that we can have robust enough dental capability within that marketplace. Region one of about 27 days, region two is 20 days and region through 13 days. It is a negotiation market by market. I want to thank you both for your explanation and want to point out, chama, i only went 255 seconds over ideal. Thank you, mr. Chairman. Thank you, senator tester. I know recognize senator cassid cassidy. Now. Doctor . You got me now. Thank you. Thank you both. One of the issues im sure youve heard of is that timely and accurate claims processing, and so theres a system back home that from about june of 2019 to about june 2020 theres just a whole batch of claims that they have not been compensated on. Subsequent to that, its going okay but there are these claims there. I say that because were all aware of the impact that covid has had an impact, on cash flow. Obviously they are still in business nonetheless part of what keeps him in business paying attention to stuff like this. Can you give us some perspective on how they handle this . If you address this in your opening marks i apologize, i had to log off for just a little bit. I will take that, if thats okay, because i filled the breach our company did before you arrived in louisiana. There is a requirement currently that providers file claims within 180 days of delivering service. Thats half the time given for medicare and have the time given for tricare in most of the programs. Whats happened to them, unfortunately, is further complicated because of the fact that sometimes v. A. Ordered the work. Sometimes healthnet or the work and sometimes we ordered the work. And so theres been a complication on the part of providers of where to file. The v. A. And we have worked extensively over the last couple of months to put a process in place thats going to allow every provided that falls into the gap that you so articulated identified, senator, that will allow them to refile the claims, have been processed and paid. We have the resources to do that on the dollar side, and the v. A. Will reimburse us. This just started at the beginning of october. Theres ben, not reach between us and v. A. Of that fact there has been common theres been 1367 claims that have been refiled that otherwise were denied for timely payment in the last couple of weeks. We look forward to working with you, v. A. And ourselves, to make sure that your constituents are aware of what to do, and how the process will work so that they can get reimbursed for the services that they delivered. If we could follow up directly with you, should there be a a continued ettrick contid concern [inaudible] directly, and so mr. Chairman, i cant see the clock so you total and im out of time. Let me address this to opt him. The mission act authorized a new care benefits for veterans which im childsupport above because expanded options for care in nature folks who can get urgent care when you need it. Tricare established a nationwide network of 7200 urgent care providers. Im told 92 of the golden veterans anything the v. A. And try with reestablishing this. Optimist in my state of louisiana. I imagine there network is not as robust, and since i care about this i i was one who sponsored the legislation, what steps is often taken to ensure Robust Network of urgent care providers alleys comparable to trilevel . Thank you should do. We establish urgent care and we did that in the midst of covid. We actually have 6600 Urgent Care Centers across all three regions, and so across those regions in region one, 98 accessibility and availability. 91 in region two region two, and 95 in region three. We have seen where those having utilized during covid because we also had some of them that use tele capability where those that wanted to access care were able to do that remotely as well. What ive been informed is your network is as robust effort whatever reason i was misinformed. Thats good news. Just returning to the others. I will just emphasize i am told the providers were unaware of the process to resubmit those claims so a degree to which all publicize that would benefit not just my folks the others, so thank you for that. With that i yield back. Mr. Chairman, if i might. Mr. Mcintyre. I will commit that i will reach out to every office thats on this committee to inform you of the communications that v. A. And thus have put together, and to help you understand the information that might be used to outreach to providers in your state and make patty aware of the same thing. Because our commitment before we fully leave the errors that she stood up and said all of the claims are paid, even those that were not otherwise done on our watch but mightve been done in another space. Mr. Chairman, if i could just add to that so we get a complete scenario on it. What weve been in her early as well, so were paying claims 11. 9 days. But when we get claims that are actually either triwest or if it was healthnet at that time, we have got an internal code so we just dont deny to get what we do is we put the code on it so that gets routed back and we work with triwest to make sure that works well as well as working with the v. A. We try to take away the friction with our providers. Gotcha. Dr. Cassidy, thanks raising these topics. I now recognize senator murray. Mr. Chairman, thank you very much. I appreciate it. Mr. Schwab, thank you for your incredibly important testimony and your recommendations today. I really want to thank Elizabeth Dole foundation for their dedication to our veteran caregivers. Ms. Beller come thank you fortunate as an advocate and a caregiver. Im so grateful to my colleagues for their support in passing the caregivers legislation as part of the v. A. Mission act to finally expand the program to veterans of all eras now we got to get this expansion right and make sure current participants are not getting unfairly pushed out of the program. Back in may i join senator tester any Public Comment letter to the v. A. Regarding the agencies propose changes to the Caregivers Program which would restrict eligibility potentially remove some veterans of the program. In the law we set the criteria to include eligibility for veterans who need assistance with at least one activity of daily living. We included other Eligibility Criteria such as supervision, protection or instruction to make sure those with invisible wounds of war or need assistance can get it. However, v. A. s new rule goes beyond Congress Intent to further limit eligibility. So mr. Schwab i wanted to ask you do you believe the v. A. The final eligibility to narrowly when compared the eligibility that was outlined and in our ld how will the new limitations rated at 70 Service Connected affect our veterans . Senator murray, thank you for the question and thank you for your leadership going back years on advocating for the expansion of this program. You are one of the first members of Congress Certainly to be with us at the foundation and calling for the expansion of the program and youve worked so hard on it and we appreciate that. Your question is super important and something i highlighted in my testimony. The program even before expansion was inconsistent at best, in integrating, including and caring for folks who are caring for a better with emotional, mental and Emotional Health care wounds and injuries. We do believe the v. A. Has gone beyond the interpretation in the ways it is implementing eligibility for folks for who e caring for mental and emotional wounds. I think my colleague molly if i could refer to her, senator, couldve spent on this as well. Molly . Yes. I do so much steve, thank you so much, senator murray for everything come for caregivers with the Elizabeth Dole foundation. As steve mentioned we do believe the v. A. Has gone a little further than the intention of what was put into both the initial caregiver bill and the mission act. We are hopeful that they treat invisible wounds such as ptsd, tbi, in other neurological or emotional or Mental Illnesses or womens as equally as the physical need, physical assistance. We have been told that the v. A. Will look into, make sure or weighing supervision as equally as the physical assistance with daily activity speech die. However, some we have in our network that were working with have expressed concerns of that. You bring up a good point also of the 70 requirement. That was something we were surprised to see. In the initial Impact Analysis that the v. A. Provided they did try to ensure the community that 95 of what they consider legacy participant as well as veterans who are already receiving care under the v. A. Health system would meet that qualification. However, that is possibly the lower bar of eligibility requirement. There is a functional assessment need, and as Jennie Beller so eloquently put it, the twohour interview process, those are the higher parts of the eligibility requirement we are concerned with. Thank you. Thank you for testimony today. Let me just say we have got to get this right and im not going to give up, thank you to your representation and i look forward to working with you. Weve got to keep working on this. I very much appreciate it. I just have a few seconds left and i wanted to ask about ivf to mr. Mcintyre. This is really important to me that veterans facing fertility challenges as result of their service has a smooth this experience possible in connection with the ivf provider that matches their families needs. I continue to have concerns about approvals from the v. A. Being delayed, and im troubled by how it will affect, process for the stems. Ive heard the v. A. Was in the ascending full responsibility for scheduling appointments with Community Providers as opposed to a Network Administrator scheduled to mr. Mcintyre, i just want to ask quickly, what if you found to be most important in getting this done in a customize way . Senator, thank you for the question and your leadership with this important topic. It is true that the v. A. Is going to be taking over the functions related to ivf. It is as you say has to be done very customized. And we anticipate that they are ramping up to do that. We will continue to do the network peace, which is customized fully for the needs of the couple when we come to understand what their authorization is and what their circumstances are. And at this point that v. A. Is planning to do the scheduling of them, but Washington State is one of the areas that we expect the v. A. To look to us for elasticity on appointing. And if we can be helpful with the appointee to assist him, we certainly will do so. Okay. Mr. Chairman, i have additional questions i want to spit for the record and i appreciate you all i need to go overtime. Without objection. Thank you. I want to submit. What you thank you for having damning. I cant mention anything more important about increasing the quality of care, maintaining the quality of care that we have, and again going forward, it can also access to care which is really what this is all about. I know that weve had a really significant backlog regarding reimbursement in the past. Weve worked hard, he has worked hard to get that down. General, recognizing that the mission act change the reimbursement plan for providers, placing a heavier burden on can you provide to commit an update on how the v. A. Is reimbursing you for care to Community Care providers and your network, and other any challenges that you are facing that we can be helpful with . Thank you so much. Thats really the bottom line. You will not have your providers if they dont get paid. Could not agree more, and prior to launching the three regions, one of the significant areas of getting provided into the network was because of the challenges of the past. I can report to you today that a think were in a very good place. We are paying providers first which is a change and we are paying them 11. 9 days, almost 99 of the time. And then the v. A. Is actually reimbursing us around seven days. So that system is working right now and we keep a very close eye on it because it is how we retain highquality providers. Very good. Again, optum is no now in arkas and is taken over which again is great. There is concern about that are under other providers that it had a longterm relationship with them. For a veteran whose current fight is not in the network, what does this transition look like . How can we come how can you help provide continuous care for veterans under the circumstances . Thank you for the question. Continuity of care which we both know is so very, very important in healthcare is a personal relationship with your provider. One of the things we have done is we have asked the v. A. To prospectively identify those individuals that do have a relationship that there is ongoing authorizations, and then the analysis to see whether or not it is a gap in the provider being in our network. And then went is we can look to evaluate does at provider meet the new standards of being a fully credentialed provider, beating all the standards. Then we are able to bring them into the network. When we meet every single month with 109, we actually talk about gaps in care. We talk about where they need us. To talk about veterans concerns and so thats another place where they can come in. And then actually the v. A. Has given us their priority providers as well us to bring this into the network. Very good. We understand it takes time to build unity Care Networks to best serve veterans. Based on your testimony, general, it appears that optumserve has been able to quickly create a network that serves almost all veterans in region three and thats very commendable. You stated that the region three, 95 of veterans are able to reach a facility within a 30 minute average drive time. This is partially a credit to your ability to as part of your network. In terms of the process, once the average timeline for a Healthcare Provider to receive accreditation to optumserve . Is a something that can be improved on . Is anything we can do as a committee to help in that regard . Early on when we were first standing at the region one we had a challenge because we were bring on hundreds of thousands of providers. It really was a large volume going through our system. We are now and in much better shape having fully operationalize region 12 one, and three. Our averages are between five to 15 days, sometimes theres some specialty like visions that may take a little bit, 20, 30 days but that process is working extremely well right now. Thank you very much. And now well go to senator blumenthal. I think. Okay. Well, we are going go to senator rounds. Thank you, mr. Chairman. Since optum is actually handling the processes within south dakota, i would like to address most of my questions to general horoho. First of all i would like to thank you for your service to our country. Thank you. I appreciate your continued to service as you work with optum. There seems to be a little bit of a disconnect between what you have shared with us today regarding the working environment that you find yourself in with the v. A. , who have decided unfortunately not to participate in this hearing, and also with regard to what our folks on the ground in south dakota have been sharing with us about the availability of the networks that you have been building and the networks that were there prior to your participation. And i want to visit about this disconnect im hearing today. Ive heard from both large and small providers that they literally have been extremely frustrated with the amount of bureaucracy that it takes to actually get into the network, and once in the network to actually get paid. On at least three occasions a veterans local v. A. Medical center has referred them, unfortunately, to a Triwest Network provider to it been there with years of service but is being denied then once they have been there. It appears to be just administrative delays in getting the move into optums network. In this particular case, those veterans were denied access to care by those providers because they were not in the network anymore. That most certainly something that as you indicated earlier and just and we had you today is something, is simply not acceptable and that care is critical. What im going to ask is, i think weve got to have an analysis of whether or not what we are seeing on the ground in terms of Ground Troops versus having perhaps 90 or a 95 success rate, thats leaving out those critical numbers in the middle that somehow suggest that there are people who are getting that behind. It appears to be a bureaucracy problem. What i would like to do is to discuss at least to hear from you what you are saying in terms of what is stopping or perhaps this was rested in part for you and im sure there frustrating parts, but youre working with the v. A. And of trying to get through with your team these former providers to get them in. And finally, and i will let you answer, i would like to know what it is are the guidelines and are they published for being an acceptable provider in your network that might have excluded those in the Previous Network . Thank you, senator, and i will absolutely i self and the team will come and meet with you and kind of layout the data for your area so we can have a further indepth conversation with it. But if i can kind of address some of the concerns that you raised. I will address first what it takes to become in the network. When we started to roll out Community Care, what we went forward with is not trying to replicate the network that was pc3 choice because Community Care change the standards and made it the mandate to ensure that the entire network was fully credentialed. Not only did have to be licensed or we had to do prime source verification of the National Practitioner data bank. We had to look at the education get. We looked at the licensing. We made sure there were not any challenges and issues either from any agency that was out there. If they meet those requirements and that is, if theres a gap in care, absolutely we bring them into the network. Or if its a continuity of care issue we bring them into the network. And so thats been the standard and thats what it takes to get into that network. The other piece on what to bring out, some of the frustration that you have raised, is we in regions 12 and three we dont do the scheduling. The schedule is done by the v. A. And so when they go into the databank the First Priority is to look at those practitioners that are part of regions one, two and three to be able to schedule those appointments. And so part of the transition we just finished going live in june of this year with all three of the regions. Some of that frustration may have been when there were the overlap which we did for all the right reasons for the veteran, is when we went life we did a 30 day overlap with triwest to ensure that there was no gap in care during that transition, but that also led the v. A. To look into system and see the current optum providers as well as the triwest, and then they have scheduled one or the other which it then tied into claims being put into the system that could have caused some of the confusion. We can do a deep dive with you on all of your data. Thank you. Look, i think what your point out here is that we do have a problem with this transition period i think the folks that are holding the bag on this our veterans that very well may have been the night care, and i dont think its been a once in with the sugar i think this happened on several different occasions. I think were going to have to go the extra step to cut through that bureaucratic red tape. Another part of this that we will have to talk about, and i like the idea that triwest is come up with where they will go back in and allow for a revisit on those claims that over 180 days old. I would like your commitment as well you would do the same thing. We are going to have that problem. Weve got folks have got claims over that time frame. They provided the services and so it looks to me like this transition has not been superclean. But i dont want those providers holding the bag and i most certainly dont want our veterans on the short end of being able to get services with the individuals that event appropriate providing them with services in the past. I think that means that as you transition into this, i do think you have to go the extra mile and focus on those veterans. I would sure like your commitment that you look at the 180 day rule the same as triwest, and that you will work through to make sure these veterans had that continuity of care where we had a problem. Eq can give me that commitment i think we can move forward. Senator, i can already tell you we are doing that right now. So as one of the claims that gets denied we actually look to see what was the reason before it goes back to the provider. We have been doing an internal code to make sure that it gets routed appropriately that didnt happen at the very beginning but when we realize a confusion that was occurring with just like triwest can realize the confusion that was occurring when you had multiple thirdparty administrators in one market and tilt was fully transitioned. So we have made that commitment and we are doing that. You have my commitment that it will great. Im assuming has that changed s occurred in the last week or so . No. Weve been doing that actually probably for the last several months. Thank you, senator browns. Thank you, mr. Chairman. Thank you, senator rounds. That is an important point. Senator blumenthal. Thanks, mr. Chairman. Thanks for being here to all of you. I am disappointed as senator moran and senator tester have expressed that the v. A. Is not here. Im also disappointed that the v. A. Has apparently declined to answer a number of the questions that we have asked regarding the disparity, racial disparity, in the impact of covid19 on our veterans. Seven months into this devastating pandemic, 3667 v. A. Patients have died, which is a devastating average of about 17 veterans every day. Right now were apparently at the beginning of another surge. Theres been a 50 increase in active cases at the v. A. Compared to last month. I will say that i am proud of the v. A. Facility in west haven because they have done prompt testing with rapid results using the pcr process. It could be a model for the whole country. And infection rate at our v. A. Facility has been much lower than the national average, and went to point out that there is some good news even amidst some of the more discouraging fact. But the result of a recent v. A. Study has shown that black and hispanic veterans are twice as likely as white veterans to test positive for covid at the v. A. My guess is that, not only infection rates, but also death rate show the same disparity. The v. A. Has refused to communicate with congress about this issue. Question sent to the v. A. In june were completely ignored, as was a followup letter sent by the committee in august. I join my colleagues in expressing grave dissatisfaction with this refusal to answer our questions. The v. A. Does a tremendous disservice to veterans when it refuses to communicate with members of congress who represent them and have a responsibility for oversight, and then refuse to come to hearing, as it has done today. I would like to ask all of you, but particularly general horoho how the covid19 bend in the has affected your operation in particular, the facilities in your network had adequate access to covid19 tests . Reliable tests and with prompt results and personal protective equipment. Thank you, senator. If i could take one second before its a bit and just talk about health disparities. Because that is been so important. One of the things that my company is actually a Data Analytics Consulting Health service and logistics and technology company. We developed a Health Disparity data analytical tool that weve been using since covid started, that we could go down to the zip code level and identify those americans that are disadvantaged or at high risk for covid19 based on their health disparities. And then we have done stop covid where are company is in philanthropic work of providing those testing for free as well as education wraparound packages to help them with that. We have also reached out to the v. A. And offered that capability to be able to utilize that as well because i agree with you, its a population that is extremely, extremely vulnerable. And to answer your other question, a couple things that we did as an enterprise when we look at our network being so tied to her Enterprise Network in making sure that providers are one, financially stable enough to keep the operations going was important, and so we have accelerated over 2 billion in payments to doctors and hospitals that are also serving veterans so that we made sure that financially they were stable. We donated over 100 million to support covid19 impacted at risk communities, and then we worked in partnership with hhs to help disperse over 100 100 billion of the cares act provide a release, we did that because we knew this Robust Network of 830,000 practitioners are not only providing care for veterans but theyre providing care for americans and we want to make sure that was stable. What we are seeing that we utilize a lot of leverage a lot of telehealth. Prior to covid only about 12 well, 12 to 16 actually use telehealth as referrals, now were up to 12,000 a month. Most of those were Behavioral Health about 31 and were starting to see the system really coming back to normal and being able to improve access. Thank you very much. Thank you, senator blumenthal. On behalf of the chairman, senator blackburn. Senator blackburn . There we go. All right. Thank you all so much. I appreciate your coming for the hearing, and i really want to thank the Elizabeth Dole foundation for the leadership on caregiver efficacy. I will tell you, this is something that from our veterans we hear a good bit about, so we thank you for that. Chairman morans statement, the va wanting to participate and look at the progress we have had with this network. I will tell you i am optimistic we will be able to expand care to our veterans in the rural areas, we are seeing an increasing number of those, from port campbell, because of its geographic location, the Community Care is something vital for them and i want to focus on the caregivers, and veterans and caregivers from the program without justification and without them knowing why, senator peters and i have a caregivers act that would put into law some guidelines to this program to continue. We think standards are going to be vital, to recognize the caregivers to veterans, Electronic Health records. Mister schwab, in your testimony, caregivers are hidden he rose. They are not to be hidden, having access to veterans medical record, this is one of the issues we have in having that precise timely coverage, lets make sure they are not going to be hidden he rose. Let me ask you Mister Schwab, in tennessee with our other Caregiver Program, we have many that are there because of ptsd and traumatic brain injury and what we term invisible wounds. Lets talk about the activities of daily living criteria set by the va, to negatively impact eligibility for the Caregiver Program. Thank you for the work your recent legislative call for consistency, access to Health Records is vital and something i said in my testimony that we responded with in our answer earlier, the definitions that have been established with respect to caregivers, care of those causing inconsistency around eligibility. I am going to ask molly to respond for your purposes as well. Standardization of those conditions is important, we will see people being booted in and out of the program. Do you want to add to that . With our requirements, with daily living, each time one activity of daily living, focuses more on the physical, as well as supervision on a daily basis. We know caregivers and veterans, on a daily basis you could go a couple days where your veteran is able to remember being put into the microwave, they are able to do that sunday but not wednesday, because that is where it works and there are instances where someone may be able to transfer themselves to use the restaurant to their beds but there may be times they are not able to do that so each time we understand, to caregivers, that seems a gray area with the fluctuation of assistance we deal with, for emotional caregivers monitoring triggers every single day. They are able to function, grandparents and to be able to be a friend, it is in the network, wholeheartedly support the list. Senator murrays question, the questions that lack of standardization, and caregiver, with discharges, it is 100 disabled and moved out of the Caregiver Program and it is just very frustrating, and important we get these straightened out. There are others to ask questions. Thank you for your husbands service and dedication and service to our country. I appreciate how you come through the daily routine. What i would like to hear from you, talk to me about what has changed for you since you became a caregiver appropriately recognized of the uncertainties that exist with the program and your fear or concern this. My life drastically changed. I left my career and that changed a lot but it required that. In my situation i have applied and interviewed tough situations, he needs a lot of care, as much and correctly that are literally the protection of veteran and trigger levels, keeping that veteran alive in preventing suicide and keeping it safe. I am hearing on social media networks, they are not communicating. Their work is not valued. That is very concerning. Great if not greater than what i do for my husband. If i could add one point, you brought up an important notion. Really large program, for inclusive care, there is an inconsistent set of protocols clinicians use to interact with caregivers. Molly mentions when a veteran goes through disability rating interview the veteran may be having a particularly good day on the interview. When those questions are rendered and those answers are dependent on the level of benefits they are going to receive our campaign and protocol call for caregivers always being included in the room, one husband or wife feels they are having a good day their spouse is by their side, youve been having a couple bad weeks and last week, you had an emotional episode, really important for the va to be aware of. Thats why your bill and the legislation you put forward is so important, with consistencies the way the va is interacting and appreciate your continued leadership on this issue. Apology for my time running over. Thank you, bill you were discussing cleared on the sidelines. Progress in that regard as well. Senator brown is next and that may be other than my ability including questioning. Appreciate your calling this hearing. They declined to attend, too much car par for the course. Appreciate what you said about caregivers being on the room. That is the point of hearings to learn from witnesses my first question is for Mister Schwab, thank you for expanding the caregiver support program, in meetings throughout ohio i do a number of roundtables, to listen to veterans to meet critical support and why caring for 15 Family Members know this kind of help is immensely helpful to them. The program is a year behind schedule. From 1975 and before 9 11, we wait another two years, the va should be here to answer questions about the delays and implementation. Question for each of you you discussed the need for greater communication and the Veterans Community it serves. Before finalizing the rules for the care River Program in addition to the threshold, to be included in the final rule. A great question. Thank you for the work youve been doing, it is important really appreciated. I would suggest evaluation and consistency evaluating eligibility is the number one concern. The implementation of the mission act. As i addressed, we love your support on this. The former member of the senate, on august group of leaders at the va to introduce legislation to speed up the expansion, with caregiver benefits, a lot of veterans being left out, we love a legislative solution for the eligibility and include everybody in the expansion in the next phase. I want to make a comment, thank you for your years of service. For the assistance, appreciate your testimony where you outlined the stress caregivers and veterans go through during the application process and additional meetings and interviews, medical records illustrate the support needed so thank you for speaking out and the courage you have shown, appreciate the testimony of all four of view. Thank you, mister chairman. I have a few questions. Let me start with caregivers. Mister schwab, i have seen the rand report suggested by the Elizabeth Dole Foundation Supporting Research Studies in regard to Mental Health concerns. It was published in 2014. I also know this topic was discussed during the fifth annual National Convention you held last week or earlier this week. I am just asking for direction. What is that you would ask of this committee in regard to the Mental Health and wellbeing of caregivers, the implementation of the act which is missing, the committee has indicated to fulfill our stated priority of Mental Health and Suicide Prevention. Your presence today is a reminder to me you need to make certain, Suicide Prevention, certainly for veterans, is helpful to them. And they would consider legislative removal of the phase expansion. They receive their benefits right away. And they commissioned, almost 6 or 7 years old with the data still rings true. They called more robust. And longitudinal studies on the situation facing caregivers. They have 0 longitudinal data and the effects of caregiving, they are providing free athome care, new civic and patriotic responsibility that will be here forever, we need to invest, the committee needs to invest in and understand implications of care and service. Mister chairman, around suicide, caregivers are the last line of defense. Enough is not being done to understand the unique role caregivers play in prevention so we would welcome wider dialogue, perhaps a roundtable with this committee and the number of caregivers and organizations, to talk about the ways of va and dod more directly support the Mental Health needs. And in trainings and protocols. It is a disjointed engagement, no requirements, i apologize. Those are the three things i would suggest is important for the committee to consider. I wasnt sure whose phone that was. I was going to scowl at one of my colleagues. Thank you for your testimony. Let me ask a similar question about Mental Health and Suicide Prevention in regard to caregivers. You heard what Mister Schwab said. One of the challenges i think we face, lack of professionals, the john hannon ask gets resources to Community Providers. Stands what would you ask of me to be of help in regard to the Mental Health and wellbeing, Suicide Prevention not only of a veteran the caregiver. Providing more resources of Mental Health issues. I have been to counseling a couple times. I am capable and healthy of taking care of my veterans and that is so critical because there are studies or indications caregivers can develop ptsd especially in situations dealing with tbi and ptsd so these are very real. I know of caregivers who committed suicide because it is very isolating and lonely occupation but with organizations like the foundation helping to raise awareness and alleviate the struggles. Thank you for that answer, you are very articulate and compelling witness and i appreciate your presence with us. Thank you for testifying before our committee. Let me return to the network issues. Neither one of you indicate you have any knowledge whether the va will move in the effort to modify their contract. If i misunderstood or you have additional information, what you told me, the va has decided not to modify their contract. I would then ask this question, perhaps this argument, the va testified they have sufficient Budget Resources to modify the contracts. It is not a budget issue. This is a fair summary, your networks are expanding voluntarily to meet those standards. What would you say a justification for not having uniform standard as suggested by the mission act. What am i missing here . General . Just to share some of the conversation, not to speak for the va but to share a conversation, some of their concerns when you look at the shortage of providers in geographical areas and look at veterans choice because some veterans are willing to drive a distance to see either a particular provider, one that is part of the va or Community Care, there is a perception that it would be overbuilding by some of the stringent drive times in some geographical areas and that is part of the hesitancy for moving in that direction. Weve looked at it through the lens, what we spoke about, wanting to ensure, in a geographical area utilize utilization data to tailor it to where veterans are living. That is part of the concerns they raised, i cant speak to other concerns but i can share that one. Retrospective look at demand, enabling enhanced access makes it very hard to accurately predict what people like to do with their decisions if they are given the opportunity. So as general horowitz said we were developing a network that matched what we believe based on analytics in a 7 year journey with the va. What likely will be sufficient to make sure there is enhanced access and availability, probably the best example of the collective success, birth between congress, the va and the community rests in texas. You used to have to drive 7 hours for care. Four Community Hospitals and all the providers in the Community Side with that. And and every kind of care, in its surrounding area and more than 400,000 appointments have been done in the valley in texas in that comprehensive network. Thank you for outlining what the goalies and indicating it can be achieved. Perhaps it appears i am carping just on insisting that the va comply with the mission act. And that is not my point here, the concern is if we dont build to those standards, veterans, some veterans will become discouraged not able to get the care they need. The mission act, successor to the choice act, for their benefit, doesnt discourage anyone from using choice, the two of you, your networks indicated youre going to build those standards demonstrate to me there is value of having standards. If you didnt have those words, you are building to what the va insists under the contract, further serve veterans who live role or have a particular reason closer to home. The va has indicated in their testimony and situations with me, they are pursuing this but more recent stories indicated the va is not interested in increasing the standards, the contracts, the provisions of the mission act, is more about caring for veterans and making certain they have confidence the mission act is fulfilling the needs of those veterans the when they didnt see it with choice in other circumstances. In kansas and across the country veterans know that we have them in a position in which they can access the care they need, in reality and image we are doing a disservice. One more thing to distrust they say i have a benefit but dont feel it or see it. Theres a real consequence to us not meeting the needs of veterans, a third or fourth id iteration of Community Care. It does matter. We have this dialogue. Center tester has returned. I have one more question but let me turn to center test there and wrap up as indicated earlier. I talked too long and the Ranking Member returned in time to have more conversations. I was told you would ask every question about longdistance Passenger Rail service that i asked. I was seen as an annoyance because you and i had the same line of questioning and you were feeling in here in the committee as chairing todays hearing, that immediately cause me to lose interest in the Commerce Committee and rushed back in case you were thinking this was a more longterm circumstance than i am hoping. I would never think that. It scares me to think you and i are on the same page when it comes to asking questions. I appreciate the opportunity to ask and make this as painless as possible. I appreciate the witnesses for being here today. This deals with covid19 and it goes to mister mcintyre. My understanding is that referrals and Community Care are on their way back up and month after the start of this pandemic. Would you either confirm that . Is that right or wrong . Are they on their way back up . I can provide the stats, with geographic territory, prior to covid19, we were receiving 7300, in the last week pulled the data and receiving over 7800 authorizations for care on a daily basis. There was, during the height of use, phase i of covid19. Some tamping down on the requests, but for the most part the things we touched minus 10 , to be rescheduled and readjusted so the veterans ultimately got their needs met. And it is a permanent picture. We have 72,000 referrals today. That leads to my next question. How has the pandemic affected the availability of networks . Mister mcintyre, talk about it generally or specifically. Providers have been immune from the impact, to make sure there was sufficient supply of services, up to treat covid19 patients and to protect, they tamp down on most volunteer services, that has now changed. Most providers now open back up for business and have been for months. It is true, the rest of the economy, we are finding by and large people are wanting to see patients. In the great state of montana. Similar trends, one thing we saw was an increased use of telehealth capability 31 of that was for Behavioral Health and a little surprising the second was for Pain Management and physical therapy, what we saw during covid19, the impact it did have across the Healthcare System but did cause a rapid change from facetoface delivery of care, which we rapidly transition to and that made a big difference. The other piece i am testifying to was the large influx of cash, accelerating payment, supporting the financial status to keep their practice because that was one of the big challenges as well. Last question, and answer second on this one. It deals with telehealth, we learned from this pandemic, is critically important, we need better Broadband Service in a rural state like montana or other areas. The Community Cares capacity, to provide telehealth servers and provide facetoface instances, in this pandemic. They do it through telehealth, that capacity, are you feeling some limiting forces in your network . I appreciate that because tele capability is one of the things that came out of this pandemic that has been a good thing. Celebrated the use of it and one of my concerns, we have been so reliant as a nation on the Authorities Congress gave to actually have transportability of licensing across state lines, waiver for interstate licensing, allowing practice at the top of your license and those of already is to leverage a network, not bound by that, made a huge difference in the affordability of the Healthcare Network being able to leverage tele capabilities. That is one of the things you didnt specifically ask but it is something, to make those authorities permanent would make a big difference in the ability for communities to provide that. Thanks for that. Im sure the chairman is taking notes and crafting a bill. The availability for the network. At the same time it is important for certain types of Services Telehealth levers for Behavioral Health, to make sure that service and the servicing provider is as close to perfection as possible because when they need to make a physical visit it is important that they see that person they have been seeing on the screen. We tried to put our focus on making sure we are enabling the existing providers within their own states to have that capacity. We all remember or we may remember telehealth was born out of alaska and hawaii and prior colleagues, senator stevens had a lot to do with that, access to the villages of hawaii and remote islands, the villages in alaska and remote islands, it is good to see it expanding but the challenge is access to broadband, and hopefully one of the things the federal government will be focused accelerating the access to broadband in rural areas so they could use telehealth as robustly as across the great state i would close by saying i agree with both of you to increase capacity across the board and both of you and others can be tremendous help to Congress Without allocating dollars for broadband and challenges you are facing and healthcare communities, it is all areas. Thank you for being here and i will turn it back to you. Let me wrap up with a few quick comments, senator chester went down the path whether providers in networks, i heard your answers, i will highlight for you the indication by the va that a significant number of providers in your network were no longer in business and are unwilling or incapable of caring for patients. It was not my experience in kansas, providers could not understand why they were being denied referrals. I would be interested in knowing, if that was your experience, you couldnt find providers during covid19 or the va made a decision to bring those appointments and referrals inhouse which i think probably the best place we could have our veteran patients is in their communities compared to traveling to a va center. Was there a real circumstance in which providers said we arent or wont, cant provide service . Reporter we found your network remain a Viable Network in the middle of this pandemic, went live to two other regions and the accessibility standards in the high to low 90s. We had providers signing up. We had them available. As an enterprise rollout, protect well which was a mechanism to ensure Healthcare Providers front lines were checking every day on their help and if they had symptoms they were not coming to work so we have a Healthy Network both from the clinicians being able to provide practices remaining open. Anything to add . Much the same. We have an opportunity to do a pointing during that time in support of va. A few providers were limiting their capacity or were in for low. We were able to find care, all the patients placed in our hands for the purpose of care in the community. I would highlight veterans and their access to care at a place of their choosing but it is detrimental to our networks or to you as providers if you are not getting referrals, we need to keep viable for your selves. Let me ask the general a question. Who came up with the 180 mile highly rural standard . Is that something the department of Veterans Affairs created . I will go back to exactly who. Thank you very much. In regard to optimum which im becoming more familiar with, i would highlight please continue to pursue more opportunities for specialized care particularly chiropractic care. We need more Network Providers closer to home than we have. I would complement you both. I had experience with both companies, you are very good helping me and my staff in regard to take casework, and come to you to solve those problems. The goal ought to be, not a burden upon the veteran to bring a problem. I hate things the way it may sound. We are not complaining about the work of veterans provide to meet their needs but we need a system that works which is not the responsibility of the veteran to call a member of congress to Say Something is not working, can you help . The ultimate goal, i want to thank you for the efforts you have undertaken to meet the needs of veterans as we bring those needs to you and they are what those concerns and problems in form me and my staff to know what we are doing and advocating not just for those veterans but for the system in which they are beneficiaries of healthcare. We look forward to working with both of you, colleagues at work in the Veterans Affairs, not an issue i complained to because it is not happening as it should be how to make sure the system make certain they are provided for to begin with. Those are challenges we all face. Thanks for helping us care for individual veterans and continue to work to meet their needs as well. Mister chairman, your focus in that space and that as Ranking Member and other members of the committee is invaluable. Some people find that a nuisance. The reality of what is present in each of those cases allows us if we choose working the case to find where the real gaps are in making this work. If we focus on that and adjust the processes and the tools to address those gaps, pretty soon there arent any more gaps. As you were speaking i was thinking there is not usually a veteran who has a unique issue. If a veteran has an issue with how things are working, there are others who do as well and they may not be people who contact me or my staff. We dont let anybody slip through the cracks for the veteran that raises the issue but fix the problem for everyone who may not have said anything about it. I would give all their witnesses the chance as is my practice to say anything they feel they need to correct, anything they would like the committee to know before i adjourn this hearing . Anyone online or on zoom that is interested in saying anything further the folks who testified today. Thank you. Again, thank you for participating. As we make certain we implement title i of the mission act appropriately, appreciate from each of us thirdparty administrators, pleased to hear more about caregivers in the testimony i heard today isnt useful and i appreciate the challenge given us, things that need to be done as i ask unanimous consent the members have 5 legislative days to extend remarks and include extraneous material. If we submit any questions please answer them as quickly as possible, get back with us with information and welcome that and encourage that. With that the hearing is adjourned. [inaudible conversations] [inaudible conversations] somebody who knows what they are talking about. [inaudible conversations] i dont think it is. [inaudible conversations] the u. S. Senate returns in just over 10 minutes. Lawmakers will take first vote on a 500 million covert relief bill. 60 votes will be needed to advance the measure. Follow the senate live when they gavilan at noon eastern on cspan2. Less than two weeks to election day. Moron campaign 2020 with barack obama, the former president , campaigning in from adelphia today on behalf of joe biden. Watch that live at 5 4 05 pm eastern on cspan. Later donald trump traveled to North Carolina for a campaign rally. Watch that live from gastonia on cspan, both also online, cspan. Org or listen in on the free cspan radio apps. With the Senate Confirmation hearing for judge amy eric concluded watch the next step in the confirmation process. Starting thursday live at 9 am eastern. The Senate Judiciary Committee Votes on judge barretts nomination friday live on cspan2 the Senate Begins debate on feltes on amy barretts confirmation. Watch live on cspan and cspan2. Stream on cspan. Org or listen live on the cspan radio apps. I had a choice to make. Toilet my people run it really well or badly . If i run it badly they will probably blame me but more importantly i want to help people. He cost 10 Million People there healthcare from their employers because of his recession. With two weeks until the 2020 election watch the second president ial debate between donald trump and former Vice President joe biden thursday from Belmont University in nashville, tennessee, live coverage begins at 8 00 pm eastern on cspan. Listen live on the cspan radio apps and go to cspan. Org debates for live or on the mainstreaming of cspans debate coverage. We are weeks away from election day, november 3rd when control of congress and who occupies the white house next year will be decided. Go to cspan to hear donald trump and joe biden make their case to the American Public and watch debate in a hotly contested house and senate races. Campaign 2020 coverage every day on cspan, cspan. Org or listen on the cspan radio apps. Your place for an unfiltered view of politics. Our first guest is doctor Richard Bester, ceo of the Robert Wood Johnson foundation, also served as acting director of the centers for Disease Control and prevention during the Obama Administration. Thank you for joining us, appreciate your time. Can you describe how you are funded . The nations largest, on health and healthcare in america and we are a large foundation, we give out grants each year, 500 million. Our focus is a recognition that health is about what takes place where we live or work, where kids go to school. It is about more than having access to highquality health care and the big focus now is on what we call health equity. Ensuring that everyone in america has a fair and just opportunity to live their healthiest lives. When it comes to issues of the pandemic you wrote a recent opinion piece for usa today and one of the lines of the peace in describing the pandemic saying it is still early in the lifecycle. We have been at this for several months. Can you explain the reasoning for saying that . A couple careers before coming to the Robert Johnson foundation i worked at the centers for Disease Control and prevention. I was there for 13 years and i am next deck Infectious Disease epidemiologist. What is clear whenever there is a new or emerging threat like a pandemic it takes time for us to learn the trajectory, learn how it will Impact Society is one thing we know is that until a significant percentage of the population has been vaccinated or had infection a virus can still spread through society and estimates by the head of the cdc are no more than 10 to 15 of people in america have been infected by the virus that causes covid19 the causes 8590 of us are still susceptible to this and that means we are in the early days. As much as we are all tired of doing those things that work, wearing masks, keeping 6 feet apart from others, washing our hands, staying home, these kinds of things that work, we have to stay at it for a long long time. If that is the case, when it comes to the vaccine issue, what are the questions that need to be addressed from your mind and experience as the Government Works on a vaccine that potentially could be administered whether donald trump wins reelection or not . The word you used that is important is potentially. There is no guarantee that we will have a vaccine against covid19. I am optimistic. This administration put a lot of money into supporting developed a vaccine. If one of these vaccines turns out to be effective, for several of them there is already production underway so that is a good thing but we have to be cautious and recognize the Public Health measures we are doing are the best tools we have for right now and the reason i put so much emphasis on that is over the course of my career in Public Health there have been tremendous efforts to create vaccines against the worlds biggest Infectious Disease threats. Hiv, malaria, dengue fever, hepatitis, zeke a virus. We dont have a vaccine for any of them. Despite the efforts of scientists putting hard work and a lot of money into those disease efforts, those control efforts we dont have a vaccine. I remember when the hiv pandemic started, i was a medical student at the time. The word was hang in there. Within a year we will have a vaccine. That has been a long time. That was in the 1980s. We should be optimistic and excited about all the work going on around the vaccine there is no guarantee we are going to have one and if we have a vaccine, vaccines very in terms of how effective they are. A measles vaccine is 95 effective, one of the best vaccines we have out there. Other vaccines reduce your risk, like a flu vaccine, that may only be 30 , 50 , it varies by year. The fda this time set a threshold of 50 . Any vaccine that would be licensed has to reduce your risk by at least half. Say a vaccine is 70 effective, 70 of the public gets it, that would leave half of the public, 50 of people still at risk of this. We still need to continue to do those measures to reduce transmission in addition to the vaccine. Results of a poll on the topic of vaccines in the New York Times saying the New York Times saying 33 say they would definitely or probably not get the vaccine until after fda approval and a harris poll of 2000 people published monday, 58 of respondents said they would get from 69 , the same in august, two sets of numbers but you have to sell the public on the validity and safety of the vaccine. What faces the administration on afferent . If i find concerning. There are systems in place to ensure that any drug, any vaccine, any medical device put forward for use by the public to ensure it is safe and effective but if we dont allow those systems to work, the fda has an external Advisory Committee meeting this week to set the standards to approve covid19 vaccine. If we dont allow them to do their work unimpeded without any political influence, trust goes down and what we have seen during this pandemic is time and time again the administration directly influencing what cdc is done, what fda has done and it raises questions in peoples mind and important questions as to whether it would be recommended is being done based on the best science, the best Public Health or for political reasons. There is a committee advising the cdc called the Advisory Committee on immunization practices. Extremely important. When fda approves a vaccine it will come to the committee to make recommendations on who should get it, how it should be given. Very important process to ensure there is no political influence. Doctor Richard Bester joining us, serves the president and ceo, former acting director of cdc for the Obama Administration in 2009. You want to call and ask questions concerning the effort on the coronavirus in response, 2027488000 in the central time zones, 2027848001 in mountain and pacific time zones. Metal professionals 2027407000 for input. Lets go to your time at the cdc. The administration had to deal with h1n1. Compare and contrast that process and the good things and bad things you learned particularly talk about how that applies to Coronavirus Relief today. I worked at cdc during democratic and republican administrations and i was inside of Emergency Response for four years during the end of the Bush Administration and island the agency at as acting director at the start of the Obama Administration but i was a civil servant, not a political appointee. Washington journal live everyday at 7 am eastern, you can watch the segment at all todays program, cspan. Org