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

Committee, though not physically present at the moment, some are joining in person and others will be joining us, almost every member of our committee will be participating expected in todays hearing. The focus of todays hearing is the implementation title 1 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 within that marketplace. When we look across our 3 regions for wait times, 27 days in the region 3. Market by market. Thank you for your explanation. I only went 25 seconds over. Thank you, i recognize senator cassidy. Doctor . Thank you. One of the issues i am sure you havent heard of is the processing, there is a system back home from june of 2019 to june of 2020, theres a batch of claims they have not been compensated on and subsequent to that it has gone okay but there are these claims, we are aware of the impact of cash flow. They are still in business but part of what keeps them in business keeps them in business. Give some perspective on how to handle this. I had to walk off. I will take that. That is okay. I fill the breach. Our company did. There is a requirement currently providers file claims within 180 days of delivery service. That is half the time given for medicare and half the time for tricare and most of the programs. What happened to them is further complicated because of the fact that sometimes they order the work and sometimes we order the work. There has been a complication on the part of providers on where to file. We put a process in place, falls into the gap, to refile the claims, have them processed and paid. We have the resources to do that on the dollar side. There has been, and outreach of that fact. There is 1367 claims to defend refiled, with timely payment in the last couple weeks. We look forward to working with you to make sure our constituents are aware of what to do. How they are reimbursed for the services they delivered. A be continued concern, mister chairman, i cant see the clock, you tell me we are running out of time. The new urgent care benefit protection, in strong support because of expanded applications for chair and they get urgent care. The tricare established, 7200 urgent care drivers, 92 establishing this. The optima ms. For region 3. And gather the urgent care and the network is not as robust. They sponsored the legislation but what steps are taken to ensure urgent care providers. We established urgent care and we did in the midst of covid19. The 600 Urgent Care Centers across all 3 regions and across those regions, 98 accessibility and availability, 91 , 95 in region 3. We had seen where those were utilized during covid19 because we had some that used tele capability, that they do it remotely as well. Your network isnt robust, for whatever reason, was misinformed. They are unaware of the process that was claimed to publicize that. With that i yield back. I will commit to every office, to ensure that communications put together, to understand the in formation that might be used to reach providers of their state and be aware of the same thing. The errors that they stood up, all the claims, they were not otherwise done. It was done in that space. I got a complete scenario on it. What we were done internally as well, we laid claims, 11. 9 days, claims that are actually try west. Weve got an internal code so we dont deny what we do is we put the code on it and make sure it works well. To take away the friction of providers. Thanks for raising these topics. Senator marie. Thank you for your incredibly important testimony. Thank you for the dedication for veteran caregivers, thank you for all you do as an advocate and caregiver. Im grateful to colleagues for their support in patching the caregivers legislation. To make sure current participants are not getting unfairly pushed out of the program. I joined senator chester in a Public Comment letter regarding the agencys changes to the program which would restrict eligibility and potentially remove veterans from the program and criteria to include eligibility for veterans who need assistance with one activity of daily living. They included other Eligibility Criteria like supervision, protection or instruction to make sure those with the invisible wounds of war who need assistance can get it. The new who goes beyond the intent to further limit eligibility. Defining eligibility for the eligibility outlined, 70 serviceconnected affect veterans. Thank you for the question and thank you for your leadership going back years on the expansionist program. To be with her for the foundation and calling for the expansion of program we have worked so hard on and appreciate that. Your question is super important and something i highlighted in my testimony, and integrating and including folks, a veteran for emotional, mental and emotional healthcare wounds and injuries. We do believe that the va has gone beyond the interpretation, for him and social wounds. To expound on this point as well. And to believe that, to put the initial caregivers bill and, we are hopeful, they treat invisible wounds like ptsd or any other emotional or Mental Illness since, and physical need for adl, assistance weve been told that the va, and the physical assistance each time and caregivers we have in our Network Express concerns, with 70 requirement that we were surprised to see. We tried to assure the community, what they were considering legacy participants as well as veterans receiving care under the Va Health System. That is the lower bar of eligibility requirements. As they put the two our interview process. With the eligibility requirements we are concerned about. I look forward to working on this. To mister mcintyre. This is important to me. And to connect the idea of providers, i continue to have concerns about approvals from the va being delayed, i assume full responsibility for scheduling appointments. And what is most important in getting this done in a customized way at the next level. Thank you for that question in your leadership with this important topic. It is true that the va will be taking over the functions related to ibf, has to be very customized. They are ramping up to do that. They will continue to do that piece which is customized fully. To understand what their authorization is and what circumstances are. The va planning to do the schedule but Washington State is one of the areas we expect the va to look for elasticity, helpful with the appointing side, to do so. Questions to submit to the record. Without objection. I want to thank chairman moran and senator tester, i cant imagine anything more important than increasing the quality of care, maintaining the quality of care going forward. And access to care which is what this is about. We had a significant backlog regarding reimbursement. Recognizing what changed the reimbursement plan for providers placing a heavier burden, can you provide the committee an update, reimbursing you for care to Community Care providers and are there any challenges that we can be helpful with. That is the bottom line. You are not going to have your providers. Prior to launching the three regions, one of the significant areas of getting providers into the network was the challenges of the past. I can report we are in a good place, we are paying provided first and 11. 9 days, almost 99 of the time and the va is reimbursing us around 7 days so that system is working right now and we keep a close eye on it because it is how we retain high quality providers. In arkansas, it is great. Other providers had a longterm relationship with them. For a veteran hers current provider is not in the network, what does this transition look like . How can you provide continuous care for veterans under the circumstances . Continuity of care which we know is so important in healthcare, very personal relationship with your provider. One of the things we have done is asked the va to prospect of the identify those individuals that do have a relationship that there is ongoing authorization and analysis to see whether or not there is a gap in their network and where there is we can look to evaluate does that provider meet the new standards of being a fully credentialed provider meeting those standards and we bring them into the network and when we meet every month with 109 dmzs we talk about gaps in care. We talk about where they need us, veterans concerns and that is another place where that can come in and the va has given us their priority providers as well to bring us into the network. It takes time to build Community Care networks to best serve veterans. Based on your testimony it appears weve created a network that serves almost all veterans in region 3. 95 of veterans are able to reach an urgent care facility with average drive time, this is partially a credit for Healthcare Providers. In terms of the process what is the average timeline for a Healthcare Provider to receive accreditation . Is this something that can be improved on. Anything we can do as a committee to help in that regard . Early on when we were first standing in region one we had a challenge in that area, hundreds of thousands of providers going through the system. We are now in better shape having fully operational region one 23 so our averages are between 5 to 15 days, some specialty, 20 to 30 days, the process is working extremely well. Thank you very much, senator blumenthal. I think. Lets go to senator rounds. Thank you, mister chairman. Since optimum is handling the process in south dakota, i want to address my questions to Patricia Horoho. Thank you for your service to the country, continued service as your work, there seems to be a little bit of a disconnect between what you shared with us today regarding the working environment you find yourself in with the va, by this hearing. With regard to what folks on the ground in south dakota share about the availability of the networks and the Networks Prior to participation and a lot of the disconnect i am hearing today. I heard from large and small providers the are the amount of bureaucracy in the network, in 3 occasions, Va Medical Center referred them to a try west network provider, was denied them once they had been there. The administrative delays moved into the network and in this case veterans were denied access to care by those providers because they were not in the network anymore, and we had a discussion here today. It is critical. And analysis of whether what we were seeing on the ground. And their success rate leaving out critical numbers in the middle of it somehow suggests there are people getting left behind and it appears to be a bureaucracy problem. I want to hear from you what you are saying, the most frustrating part for you, there are frustrating parts of working with the va, these former providers. I would like to know what it is, are the guidelines public for being an acceptable provider in your network that might have excluded those from the previous network. Myself and the team will meet with you and lay up the data so we can have a further conversation about it but if i can address the concerns you raised i will address first what it takes, when we started to roll out Community Care, not trying to replicate the network because Community Care changed the standards and made it a mandate to make sure the network was prudential. Not only are they licensed but had to do prime source verification on National Practitioner data bank. We had to look at their education and licensing, made sure there werent any challenges and issues from any agency out there. If they meet those requirements and their is a gap in care absolutely we bring them into the network and if theres continuity of care issue we bring them into the network. That is a standard and that is what it takes to get into that network. The frustration you raised is in regions one 23, we dont do the scheduling, it is done by the va, the First Priority is to look at those practitioners that are part of regions one 23 to be able to schedule those appointments so part of the transition we just finished doing with their regions. The overlap we did, when we went live we did a 30 day overlap to ensure that there was no gap in care but that allowed the va to look at the systems and see the providers and try west and they may have scheduled one or the other tied into planes being put into the system that caused the confusion. On all the data what you are pointing out his we have a problem with this transition, veterans denied care and i dont think it is a once in a while issue, the extra step to cut through the bureaucratic red tape and another part of this we have to talk about, they go back in and allow a revisit of the claims over 180 days old and your commitment as well to do the same thing. We have folks out there who provide services. It looks to me like the transition has not been the superclean nor would we expect it to be superclean. Providers holding the bag and certainly dont want our veterans on the short end of being able to get services with the individuals appropriately providing them with services in the past and that means as you transition into this you have to go the extra mile. I would like your commitment that you will look at that 180 day rule, veterans have the continuity of care. If you can give me that commitment we can move forward. I can tell you we are doing that right now. Everyone has claims that yet denied. We actually look to see the reason before it goes back to the provider. Weve been doing an internal code to make sure it gets routed appropriately happening at the beginning but when we realized the confusion that was occurring that was occurring when you had multiple thirdparty administrators in one market we have made that commitment and we are doing that, you have my commitment. Has that change occurred in the last week or so . Weve been doing that probably for the last several months. That really is and important point. Senator blumenthal. Thanks for being here to all of you. I am disappointed as senator moran and tester expressed that the va is not here. I am also disappointed that the va has declined to answer a number of questions we have asked regarding the racial despair ready and impact of covid19 on our veterans. 7 months into this devastating pandemic, 3667 va patients of died which is a devastating average of 17 veterans every day. We are at the beginning of another surge. Theres been a 50 increase in active cases at the va compared to last month. I will say i am proud of the va facility in west haven because they have done prompt testing with rapid results using the pcr process. A model for the whole country. The infection rate at rba facility was much lower than the national average. There is some good news even amid the more discouraging facts but the results of a recent va study showed black and hispanic efforts are twice as likely as white veterans to test positive for covid19 at the va. My guess is not only infection rates but also death rates show the same despair ready. The va has refused to communicate with congress, questions sent to the va in june were completely ignored. A followup letter sent by committee in august. Satisfaction with this refusal to answer our questions. The va does a tremendous disservice to veterans when it refuses to communicate with members of congress and have a responsibility for oversight and refused to come to hearings as it has done today. I would like to ask all of you but particularly Patricia Horoho how the covid19 pandemic has affected your operations as facilities in your network had adequate access to covid19 tests, reliable tests with prompt results and personal protective equipment. Thank you, senator. If i could take one second before i answer that and talk about Health Disparities because that has been so important, one of the things, my company is a Data Analytics Consulting Health service and logistics and technology company. We developed a Health Disparity data analytical tool that weve been using since covid19 started, 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 weve done stop covid19 where our company has an philanthropic work providing testing for free and education wraparound packages to help with that. We also reached out to the va and offered that capability because i agree with you. It is a population that is extremely extremely vulnerable. To answer your other question a couple things we did when we looked at our network being so tied to the Enterprise Network in making sure providers are financially stable enough to keep operations going, we have accelerated over 2 billion in payments to doctors and hospitals that are serving veterans to make sure financially they were stable. We donated over 100 million to support covid19 impacted at Risk Communities and worked in partnership with hhs to disperse 100 billion of the cares act providers and we did that because we knew this Robust Network of 830,000 practitioners not only provide care for veterans but care for americans and we wanted to make sure that was stable. We utilized and leveraged a lot of telehealth prior to covid19, only 1216 actually use telehealth and now we are up to 12,000 a month and so most of those were Behavioral Health, 30 and we are starting to see the system coming back to normal and being able to improve access. Thank you very much. On behalf of the chairman, senator blackburn. Senator blackburn . There we go. Thank you all so much. I appreciate your coming to the hearing. I really want to thank Elizabeth Dole for advocacy. This is something that from our veterans we hear a good bit about. We thank you for that. We began managing the Community Care network in tennessee earlier this year and let me say right now i really agree with chairman more ands statement, we are disappointed the va declined to participate in this and look at the progress we have had with this network. I will tell you i am optimistic that we are going to be able to expand care to our veterans, especially those in rural areas that are qualifying for care and we are seeing an increasing number of those that retire out from fort campbell. They choose to stay in tennessee because of its geographic location, also because no state income tax and the Community Care is something that is vital for them and i want to focus today on the caregivers. We know in the past, we have had problems in tennessee with the va excluding veterans and their caregivers from the program without justification and without them knowing why, senator peters and i expressed the team caregivers act which would put into law some guidelines to this program to be sure it doesnt continue to happen. We think of those standards are going to be vital and it takes steps to recognize the caregivers, their access to the Electronic Health records. Mister schwab, in your testimony you mentioned caregivers we know that they are heroes but i will tell you they ought not to be hidden. Certainly when it comes to having access to veterans medical records because this is one of the issues that we had in having that precise, timely coverage. Lets Work Together and be sure they are not going to be Hidden Heroes. Let me ask you a question, Mister Schwab. In tennessee with our caregivers program, what we see is we have many that are there because of ptsd and traumatic brain injury. What we term invisible wounds. Lets talk about the activities of daily living criteria that have been set by the va and talk to me about how that could negatively impact veterans eligibility for the Caregiver Program. Thank you for the question and the work your call for consistency, access to health records, i will echo something in my testimony that we responded with in our answer earlier. The definitions that were established with respect to mental and emotional wounds, causing inconsistency around eligibility. I will ask my colleague molly ramsey to expand on this for your purposes as well. Standardization of those conditions is really really important and we will continue to see people being booted in and out of the program. Do you want to add a little bit to that . Absolutely. Thank you for that wonderful question. With the requirement of assistance activities, daily living, each time at least one activity in daily living is performed, that focuses on the physical, the va his word safety and supervision on a daily basis. Caregivers and veterans, with my father, each time on a daily basis, you could go a couple days where your veteran is able to remember to put into the microwave. They are able to do that sunday but maybe not wednesday because that is how it can work. There are instances where someone may be able to transfer themselves from their wheelchair to use the restroom or their chair or their bed, they are not able to do that. So that each time we understand it is limiting, it would be great if the va could clarify to the caregivers, that seems to be a gray area is specially with the fluctuation of needs of assistance and especially the ptsd and other neurological caregivers, monitoring triggers every single day is something many caregivers do and it is not the supervision but must be true that they are able to function, parents or grandparents, to be able to be a good spouse or friend. Those are the things we are hearing from caregivers in our network. We look forward to working with you and wholeheartedly support the list you are working with. As you can see, senator murray has questions on lack of standardization and lack of caregiver to understand why there are these ambiguous reasons for discharges and veterans rated 100 disabled and still be moved out of a Caregiver Program and it is very frustrating and could be important that we get these straightened out. Jamie beller, first of all, thank you for your husbands service and your dedication and service to our country. I appreciate the daily routine as you gave testimony. I would like to hear from you very quickly. Talk to me about what has changed for you since to talk about the uncertainty that exists with the program or your fear or concerns with the program. Youve got about a minute. My life is drastically changed. I left my career and that changed a whole lot. To enter the program, i have been interviewed, almost exclusively, needs a lot of care in this situation. What is so concerning, literally protection of their federated maintaining trigger levels, keeping things calm, keeping that veteran alive in preventing spirals that can lead to keeping the veterans safe. Im hearing on social Media Networks exactly what you said that people are being dropped, people are not communicating. Their work is not valued. That is very concerning because their value is greater. If i could add a point, you brought up an important notion in your earlier comment. A really Large Program called the campaign for inclusive care, one of the fundamental issues is an inconsistent set of protocols clinicians use to interact with caregivers. Molly ramsey mentioned when a veteran go through disability rating interview the veteran may be having a particularly good day on that interview with the caregiver is not always left in the room when those questions are rendered, when 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. It means when husband or wife feel they are having a good day their spouse by their side to say you have had a couple bed weeks before we walked in today and last week you had one of your mental or emotional episodes, really important for the va to be aware of. Thats why your bill and legislation like the legislation you put forward is so important to create levels of consistency in the ways the va is interacting with veterans and their caregivers and we appreciate your continued leadership on this issue. I appreciate that. My apologies for my time running over. Thank you, the bill you were discussing cleared on the hotline yesterday or today so progress in that regard. Senator brown is next and others in my ability to wrap up the concluding questioning, senator brown . Thank you, i appreciate your calling this hearing and some important questions i would like to ask the department. Too much par for the course, i appreciate what you said in response to senator blackburn about caregivers being in the room. I had not through the way you said it. Thats a way to learn from witnesses. My first question for steve schwab and thank you for your testimony on a caregiver support program, up priority for a decade. During roundtable discussions and meetings, a number of roundtables with veterans, my staff does more work than i do where they sit around the table and listen to veterans who need critical support, this help is immensely helpful program, we know veterans who served after 1975, before 9 11, have to wait another 2 years, this shouldnt be the case. The va should be here to answer questions about delays and implementation. My question for each of you, you discuss the need for greater communication between the va and the Veterans Community it serves. My understanding is the va ignored input from that community before finalizing the rules to expand the Caregiver Program. In addition to the adl threshold, what is the one thing you wish the va had included in the final . That is a great question and thank you for the work youve been doing across the state to listen to veterans and their caregivers. Really appreciate it. I would suggest evaluation and consistency around evaluating eligibility is our number one concern. I addressed an ongoing concern with implementation of the mission act. As i addressed in my testimony we would love your support on this. My boss, senator Elizabeth Dole, former member of the senate put forward a recommendation in her work sharing an august group of leaders at the va to introduce legislation to speed up this expansion. And as you rightly noted, that is way behind a lot of veterans being left out for now. We love a legislative solution, the phase eligibility and just include everybody in the expansion. I like your years of service for our country, you waited far too long, for additional assistance and support. I appreciate your testimony where you outlined the stress caregivers go through during the application process, and the additional meetings and interviews, medical records illustrate the support so thank you for your speaking out in the courage youve shown in the service and appreciate the testimony. Thanks so much. Thank you, mister chairman. I have a few questions for our witnesses. Let me start with caregivers. Mister schwab, ive seen the rand report listed by the elizabeth stall foundation, supporting caregiver Mental Health concerns, in 2014, i also know the topic was discussed during the annual convention you held last week earlier this week. What is it you would ask for the Mental Health and wellbeing of caregivers, is it related to implementation of the act or is there something missing, this committee has indicated, to fulfill our stated priority of Mental Health and Suicide Prevention for veterans, it is a reminder to me at least we need to make certain when we talk about Mental Health Suicide Prevention for veterans, we are to include in the thought processes, caregivers are helpful to them. What would you like me to know . I would say three things in response. I would ask the committee to consider legislative removal of phased expansion of the mission act so all pre9 11 caregivers receive their benefits right away. Around your question on Mental Health, as you noted we commissioned and published a study in 2014, almost 67 years old now but the data rings true. One of the things the study called for was more robust longitudinal studies, research and data, we have 0 longitudinal data. The spouses family, friends, loved ones providing free athome care, a new civic and patriotic responsibility that will be here forever and the committee needs to invest in understanding implications on those loved ones, something you said, around suicide, caregivers are the last line of defense in preventing veterans suicide. We believe enough is not being done to understand the unique role caregivers can play in prevention, the roundtable and organizations to talk about ways that the va and the dod can more directly support Mental Health needs of caregivers. One way to do that is to embrace and expand the campaign care, working with the va to implement a series of training and protocols that will encourage clinicians to engage with and support caregivers throughout the care process. It is a very disjointed engagement, no requirements for the way Caregivers Work with those providers. I apologize. Those are the three things i would suggest are vitally important for the committee to consider. I wasnt sure whose phone that was. I was going to scowl at one of my colleagues that from you it is just fine. Thank you for your testimony and your suggestion. Let me ask jamie beller a similar question, with regard to caregivers. You heard what Mister Schwab said, one of the challenges we face is lack of professionals, the john cannon act gets resources to Community Caregivers which is a standup new program to help particularly in rural or isolated places. What would you ask about the Mental Health and wellbeing of Suicide Prevention not only of the veteran. Providing more resources for Mental Health issues i have been to counseling during the 10 year journey to build resilience and make sure i am capable of taking care of my veterans and that is critical because there are studies or indications the caregiver can develop secondary ptsd, and these issues are very real. I know caregivers who committed because it is very isolating and very lonely occupation but with organizations like the Elizabeth Dole foundation, raising awareness and alleviating the struggle. You are a very articulate and compelling witness and i appreciate your presence with us today. Thank you for doing an Additional Task of testifying before the committee. Let me return briefly to the network issues. Neither one of you indicate you have knowledge whether you will move in the effort to modify their contract. If i misunderstood or you have Additional Information than you have told me i would like to know if you have any indication the va decided not to modify their contract i would then add this question or this argument, the va testified they have sufficient Budget Resources to modify the contract. It is not a budget issue. You both testified a fair summary that your networks are expanding voluntarily to meet those standards so what would you say as a justification for not having a uniform standard suggested by the mission act. What am i missing here . General . Just to share the conversation, not to speak for the va but to share conversation is some of their concerns, when you look at the shortage of providers and some geographical areas, veterans choice because some veterans are willing to drive a distance to see a particular provider who is part of Community Care there is a perception it would be overbuilding by some of the stringent drivetimes in some geographical areas and thats part of their hesitancy moving in that direction. Weve looked at it through the lens of what we spoke about, wanting to ensure we blanketed a geographical area as much as we can utilize utilization data, where veterans as part of the concerns they raised. And it makes it very hard to accurately predict what people like to do with their decisions as Patricia Horoho said, we are developing network matched to what we believe is the analytics in the 7 year journey with the va what likely will be sufficient to make sure there is enhanced access and availability where it is needed. Probably the best example of the collective success birthed between congress, the va, rests in harlingen texas, where you used to have to drive 7 hours for care beyond or go without, today, with Community Hospitals and all the providers of that community decided to see bok expanded and no one drives or goes without and every kind of care is available, and more than 400,000 employment done to the valley in texas in that comprehensive network. Thank you for outlining what the goal is and indicating it can be achieved. 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, that veterans will potentially, some veterans will become discouraged not able to get the care they need and if we want to convince veterans that the mission act, the successor to the choice act, is here to stay and its for their benefit, and we have to build to a standard that doesnt discourage anyone from using choice, using mission. And the fact that the two of you, your networks have indicated you are going to build to the standards demonstrate to me why y theres value of having standards. If we didnt have those words in the mission act i dont know what you are building too. I guess you would be building to what the v. A. In such a bill to of your contract. But in my view you would be missing the opportunity to further serve veterans who live in rural or have a particular reason why they need care closer to home. It is confusing to me because the v. A. Has indicated in their testimony and in their conversations with me they are pursuing this, but more recent stories indicate that the v. A. Is not interested in increasing the standards within the contracts. And so while it is about the provisions of the mission act being utilized by the v. A. Is much more about caring for veterans and making certain that they have confidence that the mission act is fulfilling the needs of those veterans when they didnt see it with choice in some circumstances. So i want my veterans in kansas and across the country, i want veterans to know we have not got them in a position in which they can access the care that they need and is close to home. And if we fail them one more time in reality or in image, we are doing a a disservice. One more thing to distrust that they say i have benefit but it dont feel it or see it. Theres a real consequence to us not meeting the needs of veterans now for second generation, maybe a m third or fourth iditarod should of Community Care. It does matter i think greatly and we will continue to have this dialogue. Senator tester has returned. I have one more question i think but let me turn to senator tester and then i will try to wrap up as indicated earlier. I talked to a long and the Ranking Member returned to time get more conversation. Senator tester, i was when i left the commercens committee yu would ask any question about longdistance Passenger Rail service that i asked. Iou was seen as an annoyance because you and i had the same line of questioning, and then i heard you were filling in here in the committee as chair sharg todays hearing. That immediately caused me to lose interest in being in the Commerce Committee and rushed back just in case youre thinking this was a more longtermus circumstance than im hoping. [laughing] mr. Chairman, i would never think that, number one. Number two, it scares the hell out of me to think that you untie on the same page when it comes to asking questions. But i do appreciate the opportunity to ask one more question. Ill try to make this as painless as possible because i know this is been a long gearing and they do appreciate all 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 just a thank you to you, mr. Chairman and the folkses today o testified. Senator tester, thank you. Again, thank you for participating today. Thank you to our Committee Members and their interest in this. As we try to make certain we implement title i of the mission act appropriately. I appreciate hearing from each of you as a thirdparty administrators. Im pleased to hear more about caregivers and the testimony that i heard today is very useful and appreciate the challenge was given us, here are the things that need to be done. I would now asking endless consent members have five legislative days to revise and extend remarks and include any extraneous material. If we submit any questions to you please answer them as quickly as possible. Theres a couple of things that you said you would get back to us with information and would welcome that and encourage that. With that hearing is now adjourned. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] coming up live on thursday at 9 a. M. On cspan, the Senate Judiciary Committee Votes on whether to send the Supreme Court nomination of judge Amy Coney Barrett to the full senate for consideration. Democrats have announced they will boycott the meeting. And 19 e. And the second and final president ial debate on Belmont University in nashville, tennessee. On cspan2 at 10 45 a. M. House Speaker Nancy Pelosi holds for Weekly Briefing with an update on Coronavirus Relief negotiations. The Senate Returns at noon eastern. 1 p. M. Members vote on limiting debate on the nomination of Michael Newman to be a u. S. District court judge in ohio. Booktv on cspan2 has top nonfiction books and authors every weekend