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

[inaudible conversations] good morning, everyone. The committee will come to order. I welcome our witnesses in person at those appearing distantly. We look forward to the testimony and getting a better understanding of where the department of Veterans Affairs and the thirdparty administrators are in administering the mission act. Also very interested in hearing more today about the caregivers implementation as well. Almost every member of our committee though not physically present at the moment, some are joining us in person and others will be joining us almost every member of the committee will be participating. The focus of todays hearing is the implementation of title i under the mission act by the department of Veterans Affairs, relating to the Veterans Community care program and the program of comprehensive assistance for family caregivers. Io i scheduled this hearing because of my dissatisfaction with the pace of mission implementation. While v. A. Officials were invited to participate iny todays hearing to discuss these critical programs they oversee, the department chose to decline our invitation. This committee and the v. A. Shared the 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 herere for this conversation, to share all they have accomplished since the v. A. Was transformed with this legislation and to discuss what needs to be improved. The v. A. Is an integral part off this dialogue which is why i plan to schedule a subsequent hearing with va officials tohy discuss title i implementation. I would be remiss to not recognize the unprecedented challenges of this year due to the covid19 pandemic. The dedicated staff on the v. A. s frontlines deserve both our thanks and recognition for their essential role in caring for veterans and in fulfilling v. A. s fourth mission. However, at a time when accessing health care is of the utmost importance, the v. A. Has struggled to uphold the mission acts requirement of providing t veterans access to Community Care. My staff and i continue to hear complaints from veterans and providers related to poor. Communication, lapses in continuity of care, and network inadequacies. Third party administrators, like triwest and optum here with us today, are valued and essential partners in the delivery of care to veterans through the Community Care network. They play an Important Role in building a robust and resilient Community Care network that is able to provide veterans timely access to care and make Certain Community providers receive prompt payment for the care and services they provide. When the v. A. 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, my staff and i have since learned that v. A. s contracts with third partyan administrators use a completely different set of standards to determine how veterans access care. Under the contract terms, rural and highly rural veterans could be forced to drive up to 3 hours for care, which is completely unacceptable and contradicts the spirit of mission. Ive discussed this inconsistency with va officials but despite v. A. s assurances publicly and privately, it is uncertain whether the v. A. Has modified the terms. We hope to learn more today. It appears to meet possible veterans have different access for care certainly than the law, the mission act requires, different from the regulations of the v. A. And perhaps different from based upon the contact visit to visit based on the contract terms of thirdpartyhi administrators. As i i said we hope to learn me about this today. The Community Care network is central to the mission acts aim to transform v. A. Health careo into an innovative and responsive 21stcentury Health Care System capable of addressing the challenges veterans face today and providing access to the care veterans deserve under this law. As such, i want to ensure that mission act success and utilization of the Community Care network is accurately accounted for because there are sufficient numbers of local providers in the network for veterans to utilize. Ed much has changed in our country since this Committee Held ars hearing on the implementation of the Community Care Network Earlier this year, but the intent and goal of the mission act has not. We remain committed to making certain that veterans who qualify for care in the community are able to get that care, without unnecessary scheduling delays, through a mature and geographicallydispersed network of Community Providers that upholds v. A. s access standards, and that those providers are paid in timely manner. Congress has the responsibility to oversee the v. A. s execution of the laws that govern the agencys responsibility to serve veterans and we take this responsibility seriously. I believe some of the v. A. ste most Senior Leaders might agree with me that while progress may be underway, it must move faster to enable the Community Care network to serve veterans as we all envisioned. I want to know how the v. A. Is making progress in working with their third party administratoro to transform the v. A. And offer veterans access to the healthth care they deserve. Another essential component of the mission act is the expansion of eligibility for the program of comprehensive assistance for family caregivers to all generations of veterans. Many caregivers have been providing essential services for their loved ones without this support for years, and in some cases, decades. As veteran caregivers are often the main caretakers for their loved ones, many can experience depression, anxiety and other Mental Health conditions attributed in part or solely to their experience of caregiving. The stress associated with caring for a spouse or Family Members with complex Health Care Needs is a real and present concern for veteran caregivers. It is essential that in v. A. s support for caregivers, these Mental Health challenges be addressed effectively. Mission outlined a twophase process to expand these supportive resources with an anticipated start date of october 1, 2018 for phase i. Phase i implementation only just began on october 1 of this year, two years behind schedule. This delayed rollout will result in caregivers needing to wait even longer to be part of this vital support program. I look forward to hearing the testimony from everyone who will be taking part in todays hearing about issues that you face in your work to help care for and serve veterans, and steps the v. A. Can take to make certain both of these important programs are functional and ablo to deliver good results and outcomes for veterans and caregivers. I apologize. My Opening Statement is longer than the usual practice, but i had sufficient desire to say a few things this morning as we begin this hearing, and i dont want to yield to the Ranking Member and author, senator tester. Thank you, mr. Chairman. I want to thank you for holding todays hearing, and im looking forward to the discussion among our panelists of witnesses but i, like you, and very disappointed the administration chose not to participate in this dialogue. I do not know why something as important as implementation of the mission act doesnt rise to that important in the v. A. 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 take action immediately. Our foundations also strongly urges the v. A. To standardize expansion implementation. The largest source of caregiver anxiety and dissatisfaction has always been the inconsistencies between v. A. Centers. 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 c determine if i like. Mister mcintyre. I will commit i will reach out to every office thats on this committee to inform you of the communications the va and us have put together and to help you understand the information that might be used to outreach to providers in their state and make patty aware of the same thing because our commitment before we fully leave the errors that she stood out is that all the claims are paid, even those that were not otherwise done in our watch but might have been done in the health space i could add to that you complete scenario on it. What weve done internally as well, so we are up late paying claims 11. 9 days but when we get claims that are either try west or if it was, if its thealth net at that time we got an internal code. We put the code on it it gets routed back and we work closely with triwest so we try to takeaway the friction with our providers. Thanks for raising these topics and i know recognized senator murray. Thank you very much. Iappreciate it and Mister Schwab, thank you for your incredibly important testimony and your recommendation today. I want to thank the foundation for their dedication to our veteran caregivers and mrs. Beller, thank you for all you do both as anadvocate and a caregiver. Im so grateful to my colleagues for their support and passion in the caregivers legislation as part of the va mission to finally expand the program to veterans of all eras. Now weve got to get this extension right and make sure currentparticipants are not getting unfairly pushed out of the program. Back in may i joined senator tester in a Public Comment letter to the va regarding the agencys proposed changes to the Caregivers Program which would restrict eligibility and potentially remove some veterans from 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 and they included other Eligibility Criteria such as supervision, protection or obstruction. Make sure those would be visible so those who need assistance can get. However vas new rule goes beyond congresss intent to further limit eligibility. So Mister Schwab i want to ask you do you believe the defining eligibility too narrowly when compared to the eligibility of classifications outlined and how will those new limitations rated at 75 percent affect our veterans . Thank you for the question and thank you for your leadership going back years on advocating for the expansion program. You were among 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 highlightedin my testimony. The program even before expansion was inconsistent at best in integrating, including and caring for folks who are caring for a veteran with emotional, mental and Emotional Health care injuries. We guess we do believe that the balloon the va has gone beyond the interpretation and the ways that its implementing eligibility for folks who are caring for mental and emotional wounds. I think my colleague mollyif i could refer to her senator could expound on this point as well. Thank you so much senator murray for everything. As steve mentioned we do believe that the va has gone a little further than the institute of what was put in of the initial caregiver bill. We are hopeful that they treat invisible wounds such as ptsd, any other neurological or emotional or Mental Illnesses as equally as the physicalneeds. Or physical assistance with adls. We have been told the va will look into, make sure our weighing safety and supervision as equally as the physical assistance with the activities. However some caregivers that we had in our network have wexpressed concerns about tha. You bring up a good point also of the 70 percent requirement. That was something that we were surprised to see. In the initial Impact Analysis that the va provided they did assure the community that 95 percent of what they are considering legacy participants as well as veterans who are already receiving sassistance would meet thequalification. However , that is possibly the lower bar of eligibility requirements. There is a functional assessment need and as jenny beller so eloquently put, the twohour interview process. Those are the higher parts of the eligibility requirements that we are concerned with. Thank you mrs. Beller, thank you for your testimony and weve got to get this right and im not going to give up and thank you for your recommendations and i lookforward to working with you. Weve got to keep working on this but i very much appreciate. I have a few seconds left and i wanted to ask about ibs to Mister Mcintyre. This is really important to me that veterans facing fertility challenges have the smoothest experience possible and connecting with the ivf provider that matches their families needs and i continue to have concerns about approvals from the va being delayed and im troubled by how it will affect the scheduling process for these families. Ive heard that the va will soon be assuming full responsibility for scheduling appointmentswith the Community Providers. As opposed to the network administrators. Mister mcintyre i want to ask quickly what have youdone to be most important in getting this done in a customized way that fits . Senator, thank you for that question. And your leadership with this important topic. It is true that the va 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 Piece which is customized fully for the needs of that couple. Where it would come to understand what their authorization is and what their circumstancesare. At this point the va is planning to do the scheduling but Washington State is one of the areas that we expect the va to look to us for elasticity on appointing and if we can be helpful with the appointee to assist them, we certainlywill do so. Mister chairman i have additional questions i wantto submit to the record and i appreciate if you would allow me to go over time. Without objection. I want to thank chairman moran and senator tester for having the hearing. I cant t imagine anything more important about increasing the quality of care, maintaining the quality of care we have and again Going Forward and also access to care which is really what this is all about. I know that we had a really significant backlog in regarding reimbursement inthe past. Weve worked hard to get that down. General, recognizing that the mission act changed the reimbursement plan for providers putting a heavier burden on the tpas like optumserve upfront, can you come provide the committee an update on how the committee is reducing care to Community Care providers in your network and are there anyin challenges that youre facing that we can be helpful with . I think thats really the bottom line. Youre not going to have the providers. I could not agree more and prior to launching the three regions one of the significant areas of getting providers into the network was because of the challenges of the past. I can report to you today that i 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 percent of the time and then the va 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, optumserve now is in arkansas and has taken over which again is great. Theres concern about people that are under other providers that have had a longterm relationship with them. For a veteran whose current provider is notin the network , what does this transition looklike . How can we, how can you help provide continuous care for veterans under these circumstances . Thank you for that question real continuity of care which we know is very important and healthcare is a very personal relationship with your provider. One of the things weve done is weve asked the va to prospectively identify those individuals that do have a relationship tthat there is ongoing authorization and then the analysis to see whether or not there is a gap in the provider being in our network and then where there is, we can look to evaluate does that provider meet the new standards of being a fully credentialed provider . Meeting all those standards. And where able to bring them into the network. So when we meet every single month with 109 emcs we actually talk about care, we talk about where they need us, we talk about veterans concerns and so thats another place that that can come in. And actually the va has given us their priority providers as well for us to bring those into the network. Very good. We understand it takes time to build Community Care networks to best serve veterans. Based on your testimony general, it appears that optumserve has been able to create a network that serves almost all veterans in region three and thats very commendable. You said after region 395 percent of veterans are able to reach an in network urgent care facility within a 30 minute average drive time. This is partially a credit to optumserves ability to officially credit Healthcare Providers as part of your network. In terms of the process, whats the average timeline for a Healthcare Provider to receive accreditation by optumserve . Imis there anything we can do as a committee to help inthat regard . Thank you senator. Early on when we were first standing up region one we had a challenge in that area because we were bringing on hundreds of thousands of providers so it really was a large volume going through our system area that we are now in a much better shape having fully operationalized region one, two and three so our averages are between 5 to 15 days, sometimes theres some specialty like visions that may take a little bit. 20 to 30 days. But thatprocess is actually working sextremely well right now. So i dont think theres any assistance we need from congress. Thank you very much andnow we will go to senator blumenthal. I think. Well, we are going to go to senator rouse. Thank you mister chairman. Since optumserve is handling the processes within south dakota, id like to address most of my questions to general horoho. Thank you for your service to our country. And i appreciate your continued service as your work with optum. There seems to be a disconnect between what you have shared with us today regarding the working environment that you find yourself in with the va 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 a lot of this is alittle bit about the 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 in the network and once in the network to get paid. On at least three occasions a local Va Medical Center has referred them unfortunately to a Triwest Network provider who had been there with years of service but theyre being denied then once theyve been there and it appears to be just administrative delays in getting them moved into optums network and in this case those veterans were denied access to care by those providers because they were not in the network anymore. And that most certainly is something that as youve indicated earlier and we had a discussion here today is something that is simply not acceptable and that care is critical. So what im going to ask is i think weve got to have an analysis of whether or not what were seeing on the ground in terms of Ground Troops versus having perhaps a 90 or 95 percent success rate, thats leaving out those critical numbers in the middle that somehow suggest that there are people that are getting left behind and it appears to be a three bureaucracy problem and what id like to do is hear from you what youre saying in terms of whats stopping perhaps the most frustrating part for you and im sure there are frustrating parts about your working with the va and trying to get through with your team these former providers to get themin and finally ill let you answer , id like to know what it is that are the guidelines they publish for being an acceptable provider in your network might have excluded those from the Previous Network . That you senator and i will absolutely myself and the team will come to meet with you and lay out the data for your areas so that we can have a furtherindepth conversation with it. But if i can address some of the concerns that you raise. Ill address what it takes to become in the network and so when we started to roll out too many care, what we went forward with his not trying to replicate a network that was pc three choice because Community Care changed the standards and made it a mandate to ensure that it was fully credentialed. So not only did they have to be licensed but we had to do prime source verification on the National Petitioner database. We had to look at their education, looked at their licensing, make sure there werent any challenges and issues either from any agency thatwas out there. If they meet those requirements , and there is, if theres a gap in care absolutely we bring them into the network or if its a continuity ofcare issue we bring them into the network. So thats been the standard and thats what it takes to get into that network. The other piece i want to bring out to some of the frustration that youve raised is we in regions 12 and three, we dont do the scheduling area the scheduling is done by the va 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 so some of that frustration may have been when there were the overlap which we did all the right reasons the veterans is when we went live, we get a 30 day overlap with triwest to ensure there was no gap in care during the transition but that also allow the va to look into the system and see the current optum providers as well as triwest and they may have scheduled one or the other which 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. What youre pointing out here is that we do have a problem with this transition and i think the folks that are holding the bag on this are veterans that may well have been denied care and i dont think its been a once in a while issue area i think its happened on several different occasions and i think were going to have to go the extra step to cut through that bureaucratic part of this were going to have to talk about and i like the fact that triwest has come up with that theyre going to have to go in on a revisit on those claims that are over 180 daysold and id like for your commitment that you will do the same thing because were going to have that problem. Weve got folks that have plans over that time, they provide the services and so it looks to me like this transition has not been super clean and nor would we expect it to be super clean. But i dont want those providers holding the bag and i certainly dont want our veterans on the short end of being able to get services ivwith the individuals that have been appropriately providingthem with services in the ipast. And i think that means that as you transitioninto this , i think youre going to have to go the extra mile and focus on those veterans and id sure like your commitment that you will look at that hundred 80 day rule the same as triwest and workgroup to make sure they have the economy ofcare where we have a problem. And if you can get me that commitment i think we can move forward i can already tell you where doing that right now every one of the claims that denied we look to see what was the reason before it goes to the provider. We have been doing an internal code to make sure that it gets routed appropriately. That didnt happen at the beginning but when we realize the confusion that was occurring with like triwest, when you had multiple thirdparty administrators in one market until it was fully transitioned, so we have made a commitment and we are doing that. So youve got my commitment that it will continue. As that change just occurred in the last week or so . We been doing that actually probably for the last several months. Thank you again, that really is an important point. Senator blumenthal. Thanked mister chairman, thanks for being here. All of you, im as disappointed as senator moran and tester have expressed that the va is not here. Im also disappointed that the va 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. Months into this devastating pandemic, 3667 va patients have died. Which is a devastating average of about 17 veterans every day. Right now we are apparently at the beginning of another surge. Theres been a 50 percent increase in active cases the va compared to last month. I will say that im proud of the va facility in west haven because they have done, testing with rapid results using the pcr process, to be a model for the whole country and the infection rate has been much lower than the National Average and i want to point out there is some good news even amidst some of the more discouraging facts but the results of a recent va study has shown black and hispanic veterans are twice as likely as white veterans to test positive for covid at the va. My guess is that not only infection rates but also death rates show the same disparity. The va has reviewed to communicate with congress th about this issue. Question sent to the va in june were completely ignored. As was a followup lettersent by the committee in august. I join my colleagues in expressing grave dissatisfaction with this refusal to answer our questions. The va 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 the hearing as it has done today. So i would like to ask all of you but particularly general horoho how the pandemic has affected your operations in particular at the facilities in your network had adequate access to tests, reliable tests and results and personalprotective equipment . You senator. If i could take one second before i answer that onand just talk about Health Disparities because that hasbeen so important. One of the things that optumserve, my company is actually a Data Analytics and technology company. We padevelop a Health Disparities data analytical tool that we have been using since covid started that we can go down to the zip code level and identify those american or disadvantaged or at high risk for covid19 based on their Health Disparities and we done stop covid where are companiesthat work in providing those testings for free as well as education , wraparound packages to help them with that. Weve also reached out to the va and authored that capability to be able to utilize that as well because i agree with you , its a population that is 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 our Enterprise Network and making sure that providers are one, financially stable enough to keep their operations going and so weve accelerated over 2 billion in payments to doctors and hospitals that are also serving veterans that we made sure that financially they were stable. We donated over 100 million to support covid19 impacted at Risk Communities and then we work in partnership with hhs to help disperse over hundred billion dollars of the care act providing relief and we did that because we knew this Robust Network of 830,000 practitioners are not only providing care for veterans there providing care hefor americans. And we wanted to make sure that was stable. What were seeing is that we utilize a lot of leverage a lot of telehealth prior to covid. Only about 12 to 16 actually use telehealth as referrals and now were up to 12,000 a month. So most of those were Behavioral Health, about 31 percent and were starting to see the systems 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. Thank you all so much. I appreciate your coming for the hearing and i want to thank Elizabeth Dole for their leadership on caregiver advocacy. Ill tell you, this is something that from our veterans, we hear a good bit about so we thank you for that. Optumserve began managing the Community Care network in tennessee earlier this year and let me say right now, i really agree with chairman moran statement. Thats where disappointed the va doesnt want to participate in this. And look at the progress that 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 the rural areas that are qualifying for care and were seeing an increasing number of those that retire out from fort campbell. They choose to stay in tennessee because of the geographic location also, because of state income tax and the Community Care is something that is vital for them. And i want to focus today on the caregivers and we know in the past and weve had some problems in tennessee with the va proving veterans and their caregivers from the program without justification andwithout them , knowing why they got kicked off the program and senator peters and i have the team caregivers act that would put into law and guidelines and bring some elasticity to this program to major it doesnt continue to have, to. We think those editors are going to be vital and it also takes steps to recognize the caregivers, their access to the veterans Electronic Health records. Mister schwab, in your testimony you mentioned caregivers are Hidden Heroes and we know that they are heroes, but ill tell you they ought not to be hidden. Certainly when it comes to having access to that veterans medical records because this is one of the issues that we have in having that precise, timely coverage lets Work Together and make sure they are not going to be hidden euros. Let me ask you a question Mister Schwab. In tennessee with our Caregiver Program, what we see is that we have many there because of ptsd and traumatic brain injury. And really, what we term invisible risks and 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 caregiverprogram. Thank you for the question senator blackburn and thank you for the work your recent legislative call for consistency, access to Health Records isvital. Ill echo something i said in my testimony and that we responded with in our answer earlier. The definitions that have been established around adls with respect to mental and emotional wounds for caregivers, care of those citizens across veterans, its causing inconsistency around eligibility. Im going to ask my colleague molly to expand on this point for your purposes as well, but standardization of those conditions is really really important and were going to continue to see people being booted in and out of the program asyou been seeing so molly, do you want to add to that . Absolutely, thank you so much that wonderful question. With the assistance of daily living each time that we have one activity is performed, that definitely focuses more on the physical needs of the veterans. The va has awarded as well as and supervision on a daily basis. We know caregivers and veterans who even know one with my father who each time that daily basis you can go a couple of days of having great days where your veterans are able to remember to not touch a warm mug of coffee as its being put into themicrowave. Theyre able to do that someday maybe not on a wednesday. Does that how ptsd can work and also, there are instances where one may be able to transfer themselves from their wheelchair to say, to use the restroom or use a chair or to their bed but there may be sometimeswhere theyre not able to do that. So that each time we understand it can be limiting and i think it would be great if the va could help clarify, especially to the caregivers because receiving a bit of a gray area especially with the fluctuation of needed assistance that they deal with every day and especially for the ptsd and other neurological and emotional caregivers monitoring triggers every single day. Its something that many of our caregivers feel and its not the safety and supervision necessarily but its just that theyre able to function, be able to be home and get parents or grandparents just to be able to be a friend. So those are the things that we are hearing from caregivers within our network and again, we look forward to working with you wholeheartedly support that as well. L. Senator murray has this issue do with her questions that lack of standardization and the lack of caregiver to understand why there are these ambiguous reasons around discharges and a veteran can be rated 100 percent disabled and then still be moved out of the Caregiver Program and it is just, its very frustrating. And its going to be important that we get this straightened out. I bet there are others to mask what ask questions to mrs. Eller first of all thank you for your help and service and for your dedication and service to our country. I appreciate how you talked through the daily routine as you give your testimony. Id like to hear from you very quickly is talk to me about ewhat has changed for you since you became a caregiver, appropriately recognized and then talk about the uncertainty that exists with the program and your fear or concerns with the program and youve got about a minute. Okay, for me my life drastically changed. I love my career that changed a whole lot of just the way our life operated but the care requires that. Inmy situation and attempting to enter this program ive iorequired, ive been interviewed. Chuck situation is such that hes almost exclusively adl what he needs a lot of care. Were in a very obvious situation but was still concerning is the people that as humans incorrectly can have theseinvisible wounds that are literally , their protection of their veterans and maintaining trigger levelsand keeping things calm are keeping that veteran alive. And preventing spirals that can lead tosuicide and keeping that veteran safe. But im hearing on social Media Networks exactly what you said, thatpeople are being dropped, theyre not communicating. Its a sense that their work is not valued and thats very concerning because their value is and part of what ido for my husband is if not greater. Thank you. C if i could just add one point because you brought up a very important notion in yourearlier comments. A really Large Program where advocating for across the va is called campaign for inclusive care. And one of the very fundamental issues that caregivers like jenny face is an inconsistent set of protocols that clinicians use tointeract with caregivers. As molly mentioned when a veteran goes through a disability rating interview, that veteran may be having a particularly good day on the interview. And caregivers are not always let in the room whenthose questions are being rendered , when those answers are dependent on the level of benefits are going to receive. Our campaign and ourprotocols all for caregivers always being included in the room. That means that when a husband or a wife feel like theyre having a good day, their spouses by their side to say you know what, youve been having a couple bad weeks before we walked in today and last week you had one of your mental or emotional episodes. Its important for the va to be aware of so thats why your bill and legislation that you put forward is so important to create e fundamental levels of consistency in the way that the va is interacting with veterans and their caregivers and weappreciate your continued leadership on this issue. Thank you, i appreciate that and my apologies for my time running over. Thank you mister chairman. Senator blackburn thank you and thebill cleared on the highlight yesterday or today. So progress in that regard as i think editor brown is next and then that may be other than my ability to wrap up the concluding questioning. Senator brown. Thank you senator and Ranking Member tester, i appreciate your calling this hearing. I have some important questions id like to ask the department. It seems a bit too much par for the course Mister Schwab and i appreciate what you said in response to senator blackburn about caregivers being in the room. Ive not really thought that through the way you said and thats kind of the point of. Four witnesses. My first questions are for Mister Schwab and mrs. Beller. Thank you for your testimony expanding the caregiver support programs,its been a priority for a decade. During roundtable discussions and meetings i drew a number of roundtables with veterans. My staff does even more than i do where they sit around the table and listen to veterans who need this critical support and their wives and children caring for aging Family Members know that this kind of help is in mentally helpful to them. The program is already a year behind schedule as we know. Veterans who served after 1975 and before 9 11 willhave to wait another two years. This shouldnt be the case. The va should be here to answer our questions about the delays and implementation so my question for each of you Mister Schwab and miss beller, you discussed the need for greater communication between the va and Veterans Community it serves. My understanding is the va ignored input from the community for finalizing a new rule to expand Caregiver Program. In addition to the adl pressure, what is the one thing you wish the va had included in the final rule after slob . Thats a great question. Thank you for it and thank you for the work youve been doing across your state to listen to veterans and their caregivers. Its really appreciated. I would suggest that evaluation and consistency around evaluating eligibility is probably our number one concern but an ongoing concern with implementation of the mission. As i addressed in my testimony senator, we loved your support onthis. My boss, senator Elizabeth Dole, your formal poly put forward a recommendation in her work sharing an august group of leaders at the va to introduce legislation to speed up this expansion. The mission act called for a phase expansion of caregiver benefits and as you rightly noted that expansion is way behind which means a lot of veterans being left out right now. We love a legislative solution and just include everybody in the expansion in the next phase. Thank you Mister Schwab and miss beller, thank you for your years of service for our country. Assistance is important and i appreciate your testimony where you outline the stress that caregivers and veterans go throughasthrough the application process. Ca Mister Schwabs insight into that also, when the medical records and illustrate for support needed so thank you for speaking out and the current youve shownand the service youve givenand we appreciate the testimony of all four of you, thank you so much. Senator brown, thank you. If theres no other senators. I have a few questions for our witnesses. Let me start with caregivers. Mister schwab, ive seen the rand report commissioned by the Elizabeth Dole Foundation Supporting Research Studies in regard caregiver Mental Health concerns and it was published in 2014. I also know that this topic was discussed during the fifth annual National Convention you held last week. Maybe this week, earlierthis week. And im just asking for a direction. N. What is it you would ask of this committee in regard to the Mental Health and wellbeing of caregivers . What more needs to be done . Is it just related to implementation of the act or is there something thats missing and i would highlight this committee has indicated and i think is attempting to fulfill our stated priority of Mental Health and Suicide Prevention for veterans and your testimony, your presence today is the reminder to me at least that we need to make certainthat when we talk about Mental Health , Suicide Prevention , certainly for veterans also ought to include in our thought process and policy deliberations the caregivers that are helpful to them. Whatwould you like for me to know . Mister chairman, i would say three things inresponse. Theres, i would ask the committee again to consider legislative removal of the phase expansion of the mission act so that all caregivers, all caregivers receive their benefits right away. Around your question around Mental Health as you noted, we commissioned and published a study in 2014 thats almost 6, seven years old by now but the data till rings true. One of the things the study called for was more robust longitudinal studies, research and data on the situations facing caregivers. We dont have a great deal of data. In fact we have zero longitudinal data on the extensive caregiving on military caregivers is thousands ala, families, friend and loved ones for providing free athome care and to the new civic and patriotic responsibility thatwill be here forever. And we need to invest, this committee needs to invest in understanding that implementation, the implications of that care and service on love ones. Mister chairman, something you said that i want to put an exclamation point on around suicide is that caregivers are the last line of defense in preventing better andsuicide. We believe e in the elizabeth Bowl Foundation a lot enough is not being done to understand the unique roles caregivers can play in prevention so we would welcome wider dialogue perhaps a roundtable with this tecommittee and a number of caregivers and other organizations to talk about ways that this , that the va, the dod can more directly support the Mental Health needs of caregivers. One way to do that right away is to embrace and expand upon the campaign for inclusive care that i mentioned earlier. Were working with va to implement now systemwide a series of trainings and protocols that will encourage clinicians to engage with and support caregivers throw out the care process because right now its a very distorted engagement. Theres no requirements for the ways. [inaudible] i apologize. So those are the three things mister chairman i would suggest are really vital and important for the committee to consider. I wasnt sure whose phone that was. I was goingto scowl at one of mycolleagues but if you its just fine. Thank you for your testimony. Thank youfor your three suggestions. Let me ask mrs. Beller a similar question. About Mental Health and Suicide Prevention in regard to caregivers. You heard what misterschwab said. One of the challenges i think we face enis lack of professionals and john hannon act against to get resources to Community Providers which i think is to stand up new programs tohelp particularly in rural or isolated places. What would you ask of me to be of help in regard to the Mental Health and wellbeing to assign prevention not only as a veteran butalso as a caregiver. I think what you said about the findings, more resources for Mental Health issues. Candidly, i have been to counseling a couple of times during my tenure journey to build resilience and to make sure that i am capable of taking care of my veterans and thats so critical because there are studies, indications that the caregiver can develop secondary ptsd. Thats especially in situations dealing with tdi and ptsd in the veterans so these issues are very real. I know of caregivers who have actually committed suicide because its very isolating and a very lonely occupation but organizations like the Elizabeth Dole foundation, that is helping to raise awareness and alleviate some of the struggle. Thank you for the answer. You are a very articulate and compelling witness and i very much appreciate your presence with us today. Thank you for doing an Additional Task oftestifying before our committee. Let me return at least briefly to the network issues. Neither one of you indicate that you have any knowledge of whether or not the va is going to move in the effort to modify theircontract. If i misunderstood or you have additional information, then what youve told me id like to know if you have any indicationthat the va has decided not to modify their contracts. I would then ask thisquestion , perhaps this argument. The va has testified to our committee that they have insufficient Budget Resources to modify any contracts. Its not abudget issue. You both testified i think this is a fair summary that your networks are expanding voluntarily to meet those standards. So what would be, what could you say would be a justification for not having a uniform standard as suggested by the mission . What am i missing here . General. Center, just to share maybe some of i think not to seek for the va to share conversations from the va is i think of their concerns are when you look at the shortage of providers and geographical areas and you look at veterans twice because veterans are willing to see a part of the va or Community Care but theres a perception that it would be over building by some of the stringent drive times and thats part of their hesitancy from moving in that direction. We have looked at it through the lens is wanting to ensure that we blanketed the geographical area as far as we can that we utilize data to tailor it to where we believe the veterans are geomapping but i think thats part of the concerns that a grade. And i cant see two other concerns but i can share that one. Mister mcintyre. I believe that a retrospective look at the man prior to enabling enhanced access makes it very hard to accurately predict what people like to do with their decisions. If theyre given the opportunity. And so as general horoho said, we are developing a network thats matched what we believe based on our analytics and a seven year journey withthe va. What likely is going to be sufficient to make sure their enhanced access and availability where its needed. You know, probably the best example of the collective success thats been birthed between congress, the va and the community rests in harlingen texas where you used to have todrive seven hours for care. Beyond what a c block could do or go without. Today, more Community Hospitals and all the providers in the community are a side of that covid19 expanded and no one goes without and every kind of care is available in the surrounding area and more than 400,000 employments have been done in the valley in texas in that comprehensive network. Thank you for outlining what the goal is and indicating that it can be achieved. Perhaps it appears that im harping just on insisting that the va comply with the. Ission act and yet, you demonstrate and thats not my point here. I think what our concern is is if we dont build to those standards that veterans will potentially, some veterans will become discouraged. Not able to get the care we need and if we want to convince veterans that the mission act, that the successor to the choice act is here to stay in it for their benefit, then we have to build to a standard that doesnt discourage anyone from using choice, using missions. And the fact that the two of you, your networks have indicated youre going to o build to those standards demonstrates to me why theres value of having standards. If we didnt have those words in the mission act, i dont know what youd be building two. I guess youd be building to what the va insists you build to under your contract but in my view youd be missing the opportunity to further serve have a particularreason why they need click care closer to home. So it is confusing to me because the va has indicated in their testimony in their conversations with me there pursuing this, but more recent stories indicate the va 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 va, 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 other circumstance. Itso i want my veterans in kansas and across the wcountry, i want veterans to know we now get them in a position in which you can access the care that they need and its close to home. And if we fail them one more timein reality or in image , we are doing a disservice, one more thing to discuss that well, they say ive got a benefit but i dont feel it or see it so theres a real eeconsequence to us not meeting the needs of veterans now for a second i generation of maybe a third or fourth generation of Community Care 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 return to senator tester and ill wrap up as i indicated earlier u. I talked too long and the Ranking Member returned in time to have conversation. Senator tester i was told you would ask every question about longdistance Passenger Rail service. I was seen as an annoyance because you and i had the same line of questioning and then i heard that you were filling in here in the committee as caring todays hearing area that immediately cost me the rough back just in case you were thinking this is a more alongterm circumstance that ihave them hoping. Mister chairman, i would never think that. Number one, number two scares the hell out of me you and i are on the same page when it comes to asking questions. But i do appreciate the opportunity to ask one more question about trying to make this as painless as possible because i know this is a long hearing and i do appreciate all the witnesses for being here today read this deals with covid19 and this goes to Mister Mcintyre and general horoho. My understanding is the girls s for Community Care are on their way back up and this is after months after the start of this and, if you either confirm or is that right or wrong . Arereferrals on their way back up . I can provide you with the stats for our geographic territory in region four. Prior to covid, we were receiving about 7300 authorizations for care a day. We just in the last week pulled the data and now were receiving over the hundred authorizations for care on a daily basis. There was during the height of use phase i of covid some camping down on the requests but for the most part, the things that we touched mine about 10 percent, we were able to get rescheduled and readjusted so the veterans ultimately got their needs met for their work that we touched but its starting to go out and i think thats going tobe a permanent fixture. Senator, were seeing the exact same thing, were about 72,000 referrals a day. That leads me to my next question and that is how has the pandemic affected the availability of providers in your network . And to protect their staffs they tapped out on most voluntary services. That is now changed in most providerss now opened back up fr business and have been for months and a few providers have gone under as is true and the rest of the economy but we are finding, by and large, people are wanting to see patients and willing to see patients and that includes in the great state of montana. General. Server, very similar trends in one of the things that we did see in covid was an increase use of telehealth capability. 31 of that was for Behavioral Health and a little surprising the second was for Pain Management and then followed by physical therapy. I think what we saw during covid is the impact it did have across the Healthcare System but that it caused a rapid change from facetoface delivery of care to an accelerated use of telehealth which wefa rapidly transition to an i think that made a big difference. The other piece i testified earlier to was the large county influx of cash to accelerate payments that we did to support the financial status of those providers that they could keep their practices because that was one of the big challenges as well. Last question i promised mr. Chairman. We will stay on this so i will stick with you, general and then let dave answer second on this one. It deals with telehealth and deals with Communities Capacity that weve learned one thing from this pandemic it is that telehealth is critical that we need better Broadband Service with particular in montana and the general could you speak to the Community Cares capacity to provide Telehealth Service and to avoid those facetoface instances which is so critically important in the pandemic . When it is not necessary for a better and to be seen in person that they can do it through telehealth. Is that capacity theyre generally speaking . Orre are you feeling some limitd forces and your networks . Senator, i appreciate that conversation because i think tele capability was one of the things that i would submit came out of this pandemic that has been a good thing. It really accelerated the use of it in one of my concerns is that as we, you know, have been so reliant as a nation on the authorities that Congress Gave to be able to actually have transport ability of licensing across state lines and waiver for that interstate licensing allowing for practice at the type of your license and then those authorities to be able to leverage the network that was not bound by state lines made such a huge difference in the ability, i think, of the Healthcare Network been able to leverage tele capabilities and so that is one of the things that if i was asked and he did not specifically ask but if i could put forth, i do think it isof something that, if we can make those authorities permanent it would make a big difference in the ability for communities to be able to provide that. Thank you for that. Sure the chairman is taking notes and drafting a bill in his mind right now. Dave, would you want to respond to telehealth availability capacity with your network . I would agree with patty yet at the same time i think its really important for certain types of services where telehealth is leveraged with Behavioral Health to make sure that that service and the servicing provider is as close to the veteran as possible because when they need to go make a physical visit it is important that they see that person and theyve been t seen n the screen. And so we really tried to put our focus on making sure that we are enabling the existing providers in our Network Within their own states to have that capacity and we all remember or we mayve remember that telehealh really was born out of alaska and hawaii and your prior colleagues had a lot to do with that because it is out they brought access to the villages in hawaii into the remote islands in the villages in alaska and remote islands islands in hawaii and its good to see this expanding but the challenge is access to broadband. Hopefully one of things that as a federal government is going to be a focus is accelerating the access to broadband in rural areas so that they can use telehealth as robustly as they need to across the great state. I would just close by saying i agree with both of you and i agree with judy to increase capacity across the board and i also think that both of you and others can be a tremendous help when we talk about allocating dollars for broadband talking about the challengesgr you are facing and many in the healthcare communities particularly in rural areas. Actually not just rural areas but all areas. Thank you all for being here and i will turn it back to you, mr. Chairman. A senator tester, thank you. Let me see if i could wrap up with a few questions and couple questions. Senator chester went down the path of whether or not the providers in your networks were ramping up their capabilities and not post covid but latter term covid or hoped ladder turn covid but i heard your answers and i would highlight for you the indication by the va in the beginning of covid was that significant number of providers within your network were no longer in business or unwilling or incapable of caring for patients and it was not my experience in kansas. Providers cannot understand why they were being denied a referral and it was be interesting to know if that was your experience that cannot find providers during covid or the va had made a decision to bring those appointments and referrals and thats not the right word but appointments and half which i think probably is the best way we could have our veteran patients and their community as compared to traveling to aba center during covid. Was there a real circumstance at which providers said we arent or wont or cant provide services . Senator, we found that our network remained Viable Network and in the middle of this pandemic we went live with two other regions and met the accessibility standards and the high to low 90s and so we had providers signing up and had them available and as an enterprise rolled out protect well which was a mechanism to ensure that through an app that Healthcare Providers front lines were checking every single day on their health and if they had any symptoms they werent coming to work so we had a very Healthy Network both from the clinicians been able to provide from the practices remain open. Thank you. Anything to add . Li much the sameg and we had te unique opportunity to do appointing during that time in support of the a. While a few providers were limiting their capacity or in furlough we were able to find care for almost all of the patients that were placed in our hands for the purpose of care in the Community Spirit i would also highlight perhaps for you the interest is veterans and their access to care and the place of their choosing but its also determined till two networks or to you as a provider if youre not getting referrals just the financial strain that can come from that we need to keep you viable yourselves. Let me ask the general question and it occurred to me who came up with a 180mile highly rural standard . Is that something optimum created or the harmon of Veterans Affairs . They did not create that. I will go back and find out exactly who smacked thank you very much. In regard toha optimum whichi am becoming more familiar with i just would highlight that please continue to pursue more opportunities for specialized care particularly in chiropractic care and we need more network dividers closer to home than what wetu had and i ao would complement you both and ive had experience with both companies in both thirdparty administrators in kansas and you were very good about helping me and my staff in regards e e to t we call casework, veteran calls rights and a Family Member tells us theres a problem and we have been able to come to you any help solve those problems and the goal for all of us ought to be that it ought not to be a burden upon the veteran to be a problem and i hate saying this the way it may sound but we are not at all complaining about the work that veterans provide us to try to meet their needs but we need a system that works and which is not the response ability of veterans to call a member of congress to Say Something is not working so can you help me and the ultimate goal, i want to again thank you for the efforts youve undertaken to meet the needs of veterans as we bring those needs to you and they are what those concerns and complaints and problems are what informs me and my staff to know what we are supposed to be doing in advocating not just for those but for the system in which are beneficiaries of healthcare and we look forward to working with your colleagues at work to try to make certain and the apartment of Veterans Affairs try to make certain that if weve not had an issue of who do i complain to something because its not happening as it should i would make sure the system make certain that they are provided for to begin with. Those were challenges we would all face and help inks for helping us care for individual veterans and we continue to worl with the system to meet their needs as well. Mr. Chairman, your focus and no space and that of the Ranking Member and other members of this committee is invaluable and people find that a nuisance and the realityy of what is present in each of those cases allows us if we choose in working the case to find where the real gaps are and if wethis work focus on that and we adjust the processes and the tools to address those gaps pretty soon there arent anymore gaps. Well said, mr. Mcintyre bird as you were speaking i thought there was not usually a veteran that has a unique issue and if a veteran has an issue with how things are working there are niothers that do too as well ina not may be people that contact me or my staff for help so we dont let anyone slip through the cracks but we need to fix the problem because the veteran that raises the issue but we need to fix the problem for anyone who may not have said anything about it. I think im done and i would give all are witnesses the chance as is my practice to say anything thatt they feel like they need to correct for things they wish they were asked that they didnt get a chance to comment on. Is there anything anyone would like the committee to know before i adjourn this hearing . Anyone online or on zoom or webex interested in anything further . Just a thank you to you, mr. Chairman and the folks who testified today and i appreciate their input. Senator tester, thank you. Again, thank you for participating today and thank you for our Committee Members and their interest in this and 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 administrator and am very pleased to hear more about caregivers in the testimony i heard today is very useful i appreciate the challenge was given us to air the things that need to be done and i would now ask unanimous consent that members have five fledgling of days to revise and extend the remarks including the extraneous material. If we submit any questions do you please answer them as quickly as possible and there is a couple of thingsse that were said that you will get back with us with information we welcome that and encourage that. With that are hearing is now adjourned. [background noises] [background noises] Live Programming today includes the discussion on u. S. Relations with china, with assistant secretary of state for east asian and Pacific Affairs david is still well. Live from the Hoover Institution at 3 00 p. M. Eastern. Later President Trump travels to rochester, Minnesota Valley to campaign is calling it a peaceful protest due to state restrictions on the number of people allowed at the event which will be limited to 250. Watch that live at 6 45 p. M. Eastern here on cspan2, online at cspan. Org or listen on the free cspan radio app. With four days left until election day on november 3 when Voters Decide who will control congress and occupy the white house next year. Stay with cspan, watch campaign 2020 coverage every day on cspan, stream or ondemand at cspan. Org or listen on the cspan radio app. Your place for an unfiltered view of politics. Tonight on what tv conversations about politics starting at 8 00 p. M. Eastern alyssa prizewinning journalist discusses President Trump national and Foreign Policy decisions and then at 9 00 p. M. Eastern Heritage Foundation senior fellow Mike Gonzales argues that identity politics is dividing america. That is followed by msnbc political analyst who offers her thoughts on identity politics and how to greet a more inclusive Democratic Party and that starts at 8 00 p. M. Eastern. Enjoy book tv every weekend on cspan2. Joining us from cleveland, ohio and the associate director of the Community Research institute at Baldwin Wallace university Lauren Copeland thank you very much for your time this morning. Let me begin with early voting, ms. Copeland. What should and what shouldnt we read into the numbers . N w guest i dont think we should read too much into the numbers. We know that democrats