Is to see to it that veterans get world cap worldclass health care and they get it in a timely way. However we do that the important thing is to get it done. We had some bumps i have met with some of our private contractors and i appreciate those meetings and their confidence in the job that they can do. They may not have been cooperating before. See to it that the two are working seamlessly and if they cant, they will never work. You have to understand their contracts are not just subject to their performance for the veterans but their willingness to work cooperatively. There are some who do not like the nonhealth care v. A. Provisions anyway. They will have to get used to it. We will make this thing work and we will not put a square peg in a round hole. Today, the hearing is important to your report from the v. A. And contractors and later from the v is so vsos they risked their lives for each and everyone of us to be here today we can expect no less at the get the best health care. I will turn it to the Ranking Member senator blumenthal. Thank you, mr. Chairman. Thank you for having this hearing. We went through a terrible tragedy and debacle not long ago that prompted the veterans access choice and accountability act which sought to relieve some of the problems and underlying issues, including deceit and fraud that caused delays and misreporting within the va system. The discussion today is centered on the remaining flaws and failings in the va healthcare program, particularly the veterans Choice Program. And as much as this program was established to deal with the immediate crisis of access to care in the short term with an investment of 10 billion to 10 billion to provide direct Care Services in the community and 5 billion to provide a Choice Program, there is still a lot to be done the program was just a down payment, just a 1st step. I believe that it has to be improved even further. There remains underutilization of the Choice Program. The underutilization may well be the result of the failure to sufficiently publicize or make aware veterans. It may it may be the result of other more fundamental issues within the program, and i share the chairmans view that changing the 40mile rule was certainly a welcome step. The most important fact that brings us here today that we cannot lose sight of is, we still have not solved the crisis that led to this Program Veterans still way too long for appointments, healthcare delayed in effect is healthcare denied for veterans who suffer from healthcare conditions that require immediate treatment. The va most recent data as of may 1 1st indicates weightless numbers have increased significantly since the same time last month. As of april 2 300,000 veterans 2nd 300,000 veterans had appointment scheduled more than 30 days from the preferred date. As of the may 1 release that number jumped to nearly 434,000. Anyone believes this crisis has resolved is living in an alternate universe. It is not the universe that our veterans and have it. Reallife consequences that cannot be tolerated. Too many veterans are waiting too long for appointments and i am glad that the va is finally going out to facilities with long wait times trying to determine why exactly they are not utilizing non va care options. I notice a lot of the testimony today talked about further changes to geographic criteria. Every time there is an additional change more of the 10 billion allocated will be devoted to paying for access but this money is due to our veterans because better healthcare is due to them. I we will i will close on this note we still do not have accountability. The Inspector General has not completed his work. We have no reports on disciplinary action for delays that or intolerable and still are unacceptable. Accountability is absolutely necessary, and i believe the Inspector General needs more resources to effectively implement accountability. I will continue to press reports and for action by the Inspector General that will send a message to the healthcare apparatus and professionals that we mean what we say when accountability is our launch word. Thank you, mr. Chairman. Thank you, senator blumenthal. Our 1st panel is made up of the following individuals. Sloan gibson. I want to thank him for his willingness to take on tough situations. I appreciate the fact he is approaching it in a positive way. I hope you will maintain that attitude. To reiterate secretary mcdonald and undersecretary gibson invited the Ranking Member and myself for what they call a standup which we did in february and have been invited to come back in june. As many members as want to come i will make sure they are invited. Benchmark itself against itself to try to find better ways to do things to flesh out problems in advance and get themselves earlier. We have big problems to solve. We appreciate you being here to assist. I am sure that everyone appreciate you being here. Providers, mr. Mcintyre, i enjoyed our meeting earlier this week. I appreciate your being here today. Thank you, mr. Chairman. Chairman, Ranking Member members of the community, we are committed to making the program work and provide veterans timely and geographically accessible quality care using care in the community whenever necessary. I we will talk i will talk shortly about what were doing and the help we need to make it happen. First i want to talk about access to care. Most mornings at 9 00 a. M. For the last years Senior Leaders from across the department gather to focus on improving veterans access to care. We concentrate on we concentrate on key drivers of access including increasing Medical Center staffing by 11,000, adding space, boosting care during extended hours and weekends and increasing staff productivity. The result, 2. 5 million more completed appointments inside the va this year than last. Of relative value units to make common measure of care used to measure care delivered across the industry is also up 9 percent. Another another focus area and improving access has been increasingly use of care in the committee. Va issued 2. 1 million which resulted in more than 16 million appointments completed. Here today authorizations are up 44 percent which will result in millions of additional appointments for Community Care. Veterans are responding to this improved access. Among those enrolled more are using va for care, and those using va are increasing their reliance. This is especially the case where we have been investing most heavily. In phoenix we have invested hundreds of additional staff i should note that we have increased care in the committee 127 percent in phoenix over the last year, largely due to the extraordinary effort of tri west in a particular community. Wait times are not down. The surge and in addition to five the surgeon additional veterans coming in those there asking for more care. In las vegas we have a 17 percent increase in veterans receiving care. In denver we have opened Outpatient Clinics and that it more than 500 additional staff. Veterans are using va for care there up 9 percent. In North Carolina were wait times continue to be a problem we have increased appointments 13 percent to my relative value units up 19 percent command veterans using va for care up 10 percent. In all these locations we have had dramatic increases in care for the committee. The primary reason for increasing demand, increases in the number of medical conditions and a rise in the degree of disability and improving access to care. Community care is critical for improving access. We use it and have for years and programs other than choice. We spent approximately 7. 9 billion on committee care other than choice. In 2014 that row state and a half billion command reestimate at the current rate of growth va will spend 9. 9 billion. At the same time we have had a large increase. It has not worked as intended. Here are some things we are doing to fix it. We changed the measure using the fastest route. Roughly doubles the number of veterans eligible. There is much more to do. Follow on mailing will go out. We Just Launched a major change to make choice the default option for care. Additional additional staff training and communication to make sense of provider communication, improvement improvement to the website and ramped up social networking, knew mechanisms to gather feedback from veterans as well as frontline staff. These are all in place or are about to launch. In the longterm we must rationalize Community Care into a single channel. The different programs with different rules and reimbursement rates, methods of payment and funding routes are too complicated, too complicated for veterans, providers, and for employees who coordinate care. We will need your help. Let me touch on the other issue. We have completed and that indepth analysis to provide choice to all veterans more than 40 miles from where they can get the care that they need. We have sure that analysis. It confirms the extraordinary costs that have been estimated previously. We have briefed the staff on a broad range of other options and believe there are one or more worthy of discussion and careful consideration. While we are working together on an intermediate Term Solution we are requesting greater flexibility to expand hardship criteria and choice beyond geographic barriers. This would allow us to mitigate the impact of distance and hardship. We request greater flexibility around requirements that preclude us from using choice for services such as obstetrics, dentistry command longterm care. As described above, we accelerated access to care in the committee anticipating that a substantial portion would be funded through choice. For various reasons for various reasons most touched on previously we will be unable to sustain that pace without greater Program Flexibility and flexibility to utilize at least some portion of Program Funds to cover the cost of care in the committee. We are requesting some measure of funding flexibility to support this care. On may 1 the va sent a legislative proposal. We request your support. Lastly, we are requesting flexibility in one other area, hepatitis c treatment. You are familiar with the miraculous impact of this new generation of drugs, veterans that have been have see positive for years now have a cure within reach with minimal side effects. There is no funding provided in our 2015 budget request or appropriation. Remove 688 billion from care in the community anticipating the shift in cost to choice to Fund Treatment for veterans with these new drugs. Was the right thing to do, but it was not enough. We are requesting flexibility to use a limited amount of dollars to make this available to veterans between now and the end of the fiscal year. So we are improving access to care. Now a standing airport of great times the we still have work to do, but we are improving access to care. Were committed to making choice work. We need help, especially additional flexibility to allow us to make the healthcare needs of our veterans met. We look forward to your questions. Mr. Chairman, Ranking Member, members of the community, i am grateful for the opportunity to appear before you on behalf of our companys employees and its nonprofit owners to discuss the work which we are privileged to do in support of the department of Veterans Affairs. I would like to focus my testimony on three topics, the reality of this programs implementation, process of identifying and resolving gaps and those which remain to be solved, and what i believe to be the art of the possible. As you know and as secretary gibson has said, purchasing care in the community has been a lot of practice. In fact, in september of 2013 after two years of planning va sought to change that. That that contract was designed to have a consolidated integrated Delivery System built in the committee to undergird the facilities across the 28 states. Make sure at the end of the day they were not there to replace the va but supplement. It worked as intended. When the furnace went off in our hometown 6300 providers under contract Going Forward at the side of the Medical Center to assist them in eliminating the backlog. By august 14000 veterans moved through that process. Around the same time we are modification that we had primary care. We now have over a hundred thousand providers across 28 states under contract along with 4500 facilities. We are not finished. The reason why we are not it we need to make sure the networks are tailored to match demand that exists in a particular market that is not able to be met by the v. A. Facilities itself. That was a complicated program to set up, done in short order but it was training for what was to come next. On november 5, after 30 days of work, we were to stand up and in support of the v. A. Choice program, partner to receive a list of eligible veterans, design and produce a card and put it out with a personalized letter from the secretary, and stand up a Contact Center to handle all the calls coming in. After two weeks of design and hiring and training of 850 people. No one went into threehour waits. The phones were answered, but the work had only begun. We have been on a pathway since to try to secure the operation. The secretary talked about the 40 mile issue. There are additional refinements that may be needed or desired so we stand prepared to support what they might look like. There are there are other changes that may be needed to the program as we go forward. Secondly, we need to aggressively identify and resolve gaps and fix operational performance. We are in the process of doing that together. We are modernizing our i. T. Systems rolling out after memorial day after a 20 47 build. A new portal system that will serve all facilities and our own staff as we seek to move the veteran information back and forth between facilities as care is rendered downtown. We are in the process of tailoring networks to match the demand that exists in each market across our area. The Choice Program is up. It is operational. There are refinements still needed. I believe that because of the collaborative work that has been underway between all of us that are engaged in this that we are refining the pieces that need to be refined, identifying policy gaps that need to work and those things as the , secretary said, are getting attended to. I think there are a couple policy issues that remain the jurisdiction of this particular committee. One is, i would encourage you to relook at the 60 day authorization limitation that has been applied. Secondly, i respectively submit that there needs to be harmonization between the two programs and between all of the facets of how the v. A. Buys its care currently as well as how the v. A. Operates itself in engagement with us to make sure this works right. At the end of the day, i believe the art of the possible is truly within our grasp. I would like to point to dallas, texas if you permit me to do do to do so. We are under the engaged a couple of weeks ago, we sat with the director and entire staff there, including Behavioral Health, it and looked at the full demand that exists for veterans in that market. We then took out and looked at what is the network that is constructed to stand aside which is the basis on which choice runs. If there is not a network provider, you can set up an engagement with an individual provider to deliver services under choice. We then design a network map we are under the process of constructing together. Over the next 90 days, from Behavioral Health to primary care to specialty care, we will rack and stack the network to meet the demands that otherwise cannot be met by the va Medical Center in dallas. That is being repeated across our entire 28 state area and the pacific as we seek to do our part to mature the operations of choice. It is a privilege to serve in support of those who serve this country. It is an honor to serve the veterans from the states represented by half the members of this committee. Mr. Chairman, i look forward to taking questions after my colleague is finished with her remarks. Thank you. I appreciate the opportunity to testify on the health net imagination of the veterans Choice Program. Health net is proud to be one of the longestserving we are dedicated to ensuring our nations veterans have prompt access to needed healthCare Services and believe there is Great Potential to the Choice Program to help the v. A. Deliver timely, coordinated, and quality care. We were awarded a contract for three to six string regions and implemented pc 3. At the beginning of april 2014. In october, after Congress Passed and the president signed the veterans axis choice and accountability act of 2014, v. A. Amended our contract to include several parts of the Choice Program. With less than a month to implement, we hit the deck running to use a navy phrase, and we have not slowed down since. To meet the required start date of november 5, we worked closely with v. A. To develop an aggressive implementation schedule and timeline. The ambitious schedule required us to hire and train staff quickly and to reconfigure our systems for the new program. Despite this aggressive implementation schedule, on november 5, veterans started to receive their choice cards and were able to call into the Choice Program to speak directly with a Customer Service representative about their questions on the Choice Program or to request an appointment for services. Having said that, there are challenges that have resulted in veteran frustration, as well as on the part of va and our own staff, including callcenter and appointing staff. With such an aggressive schedule, there was little time to finalize process loads and make system changes. We literally had less than one week from the date we signed to the actual go live date. While the collaboration with v. A. Since the start of the Choice Program has been good there is still considerable work that must be done. So that the program is operating smoothly and the veteran experience is consistent and gratifying. We appreciate the opportunity to offer our thoughts. The Choice Program is a new one that was incremented in record time. As a result there are a number , of policy and process decisions and issues that are either unresolved for undocumented. If choice is to succeed, these items must be addressed quickly. We have been working very closely with v. A. To address these issues. Many items simply could not have been anticipated before the start of the Choice Program. Others should have been addressed before the program started, but the implementation timeline did not provide adequate time to do so. The identification of policy and operational concerns and issues have been occurring quickly. As a result, it is hard to keep up with development and adequately train our staff. The situation is not ideal. Based upon these dynamics, we have one overall recommendation to move choice forward. We recommend a comprehensive coordinated operation strategy that clearly defines program requirements. The process was in rules of engagement. The strategy should provide a clear roadmap for all of us to follow, one that is communicated to all the stakeholders. V. A. Leadership, Medical Center leadership and staff, both contractors, congress, and most importantly, the veterans. The strategy needs to identify key initiatives and timelines to initiate those initiatives it also needs to contain flexibility to address issues as they arise and make necessary course corrections. The strategy must include resolution of outstanding policy and process issues development , of policy and operational guides that are mandated across the program, comprehensive training of both v. A. And contractors staff using consistent process loads operational guides and scripting and a clear and responsive process. I would like to thank the committee for its leadership in ensuring our veterans have access to health care. We believe there is Great Potential for the program to help the v. A. Deliver appropriate care to veterans. We are committed to cooperating with the v. A. To ensure the program succeeds. Thank you. I look forward to your questions. Thank you very much. I had all of these preplanned questions. Listening to your testimony, i canceled all of them and will ask ones you raised. I start with you mr. Mcintyre. It was quick, so i want to make sure i got it. You are encouraging the 60 authorization of what . The limitation on 60 days for authorized care under choice. It puts people who have cancer in a position where we need to move them back and forth between the v. A. Medical center. It takes a person who might be with us under choice because of her pregnancy and does the same. I do not think that was intended. I think it was intentional that there were parameters drafted around it but the notion that , certain types of care would have to move back and forth between the v. A. Medical center and downtown is neither efficient or effective. I dont want to spend too much time on this, but this is important, from watching your testimony and watching everybodys head bob. You want to expand the 60 day to a longer time . I would leave it to the clinicians. I got it. What i would do is evaluate which types of care either needed authorizations that would last more than 60 days in other words what you are saying is the 60 day limitation causes things, like some Cancer Treatment or pregnancy for that patient to have to go back and forth between private and v. A. Health care because of that lender because of that limitation. The administrative process requires us to go back and forth when it is probably unnecessary. It is one of those unintended consequences. Is it any reason we cannot fix that . We are going to work on it and will come back to you with a proposal. Just listening to it, it seems more Cost Effective for the v. A. Fix it rather than go back and forth. There has to be money involved every time you do that. Is that right . Yes, sir. The bigger concern is the potential disruption to the veteran. So this is always more expensive and what youre saying is that is more efficient. I appreciate you raising that in your testimony. You are welcome. Do you have any credit cards . [laughter] i dont want them. I just want to know if you have them. You have the right to remain silent. I am trying to think which one do i acknowledge. Do you get the annual mailing out the required notification of security . It is about four pages long and apprentice so small you do not even read it anyway . Isaiah goes right in the recycling bin. In your testimony, i heard a clear statement that we need to simplify and coordinate the instructions, rules, and processes under which veterans choice works, is that right . It is mr. , chairman. I think, as i said in my written and oral remarks everything has , been moving quickly. As a result, there are number of things that maybe have not been addressed as completely as ideally we would all like to see, and it makes it difficult. It is hard for us. We talk about this at our level to keep up with everything. Youre talking about Call Center Representatives and appointing clerks trying to keep up with all the developments. Somehow, we have to find a way to make it easy for not us that to understand, but the people working closely with veterans to make the program work. They need to understand it. I think that goes a little venue all. The veteran needs to understand. All of the stuff i did as a businessman, we serve people with college and masters degrees, but we wrote everything to an eight degree level. Which is what the newspapers do as well. That is the way you communicate to the majority of the american people. Some of these things i have not read medical instructions but some of these things on the drugs label, you read all of these things your not supposed to do. It is so long and cumbersome that i can understand it and sometimes i do not do the right thing sometimes. That can be our veterans as well in the injections they are getting. I hope you would Work Together to find ways to simplify the communication mechanism to the beneficiary, which is the veteran, and the provider, which is the local provider in veterans choice. I know it is, located. I am not trying to over support for to oversupply. Sometimes out of fear we do not cover everything, we cover so much that we do not accomplish the goal. I appreciate you raising that testimony in my last question will be to sloan. You kept talking about you wanted us to give you more flexibility. Yes, sir. Put some meat on that bone. It is that stability around the determination of hardship for veterans to be able to have access to choice care. The way the law as written today, it is restricted to a geographic areas, i think is the language in the bill. We want to open that aperture , which would give us much more flexibility to extend care. Open that aperture to be a type of illness . It could be a type of illness, distance. There could be an instance where veteran lives within 40 miles of the center that does not deliver the care. I will interrupt you, and i apologize. You want the ability to exercise judgment. Yes, sir. In what you do in terms of hardship. You want the chance to exercise judgment in terms of the 60 day authorization, is that right . Yes, sir. There ought to be ways we can , was both of those things. Yes, sir. I think in raising those but doctors excited by the answer. Either one of you needs to leave. Whatever the case, you can help us write that. I recognize in those your flex ability in the 60 day authorization sounds to be more Cost Effective and less expensive. Yours probably raises cost questions, but in the end, were got to remember the person we want to serve is the veteran. Because of that, raising the hardship is not the right thing to do. Senator blumenthal. At the outset, let me say that you will be asked shortly by senator sanders, i believe, about the letter he has written to secretary mcdonald urging that he uses authority as secretary of Veterans Affairs to break patents on hepatitis c medication for the treatment of veterans suffering from that disease. I strongly urge you consider using your authority under 28 United States code sexton 1498 section to take that action 1498 that will make this medication more widely available to veterans who need and deserve it, especially since the v. A. Was involved through one of its employees and the research that undertook this initiative and successfully reach the result. I want to focus for the moment on the v. A. s proposal to Fund Construction costs at the denver facility, specifically the 1 billion cost overrun out of the Choice Programs provision for long deferred maintenance and facility capacity issues. These funds were specifically designated and intended by congress to improve Veterans Health care. Veterans in my state, who are aware of this proposal, are absolutely outraged that their healthcare, specifically the primary care upgrade at the west haven facility, would be indefinitely deferred because of 1 billion cost overruns in aurora, colorado. I suspect the same reaction will be felt equally deeply by veterans at the more than 220 other facilities whose healthcare will be compromised as a result of the proposed redesignation. Of these funds. I would like assurance from you , secretary gibson, since we are talking here about choice Program Funds and were not talking a few dollars here or there but actually 1 5 of all the funds in that 1 billion pot that you are considering alternatives to that action. Senator, we sent a letter earlier today to this committee, to the House Committee, and to the Appropriations Committee requesting the increase in the authorization to be able to complete that facility, as well as requesting the use of some hundred 30 million of those 730 million of those 5 billion to be used to complete the the denver facility i want to interrupt you because and i apologize. For me, that alternative is a nonstarter. It is just unacceptable. I expressed that view to appropriate administration officials. I realize you are dealing the hand you are dealt. I am simply urging you to consider alternatives. There are alternatives, in my view, responsible and available alternatives that do not involve deferring healthcare improvement through construction and maintenance at those facilities across the country, whether in connecticut or georgia, montana, or louisiana or vermont, and all the other states represented on this committee as well as many that are not. Senator, in years past i would tell you it is likely that if we had gone looking for that type of money, there is likely we there is a good chance we could have found it. Because of the work we have been doing over the past year to make hepatitis c care available to veterans under the circumstances, we dont have 700 million sitting on the sidelines. There are no easy answers. I am not asking you to find a billion dollars sitting on the sideline but this nation is , capable of doing better for its veterans. A supplemental appropriation for example, might be an alternative. I am asking you to go back to the drawing board and use different pencils, not necessarily sharpened pencils, but different alternatives to compensate for the absolutely unacceptable cost overruns and delays in aurora. The project should be completed, but not at the sacrifice of healthcare for other veterans around the country. What i say to you today is not personal to you or to secretary mcdonald. We have talked at great length about this issue. We have visited that facility together, along with the chairman. I have seen that vast, hulking shell of that campus that is a mockery of government contracts. We need to address this situation to complete the project, but it cannot be done , in effect at the sacrifice of , other veterans. My time has expired. I apologize for interrupting you and thank the witnesses for being here today. I would not ordinarily do this but in light of the , question raised and for the benefit for everybody on the committee to know, i think we all have an obligation to ourselves to make out of the box suggestions on what we do, the cost overruns. Particularly those of us who have seen it. Everyone on the committee. I have taken a couple of actions leading up to a meeting tomorrow where the democrats and Republican Leaders come together and talk about what we do. I hope the va people are back in their office saying what are we going to do. I have ordered a study of Surplus Property that would be liquidated bowl to try to raise money to go to veterans choice. You are dealing with a situation where you have until about may the 20th. That is about as much time we have now and we need to get at least until july 15. We have a way to do that. Through an action in this committee. It only gives us time to determine how close it is to 700,000 700 million it is we need. In that timeframe we are going to have interim bridges which i am working on, but if everyone on the committee with ink outside of the box if it was , your problem and you inherited a 700 million shortfall, where would you go looking . I want sloan to revisit the two places i mentioned because it seems like if we will take you out of the construction business, which we are and that will happen to at least a certain major extents, there will be savings and that appropriation unit in your department. And also look at the 77 ftes you are asking for an increase in the current budget. Maybe they are not as necessary is helping to build that hospital in denver. If everyone is making a contribution, despite that movie the of american president , where they got a yellow pad out and said to work on solutions, we need to get a yellow pad out and find a way to do it. It is a nonstarter. I agree that it is not the right way and i apologize for injecting that. And i want to thank the chairman. He and i have worked together. I am not speaking for the chairman, obviously, but i have alternative suggestions as well. I have no pride of authorship in meeting the needs of completing the facility but doing it without sacrificing other projects, and i will have some specific ideas and proposals tomorrow as well. My apologies to the members of the committee and taking time. I turned down to senator turn now to senator moran. Thank you. Your comments in this hearing. I hope to ask a series of questions. I want to start with a story i have told before about a vietnam veteran named larry. Larry macintyre lived in florida and indicates that he is a vietnam veteran, asus to vote swift boat navy veteran, indicates he moved to florida received excellent care moved to , rural kansas, became my constituent, lives about 25 miles from sealock and three hours from a hospital. I started the story, or the story began, in july of 2014 when larry, this vietnam veteran needed a cortisone shot. The va instructions were come to wichita. A threehour drive each way to get a cortisone shot. We raised this topic with secretary mcdonald at a hearing on september the 9th. Larry contacted us and said, i dont care how it comes. The choice act or any other way the v. A. Can provide this service. We raised this topic with the secretary in september of last year. Shortly thereafter, the director in kansas city took this issue to heart and has solved the problem, but unfortunately temporarily. In december, larry was granted an appointment near hayes which does not offer cortisone shots but he got care under the private sector then. The doctor who treated him for colonoscopy treated him then asked to follow up. The va denied that request and sent him back to wichita. They denied the request because he was not eligible for choice. The c bok exists within 40 miles of his home. So he is back to wichita. Ultimately, he then needed a colonoscopy, same series of events. The Outpatient Clinic does not provide colonoscopies, and he is trapped in this system of no one telling him what he can do or qualify for. He has gone to wichita but last week he received a letter from the va approving and for choice. He then calls triwest. Triwest says you are not eligible. You are not on this list. But i got this letter he indicates he talked to four different operators at triwest all who gave him a different answer than anyone else, the three other operators. He called the 866 number and was told he was not eligible, got the four different answers and now we are back to the question of what happens to larry. My point is it is not up to layer to solve what happens to larry, but even from the beginning, if he is not eligible for choice and because he is not and because if he is not eligible for choice, why someone not at triwest or the v. A. Telling him we have these other authorities, this would work for you, as compared to just leaving larry hanging over whether he is eligible and what he should do. How do we solve that problem i do not think it is totally unique. I hope it is, i doubt larry is the only veteran experiencing this circumstance. I doubt that the problem is unique. I suspect there are other veterans that are having similar experiences. As i described in my opening statement, we are asking for additional flexibility which would give us more authority to be able to handle that kind of situation inside choice. We handle, we actually handle many of those situations through other v. A. Care in the committee routinely, which is why we have incurred so much expense on a yeartodate basis, but we find ourselves running out of resources in order to be able to sustain that. So we wind up making sub optimal decisions. I would tell you have just given two great examples. The chairman asked whether or not we would be using judgment around the nature of the procedure. I would say yes. For someone with a routine requirement, theres no reason to travel 350 miles to do that. That is something that ought to be done locally. For the veteran that has to get a colonoscopy, im not going to drive 150 miles to get a colonoscopy. That is not going to happen. That is Something Else that must be provided for in the community. If a veteran needed a Knee Replacement i might say, ok, under the circumstances make the trip, but for therapy that must follow up, i do not want the veteran traveling 150 miles each time for physical therapy. The challenge we have is so what theyve got to do is find ways to be able to manage this such a way that we are doing the right thing for veterans and the same thing we are the best of the taxpayer dollar. You and i have had a number of conversations on this topic. I will not argue today how the 40 miles should be interpreted. My point on this episode is number one, the uncertainty and the burden line in the wrong place. It ought to lie with the veterans administration. Whether or not larry qualifies for the choice act ought not matter in the answer he gets. I agree completely. Thank you. The senator mentioned he has kindly yielded to me because i have to run out the door. Senator sanders. Thank you, mr. Chairman for the work that you have been doing and maintaining the bipartisan spirit of this committee. I understand as the former chair of this committee how easy it is to be up on the v. A. There is a problem every single day. In a nation which has a dysfunctional health care system, the private system also has one or two problem. I will not go into them that i think you should recognize that when you talk to the major veteran organizations, the vfw they say that when people walk into the v. A. The quality of care they get is pretty good. I want to thank you for trying to improve that care. I will fight vigorously i think our goal is to strengthen the v. A. Creative in terms of using the new program we have developed. I will oppose that if it is to privatize the v. A. Want to get to another issue. I wanted to get to another issue. The senator touched upon it. I wrote a i wrote a letter to secretary mcdonald about an issue that has concerned me for a while, the high cost of the drugs of all the which is a very a miracle drug so to speak, treating the veterans of our country who have high rates of habitat is see. Mr. Chairman, to me it is an outrage that you have a companys profits have soared, revenues have doubled. They have come up with the drug, charging the general public a thousand dollars a pill, charging the va Something Like 540. No comment. But that is because the v. A. Negotiates drug prices. But you are but you are running out of money and we have several hundred thousand veterans suffering with hepatitis c which can be fatal without money to treat them. Frankly, it is time to talk to the manufacturer and basically ask them if they are currently being generous in providing these drugs, hepatitis c drugs for free. Very generous. For whatever reasons they are doing that. But maybe at a time when profits are soaring they might want to respect veterans of this country who might die or become sick because they do not have access to this wonderful product. As senator blumenthal mentioned if they are not prepared to come to the table, and i no you think you have done well , i am not impressed. So i would you sit down again and tell them you up. Tell them that you are prepared to utilize frederick law to break the patents on these drugs unless they are prepared to come down significantly lower than they are now. It is not a question of taking money. Maybe that is is a good idea but it is a better idea to have them treat veterans with respect and charge a reasonable price rather than ripping off the va. [inaudible conversations] turn that clock on when they start talking. We have senator round followed by senator cassidy. Thank you, mr. Chairman. I appreciate your work and the Ranking Members work. I agree that it should not come out of the Choice Program. Mr. Gibson, i was looking back at the notes i have taken. You gave encouraging notes with regard to statistics about the areas of the country with regard to additional care being provided which is encouraging. Do you believe they are consistent across the country . Are you finding evidence of that across the country . Actually, i always worry when people quote averages to me. What you find is wide disparity across the country in terms of the length of wait times and therefore in terms of the specific areas where we are making the most intensive investments. What i would tell you is, where we have been making consequential investment you pretty consistently see a material improvement in access measured by completed appointments, growth and relative value units, but what we are not seeing consistently is a material improvement in wait time. You look behind that and realize what is happening is as we improve access to care are more veterans are coming or veterans that are already there are making additional utilization of va care. I really think we have to have the discussion about how we deliver care longterm for our veterans. I would love the veterans to be able to make that decisions for themselves. I understand right now we have a significant testament. Investment. One of the comments was made that we are looking at providing the choice opportunity there if the care cannot be met by the v. A. Self. It sounds to me like what we are saying is the v. A. Should be making the decision about whether they are delivering the care or whether or not the veteran should be making that decision. Its it sounds to me like maybe we should take the other approach and say if we gave that toys to the veterans i would that choice to the veterans i would suspect that a number of them who have very great care of being delivered might very well might want to continue that out. But there are others that would suspect that would say i dont expect you to build a new hospital near me. You have looked at asking for the ability to have flexibility to make that choice. What happened if we took it as an alternative and once again we are talking about dollars and cents. What if we let them decide for themselves whether they want to have cured through a va facility whether they want to have the care through a v. A. Facility or utilizing the Choice Program more fully and skip all of the extra stuff that you have talked about or whether or not they have already had care and now they have to go back in after 60 days. It is still the va making the decision. Share with me your thoughts, because im sure that this is not a new thought. So explain your logic in terms of not allowing them to make that choice than elves. To make that choice themselves. We have spent a great deal of time talking about this. One of the things for us to keep in mind is that 81 of the veterans we provide care for have medicare, medicaid, or some form of private health insurance. Oftentimes what you see today, you mention this fact earlier that the veterans have given the option for toys and somewhat option for choice and some would elect to stay in and that is precisely what happens today. Roughly half of 40 to 50 , depending on whos the survey you are listening to. I would tell you my perspective, part of those are deciding to stay because they are getting great care and they enjoy the camaraderie with other veterans, they have continuity of care because they have been receiving care for a long time and others come there because they have an economic and others come there. So they have 20 copay for a procedure and you look at that colonoscopy or whatever it happens to be where the knee or the Knee Replacement which is an example that we use oftentimes in the veterans can go get it with medicare but he is going to wind up with a 7500dollar bill that he has to foot. Part of the answer comes and its one of the options that we have talked about is that we step back and we look at some of the economic distortion. And find ways to eliminate that. So for example, what if other providers become the primary payer and the va then defines a veteran against a 20 copay. Then you really are providing the veteran with choice. And they dont wind up paying twice for the same care. So i think therein lies the answer. So this isnt about protecting their turf, all we are about doing is being good stewards of taxpayer resources. Where ever that leaves us, thats where we are. I think that is something we should seriously sit her on this committee. Thank you very much. Take you all for being here today and let me just say that the va has had a lot of problems as you have all talked about. Some of you have been there longer than others and some of you have had private sector. I have problems like every other state and nobody has problems like colorado has with what is happening there. But let me just say that i need to get this on record and i have a situation, i dont know if its been brought to your attention and its gone far up the ladder. Last month the office of special counsel talked about switching antipsychotic drugs based solely on cost. The providers say this is what the veterans need and they made an executive decision. Cut the medicine, did not get the right application. And i was told there is a new policy in place dispensing these drugs and we have not been able to obtain a copy of that. At the time im also told that there is a wallop investigation there is a followup investigation into the matter. And we havent heard much about that. At the same clinic which operates it has been close three times because of quality and i have a horrendous time because we are trying to get our veterans the care that they need. If you could give you an me an answer back as quickly as you can. I believe that once referred i believe that what is referred to here is oftentimes routinely when the office of special counsel has a finding that substantiate the whistleblower allegation, we have positions that really bored out and determine exactly what happened and where the accountability was an oftentimes that is part of it. It has been there and i have been trying to get an answer back. If you could help me i would appreciate that very much. We will do that, sir. Really believe that everything that we have talked about here my generation having tremendous need. That being said, do you believe this you come from the private sector. Those that have more public and more private would understand. You believe that we give better care to our veterans and i mean that in the case of quality of care in the time and the cost. And im not saying that we are going to shut the va down. But before we expand, i dont think we are going to build everything else. I would tell you that we do not believe that that is the case. If you look at the typical veteran that we provide care for they are older and sicker and poorer, we have a highly Fragmented Health Care in america and that is precisely the person that i dont think there is the best one turned into that system. If you go talk to veterans to a large number of veterans consistently what you are going to hear is are there instances where they had to wait too long for care or are we have made a mistake. Yes, there are, 55 million outpatient appointments. We used alaska and how they were given so much better quality of care and quicker. And they dont even have a va hospital. If i might, i know alaska a fair bit. About a decade of Public Service experience. And i would offer the following. I think that the real question at the end of the day is which things are fundamentally done best by the va directly in which and which things have enough demand where it justifies building it and which things should be supplemented by the private sector because its either not enough demand for where it makes sense to spread this applies simply because of the amount of resource and that is needed to deliver services and i think the band has always been true and i think that that is true in the dod system and that is why you see tricare constructed the way that it is. Alaska has destroyed facility, most of the footprint tends to be public in the dod through the Indian Health service or private. Its those two pieces working together that are ultimately going to deliver what needs to be done. The drug dispensary to our veterans is almost criminal. The types of drugs we are giving them without proper guidance, you look at the high unemployment rates in our veterans and you look towards drug addiction. We have to do something. Because drug abuse is one of the biggest killers that we have. Our military and our veterans is absolutely off the charts. We are putting a drug, Prescription Drug abuse caucus together, democrats and republicans working together. We are going to need your help. We would love to participate. We agree with you and we recognize it as a National Problem and it is a problem inside the va. Its a problem it in the general society. Thank you, senator. Thank you, mr. Chair, thank you all for being here. Just a couple of things and one is based on a comment earlier about some in the senate that are thinking that we should privatize this. I have not had a serious single discussion with anyone that has seen that in that way and if anyone here dead, all they need to do is spend some time to understand the unique nature of what they have to offer. There is no other more welcoming place in the va. Not that there arent opportunities for private care there really are already. The nonva care is already a big part of what you do long before choices implemented and so, you know, i realize in these Committee Meetings sometimes our words carry more weight than they should but i dont think anyone should leave this Committee Meeting thinking that anyone has any serious goal or objective to privatize the entire va. I want to go back to the point that the senator mentioned and i also have concerns about the overrun of the denver hospital and i completely understand your predicament is you have to have a way to build it up. Can you give me an idea about what the thought process was. And so what would that cause in terms of delay or ramping down of what we would be doing with choice over the time that that money would not be available . What we basically did in , identifying the nonrecurring maintenance and construction projects, we had a Capital Planning process it actually builds a prioritized list of his years long based upon the pace of funding that we normally expect to give. So when we look at the 5 billion in funds we basically have reached into that list and pulled a segment out to put into that priority bucket. You know, what happens now is a substantial portion if we were permitted to do this, it would wind up in the 2017 budget because theyve been, that would fall back into the prioritized cues. That is why i was asking the question because you could infer from some of the discussion that there was a 700 milliondollar hit the care nothing provided versus taking a look at how that was going to return out of the Choice Program and that is how i was asking. It sounds like theres leveling assumptions. That is exactly right, the movement has been that we would work it back to the funding stream as quickly as we could. I think that in order for what you have requested in a letter that you have and to to have any prayer of serious consideration, you need to map out how we would have assurances that it doesnt materially , affect it because of the way that you would plan to spend that money anyway. Thank you for raising the issue is. Otherwise i would tend to go back to the well articulated position of the Ranking Member. The other question that i have and the thing that i think is important is that we need to get a fiveyear or tenure or or 10 year, or twentyyear picture of what choice care and that its critically important for you going back and relooking at the capital improvement, trying to figure out how to do it, the answer is going to be different depending on where you are. Senator sullivan will rightly say that they have a higher per capita veterans population, i have one that exceeds the population of several states. This would be necessarily different and the nonva care and the choice would be necessarily different but we have to come up with that longterm visit and based on what appears to be the interest of the senate to continue down that multipronged path so that you are taking pressure off of capital arm and in some areas and maybe redoubling them in some areas and that the variant one thing this Committee Meets to see and then we need to be very specific about what we want beyond rick and mortar presence in the form of nonva care to get this right. If i could make two quick observations, your absolute spot you are absolutely spot on. First of all, we have is ourselves to make certain decisions on what can be made for the community. We have talked before my example of the chairman remembers optometry. Why would we send a veteran to get his eyes checked and classes. Why would we not be routinely referring to that unless a veteran really wanted to come to the va. The other issue that were trying to get at what we are learning what we are saying is that every time demand changes in part of what were trying to understand, when you look in phoenix where we know that we are under penetrated and the veteran market and improve access to care and we get a disproportionate response and we have to understand that the penetration phenomenon will affect the Capital Planning and i will talk with the folks about getting beyond that, looking over the horizon. We cant keep incrementally doing this because were just going to stay behind and we are going to get ahead of this. Thank you, mr. Terry. Thank you senator. , there is a shorter personnel in the testimony and a noted that youre going to be creating his residency positions in this is a matter that i have discussed with the va person in hawaii. And its more likely that the folks will be able to practice in the state. So how will these residencies be allocated by capacity, are there any increasing for medical students of hawaii raiment. I dont have a list with me today specifically aware this is specifically of where slots are going. Have you determined where this is a matter. That is a multitier type of plan to deploy the 1500. The first round of those started this fiscal year and we actually went out, i frankly i did not think that our office would be able to do it but they went out and they sought applications and there are very specific criteria in the law about them going to under resourced communities, they went out and saw those and sought those and we have awarded several hundred for this first round this year. Not as many as we had had thought, maybe, but more than we anticipated they would be able to award and specifically where they are as well. Hawaii has a lot of rural areas that are underserved with by the va. And we thank you for the information. As we look at the request of secretary gibson to pay for the denver facility, and its very difficult for us to accept that you want to take money from the Choice Program to do that. So i would like to ask you this. When a veteran goes to the va to get care for a nonservice can onnected matter in this veteran has private insurance, do you have the authority to get reimbursed from the private Insurance Company for the care that the va provides . As it goes, we will build them and collect to offset the cost of the care that we provided. Under choice we are actually the secondary payers and under the Choice Program with the way the law was written to patient has commercial insurance, the commercial insurance is the primary payer. And then we will make the provider whole up to the medicare rate. My understanding is that in the first instance are the veterans goes to the va and gets the treatment, often there is no reimbursement from his or her private Insurance Company. Are you telling me otherwise . We will build a private we will bill a private Insurance Company if the patient has insurance. Do they reimburse you . Yes, we get paid from them. A lot of the patients have insurance and have medigap insurance. Oftentimes they will not pay for the care because the insurance is specifically medicare gap insurance. Oftentimes he will not get paid by those insurers. Your reassuring me that they go after every dime from the private insurance . I can assure you that we go after every dime we can collect which is about 3 billion per year. There are some questions about outreach and the Choice Program, there is confusion out there and whether you find the veterans that have all five. My question goes to order the outreach efforts and you think you are succeeding in explaining the Choice Program and also to v. A. Employees and Community Providers to get training on how to explain the program. We know who the people are that are eligible to get a choice card and we mailed a letter to everyone of those people in the program started in november. Many found it confusing. We are about to mail as i can letter to them. Hopefully it is a lot simpler to understand, we have actually tested that with veterans for we put it in the envelope. We have made a lot of phone calls and theres no question that i think that we can do more to reach veterans through our website, mobile technology and mailings and other forms of communication and we need to do a better job of educating. We do need to do of her job. We do need to do a much better job. One of the things that we have to remind ourselves of is that there is no parallel to this its not like an insurance card where you walk into your Doctors Office and present your insurance card, there is no frame of reference for people to understand how it works. Why have a benefit, do i not if we could get feedback from my veterans that could help you do a better job, i will be happy to provide it. We would love that. Thank you. Thank you, mr. Chairman. Briefly i would like to ask a question. I understand that the thirdparty administrators raised the issue of how much clinical documentation is being sent by the va, many due to having a wait time of 30 days, which presumably is overwhelming and you now have a Pilot Program to only send the clinical information and i guess the question is is it proving successful and also if you would like to comment from your standpoint as what is going on. When we first set up the program we gave every patient in the system an appointment and put them on the choice list so that they could decide at any point in time which direction they wanted to go. We have learned to experience over the last months this but it doesnt always work. It doesnt help the veteran rs quite frankly its not Cost Effective. So we have the pilots and we have just learned this to see how it goes and how it can improve the business processes. A quite agree we are moving in the direction that the point of service, finding out what we can provide or offering them the opportunity to go outside to the Choice Program. Dr. Tuchschmidt if they choose to go up and our staff much like they do outside of choice for all of our other appointments, we worked directly to get that part of the Choice Program. At that time we hope we have learned how to do this smarter and better so that we will greatly reduce the volume of people that we are referring to and are only providing medical record documentations for the patients who choose to go outside of the system. That sounds excellent. Is a very good idea, and sitting at the table in the initial design and we are getting ready to launch we had two days to make a decision. The question was heavy make sure that all the right informations and place to be able to serve people on the front end. The back and consequences are obvious and making the change makes a lot of sense and were looking forward to supporting it. This has been going exceptionally well in our area and we just approved is a dual to move forward with this across all of the regions and we are getting this in less than 24 hours and its very effective. It is kind of a rocky road as youre working through these things but it sounds like this is encouraging. Thank you, mr. Chairman. Senator, just because you have a very good Committee Meeting here. We thank you. And thank you for your work. And quite frankly i dont know where to start, you guys do a good job in the private sector does a good job, dont think that the pirates sector doesnt have their fallibility is, just like you guys are. And in the bookkeeping nightmare that could come with this, i lived 50 miles and my nearest hospital is 12 miles away. And its staffed by a nurse practitioner. So the question becomes is that somewhere you want to go to heaven of them in and if i dont, guess where the nearest hospital is. And the bookkeeping here is just amazing and i just, i know that we are trying to do the right thing and that you are trying to do the right thing, people are mad because they think it is the wrong thing. But you talked about the 40 mile thing as far as not offering service. You talked about how it doesnt make any sense of the guy has no glasses, why shipped them halfway across the country. When you did your analysis did you include the savings that would occur to the va by not shipping them a long way away . Because i think thats really important. If i was a veteran i probably wouldve signed up for just this benefit. But the truth is that if youre talking about what it costs, its also a savings just in mileage alone. Did you include that in the overall net dollar figure . Dr. Tuchschmidt we actually do not, we have worked through several options with what it might look like. We have not taken into account a great many savings. In the short run we were modeling this. In the short run, our structure is highly fixed. 90 of costs are fixed. Mostly the rest of the of the structure and the building dont go away. Sen. Tester the mileage is also not a fixed cost. If you have to put them up in a room that is not a fixed cost. Dr. Tuchschmidt we have not looked at the travel. There are two aspects of the travel under is the true cost savings and there is the cost avoided and that is not a real savings, that is a cost that you did not realize. Sen. Tester come on, that sounds like that out there. Truthfully. I mean, the fact is that if you are doing the actual cost analysis and you wouldve spent the money, you have to include that in the savings. By no means do i think this, but truthfully if we are going to deal with honest figures this has to be included. Dr. Tuchschmidt clearly it does have to be included. Even if the level of analysis is better than what we had initially lay down to the individual patient and we havent picked up some of those incidents. Sen. Tester its wrapped up in that and it needs to be a nearterm exercise. I think its a reasonable thing to do. Mr. Gibson are we going to look at v. A. Becoming a secondary provider . Its wrapped up in that. And it needs to be a nearterm exercise. Sen. Tester lets deal with that. Because i think its confusing right now. I think there is a little manipulation going on. Mr. Mcintyre and if i might one of the issues i was attempting to address is the fact that we built a network in our area that has 100,000 providers. The requirements are more extensive than those under choice. If you are participating providers. Those things need to be blended together so that we dont have disincentive to participate in one program versus another. Sen. Tester fair enough. And the reimbursement rates need to be the same. 700 million transferred, 400 million. Sen. Tester i dont have a problem with that by the way. The questions i have is this is a miracle drug. When you anticipate those costs to flatten out so you arent going to need those kinds of dollars . Mr. Mcintyre i think the conversation that needs to be held at this House Committee and the appropriators has to do with the requirement that we managed great i would tell you our thought, the vas thought is we should be talking about a requirement where veterans that are hep c positively manage that number two functional zero by the end of 2018. Mr. Gibson that is what i think the requirement should the. So what we need to do with step back from that and lay out a plan that says this is what would be required in order to manage that requirement so we are not backandforth. The first time we deny a veteran access to treatment to his hep c positive because he doesnt have advanced Liver Disease everybody thinks we are depriving a veteran of care. We need to Reach Agreement on what the requirement is. Sen. Tester one last question. You talked about residency slots and i think that is great and i would support it but i believe residencies or three years. It depends on what the specialty is. Sen. Tester what about for internists . Three years. Sen. Tester and that is what we are short on right . The question i have is this place changes every two years and to have three years in a residency you have to have the money for that residency. Talk to me about how this works because you have forward funding but you dont have forward funding for three years. So what do you do if congress does something irresponsible. That has been known to happen a time or two. Dr. Tuchschmidt i think this is one of our concerns. When we started new residency slot all of those slots have to be funded for the duration. That is not the case today. Sen. Tester thats important to know as we move forward. And when he are going to start the Residency Program . And will it start this fiscal year . Sen. Tester we actually dont dr. Tuchschmidt we actually dont own the residency slots. They are owned by the academic centers. We pay for trainees to offset their salary. Additional slots that we added started this academic. Sen. Tester so this fiscal year. Dr. Tuchschmidt the Academic Year that will start this coming july. Sen. Tester so this budget we are dealing with this. If your budget comes in short this may be a program that goes byebye. Sen. Tester dr. Tuchschmidt i doubt it because we have made commitments at this point. Sen. Tester thank you guys for your work. Appreciate your flexibility mr. Chairman. Thank you to all the members and thanks for i appreciate every time and effort very much. We will take a twominute break. We appreciate the collaborative working relationship mr. Chairman. Its the only way to do it. [inaudible conversations] it was a good first panel. I apologize to our second panel is that it took so long but the participation you were illustrating by the looks on your face im sure you enjoyed it too so thank you very much. Sen. Isakson welcome back to the senate Veterans Affairs committee. Darren selnick advisor for concern veterans for america. Joseph violante director of disabled american veterans, mr. Bill rausch who is missing in action right now for awol. Political director for iraq and afghanistan veterans of america. Carlos field taste of the veterans of foreign wars and we welcome all of you and we will start with you mr. Butler. Mr. Butler chairman isakson six and Ranking Member blumenthal and distinguished members of the committee on behalf of our National Commander michael hamm in the 2. 3 million members of the American Legion we thank you for this opportunity to testify regarding the American Legion steel of the progress of the veterans Choice Program. The American Legion supported the access to choice and accountability act of 2014 as a means of addressing emerging problems than the department of Veterans Affairs. V. A. Waits for medical care have reached an unacceptable level as veteran struggled to reset access to Timely Health care within the Va Health Care system. It was clear this with changes were needed to ensure that veterans have access to health care in a timely matter. As a result the American Legion took charge by setting up Veterans Benefits centers in big and small cities across the country to assist veterans in need and their families as a result of the systemic scheduling crisis facing the va. The American Legion dbc charges work firsthand with veterans experiencing difficulty in obtaining health care are having difficulty in receiving their benefits. On november the fifth, 2014 v. A. Rolled out the Veterans Choice Card Program and after six months is clear the Program Fell Short of initial projections from cbo. According to the v. A. Metrics dated november 31, 2015 there were approximately 51,000 authorizations issued for nonva care since implementation of the program with about 49,000 appointment schedule. When you compare these numbers