Transcripts For CSPAN3 Hearing On Consolidation Of Non-VA Health Care Programs 20151223

Call this meeting to order. Welcome, everybody. Hope yall had a great thanksgiving and hope everybody has a wonderful Holiday Season coming up. This is a very important hearing for the United States senate. On november 4th, if my memory is correct, we had a meeting at the va. Sloane gibson, dr. Schulkin and some others were in the room. In terms of Va Health Service delivery to our veterans, veterans choice, consolidating programs, reimbursement rates so there wasnt any preference over another. A reality in our lifetime and in their lifetime. With that will come a number of decisions. This will not be the first time i heard most of this information. We had that meeting before. It will be the first time a lot of people have heard it. Of people have heard it. Of people have heard it. Of people have heard it. This is a critical there are a critical number of decisions we will have to make to make my va work. The new veterans choice work and make sure that va does what it does best well but doesnt get itself into things it has proven in the past it doesnt do very well. Information technology and Network Building i specifically want to ask. As someone who ran a Company Every time you Start Talking about Information Technology or Start Talking about building networks, you talk about infrastructure and costs, raising management people and take an agency that already has 314,000. If you grow that some more youre probably making a big mistake. Ill be very interested in the testimony of what all of you have to say on those particular points. Were delighted that with the progress we made at the va im stopped all the time in georgia and they say youre the chairman of the va committee, are you frustrated with how screwed up the va is . I said the problem is that we see every day the successes weve made, weve got a good secretary, good team, making Good Progress on veterans choice and for all the bad stories you hear about, theyre mostly stories that happened in the past that were trying to correct, not things that are happening today. This is to address a number of previous shortcoming of the Va Health Care system to improve it for the veteran in terms of access and coordination of their care and va in terms of the delivery of the system. But to ensure that we magnify choice and not minimize choice so we can deal with the challenges of the 21st century. I recognize Ranking Member senator blumenthal. Thank you. Welcome to our witnesses and thank you for your good work on behalf of our nation. This task of consolidating and reorganizing community in the care and patchwork of programs we have now is certainly an urgent one and apparently a very expensive one, 1. 9 billion is a lot of money to spend on organization. I want to know how that money is necessary and what specifically it will be used to do. I also want to know about Consumer Rights. How do we protect Consumer Rights and educate both providers and individual patients, your consumers as to their rights and responsibilities. And i want to make sure that this plan for care and community is implemented as well as possible. I know thats your goal, too. Thank you for being here. We have two panels today. First panel will be made up of honorable Sloane Gibson, secretary of the Veterans Affairs. With whom we have worked on a number of projects and look forward to this one. Accompanied by david schulkin, who i want to commend this committee on the rapid approval to his confirmation to take over a job thats critical to deliver healthcare to our veterans. I appreciate his willingness to do it. Doctor im going to mess this up. No, no, dont cheat. Dr. Joe dapias. Yall can correct me. No doctor. No doctor . Take it if you can get it. And with that well your testimony keep it within five minutes if you can. If you go a little bit over as long as its factual, important and relevant, were happy to hear from you. Sloane, thank you for being here. The program is yours. Thank you, mr. Chairman. Ill offer a bit more elaborate introduction. David has been at va for all of four months now. He comes to us from a career in the Health Sector managing systems. Dr. Valleu, has been with the va for 18 months, a brilliant young Infectious Disease doctor. And with va for over 30 years, Medical Center director and he has spent most of the past several months working with this team on this report and addressing Community Care issues. Were facing an extraordinary opportunity by consolidating and streamlining means of providing care in the community. Veterans get the best possible care no matter where they receive it. Were determined to seize that opportunity and make the most of it. Were grateful to the committee to responding to our need for consolidation. Va is already in the midst of an enterprise you alluded to. It will modernize processes and capabilities. Our proposal to consolidate Community Care programs is part of that overall effort. Care in the community has been and will always be a vital component for health care for veterans. When they live too far from a va facility, when they need care only in the community and when increasing command for care. Were referring veterans to Community Care more than ever before. Were saddled with the confusing array of programs, authorities and mechanisms that greatly complicate the task of ensuring veterans get the care they need, when and how they need it. Project arch, pc 3, choice, two different plans for Emergency Care, affiliations. And numerous individual authorities. Each has different requirements, eligibility rules, different methods of payment. Its all too complicated, for veterans, Community Providers and va staff as well. It will improve the process and make it easier for veterans to use. Providers will be encouraged to participate and provide Higher Quality care and va employees will be able to serve both better while being good stewards of taxpayer resources. Our report is based on input from veterans, independent assessment, va employees, federal stakeholders, best practice of the private sector and we also appreciate the many discussions we have have had with your staff, many of whom are in the room today. The report focuses on five functional areas. Single set of Eligibility Criteria based on distance to va provider, wait time for care and availability of services with va with expanded access to emergency and urgent care. Second, ease of access. Streamlined rules to simplify the process. Third, highperforming network. Partnering with federal and community to offer a network that will allow va to better monitor Health Care Quality and utilization. Better coordination of care. Helping veterans make the best choices among Community Care providers. And fifth, prompt payment, improving billing, claims. And reimbursement processes to allow auto adjudication of most claims and faster, more accurate payment. These efforts wont just improve the way we do Community Care. They will make Community Care part of the fabric of va care, making va truly an integrated health care system. Getting there will take time. Even as we work toward the longer time, were improving veterans experience of care in the community. In the near term, we have expanded the proed vieder base by including providers already participating in medicaid. Weve eliminated enrollment date and combat eligibility indicators as factors limiting choice availability. Yesterday we announced several new changes to the Choice Program that are products of our collaboration with this committee and your house counterparts for which we are very appreciative. Veterans are now eligible if theres not a va facility within 40 miles. When qualifying veterans for the program, we are taking into consideration many different things. If a veteran needs a flu shot or if they need a round of chemotherapy every two weeks or so they may now qualify for choice no matter where they live. Those are just a few ways were making Community Care more accessible to veterans even while working toward the longer term goal of consolidation. A number of close end consolidation objectives. A steam lined referral and authorization process. Standardization of our partnerships with dod and academic affiliates. Critical make versus buy decisions on Information Technology, in contractor support. Successful application of my systems to Community Care coordination. These objectives will be the work of a Community Care Team Dedicated full time to improving and consolidating Community Care, led by a new deputy undersecretary of health for Community Care. Were eager to move forward but it must be a collaborative effort with congress. Like many of the improvements weve already made is only possible with your support. We need congress to provide necessary legislation and required funding. I know costs are an issue. Critical cost issue right now is the 421 million. We expect to spend this fiscal year on systems redesign and business solutions. These are onetime improvements that are absolutely essential if were to move forward with consolidation and improving critical care. We may need to consider other costs to cover other possible aspects, such as increased demand and expanding emergency and urgent care. We also expect some cost savings from consolidation as well. Weve detailed our specific legislative proposals in the report, and were happy to work with any member on these items. Finally, mr. Chairman, a word about provider agreements. We need congress to act on the proposal we submitted may 1st and uncertainty about care thats outside the Choice Program and our other Community Care programs. This is especially critical for veterans in longterm care. Were already seeing Nursing Homes not renew their agreements with us, which means veterans will have to find new homes. Thank you for the support youve already shown. We look forward to integrating care in the Community Within the health care system. Thank you, secretary gibson. Appreciate your testimony. I want a short answer on this question. You said you made two changes, announced two changes yesterday regarding the 40mile rule and the services a veteran needed to expand choice access. Steps long away to consolidation, i think thats what you said. Yes, sir. In one sentence, describe what that longterm goal is. The longterm goal of consolidation of care is to improve the veterans Care Experience and deliver that at the best possible value to taxpayers. In that case when we had the field hearing in gainesville, and i dont think you were there. Secretary mcdonald was kind enough to come. I cant remember the name right now. The choice provider for the east coast, i cant remember their name right now. Health net. And a discussion ensued about issue of eligibility of a veteran to get services outside va through choice and it was an arduous process of which meant file after file going to a Third Party Provider before they could determine getting veteran the service. Is that still going on with the Third Party Provider . One of the things we want to see is easy access for the veteran, wherever it comes from, you or the private provider. This eligibility situation you used eligibility in your testimony a lot. Its evidently more cumbersome in practice than it is in words. What are you doing to streamline that process for a veteran to know they are eligible and it doesnt take a philadelphia lawyer to figure out whether they are. He will outline some of the things we have done to simplify that process. Thank you for that question. The way a veteran can access care in the community, they are two of the foundational elements of the report. The process of consolidation is to help streamline eligibility. There are not multiple programs each with different criteria in order to access Community Care. Thats what we outline here, develop a set of criteria easy for the veteran to understand and easy for our Community Providers to also be able to administer and for our employees to deliver that care. So, thats from the eligibility standpoint. When we talk about referrals and authorization, that process is very cumbersome, as you described, mr. Chairman. There is a number of steps that our employees have to go through in terms of transposing information, uploading information, sending that over to our third party contractor, steps that they go through before we can actually make an appointment for the veteran. Thats too long. What were proposing here in the plan is to streamline that so theres less redundancy. We are more automated to accomplish that. What we have done in the meantime, mr. Chairman, is we have modified the contract with both the Third Party Administrators which now allows us to almost immediately send an authorization document to the Third Party Administrator that triggers a call from the administrator to the veteran. Instead of the veteran having to call the administrator, waiting several days before doing that, and getting bounced back and forth between va and the Third Party Administrator, the burden falls on the Third Party Administrator to reach out and make contact with the veteran to get the appointment scheduled. Designed to simplify the experience and streamline the experience from the veterans perspective. All right. Im going to try to phrase this question properly so i am expressing it properly. My ultimate vision for choice was that a veteran had a choice to go to the doctor to provide the veteran with the service they need whether theyre a va provider va hospital facility or a private provider in the community. When you refer to consolidating your private providers, are you talking about a network of doctors that the va has approved that the veteran can go to . Mr. Chairman, i think the name choice was deliberate on your part. That is the way that we intend to do this. The first issue in this plan is to build a network of providers in the community, as you said, based upon high quality criteria, to ensure that veterans are getting the best care available anywhere in america. Then to allow that information to be transparent so that people have information on quality and metrics to make educated choices. Thats the intent of the program. This program doesnt specify that how we do that because this year, the first phase of it would be planning and designing how that system works. How is very important. Im going over a little bit and i apologize. Well be generous with time for everybody. But if youre one, i have a health care plan. And i know which doctors in my community are eligible and ones arent. They publish a book which says which ones are and arent. I call them up, make an appointment and i go. Its a Pretty Simple process because they all is that what youre looking at doing . That is the intent, identifying the high performing network and allowing veterans to have the choice into which providers they select. Its not only the criteria that defines the interaction with the patient and physician, its actually the personal interaction. And that is very variable, depending upon how the veteran experiences the physician. So we want to help guide veterans with right information, let them see it and allow them to make the choice. Last extension of my time. And i wont ask any more. Do you ultimately envision the third party conduit they have to go through going away because you have an approved list of doctors and the veteran makes the appointment themselves and they go . You eliminate that middleman . What we call phase one of the contract is to evaluate how do we simplify the process to allow this to be veteran centric, something were far way from because theres too many hoops to jump through. And were going to be doing a build by decision. Whats the best thing for a veteran and for taxpayers . The role of outside organizations helping us is still uncertain. Until we go through that process and decide, is it better to build and eliminate processes or is it better to seek external help . One of the things we recognized is that va doesnt always do this internally that well. We are open to the answer being that we need help to do this. But we want to have the discipline of going through every step and deciding, should we build this or should we buy this. Thank you. I apologize for going over. Senator blumenthal . Thanks, mr. Chairman. I would like to pursue the question i raised in my opening remarks about protecting consumers and patients. Kwha kinds of mechanisms and standards will be in place to assure that protection . Thats an excellent point. What we are proposing in the plan is the first step to get to Consumer Protection is to actually have the necessary information on the providers in the network, their performance so that we can make sure that consumers or patients have the information they need to make important decisions. Right now thats actually critically missing. We might have local information at the Medical Center level. Regionally and nationally, we dont have the necessary data to determine the quality of care or the health care utilization. Where do you get that data . Thats exactly what were asking for in some of the 421 million in phase one, to build a network where we can gain that sort of information. And what kinds of mechanisms will you put in place to assure that theres education of those patients . And, number two, that there is a way for them to bring complaints to bear. Ill answer that in two parts. Whats articulated in the plan is a Robust Customer service function. We want to make sure were able to get complaints or compliments or issues raised. Not only from veterans but also from Community Providers. So, health plans that function very well have a beneficiary arm as well as a provider engagement arm. We want to make sure that there are avenues to be able to communicate twoway between our customers, our patients as well as our Community Providers that serve them. In terms of the specific details were starting the process now of developing implementation plans and milestones and working out those details. The Veterans Experience Office that will be a center point or core function . The veteran experience office is, department wide, critically part of our team rolling this out. Yes, there is a role for that. Were welcome and open to discussing with you and your staff other opportunities that we can have to make sure there are safeguards for our patients in the network. I would want to pursue that. Lot of subjects to cover here, so i cant do it right now. I do want to pursue that set of issues. I was struck to learn that va data shows a loss rate of nearly 9 for physicians and 8 for nurses in the fiscal years 2014 and 2015. In each of those years the va lost about 6,000 physicians and nurses combined. Presumably, many of them would have played a key role in the coordination in care in the community. They are now going to be out in the community, presumably. What can be done to keep those people within the va so that that care is, in fact, provided by the va . The majority of staff losses for physicians and nurses for fiscal years 20142015 were due to staff who quit. I also was struck to learn that that the va has under has about 336 buildings that are vacant or less than 50 occupied. Given that the va trains about 70 of our physicians nationally, an impressive number, 70 nationwide, dont we run the risk of not being able to train enough medical professionals to work in both the private sector and the va . There are two related questions. Were losing staff. Were under utilizing buildings. Can we continue to provide quality care within the va and can we continue to train . Senator, a lot in this question. Ill try to be brief in my answer. You can supplement it. I recognize this forum is only kind of an introductory means to answering some very profoundly important questions. I appreciate that. We will take you up on that. Your issue about Consumer Rights, very important issue. Very, very big in health care. I would just very briefly say the rest of health care, the private sector is dealing with this by no longer trying to be paternalistic, you make Information Available and let people decide whats best for them. Senator isakson was also talking about this as well. On the issue of losses, the 6,000 physicians and nurses and other staff that we lose, each one of those people that leave the organization that shouldnt is painful for us. We have to figure out ways to retain people. Morale is lower than we want in the organization. And we absolutely have to address it. Thats one of my priorities, to address that issue. Its not all bad news. Between august of 2014 and october 31st of 2015, this period youre talking about, we had a net increase of 1,692 physicians and a net increase of 3,508 nurses. So while we are losing and we have to address that, we are actually hiring more and have a net increase, helping us deliver care. On the issue of training, the role of medical education, nursing education, va is critical for american medicine. We cannot lose that mission. We cannot lose that role. So we have to be able to keep a strong clinical environment to train americas professionals. We do have vacant space. And part of our plan identifies savings, another issue you had talked about in your opening statement, the costs. Some of the savings will come from right sizing some of the space we dont need. Its not going to be at the expense of us training Americas Health care professionals. I really appreciate those answers, and the answers that you have given. I really think this area is critical training our nations physicians is one of the premiere Public Service functions of our va system. And its a pillar of american medicine. And the talk around here is often of accountability and cracking down on bureaucrats who may be incompetent or corrupt. We also need to focus on keeping the good people, good docs and nurses and pharmacists and clinicians in the va. Because theyll be critical to american medicine in training but also in caring for our veterans. So thank you for your answers. Senator moran. Thank you for holding this hearing and thank you to our panelists for joining us. Undersecretary schulkin, is it your responsibility to implement the choice act . First of all, welcome to the va. Thank you for congratulations on your confirmation. And glad to have somebody rowing the boat. But choice act becomes your responsibility or is . Yes, it is. Secretary deputy secretary Sloane Gibson and i have had a history on this topic. Im going to try a fresh face and go at this again. I have had a goal at seeing that the choice act is, in my view, appropriately implemented. Part of my interest in this certainly comes from the demographics, the geography of kansas. Lots of territory, lots of distances. Choice can be a significant asset of great value to veterans across our state. My original complaint was this issue of whether it matters if the cbok provided the service that the veteran needed. If it doesnt, does it count as a facility under the choice act . Weve had this ongoing discussion. I offered legislation that passed the senate that said if the veteran cant get the service he or she needs at the cbok, it doesnt count. That legislation is pending in the house of representatives. I was encouraged, perhaps convinced by my colleagues in house and perhaps here in this committee that there was another approach. That was to define what a facility is paced upon the fulltime nature of the staff there. In particular, a physician. Legislation now in law. So, a law says that it requires for a facility to be counted under choice that there be a fulltime physician at that clinic. I was always worried about whether or not the va would interpret that in some way contrary to what common understanding would be. At least my common understanding. I had assurances from va personnel and staff, certainly on the House Committee that a physician would be required to be at a facility on a fulltime basis, 40 hours. Even as recently as two weeks ago it was confirmed to me by two of the panelists in a meeting with my staff in senator kings office. And then yesterday you report different language about what this now means. So, i feel i mean, what came out yesterday is that the interpretation is completely different than what i was assured it would be and it says multiple physicians, not one. Equivalent to. 9 fte maxing 36 hours. I think the language is clear. It doesnt say physicians. Its not plural. I would like to hear how we got to the point that we now appear to be at and to see if theres something we can do about that. Let me bring this back to kansas. Secretary gibson and i have had long before secretary gibson weve been trying to recruit a physician to cbok in kansas liberal part of our state, unsuccessful in doing so in years. Secretary gibson in an effort to solve that problem, determined in a letter to me in july of this year that that cbok would not count as a facility and veterans receiving care there could have community services. This is the issue we continue to face. In part based upon how you define what a fulltime physician is. But also why dont the veterans who live in areas other than liberal get the same kind of standard as to whether or not the cbok counts or not . For example, emporia, kansas, in the flint hills of our state. 25,000 kansans. Several thousand veterans. Its open one day a week. It counts as a facility. Seneca is opened one day a month. It counts. In fact, its now closing seneca cbok so it no longer counts. The reality is that it shouldnt count in the first place if its open one day a month. Is this just confusion in the va or is there a solution so that the veterans who get benefit of Outpatient Services at liberal, its true regardless of where you live in kansas or across the country. Okay. Well, thank you. Senator, first of all, i hope that this is that there is not there shouldnt be a difference between what you want and what the va wants. First of all, not to take away liberals benefits to make that come true. No. Right. Okay. We want the same thing. Which is particularly in rural areas where there is a severe shortage of providers in general. We want to have as much access to care as possible. Thats the goal. I think this difference of interpretation, which you learned about a short time ago, myself as well this difference of interpretation is really a wellmeaning difference that i believe we can work out. Our belief is the way we were interpreting this, or ill speak for myself, is that we want to have a fulltime physician, a provider in rural areas, in particular, we find its easier to recruit parttime physicians rather than fulltime physicians. So two parttime physicians keeping that open at 36 hours a week is in the veterans best interest. As you may know now, 25 of physicians in this country work part time. For women physicians, its actually higher, up closer to 35 . So, we are trying to staff these clinics in the best way possible. Thats our intent, to provide the office open 36 hours in whatever setting. In terms of the clinics that are open one day a week, that shall not count. If theyre not open with a provider for 36 hours, that does not count. And they dont count. If i may, the cboc, you have to provide a certain volume of primary care and Mental Health care. There has to actually be open daily and they have to be able to provide that level of service. Theres a number of categorizations for clinics that are only open one day a month or couple of days a week. Those are not used in the calculation of the 40mile criteria. I actually have a listing from liberal, seneca and emporia that you mentioned are not used to judge the 40mile geographical criteria. Time has expired. Cboc in seneca is being closed for the stated purpose of making certain it doesnt count as a facility under the choice act. The seneca as this was recently presented to me because i dont like closing facilities that serve rural areas. I think thats of concern. The seneca example is that there was such a small number of veterans, like 100 veterans, that our doctors coming from the larger Medical Center were spending a day traveling there and potentially they werent practicing during that time. We thought we could better serve kansas veterans by actually potentially closing that one clinic and using Community Providers. I only raise seneca as an example as where the va has determined, as i understand from the folks at home, that has to be closed so those veterans can access care in the community. Dr. Schulkin, maybe youre right about how were going to have to track physicians and theyll mover likely be part time than full time and fill that gap in rural places thats necessary, but i would again make the point that the law says what it says. And the conversations that weve had over a long period of time confirm that. And so whether youre right or wrong, whether veterans can get better care by a different definition, i think thats a matter that Congress Needs to deal with. Its outside your Rulemaking Authority to go beyond what the law says. Thank you. This is a very important point. Im going to follow up with a question on this. You made two changes you announced in the Choice Program. Would you read the second one again, your testimony . You said you announced two changes of veterans choice eligibility. Second, when qualifying veterans for the Choice Program, we are now taking into consideration the nature of the care they need, how often they need it and whether they need someone to accompany them. So if a veteran just needs a flu shot or if they need a round of chemotherapy every two weeks or so, they may now qualify for choice no matter where they live. Here is my followup question on seneca and liberal. Seneca is part time. Liberal is semi staffed. Is that right . No physician. No physician. You have a kansas veteran who needs Health Care Service and cant get it at either one of those facilities, why arent they eligible now to go to a private doctor . They are already, from both locations. They already are. So what am i missing . I think youre missing that youre not missing anything, mr. Chairman. Excuse me for suggesting that you are. Thats not the way its being implemented. Well, thats what im referring to. Im a Pretty Simple guy. When you read what you read it told me if i was a kansas veteran and i needed chemotherapy or i needed a regularly scheduled two week appointment or i needed whatever and neither seneca nor liberal offered it, i ought to have choice to go to a private doctor in liberal or seneca somewhere. Heres what id like to do to get clarification here. What we will do is we will go to the 40 mile roster. The list of veterans that are eligible for care under the 40 mile rule. Well look specifically at seneca and liberal and wherever else you want us to look, and well print you the list of the names of the veterans that show up on that 40 mile list. Because we know whos eligible for care under 40 miles. We know that already today now. Well do that and provide it to you. And then we can figure out whether or not those veterans are actually accessing care in the community. The reason i want to continue on this one more segment. Im slow but i want in the case we just talked about, 40 miles is irrelevant. If youre within 40 miles but you cant get the service that they need, they ought to have choice. If the clinics not open or not available, they ought to have choice to go as well. Period, end of sentence. I thought thats and that is the interpretation that we have applied on parttime clinics since we launched choice. But well go print out the list of veterans on the 40 mile list and well look for those from seneca and wherever else, whatever communities in kansas youd like for us to look for and determine whos actually using 40 mile hour el thats the way it works today. Not tomorrow but today and yesterday. Mr. Chairman, there are nine in kansas that do not have a fulltime physician that are still listed as facilities and veterans are being told they live too close to a facility to access choice care. And thats wrong. It is wrong, and if thats the case on the ground, well fix it. Yes, because whether its hartford, connecticut, macon, georgia, liberal, kansas, if the veteran cant get the service from the va and choices operable, which it is, they ought to be able to choose a physician that can liver the service to them absolutely yes. And they dont have to go through anybody to do that. I mean, they just they work, they get their appointments. Mr. Secretary, your letter to me of june or july was very appreciated and, in fact, reinforced how i thought choice should be interpreted in the first place. Yes. Is just what we want to have, the ability to do every place else. What youre telling me is thats now the case. That is now the case, yes, sir. If were not executing that way, shame on us, bad on us. Thank you. Ive taken the additional time because senator was out of room and hed have been asking those questions. I want to make sure people from kansas and montana and connecticut and georgia and washington state, everybody, yall knew we believe the choice was a veteran cannot get service at a va facility, they can go to get the service. If we talk about consolidation to provide choice and make it meaningful for our veterans, that ought to be the ultimate goal where we go. Especially the folks in liberal, kansas, thats right. That voted for jerry moran. How is that spelled . I have no idea. Senator. Thank you, i thought i was hearing wrong when you of the senator talked about liberal. I was thing on a political continuum. Obviously, that is not what were talking about. Im looking at your testimony, secretary gibson, and i would like to make sure that i understand your testimony. So in looking at page three, you say the consolidation plan will center on five functional areas. You list the five function al areas. And then going on to page five of your testimony, you say that again were talking about the new will involve. And you list one, two, three, four, five five systems. So are they enhancements . In alignment with the five functional areas . Is that how your testimony is to be read. It is. Go ahead. It is a little bit confusing. Yes. The way that we the way its presented is in these five foundational areas. Really trace the veterans journey through care. We start with eligibility. Go to referral and authorization. The providers they see in the network. How they coordinate care. The back office function of claims. So that really maps a veterans journey. When were righting out the way we should approach implementation and how we should think about system design, we use whats called a system and Systems Approach. What are the different systems that touch these five cornerstones. Those are the systems you have there. One is Customer Service. How do we improve Customer Service for veterans and Community Providers . One is for care coordination. How do we do we coordination of care including i. T. Systems. One is administration. So that deals a little bit of eligibility. The referral and authorization process. The next one is the network which is how do you actually build the network of providers that can deliver the needed care to veterans. Lastly its kind of how do you operationalize this, how do you implement it. That gets into the governance structure nationally and locally. How do you get data so we can make sure were tracking and monitoring things correctly. Theyre very related. They dont overlap 100 . One is the foundational Building Blocks of the plans. Other one is the systems to implement the plan. Were talking about a vast system and its all very complicated. And for the individual veteran to navigate his or her way through the system is really a challenge. And so while it sounds really good the way its described, each of these systems that you seek to enhance could take a whole lot of effort to even figure out how to do it. So im wondering what your time frame is because you ask for over 420 million, just to, what, design what youre going to do with these 1, 2, 3, 4, 5, enhancement systems that youre going to look at. I think youre accurate that this takes time. This is not something we can switch on and be able to implement completely. In fact, there really needs to be close collaboration with this committee and congress in order to get certain legislative relief and resources to do that. With that said, the way were designing implementation to carry out some of this work is not, you know, in three years to have some grand reveal of like heres the problem we all get its going to be quite complicated. What are the aspects youre really focusing on is the outcomes. So that is a whole huge system or process that you have to develop to figure out whether were getting the best bang for your buck. And so part of what your testimony, mr. Gibson, says this would not be possible without approval of request of legislative changes. I was trying to look at your testimony to see if you had specific legislative changes that you are requesting. The legislative changes arent incorporated into the testimony. They are incorporated into the Plan Document and theyve been briefed and discussed with senate staff. I would hate to appropriate 421 million for you to develop a system and then it cant ever be implemented because these other legislative changes you say are integral to the changes you are talking about dont happen. I want to give you an example. When secretary gates and secretary shinseki said they were committed to making sure the medical records of these of the active duty and the veterans would become integrated and after 1 billion plus, we still dont have it. So that raises, in my mind, some concerns i have about this undertaking and what kind of resources its really going to take for us to implement. Worthy goals, but i think were going to be working very closely with you all to make sure this happens. I dont know whether this is biting too much, you know, from the outside. What would your priority be within these areas that youre designating . I am going over but then, mr. Chairman, you gave us lee, so there you go. Thank you, senator. I just want to clarify. When we were talking about systems, theyre not necessarily like i. T. Systems or systems that would be built by va. There may be a combination of improvements to existing systems, enhancements to ones that exist, solutions we might purchase from the private sector. The word systems is just a term to describe for example like Customer Service or care coordination. It doesnt necessarily mean theres a platform. Its just the actual area of work. I would just have to be very specific, senator. The 421 million were requesting from 802 funds, not new additional moneys, would be to fix the problems that currently exist in the Choice Program. This is to make the veteran experience better, that we know is not working well for veterans. The biggest part of that 300 million of the 421 is to build what we call a veteran portal. A place where veterans can go, get the information on their care, have it coordinated with care from the private sector and the va. Without effective information sharing between the private sector and the va, this plan cant work and it wont work for veterans. So thats the majority of the money. Youre talking about the choice plan . The new choice plan. The new choice plan. Youre talking about the choice plan . The new choice plan. The new choice plan. The plan we have delivered to you, the new veterans choice plan, about how were going to work better with the private sector, needs to have effective care coordination and information exchange. And thats really the majority of the 421 million. I think we just want all of this to actually happen. Thank you, mr. Chairman. Thank you, mr. Chairman. Id like to follow up on what the senator from hawaiian is speaking about with regard to the portal itself and the plan on how you would implement it. Im curious, are you planning on using internal resources to accomplish this or will you be using a third party to actually create the enhancements to existing software . How do you plan on doing this . The first part of the plan, senator, is to identify the systems that we want and then make a build by decision. We dont have an answer to this now. I will tell you, though, our experience, and were often reminded about this from members of congress, about building all these systems ourselves, is not always the best. So were going to be very open to if this exists in the private sector, if we can buy this off the shelf, because time is of the essence and execution is more important, were going to have the intellectual activity to make that choice. Health information exchanges, another word for portals, are very, very robust now. Theyre out in the community. Many private Sector Institutions ive been affiliated with have functional hies, Health Information exchanges, so were certainly going to look at that option. Im one of those skeptics. I guess the reason why i bring up the discussion is that i think theres no reason for the va to try to reinvent the wheel. If it already exists. I would expect there would be the opportunity within the private sector to find competitive proposals that are out there in terms of quality. And cost. I think im asking today is that the prime approach you use or is that the fallback position with the intent to look internally first . With our new chief Information Officer laverne who came to us from johnson johnson, her bias on every system is to go commercial off the shelf. And so that is for us, thats the default position that we take until we have determined that we are unable to do that. Very good. How about with regard to the discussion about the providers and the Provider Networks that are out there right now . Currently, i believe in your early testimony, mr. Secretary, you indicated that the providers already included what include, and i believe you said medicaid. Individuals who are providing services through medicaid, is that correct, or one of the, one of the changes that Congress Passed recently at our request was to allow us that the original choice act required us to only use medicare qualified providers. If you stop and think about it, theres some, say, obstetrics, for example. We asked to open it to include medicaid providers to allow us to reach into some other specialties. Not only medicare providers but also medicaid providers to all be currently eligible as a qualified providers under your guidelines. So those providers. If youre a medicare provider or medicaid provider, you meet that standard, and then you have to join the network. A veteran cannot go to any specific medicaid medicare provider. You have to use the Network Providers which are made up of i dont mean to cut you off but im going to keep closer to a time frame here in deference to the chairman. If you have if you have an individual who, though, is identified as being a quality provider through medicare or medicaid, the option then becomes theirs to make a decision whether or not to join your network and not a matter of stepping through another hoop provided by the va for determination of eligibility. It would be the providers decision. So the way that it works is if the veteran decides to use lets say theres a doctor that takes medicaid in the community but theyre not part of the network, they can go to our contractor and say, you know, i want dr. Smith and our contractor will reach out to dr. Smith, give him an agreement and they become part of the network and that veteran can go to that doctor. There was concern you were using outside vendors to provide for those networks. Today as i understand it, youre looking seriously at doing your own network yourself. Why would you now have the expertise to do it yourself if 14 months ago you did not . Im curious. I dont think weve made that decision, senator. I think this is another example of were going to look to whats available in the private sector to help us with that, and were going to look whether if we cant get that, then we would have to look internally but weve not made that decision. Do you intend the provider net be ares also include open tom trusts optometrists . In many cases you have licensed optometrists in communities where at this stage in the game theyve not been found eligible until theyve been approved by some sort of va determination up front. Ive actually had veterans who have gone in gone to their own optometrists in a town like pierce, south dakota, and then when they go to get their eyeglasses, theyre told, im association but you dont have a qualifying optometrist giving you this information so were not going to give you your eyeglasses. What im curious about is included in this in the future will be an opportunity for optometrists to be included in this same category of providers . Um medicare, medicaid eligible . Dont know the situation youre referring to. Wed be glad to track that down for you by the way. It took this veteran six months to get a pair of glasses. Yeah, and that shouldnt happen. But we do need to have a contractual relationship with a provider today for us to be able to Exchange Money with them. In this case, they werent asking for any money. All they wanted to do was get glasses. And they wouldnt accept the prescription from that optometrist. Thats inappropriate. A qualified optometrist. Were not going to see you would see this as going away if this happens . That makes no sense were going to have criteria to get into the network and once youre in the network, once youre accepted into the network, we want all those paperwork authorizations to be minimized. I think the very simple example here is veterans got the prescription for his eye glasses, he wants to come to va to get his prescription filled, he ought to be able to do that right this minute. Thats right. No reason why that should be happening like that. Thats the way we saw it as well. Yes. In fact, we offered to go and pick up the eyeglasses for the veteran and that wouldnt work either. So im happy to hear it sounds like youre on the right track and hopefully well get this resolved. Unacceptable. Thank you, thank you, mr. Chairman. Senator murray. Thank you very much, mr. Chairman. Thank you for having this hearing. Secretary gibson, i want to ask you, some of the proposals out there would have the Va Health System provide only some socalled va specialties and get the va out of the business of doing some thing like primary care and rely just on the private sector for that type of care. That may be concerning to veterans who want to use the va facilities. And cutting out that much work i think could have serious consequences for our va hospitals and our providers. I wanted to ask you, can you talk with us about some of the impacts of taking away some of the fundamental lines of care . I would tell you at the very heart of what we must preserve is primary care. I would tell you, theres no other organization that integrates Mental Health care into primary care the way the va does. I think primary care will always be a main stay of Va Health Care. I think as we get into other situations. Weve talked about the context of different administrative parts of running this program. I think over a period of time, we wind up, if were doing our job, we wind up getting into make versus buy decisions elsewhere. I think at some point and some locations, were going to have to make a decision, are we better off continuing to use our scarce space and our scarce resources to develop basic services. So i dont see, i dont see any of those kinds of core services, spinal cord injury, traumatic brain injury, poly trauma, i got to tell you, we were in tampa a couple of months ago, and dr. Rich, former Surgeon General of the United States, saw what we were doing in poly trauma there, said, do you realize this is world class, this isnt just best in class in america, theres nobody in the world thats doing what vas doing in poly trauma. Were not going to sacrifice that for our veterans. To be more permissive in allowing our veterans the use of Emergency Care or urgent care. As i look at your plan, it seems to require veterans to pay a copay of up to 100 no matter what. Im kind of amazed we would ask our veterans to pay for care for Service Connected conditions. Thats a major reversal of a fundamental tenet of our care for veterans. We agree with you that there needs to be fundamental reforms to the er system right now. We because of various rules and regulations and laws. So when a veteran goes to the er, if they werent able to get preapproved by va or bypassed the va, they could end up getting stuck with the bill thats way more than 100 on the order of thousands of dollars. As a result of that behavior right now, a lot of veterans end up deferring er care. They end up driving to the va or waiting for our doors to be open to be seen. Thats really creating a perverse incentive. What we were trying to do here is be able to responsibly address the management of er care. What we propose is remowing all those different restrictions so a veteran can feel comfortable when they go to the er, they will get seen and va will be able to pay the bill. The idea of cost shares is really modeled off health plans in the private sector and tricare, which is we dont necessarily want everyone to go to the er for, you know, the sniffles or if they have a paper cut. We want them to be able to call their primary care doctor, have that dialogue and hopefully be seen. Even for Service Connected though . I think its regardless of Service Connected or nonService Connected, those are the same issues. If you only have a little cold and need to be seen by your primary care doctor, we want to expedite that so you get seen in the va or by your primary care physician in the community rather than going into the er. If we remove that cost share, thats something i think is up for discussion. I just would say the actual cost of that program would be way more than what we outlined in this plan. I think we have always told our veterans we would care for them for Service Connected issues so this would be a major reversal if were charging them copay for emergency visits. I think part of the problem is we have a third of claims that are denied even for Service Connected claims. The way it works today, if you dont follow all these different rules and regulations in place, even for Service Connect condition, they get stuck with a very large bill and ambulance bills. And so we were trying to find a way to be able to sustainably be able to manage that issue. Im out of time. Secretary gibson, how are you going to make sure the care veterans receive in the private sector is high quality, timely and coordinated . How do you do oversight of that . This is where were going to have a comprehensive set of quality measures, of metrics, both outcome metrics and process metrics. Actually, my area of training, has become so sophisticated that va has data sets that really are unparallel by any Health System in the country that we can produce this type of data. Im sorry, im out of time, so ill follow up with you separately. The data sets the va has looks at quality measurements. Those are for va financials. Senator murray asked about your outpatient. Yes, you would have to. If you want to have an integrated system of care and seamless between private sector and va, you have to collect those measurements. I accept that. Limited time. He spoke so long, it could have been he. As records the metrics you mentioned as well some qualitative measure, how the patient interacts with the physician. That is not defined by anyone. Well, we do do surveys. Thats part of outcome measurement systems. This is like dating, you know, you dont know what that attraction and that magic is. I accept that so you need a certain in so its going to have to be a robust data set. At the risk of just sounding like a sour lemon, ive asked for data before from the va on data that was specific to the new orleans va and i was told you segregate it from the aggregate. Not true. We can absolutely segregate it for that va and we have robust metrics. Secondly, i went recently to a very wellrun basically cross between a staff model, hmo and ipa, which is what you are aspiring to, but much smaller and much more able to bring every physician in and counsel her or him. And they found their data systems very difficult to theyre very successful, but theyre nowhere approaching the goals that youre putting here. Now, it gives me pause when you suggest to us you can achieve that when a much smaller organization has been unable to do so with a more homo genius set of providers. Any comments on that . First of all, i would very much appreciate being put in together with them so we could see what theyre doing and what theyre learning. My experience is from the private sector, where i have built these systems, so ive done this before, where we do have metrics. These are not perfect metrics. Im not suggesting they are. They get better every year. Va has capabilities to actually for the data to be worth anything, then the physician who is seeing the patient would have to spend a significant amount time interacting with the metrics. Which means a certain bulk of their patients would have to be va a patients in order to make it worth their while. Which means your ambition and the money that were going to apparently provide for this ambition, im not quite sure i see it as many a realistic ambition. Yeah, if you involve your clinicians and data gathering metrics, its going to fail. Absolutely understand your warning. That is not what your intent is. Have come off of administrative systems, merging with the clinical record. Va has the longest experience within an integrated electronic record. We have more Clinical Data we can extract and then combine it with administrative claims data and this is what were talking about doing. Were not talking about turning doctors into data collectors. Let me ask this. Again, at the risk of just because were here as secretary gibson once said about the veteran. I was in a conversation with a very highprofile medical system director. If i mentioned his name, we would all know who he is. He had a very dim view of quality in the va. Pointing out that more people in the va lose limbs from diabetic foot ulcers, which is really a failure of management, than do from trauma. And strongly saying that any wellrun private aco or system which have the same outcomes as va would probably lose their license. Now, it seems as if drsh so im just channeling now. Im sure theres statistics. The point is if the va has so far to go in quality but theyre passing judgment on other systems that quite likely will provide statistically according to this gentleman superior care than that rendered in the va, again it seems a little bit like the judge is guilty. Any thoughts on that . Yes, first of all, i would love to talk to this person. I would love to show him that since this is not an argument between difference of opinions, there is data on this. The data actually show that va does as well or better in almost every Quality Metrics study done. I just reviewed nine additional studies showing vas quality is better. Im not suggesting the vas better in every metric. When you take a look at screening, adherence to well accepted evidencebased protocols, riskadjusted mortality. The va performs better than the private sector. Certainly as well in these studies. Be glad to share with you. Just came from an hour before the hearing meeting with all of our Health Services researchers who do this type of work and have the data to prove that. I yield back, thank you. Senator manchin. Thank you very much. Thank all of you for the work you do. We all have the concerns of va. We want to make sure they get the best service possible. That seems to be our problem. In rural West Virginia and i know in rural america. When that situation happens, we dont have the expertise as you can imagine. Theres a time lapse that goes on before they can get to the proper care they need. I know you all want to move in that direction. Do you believe that the steps youre going in the direction right now is going to relieve that veteran who cannot get the Expertise Service that he or she will now have to partition and wait and go through a period of time before they can get the services they need . That is precisely the objective. When we describe the existing system as being broken. I think we all have it, dont we . All of us have it . And this takes effect when . Im sorry . When the new plan, when what you see in the plan here, as doctors been describing, an area of process. What we do, we start going through and improving the veterans care and experience. I was saying rule, rule america, especially rural West Virginia. That would be the place to come. Because thats where our greatest challenges are. We dont have these large areas where you have Trauma Centers and, you know, all that going on. So thats the thing that were running into. And how we can alleviate this. The frustration i think that senator casty and everybody, you know, they deserve the best, they really do. They might have a Family Member whos able to go and get top notch expert. They dont have that opportunity. And thats just not right. Its just not fair. I know thats what you want. And we dont have to reinvent the wheel here. Tell us how we can help you at this end of the table simplify q the process we all want. Well, thats what this plan accomplishes. There are explicit legislative requests that are part of this that will help us do that. That the two quick comments. I really bristle at the characterization that va care is bad. That is not an accurate characterization of va care period. I will tell you there is variability within the va system. Variability of Health Care Outcomest variability of access. Part of our challenge is to diminish that variability. I would tell you go out and look at the private sector. There are references in the independent assessment to the fact you actually find even in well regarded hmos wider variability in Health Care Outcomes than you find in the va system. So thats point number one. Point number two, i mentioned in my testimony, care in the community is going to be there for va for the long haul. Either a Specialized Service we need to rely on the community to be able to deliver because we dont have the Critical Mass to do it or its because of geography or extraordinary demand. The challenge we have right now is we have seven different progaps out there. Theyre confusing to veterans. Theyre confusing to providers. Theyre confusing quite frankly to va staff. If we dont streamline and simplify all that. We were in where we were . Charleston. West virginia or no, south carolina, sorry. Two weeks ago. And we sat and we watched what our staff was going through in order to set up a choice referral. It was it would dumb found and so what weve got here is weve got this patchwork quilt. Weve got to go through, streamline this, lean it all, make sure its working for the veterans, make sure its working for the taxpayer, make sure its working for the Community Provider as well. Thats where you get the kind of seamless care were talking about delivering here. What are you able to do without us . What are you able to do . And you believe you have the authority to do without us . Because if youre counting on us to get something done quickly it doesnt work that way here. Theres certain things that are outlined in the plan that we are executing now. As the deputy described in the beginning, theres iterations of choice. The choice of today is very different than the choice of a year ago. Right. And that really is because of this partnership with this committee and the hill. Were continuing to build on that. Theres a couple teams a couple items weve actually outlined within the control of va that we want to start working on now. Were calling these our quick wins. We want to be able to get those done in the next couple months. Thats to, one, tackle this referral and authorization process. Theres certain things that we can lean up and make it a little bit smoother. We want to really leverage the my va Customer Service training for folks in the community. So when a veteran calls or they have questions about Community Care, we can answer them. For our core network, we want to make sure the way we partner with them is as streamline and as simple as possible. Those are just a couple of the things within vas control were working to execute now. My times running out but i would say in the state such as West Virginia, which is population is less than 2 million people, thats proportionately high va population because its a very patriotic state. We look for any kind of way we can find somebody. Especially somebody trying to attack america. Youre going to find in these small rule states disproportionate. If youre looking if something will work, we can get you feedback immediately. You can find out without going through another year or two study very quickly if its going to serve those people or not and i would encourage you to come to charleston, west my god virginia which is different from the other charleston or the other virginia, okay . Thank you. Senator tillis. Mr. Chair, im going to ask you defer to senator sullivan. The truth is the only reason i got in the door first was he was gentleman enough to keep the elevator open for me so senator sullivan. Oh, okay. Thank you, mr. Chairman. Thank you, senator tillis. Mighty kind of you. Well, look, doctor, mr. Secretary, i think you probably know where im coming from on this. You know, im a big fan of yours. Really appreciate you coming up to alaska. You know, senator manchin talked about going to rural communities. You got a heavy dose of that in my state. You talk about quick wins, okay. I thought we were going to have a quick win in alaska. And you laid out a plan. You know, one thing i emphasized when i came up there to the veterans was i know you are frustrated but please be camp, you didnt create the problem youre here to fix the problem. But i need to tell you that now im the one getting frustrated. Because its been 100 days since you guys were up there. You talked about your six points, which i still have here. I appreciated it. Where are they . Here they are. On the alaska pilot program. And i am getting hit every day in my state. I was on a plane coming down here two weeks ago. Three veterans within a circle of two rows on the airplane were complaining to me. I was telling then, hey, dont worry, were on it, the vas got a pilot program. Its going to have a win, a quick win, in alaska. And then my staff gets told today that a lot of what you told me and committed to me, and im telling veterans this in my state, is now not going to happen. And now we were told this is going to happen in november, midnovember. Now were told maybe not. Maybe indefinitely its not going to happen. No alaska pilot program. You guys are asking for 13, 14 billion to fix the choice act. And you cant even fix it in my state. Well you know, doctor, it is a fricking disaster. I am a little bit upset. Ive been very measured. Im trying to be measured here for months. And you saw the way we operated up there in alaska. You saw the problems. This is not were not making this up. My veterans, who, by the way, top, you know, more veterans per capita in my state than any state in the union. Its not funny. Theyre not being served right. You guys are making promises that now im learning that your staff is walking all this stuff back, all your six points. When are you going to fix the problem in alaska like you committed to when you were there in august . Why are you walking back commitments that you made to me publicly . That was made here on october 7th publicly about an alaska plan . All being walked back. And i just dont understand. And on behalf of my veterans, im pissed. Okay. So what the hells going on . Senator, first of all, youve been consistent from prior to my confirmation through now that you even when we saw each other on veterans day. 100 consistent that the situation was not acceptable to you. You asked me to come up there. You were absolutely correct about how the veterans felt in alaska. I understood that. But you saw the problems yourself. I did. Youve been a tireless advocate for veterans. Im not walking back on this. But your staff was walking my staff, who i bet is watching this right now, is listening to in. As i said, we are not walking back on this. I made a commitment to you and the veterans. We are going to see this through. Okay, when. Now, heres whats been done. Number one, a Virtual Call Center was established staffed by 25 people who do not but answer the phone. Remember, you said you were going to get people in alaska. One of the biggest problems you saw was people down in wherever the heck it was scheduling for alaska, they dont even know what the we have a Virtual Call Center only answering for alaska. I said to you, i want people in alaska scheduling. And my team was told you guys are not doing that. We are doing it but it require a contract modification to a federal contract. Which is a bigger deal than i knew when i came into the government. We are committed to doing that. That is going to be in place. It happened november 2nd. Which is to imbed staff in alaska. That happened november 2nd. Fq triwest is now that that modification happened hiring staff. They believe they will be in place in six weeks. Secondly, the va alaska staff have taken their own people and now will assign them to be choice people. In kenie, anchorage and fairbanks. There helping veterans every day get through the Choice Program. This is the band aids. But it is being done now to help veterans. And we are not walking back on this plan. It is taking longer than you or i want. And youre right to be impatient. Mr. Chairman, if i may. I think the alaska plan, what youre trying to do, has implications not only of course for my state but nationally. Yes. And i think that you saw the problems. You came up with the plan supposedly to fix it. And now we are being told by your staff that theyre going to work on the National Issues before they get to alaska. The whole point according to our three days spending together going throughout the state. Was to fix this. Look at it as a template. And then try to use the lessons in alaska for the national approach. Youre telling me, your staff is, wait for the national to be fixed and then well get to alaska. Thats exactly the opposite of what you committed to me on. No, no, i do not want any of my staff to believe that alaska is not a priority and were not going to do it. We have embedded staff one place prior to alaska and its already happening in new orleans. Its because you started it in alaska. Got implemented sooner than new orleans. We are going to do this in alaska. Youre right, other places around the country have said we want that. We started the discussions in other places. The only one thats actually ahead of you is new orleans right now. Well, mr. Chairman, if i can get a commitment from you, you, mr. Secretary, on continuing to work with my team to implement what youve already committed to me. We cant wait. Absolutely. The idea of you guys pushing this back. Remember, commitment was right here. Midnovember. It was all going to be done. Its not done. Yep. I know the deputy secretary and i have spoken about this. He has committed to it. The secretarys committed to it. He was also in alaska, as you remember. He absolutely understands what youre talking about. You have never deviated from this. Were not deviating from it. It is taking longer. But thats why our staff in alaska are doing what they can to help veterans right now. Its not enough. And youre still hearing the comments. Were going to stick with it. I dont want to be giving excuses. I only want to fix the problem in alaska. Were going to stick at it. Okay, all right, thank you. Thank you, mr. Chairman. I just want to observe that this time dialogue is exactly where this committee is for, for us to work with the administration and with the department to come together and solve solutions in alaska and montana and georgia and washington state. I appreciate your active engagement. I think we had on the kansas issue earlier and the alaska issue now, i think we found some meaningful Common Ground and where we need to do better. Im going to recognize the senator in one second and then senator tillis. Im going to have to leave for about 20 minutes. I want to relinquish the gavel. I will return later on. I just wanted to make you aware of that. Thank you, mr. Chairman. I want to thank all of you for being here today. The proposal gets implemented and this i guess is for you, sloan. Do you see an increase in the overall ratio of veterans being referred to nonva care . I think its highly unlikely there will be. From looking where we are right this instant, you know, we saw a disproportionate increase in care in the community in 2015. I think were going to see a disproportionate increase in 2016 as well. Do you anticipate this is going to because we dont talk about money enough i dont think in this committee. Do you think this is going to end up costing more . Than if the va provided thats where i was alluding to, another context for decisions. I think we have to get to the point where were looking with the business eye about those make versus buy decisions for care. In different markets and different situations. And where we can buy it, where we get quality care at better value, then we need to be looking really hard at buying it in the community as opposed to delivering it ourselves. Make more efficient use of the space and the resources to deliver care that we cant buy in the marketplace. Ill ask it this way. Overall, once the programs implemented do you anticipate it costing after you do your metrics, do you anticipate it costing more money for the veterans you serve per veteran or the same or less . I would like to think it would be less per veteran. Now, let me. Is that the way it is today . I need to rephrase that. Part of what were already seeing is we make is we improve access to care and make the Care Experience better. More veterans are coming to us for more care. The bigger part of that is veterans already coming to us for care are using us for more care. I cant really say that per veteran. But i get the point that youre making. If we dont become more productive through all of this, then i would say we have not successes. Im going to go to another point. I have a very similar circumstance. As senator moran talked about in kansas. Where weve got cbots with no docs. What appealed to me is areas where they didnt have health case they could actually get access. All that being said, i am a big fan of Va Health Care. I think that what i hear from the veterans in montana regularly under your guys watch, and it faltered for a while, but under your guys watch, because you do a pretty damn good job. So the question i have for you is were building capacity in the private sector. Are we going to continue to build capacity within the va and how are you going to make those determinations of where capacity needs to be built in the va and where youre just going to outsource it to the private sector . I think a big part of that is where we have Critical Mass. Where we have a Critical Mass of veterans to serve, which means, you know and our Analysis Shows that we can deliver better care at better value, then we should be Building Infrastructure to deliver that care. But where we within the va . Within the va. But where we cant justify that business decision, we need to be outsourcing. Just one more thing that follows up with that. In another year, you guys are probably going to be gone into administration. I hope not. I hope you all stay. But youre probably going to be gone. Are you laying in to process so that whoever takes your place, assuming that the transition would be seamless and the justification keep going. Absolutely looking at ways we can institutionize what were talking about doing here. And i would say one of the important roles this committee can play is to be a source of continuity about some of these operational concepts. I think youre right. So youve got, what, six or seven different outsourcing programs out there. One of thems project darts which has been pretty successful in montana. Had a few hiccups but not bad. Can you give me how that transitions for folks once that plan is in place . Youre right, project has been very successful. In fact, we took a lot of lessons from project arch as we built this plan. The whole episode of care came from arch. A lot of Lessons Learned about how to work with Community Providers. How to make sure theres a direct connection between va and Community Providers and then also from the business side of really having one pot money for care. I think what we try to do in the plan is create these Eligibility Criteria that focus into these three big buckets. One is geography, one is weight time and one is availability of services. So for the most part a lot of the veterans currently using arch will continue to use Community Care through one of those three mechanisms. There may be some folks that may have to change providers. In those circumstances, we want to create a transition plan so we make sure theres a warm handoff as needed. Okay, thats good. What i just want to point out is actually the kansas example. And that is if you dont have people on the ground that know what you guys want, aint going to happen. So hope that communication filters all the way through middle management to the ground because youve got some great folks on the ground. Thank you. The last thing, if i might, mr. Chairman, the last thing im going to say is, you know, sloan youre right next to the big guy. We had a scheduling hearing a month or two ago on scheduling within the va. They said va is working on a new scheduling program. Is this correct . Yes, we are. How much is that baby going to cost . So were going to be very open to if this exists in the private sector, if we can buy this off the shelf, because time is of the essence and execution is more important, were going to have the intellectual activity to make that choice. Through a mobile app. This was developed inside va. The other thing, the second leg of the effort is what we call scheduling enhancement where weve taken and modified actually put a graphical user interface on top of the old 1980s era scheduling system so it looks like a 21st century app and works like one. And thats happening within the next six months or so. The longer term scheduling process is this comprehensive replacement. Were going to do that in a very deliberate kind of way because were about to deliver the field a substantial improvement in scheduling functionality. People in the field who have seen this working are awestruck. They cant believe we have something coming that soon. With the graphical user interface. So let me just ask you this because the last and good people at the panel but didnt give me much hope. They said if im a veteran and its the first of va and i schedule on the 20th theres no wait time. But if that if that appointment was delayed until the 25th of december, when it was supposed to be thats a fiveday wait time. Thats how its valued. Is that going to change because thats not real . Let me tell you whats real. We want appointment scheduling to be clinically relevant or we want it relevant to the desires of the veteran. When you measure as the create date, if my doctor tells me im seeing my doctor for a chronic condition, i want to see you back in 90 days and we schedule an appointment in 90 days, did i wait 90 days for that appointment . It was scheduled coincident with the clinically indicated date. If i call in and i say, i need to come see the doctor, see the dermatologist, but im going to be traveling for the next three weeks, when can i get in after that . And we schedule that veteran in 24 days, whats my wait time . Did i wait 24 days for that appointment . So what were trying to do here is make it either clinically relevant or relevant to when the veteran wanted to be seen. Thats where we measure the wait time gap from. There is no relevance versus the create date. The large majority are returned to clinic appointments and so you would see consistently if you were looking at wait time data, examples of people waiting 120 days or people waiting 60 days or people waiting six months, 180 days for an appointment when, in fact, thats exactly when had he were supposed to come in and be seen. Youre right. Except for the fact that i am sorry, mr. Chairman, i went down this road, but how the hell do we measure wait times . Because if im a veteran look, took my grand daughter to the emergency room the other day. Everything worked out fine. I spent five hours in the emergency room. They looked at her for maybe 20 minutes of that five hours. I still spent five hours in the emergency room. Right. When that person sets up an appointment, how are we to know which is which that person has a heart a pain in his heart and needs to get in today and was put off for three days . Youre right, its more critical. How are we going to know whats going on as an Oversight Committee . Quite frankly why this is important, and i dont mean to be critical, what is important we had a real bad hearing here on phoenix a couple, few years ago. It was a horrible hearing. How are we going to know the metrics . You can get back to me. Tillis wants to ask some questions, too. How do we do any oversight . I got you. I understand. How do you get oversight on that . We check that every two weeks. Well take this up off line. The truth is that it doesnt work so good, all right . Thanks. I appreciate thank you, senator tester. Your flexibility. Senator tillis . I never get tired of hearing your questions. You havent been here long enough. I want to shift gears to really get back to tap on what senator tester was getting at earlier in terms of institutionalizing this so were not all after sudden restarting in 2017. Said a couple of things that give me hope and give me concern and im coming from a systems person thats helped Large Companies decomplex their environment. I like the idea of the graphical user. I use this as an example where its a good shortterm fix. On the other hand it adds another layer of complexity. Ive implemented those systems. We used to call them lipstick on a pig. So what youve done is implemented something that makes it easier in the process of doing that youve probably not only aggregated data from other systems, you probably added data which adds another layer of complexity when you finally get to the ultimate task of replacing it. We have to be careful not to go after shortterm priorities that may be voiced from us or others at the expense of creating a longterm, sustainable, economically viable fix. Thats more of a direction than i would think that you all would agree with that. I would be fascinated if any of you didnt. We agree wholeheartedly with you. One thing that i think we need to do, i sometimes think we need to have hearings here where the only thing that is at the witness stand is a really big plate glass mirror. The cio is topnotch. Has great experience, great relevant experience for the job shes been assigned. What you need to do as you go through these buy versus build decisions is make absolutely certain that youre buying what creates a best practice and not necessarily creating a franken system where you start out and it looks great, but then you say this congressional mandate needs this reporting. This congressional mandate or this special project is requested by some senator requires so many variants that by the time you get finished what you bought bears no resemblance to the baseline project you want to maintain. We had a hearing where senator brown and i moved a bill thats going to provide a benefit, and i think, sloan, you were in that hearing, where i said, its a shame that a benefit that over ten years will equate to about 6. 2 million is going to require 5. 1 million in systems changes before you can start providing the benefit. We need to make sure you can come back. I want to associate myself with the comments made by most of the members and i share the frustration of senator sullivan. I will not get into the episodic issues with fayetteville or anything else in this hearing. Thats why well have conversations outside of the hearing. But at some point there needs to be a cost associated with the shift of priority yes. That comes from the direction youre receiving from this committee. I will take at face value that the value provided to the states that youre prioritizing like senator sullivans is worth it over the distraction and the diversion of resources. But we have to start getting very serious and have everyone understand what the distraction possibly cost us in terms of shortening the time to benefit for the overall transformation. We also need you all very quickly to be able to articulate in a way that we can understand what the time limits that we have in the va committee why what i may be asking you to do may move us further to the right in getting the transformation done. And the way youre going to do that is to create a plan that we can communicate before this committee on a statebystate basis what the footprint looks like, what is the mix of va, nonva choice, what is the time line of benefit . What are the things that we can expect on a fairly immediate basis so that each one of us can feel like we have that information, and then we can determine whether or not it needs to be juggled or whether or not its appropriate. We havent had that. And i think thats one of the reasons why we get more of the episodic discussions that we have in a lot of these hearings, but i would encourage you very quickly. The list of legislative programs, its disturbing that we will have to spend 300 million on a portal because these portals are fairly well established. I know we have a hairball of systems that we have to connect them to. Thats where most of the costs come from. Its not the website, but its disturbing to me that, again, if we do these shortterm things, were adding complexity and time to the longterm, integrated solution. And we have to reach a point where like all largescale transformations there has to be a freeze but for emergencies so that you can start getting to work on what were all wanting here sooner rather than later. I think you need to go back and you need to take a more critical look at the things that youre having to accept as a given that congress has mandated that you believe no longer have a place in the transformed va. And it needs to go far beyond what youve probably thought about in terms of the enabling legislation for this particular program. If you dont do that, then youre building the transformed system on outdated policies that may or may not have ever been appropriate. They just happened to get through congress and you happen to live up to them because theyve been mandated to you. Im not going to get into a lot of questions except that the reason i continue to have this flavor to my discussion is i want to help you establish a plan that transcends your tenure and your positions. So do we. That continues to show progress as we get another president. I want to be an advocate for that. It has to be articulated. And we need people in the va to put the mirror back on us, saying youre asking me to do something thats shifting me away from the other thing you asked me to do. If we do at that, and you put the mirror in, its our problem. If we make a request, and you dont reflect back on us, its your problem. And i want to make this our problem so that we can help facilitate the transformation. Last things that ill just mention, and we can speak first off, i appreciate the secretary and his staff for the update. I look forward to getting the information. Thank you for that progress. Its important. I also want to reinforce what senator murray said. Anytime ive heard it brought up. Ive spoken with hundreds, probably at this point been in the presence of thousands of veterans over the last 11 months since ive been senator. I have yet to hear a single veteran whos received care from the va say that they want purely a private choice. They want the optimum mix. They want veterans serving veterans. We want the best possible health care. We know we have world class practices out there. So we want to make sure that the people who come to us and say privatize it they almost all have one thing in common. Theyre not a veteran. And i want to listen to the veterans voices and make sure we do a better job of providing the best care for them. Which it includes choice. It includes nonva and includes it in different proportions based on the state. There are seven states who have one of the highest per capita ratio of veterans per population. I have a state that has more veterans than those states have total people. We all have unique needs, and we need to solve them. But i hope you all will go back and come back with a larger list of things saying that a part of the complexity is because youve told me to do things that are not best practice and not necessary for me to produce the best clinical outcomes, so please relieve me of this burden. If you start doing that, your jobs going to be a lot simpler, and what we do for the veterans is going to be a lot better. If i may, just 15 seconds. I cant tell you how much i appreciate that perspective, the willingness. I like to think that bob and i have done more of that kind of challenging over the last year and a half or so than has been done in a long time, but what youre describing is a real paradigm shift for the department, and it is an extraordinary opportunity, and well do our best to seize it. Senator tillis, thank you for your commentary and analysis. Very valuable. In the absence of the chairman, there is no second round, but i have a question. And it is in response, its a question that follows, in fact, a question that you asked, i think, secretary gibson of me. As i understand it, my take away from this hearing as far as the choice act is that it no longer matters. If you live within 40 miles of a facility that doesnt provide the service that you need, you qualify to have services at home . No. I thought thats what you said in response to chairman isakson. No, if you live within 25 miles of a cbac, it doesnt provide the service that you need, what happens . So first of all, the definition of cbac kind of going back, it has to be 25 miles from a facility or cbac that has a primary, that provides primary, care and Mental Health care. Not the one off that has one doctor one day a week or something. If its 25 miles from that you dont qualify under the geography criteria, however, you might have a wait time for cardiology and you can access Community Care that way. That cbac may not refer folks to the local Medical Center for neurosurgery or ct surgery and all those services are provided in the community. I think a lot of times people get fixated on the geography. Theres more than one way that people can access Community Care. Some of that is through wait times or they just dont access that local referral in the cbac. So veterans than 40 miles to a cbac that has who live closer a Fulltime Position have a different standard than those who live further than 40 miles, is that true . Thats correct. So the veteran that lives 25 miles from the cbac who has a fulltime physician, needs an optometrist, there is no optics at the cbac would be told to travel the 200 miles to wichita . Thats what weve described in here, the nature of the service that i read to the chairman. In the past, i think thats exactly what would often times happen. And what were saying is we dont want that to happen. So it makes absolutely no sense for a veteran to drive 200 miles to get his eyes checked. Thats the kind of care that we should be referring to the community under choice. But to be very clear, and i think you realize this. If the apperture is opened all the way to where you can get the care, the cost goes through the roof. And we simply do not have the resources to be able to deliver that. Thats why were trying to do this in a very deliberate so your plan described to us today is intended to resolve those kind of issues . No . The way that we resolve those issues is it allows the local provider physician and the veteran to make that determination. So we have geography, wait time and availability of services, but there is this one thing passed by the hill, the unusual and excess burden, which allows nuance, which is what they need. When i see patients, and i see that physical therapy, you should not be driving 200 miles to get pt, we can make that decision together. And they can access Community Care. Do you make that decision in the office. Together today regardless of what happens with your plan for the future. Thats already available to that veteran . It is now, based upon what we put in place effective yesterday. So today is a new day. It is a new day, yes. And many of the concerns and complaints that ive raised over a long period of time are resolved in your mind by what happened yesterday at the va. You asked me where, you indicate that where do i get my concern. Emporia shouldnt qualify, and it does. It comes from casework. Its what you heard around the table, its people bringing us issues, and the veteran who lives 25 miles from the cbac who cant get his eye glasses adjusted because they dont do that, is told to drive 20 miles to wichita. I checked with my staff. Just this week weve had ten new cases in kansas related to the choice act and the distance necessary to travel. It is an ongoing would you share those with us so that we can go do a deep dive and understand thats where we can help identify the defects in the system, to understand where things arent working. It would be great. Hugely helpful. If i could add one other thing, some of the 421 million were requesting have to do with education and training. Theres a big chunk of that. We didnt talk about that today. But what youre experiencing and what were getting is if that information flow doesnt occur at every level of the organization theres a problem. Thats some of the costs is to improve the communication channels. Thank you very much. My understanding, and ive asked this question previously. Theres something called an abandonment rate. And that is described to me as those who apply for choice and conclude its not worth it. Those youve even perhaps reached out to, and they actually make a request to use choice and conclude to walk away. That could be a good thing, because they want to use the va in its traditional sense. It could be a bad thing, because theyve hit the brick wall. Theyve hit the bureaucracy. Id like to know the abandonment rate. I understand thats a number you keep. I have no standing to deny the senator another question. Thank you. Thank you, chairman moran. The Caring Community and generally nonva medical services involve payments. And there have been various efforts over the years to make sure that those payments are validly made. The va authorized a Recovery Audit Program in the 112th congress, i believe. And the inspector general, as you well know, recently found, i believe, 311 million for fy 2014 in quotes, improper payments for the nonva medical care program. I would like to know what progress theres been made in the Recovery Audit Program. My understanding is there is a request for proposal or that that program is in the works. Could you update me . This Recovery Audit Program i am not immediately familiar with. Im familiar with the efforts that were doing to expedite and improve the processes around prompt payment. I know that some of the payments that were identified as improper payments associated with care in the community had to do with the fact that they were done under individual authorizations instead of being done under provider agreements, which is one of the reasons were anxious to have provider agreement authority. Well get you some information on the recovery effort and because i am not conversant on that at all. I would appreciate you getting me any information you can and hopefully in the near future. Well do that, yes, sir. Thank you. Senator . This time i wont do a speech. This time its gone from 50,000 foot to the ground level. Doctor, you mentioned when we were talking about for doctors who may go into the Choice Program that if theyre already certified to provide medicare or medicaid coverage that you provide that doctor or provider an agreement to allow them to actually provide va care. What is that provider agreement like . So the way that it works right now is we have these contractors, health net and tri west. Its but its not a twopage agreement with 75 attachments . No. Its a simple agreement. It has issues that relate to credentialing, et cetera, the ability to share medical information, things like that. Do you have any idea what the rejection rates are on, acceptance or rejection rates are on these provider agreements . I dont know. Very low . Okay. Do you have any information on how well were doing with reimbursements for people who come under that versus a medicare or medicaid provider in terms of timeline to reimbursement, those sorts of things . Yeah. In the Choice Program through our contractors, they are close to 100 payment within 30 days. In the direct payment, we are at 79 payment within 30 days, working on an upward trend to get that much better. Is the 79 relatively simple care versus complex care so you get an idea of the dollars outstanding, not just the no, our care in the community can be very complex care as well. And thats what i was referring to. So is there any potential 80 20 rule, where the 21 thats how long over 30 days is 80 of the dollars outstanding . The common metric that they use is they differentiate claims that are clean claims and claims that are not clean claims. They dont distinguish them by clinical criteria. If i go out and tualk to providers who are getting into choice, theyre no longer telling me its very, very difficult to do and theyre not getting paid on a timely basis. Providers sometimes dont differentiate choice from va. So youre going to hear both things. They should be getting their payments 100 of the time within 30 days through choice. And thats because it would be a nonva provider by contract and a choice provider by episode. Exactly. Right. Thank you, mr. Chair. Youre welcome. Gentlemen, thank you very much. Secretary, doctor, thank you. I ask the next panel to join us at the table. We should be joined by mr. Roscoe butler, the Deputy Director of the Veterans Affairs and Rehabilitation Division of the American Legion. Doctor the car mr. Darren selnick, for concerned veterans of america. Mr. Bill roush, political director for iraq and afghanistan veterans. Mr. Kelly, director of National Services for veterans of foreign wars. And while youre taking your seats, i want to apologize that i have another commitment. I didnt realize that this hearing would last as long as it has. And so i may have to depart before youre done with your testimony, if that happens, i apologize and ill leave the hearing in your hands, mr. Chairman. You have no alternative. Thank you, senator blumenthal. Gentleman and maam, thank you for joining us. Well begin. I cant see the nametag, but i think its mr. Butler. Please proceed. Thank you, acting chairman moran. Ranking member blumenthal and members of the committee. The American Legion believes in a strong, robust veterans Healthcare System designed to treat those who have worn the uniform. However, in the best of circumstances, there are situations where the system cannot meet the needs of the veteran. And the veteran must seek care in the community. I am privileged to be here today and to speak on behalf of American Legion, our National Commander dale burnett and more than 2 million members in over 14,000 posts across the country that make up the backbone of the nations largest wartime Veterans Service organization. The American Legion recognizes that the Choice Program was an emergency measure to make Health Care Accessible to veterans where va was struggling with delivering such care. In recognition of the needs of an integrated to deliver nonva healthcare when needed, the American Legion believes va needs to develop a welldefined and consistent nonva Coordination Program that includes a patient strategy and takes their unique illnesses and injuries as well as travel and distance into consideration. The va Purchase Care Program dates back to 1945 when the chief medical director of the Veterans Administration implemented vas hometown program. General holley recognized that many hospital admissions of world war ii veterans could be avoided by treating them before they needed hospitalization. As a result, general holly instituted a program for Hometown Medical and dental care at government expenses for veterans with serviceconnected ailments. Under the hometown program, eligible veterans could be treated in their community by a doctor or dentist of their choice. Fast forward 70 years. Va has implemented a number of programs for nonva programs. At the request of congress, programs like fee basis, project arch, patient centered Community Care and the veterans Choice Program were implemented to ensure eligible veterans could be referred outside the va for health care if needed. Va states that their Community Care program would streamline the above programs by transitioning them into a Single Community Health Care Program that is seamless and transparent to veterans. While these goals sound positive, the American Legion believes by resolution that a proper plan for nonva care must include the following elements. Ensure all nonva Community Care contract provides complete military cultural awareness and evidencebased training. Provide all nonva providers with full access to vas computerized records system. Ensure va continues to improve its nonva coordination through the nonva care Coordination Program office. Ensure va improves collection of information into the veterans medical record. Ensure va develops a National Tracking system to avoid national or local purchase care contracts from lapsing, and an automated claims Processing System that fully automates the authorization and payment process. We are pleased to see that vas plan incorporates many elements of our resolution. If approved by congress, the plan would be rolled out using a threephase approach. That plan would be implemented gradually, much like tri care by developing appropriate no idea network streamlining business processes. It calls for cultivating a Provider Network to serve veterans utilizing federal health care providers, academic affiliates and Community Providers. The American Legion believes va has not yet demonstrated it has the expertise or experience for establishing large Provider Networks. So far this year it has relied on Third Party Participants such as health net and try west to fulfill these requirements. It does not specify whether it would continue utilizing thirdparty contractors to fulfill this requirement if the plan is approved. Sear thought needs to be given to this question. Its clearly a huge undertaking and we have concerns about vas ability to implement the plan. Va has attempted to roll out or has rolled out numerous projects in past years that require dramatic system information and technology changes. We are concerned that their Community Care plan will not result in similar failures like other projects such as corps fls, scheduling redesign, a veterans lifetime Electronic Health record, vafour Major Construction projects, or the initial rollout of the Choice Program to name just a few. Veterans are calling on v. A. To get it right, and on their first attempt and not continually waste taxpayers dollars. In summary, if va can address the American Legions concerns, we are cautiously optimistic that va plans for moving forward may work and could represent an important step toward a truly integrated model for delivering Veterans Health care within va and the community collectively. And again, i thank the committee for their hard work and consideration for this legislation as well as your dedication for finding solutions for problems that stand in the way of delivery of Veterans Health care, and im happy to answer any questions. Thank you very much. Mr. Selnick. Thank you, chairman and members of the committee. I appreciate the opportunity to testify at todays hearing and the recently released va plan for consolidating nonva programs. In the interest of full disclosure, i am the commissioner of va care. In no way does my testimony reflect the commission, the or the va. Cva agrees there needs to be one veterans Choice Program that deals with root problems and is fiscally responsible. To meet the veteran how, when, although we applaud the va for coming up with a comprehensive program, in our review it does not meet the criteria listed above. Instead it customery picks the independent assessment, ignores the commission on care. The plan will fail, cost the taxpayer billions, and impact negatively on Veterans Healthcare. The va has developed of a grandiose program that does not deal with the challenges it faces, nor is it in line with the doctors comments that the va would shift the way it does healthcare by ceasing to provide Services Commonly found in the Healthcare Industry. Its expanding into areas it does not have expertise in. We identified five key flaws in the plan. First, implementation requires a high performing Healthcare Organization such as the cleveland clinic. Vha is a lowperforming Healthcare System based on socialized medicine, using antiquated hmo staff models, focusing on a high degree of control. As an independent assessment has stated, farreaching changies. Vha is in the midst of a leadership crisis and Healthcare Systems are in danger of becoming obsolete. Last year vha made appointments but only completed 55 million appointments. Recent headlines such as lapses in urology care at phoenix va endangered patients. Gao reports suggest vha is not up to the task. Second, va has provided a concept plan that proposes some lofty goals and operating principles. It is not grounded in the reality of the way veterans access their care. It is a false premise that it is a healthcare home for the veterans they serve. Veteran patients reliance relies on 15 to 40 for office space and laboratory visits. Third, va gives lip service to the recommendations, findings, and Systems Approach. But cherry picks some recommendations and ignores others. The va has focused on what is best for instead of embracing the governance, operations, and leadership reforms needed. Fourth, veterans want choice in proust healthcare. According to a poll, 91 of veterans want more healthcare choices. Instead, va takes greater control over veterans eligibility and access. Veterans would be eligible if they are more than 40 miles from a vapcp. This is unrealistic because most of their needed care is from a specialist. With wait times, va is gaming the system by having undefined wait time goals for every service and leaving it up to the va provider to decide the clinically necessary time frame. Accessing the High Performance network is another example. The va has undetermined referral process which could take months for each step. The first hurdle is the va core network, then the preferred and standard tiers, all controlled by va. Fifth, the plan is extremely premature, especially in light of the charge Congress Gave the commission on care to examine how best to organize vha and deliver healthcare to veterans. The va plan coulding shortcircuit this existing charge in conflict with the recommendations. Cva proposes the following three steps. One, the va should focus on the short Term Solution of consolidation. That is phase one of the plan which should be done in consultation with the commission on care. Two, va should refine phases two and three of the Program Using an integrated system approach with operations and leadership reforms. Three, va should finalize phases two and three only after the commission on care provides its findings and recommendations to the president and congress. Although it is attempting to move too quickly on consolidating the nonv after programs, we must break the cycle of reform and failure by having the right plan that focuses on the Veterans First, not va. President three odor roosevelt said a man who is good enough to shed his blood for the country is good enough to be given a square deal afterwards. Lets make sure veterans get the square deal they deserve on their healthcare. Cva is committed to overcoming any and all obstacles and working with all members on this committee to achieve this shared commitment to veterans. Thank you. Mr. Rausch. olchairman, Ranking Member, behalf of our supporters, thank you for the opportunity to share our views with you today at the hearing, consolidating nonva care programs. Iva is proud to have previously testified in front of this committee recommending the need for consolidation of care in the community for veterans enrolled in va healthcare. And we applaud congress for requiring va to put forward a plan for consolidation. We also want to recognize Senior Leaders at va who are still with us here today for acknowledging the need for consolidation and providing an approach and process that was inclusive, transparent, and veterancentric. Last year, the choice and accountability act was implemented. It became apparent that it was confusing and added to existing programs designed to provide care in the community. According to our most recent members survey, 43 of respondents said the main reason for not used to go choice was simply because they did not know how, while 28 of our members who utilized the program said their experience was extremely negative. Although necessary to address the access crisis at va revealed by the scandal in phoenix, the Choice Program quickly became an example of what was and what was not working for veterans, physicians, and va employees when it came to providing an accessible, timely, and high quality care in the community. Iva has conducted numerous surveys, polls, focus groups, collecting feedback from thousands of our members while working with industry and other stakeholders to understand what was needed in order to have a successful consolidation of care in the community. Weve attended over 25 meetings with staff to share what our members were experiencing at the local level in terms of care in the community and have had dozens of additional informal calls recalling meetings, and opportunities to provide direct feedback from post9 11 veterans. Based on feedback from our members, we believe any plan to consolidate care in the Community Must be simple to understand. It must be consistent across the country and place the needs of veterans above all else. The plan put forward by va meets the above criteria and shush the framework for legislation in order to consolidate care in the community and provide improved and seamless access to care for veterans. Despite the progress thats been made by congress, va, and veterans across the community, we still have three main concerns. One, congress drafting and enacting the required legislation to effectively consolidate care. Two, vas ability to effectively implement the new laws designed to designate and consolidate care. And three, a continued focus on access without enough emphasis on healthcare outcomes for veterans, which was talked about earlier in todays hearing, especially, though, as veterans start to see Community Providers who have not historically served the veteran community. Congress acted swiftly and put Veterans First in the wake of the crisis. This committee has been a Strong Partner with iva. Unfortunately, even as Congress Mandated the va provide a consolidation of care plan, some members of congress continued to put forward incomplete oneoff plans and legislation that did not include feedback from veterans, vsos, or va. As congress rightly moves forward to simplify the process for veterans, iva highly recommends congress utilize a plan that doesnt add to confusion and inefficiencies. We believe congress should be mindful of these Lessons Learned and leverage the plan as the framework moving forward. We are concerned about the way to implement a plan in a way that avoids the mistakes made and truly puts the veteran at the center of every decision. During a recent roundtable discussion here in washington, dc at my va Medical Center with postnine 11 veterans, one of our members stated, quote, there seems to be significant inconsistencies across va, and although ive had positive experiences at va, there are too many veterans who have had bad experiences. And i couldnt agree with him any more. In order to address these incan say inconsistencies, we share putting the veteran first and focusing on valuesbased leadership to change the culture of va across the country. Given the serious shortcomings related to training front line personnel in the implementation of choice and Customer Service generally, the va should continue its efforts with my va and ensure all va employees are properly and consistently trained on any new plan to consolidate care. Finally, iva encourages everyone, congress, va, vsos, industry and other stakeholders to place an increased importance on the quality of care veterans are receiving, especially, especially as new providers who have not traditionally served veterans join new networks to provide care in the community. We need to pay special attention to the care veterans receive in the community to ensure that the quality of care is consistent, its consistent with the high quality of care provided by va, and that private providers are educated on how best to treat our veterans. As Community Providers are increasingly called upon to serve this population, a recent rand report suggests Community Providers might not be wellequipped to address the needs of veterans and their families, specifically in understanding how quality treatments for post trautrauma stress and other conditions. Its a privilege to testify in front of this committee today and we reaffirm our commitment to you and working with all of congress. Va and our vso partners to ensure that veterans have access to the highest quality of care available in our country fulfills its sacred obligation to care for those who have truly borne the battle. There have been really challenges and tragedies in the past. We have talked about some of them today. However we believe theres a real opportunity, a real opportunity to transform the environment for todays veterans. Mr. Kelly. Mr. Chairman, Ranking Member, on behalf of the independent budget partners, thank you for the opportunity to testify today. The partners strongly believe that veterans have earned and deserve to receive high quality, comprehensive, accessible, and veterancentric care. In most instances, va care is the best and preferred option. But va cannot provide all services to all veterans at all locations at all times. That is why va must leverage proust sector providers and other public Healthcare Systems to expand viable options. After months of working closely with va officials and other stakeholders, were pleased that many aspects of the vas plan are closely assigned with ivas veteran reform framework. The ib supports the concept of consolidating existing care in the Community Programs into a Single Program that would seamlessly combine the capabilities of the va Healthcare System with other public and private Healthcare Providers in the community wherever necessary. As part of the consolidation, several Community Care programs would be allowed to sunset. While allowing these programs to sunset is a natural progression in the development of the consolidated Community Care program, allowing them to expire without assurances that the new plan has the capability to handle the current workload is unacceptable. The ib partners also support the idea of expanded access to emergency treatment and provide access to urgent care. But we cannot support an acrosstheboard copayment for this these services. The idea of charging veterans who are serviceconneced for care is unacceptable. Effort in to ensure veterans utilize emergency and urgent care promote, we suggest the establishment of a nurse advice line. While the ib partners agree that va must do a better job of collecting third party payments, we adamantly oppose withholding care from veterans. Rather than punish veterans for not providing private insurance, va should incentivize patients to provide that information. Ill discuss the plans limited scope now. Our framework looks beyond the division between va care and Community Today care to create a blended and seamless system that will restructure the Veterans Healthcare delivery system, redesign the system and the systems that facilitate access to healthcare, realign resources to reflect its mission, and reform vas culture with workforce initiatives and accountability. The ib framework would combine the extents and abilities of the of the va with other combiner. It would provide rural and remote veterans with options to receive veterancentric and coordinated care regardless of where they live. We recommend that va move away from a single arbitrarily regulated access standard. Access to care would be clinically based decision made between veterans and their doctor or healthcare professional. Once the clinical parameters are determined, veterans would be able to choose among options developed within the network to schedule appointments that are most convenient to them. The ib calls for significant changes to vas Strategic Capital Investment Plan for skip process by including Publicprivate Partnership options and blended existing replacement options to better leverage federal and local resources. We have called for the establishment of a quadrennial veterans review process, similar to the quadrennial events review, to align vas Strategy Mission and help provide continuity of planning across all administrations. The ib framework would establish a biennial independent audit of vas budgetary accounts to identify programs that are su susceptible to waste, fraud, and abuse. We call for combining its capabilities with a patient advocate program. Veterans advocate officers would advocate for the needs of individual veterans who encounter problems obtaining va services. They would also be responsible for ensuring the healthcare protected under title xxxviii are enforced. Our plan uses the same public and private resources as that provide veterans with vouchers or insurance plans but our plan makes public and private resources complementary instead of in competition with each other, which will be key too truly providing high quality care with the most ease of access possible for veterans. Mr. Chairman, this concluding my testimony and me and my partners look forward to any questions you may have. Senator blumenthal. Thank you. I appreciate your courtesy in allowing me to ask just the a couple of brief questions first. Mr. Sellnick, your recommendation is that the va should finalize its Choice Program, the long term new veterans Choice Program, only after the commission on care. Do you have a time frame as to when those recommendations will be made . As of right now, based on the legislation, we are due at the end of february. In february . That is as of right now, thats when were due. So you would advise waiting until sometime this spring or later when there is feedback from the president and congress before the va finalizes its Choice Program . Personally i feel that can be a more collaborative process and as part of that collaborative process, lets have a process where we have a really integrated Systems Approach where we come up with an overall comprehensive solution. The Choice Program is not a solution on its own. It has to be integrated with the rest of the Healthcare System. So coming up with a program on your own that may be in conflict with other recommendations would just cause more confusion. Mr. Rausch . I would just like to add, although we have differing views and opinions about this specific plan, i would challenge anyone to suggest that the process hasnt been collaborative. And in contrast to, say, two years ago, working with the va, i dont believe that this process would have taken place, and based off of a lot of the discussion between member of this committee and senior va officials just a moment ago, it seems your experiences have also changed with va. So i would just like to highlight, as i did in my testimony, the numerous, over 35 it was almost daunting, frankly. So i would just emphasize that its been transparent, its been collaborative, its been unprecedented in the federal government from our perspective. Thank you. Mr. Blake . Senator, in full disclosure, i think it would be fair to say that the commission on care, weve met with their professional staff, and its our understanding theyre hoping to extend their charge until least next summer, which would mean this discussion woulh o presumay be put off until june, july, or august of next summer at the earliest. I think that would be an unfortunate occurrence for the va, because as most of us here have testified, this plan that the va has put forward is a good idea, its a very good concept for how healthcare should be delivered. If we just put it 0 off for potentially another 12 months, where will we be . I understand mr. Sellnicks point about collaboration, but im heartened and encouraged by the feeling that i think is generally shared among this panel that the process has been collaborative, and to that end, i am going to invite, in fact request that the va react to some of the excellent ideas that have been suggested by this panel, if they havent done so, i would ask that the va, who are still present, let the record show that all of the witnesses on the prior panel are still here, and can hear me make this request, i would ask that they react to these proposals, because these ideas are very promising and important. And i think collaboration is the keyword here. The vsos have been extraordinarily and profoundly important in this process. And i want to thank all of you, gentlemen and lady, for the excellent ideas that youve offered today and throughout this process. Those who are represented here and others who are not on this panel. So thank you very much. And ill look forward to additional collaboration. I think thats the operative word. Thank you. Senator moran. Mr. Chairman, thank you very much. I think it was mr. Rausch who had statistics about experiences with the Choice Program, access to care in communities. Let me ask all of you, youre all involved in helping your members helping veterans access care. Whats been the experience with the choice act for each of you, each of your organizations members . I would say for the American Legion, weve had experiences where veterans have had positive experiences, as well as not so positive experiences. It all depends upon the type of relationship the va has within the community, and with the health net and triwest. Were still getting calls where even from veterans where their claims have been turned over to collection because theyre not being processed and paid in a timely manner. When we get those type of issues and concerns and we turn them over to our vso liaison in Central Office and they check into that, we get an affirmative answer as to what was the breakdown and an easy solution to fix it. But the question then becomes, how come why did we get to that point, how come it was appropriately dressed in the beginning . For our members, its been mostly a nightmare. The number one thing that they say is theyve had a congressman or senator interfere on their behalf. They say, why does it takes a congressman or senator to get some help . The whole process for our members, and you can go online and see the facebook posts, has just been a continual struggle and battle. One of the number one questions that we get is, look, if im within 20 miles of a va hospital but a heart surgeon is in 40 miles, why do i not get the choice . Why does tricare offer metrics and the va has this convoluted process . 43 of our respondents say they dont use it because of confusion. A lot of it is flash polls or social media. Weve seen it increase, albeit generally its still been a negative experience, but its increased exponentially. I spent some time in Fort Leavenworth because i was assigned there, by choice. I knew kansas fairly well. I was looking at a map recently that the triwest had showed me today or last month, excuse me, versus a year ago, the provides and the network that theyve built in kansas specifically has been tremendous. So what we have weve seen is not a linear increase but an exponential increase in number of providers, veterans who understand it better, the va, who frankly were the worst in providing the care, theyve improved significantly. Although its been a challenge, we have seen it start to sort steadily uptick, which is why we mentioned in our testimony that there are really positive things and Lessons Learned from choice but also some negative things weve learned. Just on the broader concept of choice that was mentioned earlier about the different plans that have been floated, and again, one of the reasons we support this framework and reject some of the oneoff plans, you know, there are certain plans that want to take, as someone mentioned earlier, primary care out of the va. Well, as someone who has actually had my primary care Health Appointment at the va, and i have choice because i have private healthcare as well, that would be removing choice for me. So there are certain plans out there that dont reduce but completely eliminate choice by pulling resources out of the va, which is, again, why we think this collaborative approach thats been taken is a great and clear, you know, path forward. Thank you very much. And i appreciate your waish pat in waiting for the opportunity the testify, which gives me the opportunity for me to tell the va how i appreciate their patience in waiting and listening to the testimony. And i apologize for having to go to the floor and make a brief speech so i missed almost all of your testimony, which i apologize for. But i read through last night the testimony. I have a couple of quick questions. I know its a been a long time. But i thank you for staying. I thank the va representatives for staying and listening as well. Mr. Sellnick, you heard the exchange between senator moran and myself about the problems in liberal, texas, about the Choice Program. You made the comment that you werent sure those providing services at the local level and the va at the washington level didnt understand how the program works, did i hear you right . I mentioned a number of different challenges with the program, its staff, its process, its the call center. Its the whole thing has been a problem. I think and i think youre right. And i think and i dont blame anybody for this, but i think there is a misunderstanding up and down the chain of command. I hope as we implementation the changes, youll make sure that the people at the local levels, the cbacs and hospital facilities, make sure that veterans understand what it means. It will make choice better for every single veteran tomorrow. But if they dont experience it at the local cbac, it wont be good to them at all. Mr. Butler. I want to read a ive got two questions for you. I am the to read this sentence to you. Va needs to provide all nonva providers with full access to vas computerized patient record system to ensure that community Healthcare Providers can review the patients full medical history and continuity of care purposes. Earlier in your testimony, you referred to the lack of coordination between the nonva providers and the va in terms of getting the documentation of Services Provided so the Veterans Healthcare file was complete, is that right . Correct. And i agree with you that no system is going to work if you dont have the medical history of the patient and the services theyve received in one place easily accessible. Do you think theyre capable of doing that . Well, the va has been working on an Electronic Health record for years now with very little success. Their plan calls for taking the snapshot, the vlj process, i believe, which is a virtual snapshot of the veterans record, and incorporating that initially as part of the health record, and then moving on with a future design of[fbx a more coordinated health record. I think that for any process to work, youre going to have to allow a virtual Electronic Health record. And thats the whole Healthcare Industry is struggling with. But youll have to develop a virtual Electronic Health record that is transportable and shareable between any healthcare institution. So until we get to that point, youre going to still see the challenges of sharing electronic Health Information either way, between the va versus nonva provider and viceversa, between the nonva provider and va. You just hit the nail on the head, because the biggest problem, forget about the va healthcare for a second, the biggest problem in healthcare today is the lack of interoperability between data systems. Youve got greenway, youve gone cerner, youve got epic, youve got these systems that dont talk to each other. Its great to talk about the information, but if they cant talk to each other, you cant have the ease of a file. If were going to make this thing work, and if its going to work the way you suggest you would be supportive of it working in your conclusion, the first hurdle theyre going to have to overcome is how do they make the systems interoperable between the nonva providers we use and the va system to get the information on the veteran in one place, at one time, accessible by the physician and the veteran as well . Right, sloan . Has our new technology lady figured out how to do that yet . [ inaudible ] some of whats an actually been described is available. I think that observation you made, roscoe, in your testimony is the key to this thing functioning and doing well. I appreciate all of you being here to testify today. I appreciate everybody who stayed for the duration of the hearing. I think it was very effective. We look forward to working with the va and all of the vested parties to see to it as we roll this plan out, it helps the person were here to serve, the veterans of the United States military. With that said, we stand adjourned. Tonight, American History tv on the civil war. At 8 00 p. M. Eastern, the anniversary of the confederate surrender. More on the two generals who surrender, Ulysses Grant and robert e. Lee. And a look. This holiday weekend, American History tv on cspan 3 has three days of featured programming. Beginning friday evening at 6 30 eastern, to mark the 125th anniversary of the birth of president dwight david eisenhower, his granddaughters gather for a rare family discussion at Gettysburg College to talk about his military and political career, as well as his legacy and relevance for 21st century americans. Then on saturday afternoon at 1 00, 60 years ago rosea parks defied a City Ordinance on a city bus. Had he stand helped