Transcripts For CSPAN3 Hearing On Veterans Choice Program Implementation And Future 20150529

Captioning performed by vitac forward to hearing first from sloan gibson. Thank you, mr. Chairman. Chairman isakson Ranking Member blumenthal and the committee, were committed to making the Choice Program work and to providing veterans timely and geographically accessible care, using care in the community whenever necessary. Ill talk shortly about what were doing and the help that we need from congress to make all of that happen. First, i want to talk very briefly about access to care. Most mornings at 9 00 a. M. , for the last year, Senior Leaders from across the department gathered to focus on improving veterans access to care. Weve concentrated on key drivers of access, including increasing Medical Center staffing by 11,000, adding space, boosting care during extended hours and weekends by 10 and increasing staff productivity. The result, 2. 5 million more completed appointments inside va this year than last. Relative value units, a common measure of care delivered that measured care delivered across the industry are also up 9 . Another focus area for us improving access has been increasing the use of care in the community. In 2014, va issued 2. 1 million authorizations for care in the community which resulted in more than 16 million appointments completed. Year to date in 2015, authorizations are up 44 , which will result in millions of appointments for Community Care. Veterans are responding to this improved access. More are enrolling for care at va among those who are enrolled, more are actually using va for care and those using va are increasing their reliance on va care. This is especially the case where weve been investing most heavily due to long wait times. In phoenix, for example, where weve added hundreds of additional staff, weve increased completed appointments 20 this year. I should also note that we have increased care in the community 127 in phoenix over the last year, largely due to the extraordinary effort of triwest in that particular community. But wait times arent down. The wait times are not down because of the surge of veterans coming in for care and the veterans that are there asking for more care from the va. In las vegas, we have a 17 increase of veterans receiving care since we opened the new Medical Center there less than two years ago. In denver, weve opened up clinic and added more than 500 additional staff. Veterans are using va for care there and are up 9 . In fayetteville, North Carolina, wait times continue to be a problem and weve increased appointments 13 , relative value up 19 and veterans using care are up 10 . In all of these locations, weve had dramatic increase in care in the community. As secretary mcdonald has testified, the primary increase for demand are an aging veteran population increases in the number of claims and the rise in the degree of disability and as we can see here, improving access to care. As i mentioned at the outset, Community Care is criminal for critical for ipmproving access. We use it and have for years in programs other than choice. In 2014, that rose to 8. 5 billion and we estimate that at the current rate of growth, va will spend 9. 9 billion, including choice, a 25 increase in care in the community in just two years. At the same time, weve had a large increase in care in the community. Choice hasnt worked as intended. Here are some things were doing to fix it. On april 24th, we changed the measure from Straight Line to driving distance using the fastest route. This roughly doubles the number of veterans eligible for the 40mile program under choice. But there is much more to do. A follow on mailing to all eligible veterans is about to go out. Weve Just Launched a major change in internal processes to make choice the default option for care in the community. Additional staff training and communication, extensive provider communications, improvement to the website and ramped up social networking, new mechanisms to gather timely feedback, directly from both veterans and frontline staff. These are all already in place or about to launch. In the longer term, we must rationalize Community Care into a single channel. The different programs about different rules and reimbursement rates, methods of payment and funding routes are too complicated for veterans, for providers and for va employees who coordinate care. Im confident we will need your help on that. Next, let me touch on the other 40mile issue. Weve completed indepth analysis with patient level data to estimate the cost of legislative change to provide choice to all veterans, more than 40 miles from where they can get the care they need. Weve shared that analysis with some members of the committee, with staff and with the cbo. It confirms the extraordinary cost that had been estimated previously. Weve also briefed the staff on a broad range of other options and believe there are one or more options worthy of discussion and careful consideration. While we are working together on an intermediate term solution, were requesting Congress Grant greater flexibility to expand the hardship beyond just geographic barriers. This authority would allow us to mitt gate the impact of distance and hardships for many veterans. We request greater flexibility among some requirements that preclude us from using choice for obstetrics, dentistry and longterm care. As described above, we accelerated access to care in the community this year, anticipating that a substantial portion would be funded through choice. For various reasons, most touched on previously, we will be unable to sustain that pace without greater Program Flexibility and flexibility to utilize at least some portion of Choice Program funds to cover the cost of other care in the community. We are requesting some measure of funding flexibility to support this care for veterans. On may 1st, va sent to congress a legislative proposal providing major improvements to use provider agreements for the purchase of Community Care. We request your support. Lastly, we are requesting flexibility in one other area of veteran care, hepatitis c treatment. You are all familiar with the impact of this new generation of drugs. Veterans that have been hep c positive for years have a cure within reach with minimal side effects. Because of the newness of these drugs, there was no funding in the budget or appropriation. We moved 688 million from care in the community anticipating the shift in cost to choice to Fund Treatment for veterans with these new drugs. It was the right thing to do but it wasnt enough. Were requesting flexibility to make this cure available to veterans between now and the end of the fiscal year. So, we are improving access to care, notwithstanding the reported wait times that you see. That means we still have work to do on wait times but we are improving access to care. Were committed to making choice work and have very specific actions to do just that and we need some help, especially additional flexibility to allow us to meet the Health Care Needs of our veterans. We look forward to your questions. Mr. Chairman, Ranking Member blumenthal and members of the distinguished committee, im grateful for the opportunity to appear before you this afternoon on behalf of our companies employees and nonprofit owners to discuss triwest work in which were privileged to do in support of the department of Veterans Affairs. I would like to focus my oral testimony on three topics. The realities of this programs implementation, the process of identifying gaps and those that remain to be resolved and what i believe to be the art of the possible going forward. Mr. Chairman, before the veterans Choice Program, there was pc3. As you know and as secretary gibson has said, purchasing care in the community from Community Providers has been a long practice of the va. In fact, in september of 2013, after two years of planning, va sought to change that with the awarding of the Patient Center Community Care contracts that we and health net. That contract was designed to have a consol dated integrated Delivery System built in the commune toy undergird the va facilities across the 28 states in the pacific that were privileged to serve. And make sure at the end of the day that we werent there to replace the va, we were there to supplement it. In fact, it worked as intended. When the furnace lit off in our hometown of phoenix, arizona, 6400 providers under contract leaned forward at the site of the va Medical Center to assist in the backlog and by august, 14,000 veterans had moved through that process. Around the same time, we got a modification to add primary care to those contracts. And within 90 days, we stood up a network of primary care providers. We now have over 100,000 providers across 28 states in the pacific under contract along with 4500 facilities and were not finished. The reason were not finished is we need to make sure that the networks are tailored to match the demand that exists in a particular market that is not able to be met by the va facilities itself. The fact of the matter is, that was a complicated program to set up. It was done under very short order but it was training, if you will, for what was to come next. Because on november 5th, after 30 days of work, we were to stand up in support of va the Choice Program. We had to partner with va to receive a list of all eligible veterans. We had to design and produce a card and put it out with a personalized letter from the secretary. And we had to stand up a Contact Center to handle all of the calls coming in. After two weeks of design and two weeks of hiring and training of 850 people. No one went into threehour waits, the phones were answered but the work had only begun. And weve been on a pathway since to try and mature the operations. The secretary talked about the 40mile issue. Theres additional refinements that may well be needed and desired in that area and, if so, we stand prepared to support what those might look like. Theres some other changes that may well be needed to the program as we go forward. Secondly, we need to aggressively identify and resolve our gaps and fix our Operational Performance and were in the process of doing that together. Were modernizing our i. T. Systems after a 24 7 build, a new portal system that will serve all of the facilities and our own staff as we seek to move the veteran information back and forth between the two facilities as care is rendered downtown. And were in the process of tailoring networks to match the demand that exists in each market across our area. The Choice Program is up, its operational and theres refinement still needed. I believe that because of the collaborative work thats been under way between all of us that are engaged in this, that we are refining the pieces that need to be refined and were identifying the policy gaps that we need to work and those that the secretary said are getting attended to. I think there are a couple of policy issues, though, that remain the jurisdiction of this particular committee. One is, i would encourage a relook at the 60day authorization limitation thats been applied. Secondly, i would respectively submit that there needs to be harmonization between the two programs and between all of the facets of how the va buys its care currently and how the va operates in order to make this work right. At the end of the day, i believe the art of the possible, which you sought, is truly within our grasp. Id like to point to dallas, texas, where under the engaged leadership of the 17 director, a couple of weeks ago, we sat with the medical director and the entire staff there, including behavioral staff, and looked at the full demand that exists for veterans in that market. We then took out and looked at whats the network that is constructed to stand at its side, which is the base on which choice rides. So, in other words, if theres not a network provider, you can set up an engagement with an individual provider to deliver services under choice. We then designed a network map that were now in the process of constructing together and over the next 90 days, from Behavioral Health to primary care to specialty care, we will rack and stack the network to meet the demands that otherwise cannot be met by the va Medical Center in dallas. That is being repeated across our entire 28state area in the pacific as we seek to do our part to ensure the operations of choice. Its a privilege to serve in support of those that serve this country. Its an honor to serve the veterans from the states represented by half of the members of this committee. And mr. Chairman, i look forward to taking questions after my colleague, Donna Hoffmeier is finished with her remarks. Thank you. Miss hoffmeier . Chairman isakson, Ranking Member blumenthal and other members of the committee, i appreciate the honor to testify on behalf of the veterans Choice Program. Health net we are dedicated to ensuring our nations veterans have prompt access to needed Health Care Services and believe there is Great Potential for the Choice Program to deliver timely, coordinated and convenient care to veterans. In september 2013, health net was awarded a contract for three of the six pc 3 regions. Completing implementation at the beginning of april 2014. Then, in october, after Congress Passed and the president signed the veterans access choice and accountability act of 2014, va amended our pc 3 contract to include several components of the Choice Program. With less than a month to implement choice, as dave just mentioned, we literally hit the decks running. Im a navy veteran, to use a navy phrase, and we havent slowed down since. To meet the deadline, we worked closely with the va and triwest to develop an aggressive implementation schedule and timelines. The ambitious schedule required us to hire and train staff quickly and to reconfigure our system for the new program. Despite this very aggressive implementation schedule, on november 5th, veterans started to receive their choice cards and they were able to call into the toll free choice number to speak directly with a Customer Service representative about their questions on the Choice Program or to request an appointment for services. Having said that, there certainly have been challenges that have resulted in veteran frustration as well as frustration on the part of va and, to be honest, even our own staff, including call center and appointing staff. With such an aggressive implementation schedule, there was little time to make system changes. We literally had less than a week from the date we signed a contract modification with veterans to the actual go live date. While the collaboration with the va since the start of the Choice Program has been good, there is still considerable work that needs to be done to reach a state of stability where the program is operating smoothly and the veteran experience is consistent and gratifying. We appreciate the opportunity and offer our thoughts in the future of the Choice Program. The Choice Program is a new program that was implemented in record time. As a result, there are a number of policy and process decisions and issues that are either unresolved or undocumented. If choice is to succeed, these items must be addressed quickly. As i mentioned earlier, weve been working very closely with the va to address these issues. Many of the items simply could not have been anticipated before the start of the Choice Program. Others, however, should have been addressed before the program started but the implementation timeline did not provide adequate time to do so. The issues and concerns have been occurring very quickly. As a result, weve struggled to keep up with developments and adequately train our staff with the most uptodate and accurate information. This situation is not ideal. Based on these dynamics, we have one overall recommendation for moving choice forward. We recommend va develop a comprehensive strategy for choice that clearly defines the program requirements, the process flows and rules of engagement. The strategy should provide a clear road map for all of us to follow. One that is communicated to all of the stakeholders. Va leadership, both contractors, congress and, most importantly, the veterans. While the strategy needs to identify key initiatives and reasonable timelines for implementing those initiatives, it needs to contain the flexibility to address issues as they arise and make necessary course corrections. The strategy must include resolution of outstanding policy and process issues, development of policy and operational guides that are mandated across the program, comprehensive training of both va and contract staff, using consistent process flows, operational guides and scripting. And a clear and responsive process for resolving legitimate issues and challenges. In closing, id like to thank the committee for ensuring our nations veterans have help to the needed services. We believe there is Great Potential to help va deliver appropriate and coordinated convenient care to veterans. We are committed to collaborating with va to ensure the Choice Program succeeds. Working together with the leadership of this committee, were confident that choice will deliver on our obligation to this countrys veterans. Thank you. I look forward to your questions. Well, thank you all very much and i had all of these preplanned questions and in listening to your testimony, ive canceled all of them and raise the ones that you started in your testimony, starting with you, mr. Mcintyre. It was quick. You were encouraging to put in an authorization of what . I would look at the limitation on 60 days for authorized care under choice. It puts people who have cancer in a position where we need to move them back and forth between the va Medical Center. It takes a person who might be with us under choice because of a pregnancy and does the same. And i dont think that was intended. I think it was intentional that there were parameters drafted around it but the notion that certain types of care would have to move back and forth between the va Medical Center and downtown is neither efficient or effective in the delivery of care. All right. I dont want to spend too much time on this but this is very important, i think, from listening to your testimony and watching everybodys head bob. You want to expand the 60day authorization to a longer period of time . I think i would leave it to the clinicians okay. You wont get off with that. Okay. I got it, sir. What i would do is evaluate which types of care are there needed authorizations that would last more than 60 days. So what youre saying is the 60 day limitation requires things like cancer treatments, pregnancy and things like that, for the patient to have to go back and forth between private and Va Health Care because of the 60day . The administrative process requires us to go back and forth in support of that veteran when its unnecessary. Its like medicare and two nights in the hospital. Its one of those unintended consequences. Yes, sir. Is there any reason we cant fix that . Were going to work on it and come back to you with a proposal. Just listening to it, it seems like it would be more Cost Effective to the va to fix it rather than go back and forth because theres got to be money involved every time youre doing that. Is that right . Yes, sir. There is a fee thats paid for each authorization but the bigger concern is the potential disruption to the veteran. Efficiency is always less expensive and thats more efficient, it seems like to me. I appreciate you raising that in your testimony. Yes. Miss hoffmeier, do you have any credit cards . I dont want them i just want to know if youve got them. You have a right to remain silent. Im trying to think, which ones do i acknowledge . Yes, sir, i do. Do you ever get the required mailing, the four pages long and print is so small and you dont read it anyway . I think that goes right in the recycle bin, mr. Chairman. Okay. In your testimony i heard from you a clear statement that we need to simplify and coordinate the instructions, the rules and processes under which veterans choices works, is that right . It is, mr. Chairman. Go ahead. I just think as i said in both my written statement and opening remarks, everything has been moving very, very quickly. As a result, there are a number of things that maybe havent been addressed as completely as ideally we would all like to see. It makes it really difficult. Its hard for us, you know, we talk about this at our level to keep up with everything. Youre talking about Call Center Representatives and appointing clerks trying to keep up with all of the developments and somehow we have to find a way to make it easy for not us to understand but the people that are working closely with veterans to make it work. They need to understand it. I think the veteran needs to have a all of the stuff that i did as a businessman, we wrote everything to an eighth grade level, which is what the newspapers do as well because thats the way you can communicate to the majority of the american people. Some of these things i read on drug notices, the regular drugs, the real ones, prescriptions, you read all of these things that youre not supposed to do or watch out for its so long and cumbersome i cant understand it, so i dont do the right thing sometimes. I think that could be our veterans as well. I would hope that what all of you would do is find ways to simplify the process to the veteran and the provider, the local provider in veterans choice. The simpler it is i know its complicated. Im not trying to oversimplify but sometimes out of a fear or desire to make sure we covered everything, we cover so much that we dont accomplish the goal. I appreciate both of you raising that testimony. My last question is going to be for sloan until we come back for a second round, if we do. You kept talking about wanting us to give you more flexibility. Yes, sir. Put some meat on that bone. Flexibility on what . I would say at the very top of the list is flexibility around the determination of hardship for veterans to have access to choice care. And so the way the law is written today, its restricted to geographic barriers, i think is the right the language that is in the bill. We want to open that aperture that would give us more flexibility to be able to expand care. Open that aperture to be a type of illness . It could be a type of illness, it could be distance, an instance where a veteran lives within 40 miles of a va facility that doesnt deliver the care and we want to deliver the care into the community. In other words im going to interrupt you and i apologize. In other words you want the ability to exercise judgment. Yes, sir. In terms of hardship . Yes. In terms of the 60day authorization, is that right . Yes, sir. There ought to be ways that we can accomplish both of those things and in raising those hes excited about that answer or he needs to leave, one or the other, whatever the case is, you can help us write that because i think those are both determinations we ought to be able to do. I recognize in your flexibility on the 60day authorization sounds more Cost Effective and less expensive and yours raises cost questions but in the end, again, weve got to remember the person that we want to serve is the veteran and deny them service because of a hardship is not the right thing to do. Yes. Ranking member blumenthal. Thank you, mr. Chairman. At the outset let me say that you will be asked shortly by senator sanders, i believe, about the letter that hes written to secretary mcdonald that he use his authority as secretary of Veterans Affairs to break patents on hepatitis c medications for the treatment of veterans suffering from that disease. I would strongly urge that you consider using your authority under 28 United States code section 1498 to take that action that will make this medication more widely available to veterans, especially since the va was involved through one of its employees and the research that undertook this initiative and successfully reached the result. I want to focus for the moment on the vas proposal to Fund Construction costs at the denver facility, specifically the 1 billion cost overruns out of the Choice Programs provisions for long, deferred maintenance and capacity issues in the va system. These funds were very specifically designated and intended by congress to improve Veterans Health care. Veterans in my state who are aware of this proposal are absolutely outraged that the care at the west haven facility would be indefinitely referred because of 1 billion cost overruns in aurora, colorado. I suspect the same reaction will be felt equally deeply by veterans at the more than 220 other facilities whose health care will be compromised as a result of the proposed redesignation of these funds. So i would like to have assurance from you, secretary gibson, since were talking here about Choice Program fund and were talking about not just a few dollars here or there but actually onefifth of all of the funds in that 1 billion pot, that you are considering alternatives to that action. Senator, weve sent a letter earlier today to this committee, to the House Committee and to the Appropriations Committee requesting the increase in the authorization to be able to complete that facility as well as requesting the use of 730 million of those 5 billion to be used to complete the denver facility. We have identified 100 billion from i apologize for me, that alternative is a nonstarter. Its just unacceptable. Ive expressed that view to appropriate administration officials. I realize that youre dealing the hand that you were dealt. Im simply urging you to consider alternatives. There are alternatives, in my view, responsible and available alternatives that do not involve deferring Health Care Improvements through construction and maintenance at those facilities across the country, whether in connecticut or georgia or montana or louisiana or vermont and all the other states represented on this committee, as well as many who are not. Senator, in years past i would tell you its very likely if va had gone looking for that kind of money, theres a pretty good chance that we would have found it. But because of the work that weve been doing over the past year to accelerate access to care to make hepatitis c care under the circumstances, we dont have 700 million sitting on the sidelines. There are no easy answers here. Im not asking you to find 1 billion sitting on the sideline but this nation is capable of doing better for its veterans. And a supplemental appropriation, for example, might be an alternative. Im asking you to go back to the drawing board and use different pencils. Not necessarily sharpened pencils but different alternatives to compensate for the absolutely unacceptable cost overruns and delays in aurora. The project should be completed but not at the sacrifice of health care for other veterans around the country and what i say to you is not personal to you or to secretary mcdonald and we have talked at great length about this issue. We have visited that facility together along with the chairman and i have seen that vast shelf shelf a campus that is a mockery of government contracting. So we need to address the situation to complete the project but it cannot be done, in effect, at the sacrifice of other veterans. My time has expired. I apologize for interrupting you and thank the witnesses for being here today. I wont ordinarily do this but in light of the question raised and for the benefit of everybody at the committee to know and i dont want this to limit it, but we have an obligation amongst ourselves to make out of the box suggestions about the cost overruns in denver, particularly those of us have that have been there and seen it. Ive taken a couple of actions which i will share with the committee leading up to a meeting tomorrow to say what are we going to do with this, which i hope that the va people are saying what are we going to do with this, too, not just theres nothing that we can do. Ive ordered gao to do a study of surplus of property that would be liquidatable to raise money to go to veterans choice to offset what might be borrowed from it. Youre dealing with a situation where youve got until may the 20th, about as much time as weve got right now and get to july 15th. We have a way to do that. Its going to take an action of this committee but that gives us time to determine how close to 700 million we need to work to do that. In the time period, were going to have interim bridges to im going to present to the committee tomorrow. If everybody on the committee would think outside the box, if it was your problem, if you were in sloan gibsons place and inherited a 700 million short fall in an Agency Second biggest in the government where would you be looking . I want sloan to look where i mentioned in denver. If we take you out of the construction business, which we are, and thats going to happen at least to a major and certain extent, there are going to be savings within that appropriations department and also look at the ftes that youre looking for an increase in the budget, maybe those ftes are not as necessary as building that hospital in denver. I think if everybody is making a contribution like that, its like that movie the american president when the guy became a president as a fillin, they got a yellow pad out and worked on the solutions. We need to get out the yellow pad and start working on solutions. Not building the hospital is a nonstarter. Just saying were going to borrow it from the Veterans Health care benefit, i agree with mr. Blumenthal, thats not the way to do it. I apologize for injecting that. I want to thank the chairman because he and i have worked together. I am not speaking for the chairman, obviously, but i have some alternative suggestions as well. I have no pride of authorship, i dont think anybody does, of meeting the needs of completing that facility but doing it without sacrificing these other projects and ill have ideas and proposals tomorrow. My apologies to the members of the committee and now i turn to senator moran. Thank you for your comments and conducting this hearing. Welcome to the committee, secretary and others. I hope to ask a series of questions but the time on the clock will run quickly. I want to start with a story that ive told before about a vietnam veteran named larry. He lives in florida and hes a vietnam veteran, a swift boat veteran. Indicates while in florida he received excellent care from the va, moved to rural kansas, became my constituent, lives about 25 miles from the cboc and three hours from a hospital. I started this story or this story began in july 2014 when larry, this vietnam veteran, needed a cortisone shot. The vas instructions were to come to wichita. So a threehour drive each way to get a cortisone shot. We raised this issue with secretary mcdonald at a hearing here on september the 9th. Larry contacted it us and said i dont care how it comes, the choice act or any way that the va can provide this service. We raised this topic with the secretary in september of last year. Then, in shortly thereafter, the director took this issue to heart and at least solved the problem but unfortunately, temporarily. In december, larry was granted an appointment in hayes. The place where the cboc exists, that doesnt offer cortisone shots, but he got care in the private sector of last year. The doctor who treated him, who provided the colonoscopy wanted to follow up and va denied that and sent him back to wichita. They denied that request because he was not eligible for choice. It exists within 40 miles of his home. Hes back to wichita, ultimately he needed to instead of a cortisone shot, a colonoscopy. He is trapped in this system of no one telling him what he can do except that he doesnt qualify for choice, go to wichita. Hes done that. But then, just recently, just last week he received a letter from va approving him for choice. He then calls triwest and triwest says youre not eligible. We dont have you on this list. But i got this letter. He indicates that he talked to four different operators at triwest all who gave him a different answer than anyone else than the three other operators. He called the 866 number and was told he wasnt eligible, got the four different answers and now were back to the question, what happens to larry . And my point here is, why not it be larrys problem to solve what happens to larry, but even if hes not eligible for choice or today because its there and doesnt provide the colonoscopy or the cortisone shot, why is someone not saying, oh, we have these other authorities, this would work for you, as compared to leaving larry hanging and whether hes eligible and what he should do. How should we solve that problem . I dont think its totally unique. I hope it is but i dont think larry is the only veteran that experiences this. I doubt that the problem is unique. I bet that other veterans are having similar experiences. As i described in my opening statement, we are asking for additional flexibility which would give us more authority to be able to handle that situation inside choice. We actually handle many of those situations through other va care in the community routinely, which is why we have incurred so much expense but we find ourselves running out of resources in order to be able to sustain that. And so we wind up making suboptimal decisions. Youve just given two great examples. Chairman asked earlier about whether or not we would be using judgment around the nature of the procedure. The answer is yes. I would tell you, for someone who has a routine requirement like a cortisone shot, theres no reason to travel 150 miles to do that. Thats something we ought to be getting done locally. For a veteran that has to get a colonoscopy, im not going to travel 150 miles to get a colonoscopy, thats not going to happen. Thats Something Else that needs to be provided for inside the community. Travel 100 miles. Now, if a veteran needed a Knee Replacement, i might say, under the circumstances, make the trip. But the therapy that has to follow up after that, i dont want the veteran having to travel 150 miles each time he has to go to physical therapy. The challenge that we have is 40 miles to get care, we keep running the numbers and the tab is horrendous. Its huge. What weve got to do is find a way to be able to manage this in such a way that were doing the right thing for veterans and were being the best stewards of the taxpayer dollar. Weve had a number of discussions on this topic and today i would argue given the chance but i wont argue today about whether or not how the 40 miles should be interpreted. My point on this episode, one, is the uncertainty and the burden lying in the wrong place. It ought to lie with the va or triwest, not the veteran. My second point is, if you have these other authorities, whether or not larry qualifies for the choice act, ought not matter in the answer he gets. I agree completely. Thank you. Senator manchin has senator manchin has kindly yielded to me because ive got to run out the door. And to the gentleman that has to run out the door, senator sanders. Thank you for your work that youve been doing and maintaining the bipartisan spirit of this committee. Congratulations for all youre doing. Thank you. I want to make two points. First of all, i want to thank sloan gibson and his boss bob mcdonald for the impressive work that you are doing. I understand how easy it is to beat up on the va. Running 151 Medical Centers, 900 cbocs. There is i problem every single day. In a nation that has a dysfunctional health care system, the private sector also has one or two problems. I wont go into them but i think we should recognize when you talk to the major veterans organizations, the American Legion, the vfw, you know what they say . Youve heard this mr. Chairman. When people walk into va, the quality of care is pretty good and i want to thank you for trying to improve that care. I will fight vigorously for those who want to try to privatize the va or dismember the va. I think our goal of trying to use the program that we have developed so the people can get care in the community locally thats a good mix. But i will oppose to trying to privatize the va which is serving our veterans so very well. I want to get to another issue and senator blumenthal touched on it today. I wrote a letter to secretary mcdonald about an issue that has concerned me for a while and that is the high cost of the drug sovaldi, which is a very a miracle drug, so to speak, which is now treating the veterans of our country who have very high rates of hepatitis c. Mr. Chairman, to me, it is an outrage that you have a Company Whose profits have soared in the last few years. Their revenues have doubled, i believe, in the last year. Theyve come up with the drug. They are charging the general public 1,000 a pill for that drug. They are charges, i believe i dont know if this is a great secret but i will tell it anyhow, Something Like 540, is that right . No comment. All right. But thats because the va negotiates drug prices. But youre running out of money. Now, we have several hundred thousand veterans suffering with hepatitis c which can be a fatal disease and you dont have money to treat them and, frankly, i think its time to talk to the manufacturer of this drug and ask them if they are being very generous in providing these drugs, hepatitis c drugs, for free. Very generous. For whatever reasons they are doing that. But maybe at a time when their profits are soaring, maybe they might want to respect the veterans of this country who might die or become much sicker because they dont have access to this wonderful product. And as senator blumenthal mentioned, if they are not prepared to come to the table you think youve done well by getting the prices down by half, im not impressed. Paying 540 bucks per pill for people who defended our country. You sit down with them and say youre prepared to use 28 usc 1498 to break the patterns on these drugs unless they are prepared to come down significantly lower than they are right now. Its not a question of taking money. I know youve requested to take money out of the Choice Program. Maybe thats a good idea. But its a better idea to have them treat the veterans of this country with respect and charge the va a reasonable price rather than ripping off the va as they currently are. With that, i would yield. Turn that clock on and start talking, if you would. We have senator rounds followed by manchin and tester. Senator rounds . Thank you, mr. Senator. I appreciate your work and the Ranking Members work on the hospital in aurora. I agree it shouldnt come out of the Choice Program as the alternative. Mr. Gibson, i was looking back at the notes ive taken here and you gave some very encouraging notes with regard to some of the stats about some of the areas of the country with regard to additional care being provided. And thats encouraging. Im just curious, do you believe the stats are consistent across the country . Are you finding evidence of that across actually, thats i always worry when people quote averages to me and what you find is wide disparity across the country in terms of the length of wait times and, therefore, in terms of the specific areas where were making the most intensive investments. So what i would tell you is, where we have been making investments, you see improvement in access measured by appointments and relative value units. But what we are not seeing pretty consistently is a material improvement in wait times. And so you look behind that and you realize that what is happening is, as we improve access to care, either more veterans are coming or veterans that are already there are making additional utilization of va care. Im just curious. It almost sounds like we have a i think senator sanders suggested this in a way. I think we have to have the discussion about how we deliver care long term for our veterans. And i guess i come back to it. Id love to be able to allow the veterans to make that decision themselves as to how we deliver the care to them. And i think the choice act allows that to begin. And, you know, and i understand right now weve got a significant investment. If weve got over 150 Health Care Communities right now, what do you see as the answer here . One of the comments was made that were looking at providing the choice opportunity there if we cant or if the care cant be met by the va itself. And it sounds to me like what were saying is that the va should be making the decision about whether or not they are delivering the care and or whether or not the veterans should be making that decision. And it sounds to me like maybe we ought to take the other approach here and say, if we gave that choice to the veterans, i would suspect that a number of them who have a very great care being delivered to what would happen if we took as an alternative and once again, were talking about dollars and cents now being the deciding factor in this case, what would happen if we allowed the veterans to decide for themselves whether they wanted to utilize the Choice Program more fully and skip all of the stuff that youve talked about in terms of the 40mile rule and whether or not theyve already had care and now theyve got to go back in after 60 days and so forth, still the va making the decision. Why not and share with me your thoughts. Im sure this is not a new thought. Share with me your reasoning and logic and why you are where you are at in terms of not allowing the veterans to make that choice themselves. Not at all a new thought. Weve spent a great deal of time talking about it and options that weve briefed the staff on. One of the things to first keep in mind, 81 of all of the veterans that we provide care for have either medicare, medicaid, tricare or some form of private health insurance. Oftentimes what youve seen today, you mentioned the fact earlier that veterans, if given the option for choice, some would elect to stay in and, in fact, thats precisely what happens today. Roughly half, 40 to 50 , somewhere in that neighborhood, depending on whose survey youre listening to. And i would tell you, my perspective, part of those are deciding to stay because they want to stay. They are getting great care, enjoy the camaraderie with other veterans, they have continuity of care because they have been receiving care for a long final. Others come there because they have an economic incentive to come there. Because if they go out to medicare, they have a 20 copay for a procedure. So you look at that colonoscopy or whatever it happens to be, or the Knee Replacement and the veteran can get it with medicare but hes going to wind up with a 7,500 bill to foot. And so i think part of the answer comes and its one of the options that weve talked about here is that we step back and we look at some of the economic distortion that exists today and find ways to eliminate that. So, for example, what if medicare, medicaid, tricare and others become the primary care payer. So i think in there lies the kind of answer. This isnt about protecting the turf. All were about is doing the right thing for veterans and being good stewards of taxpayers resources. Thank you, sir. Mr. Chairman, thank you very much, and thank all of you for being here today. Let me just say that needless to say that the v. A. Has a lot of problems and had a lot of problems you all have been dealt. Some of you been there longer than others, some of you have had careers. Nobody has problems like colorado has right now with whats happening there, but let me just say i need to get this on record. I have a situation in beckley va Medical Center. I dont know if its been brought to your attention or not, if it got that far up the ladder. But last month the office of special counsel released a report of switching antipsychotic drugs based solely on costs. The providers said this is what the veteran needs, and they made an executive decision that it was too cost prohibitive, cut the medicine, didnt get the right application. We dont i was told there was a new policy in place and i havent been able to obtain a copy of that. At the same time im also told that theres a follow along investigation into the matter. Havent heard much about that. At the same beckley, va the greenbriar clinic has been closed three times because of air quality. Im having a horrendous time because we have a very rural state trying to get our veterans the care they need. Only thing i can ask, if it hasnt gotten to your level, if you can get me an answer back as quickly as you can. Well get you the regulation. Two, i believe the follow on investigation thats referred to here is often times well, routinely when the office of special counsel has a finding that substantiates a whistleblower allegation, if its medical care, its turned over to the office of the medical inspector and we have a team of physicians that really bore it out and come and determine exactly what happened, where the accountability was, and then those often times will come to me. Sure. Sir, ive heard already its at that level now, its been there and ive been trying to get an answer back. We will get you an answer. If you can help me, i would appreciate it very much. Really what it comes down to, this leads up to everything weve talked about here, and i think senator sanders says privatization i just care about the veterans. Theres going to be an awful lot of them coming back that need a lot of care. My generation coming out of vietnam, here they are 40 years later having tremendous need. With that being said, do you believe you come from the private sector, you come from the private sector. Youre public, youre public. Shes private. Private . I read here you had 15 years in government. Okay. All righty. Well, those who have more public more private would understand. Do you believe we can get better care to our veterans through private through the private sector and i mean that in the case of quality of care, the time, and also the cost. And im not saying were going to shut the va down, but before we expand i dont think were going to build another hospital. I dont think were going to build anything else. We have to maintain what we have and give better care for more people. No, i dont believe that thats the case. If you look and why . If you look at the typical veteran we provide care for, theyre older, sicker, and poorer. We have a highly Fragmented Health Care system in america and thats precisely the person i dont think fares best when turned loose in that fragmented system. If you go talk to veterans to a large number of veterans consistently what youre going here, are there instances they had to wait too long for care . Are there instances where we made a mistake in yes, there absolutely are. 55 million outpatient appointments look at alaska. Use alaska as an example. We use alaska for the choice. Thats how we come up with choice. We used alaska and how they were given so much better quality of care and quicker wait times than anywhere else and they dont even have a va hospital. Who wants to take that one . You know that market very well. If i might, i know alaska a fair bit, and about a decade of Public Service experience. I would offer the following. I think it takes both. Okay. And i think the real question at the end of the day is which things fundamentally are done best by the va directly . Which things have enough demand where it justifies building it, and which things ought to be supplemented by the private sector because its either not there isnt enough demand to justify a build or where it makes sense to spread the supply simply because of the amount of resourcing thats needed to deliver services. I think thats always been true. I think thats true in the dod system. Thats why you see tricare constructed the way it is. And alaska has a joint use facility in anchorage, but when you get outside of anchorage, most of the footprint tends to be public in the dod, public through the Indian Health service, or private, and its those two pieces working together that are ultimately going to deliver what needs to be done. I can talk to you all, but my time has run out. The thing on drugs, the drug dispensing to our veterans is almost criminal, what were doing to them. Concoction of drugs were giving them without proper guidance and when you look at high unemployment rates in our veterans and you look to drug addiction, weve got to do something there. Prescription drug abuse is the biggest killer i have in my state of west virginia, its everywhere. Its horrific, but in the ranks of our military and our veterans, its absolutely off the charts. So were putting a drug Prescription Drug abuse caucus together, democrats and republicans working together. Were going to need your help because this is where we can we would love to participate. We agree with you. We recognize that it is a national problem, and its a problem inside va. Thank you. Its a problem in general society. Thank you senator manchin. Senator tillis. Thank you, mr. Chair. Thank you all for being here. Just a couple of things. One is based on a comment here earlier about there are some here in the senate that are thinking that we should completely privatize the va. I honestly have not had a single serious discussion with any member that saw that as an end state, and if they did, if anyone here did, all they need to do is spend some time in the vas to understand the unique nature of what the va has to offer. There is no other more welcoming place for a veteran than the va. Not that there arent opportunities for private care. There clearly are already. The nonva care is a very significant part of what all do every day long before choice was ever implemented. Choice is just another safety valve. So, you know, i realize in these Committee Meetings sometimes our words carry more weight than perhaps they should, but i dont think anybody should leave this Committee Meeting thinking that anybody here has any serious goal or objective to privatize the entire va. I want to go back to the point that senator blumenthal mentioned. I also have concerns about the overrun in the denver hospital. I completely understand your predicament. You got to figure out a way to get it built out. Can you give me an idea of what the thought process was because presumably if you were going to shift that money over for the shortterm need to fund the build out of the aurora facility, what would that cause in terms of delay or ramping down of what wed be doing with choice over the period of time that that money would not be available . What we basically did is in identifying the nonrecurring maintenance and minor construction projects, what we did was we pulled in we have a Capital Planning process that actually builds a prioritized list thats years long based upon the pace of funding that we normally expect to get. And so when we looked at the 5 billion in choice funds, we basically reached into that skip list and pulled a segment out to put into that priority bucket. What happens now is the substantial portion of those if we were permitted to do this in all likelihood would wind up in the 2017 budget because they then fall back would fall back into that prioritized queue. Thats why i was asking the question because you could infer from some of the discussion that theres a 700 million hit and care not being provided versus taking a look at how that money was spent over time to build the ramp out of the Choice Program. Thats why i was asking. It sounds like theres some leveling assumptions youre making about having the money when you need it. Thats exactly right. Our commitment has been we would work it back into the funding stream as quickly as we could. There are hundreds i think its critically in order for what youve requested in the letter that youve sent us to have any prayer of serious consideration, you need to map out how we would have assurances that it doesnt really materially affect it because of the way that you would plan to spend that money anyway. Thank you. Thank you for raising the issue. Because otherwise i would tend to go back to i think the well articulated position of the Ranking Member. The other question that i had or the thing that i think is very important is we need to get a fiveyear, tenyear, 20year picture of what choice nonva care means. I mean to get some parameters set about it. Because that is critically important for you going back and relooking at your Capital Improvement plan and figure out how to do it. The answer is going to be different depending upon where you are. Senator sullivan will rightly say his state has a higher per capita veterans population than any state in the nation. I have a veterans population that exceeds the population of several states. The Capital Planning requirements in North Carolina will be necessarily different than nonva care and the choice mix in alaska will be necessarily different, but we have to come up with that longterm vision so we can relook the current Capital Improvement plans based on what appears to be the interest of the senate to continue down that multiprong path so that you are taking pressure off of Capital Requirements in some areas and maybe redoubling them in other areas, so thats a very important thing that i think this committee needs to see, but then we need to be very specific about what we want beyond just brick and mortar va presence in the form of nonva care and choice care to get this right. If i can make two quick observations. I think youre absolutely spot on. First of all, we have to force ourselves to make certain decisions about what care can be most efficiently delivered in the community. So weve talked before my example the chairman remembers optometry. Why would we send a veteran 100 miles to get his eyes checked and get some glasses. You can do that anywhere. Why wouldnt we routinely be referring that out to the community unless a veteran really wants to come to va. The other issue were trying to get at and were learning right now again working to manage towards requirements rather than just a budget number. Every time we improve access to care with a new facility, with additional staff, demand changes. Part of what were trying to understand are what are the dynamics. For example, you look in phoenix where we know were under penetrated in the veteran market. We improve access to care and we get a disproportionate response back. Weve got to understand that Market Penetration phenomenon because it will affect our Capital Planning. I have already talked with the folks in phoenix about getting beyond looking over the horizon as it relates to demand for care among veterans in phoenix. We cant keep incrementally doing this because were just going to stay behind. We have to get ahead of that demand. Points are excellent. Thank you. Thank you. Thank you. Theres a shortage of medical personnel in the va, and i note in your testimony, secretary sloan, that youre going to be creating some 1,500 new residency positions, and this is a matter that i have discussed with our va person in hawaii because if you can create residency positions in the state, more likely that those folks will be able to practice in the state. So how will these residency spots be allocated, by region, by capacity . Are there any planning to increase for hawaii medical students . I dont have the list with me today specifically of where the slots are going. Have you already determined where the residency not all 1,500. So that is a multiyear plan to deploy the 1,500, and the first round of those started this fiscal year. We actually went out i quite frankly did not think our office of academic affiliations would be able to do it, but they went out and sought applications. There are very specific criteria in the law about them going to under resourced communities and specialties. They went out and specifically caught those. We have awarded several hundred for this first round this year. Not as many as we had thought maybe, but a lot more than i anticipated that they would be able to award, and i can get you specifically where those because hawaii has a lot of rural areas on the islands that are underserved by the va. Thank you. You can send me the information or the committee. As we look at the requests of secretary gibson to pay for the denver facility and were looking i think that is really difficult for us to accept that you want to take money from the Choice Program to do that. So id like to ask you this, when a veteran goes to the va to get care for a nonservice connected matter, and this veteran has private insurance, do you have the authority to get reimbursed from the private Insurance Company for the care that the va provides . So if the patient goes out into the community in our normal Purchase Care Program and has insurance, we will bill that Insurance Company and collect to offset the cost of the care we provided. Under choice were actually the secondary payer. So under the Choice Program, the way the law was written, if the patient has commercial insurance, the commercial insurance is the primary payer and then we will make the provider whole up to the medicare rate. All right. So under the Choice Program, thats good because va becomes a secondary payer. My understanding is that in the first instance where the veteran goes to the va and gets the treatment, then often there is no reimbursement from his or her private Insurance Company. Youre telling me otherwise. We will bill the private Insurance Company if the patient has insurance. Yes. And do they reimburse you . We get paid from them. A lot of the patients actually have that have insurance have medigap insurance. And without a medicare eob often times those Insurance Companies will not pay for the care because its not medicare the insurance is specifically medicare gap coverage, and so we will not often times get paid by those insurers. So youre reassuring me that the va goes after every dime from the private insurance carriers that you can get your hands on. I can assure you we go after every dime we can collect. About 3 billion a year. Thats reassuring. There are some questions about the outreach and the choice card program. Theres still confusion out there and whether you have found all of the veterans who would qualify for the choice card, so my question goes to what are the outreach efforts that youve engaged in . Do you think that you are succeeding in explaining the Choice Program and also to va employees and Community Health care providers who need to get training on how to explain the program. So we originally mailed we know who the people are who are eligible to get a choice card, and we mail a letter to every one of those people back when the program started in november. I have talked to veterans, and they found that letter to be rather confusing. Yeah. Were about to mail a second letter to all of them. Hopefully its a lot simpler to understand. We have actually tested that with veterans before we put it in the envelope. Good idea. And weve made a lot of phone calls and outreach to people. There is no question that i think we can do more to reach veterans through our website, through mobile technology, through mailings and other forms of communication, and we need to do a better job of educating them. Good. We do need to do a much better job. One of the things weve got to remind ourselves of is theres no parallel to this out there. Its not like an insurance card where you just walk into your Doctors Office and present your insurance card. Theres no frame of reference for people to understand how it works. You know, do i have a benefit or do i not have a benefit . And thats one of the reasons its hard for us to explain and why we have to keep trying. If we get feedback from my veterans, for example, that could help you all do a better job, id be happy to pass that on. Wed love it. Thank you. Thank you, senator. Senator bozeman followed by senator tester. Thank you, mr. Chairman. Really very briefly id like to ask a question of efficiency. I understand that the thirdparty administrators have raised the issue of how much clinical documentation is being sent to them by the va. Apparently va is sending the clinical documentation of every veteran who was approved due to having a wait time in excess of 30 days, which presumably is overwhelming the tpas. You now have a Pilot Program in business 8 and 17 to only send the clinical information of veterans who choose to participate in the Choice Program. I guess the question is, are the pilots proving successful . And then also, mr. Mcintyre and miss hoffmeier, if youd like to comment from your standpoint as to whats going on . When we first set up the program, we put we gave every patient in the system an appointment in our system and put them on the choice list so that they could decide at any point in time which direction they wanted to go. We have learned through experience over the last six months that that doesnt work. Its not it doesnt help the veteran, it doesnt help us, and, quite frankly, its not costeffective. So we have the pilots. We have just started these pilots to see how this goes and how we can improve those business processes, but we are moving, quite frankly, in the direction of at the point of Service Offering the veteran finding out what is the appointment we can provide in the va, offering the veteran that appointment, or offering them the opportunity to go outside through the Choice Program, and at that time if the veteran chooses to go out, then our staff, much like they do outside of choice for all of our other purchase care appointments will work directly with triwest and healthnet to get that patient an appointment through the Choice Program, and at that time we hope we have learned from our pilots in 8 and 17 how to do this smarter and better so that we will greatly reduce the volume of people that we are referring to the tpa and are only providing medical record documentation for those patients who actually choose to go out the system. That sounds excellent. The pilot is a very good idea. Sitting at the table in the initial design when we were getting ready to launch, we had two days to make a decision. And the question was how do you make sure that all the right information is in the right place to be able to serve people on the front end . The back end consequences are now obvious and making the change makes a lot of sense and were looking forward to supporting it. Okay. The pilot has been going exceptionally well in our area and, in fact, we just approved a schedule with va to move forward with implementing the concept across all of our regions here very soon. So its were getting the consults in less than 24 hours on the veterans we need. Its very effective. Good. Thats excellent. I know that its kind of a rocky road as youre working through these things, but it sounds thats encouraging that you are working through it. So thank you, mr. Chairman. Thank you, senator. The patience of the year award goes to senator tester. Just because you have a very, very good Committee Meeting here, mr. Chairman. You got good testimony. And i thank the Ranking Member for having you guys, and thank you for your work. I just really dont know where to start, quite frankly. First of all, you guys do do a good job. I think the private sector does a good job. You have your fallabilities. Dont think the private sector doesnt have their fallibilities, too. Theyre short in doctors and nurses and Mental Health professionals and Mental Health facilities just like you guys are. And the bookkeeping nightmare that comes with this let me give you an example. Just say i was a vet. I live 50 miles from a sea box. My nearest hospital is 12 miles away. But that nearest hospital doesnt have a doctor in it. Its staffed by a nurse practitioner. So then the question becomes is that somewhere where you want to go an appointment and, second of all, if i dont, guess where the nearest hospital is, in the same town where the sea box is. The bookkeeping here is just amazing and i know were all here trying to do the right thing and youre trying to do the right thing, but sometimes even when you do the right thing, people are mad because they think its the wrong thing. So i thank you for that. Sloan, you talked about the 40 sloan, you talked about the 40 mile thing not Offering Service several times and you talked about how it doesnt make any sense if a guy is going to have a set of glasses why ship them halfway across the country. When you did your analysis, did you also include the savings that would occur to the va by not shipping them a long ways away because i think thats really important. Look, if i was a veteran and had to do over again, i probably would have signed up just for this benefit, but the truth is that if youre talking about what it costs to ship them to the private sector, it also is a savings if just in mileage alone, and did you include that in the overall net dollar figure . No. So we actually do not in the analysis weve worked through several options from what 40 miles from the care you need might look like. Yeah. We have not taken into account a lot of savings. Okay. In the short run so we were modeling this for the Choice Program n the short run, our cost structure is highly fixed. 90 of our costs are fixed. So there are variable costs and its mostly the eyeglasses that you dont prescribe. But the rest of the infrastructure, the building, a lot of the people, et cetera, dont go but the mileage is also not a fixed cost and if you have to put them up in a room, thats not a fixed cost. We have not specifically looked at the bene travel and theres two aspects of the bene travel. Theres the true cost savings and the cost avoided because you havent made them travel. Thats correct. But thats not a real savings. Thats a cost that you didnt realize. Yeah, yeah. But really, i mean, come on. That sounds like cbo stuff here truthfully. I mean, i dont want to get in this debate, but the fact is if youre doing the actual cost analysis and you would have spent the money if they went to a facility of yours, you have to include that in the savings, and i by no means think that the veterans but truthfully, if were going to deal with honest figures, it has that savings has to be included even if it didnt accrue. Clearly it does have to be included. Right. Even though the level of analysis today isnt to that level. A better than what we had initially all the way down to the individual patient level, we havent picked up some of those incidental costs. Mr. Mcintyre, you talked about harmonization, i talked with sloan about harmonization before with the arch program and pc3 and choice. Im assuming youre for harmonization. I heard it in your testimony. Just nod your head if thats correct. Yes. Sloan, youre for harmonization. Can i ask you a question, can you get us some language on how we can harmonize the programs. I dont want to be the micromanager here. If you need language to harmonize the programs, i think its reasonable thing to do. And we need to do that. I think part of that picture is how do we manage the 40mile issue. I think we need to think through this, are we going to look at va becoming a secondary provider to those that have other insurance alternatives because it changes the nature okay. Well but its wrapped up in that and it needs to be a very nearterm exercise. Lets deal with that because i think its confusing right now and i think theres a little manipulation going on. Well, and if i might, one of the issues i was attempting to address and allude to is the fact that we built a network out now in our area thats got 100,000 providers in it. The requirements are more extensive than those under choice. Yeah. If youre a participating provider. Those things need to be blended together so that we dont have disincentive to participate in one program versus another. Fair enough. And the reimbursement rates need to be the same. Hep c. You want some additional dollars, 700 million transferred, 400 million . If were allowed to be able to tap it. I dont have a problem with that, by the way. The question i have is this is a miracle drug. When do you anticipate those costs for hep c to flatten out so you wont need those kind of dollars . I think the conversation that needs to be held with this committee, with the House Committee, and with the appropriators has to do with the requirement that we manage tort. I would tell you my thought, our thought, vas thought is we should be talking about a requirement where veterans that are hep c positive we manage that number to functional zero by the end of 2018. Thats what i think the requirement should be, and so what we need to do is step back from that and lay out a plan that says this is what would be required in order to manage to that requirement. I agree with that. So were not back and forth about because the first time we deny a veteran access to the treatment who is hep c positive because hes not doesnt have advanced liver disease, everybody thinks were depriving a veteran of care. We need to Reach Agreement on what the requirement is. One last question if i might since i get the award for being patient, you talked about residency slots, and i think thats great and i support it and well do everything we can but i believe residencies are three years. It varies depending on the specialty. How about for an internist . Thats three years. Thats what were short on, right . Yeah. The question i have is this place changes every two years, and to have three years in a residency, you have to have the money for that residency. Yes. Talk to me about how this works because you got a twoyear you got forward funding but you dont have forward funding for three years. And so what do you do if congress does something irresponsible, and that has been known to happen a time or two, and doesnt fund you . I think this is actually one of our concerns. So these residents all have tails. When we start a new residency slot, all of those slots have to be funded for the duration of that res in that budget. Exactly. And thats not the case today. Okay. Thats important to know as we move forward. And just if i might, when are you going to start the Residency Program . Is it going to start in this fiscal year . So we actually dont own the residency slots. Theyre owned by the academic centers. Yes. We pay for trainees, off set their salary. The additional slots we added started this Academic Year. This fiscal year. The Academic Year that will start this coming july. In this budget were dealing with this. Yes. If youre budget comes in a little short, this may be a program that goes byebye. I doubt it because weve made commitments at this point. Appreciate it. Thank you for your work. Appreciate the flexibility, mr. Chairman. Thank you, senator tester. Thanks to all the witnesses. Its been a long but productive hearing. I think were on the path to solving some problems and recognizing a few we need to solve but i appreciate everybodys time and effort very much. Well take a two minute break while we shift name plates and go to panel two. We appreciate the collaborative working relationship, mr. Chairman. Its the only way to do it. It is. It was a good first panel. I apologize to our second panelists it took so long. But i think it was beneficial. I think from the participation you were illustrating on your faces, im sure you enjoyed it too. So thank you very much. Welcome back to the senate Veterans Affairs committee. We have mr. Roscoe butler, the Deputy Director of health care for the American Legion here. Rosc