[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
CHOICE CONSOLIDATION: EVALUATING ELIGIBILITY REQUIREMENTS FOR CARE IN
THE COMMUNITY
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
TUESDAY, FEBRUARY 2, 2016
__________
Serial No. 114-51
__________
Printed for the use of the Committee on Veterans' Affairs
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Available via the World Wide Web: http://www.fdsys.gov
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25-017 PDF WASHINGTON : 2017
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado CORRINE BROWN, Florida, Ranking
GUS M. BILIRAKIS, Florida, Vice- Minority Member
Chairman MARK TAKANO, California
DAVID P. ROE, Tennessee JULIA BROWNLEY, California
DAN BENISHEK, Michigan DINA TITUS, Nevada
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American
Samoa
MIKE BOST, Illinois
Jon Towers, Staff Director
Don Phillips, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
DAN BENISHEK, Michigan, Chairman
GUS M. BILIRAKIS, Florida JULIA BROWNLEY, California,
DAVID P. ROE, Tennessee Ranking Member
TIM HUELSKAMP, Kansas MARK TAKANO, California
MIKE COFFMAN, Colorado RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana BETO O'ROURKE, Texas
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Tuesday, February 2, 2016
Page
Choice Consolidation: Evaluating Eligibility Requirements For
Care In The Community.......................................... 1
OPENING STATEMENTS
Honorable Dan Benishek, Chairman................................. 1
Honorable Julia Brownley, Ranking Member......................... 2
WITNESSES
Adrian M. Atizado, Deputy National Legislative Director, Disabled
American Veterans.............................................. 3
Prepared Statement........................................... 36
Carl Blake, Associate Executive Director for Government
Relations, Paralyzed Veterans of America....................... 5
Prepared Statement........................................... 40
Duane Williams, Georgia Leadership Fellow, Iraq and Afghanistan
Veterans of America............................................ 7
Prepared Statement........................................... 44
Baligh Yehia, M.D., Assistant Deputy Under Secretary for Health
for Community Care, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 23
Prepared Statement........................................... 45
Accompanied by:
Kristin Cunningham, Director, Business Policy, Chief Business
Office, Veterans Health Administration, U.S. Department
of Veterans Affairs
STATEMENTS FOR THE RECORD
Military Officers Association of America......................... 49
Veterans of Foreign Wars of The United States (VFW).............. 54
CHOICE CONSOLIDATION: EVALUATING ELIGIBILITY REQUIREMENTS FOR CARE IN
THE COMMUNITY
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Tuesday, February 2, 2016
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. Dan Benishek
[Chairman of the Subcommittee] presiding.
Present: Representatives Benishek, Bilirakis, Huelskamp,
Coffman, Wenstrup, Abraham, Brownley, Takano, Ruiz, Kuster, and
O'Rourke.
OPENING STATEMENT OF DAN BENISHEK, CHAIRMAN
Mr. Benishek. Good morning. The Subcommittee will come to
order.
Thank you all for joining us for today's Subcommittee
hearing, Choice Consolidation: Evaluating Eligibility
Requirements for Care in the Community.
Today's hearing is our first of the new year, our first
during the second session of the 114th Congress, and most
importantly our first in a series of hearings that we will be
holding on different aspects of the Department of Veterans
Affairs' plan to consolidate care in the community under the
Choice Program.
The VA currently uses seven mechanisms to provide care to
veteran patients in the community. Each of these seven
mechanisms works differently using seven different eligibility
criteria, seven different reimbursement rates, seven different
administrative processes, and seven different sets of business
rules.
Recognizing that using multiple means to achieve the same
end was confusing and inefficient, Congress required the VA to
develop a plan to consolidate all seven community care programs
under a single umbrella, a new, improved Choice Program.
The VA provided the bare bones of that plan last year and
over the next several weeks, we will examine it in depth
beginning with today's conversation on eligibility. Determining
who will be eligible for what and when under the new Choice
Program is perhaps the most important of all the discussions we
will be holding over the next few months.
Eligibility for care in the community now is determined
largely by how long veteran patients have to wait for an
appointment, how far they have to drive to get to the nearest
VA medical facility, and when they get there, whether the VA
can provide the service that they need.
While these existing criterions are not perfect, VA's
proposed plan does not change them significantly. The VA's plan
does include several significant changes to eligibility
criteria for emergent care, however, by authorizing veterans to
seek care in urgent care centers and requiring cost sharing for
emergency care services in non-VA centers in order to
incentivize appropriate behavior.
I am cautiously supportive of the eligibility criteria that
the VA has laid out in the consolidation plan, though I remain
concerned about many of the lack of details that the plan
includes.
Moving from seven disparate methods for referring veterans
to community providers to one streamlined common-sense program
is certainly necessarily, but changing the status quo is never
easy. And as the saying goes, the devil is in the details,
precious few of which the VA has provided so far.
That is why I am glad to be joined this morning by Dr.
Baligh Yehia, the new Assistant Deputy Under Secretary for
Health for Community Care, who is leading the VA's
consolidation efforts. I am hopeful that Dr. Yehia will be able
to provide us some of the concrete details about how the VA
will determine eligibility under the new Choice Program that
the plan did not include. And I am looking forward to that
discussion.
I am also glad to be joined this morning by representatives
from many of our veteran service organizations. As veteran
advocates and veterans themselves, I look forward to hearing
their unvarnished opinion about the proposed consolidation plan
and whether they believe it will help us accomplish our most
important goal which is increased access to high-quality care
for veterans we are all here to serve.
I thank you all for being here this morning and now yield
to the Ranking Member, Ms. Brownley, for any opening statement
she may have.
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Mr. Chairman, and thank you for
calling this hearing today.
After more than a decade of war, veterans deserve to have
ready access to the best health care available to them. Time
and again, that is shown to be care provided by the VA. I am
pleased the VA is here today to talk about their new Veterans
Choice plan that will consolidate the seven disparate care
authorities that exist currently in law. This plan submitted to
Congress in 2015 would bring under one umbrella a program that
is easy to understand and more importantly to implement. The
program is intended to bring high-quality, safe health care to
veterans wherever they choose to live.
When Congress passed and the President signed the Veterans
Access Care and Accountability Act in 2014, this was a promise
to all veterans from all eras that they would get the care they
earned on the battlefield in defense of our Nation.
The Choice Program was rolled out in a rushed timetable
under conditions dictated by Congress. I believe the department
implemented the program to the best of their ability under
trying circumstances.
Today, Mr. Chairman, I am interested in hearing from the VA
what the estimate of this new care in the community will cost
and how long it will take to implement, also what this
consolidation ultimately means for veterans and their access to
quality health care. After all, making it easier for veterans
to access care is the goal that we all have in this room of
this plan.
One aspect of health care often overlooked is helping those
navigate the system with physical disabilities that force them
to bring a caregiver with them. I have introduced legislation
that would authorize payment of beneficiary travel expenses in
connection with the care of a veteran with vision impairment, a
spinal cord injury or disorder, or double or multiple
amputations whose travel is in connection with care provided
through the VA.
It is important that all veterans have access to quality
health care whether at the VA or in the community, but the care
needs to be at the standards we have come to expect from the
VA.
I look forward to hearing from all of the witnesses today.
I thank you for being here and moving forward in the coming
days to bring the very best quality care to all of our
veterans.
And I yield back, Mr. Chairman.
Mr. Benishek. Thank you.
Joining us on our first panel this morning is Adrian
Atizado, the Deputy National Legislative Director for the
Disabled American Veterans; Carl Blake, the Associate Executive
Director of Paralyzed Veterans of America; and Duane Williams,
Georgia Leadership, Fellow for the Iraq and Afghanistan
Veterans of America. Thank you all for being here today,
gentlemen.
Mr. Atizado, we will begin with you. Please proceed with
your testimony.
STATEMENT OF ADRIAN ATIZADO
Mr. Atizado. Mr. Chairman, Members of the Subcommittee, on
behalf of the 1.3 million wartime ill and injured veterans of
the DAV, I want to thank you for allowing us to testify today.
You had asked to examine VA's plan to consolidate certain
authorities that it uses to purchase care in the community into
the proposed new Veterans Choice Program. You also asked us to
assess whether the proposed eligibility criteria to access the
new VCP are sufficient to increase access to care among veteran
patients.
The way we see it, Mr. Chairman, we believe VA's entire
plan will increase access to care, no doubt. Whether it is
sufficient, though, will remain to be seen.
So, for example, the plan proposes to continue the existing
geographic and temporal eligibility criteria of the current
Veterans Choice Program as well as the availability of services
criteria currently utilized in other authorities such as
dialysis and PC3 contracts as well as the now defunct fee-basis
care.
All these criteria have their own limitations and
vulnerabilities from veteran patients' perspective in allowing
them to access care in the community. Now, on a system level,
these criteria would continue to administratively separate the
new VCP from the VA health care system which we believe does
not foster full integration and limits the performance of these
networks to the detriment of veteran patients.
Under the separated construct, Mr. Chairman, we recommend
serious consideration that eligibility to use the new VCP
should mirror the current eligibility for VA health care giving
the highest priority to service-connected veterans.
However, DAV also believes clinical decisions about when
and where and with who to receive care is one that should be
between a veteran and his or her doctor without bureaucrats or
regulations getting in that way.
Under this construct, all of VA's authorities are
consolidated and its medical benefits package reflects what is
generally available and acceptable in the private sector. The
seamless integration of community care into the VA health care
system would be able to provide a full continuum of care.
From a veteran patient's perspective, the future VA health
care system with the integrated VCP should be responsive to the
decisions between veterans and their providers. Veterans should
be able to choose among the options within VA in the new
Veterans Choice Program network and schedule appointments that
are most convenient for them.
For emergency and urgent care coverage, we applaud VA for
including them in its plan. In fact, DAV had specifically urged
the inclusion of urgent care into VA's medical benefits package
and to better integrate emergency care with the overall health
care delivery system.
However, there is nothing more glaring that will deter
appropriate access to emergency and urgent care in the
community as the plan's imposition of co-payment to all
veterans with little relief. VA clearly knows the value of ERs
and urgent care clinics and their appropriateness as clinical
settings because it owns and operates them in VA facilities
across the country.
If certain veterans do not pay co-payments today when
receiving VA emergency and urgent care, we question why VA's
imposition of co-payments to all veterans who receive similar
care in the community. Simply put, if the future VA health care
system with the integrated new Veterans Choice Program are
unresponsive to the medical needs of veteran patients, why
should veterans be penalized with a co-payment for a health
care delivery system's shortcomings?
At the very least, service-connected veterans should not
face greater restriction in the future VA health care system
when accessing care in the community.
Finally, Mr. Chairman, we understand the scope of the
consolidated plan is limited. However, we do caution Congress
and the Administration on this fragmented approach to providing
veterans timely access to care in the community.
If Congress intends to increase veterans' access to high-
quality care across a continuum of care including care in the
community, not addressing gaps and inconsistencies in VA's
plan, in VA's medical benefits package as it sits against all
available services in the community, we believe that VA will
assuredly continue certain fragmentations of care that veterans
experience today into the future.
Veterans could be left unassisted across different
providers and care settings fostering frustrating and unsafe
patient experiences leading to medical errors, waste, and
duplication that foster poor overall quality of care.
You have our commitment, Mr. Chairman, that DAV stands
ready to work both with you, the Congress, and VA to ensure
veterans have ready access to high-quality care both in VA and
in the community.
Mr. Chairman, thank you for your time and attention and for
the opportunity to present this testimony. I would be pleased
to answer any questions you or Members on the Subcommittee may
have. Thank you.
[The prepared statement of Adrian M. Atizado appears in the
Appendix]
Mr. Benishek. Thank you, Mr. Atizado.
Mr. Blake, you can go ahead.
STATEMENT OF CARL BLAKE
Mr. Blake. Thank you, Mr. Chairman.
Chairman Benishek, Ranking Member Brownley, Members of the
Subcommittee, on behalf of Paralyzed Veterans of America, I
would like to thank you for the opportunity to testify today.
Let me say up front that we believe that the VA's community
care consolidation plan lays out a positive path towards the
delivery of timely quality care and improving access for
veterans. However, we do believe that there are questions that
remain as it relates to the veterans that we serve, veterans
with catastrophic disabilities like spinal cord injury and
disease.
As eligibility dictates access to health care, so, too,
does the capacity of the systems to provide that care. Over the
years, the VA health care system has relied upon a number of
methods and standards to measure access and timeliness of
health care delivery.
We have seen the VA standard evolve from the 14-day wait
time to the 30-day wait time. We have seen Congress and the
Administration seemingly accept an arbitrary 40-mile,
geographic-based access standard. The fact is, there is no
evidence to suggest that arbitrary wait time standards are an
indicator of quality.
Rather, they are bureaucratic tools to self-assess output
performance. They are not a measure of quality care. To suggest
otherwise is unfounded. Similarly, geographic-based access
standards are not derived from industry best practices for the
provision of health care.
The independent assessment on access standards conducted by
the Institute of Medicine determined that industry benchmarks
for health care access vary widely throughout the private
sector. IOM was unable to find national standards for access
and wait times similar to the Veterans Choice Program 40-mile
and 30-day standards.
PVA, along with our partners in the Independent Budget, DAV
and VFW, strongly agree with the IOM's recommendation that
decisions involving designing and leading access assessment and
reform should be informed by the participation of patients and
their families and their providers. We believe that this
concept will also best serve the needs of our members and all
veterans.
The irony of all this discussion about access standards is
PVA members often travel farther than any other population in
the specialized population of veterans or even all veterans in
general seeking care from the VA. It is not unusual for PVA
members to travel more than several hundred miles to reach one
of the 25 SCI centers of care in the VA system. They do this
because the VA SCI system of care is far and away the best
option that they have to meet their specialized health care
needs.
The access problems these veterans face are usually not
wait times or distance. They are the burden of cost. Ms.
Brownley, I would like to thank you for bringing attention to
that issue in your opening remarks.
As a result, veterans may wait to be seen until their
condition deteriorates requiring more costly and intensive
care. This Subcommittee is reviewing the question of
eligibility without even considering this important fact.
Congress should expand travel benefits to include non-
service-connected, catastrophically-disabled veterans who are
already granted a higher priority in the system to ensure that
they are able to receive quality specialty care.
PVA believes that the 30-day and 40-mile eligibility
standards that determine access under the new VCP do not
consider what is best for veterans with catastrophic
disabilities to include SCI and D or any other veterans seeking
care for that matter.
PVA along with our IAV partners also support the plan to
expand emergency care and urgent care in the community.
However, we strongly oppose the proposal to charge $100 as a
co-payment for emergency care and $50 for urgent care. This
proposal seemingly makes no exception for veterans with
service-connected disabilities or who are currently exempted
from co-payments. These veterans should not be required to bear
a cost share as it may disincentivize that veteran or their
caregiver from accessing emergency treatment or urgent care
defeating the whole purposes of expanding these two
opportunities.
As an alternative, VA should also consider establishing a
national nurse advice line to help reduce over-reliance on
emergency room care. The Defense Health Agency has reported
that the TRICARE nurse advice line has helped triage the care
for TRICARE beneficiaries.
Those who are uncertain if they are experiencing a medical
emergency and would otherwise visit an emergency room call the
nurse advice line, and are given clinical recommendations for
the type of care they should receive, when and where they
should receive it.
This advice line must also include, must include SCI
trained providers who are able to identify potential
complications specific to an SCI or D veteran.
Mr. Chairman, I would like to thank you again for the
opportunity to testify. Be happy to answer any questions that
you may have.
[The prepared statement of Carl Blake appears in the
Appendix]
Mr. Benishek. Thank you, Mr. Blake.
Mr. Williams, go ahead.
STATEMENT OF DUANE WILLIAMS
Mr. Williams. Good morning, Mr. Chairman.
Mr. Chairman, Ranking Member Brownley, distinguished
Members of the Subcommittee, on behalf of Iraq and Afghanistan
Veterans of America and our 425,000 members and supporters,
thank you for an opportunity to share our views with you at
today's hearing.
By way of introduction, I am a retired Army person having
served 26 years active duty, six years in the reserves. I serve
as the Chairman of the Veterans Affairs Advisory Board of
DeKalb County, Georgia, and I am responsible for Veterans'
Recognition Advocacy and Research Program on behalf of 41,000
veterans in that county.
I also serve as the Iraq and Afghanistan Veterans
Leadership Fellow focused on veteran leadership, development,
policy advocacy, and team building. These experiences help me
to understand the needs and challenges of veterans accessing
quality care.
IAVA is proud to have previously testified in front of this
Subcommittee recommending the need for consolidation of care in
the community of veterans enrolled in VA health care. We
applaud Congress for requiring VA to put forth a plan for
consolidation. We recognize the senior VA leaders for
acknowledging the need for consolidation and for providing
inclusive veteran-centric and transparent plans.
The 2015 Choice Improvement Act helped begin the process of
removing confusion for veterans. However, IAVA's most recent
member survey indicated that five percent of the respondents
that use the Choice Program and their reviews were mixed. For
the 95 percent of IAVA members who have not used Choice, 43
percent didn't use it because of confusion on how to use it and
half were totally unfamiliar with the program.
In Atlanta, Georgia, the enrollment for health care at the
Atlanta VA Medical Center is growing faster than the capacity
for primary care. According to the 2013 vet pop data, the
number of veterans living in the 28-county metro Atlanta area
was 294,000. By 2014, the data reflects 361,000 veterans living
in the same area. And during the same period of time, the
Atlanta VA hired 600 additional employees.
Related to this, on January 20th, the Atlanta VA stated
that the current completion for VA primary care appointments
was 60 days. But by January 26th, the director advised me that
the wait was reduced to 20.6 days. If these numbers hold true,
the reduction in wait time by nearly 40 days within six days is
remarkable. We hope other VA medical centers follow suit. We
hope this Subcommittee will continue to monitor, analyze, and
ensure the accuracy of wait time data.
As Congress moves forward to simplify this process for
veterans, IAVA recommends that the Congress works with the VA.
Use the VA as a plan, as a framework for legislation to avoid
the one-off proposals that might be misinformed or put politics
ahead of veterans. After all, the Congress provided different
plans that added to the confusion and inefficiencies leading to
the need to consolidate care.
We believe Congress should be mindful of these lessons
learned from them and leverage the VA's plan as a framework for
consolidation of care.
Our second concern is VA's ability to effectively implement
a plan to consolidate care across VA to avoid the mistakes made
during the implementation of Choice. While the Choice
Improvement Act of 2015 extended provider eligibility to any
provider meeting VA criteria, the VA must use this opportunity
to streamline and standardize the medical documentation
requirements.
Under the 2014 law, reimbursement rates for non-VA
providers is limited to no more than Medicare. Reducing the
administrative requirements can remove a barrier to more
providers joining the network.
VA intends for its health delivery model to be a patient-
centered medical home for veterans. Therefore, VA holds
responsibility for the direct coordination of services for each
veteran. Care coordination is a core function of primary care.
Significant numbers of VA patient needs are complex.
The factors that increase the complexity for our veterans
are a number of them have multiple chronic health problems,
social vulnerability, a large number of providers, and the
patients lack the ability to coordinate their own care.
Significant numbers of VA patients have anxiety disorders,
dementia, depression, and kidney failure.
IAVA recommends VA continue to collaborate with all
stakeholders who share their vision to put the veterans first
and focus on value-based leadership to change the VA culture.
Given the shortcomings related to training front-line personnel
in the implementation of Choice and customer service, VA should
continue to put forth efforts to train all employees in the
consolidated care model.
Finally, IAVA encourages the Congress, VA and VSOs, the
industry and other stakeholders to place increased importance
on the quality of care that veterans receive, especially
providers who haven't served veterans since their residency
training.
In closing, thanks to this Subcommittee for your leadership
and your commitment to veterans. Mr. Chairman, I stand ready to
answer any questions you may have.
[The prepared statement of Duane Williams appears in the
Appendix]
Mr. Benishek. Thank you. And thank you all for your
statements. I am going to yield myself five minutes for my
questions.
You know, as a doctor who took care of veterans in my
private practice and with some VA coordination and also working
at the VA doing care, many of the things that you brought up
today, I have experienced in reality.
And the frustration of veterans that I hear from now, and
the work that my staff does to try to get veterans into care is
so frustrating. And having a single system that really is based
on clinical need makes much more sense and I completely
understand that.
And the whole difficulty with the criterion, I think is an
effort to contain costs. One of my biggest gripes in my time
here has been the inability to figure out what it actually
costs the VA to take care of a patient. So, we don't know if
care in the community is more expensive than care in the VA,
frankly, although it seems to add more to the total cost.
But let me just ask a couple of questions that have come up
based on your testimony and some of the written statements. The
Military Officers Association of America, for example, called
on the elimination of these access standards and the
establishment of clinically-based access standards instead.
Can you elaborate a little bit more on your thoughts
relating to that? I mean, the miles and the time versus what is
clinically right, does anybody want to comment on that?
Mr. Atizado, can you talk to me a little bit more about
some of the things you brought up in your statement?
Mr. Atizado. Sure, Mr. Chairman. I think first and
foremost, what has to be said is where we come from which is
from the patient's perspective. This plan really comes from a
systems perspective, from the providers' perspective.
And what we are trying to say is, in order to simplify
eligibility and to ease access to care, whether it is in VA or
in the community, there should really just be one eligibility
criteria. Once you are enrolled in VA, you should have the
option to use VA or the community, whichever is most convenient
for the patient.
As it relates to the doctors' recommendation,
unfortunately, as you had mentioned, these criteria are really
cost-containment measures. And we understand that. It is a
feature of the health care system today, and most likely, will
remain a feature in the future VA health care system.
But by and large, the approach in the plan really is to
disincentivize or make harder accessing care in the community.
We think it should be the other way around. The plan should
incentivize veterans to use VA, not disincentivize them from
using the community. The plan should simplify accessing care as
patients see it. It is very simple.
Mr. Benishek. Well, I agree with you.
Mr. Atizado. And our proposal really does that. Once you
are in, you are in.
Mr. Benishek. Mr. Blake.
Mr. Blake. I think it is fair to say that part of the
reason the Institute of Medicine couldn't find examples of 30
days and 40 miles is because that is not how the larger health
care system in America works. I think it is based on the idea
that I meet with my provider and we determine as a partnership,
as it were, what is best for me as a patient, when should I be
seen, where would it be most appropriate for me to be seen,
what procedure would be most appropriate.
And while I think on some level that exists in VA in some
places, the strictures that are in place right now, as Mr.
Atizado mentioned, allow it to be maybe more rigidly managed is
just not optimal. That is why we have joined with our partners
in the IAV to say that the VA should move to a clinically-based
access standard.
I don't know if Dr. Yehia would admit it, but, you know, we
were involved in a lot of the meetings, and I think they
understand that. But they have to figure out how to develop a
workable plan within the construct that they have available to
them. I think 30 days and 40 miles allows you as the Congress
to control based on how much it is going to cost. And if you
open up the possibilities with a clinically-based access
standard, it is a little more uncertain what the cost might
actually be.
Mr. Benishek. Well, my thoughts in talking to some of the
VA administrators that I have talked to said that the different
rules make their bureaucracy work so hard to try to get people
to--one or the other, one of these criteria than we have now is
just slowing the whole process down. And I think streamlining
the eligibility would help in that regard because that is the
biggest complaint I have had from the VA.
Mr. Williams, do you have any further comments on that?
Mr. Williams. Mr. Chairman, the only thing I would do if I
put that in the context of the patient-centered medical home,
the primary care physician has to be the person that decides
what type of care the patient needs and what frequency they
need. And I would think VA's primary care provider would know
that. That is a frustration I dealt with myself.
That provider ought to be able to say that this patient
needs to be seen for specialty care at this point, and I need
that information back to me within a reasonable amount of time
and get that done. And they have to do that for the patient.
Mr. Benishek. Thank you very much. I am out of time.
Ms. Brownley.
Ms. Brownley. Thank you, Mr. Chairman.
I think your statement regarding we really don't know what
the cost of VA care is versus community care, we really don't
know the answer to that. And that is a fundamental, I think,
piece of data that we really need to understand.
And I was just wondering for all three of the panelists
here based on your organizations and the research that you do
to support our veterans, if you have any sense of an answer to
that sort of fundamental question in terms of health care
delivery through the VA versus community care.
Mr. Blake. I would only offer this much. I think there has
been a number of studies that have probed at the question about
cost differences and no definitive answer has ever been
delivered.
I think from the perspective of having done some of the
budget work with the Independent Budget, I think the challenge
is the VA health care system is not the private health care
system. And we have to accept that up front first, so you can't
just assume--you can't make it an apples to apples comparison
even down to cost because the nature of the system and how it
provides its services is not entirely reflective of the private
health care system.
So I don't know that we can ever get to a definitive answer
and maybe that is the challenge. Maybe we need to set that
aside as the question. Unfortunately, that is a key focus that
Congress has to be focused on because you decide how much
resources the VA is going to have to operate. And I don't envy
that position that you set in.
Ms. Brownley. Yeah. I just think, you know, intuitively
there are some services that veterans receive. I am thinking
about, you know, getting your eyes checked and getting a pair
of glasses or audiology, services like that, which seems to me
would be cheaper if that was all handled, you know, within the
community than for veterans having to travel long distances and
so forth and so on to get to their VA.
So, I mean, I think it is a hard question to try to answer
because I think it probably breaks down into a lot of different
pieces as it relates to kind of specialty care beyond primary
care. So it gets difficult.
Mr. Williams, you had mentioned some of the surveying
results that you have done with your organization, and I think
you said that 43 percent of your veterans aren't utilizing the
Choice Program because of confusion.
Did you get any results in terms of veterans not using the
program because the providers weren't there in the community
and set up with the VA to be able to provide that care at all
or--
Mr. Williams. I don't think that was part of our surveys. I
would have to get back with the IAVA leadership on the
availability of providers in the community.
Ms. Brownley. Because I think that, you know, I mean, we
hear a lot about the Choice Program and, you know, I think in
some sense about what we are talking about today and
consolidating all of these programs. I think we all agree that
consolidating these programs for community care is a good idea.
You know, this criteria for access is, you know, is up for
debate. But I think the consolidation pieces minimizing the
confusion for the veteran, I think we all agree that is
absolutely the right way to go.
I mean, some of the criticisms that I hear, I was just
talking to one of my colleagues from Florida earlier this
morning and she was bending my ear about how the Choice Program
in her district is just not working and she is hearing a lot of
complaints from her veterans about the program and access to
the program.
So I don't know where I am really going with this, but I do
hear a lot of feedback from people that are still--I know that
there is a lot of work to increase the amount of providers in
the Choice Program specifically, but I don't think that we
are--again, probably in some areas, we have the right amount of
providers and other areas, certainly in my district finding the
providers has still been a challenge.
So even if you wanted to utilize the program, even if you
were willing to do all of the research to figure it all out and
you met the criteria, in, you know, in some cases, the
providers simply just aren't there yet. And perhaps part of
that is because of the confusion.
But, you know, I would be interested to hear from the two
other gentlemen about just, and I have like two seconds left
now, but maybe we can talk about it later, you know, what the
feedback is from your members in terms of the success or
challenges within the program.
So I will yield back.
Mr. Benishek. Dr. Huelskamp, you are recognized for five
minutes.
Mr. Huelskamp. Thank you, Mr. Chairman.
I would like to follow-up on the questions from Ms.
Brownley about the provider network and see how we can--I think
Mr. Williams talked about reducing some of the administrative
burdens.
I will say in the 1st district of Kansas which I represent,
it is probably the most rural and least served district by the
VA. There are no VA hospitals, but I have 70 community
hospitals. Just got the numbers last week. We have 1,309
providers. That doesn't mean they are all happy to get into
that network. They are willing, but the administrative burden
is overwhelming.
Every one of these facilities has been certified by
Medicare for years. Now we have a separate certification
process through the VA.
Mr. Williams, you brought up in your testimony, are there
things that you can recommend that we can get the VA--could you
reduce the administrative burden so these providers are there?
They are ready and willing. They will take the Medicare
reimbursement which beats Medicaid. The Medicare, they will
take that reimbursement, but the paperwork is much, much more
intensive than anything else in the network.
So some input from Mr. Williams. Mr. Blake or Mr. Atizado
on that?
Mr. Williams. Sir, I would just have to say, and this is
pulling away from that, but I met with some of the leaders from
the Georgia Medical Association and that was one of their
concerns when it comes to the cost of physicians working in the
network with the administrative costs that it costs their
physicians because they were even concerned about reimbursement
rates for Medicare and Medicaid versus administrative
requirements.
But they brought up that that was an issue with their
participation in Choice, was the simple administrative
overhead.
Mr. Huelskamp. Yeah. Mr. Blake or Mr. Atizado?
Mr. Atizado. Mr. Huelskamp, thank you for that question.
I guess I think the first thing we need to recognize is
that the Choice Program really is a pilot program. It is a
temporary measure that was meant to address an access issue.
The administrative rules as it relates to the law that was
passed adds to that confusion.
I do understand from Ranking Member Brownley's question
that whether or not the networks are, in fact, meeting the need
is a two-way street, you know. TRIWEST and Health Net have in
my estimation tried to do a tremendous job in creating a
national network in so many months and not having the
appropriate description of demand from the VA health care
system makes that job a little bit harder.
I do believe that network is working much better now. They
are increasing appointments at an incremental rate. But the
administrative burden for providers to join any kind of network
is inherent, right? If we want providers to be of a certain
quality, they have to meet certain standards. Whether that be
Medicare, so be it.
Part of the provider agreement authority legislation that
this Subcommittee has been wrestling with is that. Who are the
providers we would want our veterans to seek care from? We can
make that as hard or as simple as possible, but that really is
a feature that is within our control.
Mr. Huelskamp. I think you raise a great point and
especially your first one about this being seen as an almost
temporary program as to deal with a problem. I will say in
rural areas, this is an ongoing problem and it didn't just
start two years ago. We drive hundreds and hundreds and
hundreds of miles and you are driving by ten hospitals to get
to the VA hospital. Then you wait in line. And that is not good
enough.
And I think we have heard from the VA as well. They see
this as temporary, a pilot program, an approach that maybe two
years from now, it might go away. I will note to the Committee,
don't forget the House bill didn't have some of these arbitrary
standards. And we had some cost concerns and I understand that.
But what is magic about 30 miles? What is magic about 30
days or 40 miles? There is not, other than you have to drive
that. And so I appreciate the input on that particularly.
Are veterans still just presuming, and maybe Mr. Williams
particularly with your survey, are they presuming this is just
a pilot program that will go away and there will be another
variation of this in the future, and does that limit their
participation or any of the three?
Mr. Blake. Well, I wouldn't say they presume it. I mean,
everybody, I think, understands that this program will sunset
either on a date certain or when the money runs out. You know,
your district is one of those ones that has always sort of
befuddled me.
It was sort of tailor made for the old fee-basis standards
which had written in regulations geographic inaccessibility.
And for the life of me, I never understood what it would take
to define it. That is what was attempted with the Choice
Program with 40 miles in particular.
Adrian mentioned an interesting point about the networks
that TRIWEST and Health Net are trying to build. The challenge
is building a demand-appropriate network. Within the construct
of the framework that we propose with DAV and VFW is the idea
that through the integrated network, which is the right way to
deliver care by and large, it needs to be distilled down to the
most local level.
Mr. O'Rourke looked at this idea in El Paso. They went out
and figured out exactly what the community was capable of,
particularly in the area of mental health, to figure out what
it would take in a partnership between VA and the community to
meet demand.
All that being said, most of our members from the PVA
perspective just don't use Choice because the networks do not
meet the demand that they have. And at the end of the day, the
private sector struggles to meet the unique needs of SCI
veterans, blinded veterans, veterans with polytrauma.
So there is a complicated circumstance that exists here
where the VA has to meet demand for principally primary care
and mental health care which are sort of the big elephants, but
you can't forget that there are many veterans who the VA is
their only and best option and how that gets right-sized with
whatever the new VCP ends up looking like.
Mr. Huelskamp. All right. Thank you, Mr. Chairman.
Mr. Benishek. Dr. Ruiz, you are recognized.
Mr. Ruiz. Thank you, Chairman Benishek, Ranking Member
Brownley, for holding this series of hearings centered on VA's
proposal to consolidate community care.
We have asked the panelists to tell us how they would
modify the eligibility standards that are necessary to create a
veteran-centered VA. But to answer these questions, you know,
we need to look at the cracks that the Choice Act has left
behind or the cracks within the Choice Act because these are
the cracks that our veterans are falling through and these are
the reason experiences of veterans in my district that do not
reflect the successes that the department boasts.
So my first question is, can you specifically identify what
are those cracks? Which of our veterans are not getting the
care through the Choice Program that it was intended to do?
Mr. Atizado. I will give you a good example, Congressman
Ruiz. Veterans need home and community-based services. The
Choice Program does not allow VA facilities or doctors no
matter how clinically appropriate it is to use Choice money to
buy home and community-based services.
In fact, only home and community-based services as we all
know is a cheaper alternative to institutional care, less
expensive, more veteran-centric. It is skilled nursing care.
That is it. Out of all the home and community-based services
that veterans can receive that VA can provide under existing
law, that is it.
Mr. Ruiz. How about you, Mr. Blake?
Mr. Blake. Well, I would say that the Choice Program is
simply not built to meet the specialized health care needs of
veterans like SCI and D, substance abuse, polytrauma, and TBI,
blinded veterans.
I think that wide spectrum of unique populations of
veterans that the VA serves, I don't think the Choice Program
is designed to serve because they might be able to go outside
the system, only in a perfect world might it work, where full
integration with the community so that it is seamless, but that
might be a dream.
Mr. Ruiz. I think one of the problems with the eligibility
criteria of a 40-mile distance is that you can have a VA clinic
that does not offer the specialty care that our veterans need.
For example, in my community, we have a clinic in Palm
Desert in the center of the Coachella Valley, but it does not
have a pain specialist working at that clinic, does not have,
for example, a dentist or other specialty kind of care. So our
veterans still have to travel an hour, hour and a half to the
VA hospital to get that kind of specialty care.
So when you talk about clinically appropriate eligibility,
is that what you mean, like making sure that what they need in
terms of the specialty care, they can acquire if it is not
within the 40-mile distance?
Mr. Atizado. Congressman Ruiz, what we mean by clinically-
based decisions is when veterans get to access the community
care network. The way the plan is and even the Choice plan as
it stands, it really requires veterans to, one, enroll in the
VA health care system and then, two, be eligible for the Choice
Program or even this new Choice Program. So it is really two
separate eligibility criteria to begin with.
Mr. Ruiz. Yeah. I think that we need to take pause and
throw out a big caution out there. Many of our veterans are
working poor, are retired, or work in rural areas. And we are
working under the assumption that in those communities for some
reason, those services exist.
I come from an area that has both affluent and under-served
communities. And I can tell you that in the under-served
communities, you don't have specialists. You don't have
community homes. You don't have any of the care that we are
assuming that veterans can achieve outside of the VA.
So I think that we have to really identify and not think
that because we have the Choice Program because veterans can go
to their neighborhood doctor that they are going to get the
care that they need. We need to take into account the
insufficiencies and the lack of resources and the vast majority
of America that live in rural communities as well.
Hotline, tell me about the hotline and what evidence is out
there that it actually saves money and also incentivizes
patients to use the VA?
Mr. Blake. Well, I think there is a reference in my
testimony what they have done through TRICARE shows that it is
certainly a workable solution. That is not to say that TRICARE
is the model of perfection in this case. But I think what we
are trying to do is ensure that veterans are making the right
decisions when it comes to emergency care and urgent care.
I think we all believe that urgent care is a must. It is
something the VA has not really ever done and, unfortunately, I
think you have seen in the community in private sector now, a
lot of health care is delivered through an urgent care setting.
And so it is probably time for the VA to get involved in that
because that alleviates the pressure on primary care. In the
health care setting in VA, it relieves the pressure potentially
on the mental health care which is--
Mr. Ruiz. Right.
Mr. Blake [continued]. --a big part of it.
Mr. Ruiz. Urgent care was a result of a failed primary care
system where people weren't able to access their primary care
so they needed a quick in and out type of thing. But it can't
replace primary care because when we are talking about a
medical home, a place where a patient can get integrated care
with case management that can really take care of the entirety
of the patient, urgent care doesn't necessarily provide that as
we think of them now.
So there are some benefits to urgent care, but we also have
to make sure that the veterans also get home-based
comprehensive primary care that they deserve.
Mr. Atizado. I agree with you, Congressman Ruiz. Yes,
primary care is integral in coordination with care, but primary
care is not all.
Mr. Ruiz. Correct.
Mr. Atizado. And it never will be all. And you are right.
Urgent care has a place. There is an appropriate setting for
seeking care in that. And we don't think veterans should be
penalized because that is the appropriate setting for care.
Mr. Blake. And I wasn't suggesting that urgent care is the
solution. I mean, what we find now is a lot of veterans go to
the emergency room. That would be true in the private sector
except now you have urgent care everywhere, so the solution in
the community has become everybody goes to urgent care.
Veterans don't even have that option so they just overrun the
emergency care setting in the VA while the primary care system
just sort of lumbers along because it is overwhelmed as well.
Mr. Ruiz. Well, my time is up, but I wanted to say that the
veterans that I take care of in the emergency department and
the veterans that I take care of in the office who are
struggling with their benefits, who are struggling to make ends
meet, who are struggling to get back on their feet, who are
struggling to find a home that are homeless, $50 co-pay for
urgent care, $100 in co-pay for the emergency department is
completely a barrier that will continue the burden of illness
and disease that they already have. So I agree with that.
Mr. Benishek. Thank you.
Dr. Abraham, you are recognized for five minutes.
Mr. Abraham. Thank you, Mr. Chairman, Ms. Brownley, for
having this hearing.
Thanks to the witnesses. Appreciate your very direct
testimony.
And like Dr. Benishek and Dr. Ruiz, I come from a private
setting, so looking at it from the outside in, so to speak,
this should be such a simple solution, but evidently it is
being muddled up and the water is being muddled by bureaucracy.
I made some notes and I will go down them very quickly.
Again, it should seem simple. I know that the VA and we as
Congress have to watch the purse, but I am afraid we and the
VA, especially on cost, is looking through the soda straw and
not the overall picture simply because we in the medical field
know that if that patient comes back and back and back for a
problem that is not being addressed or not being fixed, costs
just incrementally increase.
And if the VA is unable to give us a cost per patient, then
I wouldn't bet the house that they could give us how many times
that veteran is having to come back because that issue was not
resolved. And that just adds exponentially to the cost.
So I am going to paraphrase, and please correct me if I
misstate what I perceive that you told us in testimony, that
the way to streamline and fix this issue is again simple. Once
in, you are in. That should be fairly simple.
I like the nurse assistant line. I know that does work in
the private sector. I know it worked in my clinic, saving
patients going to the emergency room. We had a nurse on call
and countless of thousands of dollars I am sure were saved from
either waiting until tomorrow, treating that patient over the
phone, going to a not emergent facility as opposed to an ER.
Mr. Blake, you said that no co-pay is a good thing and I
would tend to agree with that. I will tell you that.
Mr. Williams, you said there is still a lot of confusion in
Choice. I think that goes back to both the fault of the VA and
the Congress. We should have done a better job of putting it
out there with bullet points and making it, you know, a one-
pager. It should not be that hard to explain this program. It
should not be.
Also, Mr. Williams, you said in your VISN that the VA added
significant more employees and you saw wait times come down. Do
we know or can we extrapolate that that actually improved care,
or did it just eliminate wait times? I know it is a theoretical
question, but just give me a gut feeling. What do you think?
Mr. Williams. Congressman, it was absolutely important to
hire those employees to cut the wait times.
Mr. Abraham. And, again, I know, but do you think by
cutting the wait, and, again, I am just asking an opinion, in a
non-emergent setting, does cutting the wait time improve the
quality of care that that veteran gets? I am assuming it does,
but I am asking you. You have talked to your veterans. Do they
perceive that as being an improvement of quality of care?
Mr. Williams. In Georgia, the access to care is critical
and access in a lot of our veterans' minds is interpreted as
quality.
Mr. Abraham. Okay. And I think one of you guys made a
statement or maybe somebody on this panel about another issue
is paying our providers, non-VA providers appropriately enough
money to come into the system. And I can tell you it is still a
very big problem.
In my VISN 16, we have arrears of the VA system to our
ambulance services, to our providers in the millions of
dollars. So you are spot on there. It is a big problem. And
that, again, I will put that on the VA explicitly for not
paying their claims.
So anything else? The no co-pays, the once in, all in, the
increased--I am just looking for simple solutions to what
should be a simple problem here.
Mr. Blake. Mr. Abraham, I want to go back to something you
said at the beginning about escalating costs and I am using
this to piggyback on comments that Ms. Brownley made at the
beginning.
We have been advocating for travel reimbursement for, while
it is a non-service-connected population, it is
catastrophically-disabled veterans, and usually we get folks
who balk at the idea that we recommend that for non-service-
connected disabled veterans.
But they are already granted higher priority in the VA
system because of the nature of their disabilities and the
ability of the VA to meet their demands for health care when
the private sector struggles with that challenge.
And one of the reasons we have advocated for the
beneficiary travel issue is because what we have seen in our
membership is those folks who are non-service-connected will
choose not to go to the VA and wait as long as possible because
it is costly for somebody with a catastrophic disability to fly
long distances, drive long distances, or whatever it may be to
go seek that care.
And the long-term cost to the VA when they finally show up,
because they will show up and the VA is obligated by priority
to care for them, will be substantially higher. So we would
hope you would take a look at that as an issue, because it is a
unique population that the VA serves because, yes, they are
non-service-connected, but they have some of the most profound
disabilities that VA serves.
And that is the reason they go to the VA and yet the VA,
many times, they are bearing a higher cost burden than they
should have to because the veterans are disincentivized to get
that care as soon as possible.
Mr. Abraham. Thank you.
I am out of time, Mr. Chairman. Thank you so much.
Mr. Benishek. Thank you.
Mr. Bilirakis, you are recognized.
Mr. Bilirakis. Thank you so very much. I appreciate it.
Thanks to the panel as well.
Let me ask you a question on dental care. I know it is very
limited as far as eligibility for veterans, but are veterans
receiving dental care, let's say in the community if no one is
available within the 40-mile range or the 30 days? I mean, what
is going on with that?
Mr. Atizado. I couldn't really tell you, Mr. Bilirakis.
That is actually a very good question. I believe the
eligibility for dental care as strict as it is already, getting
it in the community is par for the course for VA when you are
eligible for dental care.
But, you know, that question really goes to a much larger
issue which is, as good as VA's plan is as a first step towards
creating an integrated community health care system that is
integrated in the VA health care system, it is a good first
step.
The issue is it is not comprehensive enough. In other
words, the authorities that the VA looked at to create its plan
is not all its purchase care authorities. It is some of it.
And those other parts that is not included in this plan
which could very well not be included in the solution or the
next iteration of Choice, as I mentioned in our testimony, if
you carry that forward, you will still have fragmented care,
whether that be dental care or home and community-based
services or specialty care. There are other purchase care
authorities that VA has and uses that is not part of this plan.
Mr. Bilirakis. If you, in a perfect world with regard to
the specialty care, if we wanted to open it up to the community
for the veteran to have the ultimate choice, even if he lives
within the 30-mile range, what have you, or she, what specialty
would you recommend where the veteran would have direct access
to community care? Can you give me a couple specialties?
Mr. Blake. I don't think you can cherry pick and say, well,
we are just going to let this group of veterans with this
unique need have this option. That is probably--
Mr. Bilirakis. Well, where is it they are having the most
trouble accessing care in that specialty area?
Mr. Atizado. Well, a good example would be if you were in
the high plains, cardiologists. Here in D.C., a dermatologist.
It really depends on what is available in the community.
Mr. Bilirakis. Okay. So it depends on--
Mr. Atizado. And it can vary widely. The Merritt Hawkins
survey, that kind of shows that actually.
Mr. Blake. I think that is why you can't just sort of apply
a national fixed standard to it. When I mentioned earlier in my
comments as they flesh out the details of an integrated
network, you can't just sort of lay a national standard on it
and say this is what the network should look like. I think that
is probably the challenge that TRIWEST and Health Net are
experiencing now.
It has to be distilled down to the lowest level possible.
That is the idea I think that Mr. O'Rourke was trying to get at
with what he was looking at in El Paso because you have to
understand every individual city, every individual town, the
rural counties across America, everything is going to be
different.
So you can't just say, well, we are going to grant all
these folks who maybe have a cardiology need, you know, access
and nobody else when some veterans might be perfectly served by
the VA and some not in that little cohort alone.
Mr. Bilirakis. Okay. So, in other words, we would specify
based on the area, the region in the country where there is a
lack of maybe care, access to care in that particular region.
All right. Let me go on to the next question. VA's
consolidation plan addresses eligibility for community care,
but not eligibility for enrollment in the VA health care system
in the first place.
So the question is, do you think that a review of VA's
overall eligibility and enrollment is needed at this time, and
would you support such an effort? And that is for the panel.
Mr. Blake. Well, Mr. Bilirakis, I would point you to the
concluding part of my written statement which suggests that
perhaps it is time to consider whether veterans should just be
eligible to enroll in the VA health care system.
The vision of the Affordable Care Act which I hasten to
mention because that brings up all kinds of political
ramifications is to expand access to care for people in
general. And we fought when the law was being written for the
Affordable Care Act to ensure that VA was deemed credible
coverage under that law.
And the law says VA is deemed acceptable coverage under the
strictures of the Affordable Care Act and yet there is a large
group of people, particularly in the priority group 8 arena who
are denied even accessing that. So why would you deny them an
option for health care and say, well, you can only go over here
under the rules of the Affordable Care Act, but under the rules
as set for VA, you can't actually come into the system?
So we think maybe it is worth considering whether there is
this fear that if you just sort of open enrollment, sort of if
you build it, they will come, that it will flood the VA system,
but history has never proven that to be the case. When VA's
system was open, veterans didn't flood the system. Even then,
fully two thirds of all veterans chose not to enroll in the VA.
So I think it is sort of a scaring assumption that, oh, all
these veterans would enroll, which would increase utilization.
It might, it might not. And I mean it is high risk, but there
is a potential high reward from allowing veterans to access the
benefits of VA health care.
Mr. Bilirakis. Thank you very much, I appreciate it.
I am out of time, Mr. Chairman. I yield back.
Mr. Benishek. Mr. Coffman, you are recognized for five
minutes.
Mr. Coffman. Thank you, Mr. Chairman.
Are there--and I will ask every panelist--are there any
types of health care services that should be eligible for
Choice without regards to any time or geographic requirements?
And the reason why I mention this is because obviously
mental health has become such a big issue for our veterans, and
we have had testimony before to this Committee about VA's
mental health being at times drug-centric in its treatment. And
so to me, having had veterans commit suicide in my district and
meet with those families and try and trace it back, when it
becomes evident that they couldn't navigate the bureaucracy to
be able to get an appointment in time to save their lives. And
so wouldn't it make sense to allow veterans to see who they
feel more comfortable with, see who they want, when they want,
in terms of access to mental health care, as an example, and
are there other examples?
Whoever wants to start with that.
Mr. Williams. Congressman, I will say this from the
perspective of with my sisters and my late wife being Marines.
My wife was adamant after one visit to the VA that she would
never, ever go back in after having walked through a gauntlet
of men. And it brought up something I did not know about what
had happened when she had first joined the military. I don't
think we should make women have to go through a gauntlet
because I think it also discourages some of those who need the
health care from getting it because they just don't want to
walk through a gauntlet of men.
Mr. Coffman. Okay. Mr. Blake?
Mr. Blake. I would answer the question in this way. I would
throw out the concept of choice all together for a second. If
you had a fully integrated health care network, which is a
division, I think that the VA has even though this is billed as
just for community care, the way the health care network should
work is a fully integrated health care network, and you have
the patient-provider relationship within the construct of that
network. The veteran goes to their provider, that veteran and
that provider, which is the way in the private sector it also
works, decide what is best for that veteran. Should I be seen
at the VA? Should I be seen in the community? What is available
now, what is available later? What services do I need?
So the question of choice is sort of a false question.
Mr. Coffman. Well, I don't know if it is a false question
to the veteran. Let me phrase it this way. Who should make the
decision? Should it be the veteran making the decision or
should it be a bureaucrat making the decision in terms of
access to mental health care?
Yes?
Mr. Atizado. Mr. Coffman, so this shared decision is really
what we are talking about. When a veteran meets their primary
care provider, hopefully it's a VA primary care provider, that
discussion should go something like this. Well, it looks like,
sir, that you have this condition, here are your options. I
prefer as a provider you go down this route, but these are
options of therapies that you can use to deal with this issue.
Well, that is great, Doctor. I tell you what, I would rather go
this route, I would rather take this option. Where can I get
that care?
That is the kind of decision-making we are talking about.
The network should be responsive to that--
Mr. Coffman. Well, let's take a step back here.
Mr. Atizado. Sure.
Mr. Coffman. Who are you going to empower to make the
decision? This is my question. We are not bureaucrats here, we
are veterans. I assume everybody here is a veteran. Who makes
the decision? Does the veteran make the decision in terms of
their own mental health care or are you saying that it is a
shared decision between a VA employee and the veteran?
Mr. Atizado. Okay, let me give you a straight answer. There
is no one.
Mr. Coffman. Well, that is the problem.
Mr. Atizado. It really depends on--
Mr. Coffman. These veterans that I have in my district that
committed suicide, they couldn't navigate this system. So let
me ask everybody one more time. As a veteran--now, what branch
were you in?
Mr. Atizado. I was in the Navy, sir.
Mr. Coffman. Branch?
Mr. Blake. Army.
Mr. Coffman. Branch? Navy or Army?
Yes or no, should veterans make the choice of their mental
health care irrespective of the Choice Act? What is your
position?
Mr. Atizado. If they are capable in making that kind of a
decision, yes.
Mr. Coffman. Okay, great.
Mr. Blake. It should be an informed choice.
Mr. Williams. The veteran.
Mr. Coffman. Thank you.
Mr. Chairman, I yield back.
Mr. Benishek. Dr. Wenstrup, you are recognized for five
minutes.
Mr. Wenstrup. Thank you, Dr. Benishek.
I appreciate you all being here today. You know, my
concern, I think everyone's concern here is that the veteran
get care. And I think we get hung up on a little bit of optics.
As someone coming from private practice, I guarantee you every
member of my 26-doctor group would have been glad within our
practice to have a sign up front that said we are VA providers
and have the VA logo there. We just don't happen to practice
within the walls of the VA and in part because it is a mess to
deal with from the bureaucracy, and you can't be productive in
the way that you can in private practice for a variety of
reasons and we won't go into that.
But even recently in hearing, you know, VA officials were
saying, oh, we are seeing more patients than ever before. That
is because they increased the number of doctors and expanded
their hours, but they didn't get more productive. And when you
are in private practice, you have got to maintain the quality
if you want people to keep coming to you. That doesn't exist in
the VA, although I think we have some great providers. So I am
not knocking them, but the system makes it very difficult to be
productive.
So I am going to ask you, do you think there is an optical
problem? And I don't like when we keep saying non-VA providers
and I think we should just say that they are VA providers. They
just happen to be outside the wall of the VA. And in that case
you give people a choice on where they want to go.
And when you talk about lack of specialities in different
areas, well, that exists for everybody and people make a choice
on where they live. Some people move close to a hospital
because they have a heart problem. I mean, those are choices
people have and we can't expect the VA, just because you are a
veteran, have every speciality follow you around wherever you
happen to live. So people have to make choices like that,
whether they are veterans or not, that is just the reality of
things.
So my first question is, should we stop calling these
providers non-VA providers like they have got some stigma? And
do you think that veterans really really feel that they have to
be within those walls to get proper care?
Mr. Atizado. Congressman Wenstrup, the idea that calling
private providers non-VA providers is a little bit of a
misnomer. That really talks to not the quality of care that
private providers are able to provide, it doesn't talk about
their--what it really talks about is the kind of care VA
provides.
VA is a health care system unlike any other health care
system in this country. Its dependencies stretch beyond the
walls of a hospital or a CBOC. It has to work with VBA, NCA,
IHS, rural community health centers. It is part of a social
support ecosystem.
Mr. Wenstrup. But there would still be that link.
Mr. Atizado. I understand there should be that link. So
whether you call it a VA provider or not, the recognition has
to be that the VA provides a different kind of care, that it
has different responsibilities. It has a teaching mission, it
has a research mission, it has all sorts of--
Mr. Wenstrup. You know what? that veteran who is sick
doesn't care. They want to be seen and they want to be taken
care of. They are not saying, oh, you do research here? They
don't care about that. It is about getting the veteran taken
care of.
And so anyway, I am just going to move on from there
because I want to make a point of something that we have
discovered through this Committee when there was a study done.
And you talk about costs and we have got to be concerned about
costs, but a well visit to an average primary care doctor is
about $85. Pay the copay if they want to go outside the VA.
Guess what we discovered it costs? Because, see, no one in the
VA talks about what it costs for your physical plant, your
insurance, your supplies, your staff, your administration, they
don't even know what that is until this study was done. It is
about four to $600 per patient visit to go to the VA. We can't
do that forever and it doesn't make any sense.
When you send someone outside the VA and if they want to go
there, if they want to go there it may be $85 and the VA is not
picking up all the malpractice and everything else and I think
we have got to consider that. And I want the veterans to have a
choice, but as a provider, you know, I would say, hey, I am a
provider for Blue Cross/Blue Shield, United Healthcare, the VA,
whatever, I am a VA doc.
And I think we have got to break that stigma and really
look at what we are doing, so the patients do have a choice
between going to the VA, going outside it if that is their
preference, but really, start to look at the dollars and cents
of what is taking place within the VA where it costs way too
much to see a patient.
And I yield back.
Mr. Benishek. Thank you, Dr. Wenstrup.
Does anyone else have a question for the panel?
I really appreciate all of you coming here to testify and I
really welcome your input as this process goes forward to feel
free to come before any of us with further ideas as we explore
how to make this better. So I really appreciate that and you
are hereby excused from the panel.
Thank you.
Joining us on the second panel from the Department of
Veterans Affairs is Dr. Baligh--and I am struggling with your
name, sorry, Doc--Yehia, the Assistant Deputy Under Secretary
for Health for Community Care, and he is accompanied by Kristin
Cunningham, the Director of Business Policy for the VA's Chief
Business Office. Thank you both for being here.
Dr. Yehia, you may begin when you are ready.
STATEMENT OF BALIGH YEHIA, M.D.
Dr. Yehia. Thank you. Good morning, Chairman Benishek,
Ranking Member Brownley, and Members of the Subcommittee. Thank
you for the opportunity to testify today regarding the
Department's plan to consolidate community care programs,
specifically streamlining eligibility criteria.
I am accompanied today by Kristin Cunningham, who is the
Director of Business Policy.
I want to acknowledge our VSO partners, we have been
working with them hand-in-hand since we started this process,
and also your comments, Mr. Chairman, on the need to get to one
system that works for veterans. And I am looking forward to
discussing a little bit more about those clinical criteria that
were mentioned.
This plan aims to clarify eligibility criteria, build on
existing infrastructure to develop a high-performing network,
streamline clinical and administrative processes, and implement
a continuum of care coordination services.
These actions will improve access to care, expand and
strengthen our relationship with community providers, allow us
to operate more efficiently, and improve the veteran
experience.
As you know, VA is taking part in an enterprise-wide
transformation called MyVA. MyVA will modernize VA's culture,
processes and capabilities to put the needs of veterans and
their family members first.
Just a few weeks ago Secretary McDonald highlighted the
department's 12 breakthrough priorities, all of which are
designed to improve the delivery of timely care and benefits to
veterans. One of those priorities is to improve community care.
Community care has been and will always be a vital part of
VA health care for veterans. In 2015, VA issued authorizations
that resulted in about 12 million community care appointments
and that is compared to 8.8 million in 2013, representing an
increase of about 36 percent. Even though we have been
providing more community care, we are eager to seize the
opportunity to improve the experience for veterans, community
providers and our employees. However, we need help from
Congress to consolidate the complex and varied eligibility
criteria for community care into a single set of standards. By
doing this, veterans will have a clear understanding of their
eligibility for community care and VA community providers will
have a significantly lower administrative burden.
The eligibility criteria outlined in the plan aim to
increase access to timely care and patient choice while being
mindful of taxpayer dollars. The plan gives veterans a choice
to access some or all of their health care in the community if
they meet one of the following criteria that is related to
access, geographic distance and availability of service.
A veteran would meet the access criteria if they are unable
to schedule an appointment within VA's wait-time goals for
providing that service or within the clinically necessary
timeframe indicated by their provider.
In terms of geographic distance, a veteran may receive
community care if they are 40 miles or further driving distance
from the primary care provider or they face an excessive burden
in accessing a VA facility.
Lastly, a veteran may access community care if the VA does
not provide the service or if there is a compelling reason why
the veteran needs to receive community care.
By implementing a single set of eligibility criteria,
veterans will have a clear understanding of their community
care benefit. However, built into these criteria is a
flexibility that I and my fellow clinicians at VA need to
respond to unique circumstances. This is critically important
to ensure that we meet the needs of individual veterans.
The plan also addresses the challenges that many veterans
face today when seeking emergency room care within the
community. Due to complex laws and processes for veterans, VA
is many times forced to deny a significant number of emergency
treatment claims, leaving some veterans to shoulder that
financial burden. By tackling these pain points, we anticipate
that it will improve reimbursement of emergency room claims and
reduce the need for manual review of every claim.
In addition, the plan asks for congressional authority to
offer urgent care services in the community. This action will
increase access to care and reduce the number of emergency room
visits.
We are eager to move forward and we are open to any ideas
that veterans, Congress, veterans' service organizations, and
other stakeholders may have. We recognize this must be a
collaborative effort and need Congress to provide necessary
legislative changes and support moving forward to consolidate
care, including the enactment of provider agreements and
flexibility in funding for community care.
I appreciate the opportunity to appear before you today and
I am prepared to answer any questions that you and other
Members of the Subcommittee have.
[The prepared statement of Baligh Yehia, M.D. appears in
the Appendix]
Mr. Benishek. Thank you, Doctor. I will yield myself five
minutes for questions.
So can you go into a little bit more detail about one of
the big problems that we have of course is this emergency
reimbursement issue. And, I mean, that happens all the time
where a veteran goes to an urgent care clinic or the ER and the
local hospital and then tries to get that approved and that is
a pretty good example, I think.
So how specifically are you going to fix that problem?
Dr. Yehia. Thank you for that question.
We knew when we started this work we have to tackle the
emergency room benefit. We have talked with a lot of veterans,
we received a lot of letters, as I am sure you have and others,
about the challenges that many of them face when accessing
community care as it relates to the ER benefit. And the biggest
challenge is that they don't know if VA is going to end up
paying for that care and I think that creates a perverse
incentive many times to delay that care, and they feel they
have to drive to a VA to be seen and part of that is the way
that the laws and regulations have been written over time. We
can't provide that clarity that we need.
And so what we are hoping to do in the plan is to
streamline that. We are using principles based on industry, so
a lot of the things that we talk about in the plan of
consistently applying what is called the prudent layperson
definition of ER, the idea of copayments to make sure that we
incentivize the right health behaviors. Those all came from
TRICARE, from health plans, they are standard and common
practice in many health systems.
And then by doing that, we hope to minimize by a
significant amount denied claims and kind of empower our
patients and the veterans so they know that when they access
the ER care in the community, that VA is going to be picking up
the bill and they won't be shouldering that financial burden.
Mr. Benishek. I understand your thoughts, but specifically
how are you going to get the VA to be assured that they are
going to be paid? Is there going to be a central number to
call? I mean, your goal is, you want to make it right, but the
reality of it is, it is not right now and you didn't tell me
anything specifically that is going to make it right, from what
I could understand.
Dr. Yehia. Well, let me clarify it.
So in our plan and to the Committee we have also provided
some technical assistance that has specific legislative
language to make it right. Right now when it comes to ER under
our current authorities, we are the primary payer when it is
service-connected care, we are the payer of last resort when it
is non-service-connected care. And then there is a whole bunch
of criteria that are outlined in rules and regulation where if
someone passes a VA or--
Mr. Benishek. The question is, so is there somewhere in
your plan that will allow a veteran to make a single phone call
and find out? I mean, it doesn't sound like you have said
anything that allows that uncertainty to go away.
Dr. Yehia. Well, yes. I think the first step is we have to
actually consolidate and fix the problem, and once we fix it
and it requires congressional action, then we communicate and
make sure that folks understand.
Mr. Benishek. I am not sure that requires congressional
action, I think it may be more of a bureaucratic solution.
I want to discuss this, one of the things you said in your
statement, the distance and then how do you define unusual or
excessive burden that may necessitate community care? Because
that is a vague criterion. Can you tell me about that?
Ms. Cunningham. Sir, I will help Dr. Yehia with that.
In our current Choice law, the additional enhancements that
were given to us in the May law, we were able to define the
unusual or excessive burden. We implemented three of those
provisions in June. The last provision required us to further
define in regulation, we did that in the beginning of December
and then rolled that out to our facilities.
And we looked at that providing either the ability for
clinicians to make a medical determination that the person's
condition required them to get care closer to their home or we
identified things that were just the nature of simplicity or
the frequency of the services.
So earlier during the VSO testimony, there was some
discussion of getting, for instance, eye exams or audiology
exams in the community because they are simple in nature. And
those are actually some of the examples that we use when we
talk about the simplistic nature of the type of service and
being able to get that care under the unusual-or-excessive-
burden provision.
Mr. Benishek. All right, thank you. I am out of time.
Ms. Brownley, you are recognized.
Ms. Brownley. Thank you, Mr. Chairman, and I thank the
panelists for being here.
Just a very direct question, if you could just give me the
rationale the VA has for imposing the copay of $100?
Dr. Yehia. The copayment of $100 is meant to make sure that
we provide care in the right venue. Many of our ERs are clogged
up today and there is long wait times when folks go to the ER,
and part of the problem is that a lot of non-emergent care is
being driven to the ER.
And increased access to urgent care, which is what we are
proposing in our plan, a robust primary care health care
system, those are all kind of tools in the toolbox to ensure
that folks use the right setting. So the idea of the copayment
here is to make sure that folks are able to seek the right care
setting when they receive their care.
Ms. Brownley. Did you evaluate other ways in which to
accomplish the goal that you are describing?
Dr. Yehia. Yes. And so I think I view this as more of like
a suite of packages. When we look at kind of the data that is
out there on how to make sure that we appropriately use ER
care, some of the things that come up is, if you have readily
access to primary care. So there are initiatives that are going
on at VA today that are working more on providing increased
access to same-day primary care.
Urgent care, which is something that we propose in the plan
as another option if you have, you know, the sniffles, you need
a shot, you can go to urgent care as in the ER.
I think the nurse hotline that was suggested by the VSO
partners is another tool that many health plans including
TRICARE use.
All of those things are tools in the toolbox. I don't think
they are meant to replace one or the other. They are actually
supposed to be kind of supplemental, so at the end of the day
we make sure that folks are using the right setting.
In the future, as we kind of build this high-performing
network, one of the other things that we really hope to do is
focus on what is called super-utilizers and this came up a
little bit earlier, those folks that are constantly going to
the ER. There is a reason why they are doing that. Sometimes
they don't have the right case management or they need other
support, or need to be connected with certain services. And
robust health plans and high-functioning organizations are able
to identify who those folks are and provide services that they
need.
So I think at the end of the day copayments, as I said, is
just one tool that we hope to use to make sure that folks
access care in the right setting.
Ms. Brownley. Well, it just sounds to me that we have--you
have mentioned a couple of tools in the toolbox and so it seems
to me that we should try to utilize those tools first before we
use a more punitive tool of a $100 copay, but I am sure we will
be talking more about that as time moves forward.
So you had mentioned appointments and community care have
grown over the last couple of years and you talked about 12
million appointments within the community care. So what does
that compare to, what is the amount of appointments that the VA
has provided over the same period of time? Is this a ten-
percent number of overall appointments?
Dr. Yehia. Yeah, I actually don't have that number off the
top of my head, but I can take it for the record.
Ms. Brownley. And in terms of the 30-day wait and the 40-
mile driving distance rule, is the VA trying to look at other
approaches on that? Have you decided for cost purposes that
this has to be a hard-and-fast rule?
And I think we are trying to drill down on what the costs
are. I mean, Dr. Wenstrup talked about, you know, and cited
examples where it might be a lot cheaper in the community to
receive services.
So if you could address some of that, please.
Dr. Yehia. Sure.
So I think an important point to keep in mind is we are
kind of considering this as an entire health care system, so
the VA and community care and I view them as two sides of the
same coin.
The criteria that are set that relate to access, wait time
and availability of service are really meant to serve as the
floor. So we heard a lot of comments about clinical criteria.
Embedded into each of those, as I tried to highlight in my
opening statement, are decisions that the doctor and the
patient together in the office can make. But the challenge with
just keeping something very local is we won't be able to
explain to our veterans, can I access community care? The
answer would be, well, you have to talk to your doctor. And I
don't think that is good enough.
I think what we wanted to do is to provide at least some
clarity and transparency and those are based on when you can't
see a primary care doctor or they live far away from you, 40
miles driving distance, then you have the choice to access
care. There might be criteria above and beyond that, that we
described a little bit in terms of unusual and excessive burden
that in the office people can use to decide, but at least they
know at minimum that they can access to community care if they
hit that standard. The same thing goes with wait time and the
same thing goes with availability of service.
So I think the concept here is to make sure there is a
level of transparency to what people's benefit is. If it is
completely left up to be in the office, then I think we are
left a little bit of where we are today, and before Choice,
where people don't really know what are the criteria that they
have to access community care.
Ms. Brownley. I have exceeded my time. I yield back.
Mr. Benishek. Dr. Wenstrup, you are recognized.
Mr. Wenstrup. Thank you, Mr. Chairman.
Doctor, I appreciate your approach to this and I think you
are trying to find the best practices and you are keeping the
veteran and the patient in mind as much as anything else, and
to have that continuity of care.
And I will go back and I am speaking from my personal
experience as a practitioner and from those that I know are
still out there every day that want to take care of veterans in
their private practice or some that give one day a week to go
to the VA. Their frustration at the VA is, you know, I spent
all day and I operated on two people, if they had been part of
my system here, I could have operated on eight veterans today
and with the same results.
So I think you get that and understand where we are going.
And I think you are headed in the direction where you see that
the VA has to make those types of changes too, and try to get
it to be more of a balanced type of system and not so
drastically different from one another.
Can you comment on any efforts in that direction?
Dr. Yehia. Yeah, I really appreciate that.
I think when we started kind of this work and part of the
reason how we built this high-performing network is really
putting at the center our partners, especially like DoD, our
Federal partners and academics, because I practiced both at the
VA and across the street in an academic facility and I have
experienced similar things. And so the concept here is how do
we make sure that we are good partners for our community
providers. There was a number of comments earlier about that. I
think the more consistent we can be and similar in areas to the
private sector the better.
I think there was a few comments about the different
paperwork that our community providers have to fill out to
partner with us, for that paperwork burden to be exactly the
same as it takes for them to sign up with a United or a Humana
or someone else.
So I think our intention and our goal in the plan is to
move as much as possible to what the industry does so that we
don't put any excess burdens on community providers and for
that matter our employees to operate differently.
The thing that gives me a little bit of pause is, once we
start getting off on these one-offs and things like that, we
create complexity and we lose that. And so that is something
that we are trying to push forward as being respectful of the
differences, but at the same time really pushing towards that
industry standard.
Mr. Wenstrup. And to that point, one of the complaints that
I hear is, well, I am seeing patients now but, you know, I am
waiting forever for pay.
Dr. Yehia. Yes.
Mr. Wenstrup. Whether it is hospital systems or private
practice and that is very frustrating. And there is people that
do this all the time and maybe they should be doing it and not
within the walls of the VA, taking care of those claims, it
might be more efficient and better. I don't know if you have
any comments on that.
Dr. Yehia. I do have comments on that. And I am looking
forward to the next hearing that discusses specifically prompt
paying claims, because I am on the phone all the time with
health systems that are frustrated with Choice. I think, you
know, in the short amount of time that we have to stand up this
program ourselves and our contracting partners, I think have
done a good job, but we are not where we need to be.
I think your comment about claims, it actually just so
happens that today we released our first draft statement of
work for what will be a new contract to support kind of this
high-performing network and we are seeking input from industry
on that. Part of that statement of work includes processing
claims.
And so I am happy to share that with you, I shared it with
the Committee Members--or Committee staff earlier this morning,
but I think you might be interested in looking at some of
those.
Mr. Wenstrup. No, I appreciate it. And I think that the
more that you approach those difficulties, if you will, the
more you will see excellent providers in the community taking
care of veterans and they want to anyway, and I think that that
will be a win-win for everybody. So thank you.
I yield back.
Mr. Benishek. Thanks.
Mr. Takano, you are recognized.
Mr. Takano. Yes. Thank you, Mr. Chairman.
Dr. Yehia, as you streamline the eligibility requirements
for the various care in the community pathways, what impact do
you think it will have on the number of veterans who get their
care in the community? Do you have any idea of how many more
veterans will be seen through this new Veterans Choice Program?
Dr. Yehia. So I will start and I will ask Kristin to jump
in.
We have been seeing more and more unique veterans using
community care over the last couple years. The numbers that I
just received recently were in the last fiscal year, we had
about a million and a half veterans, unique veterans that at
some point accessed community care. That is about a third of
our veteran population is receiving some of their care outside
of VA's walls. And that really gets to this whole concept of
this integrated health care system that is both internal VA
care and kind of community care.
We think that as we improve the program, including
streamlining eligibility, making sure that it is clear we have
a good network that includes the best performers in the private
sector that more people will use it. And when we articulate the
costs of the program, we think that increased demand will come
as the product is better, which will also increase the costs in
some ways.
So I think that the--I don't have like a crystal ball of
the exact number, but I think--
Mr. Takano. Of course not.
Dr. Yehia [continued]. --the idea is, as we make it better
and simpler and easier to use, more people will use it.
Mr. Takano. Well, you kind of alluded to what I wanted to
get to know is, do you have a ballpark projection of the
overall estimated costs of the program to be, you know, as you
kind of rough out this number, aside from the 1.5 billion for
emergency treatment? It is going to be helpful for us to kind
of know this.
Dr. Yehia. Yes, and I can't agree more.
So in our plan that we submitted, there is a section
specifically on costs. We think that increased demand will be
in the order of about $2 billion annually for the program. That
includes a lot of the kind of eligibility criteria that
Congress helped us out with over the course of the last year as
we kind of continued to iterate and improve the program, kind
of removing the enrollment date, some things about changing
from a primary care provider to a primary care physician. So
there has been a number of different things that have been
passed over the last couple months that expand eligibility.
But roughly speaking, I think with the eligibility criteria
that we are proposing in the plan, it would be about $2 billion
on top of the Care in the Community budget.
Mr. Takano. On top of the, what was it we approved, like
ten--
Dr. Yehia. Yes, about--
Mr. Takano [continued]. --$12 billion? And we thought we
would have it used up by now, but we have seen a number of
impediments to actually spending down that money and we thought
we would have to be appropriating more.
How many different appropriation accounts affects non-VA
care would you say? I mean, my question is really, you know,
how many different accounts do we have to sort of deal with for
just this non-VA care space?
Dr. Yehia. So I don't know the exact number. I know we have
more than one and that has been a challenge that a lot of our
field folks tell me.
Part of what we are proposing and one of our legislative
proposals is to get that one funding stream. We did have some
flexibility at the end of the last fiscal year, so thank you
for that. That allowed us to kind of access the Choice fund to
pay for community care. I think it will be very important to
have kind of one pot of money, one funding stream for community
care, so that our clinicians and our medical centers know
exactly how much they have to spend in this area.
This has been a challenge because right now we go through
Choice and if something doesn't work, we use another pot of
money and it creates unnecessary redundancy. And so getting to
that one funding stream I think will be important.
Mr. Takano. You might have already covered this, I was just
sort of jumping between Committee meetings here, but how much
will extending emergency care to veterans cost? Did you already
mention that in your testimony?
Dr. Yehia. I did not, but it is in the report. It is on the
order of about 1.5 to $2 billion, that's both ER care and
urgent care.
Mr. Takano. I am going to ask you this sort of offline, but
I am real curious about drug treatment for veterans, whether it
includes rehabilitation, just to what extent we have case
management. I just want to understand that better in terms of
our vets that are coming back with PTS and then some that are
having some real substance abuse challenges. So I will follow-
up with the Department later.
But, Mr. Chairman, my time is up. Thank you.
Mr. Benishek. Mr. O'Rourke, you are recognized.
Mr. O'Rourke. Thank you, Mr. Chairman.
Dr. Yehia, thank you for your testimony and for all of your
efforts to transform the VA and improve access, quality of care
and outcomes for veterans.
Earlier in the day, I was at a conference that Under
Secretary Shulkin organized around preventing veteran suicide,
which I would argue should be the priority here. And the word
priority means something, right? If you prioritize something,
it puts that at the top of the list.
So I understand that there are 12 priorities, breakthrough
priorities that the secretary outlined. I know there are a lot
of moving parts and there are a lot of things to improve and to
work on. But what strikes me is that if we really think that we
have a crisis in veteran suicide and access to mental health
today and it really requires urgency in resources, rethinking
how we deliver that care and provide access to it, then we
should really be organized around that. As you know and just
for the benefit of the Committee and others who might not, in
El Paso, which had the worst mental health access rates in the
country and still struggles, I think we are third-from-worst
today, which is an improvement, we essentially adopted a plan
as a community with the VA and with your help to prioritize
access to mental health care and to try to prevent veteran
suicide. And the idea is that as important as it is to see a
podiatrist to get your foot fixed or an endocrinologist if you
have diabetes or a dentist to get your teeth fixed, preventing
veteran suicide is more important than all of those. And
ensuring that if you go to the VA, it is a--I know this is a
term of art, but it is a center of excellence for PTSD, TBI,
those unique conditions associated with combat and service.
And you, the VA, has helped by piloting a navigator concept
or care coordinator who helps if you have one of these service-
connected conditions you are seen in the VA by hopefully a
world-class provider. If not, we are going to prioritize your
care that is comparable to what a civilian would experience to
the private sector. We have got great partnerships with Texas
Tech, which is providing five psychiatrists so that we can
expand capacity for care in the VA.
And yet we just looked at the numbers, you have 116 or
Congress has authorized 116 mental health provider positions
within the El Paso VA and right now we are at 91 filled, which
leaves us 25 short, and I would argue that 116 is probably too
little to meet the demand that you have in El Paso.
So what do we have to do? We have adopted the plan, we have
got additional resources. If we are maximizing capacity in the
community and implementing this transformation plan that you
and the secretary have introduced and touted and which I am a
big fan of, why aren't we seeing better results in terms of
meeting what I think is the single greatest crisis facing
veterans in this country, which is 22 veterans a day taking
their own lives? If that is truly a priority, why are we not
beating all the bushes, taking over the airwaves to recruit
those mental health providers to communities like El Paso and
others who are historically under-served, where I know for a
fact because I talked to the surviving family members that
veterans are killing themselves because they don't have access
to mental health care?
Why can't we hire those 25 positions? What is the holdup?
Dr. Yehia. So I can't agree more with your sentiment and as
you know many of the elements in the plan that you had for El
Paso, there is a lot of that in the plan that we presented for
the entire VA. I think the part of the challenge is, as to
quote Secretary McDonald, you know, the VA is the canary in the
coal mine. I think we have to get out there and do more
recruiting.
I have been on a number of trips with the secretary
speaking at grand rounds in various hospitals across the
country trying to recruit doctors, specifically mental health
professionals and nurses to the VA. I have done it by myself as
well, and I think we need to do that.
I think we have an opportunity as we start to kind of
change the message a little bit about where VA is going, but we
will get--
Mr. O'Rourke. Let me interrupt you just because--
Dr. Yehia. Sure.
Mr. O'Rourke [continued]. --of very little time. My fault
for taking too much time at the outset, but with the Chairman's
indulgence. Could the VA instruct the director in El Paso don't
hire any more podiatrists or endocrinologists, you have got
them in the community, you can refer them, that is a condition
comparable to what the civilian population has, PTSD is very
unique to veterans, only hire your traumatic brain experts,
your PTSD experts, your psychologists and psychiatrists?
I recognize your canary-in-a-coal-mine analogy that
medicine in America is struggling with this and yet there is a
way to resolve this with the current capacity, I know there is.
I know there are psychiatrists and psychologists working in
private practice who could be brought over to the VA with the
right inducements, focus and leadership. Are we going to see
that this year?
Dr. Yehia. Well, I know that, as you know, Gail Graham who
is working in El Paso at the Medical Center there, I think she
is pulling out all the stops to try to recruit as many of those
professionals as possible.
I don't think the idea that like as you mentioned there is
approved FTE slots for those, so I don't think that a
podiatrist is standing in the way of a psychiatrist coming in
the door in El Paso.
Mr. O'Rourke. I am talking about a single-minded, almost
exclusive focus on getting that up. It doesn't mean that other
things are unimportant, all these conditions are important, I
would just say this is the most important preventable way that
veterans are dying that--
Dr. Yehia. I think that is something that we have to kind
of--we should chat a little bit more about that. I think there
may be some different tools that we can use.
Mr. O'Rourke. Okay. Thank you.
Thank you, Mr. Chairman.
Mr. Benishek. Ms. Kuster, you are recognized.
Ms. Kuster. Thank you very much, Mr. Chairman. And good
morning, great to be with you.
I had a quick local question just off the bat and we have
talked about this in the past, but New Hampshire, Alaska and
Hawaii are the three states without a full-service VA hospital
and we had a special agreement under the previous rule to drop
the 40-mile requirement down to 20 miles. I am just wondering,
the last time we talked that was under review and I wondered if
that process has proceeded since November.
Dr. Yehia. Thank you. We have continued to engage with
various stakeholders as you mentioned, Alaska, Hawaii and New
Hampshire. I have had calls with the field leadership in all of
those different states to try to get a good understanding of
what their specific needs are. This is a tough issue and I am
looking for kind of suggestions and ideas here as well, because
on one side we want to make sure that we streamline the
program, create something that is easy to understand and
administer and I think the more nuanced or one-offs that we do,
the more complexity that is built in.
So I want to be respectful of the local circumstances
there, but at the same time, I am also keeping my mind on how
can we make sure that there is some uniformity so that every
state is not treated differently.
So with all that said, I think some of the criteria that we
have articulated in the plan really do provide good access to
care for New Hampshire specifically. And one of the things that
I think a lot of people sometimes gloss over, the availability
of service is such a key component, because if that service is
not offered at those centers it is automatically folks have the
choice in the community. So even with the current criteria, I
think that the folks specifically in New Hampshire will be well
served.
Ms. Kuster. And I think one way to do that is the expansion
of the CBOCs, Community Based Outpatient Care. We just opened a
beautiful new CBOC in Littleton, New Hampshire. But just for
you to take back, I am still waiting for progress on two
others, one in a town called Colebrook, New Hampshire, almost
to the Canadian border, and another in a town that we call
Berlin, New Hampshire. And they have to do with negotiations
that are going on with community-based care and partnerships,
which are a good thing, but I would love to get a little
shoulder to the wheel here from headquarters in D.C. to move
those along.
I also wanted to just talk about how we are very frustrated
by the third-party administrator and I know that is not the
purpose of this hearing, but I want to put that complaint out
there. Senator Shaheen, Senator Ayotte and I, have done a
series of events around the state talking directly with
veterans. This is our primary, the phone calls that we get in
the office. It is just very very frustrating. And I know that
the VA physicians and staff, medical professionals would prefer
to be making the appointments anyway because they would prefer
to have that relationship with the community provider, get the
records back, be able to call the patient and say don't forget
your appointment tomorrow.
So are we making any progress on that? Because frankly, I
would rather just take that back and this third-party
administrator is not working out for my constituents.
Dr. Yehia. Yeah, I appreciate that. I think I have a call
with some of those Senators later this week. And I will say
this, that our partners are our partners. We modified a
contract at the very beginning to implement Choice in a short
amount of time. That contract, that PC3 contract was not
designed to run the Choice program, it just wasn't designed to
do that.
With that said, as I was mentioning a little bit earlier,
today we released the statement of work. It is a draft
statement of work, so it is the first step in a contracting
process. I think you would be happy to note that in that
contracting process or that statement of work the scheduling
piece would reside at the VA and not with a contractor.
So we are making progress. I think it is going to take some
time for us to get there, but I have heard from the Medical
Centers, I have heard from veterans, and I think that is the
direction we want to move. So slowly we continue to provide
oversight and work with our TPAs to improve their performance,
but in the end when we are drafting the right kind of car to
drive this program those things would be residing on the VA
side, not on the contractor side.
Ms. Kuster. That is good news and I apologize for missing
that earlier, I was over in AG talking about veteran farmers.
So thank you very much for your testimony.
Mr. Benishek. Thanks, Ms. Kuster. And I reiterate or echo
your feelings about this third-party administration thing and I
realize that there was an urgency in getting the Choice
started. I am going to ask a couple quick questions here too.
Do you know when the Choice fund is going to be depleted
this year?
Dr. Yehia. To do a little bit of math, we started with the
$10 billion. Last year we spent, in the last fiscal year about
3.5 billion, this year we are anticipating about two billion,
and then the remainder will be the year after.
I want to caveat that just a little bit. Over the last
three months we have seen kind of a dramatic increase in Choice
use, almost double the three months prior. A lot of that has to
do with more proactive outreach to veterans. So rather than
kind of the onus on them picking up the phone and calling, we
are doing the calling and saying, would you like to partake in
Choice, is this something that you want? And we have seen a
dramatic up-tick.
So that is a little bit of the projections. I think we
still haven't reached kind of steady state--
Mr. Benishek. Okay.
Dr. Yehia [continued]. --but we will get there.
Mr. Benishek. Is the $2.1 billion estimate per year above
current non-VA care costs expected to be the yearly program
estimate going forward?
Dr. Yehia. Is that outlined in the plan?
Mr. Benishek. Well, I mean, you estimated me $2 billion
more, is that the estimate for yearly--
Dr. Yehia. Yeah, we estimated the costs for the first three
years. As you know, it is a little hard to try to predict past
that, but in those first couple years, it would be $2 billion
on top of the normal community care budget.
Mr. Benishek. So does the 2017-2018 budget request reflect
the numbers that we have been talking about here? Isn't that
coming out shortly?
Dr. Yehia. I don't think that is--let me take that back.
Mr. Benishek. All right. Any other questions?
Thank you very much for your being here today, and you can
look forward to some further questions from us as we go forward
here. You are now excused.
I ask unanimous consent that all Members have five
legislative days to revise and extend their remarks and include
extraneous material.
And without objection, that is ordered.
The hearing is now adjourned. Thanks.
[Whereupon, at 11:52 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Adrian M. Atizado
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting DAV (Disabled American Veterans) to submit
this statement for the record of today's hearing. As you know, DAV is a
Congressionally chartered national veterans organization of 1.3 million
wartime veterans, all of whom were injured or made ill due to military
service.
Your invitation letter indicated the focus of today's hearing is to
examine plans of the Department of Veterans Affairs (VA) with regard to
eligibility for non-VA care under the proposed New Veterans Choice
Program (VCP), as mandated in Public Law 114-41, and to assess whether
they are sufficient to increase access to care among veteran patients.
We appreciate the opportunity to share our views and recommendations in
this regard.
When it comes to our nation keeping its promises, perhaps none are
as important as the promise to care for injuries and illnesses suffered
by the men and women who served. VA's capacity to meet its needs is
limited by its annual appropriations allocated to VA by Congress. Thus,
VA's health care mission involves, among other things, keeping
expenditures under a resource ceiling. The inherent limitation
impacting veterans' access to care is what type of service they may
need, where it is available and the availability of resources to
purchase the care in the community.
Indeed, the findings of a presidential task force reported in 2003
and the Independent Assessment report issued by MITRE Corp., Rand Corp.
and others last September confirm what DAV and our Independent Budget
(IB) partners (Paralyzed Veterans of America and Veterans of Foreign
Wars) have said for more than a decade: the resources provided to VA
health care have been inadequate to meet the mission to care for
veterans. In fact, we have repeatedly testified to Congress about this
``mismatch'' and ``misalignment'' of resources and demand.
To be clear, DAV does not believe that simply increasing funding by
itself-without making some significant reforms to the underlying VA
health care system-will lead to better health outcomes for veterans
over the next 20 years. However, no VA reform plan has any chance of
success unless sufficient resources are consistently provided to meet
the true need and demand for services by veterans, when and where they
need them.
Our members have unfortunately experienced the adverse consequences
of this mismatch first-hand when VA policy for purchasing certain care
is inconsistent, unclear, and/or comes without commensurate resources.
Funding uncertainty compels some facilities to develop local policies,
procedures, or dicta which generally limit veterans' access to
community care paid for by VA.
Unless tensions between resources, demand and authorities are
addressed with a clear understanding of the circumstances in which care
is purchased in the community, and how this policy fits into VA's
broader health care mission, the probability is quite high that even
the best intended policies and procedures will continue to undermine
the veterans' perception and experience of the coordination, quality
and value of health services provided or paid for by VA.
In reviewing the eligibility for non-VA care under Choice
consolidation, as mandated in Public Law 114-41, and whether they are
sufficient to increase access to care among veteran patients, we
believe it offers the potential for expanding and improving access to
care. According to VA, its entire plan will increase access to non-VA
care and ``require additional annual resources between $1.5 and $2.5
billion in the first year and are likely to increase thereafter.''
The eligibility for non-VA care under Choice consolidation is laid
out in four parts: hospital care and medical services; emergency and
urgent care; and outpatient medication and durable medical equipment.
DAV's statement will review each of these parts including grievances,
disputes, and appeals, and provide our views and recommendations where
warranted.
Hospital Care and Medical Services:
VA's plan: ``The eligibility criteria for Hospital Care and Medical
Services, including Dentistry services, in the community will continue
to be focused broadly on wait-times for care, geographic access/
distance, and availability of services. The criteria will be
streamlined into a single set of rules applied across the VA health
care system.''
Geographic and temporal eligibility criteria
The plan proposes to continue the existing geographic and temporal
eligibility criteria of the Veterans Choice program as authorized by
the Veterans Access, Choice, and Accountability Act of 2014. We note
the choice program criteria remains underdevelopment having been
amended from its original form, and veterans today remain frustrated by
the current criteria not being sensitive to their medical care needs
and preferences.
We believe VA's proposed geographic and temporal criteria for
community care eligibility in the New Veterans Choice Program (NVCP),
while simple in concept-are arbitrary. It continues to administratively
separate NVCP from the VA health care system, does not foster full
integration, and limits performance to the detriment of veteran
patients.
Under this separated construct, because DAV was founded on the
principle that this nation's first duty to veterans is the
rehabilitation and welfare of its wartime disabled, because VA's
capacity to provide for ``the rehabilitation and welfare of its wartime
disabled'' is limited by its annual appropriations allocated to VA by
Congress, and because of the natural tension between demand, resources,
and authorities, we recommend consideration that the eligibility to use
the NVCP should mirror the eligibility for VA health care, giving the
highest priority to service-connected veterans.
Notably, the independent assessment on access standards conducted
by the Institute of Medicine (IOM) determined that industry best
practices focus on clinical need and the interaction between clinicians
and their patients. We could not agree more.
For veteran patients, waiting for a health service begins when the
veteran and the appropriate clinician agree to a service, and when the
veteran is ready and available to receive it. Thus, DAV, along with the
co-authors of the IB, believes it is time to move towards a health care
delivery system that keeps clinical decisions about when and where to
receive care between a veteran and his or her doctor - without
bureaucrats, regulations or legislation getting in the way.
From the veteran patient's perspective, the decision-making process
can be more than a clinical decision-and it can often be a complicated
one. Many veterans who use the VA health care system present complex
health and social challenges requiring more than simple coordination of
care, often including coordination of supports and other services. A
decision on where, when and with whom to obtain care may need to
involve the veteran's social support network such as caregivers, family
members and friends to address factors and limitations such as the time
required to complete a visit, procedure, or treatment plan,
availability of appropriate transportation when needed, and various
financial considerations.
This is why DAV, as part of the IB, proposed creating local
Veteran-Centered Integrated Health Care Networks to seamlessly
integrate community care into the VA system and to provide a full
continuum of care through such networks. The future VA health care
system with an integrated NVCP should be responsive to the decision
made between veterans and their providers. Veterans should be able to
choose among the options within VA and the NVCP network and schedule
appointments that are most convenient for them.
Availability of service eligibility criteria
In addition to geographic and temporal criteria, VA's plan also
proposes an eligibility criterion for hospital care and medical
services, including dentistry services, in the community that focused
on ``availability of service.'' Specifically, when a VA facility cannot
directly provide a particular service or when a VA facility determines
there is a compelling reason a veteran needs to receive care from a
community provider, then outside care would be authorized.
We believe the ``compelling reason'' criterion may inappropriately
limit access to community care through NVCP. We have received reports
about treatments, procedures or tests available in the private sector,
which the veteran's VA health care team has determined ``is not
necessary.'' These complaints are more pronounced when a veteran's non-
VA provider recommends a service that is neither cosmetic nor
experimental, but which VA has determined ``is not necessary.''
Veterans-centric care means including veterans participation in
their care. This means providing veterans options, whether that be a
second option or describing all the different treatments that are
endorsed by clinical literature and even though the veteran's doctor
may favor one over another, the final decision ultimately stops-or
should stop-with the patient. When these options are not presented
particularly for preference-sensitive conditions and treatment options,
disagreements between the veteran and their provider can and does
occur.
Grievances, Disputes, and Appeals
We agree with VA's plan that ``[T]o ensure VA meets the unique
needs of Veterans.the process also will include clear appeal and
grievance mechanisms for Veterans to dispute eligibility
determinations.'' We also support VA's plan for ``[a] formal, timely
appeals process will provide Veterans a clear point of contact for
concerns about the status of their authorization.'' When authorization
questions arise, there is a clear path for appeals through the call
center.
Congress and VA should consider an appeal mechanism that covers all
decision and determination points, not just eligibility determinations
for the NVCP. To this end, DAV stands committed to working with VA in
developing mechanism(s) designed to address grievances, disputes, and
appeals.
As part of the IB, we envision the Veterans Experience Office
playing a role in this regard. VA Secretary McDonald has made improving
veterans experience a main pillar of the MyVA transformation. To ensure
VA leaders are aware of the issues veterans face when they obtain their
earned benefits and health care, the MyVA taskforce has established the
Veterans Experience Office, with a Chief Veterans Experience Officer
who reports directly to the Office of the Secretary. VA plans to have
veterans experience officers throughout the country who collect and
disseminate best practices for improving customer service, coordinate
community outreach efforts, and serve as subject matter experts on the
benefits and services VA provides to veterans.
The Veterans Experience Office should be strengthened by combining
its capabilities with the patient advocate program. Veterans experience
officers would advocate for the needs of individual veterans who
encounter problems obtaining VA benefits and services. They would also
be responsible for ensuring the health care protections afforded under
title 38, United States Code, a veteran's right to seek redress through
clinical and administrative appeals, claims under section 1151 of title
38, United States Code, the Federal Tort Claims Act, and the right to
free representation by accredited veterans service organizations are
fully applied and complied with by all providers who participate in
Veteran-Centered Integrated Health Care Networks, both in the public
and private sector.
The Plan for Emergency and Urgent Care:
VA's plan: ``Eligibility criteria will increase access to these
services and simplify access rules to prevent the denial of claims for
the appropriate use of these services.''
During our engagements with VA in the development of its plan, DAV
specifically urged the inclusion of urgent care into VA's medical
benefits package and to better integrate emergency care with the
overall health care delivery system.
VA's plan also indicates it will focus on a more consistent
application of the ``prudent layperson'' definition of emergency
treatment across claims to reduce the administrative burden on VA to
conduct a nuanced review of each emergency treatment claim.
Presumably, the more consistent application of the prudent
layperson standard will rely in part on ``Develop[ing] business rules
to trigger audit of emergency treatment and urgent care claims to
identify potential overuse or fraud, waste, and abuse of these
services.''
VA believes its plan will ``encourage Veterans to use these
services appropriately and not as a substitute for primary care.by
requiring cost-sharing for emergency treatment'' unless the veteran is
admitted to an inpatient status, or if it [causes] an undue financial
burden to the veteran. In addition, it will ``limit cases where
Veterans are held responsible for a bill for emergency treatment or
urgent care because they did not fully understand the criteria for VA
coverage.''
We applaud VA for including in its plan expanded access to, and
simplification of the eligibility requirements for, emergency and
urgent care coverage.
Prudent Layperson
DAV has received a resolution from our membership regarding urgent
and emergency care as they pertain to the VA health care system.
Specifically, our members believe urgent and emergency care should be
integral to VA's medical benefits package.
Our resolution regarding emergency care also urges the VA to
provide for a more liberal interpretation of its policy governing
reimbursement to veterans who have received emergency care at non-VA
facilities. VA readily admits that ``[M]any of these denials are the
result of inconsistent application of the ``prudent layperson''
standard from claim to claim and confusion among Veterans about when
they are eligible to receive emergency treatment through community
care.''
We recommend VA's plan use a national prudent layperson emergency
care standard that provides coverage based on a patient's presenting
symptoms and relative urgency of need, rather than the final diagnosis,
VA's current standard.
24-Month Requirement
The VA plan proposes the eligibility for reimbursement of costs
associated with emergency treatment be limited to those enrolled in VA
health care and who are active VA health care patients (i.e., sought
care from VA within the past 24 months).
As opposed to VA, DAV believes the 24-month requirement does not
``incentiviz[e] appropriate health behaviors,'' as claimed in VA's
plan. DAV has testified on a number of occasions in support of
legislation to eliminate the current law provision that requires
enrolled veterans to have received care from VA within the 24-month
period prior to date of the emergency care, as a precursor to
reimbursement.
Absent a change in law, veterans who are fortunate enough to not
need VA or VA-authorized care at least once every 24 months would need
to make an unnecessary VA medical appointment in order to remain
eligible for emergency and urgent care reimbursement under the NVCP.
DAV continues to recommend to Congress that this artificial limitation
on use of emergency care be lifted.
Copayment
DAV has received a resolution from our membership calling for the
elimination or reduction of VA health care out-of-pocket costs for
service-connected disabled veterans.
Premiums, health care cost sharing, and deductibles are a feature
of health care systems in which some costs are shared by the insured
and the insurer in a contractual relationship between the patient,
payer and provider. In DAV's view service-connected disabled veterans
have already paid the price of any health care copayment or cost-
sharing scheme imposed the federal government.
Notwithstanding the imposition of copayments to all veterans
seeking emergency and urgent care, the plan fails to consider those
instances where an emergency department or urgent care clinic would the
most appropriate setting for the care veterans need.
DAV recommends, in addition to those situations where copayments
would be waived under the plan, including similar relief when an
emergency department of urgent care clinic is the most appropriate
setting.
From the veteran patient's perspective, not all VA primary care
clinics or teams are capable of providing fast, life-or-limb-saving
care. Moreover, veterans need urgent care when VA primary care
appointments are unavailable or treatment is needed outside of office
hours. If the VA health care system and the integrated NVCP are
unresponsive to these needs, the proposed co-payments should not apply.
We appreciate VA's desire to incentivize appropriate health
behavior; however, we insist VA provide positive rather than punitive
incentives. As part of the IB, VA should consider establishing a
national nurse advice line to help reduce overreliance on emergency
room care. The Defense Health Agency (DHA) has reported that the
TRICARE Nurse Advice Line has helped triage the care TRICARE
beneficiaries receive. Beneficiaries who are uncertain if they are
experiencing a medical emergency and would otherwise visit an emergency
room, call the nurse advice line and are given clinical recommendations
for the type of care they should receive. As a result, the number of
beneficiaries who turn to an emergency room for their care is much
lower than those who intended to use emergency room care before they
called the nurse advice line. By consolidating the nurse advice lines
and medical advice lines many VA medical facilities already operate, VA
would be able to emulate DHA's success in reducing overreliance of
emergency room care without having to increase cost-shares for
veterans.
Define Emergency Condition
Moreover, in the interest of parity in VA's legislative proposal to
address its existing authorities to reimburse the cost of emergency
treatment, we recommend ``emergency condition'' be defined. We urge
serious consideration be given to reliance on the Emergency Medical
Treatment and Labor Act (EMTALA), with a minor amendment to include
behavioral conditions, so that the definition of an emergency condition
for VA purposes would be ``a medical [or behavioral] condition
manifesting itself by acute symptoms of sufficient severity (including
severe pain) such that the absence of immediate medical attention could
reasonably be expected to result in placing the individual's health [or
the health of an unborn child] in serious jeopardy, serious impairment
to bodily functions, or serious dysfunction of bodily organs. With
respect to a pregnant woman who is having contractions that there is
inadequate time to effect a safe transfer to another hospital before
delivery, or that transfer may pose a threat to the health or safety of
the woman or the unborn child.''
Outpatient Medication and Durable Medical Equipment; Extended Care
Services:
VA's plan: ``Eligibility criteria will not be altered in this
report, as any adjustment would constitute a fundamental change to the
VA health benefit.''
VA's plan is to leverage its rates for outpatient medical and
durable medical equipment (DME) by requiring veterans to receive these
services through VA facilities with limited exceptions, including
urgent prescription medications, allowing veterans to pay out of pocket
and seek reimbursement from VA.
Limitations of Plan and Approach
We understand the scope of VA's plan being limited to those ``non-
Department provider programs'' prescribed by Congress in P.L. 114-41;
however, we caution Congress and the Administration on this fragmented
approach to provide timely access to care in the community, which may
produce adverse consequences.
VA's health care mission covers the continuum of care providing
inpatient and outpatient services, including pharmacy, prosthetics, and
mental health; gender-specific care, long-term care in both
institutional and non-institutional settings. The limits of the plan is
identified by some health care benefits such as dental care that carry
additional statutory eligibility requirements, and extended care, which
VA indicates is ``out of the scope of this effort to adjust the
eligibility criteria.'' The VA plan for the NVCP also does not propose
changes to the VA health benefit or to other eligibility requirements
for care purchased through other authorities not contemplated in
Section 4002 of PL 114-41.
If Congress intends to increase veterans' access to care, including
care in the community, it should recognize that by not addressing gaps
and inconsistencies in VA's plan (all of VA's purchased care
authorities-including cost controls through differing eligibility
requirements and other stipulations), VA's medical benefits package,
and the full range of health services available in the community, VA
will assuredly continue certain fragmentation of care veterans
experience today into the future. Veterans could be left unassisted
across different providers and care settings, fostering frustrating and
unsafe patient experiences, leading to medical errors, waste, and
duplication that foster poor overall quality of care.
Mr. Chairman and Members of the Committee, thank you for the
opportunity to present this testimony. DAV will be pleased to respond
to any questions on the topics discussed in this statement that need
additional information or clarification.
Prepared Statement of Carl Blake
Chairman Benishek, Ranking Member Brownley, and members of the
Subcommittee, on behalf of Paralyzed Veterans of America (PVA), I would
like to thank you for the opportunity to testify today. We appreciate
the fact that the Subcommittee is addressing the very serious question
of eligibility for health care services for veterans through the
Department of Veterans Affairs (VA) community care plan. Let me say up
front, that PVA generally thinks that the VA plan is a very good one.
It clearly represents a model of how health care should be delivered.
In fact, it mirrors in many ways the veterans' health care reform
framework that PVA, along with our partners in The Independent Budget-
Disabled American Veterans and Veterans of Foreign Wars-have presented
to the full Committee, as well as to Senate VA Committee, the
Commission on Care and the VA itself.
As eligibility dictates access to veterans health care, so too does
the capacity of the systems providing that care. Over the years, the VA
health care system has relied on a number of methods and standards to
measure access and timeliness of health care delivery. Prior to the
scandal that enveloped the VA health care system in the spring of 2014,
the Department's wait-time goal was 14 days from a veterans preferred
date for existing patients or 14 days from the date an appointment
request was created for new patients. After the health care access
crisis exposed that the 14-day goal was unattainable, VA reevaluated
its standard and moved to 30 days from a veteran's preferred date. Less
than a year later, VA changed its wait-time standard again to
facilitate the implementation of the Veterans Choice Program. In an
attempt to align its standards with industry best practices, VA elected
to base its wait-time goal on clinical need first and rely on a
veteran's preference when a clinically indicated date was not
identified. There is no evidence to suggest that arbitrary wait-time
standards are indicative of quality, rather they are bureaucratic tools
to self-assess output performance. They are not a measure of quality
care and to suggest otherwise is unfounded.
Over the years, VA has also relied upon a number of geographic-
based access standards to determine eligibility. Through the Strategic
Capital Investment Planning (SCIP) process, dating back to its fiscal
year 2008 budget request, VA has used a 60-minute drive-time distance
for veterans who live in urban areas and 90 minutes for veterans who
live in rural areas as a standard for specialty care. In 2013, VA's
long range SCIP process began to include a corporate target of 70
percent of veterans having access to VA primary care within a 30-minute
drive time in urban areas and 60 minutes in rural areas. Additional
geographic-based standards have accompanied statutory programs, to
include 40 miles from a primary care provider (as well as 30 days) for
the Veterans Choice Program, or 60-minute drive time from primary care,
120 minutes from acute care, and 240 minutes from tertiary care under
Project ARCH. VA has also established geographic-based network
standards for contracted programs. Under Project HERO, VA required
Humana to provide access to required services within 50 miles of a
veteran's home. Under PC3, HealthNet and TriWest are required to
provide health care options within a 60 minute drive for veterans who
live in urban areas, 120 minutes for veterans who live in rural areas,
and 240 minutes for veterans who live in highly rural areas, when
seeking general care. For veterans who need a higher level of care, the
PC3 network must provide them with options within 120 minutes for urban
areas, 240 minutes for rural areas, and an acceptable community
standard for highly rural veterans. Geographic-based access standards
are another means of narrowing the scope of how VA measures its
performance and simplifies the budgeting projections. Geographic-based
access standards are not derived from industry best practices for the
provision of health care.
The independent assessment on access standards conducted by the
Institute of Medicine (IOM) determined that industry benchmarks for
health care access vary widely throughout the private sector. IOM was
unable to find national standards for access and wait-times similar to
the Veterans Choice Program's 40-mile and 30-day standards. Instead of
focusing on set mileage or days-based calculations, IOM found that
industry best practices focus on clinical need and the interaction
between clinicians and their patients. PVA, along with our partners in
The Independent Budget, strongly agrees with the IOM's recommendation
that ``decisions involving designing and leading access assessment and
reform should be informed by the participation of patients and their
families. \1\'' We believe that this concept will also best serve the
needs of our members and all veterans.
---------------------------------------------------------------------------
\1\ IOM (Institute of Medicine). 2015. Transforming Health Care
Scheduling and Access: Getting to Now. Washington, DC: The National
Academies Press
---------------------------------------------------------------------------
The Independent Budget has reported for years that VA's access
standards are not aligned with veterans' perceptions. Moreover, the IB
firmly believes that federally regulated, arbitrary access standards,
such as living 40 miles from a VA clinic or waiting up to 30 days for
an appointment, should not inhibit a veteran's access to care. That is
why we propose to move away from federally regulated access standards.
Under the IB's framework, access to care would be a clinically based
decision made between a veteran and his or her doctor or health care
professional. Once the clinical parameters are determined, veterans
would be able to choose among the options developed within the network
and schedule appointments that are most convenient to them. Veterans
not satisfied with clinical determinations or scheduling options would
be able to seek a second clinical review of their health care needs.
The irony of all these access standards is PVA members often travel
farther than any of the other special populations of veterans served by
VA, or even veterans in general seeking care from VA. It is not unusual
for PVA members, and other veterans with spinal cord injury or disease
(SCI/D), to travel hundreds of miles to reach one of the 25 spinal cord
injury centers located around the country. They do this because the VA
SCI system of care is far and away the best option they have to meet
their specialized health care needs. The access problems these veterans
face are usually not wait times or distance, but the cost of travel. As
a result, veterans may wait to be seen until their condition
deteriorates, requiring more costly and intensive care. Congress should
expand travel benefits to non-service connected, disabled veterans, to
ensure they are able to receive quality specialty care. This
Subcommittee is reviewing the question of eligibility without even
considering this important fact. PVA believes that the 30-day and 40-
mile eligibility standards that determine access under the new Veterans
Choice Program (VCP) do not consider what is best for veterans with
catastrophic disabilities, to include SCI/D. Moreover, arbitrary access
standards will not increase eligibility or guarantee timely, quality
care.
PVA strongly believes that veterans have earned and deserve to
receive high quality, comprehensive, accessible and veteran-centric
care. In most instances, VA care is the best and preferred option,
particularly for veterans with SCI/D and other specialized health care
needs. However, we acknowledge that VA cannot provide all services to
all veterans in all locations at all times. This became clear from the
access crisis that came to the forefront in April 2014 and has
continued to burden the VA as more and more veterans seek care from,
and through, VA. Adequate resources should be devoted to building a
comprehensive health care system within VA supported by a dynamic,
integrated health care network that leverages private sector providers
and other public health care systems to expand viable options. This is
essentially the concept the VA has proposed in its community care
consolidation plan and is mirrored by the framework the IB has
presented as well.
PVA supports the idea to move beyond arbitrary federal standards
regulating veterans' access to care in the community. However, we are
not convinced that the VA's plan goes quite far enough. We believe it
is time to move towards a health care delivery system that keeps
clinical decisions about when and where to receive care between a
veteran and his or her doctor-without bureaucrats, regulations or
legislation getting in the way.
PVA, and our IB partners, also supports the plan to expand
emergency treatment and urgent care in the community. However, we
strongly oppose the proposal for an across the board $100 co-payment
for emergency care and $50 for urgent care. This proposal seemingly
makes no exception for veterans with service-connected disabilities or
who are currently exempted from co-payments. These veterans should not
be required to bear a cost-share as it may disincentive the veteran or
their caregiver from accessing emergency treatment or urgent care. For
many disabled veterans who are unable to work and living off their
earned benefits, a trip to an urgent care clinic for $50 might be just
enough of a burden that they delay being seen. We know this delay means
an increased chance that something as seemingly benign as a small wound
becomes a costly infection.
As an alternative, VA should consider establishing a national nurse
advice line to help reduce overreliance on emergency room care. The
Defense Health Agency (DHA) has reported that the TRICARE Nurse Advice
Line has helped triage the care TRICARE beneficiaries receive. Those
who are uncertain if they are experiencing a medical emergency, and
would otherwise visit an emergency room, call the nurse advice line and
are given clinical recommendations for the type of care they should
receive. Such an advice line must have available SCI trained providers,
who are able to identify potential complications specific to an SCI
veteran. As a result, the number of beneficiaries who turn to an
emergency room for their care is much lower than those who intended to
use emergency room care before they called the nurse advice line. By
consolidating the nurse advice lines and medical advice lines many VA
medical facilities already operate, VA would be able to emulate DHA's
success in reducing overreliance of emergency room care without having
to increase cost-shares for veterans.
Additionally, PVA, as well as the IB, has raised serious concerns
with the requirement that eligible veterans must be ``active health
care participants in VA'' in order to access these benefits. The strict
24-month requirement is extremely problematic for newly enrolled
veterans, many of whom have not been afforded the opportunity to
receive a VA appointment due to limited capacity, despite their timely,
good faith efforts to make appointments following their separation from
military service. This barrier has caused undue hardship on veterans
who are undergoing the difficult transition from military service back
to civilian life, and has resulted in veterans receiving unnecessarily
large medical bills through no fault of their own. VA is aware of this
problem and has requested the authority to make this exemption;
however, the consolidation plan does not specifically address this
needed change. Furthermore, this restriction could negatively impact
healthier veterans who do not need as much health care as others and
may go more than two years without accessing VA care. This requirement
could encourage veterans to seek unnecessary services from VA in order
to remain eligible for VA's emergency and urgent care services.
Ultimately, a comprehensive health care network should not be
designed to limit eligibility and exclude veterans seeking care. PVA
has long argued that limiting eligibility to VA health care services
undermines the intention of the Affordable Care Act (ACA). PVA played a
key role in ensuring that VA health care was deemed acceptable coverage
under the ACA. And yet, millions of veterans are still denied
enrollment into the VA due to the prohibition on new Priority Group 8
enrollments.VA should immediately lift the ban on Priority Group 8
enrollments to make veterans who need health care eligible for these
critical services. If VA will not make that decision, then Congress
should pass legislation to do so.
Mr. Chairman, I would like to thank you once again for the
opportunity to testify. We encourage this Subcommittee, and all of
Congress, to closely examine the VA's community care consolidation plan
and provide the necessary resources and support to see this plan
through to implementation. While there are issues that must still be
worked out with this plan, this is a real step towards ensuring greater
access to critical health care services for veterans. We would be happy
to answer any questions that you might have.
Information Required by Rule XI 2(g)(4) of the House of Representatives
Pursuant to Rule XI 2(g)(4) of the House of Representatives, the
following information is provided regarding federal grants and
contracts.
Fiscal Year 2016
Department of Veterans Affairs, Office of National Veterans Sports
Programs & Special Events - Grant to support rehabilitation sports
activities - $200,000.
Fiscal Year 2015
Department of Veterans Affairs, Office of National Veterans Sports
Programs & Special Events - Grant to support rehabilitation sports
activities - $425,000.
Fiscal Year 2014
No federal grants or contracts received.
Disclosure of Foreign Payments
Paralyzed Veterans of America is largely supported by donations
from the general public. However, in some very rare cases we receive
direct donations from foreign nationals. In addition, we receive
funding from corporations and foundations which in some cases are U.S.
subsidiaries of non-U.S. companies.
William Carl Blake
Associate Executive Director for Government Relations
Paralyzed Veterans of America
801 18th Street NW
Washington, D.C. 20006
(202) 416-7708
Carl Blake is the Associate Executive Director for Government
Relations for Paralyzed Veterans of America (PVA) at PVA's National
Office in Washington, D.C. He is responsible for the planning,
coordination, and implementation of PVA's National Legislative and
Advocacy Program agendas with the United States Congress and federal
departments and agencies. He develops and executes PVA's Washington
agenda in areas of budget, appropriations, health care, and veterans'
benefits issues, as well as disability civil rights. He also represents
PVA to federal agencies including the Department of Defense, Department
of Labor, Small Business Administration, the Department of
Transportation, Department of Justice, and the Office of Personnel
Management. He coordinates all activities with PVA's Association of
Chapter Government Relations Directors as well with PVA's Executive
Committee, Board of Directors, and senior leadership.
Carl was raised in Woodford, Virginia. He attended the United
States Military Academy at West Point, New York. He received a Bachelor
of Science Degree from the Military Academy in May 1998.
Upon graduation from the Military Academy, he was commissioned as a
Second Lieutenant in the Infantry in the United States Army. He was
assigned to the 2nd Battalion, 504th Parachute Infantry Regiment (1st
Brigade) of the 82nd Airborne Division at Fort Bragg, North Carolina.
He graduated from Infantry Officer Basic Course, U.S. Army Ranger
School, U.S. Army Airborne School, and Air Assault School. His awards
include the Army Commendation Medal, Expert Infantryman's Badge, and
German Parachutist Badge. Carl retired from the military in October
2000 due to injuries suffered during a parachute training exercise.
Carl is a member of the Virginia-Mid-Atlantic chapter of the
Paralyzed Veterans of America.
Carl lives in Fredericksburg, Virginia with his wife Venus, son
Jonathan and daughter Brooke.
Prepared Statement of Duane Williams
Chairman Benishek, Ranking Member Brownley and distinguished
Members of the Subcommittee:
On behalf of the Iraq and Afghanistan Veterans of America (IAVA)
and our 425,000 members and supporters, thank you for the opportunity
to share our views with you at today's hearing: ``Choice Consolidation:
Evaluating Eligibility Requirements for Care in the Community.''
By way of introduction, I am retired from the U.S. Army having
served 26 years on active duty and 6 additional years in the reserve
component. Currently I serve as the Chairman of the Veterans Affairs
Advisory Board of DeKalb County, Georgia, which is responsible for the
county's veteran recognition, advocacy and research programs on behalf
of its 41,000 veterans. I also serve IAVA as a Georgia Leadership
Fellow, focusing on veteran leadership development, policy advocacy and
team building. These experiences help me better understand the needs of
veterans but also the challenges they face accessing quality care in a
timely and efficient manner.
IAVA is proud to have previously testified in front of this
Subcommittee recommending the need for consolidation of care in the
community for veterans enrolled in VA health care, and we applaud
Congress for requiring VA to put forward a plan for consolidation. We
also want to recognize senior leaders at VA for acknowledging the need
for consolidation and providing an inclusive, veteran-centric and
transparent plan.
Last year, when the Surface Transportation and Veterans Health Care
Choice Improvement Act of 2015 became law, it helped begin the process
of removing a lot of confusion for veterans. However, according to
IAVA's most recent Member Survey, only five percent of respondents had
taken advantage of the Choice Program, and their reviews on
satisfaction were mixed. For the 95 percent of IAVA members who had not
used it, 43 percent reported not using it because of confusion as to
how to use it. It's clear that simplification is needed.
Confusion over the Choice Card is not the only barrier to accessing
timely and quality care. In IAVA's member survey, nearly half of the
respondents were not even familiar with the Choice Program.
In my home of Atlanta, Georgia, the enrollment for health care at
the Atlanta VA Medical Center (VAMC) is growing faster than the
capability for primary care. According to VA population data, the
number of veterans residing in the 28-county metropolitan Atlanta area
in 2013 was 294,000. The 2014 VA population data reflects more than
361,000 veterans living in that same area. To meet this increased use,
in the past 18 months, the Atlanta VAMC has hired an additional 600
employees.
Related to this move, on January 20, 2016, Atlanta VAMC stated the
current wait for VA initial primary care appointments was at 60 days,
but after speaking to the VISN 7 VHA Director on January 26, she
advised me she was able to help the Atlanta VAMC Director reduce the
60-day wait time down to 20.6 days. If this number holds true, the
reduction in wait time by nearly 40 days in the matter of 6 days, is
remarkable. We hope other VA medical centers will follow suit, and we
hope this Subcommittee will continue to monitor, analyze and ensure
accuracy of wait time data, including at the Atlanta VAMC.
As Congress hopefully moves forward to simplify a confusing process
for veterans, IAVA highly recommends Congress work with VA and use its
plan as the framework for legislation in order to avoid one-off
proposals that are misinformed or put politics ahead of veterans. After
all, it was Congress who provided the numerous different plans that
added to the confusion and inefficiencies which resulted in the need to
consolidate care. We believe Congress should be mindful of these
lessons, learn from them and leverage the VA's plan as the framework
for consolidation of care moving forward.
Our second concern centers around VA's ability to effectively
implement a plan to consolidate care across their enterprise in a way
that avoids many of the mistakes made during the implementation of
Choice and truly puts veterans at the center of every decision. While
the VA Budget and Choice Improvement Act of 2015 extended provider
eligibility to any health care provider meeting VA criteria, the VA
must use this opportunity to streamline and standardize the
requirements for medical documentation. Under the Choice Act of 2014,
reimbursement rates for non-VA providers is limited to no more than the
MEDICARE reimbursement rate, thus standardizing and reducing
administrative requirements can remove a barrier to more providers
joining the network.
The VA intends for its health delivery model to be the patient-
centered medical home for the veterans under its care; therefore, the
VA holds responsibility for direct coordination of services for each
veteran. Care coordination is one of the core functions of primary
care. A significant number of the VA's patient needs are complex, and
as the complexity increases, the challenges in facilitating the
delivery of the appropriate care increases. Factors that increase the
complexity of care include: multiple chronic health problems, the
social vulnerability of the patient, the number of providers and the
patient's ability to coordinate their care. Due to the significant
number of VA patients with anxiety disorders, dementia, depression and
kidney failure, it is necessary for the VA to maintain significant
control and accountability for the provision of veterans' care.
To address these inconsistencies and shortcomings, IAVA recommends
the VA continue to collaborate with all stakeholders who share their
vision of putting the veteran first and focus on values-based
leadership in an attempt to change the culture of VA across the
country. Given the shortcomings related to training frontline personnel
on the implementation of Choice and customer service generally, the VA
should also continue its efforts with myVA and make sure all VA
employees are trained properly and consistently on the VA plan to
consolidate care.
Finally, IAVA encourages everyone, Congress, VA, VSOs, industry and
other stakeholders, to place an increased importance on the quality of
care veterans are receiving, especially new providers who have not
served veterans since their residency training. It is important under
the medical home model of primary care that the VA continues to
coordinate and be accountable for the care provided to veterans given
the complexity of care required.
In closing, IAVA would like to thank this Subcommittee for your
leadership and continued commitment to our veterans. It is a privilege
to testify in front of the Subcommittee today, and we reaffirm our
commitment to working with Congress, VA and our VSO partners to ensure
veterans have access to the highest quality care available, and our
country fulfills its sacred obligation to care for those who have borne
the battle. We do believe there is an opportunity to transform the VA
for today's veterans if we all work together.
Thank you, and I'd be happy to answer any questions you may have.
Biography
As Leadership Fellow, Mr. Williams is a catalyst for veteran
leadership development, policy advocacy and team building. He spent 26
years in the Army, two years in the National Guard and four years in
the Army Reserves. In his last combat assignment, he was responsible to
the MNFI Surgeon and MNFI Commanding General for independent
coordination with various government and non-governmental agencies to
support health sector partnership programs with the Iraqi government.
He is currently the Chairman of the Veterans Affairs Advisory Board of
DeKalb County, Georgia, responsible for the county's veteran
recognition, advocacy and research programs on behalf of the 41,000
veterans in one of Georgia's largest counties. Mr. Williams holds
advanced degrees in Religion and Public Policy.
Statement on Receipt of Grants or Contract Funds
Neither Mr. Williams, nor the organization he represents, Iraq and
Afghanistan Veterans of America, has received federal grant or contract
funds relevant to the subject matter of this testimony during the
current or past two fiscal years.
Prepared Statement of Baligh Yehia, M.D.
Good morning, Chairman Benishek, Ranking Member Brownley, and
Members of the Committee. Thank you for the opportunity to discuss the
Department of Veterans Affairs' (VA) proposal to consolidate VA's
community care programs to increase access to health care, specifically
the portion of the proposal that would streamline eligibility criteria
to reduce confusion and frustration among Veterans, community
providers, and VA staff. I am accompanied today by Kristin Cunningham,
Director, Business Policy in VHA's Chief Business Office.
VA is committed to providing Veterans access to timely, high-
quality health care. In today's complex and changing health care
environment, where VA is experiencing a steep increase in demand for
care, it is essential for VA to partner with providers in communities
across the country to meet Veterans' needs. To be effective, these
partnerships must be principle-based, streamlined, and easy to navigate
for Veterans, community providers, and VA employees. Historically, VA
has used numerous programs, each with their own unique set of
requirements, to create these critical partnerships with community
providers. This resulted in a complex and confusing landscape for
Veterans and community providers, as well as VA employees.
Acknowledging these issues, VA is taking action as part of an
enterprise-wide transformation called MyVA. MyVA will modernize VA's
culture, processes, and capabilities to put the needs, expectations,
and interests of Veterans and their families first. Included in this
transformation is a plan for the consolidation of community care
programs and business processes, consistent with Title IV of the
Surface Transportation and Veterans Health Care Choice Improvement Act
of 2015, the VA Budget and Choice Improvement Act, and recommendations
set forth in the Independent Assessment of the Health Care Delivery
Systems and Management Processes of the Department of Veterans Affairs
(Independent Assessment Report) that was required by Section 201 of the
Veterans Access, Choice, and Accountability Act of 2014 (Choice Act).
On October 30, 2015, VA provided Congress with its plan for the
consolidation of all purchased care programs into one New Veterans
Choice Program (New VCP). The New VCP will include some aspects of the
current Veterans Choice Program established by section 101 of the
Choice Act and incorporate additional elements designed to improve the
delivery of community care.
One aspect to the New VCP would be establishing clear eligibility
requirements for community care. Currently, overlapping eligibility
criteria for different methods of accessing community care creates
confusion among Veterans, community providers, and VA staff.
Eligibility to enroll in and access VA's health care system would not
change with the New VCP. However, the New VCP would define a single set
of eligibility requirements for the circumstances under which Veterans
may choose to receive health benefits from community providers as well
as expand and simplify access to emergency treatment and urgent care.
This will enable timely and convenient access to care in alignment with
best practices.
Background
Current eligibility creates confusion due to multiple, overlapping
criteria for each different method of purchasing care. The New VCP
would reduce confusion by standardizing requirements across facilities
regarding when a Veteran may choose to receive community care, while
still providing local flexibility to respond to unique needs of
Veterans (e.g., local services, geography, and unusual or excessive
burden). The need for simplifying eligibility criteria directly
addresses the recommendation to ``streamline programs for providing
access to purchased care and use them strategically to maximize
access'' outlined in the Independent Assessment Report \1\. The
eligibility criteria will be grouped into the following categories:
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\1\ Independent Assessment Report Section B: Health Care
Capabilities
u Hospital Care and Medical Services: Patient eligibility criteria
for the New VCP will provide Veterans with timely and convenient access
to care based on wait times, distance to a VA Primary Care Provider
(PCP), or availability of services.
u Emergency Treatment and Urgent Care: Eligibility criteria will
increase access to these services and simplify access rules to prevent
the denial of claims for the appropriate use of these services.
u Outpatient medication and Durable Medical Equipment (DME):
extended care services: Eligibility criteria will not be altered as any
adjustment would constitute a fundamental change to the VA health
benefit.
VA compared the current eligibility criteria for purchasing
community care to commercial health plans and Federal program
approaches to develop the New VCP criteria. A number of findings from
this review informed design of the patient eligibility criteria for the
New VCP.
Eligibility for VA Health Benefit and Eligibility for Community Care
Eligibility for community care is independent of eligibility to
enroll in VA health benefits. A Veteran must be eligible for and
enrolled in the VA health benefit before VA will evaluate the Veteran
for eligibility for community care. Eligibility for enrollment in the
VA health benefit is based on level of Service-Connected (SC)
disability, other special authorities (e.g., awardees of the Medal of
Honor and former Prisoners of War), and income. These characteristics
determine a Veteran's enrollment priority group. Enrollment priority
groups range from 1 to 8, with 1 being the highest priority. All
enrolled Veterans enjoy access to VA's comprehensive medical benefits
package; however, some benefits (e.g., dental care) have additional
statutory eligibility requirements. After a Veteran is enrolled in VA
health care, the eligibility criteria for VA's various methods for
purchasing care in the community then can be applied to determine when
a Veteran may receive his or her health benefits outside of a VA
facility.
Unique Considerations for VA
There are a number of factors that make VA unique compared to
commercial health plans.
u Coverage - VA is required to provide coverage to Veterans in
areas where VA does not have physical facilities or an established
provider network. Commercial health plans generally do not offer
products where they cannot meet coverage requirements.
u Other Health Insurance (OHI) - Approximately 78 percent of
Veterans have OHI and only rely on VA for certain services (e.g.,
hearing aids and eyeglasses). Changing the services Veterans are
eligible to receive in the community or what they pay for those
services could affect Veteran's reliance on VA versus OHI, including
TRICARE, Medicare, and Medicaid.
u Teaching and Research Missions - In addition to providing high-
quality care to men and women Veterans, VA has research and education
missions critical to the VA system and the nation as a whole. In 2014,
VA supported 2,224 medical and prosthetic research projects totaling
$586 million in research investment \2\ and provided clinical training
to 41,223 medical residents, 22,931 medical students, 311 Advanced
Fellows, and 1,398 dental residents and dental students \3\. In
addition, many Veterans value participation in VA training and research
and consider them to be an important part of the VA care experience.
Over time, decreasing utilization of VA facilities may jeopardize VA's
ability to deliver on these missions.
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\2\ Source: Veterans Health Administration, Office of Research and
Development
\3\ Source: Veterans Health Administration, Office of Academic
Affiliations
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Current State
VA has multiple sets of eligibility criteria for the various
authorities and methods of purchasing community care. Several of these
criteria overlap, creating confusion among Veterans, community
providers, and VA staff and providers. Broadly, these criteria have
focused on providing surge capacity and have been grouped into three
categories:
1. Wait-Times for Care: VA was not able to provide the service
within an acceptable time frame, based on medical need.
2. Geographic Access/Distance: A VA facility was not available
within an acceptable travel distance of the Veteran's home.
3. Availability of Service: A facility in the local VA network
either did not provide the required service or there was a compelling
reason why the Veteran needed to receive care from a community
provider.
Additionally, eligibility varies by the category of care (hospital
care and medical services; and emergency treatment):
Emergency Treatment
Currently, a Veteran is eligible to receive emergency treatment
through community care by authority of 38 United States Code (U.S.C.)
Section 1703, 38 U.S.C. Section 1725, and 38 U.S.C. Section 1728.
Eligibility for emergency treatment varies by authority.
Since determination of these claims is nuanced, and unclear for
Veterans, there are a large number of denied claims. When denied, the
financial responsibility for these claims, which can be substantial,
often falls on Veterans or their OHI, resulting in unanticipated
financial challenges for Veterans. As an example, between the beginning
of FY 2014 and August 2015, approximately:
u 89,000 claims were denied because they did not meet the timely
filing requirement.
u 140,000 claims were denied because a VA facility was determined
to have been available.
u 320,000 claims were denied because the Veteran was determined to
have OHI that should have paid for the care.
u 98,000 claims were denied because the condition was determined
not to be an emergency. \4\
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\4\ Source: VHA Chief Business Office, Office of Informatics
In FY 2014, approximately 30 percent of the 2.9 million emergency
treatment claims filed with VA were denied, amounting to $2.6 billion
in billed charges that reverted to Veterans and their OHI. Many of
these denials are the result of inconsistent application of the
``prudent layperson'' standard from claim to claim and confusion among
Veterans about when they are eligible to receive emergency treatment
through community care. Additionally, VA is not authorized to reimburse
Veterans for urgent care, which is typically lower cost than emergency
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treatment, and encourages health care in the appropriate setting.
Future State
The objective of the New VCP is to create a set of criteria that
are simple and intuitive for Veterans, community providers, and VA
staff. This will be accomplished by eliminating the multiple
overlapping criteria for accessing Hospital Care and Medical Services,
including Dentistry, in the community. The single, nationally defined
set of eligibility criteria for the New VCP can be consistently
implemented while providing VA facilities the flexibility to respond to
unique circumstances, such as excessive burden in traveling to a VA
facility or the medically-indicated need to see a provider in a
timeline shorter than the VA wait-time standard for a service. In
addition, the New VCP includes simple criteria for accessing Emergency
Treatment and Urgent Care. This should increase access and reduce
denied claims while incentivizing appropriate use of these services.
Eligibility criteria for each category of care are as follows.
Hospital Care and Medical Services
The eligibility criteria for Hospital Care and Medical Services,
including Dentistry services, in the community will continue to be
focused broadly on wait-times for care, geographic access/distance, and
availability of services. The criteria will be streamlined into a
single set of rules applied across the VA health care system. To ensure
VA meets the unique needs of Veterans, VA will have flexibility at the
local level through clarified guidance on exceptions. The process also
will include clear appeal and grievance mechanisms for Veterans to
dispute eligibility determinations.
When Veterans are determined to be eligible for community care, VA
will provide them with information on providers and appointment
availability at VA and in the community. This will allow Veterans to
choose a convenient appointment from the provider of their choice. The
primary change in this proposed vision is to focus eligibility for
geographic access/distance on access to a PCP. PCPs play a critical
role in coordinating care and providing preventative care, so
convenient access is necessary. Veterans eligible for the New VCP under
either of the geographic access/distance criteria will have the option
to choose a community PCP. The community PCP could then refer the
Veteran to specialty care in the community or at VA as appropriate and
authorized by VA. This approach is consistent with best practices,
which emphasize providing access to a PCP.
Emergency Treatment and Urgent Care
As part of the New VCP, VA had proposed an update to emergency
treatment and urgent care in the community authorities, as one option
to attempt to simplify Veterans' experiences in seeking care. VA
estimated that the expanded emergency treatment and urgent care
proposal could cost over $1.5 billion, independent of other aspects of
the New VCP.
Conclusion
As VA continues to refine its health care delivery model, we look
forward to providing more detail on how to convert the principles
outlined in VA's plan into an executable, fiscally-sustainable future
state. In addition, VA plans to review feedback and potentially
incorporate recommendations from the Commission on Care and other
stakeholders including Veterans, community providers, VA staff, and
industry leaders. VA will work with Congress and the Administration to
refine the approach described in the plan, with the goal of improving
Veteran's health outcomes and experience, as well as maximizing the
quality, efficiency, and sustainability of VA's health programs.
Delivering the New VCP will not be successful without approval of
recommended legislative changes and recommended budget. Expanded Access
to Emergency Treatment and Urgent Care is important in providing
Veterans with appropriate access to these services, but is severable
from other aspects of the program and could be implemented separately.
VA is willing to work with Congress to address the cumbersome emergency
treatments authorities which have a negative impact on Veterans both
reducing access to critical services and increased financial liability.
Transformation of VA's community care program will address gaps in
Veterans' access to health care in a simple, streamlined, and effective
manner. This transformation will require a systems approach, taking
into account the interdependent nature of external and internal factors
involved in VA's health care system. MyVA will guide overall
improvements to VA's culture, processes, and capabilities and the New
VCP will serve as a central component of this transformation. VA looks
forward to a successful implementation of the New VCP and partnering
with Congress to support requested legislative authorities and
additional resources. This transformation will position VA to improve
access to care, expand and strengthen relationships with community
providers, operate more efficiently, and improve the overall Veteran's
experience.
Thank you. We look forward to your questions.
Statements For The Record
MILITARY OFFICERS ASSOCIATION OF AMERICA
CHAIRMAN Benishek, RANKING MEMBER Brownley, and Members of the
Subcommittee, on behalf of the more than 390,000 members of the
Military Officers Association of America (MOAA), I am grateful for the
opportunity to present MOAA's views on the Department of Veterans
Affairs (VA) eligibility requirements as outlined in its proposed Plan
for Consolidating Community Care.
MOAA does not receive any grants or contracts from the federal
government.
MOAA is grateful for the Subcommittee's steadfast commitment and
exceptional support to our nation's veterans and their families.
Notably, the passage of the two key bills, the Veterans Access, Choice
and Accountability Act of 2014 (VACAA P.L. 113-146, or the Choice Act)
and the Title IV of the Surface Transportation and Veterans Health Care
Choice Improvement Act of 2015 (VA Budget and Choice Improvement Act),
as well as additional funding to address shortfalls in several Veterans
Affairs Health Administration (VHA) accounts. These bills and funding
are foundational steps to reforming VA to better serve our veterans and
their families.
The Secretary of VA, Bob McDonald, and his leadership team have
also committed significant resources and attention to not only fixing
current access problems, but are also moving swiftly to implement
reform through a major effort called MyVA. We applaud the Secretary's
vision and determination to get MyVA implemented and institutionalized
as much as possible before leaving office.
EXECUTIVE SUMMARY
The guiding question before the Subcommittee today is, ``Will the
eligibility requirements outlined in the Department of Veterans
Affairs' (VA) plan to Consolidate Community Care Programs be sufficient
to increase access to care among veteran patients?''
The Military Officers Association of America (MOAA) appreciates the
opportunity to explore the question with the Subcommittee and to share
our thoughts on the Secretary's proposed New Veterans Choice Program
(VCP) Plan, congressionally mandated in Title IV, Surface
Transportation and Veterans Health Care Choice Improvement Act of 2015.
Generally, MOAA supports the plan to consolidate VA's multiple and
disparate purchased care programs into one New VCP. We believe it has
the potential to improve and expand veterans' access to health care.
Much depends, however, on the Department's success in working with its
employees, Congress, the VA Commission on Care, veterans and military
service organizations (VSOs/MSOs), and other stakeholders as the agency
moves forward in developing and implementing the plan.
MOAA commends VA Secretary Bob McDonald for his MyVA vision and
tenacious leadership as he leads the largest and most complex
integrated health system in America in a new direction, seeking to
transform the Department into a veteran-centric organization by
``modernizing VA's culture, processes, and capabilities in order to
meet the needs, expectations, and interests of Veterans and their
families first.'' We are also pleased to see the New VCP aligns with
the Secretary's MyVA transformation efforts.
VA established a strong communications channel and process to
engage stakeholders. This unprecedented collaborative process included
frequent and ongoing dialog and feedback which continues today as VA
moves forward in further developing and implementing the plan. Such
effort indicates VA's sincere commitment to putting veterans and
families first and is at the center of its plans for consolidating
community care.
While MOAA is very encouraged by the Secretary's transformation
efforts, we respectfully urge Congress, the Commission on Care and the
VA to:
Adopt The Independent Budget's (IB) recent concept paper,
a Framework for Veterans Health Care, incorporating the Disabled
American Veterans (DAV), Paralyzed Veterans of America (PVA) and the
Veterans of Foreign Wars (VFW) recommendations for transforming the VHA
into a more robust system of health care for veterans.
Eliminate the current arbitrary federal access standards
(based on wait times, distance to a VA facility, or availability of
services) and consider establishing a new clinically-based standard for
both in-house and community care, where decision-making involves the
veteran (including family/caregivers) and physician or medical
professional in the process (per the IB VSOs) to provide a less
complicated standard for accessing care.
Support VA's plan for expanding access to emergency
treatment and urgent care services, but oppose the copay requirement
for veterans accessing such care, particularly those with service-
connected conditions.
Direct resources and funding at modernizing the VA human
resources system and requiring VA to implement a workforce management
and succession planning strategy for attracting, training, retaining,
and sustaining high quality personnel.
The ultimate test of any successful reform is whether VA is able to
deliver the things veterans and their families value most-high quality,
accessible, comprehensive, and culturally competent medical care and
services that will meet their unique needs and circumstances.
BACKGROUND
The MyVA initiative was launched soon after Secretary McDonald's
confirmation and the passage of the Choice Act. MyVA is an enterprise-
wide transformation initiative. According to the Secretary, the
initiative will modernize VA's culture, processes, and capabilities to
put the needs, expectations, and interests of Veterans and their
families first.
Issues related to access to medical care have long plagued the
system. After news broke of secret waiting lists at the Phoenix,
Arizona VA medical hospital in the early 2014, MOAA wrote a letter to
the President and leaders of the House and Senate Veterans Affairs
Committees to say bureaucratic red tape and gross inefficiencies were
preventing veterans from accessing care and required immediate
attention.
MOAA urged the President to establish an independent, high-level
commission to examine the VHA to better understand the challenges that
lie ahead so the VA is prepared to meet the long-term needs of millions
of veterans who have served our nation. Lawmakers heard our message and
passed the Veterans Choice Act on August 7, 2014, which included
establishing a VA Commission on Care.
The Commission was established on August 7, 2015 to examine the
access of veterans to health care from VA and how best to organize VHA,
locate health care resources, and deliver health care to veterans over
the next 20 years. It is expected to submit its findings and
recommendations to the VA and Congress early this year.
The Choice Act also directed an independent study to look at the
delivery systems and management processes of VHA in order to provide a
holistic view of the system and its relationship within the VA. The
Independent Assessment was completed on September 1, 2015.
Within three months of the passage of the Choice Act, VA
implemented the Choice Program on November 5, 2014. The program allows
eligible veterans to receive health care in their local communities
from private or non-VA providers. But VA struggled from the beginning
to transition to the Choice Program. Accessing the program was
problematic and eligibility requirements were confusing and frustrating
not only to veterans, but also to VA employees and providers trying to
implement the program. As a result, veterans continued to experience
long wait times for care.
At the urging of MOAA and several partners in The Military
Coalition, VA expanded the Choice Program rules on December 1, 2015. VA
changed the eligibility rules to measure distance from a veteran's home
of record to the closest VA facility using the more reasonable driving
distance criteria rather than the former straight-line method. The
change increased patient eligibility so more veterans could get care at
private hospitals and clinics closer to home, more than doubling the
number of veterans eligible for the program.
Even with the change and more individuals eligible for the program,
veterans continued complaining about having trouble accessing medical
care through the Choice Program.
On July 31, 2015, Congress took bold action by passing the VA
Budget and Choice Improvement Act to address lingering Choice Program
problems and to fix a major budget crisis that had been brewing in VA
because of increased demand from veterans for health care services.
The law provided for important modifications and enhancements to
the Choice Program, such as:
Eliminating the prior enrollment date requirement of
August 1, 2014 for veterans to have been enrolled in the VA health care
system, allowing all veterans enrolled in VA health care to be
eligible;
Allowing the agency to waive the 30-day wait time for
veterans needing care;
Increasing the number of providers in the program; and,
Changing the distance requirement, allowing veterans
seeking primary care who live within 40 miles of a VA medical facility,
including a community-based outpatient clinic that does not have a
full-time physician to use Choice for that care.
Additionally, the bill also provided some significant reforms to
improve health service delivery and access in the future, including
directing the Secretary to submit a plan to Congress by November 1,
2015, on how it will consolidate all non-VA care programs under one,
the Choice Program.
VA submitted its Plan to Consolidate Community Care Programs
October 30, 2015. The plan proposes consolidation of all seven
purchased care programs into one New Veterans Choice Program called the
New VCP.
CURRENT STATUS OF THE CHOICE PROGRAM
Despite frustrations with the Choice Program implementation, most
agree there has been significant progress in improving access in a
relatively short period of time. Though access to care is improving, VA
continues to experience multiple systemic issues across the agency,
impacting current mission as well as its ability to modernize to meet
the growing demand and changing veteran population.
In fact, the 2015 Independent Assessment Report required by the
VACAA cited four systemic findings that impact VHA's ability to execute
its mission (Page xii):
A disconnect in alignment of demand, resources and
authority.
Uneven bureaucratic operations and processes.
Non-integrated variations in clinical and business data
tools.
Leaders are not fully empowered due to a lack of clear
authority, priorities and goals.
Although the veteran population is expected to decline over the
next decade, a unique mixture of demographic factors is leading to
increased demand for VA services and is expected to continue for the
foreseeable future.
Aging Vietnam veterans are using more services at increased costs.
Successful marketing of the Choice Program to increase awareness has
led veterans to seek care who may previously have decided not to use
the VA. The conclusion of conflicts in Iraq and Afghanistan is bringing
in a new generation of Post-9/11 veterans to the system. A growing
number of women veterans, now 10 percent of the military, are seeking
VA treatment at higher rates than their male counterparts.
Aging infrastructure; antiquated financial, human resource, and
technology systems; and budget shortfalls further limit VA's ability to
make much-needed change and improvements on its own.
Today's VA health system is more complex and access requirements
more complicated than ever, even after decades of reform efforts and
enhancements like the Choice Program. Veterans must contend with a
multiplicity of access points, eligibility criteria and gatekeepers in
trying to access health care and services. The experiences of veterans
using VA health care vary widely across the country. The
inconsistencies and complexities across the health system erode the
trust and confidence veterans have in their system, particularly when
they are told that new programs like Choice will help them get the care
they need sooner, rather than later.
MOAA members reflect some of the mixed experiences and feelings
veterans have with VA health care, including accessing the Choice
Program. Some of their comments include:
90 Year Old Male WWII Veteran-``I've always had a great
experience with my audiology care and responsive service at the VAMC in
Phoenix, Arizona.''
70+ Year Old Female Vietnam Veteran-``I did not intend to
use the Choice Program. I have always been satisfied with the
responsive on- and off-site services offered at the Sheridan, Wyoming
VAMC. However, I was advised that I ``have no choice'' with the
inaccurately named VETERANS CHOICE PROGRAM. I must acquiesce in the new
procedures for off-site services or pay for those services myself.The
vets on the bottom of this avalanche of bureaucratic insanity are worse
off than ever in their access to timely healthcare.''
40+ Year Old Male OIF/OEF Veteran-``Thank goodness the
VAMC in Los Angeles, California stepped in and helped me get my
benefits and medical care I desperately needed.'' This wounded warrior
was forced out of the military with no assistance in helping him with
his transition. He ended up being rated 100% unemployable, and the VAMC
helped him get immediate medical care and services, giving him and his
family the longer term security they needed.
32 Year Old Male OEF Veteran-``I'll never go back to the
Washington, DC VAMC again.'' This veteran was in a very unstable
condition when coming to MOAA for help. He was suffering with chronic
pain and post-traumatic stress from combat and had been sexually
assaulted post-deployment before leaving active duty. The system was
unresponsive in helping him move up his appointment to see his primary
care provider, directing him instead to seek care in the emergency room
if he thought he needed immediate mental health attention-the ER would
then send him to the clinic to see a behavioral health provider.
Implementing the Choice Program has brought to light many of the
systemic issues mentioned earlier and with it the perfect opportunity
to consider a new vision for VA health care that might otherwise have
been missed.
VA has certainly embraced the opportunity for a new vision for
reform in its New VCP concept. The plan is a step in the right
direction to simplify community care and integrate the entire system to
enhance the veterans' experience and health outcomes.
THE NEW VETERANS CHOICE PROGRAM (NEW VCP)
The Secretary and his staff deserve great credit for the work
undertaken to coordinate and produce the New VCP, particularly given
the tight time constraints for producing the end product. The proposed
plan to consolidate community care provides a good foundation for
Congress, the Commission on Care, the VA, and other stakeholders to
consider in the process of deliberating the future of VHA.
MOAA, like many of our VSO and MSO colleagues working with VA to
develop the New VCP concept, believes the plan offers the potential for
expanding and improving access to care, particularly for veterans in
need of emergency services and urgent care. Regardless of what the
system of care in the future will look like, the nation has a
responsibility to ensure veterans have access to the care, benefits and
services they have earned, deserve and value.
The key elements of a health system veterans and their families/
caregivers value most include high quality, accessible, comprehensive,
and veteran-centric care-a system that is simple, easy to understand
and navigate, and is seamless whether the care is delivered in-house or
in the community.
VA's intent in its plan for consolidating community care program is
to have ``clear eligibility criteria, streamline referral and
authorization processes, make customer support available when needed,
and eliminate ambiguity around eligibility and personal financial
obligations for care.''
VA states the New VCP criteria will also be flexible enough to
respond to the unique needs of veterans and eligibility requirements.
This will be evaluated over time depending on health care innovations
and changes to the veteran population.
However, VA's plan for hospital and medical services continues to
base eligibility on wait times, geographic access to care and
availability of services. That is, the same confusing and
inconsistently applied eligibility criteria used in the current Choice
Program.
VA does propose expanding eligibility for emergency treatment and
urgent care services. MOAA is very supportive of the expansion but
opposed to requiring veterans to pay a cost share to access these
services. VA's plan would require copays of $100 for emergency
treatment and $50 for urgent care services for veterans with or without
a service-connected condition. We believe this is a major departure
from current eligibility requirements and will negatively impact
veterans and their families. Such a requirement presents yet another
set of criteria for VA to manage and another impediment to veterans
accessing care.
The new VCP is an ambitious plan. Any significant reform of VHA
will require strong, sustained leadership at all levels of the
Department. Ten of the top 16 VHA executives are new since the
Secretary took office, and VA is facing some of the most troubling
human resource challenges of its time in recruiting, training,
retaining, and developing a viable workforce for the future.
Clearly, VA must reform. What remains to be seen is whether VA will
have the strong, consistent leadership, vision and commitment at all
levels of the organization necessary to drive the real, cultural and
transformative changes needed across the entire VA Health
Administration (VHA)-one that remains focused on veterans and is agile
enough in adapting to the changing veteran population and advances in
American medicine.
At its January 2016 VA Commission on Care meeting, Dr. Kenneth
Kizer, the former Under Secretary of Health Administration from 1994-
1999, told commissioners the issues facing VA today aren't much
different from earlier times when he led the last major reformation.
When commissioners asked him what needs to be done to fix VA, Kizer
said, ``These are all fixable issues with the right leadership and
commitment.'' He went on to say, ``VA's biggest challenge is
leadership-the culture is driven by the right leadership in the right
places at all levels, including Congress.''
Multiple ideas and solutions to reform VHA have come forward in
recent months, providing a unique opportunity to take a fresh look at
health care.
One such idea MOAA believes should be seriously considered is the
Independent Budget's (IB) VSO concept. The IB's Framework for Veterans
Health Care approach builds upon VA's progress in transforming VHA, but
goes beyond the legislative, regulatory and bureaucratic constraints
confining the system today.
For example, the IB recommends moving away from arbitrary federal
access standards to a clinically-based decision made between a veteran
(to include family/caregivers) and their physician or health care
professional, offering great potential for simplifying eligibility
requirements and expanding access across the system, beyond just
community care.
The IB framework starts with the idea of what a veterans' health
care system should look like, rather than what VHA should look like.
MOAA believes this is an important distinction for the Commission on
Care to consider when making its recommendations to Congress.
MOAA RECOMMENDATIONS
While MOAA is very encouraged by the Secretary's transformation
efforts, we urge Congress, the Commission on Care and the VA to:
Adopt the Independent Budget's (IB) Framework for
Veterans Health Care approach by incorporating the concept
recommendations in any plans for transforming the VHA.
Eliminate the current arbitrary federal access standards
and establish a new clinically-based standard for both in-house and
community care, to include veterans (and family/caregivers) and their
physician or medical professional in the decision-making process to
yield a less complicated standard for accessing care.
Support VA's plan for expanding access to emergency
treatment and urgent care services, but oppose the copay requirement
for veterans accessing such care, particularly those with service-
connected conditions.
Direct resources and funding at modernizing the VA human
resources system, requiring VA to implement a workforce management and
succession planning strategy for attracting, training, retaining, and
sustaining high quality personnel.
CONCLUSION
MOAA is grateful to the Members of the Subcommittee for your
leadership in supporting our veterans, their families and caregivers.
We look forward to working with Congress, the Commission on Care
and the VA as we seek to reform VHA into a world-class system that puts
veterans and their families/caregivers at the center of their health
care.
Biography of Rene Campos, CDR, USN (Ret.)
Deputy Director, Government Relations
Commander Rene Campos rejoined the MOAA staff in February 2015 as
the Deputy Director, Government Relations, managing matters related to
military and veterans' health care, wounded, ill and injured, and
caregivers. She previously helped establish a military family program
at MOAA, working on defense and military quality of life programs and
policy issues. In September 2007, she joined the MOAA health care team,
specializing in Departments of Defense and Veterans Affairs health care
systems, as well as advocating for seamless transition programs and
women in the military issues.
She began her 30-year career as a photographer's mate, enlisting in
1973 and was later commissioned a naval officer in 1982. Her last
assignment was at the Pentagon as the Associate Director, Office of
Family Policy in the Office of the Deputy Under Secretary of Defense
for Military Personnel and Family Policy.
Commander Campos serves as a member of The Military Coalition (TMC)
- a consortium of nationally prominent uniformed services and veterans'
organizations, representing approximately 5.5 million current and
former members of the seven uniformed services, including their
families and survivors, serving on the Health Care; Morale, Welfare &
Recreation and Military Construction, and Base Realignment & Closure;
Veterans; and Personnel, Compensation and Commissary Committees.
VETERANS OF FOREIGN WARS OF THE UNITED STATES
MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
On behalf of the men and women of the Veterans of Foreign Wars of
the United States (VFW) and our Auxiliary, thank you for the
opportunity to offer our thoughts on the Department of Veterans
Affairs' (VA) plan to consolidate its community care programs.
The VFW strongly believes that veterans have earned and deserve
timely access to high quality, comprehensive, and veteran-centered
health care. For the past year, Congress and VA have devoted time and
resources to determining when such care should be delivered at VA
medical facilities and when veterans should be afforded the opportunity
to receive care through private sector health care providers. To the
VFW the answer is simple: when a veteran and his or her doctor
determine it is clinically necessary, the highest quality and the most
accessible option.
Since the access crisis erupted in the spring of 2014, the VFW has
taken a proactive approach to evaluating the state of the VA health
care system. Through our work we have collected direct feedback from
tens of thousands of veterans regarding their experiences receiving
health care. What we have learned is that veterans turn to VA despite
80 percent of them having other health care options because they like
the quality of care they receive, they believe VA health care is an
earned benefit, and VA is best suited to care for their service-
connected injuries and illnesses. While VA is the preferred option for
eligible veterans, it is not always the most convenient one. That is
why the VFW strongly believes that community health care providers must
be integrated into the VA health care system to expand access to
timely, high quality, comprehensive and veteran-centric health care to
the veterans who rely on VA for their health care needs.
The VFW supports many aspects of VA's plan to consolidate its
community care programs. Specifically, the VFW strongly supports VA's
plan that would move away from federally mandated wait-time standards
and enable veterans and their doctors to determine how long they are
clinically able to wait for their health care. We agree with VA that
the amount of time veterans wait for care should not be confined by
statute. The number of days a veteran is able to wait for care must be
a determination based on his or her medical conditions and symptoms.
For example, a veteran who is likely to have heart complications and is
experiencing chest pain cannot wait 30 days to be seen by a
cardiologist, which is the current practice, regardless if it is at a
VA medical facility or private sector hospital. However, a veteran who
requires a routine medical examination may be able to wait longer than
30 days.
Furthermore, allowing access to be defined by a patient and his or
her doctor would align VA access standards with industry best
practices. In a recent Institute of Medicine (IOM) study on access
standards, IOM recommended that ``decisions involving designing and
leading access assessment and reform should be informed by the
participation of patients and their families.''
IOM's study also recommends that VA ``continuously assess and
adjust the match between the demand for services and the organizational
tools, personnel, and overall capacity available to meet the demand.''
That is why the VFW supports VA's intent to create high performing
networks based on the availability and capabilities of each health care
market. Doing so would ensure VA is able to identify private sector
providers who are ready and able to deliver timely, high-quality,
comprehensive and veteran-centric health care and empower those
providers to care for America's veterans.
However, the VFW does not agree with VA's plan to continue to use
the arbitrary 40-mile standard to determine when veterans are afforded
the opportunity to access the private sector providers within its high
performing networks. Instead of using distance to determine when
veterans are able to leave VA, distance should be used to determine
when VA must expand health care options to ensure all veterans are
afforded the opportunity to receive veteran-centric and coordinated
care when they need it and where it is most appropriate.
That is why the VFW strongly believes that private sector health
care providers who participate in VA's high performing networks must be
integrated into the VA health care system and considered an extension
of VA health care. Meaning, a veteran must receive equal or greater
quality of care through a high performing network private sector
provider than a veteran would receive from a VA medical facility. To
the VFW, this includes the ability to seamlessly schedule and navigate
from a VA medical facility to a private sector provider and vice versa.
For example, a veteran who has a private sector primary care
provider must be able to schedule a specialty care appointment at a VA
medical facility and have all related medical records from that visit
transmitted to the veteran's provider to ensure the veteran's care is
integrated as it would be if he or she were receiving all his or her
care at a VA medical facility. Conversely, a veteran who receives his
or her primary care at a VA medical facility must have a seamless
experience when receiving specialty care through a network provider.
That is why the VFW believes that once a veteran and his or her
doctor determines clinically based limits on a veteran's ability to
travel, that veteran must be allowed to pick from options available
within the local high performing network, including all public and
private sector options.
To properly size high performing networks to each community, the
VFW recommends establishing metrics to identify clinical access gaps
based on veteran population density and distance to care and services
available within high performing networks, including VA and community
providers. Such access gap metrics would serve to identify areas where
the veterans' health care system must expand capacity through
agreements with community health care providers, sharing facilities
with private or public health care entities, or building capacity.
We do not have to look far for an example of how distance is used
to expand capacity instead of determining when veterans are able to
consider non-VA options. Instead of requiring every veteran who lives
within 75 miles of a national cemetery to be interred in that cemetery,
the National Cemetery Administration's (NCA) goal is for 96 percent of
all veterans to have interment options within 75 miles of their home.
This includes viable burial options at cemeteries that have been built,
expanded, or improved through NCA cemetery grants.
When the demand exists, NCA proposes the construction of a new
national cemetery. However, NCA also uses agreements and grants with
states, United States territories and federally recognized tribal
organizations to establish, expand, or improve veterans' cemeteries in
areas where NCA has no plans to build or maintain a national cemetery.
Cemeteries assisted by an NCA grant are required to be exclusively
reserved for veterans and eligible family members and maintained by the
same standards as an NCA managed national cemetery - meaning that
veterans interred in NCA assisted state, territorial, or tribal
cemeteries are afforded the same honors as those interred in a national
cemetery.
The VFW also supports VA's plan to expand access to urgent care at
VA medical facilities and through private and public urgent care
clinics across the country to fill the gap between emergency room care
and outpatient care. We also support VA's plan to loosen its definition
of an emergency to expand access to private sector emergency room care.
However, the VFW strongly opposes any recommendation to bill veterans
for service-connected care. Any cost share associated with emergent or
urgent care eligibility must be aligned with VA's current copayment
structure, which exempts veterans who do not have the financial means
to pay cost shares and veterans who receive cost-free care due to
service-connected disabilities.
To curb overreliance of emergency room and urgent care, the VFW
recommends that VA establish a national nurse advice line that would
help veterans determine the appropriate level of care needed to address
their medical concerns. The Defense Health Agency (DHA) has reported
that the TRICARE Nurse Advice Line has helped triage the care TRICARE
beneficiaries receive. As a result, the number of beneficiaries who
have turned to an emergency room for their care is much lower than
those who intended to use emergency room care before calling the nurse
advice line. VA could leverage its existing pool of nurse and medical
advice lines to establish a national advice line to emulate DHA's
success or partner with DHA to expand the TRICARE Nurse Advice Line to
veterans.
As this Subcommittee continues to evaluate VA's plan to consolidate
its community care programs, the VFW will continue to ensure the voice,
preference, and health care needs of veterans are prioritized and
ensure VA health care reforms serve the best interest of our Nation's
veterans.
Information Required by Rule XI2(g)(4) of the House of Representatives
Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW
has not received any federal grants in Fiscal Year 2016, nor has it
received any federal grants in the two previous Fiscal Years.
The VFW has not received payments or contracts from any foreign
governments in the current year or preceding two calendar years.
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