[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
CHOICE CONSOLIDATION: LEVERAGING PROVIDER NETWORKS TO INCREASE VETERAN
ACCESS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
TUESDAY, MARCH 22, 2016
__________
Serial No. 114-61
__________
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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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, March 22, 2016
Page
Choice Consolidation: Leveraging Provider Networks To Increase
Veteran Access................................................. 1
OPENING STATEMENTS
Honorable Dan Benishek, Chairman................................. 1
Honorable Julia Brownley, Ranking Member, Subcommittee on Health. 2
WITNESSES
Billy Maynard, President, Health Net Federal Services............ 3
Prepared Statement........................................... 32
David J. McIntyre, Jr., President and Chief Executive Officer,
TriWest Healthcare Alliance.................................... 5
Prepared Statement........................................... 35
Baligh Yehia, M.D., Assistant Deputy Under Secretary for Health
for Community Care, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 7
Prepared Statement........................................... 46
Accompanied by:
Gene Migliaccio, Dr.P.H., Deputy Chief Business Officer for
Purchased Care, Veterans Health Administration, U.S.
Department of Veterans Affairs
STATEMENTS FOR THE RECORD
The American Legion.............................................. 49
Veterans Choice in Health Care Factsheet......................... 52
CHOICE CONSOLIDATION: LEVERAGING PROVIDER NETWORKS TO INCREASE VETERAN
ACCESS
----------
Tuesday, March 22, 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, Roe,
Huelskamp, Coffman, Wenstrup, Abraham, Brownley, Takano, Ruiz,
Kuster, O'Rourke, and Brown.
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: Leveraging Provider Networks to
Increase Veteran Access. This is our third in a series of
hearings on different key aspects of the Department of Veteran
Affairs' plan to consolidate care in the community programs
under a new and improved Choice Program.
In February, we discussed eligibility for care and billing
and reimbursement under the consolidation plan. Today we will
discuss provider networks. VA's consolidation plan proposes a
tiered provider network composed of a core and external network
of providers.
The so-called core network would be managed by VA and
consist of federally funded health care entities from the
Department of Defense, the Indian Health Service, tribal health
programs, and federally qualified health centers, as well as
academic affiliates.
The so-called external network would be managed by third-
party contractors across four distinct regions and consist of
commercial health care providers from the private sector who
would be divided into a preferred network of providers who meet
certain quality and performance metrics, and the standard
network of providers who meet minimum standard criteria.
I understand the advantages of a tiered network. Namely,
that it allows the VA to organize and differentiate between
providers by type and quality. However, I am concerned that the
tiered network the VA has proposed will hold government and
academic affiliate providers to a different, perhaps a less
stringent, standard than private sector providers will be held
to. That is fundamentally unfair; it is also unnecessary.
Government and academic affiliate partners have existing
relationships with VA that are longstanding, unique, and
important that already put them at a significant advantage when
compared to private sector providers who, for far too long,
have been held at arm's length by a department who did not want
to treat them like peers and partners in providing high-quality
care to veteran patients.
What's more, government and academic affiliate providers
are fully capable of competing with private sector providers
using the same quality and performance criteria that VA has
proposed, and they should compete. Some government health care
entities and some academic health care entities are world-
class, best in show providers. But some are not. We need to
know the difference between the two, and more importantly, our
veterans deserve to know the difference between the two, and to
be referred for care accordingly.
I also want to ensure that under the VA's tiered network
proposal and individual veteran's choice in who to receive care
from will still be preserved. Our veterans have earned their
health care benefits in many cases through blood, sweat and
tears. The least that they deserve in return is a choice.
Finally, I want to make sure that the significant
infrastructure that has been built, largely with taxpayer
dollars, since the current Choice program was created in 2014
is not lost as the VA transitions to a consolidated approach.
Implementation of the current Choice program has not been a
smooth or as easy as any of us would have hoped. Indeed,
setting up a program of such magnitude under such time
constraints never is.
I have heard complaints from providers in northern
Michigan, for example, that report having to spend significant
amount of staff time on the phone resolving authorization,
scheduling, and payment issues. It is far from ideal. I would
encourage the VA and both of the third-party administrators to
continue to work to resolve issues as they arise and make
Choice work better, faster, and easier for veterans and
community providers.
However, a lot of gains have been made, a lot of lessons
have been learned, and a lot of relationships have been built
in the last year and a half around the current Choice program.
As we move forward, we have to ensure that those gains are not
needlessly sacrificed in pursuit of the new, which is sure to
carry unforeseen problems all its own.
I look forward to hearing from all of our witnesses this
morning, and thank you all for being here. And I will now yield
to Ranking Member Brownley for any opening statement that she
may have.
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Mr. Chairman. And thank you for
calling this hearing on VA's future plan to provide safe,
quality health care to veterans by implementing a high-
performing network in partnership with Federal partners,
academic affiliates, and the community. VA believes veterans
will exercise their choice when it comes to where and when they
receive health care.
This is the third in a series of hearings held by the
Subcommittee to examine details of the care consolidation plan,
which was submitted to Congress in October of last year. Last
month we heard from stakeholders on eligibility criteria and
VA's plan to improve community care billing and reimbursement.
Today, we will receive testimony on the very important provider
networks.
I understand the VA's plan is to build a high-performing
network that will consist of three separate tiers, with tier 1
being with our Federal partners and academic affiliates. Tier 2
will consist of top-rated community providers. And tier 3 will
be the community providers who meet standard criteria.
VA's objective is to ensure veterans will have the ability
to choose which provider he or she would like to see for care.
According to the VA, the tiered network structure will allow VA
to provide the veteran with information to make an informed
choice about the right provider to see. The goal is to reduce
confusion for the veteran on where to seek high-quality health
care by streamlining the transition from a VA facility to a
community facility.
We are all aware that the devil is in the details. When the
plan was first received, the implementation of a high-
performing network was somewhat confusing and unclear. I hope
the VA today will shed more light on their plan regarding how
this network will be built and how veterans will, in fact, be
able to choose their provider. Continuity of care and the
quality of care provided through this network should be first
and foremost the top priority of VA.
Additionally, we must ensure that lessons learned from the
past programs such as PC3, ARCH, and the current Choice program
will be considered as we move forward with a new veterans
choice program. I appreciate the testimony we have received,
and I look forward to hearing from all of our witnesses today.
So thank you, Mr. Chairman, and I yield back.
Mr. Benishek. Thanks, Ms. Brownley. Joining us on our first
and only panel this morning is Billy Maynard, the President of
Health Net Federal Services; David McIntyre Junior, the
President and CEO of TriWest Healthcare Alliance; Dr. Baligh
Yehia, the VA Assistant Deputy Under Secretary for Health for
Community Care, who is accompanied by Dr. Gene Migliaccio, the
VA Deputy Chief Business Officer for Purchased Care. Thank you
all for being here today, I am looking forward to this
discussion.
Mr. Maynard, we will begin with you. Please proceed with
your testimony, and you have five minutes.
STATEMENT OF BILLY MAYNARD
Mr. Maynard. Thank you, Chairman Benishek, Ranking Member
Brownley, and distinguished Members of the Subcommittee, thank
you for the opportunity to participate in this hearing.
Health Net Federal Services is proud of our work leveraging
private sector best practices to supplement and complement
Federal agency capabilities. To this hearing, we bring the
perspectives and lessons learned from throughout our nearly
three-decade history supporting government health care entities
at the intersection of their care capacity and their need to
support their beneficiaries, in this particular case, eligible
veterans with care in the community.
My commitment to VA health care is personal. I am a veteran
myself. I served in the U.S. Army for ten years. I am the son
of a Navy retiree, born at Portsmouth Naval Hospital, and I am
the grandson of a World War II combat veteran who benefitted
greatly from the services of the VA following his return from
that conflict.
I take the mission of the Choice program to heart and in
this vein, I offer comments informed as much by the spirit of
service, the spirit that led me and many members of my family
to service, as by our business experience.
I want to thank this Subcommittee, and the Committee as a
whole, for your leadership on the issues at hand. This
Committee acted decisively in response to the revelations of
extensive wait lists at some VA facilities. In Choice, you have
created the foundations of a program that can serve as a viable
model for the integration of VA's direct care capacity and care
in the community as we look forward.
I also want to express my thanks to senior members from the
VA, who from Secretary McDonald on have worked tirelessly over
the past year to make the current Choice program work. In
particular, Dr. Baligh Yehia and Gene Migliaccio, both of whom
are here, have led key efforts to evolve the initial program
and proactively address issues that have hindered program
effectiveness in its initial implementation.
Today, over 2400 Health Net Associates located throughout
the regions we support, and the Nation as a whole, directly
support the Choice program, and it is a great honor for us to
do so. Working with their VA counterparts, our associates have
accomplished much. We have fielded some 2.5 million phone calls
from veterans and community care providers as well as veterans'
affairs staff; appointed what is rapidly approaching half-a-
million individual veterans to community providers who might
otherwise have remained on a VA wait list, and we have built a
registry of nearly 250,000 participating providers located
throughout the VA regions we support.
While there is still much to do, real progress has been and
is being made towards the kind of public-private partnership
through contracts upon which the effective delivery of health
care for our Nation's veterans now depends.
A few points specific to the topic of this hearing. First
and foremost, we believe all health care provided in support of
veterans is VA care, whether delivered directly by the VA, by
its close affiliates, or by community providers. Seamless
integration of that care, therefore, is key, particularly at
the intersection of the VA's capacity and community care.
Based upon our years of experience, we believe the only way
all care will be seen and received by veterans as VA care is
through mutual accountability in the framework of a public-
private partnership contract structure.
Second, it is now clear, based on eligible veteran demand,
that significant and continuing access to community-based care
will be absolutely necessary to support veterans' health care
needs in the future. Standardization in consolidation and the
development of clear and comprehensive policies addressing the
full range of community care eligibility and programs is,
therefore, vital. This was a central point in the independent
assessment, and it has been a lesson learned in the initial
implementation of Choice.
Third, we believe the preferred, also often referred to as
a tiered provider, network construct that is part of VA's plan
for the future can effectively deliver the necessary access to
care in the community going forward. While there are other
approaches, given VA's significant direct care mission and
capacity, a tiered approach will ultimately be the most
effective way for VA to optimize and integrate care while
extending VA's ability to better focus on its core
competencies. Of course, throughout that development, veteran
choice must be extended and preserved.
Whatever geographic or provider network development
approach VA takes, we feel it is necessary that VA partner with
single third-party entities within each geographic area to
administer all community-based aspects of the program. TRICARE
is a good example of the lessons learned from attempting to do
otherwise, as learned in the early days of their journey to the
integration of community and direct care.
The seamless integration of community care is vital for the
provider and veteran experience, and without seamless
integration, neither providers nor veterans will ultimately
want to participate at the levels necessary to ensure all
eligible veterans are cared for.
In closing, let me say that in a program like Choice,
veteran and provider experience is paramount. The success of
any future program will depend, in large measure, on three
interrelated imperatives. First, strengthening VA's capacity
planning and optimizing their capacity in the face of veteran
demand through Choice so that community care can be tailored to
ensure ready access in every location.
Second, making the provider experience as consistent with
community standards as possible, while respecting and
recognizing the VA's need for visibility and access to veteran
health care information.
And, third, streamlining the veterans' and provider
experience so they are better able to control the process and
receive and deliver care when and as necessary.
Health Net is proud to stand as a partner with the VA and
this Congress in helping deliver care to our Nation's veterans.
Thank you, Mr. Chairman and Committee for this opportunity to
present our views. I look forward to answering any questions
you may have.
[The prepared statement of Billy Maynard appears in the
Appendix]
Mr. Benishek. Thank you. Mr. McIntyre, you are recognized.
STATEMENT OF DAVID J. MCINTYRE, JR.
Mr. McIntyre. Chairman Benishek, Ranking Member Brownley,
and distinguished Members of this Subcommittee, it is a
privilege to appear before you this morning on behalf of our
company's nonprofit Blue Cross/Blue Shield and University
Hospital System owners, and our 3,600 employees, most of us who
are veterans and veteran family members, to discuss how the
Choice program is evolving in our 28-state geographic area
responsibility. I am going to focus on the current, and I am
going to focus on the journey we have taken.
Mr. Chairman, Janet Van Hagen is an Army veteran who lives
in rural America. Before you passed the Choice Act, she used to
drive four hours each way for health care. Now, thanks to you,
she receives her health care close to home. Janet's doctors,
joined by more than 180,000 providers in our geographic area,
that are leaning forward in at the side VA, to make sure that
those who are in the 28 states, that we are responsible for
supporting--receive the care that they need when VA is unable
to deliver it directly.
Yesterday, as is the case every day, more than 5,000
veterans in our area received care from this consolidated
network, accredited by your Act. That is up from 500 a day a
year ago. Of course, you might ask if things are happening as
result of Choice, why am I hearing complaints from my
constituents? That is a fair question. I would like to be
candid with you.
In spite of the early successes of standing up the program,
there has, and remains work to be done. You have modified the
law that was originally passed. We and VA together have been
modifying the tools and the processes to make the program as
you would have expected it. I would submit, however, that a 90-
day implementation period is extremely short. And at the end of
the day, those of us in the private sector had a little more
than 30 days to do our part of that work.
If you look at the comparative of TRICARE, and I was there
20 years ago at the beginning, they had more than three years
to design the program and implement it. And it did require
adjustments as we went forward. I know it is probably not
positive or popular in some quarters, but I believe that this
was a good thing for you all to do. I think it was the right
answer in response to the challenge that came out of Phoenix
and the other areas, and Janet Van Hagen would agree with that.
I have been impressed with the courage and the uncommon
intensity with which the VA has acted. Just like you, their
focus remains sharp. And the sustained pace and intensity at
which we all continue to operate is daunting. However, if you
look at our geographic area of responsibility, I believe that
we in VA are gaining on it.
This month, we will field more than one million phone
calls, with an average speed of answer of less than 16 seconds,
and an abandonment rate of less than 2 percent. More than
100,000 veterans in our part of the country will receive care
closer to home; a long way from the 2,000 served in the first
month of this program. And our claims processor will pay more
than 97.5 percent of clean claims within 30 days. And we have
now processed more than 1.8 million claims for providers.
Is our work finished? Not at all. We all have a lot of work
to do. The topic of this hearing gets to the next generation,
but we have work to do in our current generation. Our network
is finished, it is tailored to the demands of the VA medical
centers that we support. It includes the federally qualified
health centers, and it includes most of the academic medical
centers.
It is ready to be leveraged to have a tiered network in our
area. And most of the network is at market rate, which means
that we extend the buying power of the taxpayer in support of
the VA with any discount accruing to the budget of the VA. And
our turnover in network is less than 2 percent. It includes
specialty, primary care and behavioral health. And less than 1
percent of the appointment requests that we have require us to
go outside of our network looking for another provider.
Second, getting to scale is a challenge. We now have ten
sites of operation, 3,600 employees. On Friday, I was
privileged to be in El Paso to roll out the final operations
center, which is now serving our area.
Chuck Byers is a Vietnam veteran. Chuck Byers asked me to
convey to you his gratitude. Chuck Byers has cancer. Chuck
Byers was in a line to get care. And he was in a line to get
care not because people don't care, he was in a line to get
care because the number of providers available to deliver care
in the VA, in the market in which he resides, was not
sufficient enough to meet his needs.
Chuck Byers saw a cancer specialist in our network. Chuck
Byers is alive today. There are many Chuck Byers, and there are
many Janes across our area. We are on a pathway to improvement,
we are on a pathway to refinement, and we have work to do.
I believe that the leadership of the two gentlemen that are
on this panel, the Secretary, the Deputy Secretary, the Under
Secretary Shulkin, and this Committee, and Subcommittee, and
those on the Senate side are going to allow us to achieve the
success that we all desire. And that is that the Chuck Byers of
this world, who served our country with distinction, have the
opportunity when they have a need to have that need met,
whether it is met in the VA directly, at an academic facility,
a DoD facility, or in the community. Thank you for the
privilege of being here today. Thanks for the privilege of
supporting this population. And we, and our 3,600 employees,
and 180,000 providers are privileged to lean forward at the
side of those that served in the VA. Thank you very much.
[The prepared statement of David J. McIntyre appears in the
Appendix]
Mr. Benishek. Thank you. Dr. Yehia, you are recognized.
STATEMENT OF BALIGH YEHIA, M.D.
Dr. Yehia. Good morning, Chairman Benishek, Ranking Member
Brownley, and Members of the Subcommittee. Thank you again for
the opportunity to testify today regarding the Department's
plan to consolidate community care, specifically to further
discuss our community care network. I am accompanied today by
Gene Migliaccio, who is a Deputy Chief Business Officer for
Purchased Care.
Establishing a robust provider network is critical to
increasing access to quality care for veterans. Our proposed
network emphasizes veterans' choice, access to care, and
quality by partnering with community providers. Let me be
clear. Veterans will have a choice in our network.
First, they will choose whether they want to access
community care at all. Second, for those who choose to access
community care, they will be able to select a provider that
best suits their needs and their preferences.
Over the last couple of weeks, I have had a number of
meetings with folks on the congressional staff to discuss VA's
proposed community care network. During those conversations, it
became apparent to me that tiered networks has a different
meaning for different people. Some think of having to pay a
different cost share for providers in different tiers, others
think of a narrow network that limits the numbers of providers
or restricts choice. And when it comes to distinguishing
between providers, some people describe tiered networks as
emphasizing cost over quality. This is not how VA wants to set
up our community care network.
First, there will not be any difference in VA copayments
from provider to provider in the network. If a veteran does not
pay a co-pay in the VA, they will not pay a co-pay in the
community.
Second, we understand that some health plans distinguish
providers as preferred based on their ability to control costs
over quality. We want to flip that on its head by placing
greater emphasis on performance metrics that are related to
quality and satisfaction over cost. That is why we are working
hand in hand with industry to determine which quality and
satisfaction metrics are most appropriate and also commonly
used in the community.
Last, some networks are often narrow, meaning there is a--
they have a limited number of providers. That will not work for
our veterans. We have veterans in every community across the
United States and abroad. Therefore, we want to partner with as
many providers as we can.
At the heart of it, a community care network is simply a
way to organize our community partners and identify and reward
high-performing providers. This structure will provide veterans
with easier access to information so they can make informed
decisions.
Veterans who are eligible for community care will have the
ability to decide whether they prefer to receive care at a
local VA or in their community. And if they choose to receive
care in the community, they will have the ability to choose a
provider. However, just giving them a list of providers is not
enough. In my experience as a clinician, patients look towards
us to help them navigate the health care system and their
options. That is why it is critical for our network to identify
quality providers which will ensure that veterans are able to
make an informed choice.
We also want to be better partners for our community
providers. Just this month, I sat down with a roomful of
providers ranging from small practices to large health care
systems in Florida. They were direct about what works and what
doesn't work with Choice, and the changes they would like to
see in the future.
Their comments mirror the more than 600 responses received
from the private sector and 300 responses we received from our
own employees on our draft community care network performance
work statement. We are actively engaged, and this important
feedback is being used to draft the next step of our
contracting process, which is a draft request for proposals.
As we continue to move forward toward consolidating
community care, it is important to maintain our relationships
with Federal partners like DoD, and also our academic
affiliates. For decades, they have served as a foundation of
our community care network, and over time, these relationships
have led to the delivery of high quality care and also robust
care coordination.
Growing them will ensure that veterans continue to have
access to not only quality care, but in many circumstances,
state-of-the-art care while ensuring that we continue to train
the next generation of clinicians that will serve veterans.
Therefore, we want to make sure that these valued partnerships
are supported by the consolidation of community care programs.
In summary, we want to empower veterans to make informed
choices and improve their health outcomes. We also want to
ensure that we set up a program that aligns with the private
sector and encourages collaboration between VA and community
providers.
Mr. Chairman, I appreciate the opportunity to appear before
you today, and we are prepared to answer any questions you or
other Members of the Subcommittee may have.
[The prepared statement of Dr. Yehia appears in the
Appendix]
Mr. Benishek. Thank you, Dr. Yehia. I will now yield myself
five minutes for questions. And there are so many things I want
to talk about because I don't really understand the different
tiers, to tell you the truth, and how it all works. But I guess
the key question that comes to my mind is, is a veteran going
to be able to call and get an appointment for themself?
I mean, it seems to me that a huge part of the problem in
getting an appointment is somebody is making the appointment
for the veteran. Are you going to change this? When I, as a
physician, I refer the patient to somebody, I tell the patient
who I am planning to refer them to, and then they make their
own appointment. So is that going to happen now in this new
community care program? Dr. Yehia, can you answer that?
Dr. Yehia. I can. So let me--I think that is an excellent
question, and we want to move more and more towards--in that
direction.
Mr. Benishek. I think that maybe they can't hear you.
Dr. Yehia. Okay.
Mr. Benishek. Okay.
Dr. Yehia. Is that better?
Mr. Benishek. Yes.
Dr. Yehia. Currently what we do is, we do outbound calls.
So once a veteran is eligible, we send the phone number--their
information to our contracting partners and they reach out to
the veteran. But just as you describe, some patients want to
coordinate their own care.
Mr. Benishek. Like most patients, I would say.
Dr. Yehia. A lot of patients, yes. In our future state,
where we are hoping to move towards, is VA would be more in the
center of customer service and care coordination. I think for
veterans that want to make their own appointments, we want to
be able to provide that option. However, we want to make sure
that we can connect the dots. And so we don't want to just say,
here, go see your--make your own appointments, we want to
figure out a way to get that information back, so when they do
come back to the VA if they have to see another doctor, we have
the clinical information from that community provider.
And, as you know, some veterans have a lot of comorbid
conditions or complicated social circumstances, and they want
the VA to help them with--
Mr. Benishek. Yeah, I know, but that is sort of a
internalistic viewpoint, in my opinion.
Dr. Yehia. I think what I was getting at is that we want to
give them choices. Some folks want to say I want to make my own
appointment. And with that, we say great, we want to make sure
that we have the right process to get the information back.
Mr. Benishek. Well, can't the appointment be made right at
the time that the patient is referred, right there so the
patient can participate? The problem is that the appointment is
made without the patient's awareness, so then they find out he
is not available when the appointment was made.
Dr. Yehia. Yeah. We definitely don't want to do anything
that you are describing, which is more blind scheduling. So the
way that we work now, it is more of we get the veteran's
preference, and then we contact the community provider, and we
link the two up. But in some circumstances like you are
describing, a lot of patients say, hey, I will just make my own
appointment. And I think that is great, we just want to make
sure that we are able to track that, yes, they were able to get
in to see a doctor, and that we were able to get the health
information back from that visit.
Mr. Benishek. So the other question is, I guess I don't
understand the difference between why are there separate tiers?
I mean, why is there a core provider and then there is a
preferred provider? And what is that all about? I don't
understand that. Why isn't there one set of providers?
Dr. Yehia. Yeah. So over the last couple of months I have
been talking more and more about this. And the way that we
present it in the plan is just a way to organize providers. So
from the veterans' perspective they will not see tiers, they
will see a directory of providers. And those providers, as best
as possible, will have information about where they are, what
specialty they are, their affiliations, their quality,
satisfaction.
So it will be--this is kind of behind the scenes stuff. It
is, now we organize ourselves so that we can make sure that we
know that like providers are grouped together. For example, we
talk about DoD and Indian Health Service. We work with them in
a completely different way than the private sector. We don't
use Medicare rates. We pay Indian Health per person. So the way
that we actually interact with them is different. That is why
they are grouped together. And then we want to be able to
distinguish and reward those top quality providers, and they
are another group. So to the veteran, they won't see tiers.
They will see information about different providers. But for
the VA and for the provider community, we will be able to
organize ourselves so we can--we know the different types of
providers in a network.
Chairman Benishek. So the top tier providers are
incentivized some way than some other providers?
Dr. Yehia. No. The way that the incentives will work, the
incentives of giving no value-based payments is independent of
the structure of the network. So we want to group like
providers together. So if you are delivering excellent quality,
other veterans are recommending you, they are giving you high
satisfaction scores, somehow, we want to say that we are
measuring those, and we are providing the information for the
veteran to make a choice.
Based on those metrics, you will be able to get, as we move
more and more towards value-based payments, you will be able to
get rewarded for delivering excellent quality care.
Chairman Benishek. I am out of time. Ms. Brownley, you are
recognized for five minutes.
Ms. Brownley. Thank you. Well, just to follow up on that
line of questioning, so I understand in terms of the tiered
process, the veteran will not know the different tiers, in
essence. It is for internal use.
But it seems to me, I still, you know, in terms of the
second and third tier, you know, a preferred, well-qualified
doctor compared to a adequate doctor. And it seems as though,
quite frankly, we would want, you know, the best qualified
doctors for our veterans. And to make a distinction between two
qualifications seems odd to me.
Dr. Yehia. We, because we serve veterans in every corner of
the United States, we need as many as providers to partner with
us as possible. And so I think, at minimum, we want to set the
standards. You have to have a license. You have to be able to
practice in that state. So we will set a bar so that we make
sure that the veterans, when they see community providers, they
are credentialed, and they are able to serve them.
But just by setting one bar and not being able to reward
those providers that perform really well, I don't think that
goes far enough. And so the idea is, we would love to have
every single one of our providers preferred. It is not like we
are going to set, like, a percentage of all the providers will
be preferred. If you meet the quality and the satisfaction
metrics of the VA, anyone can become a preferred provider.
So it is not like we are limiting who can enter that group.
It is just based on your performance.
Ms. Brownley. Okay.
Dr. Yehia. We want to make sure that those performance
metrics align with industry. A lot of folks are already
reporting on those today. So we are not going to create some
new measures that don't exist. We want to use existing data
sets.
Ms. Brownley. So to Mr. McIntyre and Mr. Maynard both, I
think the VA just testified that they had had interviews in
Florida in terms of their network providers, to ask what works
and what doesn't work. I wasn't there for that process, so I
would ask you the same question in terms of your experience so
far. What do you think is working, what is not working, where
improvements should come from?
Mr. McIntyre. We have done interviews with providers in our
network for the last nine months to determine what changes
needed to be made in our processes. And we have implemented
those changes. We put the provider first from that standpoint,
because if the provider engagement doesn't work, nothing else
works at the end of the day. And we are in the process of
finalizing what we call Provider 2.0.
I will tell you as part of that, and a follow-up to the
question on tiering of networks, we set up our systems at the
beginning of 2014 with the adoption of PC3 to actually give our
appointing staff the ability to tier the networks. And so among
the best providers in our communities, they are the first that
we go to for appointing.
So if we know, for example, there is a neurology
appointment need in a particular community, or there is a
urology need that is very specific, we will seek the top
urologists out of our network, and they will end up in our
systems in the front of the appointing staff first. That is not
an uncommon strategy, and we have been using that from the
start.
Ms. Brownley. So in terms of providers and--I understand
that you are interviewing. You are hearing from them. You are
making improvements, you know, daily as you have moved forward
to kind of perfect the system--
Mr. McIntyre. Yes, ma'am, it is--
Ms. Brownley [continued]. --and within the network, and are
there any outstanding issues that you have limitations, where
you are hearing from the provider, but because of VA and
regulations that are limitations to you to improve it, do you
have full authority to make all of those improvements?
Mr. McIntyre. Yeah, great question. The first set of things
we brought back to Congress. Because there were limitations in
the original law that was passed, and you all have acted on
those now, and the VA has acted on them policy-wise and pushed
them over to us operationally.
The set that we are working now, and we are down to the
lower part of that list, we in the VA, particularly these two
individuals that are leading the effort internally to VA, are
working those last remaining mile issues to make sure that we
have worked through what needs to be done to make the provider
engagement better in our geographic space.
Ms. Brownley. Thank you. And Mr. Maynard, do you have
anything to add?
Mr. Maynard. Yes, if I could just add one thing specific to
the questions both you and the Chairman have asked on this
issue. If there is a remaining challenge as we look forward, I
think it centers on the concept of eligibility and the
parameters of authorizations under which eligible veterans are
seen.
And this begins even at very routine levels. I know there
are many doctors here on this distinguished panel. But even at
the primary care level you have providers that are looking at a
presenting patient who presents with a variety of conditions
that may, in fact, go beyond the boundary of the eligibility.
Many of the challenges in delivering care begin right then and
there around the boundaries of the authorization or the
eligibility and what presents itself as medically necessary.
So we continue to work with the VA around the definitions
of those eligibility parameters, particularly at levels like
primary care, where patients present and may actually need to
be expedited directly from there to a specialist or to some
further care beyond the boundary of the original eligibility.
I think the more that we can do to expedite that and ensure
that providers are not prohibited from addressing what is
medically necessary while they are there as the veteran
presents, and that from there, the path to whatever follow on
care is itself expedited, the more we are focused on those
issues, the more the program will improve in support of
veterans.
Ms. Brownley. My time is up. I yield back. Thank you.
Chairman Benishek. Dr. Roe, you are recognized.
Mr. Roe. Thank you, Mr. Chairman, and thank you and the
Ranking Member and the staff for putting this together. And I
certainly appreciate the fact that this is not easy. To put a
network together across the country is a big bite of the apple.
And I think consolidating all of these, certainly into
tiers, I don't have any particular problem with that. The real
question that I have are more about function. I have a health
care card here. I know exactly where I can use it, what it is
good for. Does a veteran actually have that?
And the example I am using here is, like with Dr. Benishek
was trying to get to it a minute ago, if I go in and I don't
think I am getting the care that I need--and Mr. McIntyre
presented a very compelling case of a veteran who did get the
care they need, I can tell you one who didn't, who last April
went to a VA, got a FIT test for colon cancer screening,
because they don't do routine colon cancer screening.
He had some bowel changes. Came back in August of this past
year. Had a positive FIT test. His colonoscopy was scheduled
for April 5th of this year, 2016. Went to the Choice--finally
got to the Choice program after having X-rays done. That was in
November. He finally got his colonoscopy in January, and he has
Stage IV colon cancer.
So those stories can be told over and over. That was a
failure. The question is, does the veteran actually have a
choice when, what Dr. Benishek was saying, when I go in there,
if I don't like the care I am getting, can I go take my card
and make an appointment and see a doctor that I want to see?
Because I think that is how the VA gets better and, certainly,
we can credential easily.
I mean, I look at our local system--at our hospital
system--if you are credentialed to do surgery at the hospital,
your license is good in the state, that can be done fairly
expeditiously, because the patients go back and forth between
those hospitals anyway.
So that is not a hard thing to do. Maybe in rural areas it
is a little harder, but in most areas of the country now, we
have primary care people and specialists. Can the veteran
actually take this card and go see a doctor that they choose?
That is a question I am asking.
Dr. Yehia. In part. I mean, that--what you are asking--what
you are describing is the way that typical health insurance
plans work, which is, you have a health insurance--you go--you
look at the network, go to whoever you want. But VA's community
care network is not a health insurance plan. It is an
integrated system with the direct care and the community.
So who can do--there are some folks that could do that, so
our 40-milers today. If you live more than 40 miles' driving
distance from a facility, you can take that card, and you can
go to someone in the network and receive care. But the other
criteria of how you access community care is from being--not
offering the services of the VA or a wait time. So it is harder
for someone to just walk--without knowing if you are actually
waiting on a list to know if you can actually access community
care.
Mr. Roe. See, I think that is a mistake. I think what we
need to do is, the veteran needs to be in charge of their
health care, and we as providers, both the VA and the
community, need to provide that care for them.
Many veterans will very much like the care they get at the
VA at home.
Dr. Yehia. Yeah.
Mr. Roe. They love it. I mean, I have to say that they have
very high marks. I meet very few people who don't. There are
some, but for the most part, I think if you surveyed the folks
in our area, they would say the VA does a great job, and there
would be no problem. In other places that is not true.
And so I think the veteran should be able to have a choice,
a real choice, and not get hung up like this particular--and
hundreds or thousands of other veterans--are tied up in the
system.
And as Dr. Benishek was also saying, that the absolute
simplest thing I ever did in my practice--I have said this
until I am blue in the face--is to make an appointment. And if
I saw someone, I would walk them out or send them out to the
front desk, make an appointment with Dr. Jones. My staff would
pick the phone up and call and get an appointment with Dr.
Jones. If it had to be urgent, I might even get on the phone
with Dr. Jones. That is how it works. And it works really well.
Dr. Yehia. Yeah.
Mr. Roe. And what we have done with the VA has complicated
this with so many layers of bureaucracy. We have made something
that is complicated, that is not. So I think the choice needs
to be the veterans'. And they should be able to have that
appointment when they leave the VA. If they see a VA provider
that day and that VA provider says, ``Well, you need to see so-
and-so, and he is not available here at our VA,''--maybe it is
a back issue, hip, whatever--before they leave that VA that
day, that appointment should be made.
And what I was told when I went home and talked to the
providers that a primary care provider has a registered nurse,
an LPN, and an assistant. I never had anywhere near that kind
of sophistication. If four people like that could not make an
appointment that day, you need to re-evaluate your processes, I
think.
Dr. Yehia. Yeah.
Mr. Roe. You agree with that?
Dr. Yehia. No, I agree. I think that, you know, I was just
in clinic last Friday, and I did the same thing. I had a
patient that needed to be seen by a specialist, and I picked up
the phone, and I called them and got them in for next week. So
I think that is how a lot of people--
Mr. Roe. That works.
Dr. Yehia [continued]. --practice. I think that is the
intent why we are here today, is to consolidate and improve
care. There is a part of the plan that we talk about, this
referral and authorization process, that is so clunky right
now. And there is the eligibility criteria that we have been
talking about. There is so many variations on it.
If we get to very crystal clear, if you are eligible or you
are not eligible for community care, then I think we can move
up when you can--an appointment to the time when you are
leaving the clinic. We have to get there first, because right
now we have to double check and triple check--
Mr. Roe. Yeah.
Dr. Yehia. --if they meet this, if they meet that. And that
requires people. And the scheduling clerk sometimes can't do
all that, which is different than what it is in the private
sector.
Mr. Roe. Sorry, my time has expired. But just, your
motivation when you saw that patient last week was to get their
care given.
Dr. Yehia. That is right.
Mr. Roe. And all that other stuff in between, you weren't
interested in. And all the patient was motivated was to get the
care.
Dr. Yehia. Yeah.
Mr. Roe. That is what we need to simplify. Yield back.
Dr. Yehia. I agree with that.
Chairman Benishek. I now recognize Ms. Brown, the Ranking
Member of the full Committee.
Ms. Brown. First of all, I want to thank both of you all
for letting me sit in on this meeting, and I am going to be
really quick. But I have two people there from my area, Dr.
Yehia, and I want to follow up. And also, I have a statement
from Action News Jacksonville Investigation, and I want both of
you, one from Jacksonville and one from Gainesville University
of Florida, we are very happy.
But following up with Dr. Roe's question, because I
understand the card, but the main thing is that patient has to
have prior approval in order to get paid. And Dr. Roe would be
very upset--and I have heard lots of discussion in this
Committee about people not getting paid and why they are not
getting paid, and so their practice is closing or something. So
you have to address that.
And then the person, Madeline (?), who attended school in
Jacksonville, the same school my daughter attended, Sandalwood,
I need you to talk about this Action News investigation of the
VA in my area, because I am the Ranking Member, and there is a
serious wait time, or not happy with Choice. So those are my
two questions. I met with all of you all before, had hearings
in my area. So can you please address it?
Dr. Yehia. Sure, why don't I start?
Ms. Brown. Yes, sir.
Dr. Yehia. Thank you so much for that question and for
representing your area so well. We have to be good partners to
community providers. It is how you build a network, and one
of--the most critical thing, probably, is making sure that we
pay timely and accurately, 100 percent.
And I think right now there is three areas that we have to
improve on. Number one is the eligibility criteria that we just
talked about with Dr. Roe, is some veterans will take their
Choice card, and they will just walk right up to a community
provider and they will deliver care. However, that is not how
the law was written. There is certain criteria that you have to
meet in order to receive that health care.
So when we get a bill, we can't pay that bill. Even though
we would like to pay it, we can't pay it, because that veteran
did not meet criteria that were established. So getting to a
simple set of criteria that makes sense to the veteran and that
we clearly communicate to everyone so they know who is eligible
and who is not, will be very important.
Number two--and this is something that we fixed about a
month ago--is that we were requiring medical records before we
actually paid the bills. And as a clinician, I want the medical
records back. It is very important. And we still want them
back. But we don't have to tie it to payment, and remove that,
and the payments have become better and better and better on
both sides of the United States for Health Met and TriWest.
Ms. Brown. Is that retroactive so those physicians will get
their pay.
Dr. Yehia. I--is that retroactive, do you know? I would
have to check.
Mr. Maynard. Yes. Coupling with the medical bills.
Dr. Yehia. Yes, it is. Thank you for that.
Ms. Brown. Okay.
Dr. Yehia. And then lastly is, we want to provide more
transparency for the doctor. So the doctor right now sends a
bill, and they don't know where it is at. And I think on both
our partners, Health Met and TriWest, are taking action so that
we can improve the visibility into the system, because many
times, you just want to know did I get--did they receive the
bill? Do we have to send them another one? When am I going to
get my check? And that ambiguity, or lack of information,
creates anxiety. And so we want to be able to improve that. And
that is some of the things that we are doing over the last
couple weeks.
Ms. Brown. Thank you.
Mr. Maynard. Yes, ma'am? Good to see you again and good to
meet with you earlier this morning on some of these issues.
First of all, I would just like to state that any
shortcoming or inability to facilitate health care in support
of eligible veterans is, obviously distressing and requires
attention, every single individual one, even in the face of the
increasing demands and the volumes that are there.
I think it was particularly unfortunate--you know, we have
been reaching out in Jacksonville to the press outlet, in
particular, about the specific issue, and I think it is quite
unfortunate that both the personnel from the provider offices
where veterans were involved chose to remain anonymous, which
makes it very difficult to find exactly the specific instance
that they are addressing there. Nevertheless, it is something
that we take quite seriously.
I think as Dr. Yehia addressed in a previous response just
a few minutes ago, real progress has been made, but there have
been challenges around some of the--and I think he used the
word "clunky"--procedures of referrals and particularly
incidents that began where a veteran was seen and required
further care, does activate a loop going back through from that
provider or veteran back into the VA and back out through our
processes to authorize that care and actually get it appointed
again.
I think as this Committee has been rightfully focused on,
that is not directly in accordance with all the commercial best
practices that could be applied, and I do believe that not only
the improvements that we have seen, as you and I discussed, we
are appointing some 800 to 1,000 veterans just within the
Jacksonville domain itself, not counting all the way down to
Gainesville, more than 90 percent of those are being appointed
well within the five-day standard. There is plenty of access
within the network.
Nevertheless, as veterans need to be seen, secondarily or
subsequently, there is much that we can continue to do, and
will continue to partner on with the VA to expedite that care
as it presents itself to providers and as it develops.
And just on the provider payment issue, quickly to follow
up to Dr. Yehia, I want to, again thank the Department's very
close collaborative work with both Dave McIntyre and my company
over the past three to four months to evolve and modify the
contract. I think we are all very convinced and already have
evidence that those providers that were challenged by the more
complex payment methodologies are already seeing a very
significant relief in the first three weeks after that
modification. I think we expect all providers to be current
very expeditiously as we move into the spring.
Ms. Brown. Well, thank you all for your service, and thank
you all for letting me sit in.
Chairman Benishek. Dr. Abraham, you are recognized.
Mr. Abraham. Thank you, Mr. Chairman. I want to kind of
reflect on what Dr. Benishek and Dr. Roe started the discussion
on. I am just a country doctor here, private care. I have
practiced for many, many years. And, yeah, it is a big bite of
the apple to institute this. But I don't think it is that big
of a bite. I mean, this is what you two guys do for a living. I
mean, you enroll people, and this is you all's forte. You all
are experts in your field.
And like Dr. Roe said--again, maybe I am making it over
simplistic--but have the card, get the providers accredited.
And, again, we keep having the same discussion over and over
about accreditation. Well, if they come from an accredited
medical school, if they are licensed, and they don't have any
criminal investigations, well, why not put them in the network
and see how they do?
And I know you need your records back. Well, let them have
access to the EHRs or put the onus on the private physicians to
either fax or email you a copy of that office visit. Again, I
am the private practice guy, and I am the primary care guy
here.
I guess my question to you Dr. Yehia first, what is a
veteran going to see? You say these objective datas, these
quality measurements, are internal. What is that veteran going
to see that will steer him or her to a tier 2 or tier 1
provider as opposed to a tier 3 provider?
Dr. Yehia. So what we want to do is provide them with
information. So they won't even see a tier 1 or tier 2. That
won't be a term that--
Mr. Abraham. No, I understand, but--
Dr. Yehia [continued]. Yeah. The way that--
Mr. Abraham [continued]. --how are they going to know--
Dr. Yehia [continued]. Exactly.
Mr. Abraham [continued]. --whether it is a tier 2 or tier 3
based on just, you know, pixie dust, basically, if you are
going to say, well, it is tier 2 or tier 3. But what is a
veteran going to see, he or herself--
Dr. Yehia. Yes.
Mr. Abraham [continued]. --that will actually--this is why
this is a tier 2 or a tier 3, or a tier 1 provider?
Dr. Yehia. So they will be able to choose whoever they
want. What we are going to be able to do is give them
information to choose what they want. So first there will be
basic information about the provider, where they are located,
their specialty, what they do. That is, kind of, that is set.
And then using, kind of, private sector metrics, so things that
are already agreed upon that CMS uses--
Mr. Abraham. Do--
Dr. Yehia [continued]. --such as--I was going to--
Mr. Abraham. And let me interrupt you.
Dr. Yehia. Yeah.
Mr. Abraham. Do you already have that objective check box
formulated for the VA as for those metric measurements that
will distinguish between a tier 2 and a tier 3 provider?
Dr. Yehia. We have--we don't have that today in our
community care program, but in the draft request for proposals
that we are developing, we are putting a list of different
quality metrics that we want to measure. And so those get to--
like do you have--is your hemoglobin A1C in control?
Mr. Abraham. Right.
Dr. Yehia. Are you asthmatic and do you actually have an
inhaler? So they are not--we are not talking about things that
are so off the wall. These are basic things that a lot of your
providers--
Mr. Abraham. And I guess that is my point. These metrics--
Dr. Yehia. Yeah.
Mr. Abraham [continued]. --are already in any electronic
health record--
Dr. Yehia. Yes.
Mr. Abraham [continued]. --I have ever accessed.
Dr. Yehia. Yes.
Mr. Abraham. And I have seen my share of them, I am sure.
And, again, you check the box. It is a matter of hitting the
key--
Dr. Yehia. Yeah.
Mr. Abraham [continued]. --and the computer picks it up.
And then it is part of the record. I guess my other concern is,
as a family doc--like, Dr. Roe was saying, like you were
saying--when you had your patient the other day and you
immediately went and made a referral, if I need--if I have got
a patient with hematuria, blood in the urine--
Dr. Yehia. Sure.
Mr. Abraham [continued]. --and going back to your urologist
example, and I need a urology appointment, am I going to have
to go back to the VA to get that specialist, or can I walk out
to my receptionist and say, ``Go to Dr. Smith right down the
street, the urologist?'' Again, if I have to go back to the VA
for that specialty care, then I worry what--all of a sudden the
cycle starts again, and it may be 30, 60, 90 days before he or
she can be seen.
Dr. Yehia. No, I think you have a great point. So if you
are being seen in the community for urology and let's say you
discover that someone has diabetes and you can't just directly
refer them to the endocrinologist because we didn't authorize
that care. However, the way that they would do is, they would
call the VA and they say, ``Hey, this person who I figured out
has diabetes, is there a diabetic specialist that could be
seeing him timely?'' If not, then we will--then they can access
the network for that.
Mr. Abraham. And I guess that is my rub, is that call that
I have to make that interrupts my patient care, because then I
lose that patient back to the VA and may or may not get those
records back, if I don't have that access to the electronic
health record. So it is just that continuity of care that I
worry about.
Dr. Yehia. I am agreeing with you in that spirit is that we
have to find better ways to share information. You made my
point for me, which is a lot of those things are in the EHR.
The only thing that we want is to be able to get that
information and present it to the veteran.
And so it is not asking for the community provider to take
something more onersome than what they normally do. And to be
able to report this information will be voluntary. It won't be
a requirement for them to share that with us. So for those that
have--that feel inclined, will be able to take that information
and share it with--for the veteran, so they can make decisions.
What we are working on doing is, how do we get to a place
where they don't even have to fax us anything?
Mr. Abraham. Exactly.
Dr. Yehia. Like, we can actually start sharing information.
Mr. Abraham. Right.
Dr. Yehia. This is something that I think all of health
care is struggling with now. So it is not just the VA, because
I don't think anyone has, you know, figured it out completely.
When you are in an internal health care system, it is easy to
share records. But when you start going from one health care
system to the other, it becomes harder.
So I think we are going to continue to evolve as health
care evolves there.
Mr. Abraham. Okay, thank you.
Dr. Yehia. Thank you.
Mr. Abraham. Thank you, Mr. Chairman.
Chairman Benishek. Mr. Takano, you are recognized.
Mr. Takano. To follow up on these concerns, I would just
take my own--the kind of questions that Dr. Abraham was asking
and Dr.--
Voice. Roe.
Mr. Takano [continued]. --Dr. Roe--excuse me I was blanking
on his name--Dr. Roe is asking about patient choice, I think we
face in the private sector health care the same anxieties. But
the stakes can even be even higher, right?
If I go out of network, I can pay 50 percent more for going
out of network. And it is on me to find that out. And I don't
know that dealing with my private sector health care folks are
any easier getting through on that customer service line.
So I don't know that, you know, putting these expectations
on the VA, which is not an insurance plan, right? Well, you
were not set up as an insurer. You are having to do a whole new
thing in terms of creating payment plans.
I mean, the concerns of my colleague from Florida, our
Ranking Member, about making sure providers get paid, you are
trying to simplify and consolidate all the different care in
the community. In other words, care in community means--care in
community means are non-VA private sector providers out there
who are under all these different plans, right?
So my question is for Mr. Maynard and Mr. McIntyre. Do
you--are you optimistic that this consolidation plan under the
VA is going to make it far more easier for you to recruit
people into your networks if providers can be assured that they
are going to be paid timely and there is a simplified process,
do you think that is going to really enable you to provide
robust networks?
Mr. McIntyre. I think that the consolidation makes a lot of
sense. It is confusing to everybody that is involved in this
process when you have got multiple plans that pay at different
levels, that have different requirements, and require different
types of management. And the VA is to be commended for taking a
look at how do they bring those pieces together?
As it relates to recruiting itself on the provider side in
the area that we are responsible for, we have been able to
successfully reach out and bring providers into the network in
the areas where we in the VA believe that they are necessary.
The one thing that I would say is that, you know, these things
take a while to refine.
And back to the issue of tiered networks, the Defense
Department has a term called ``right of first refusal.'' And
the objective there is to make sure that the Federal footprint
that has been paid for by the taxpayers is maximally leveraged.
And what we did in TRICARE during the term that we were
involved in that, was to actually profile each facility and
determine what kinds of services were available and in what
supply. And those were the only ones that we went back and
determined whether there actually was the ability to push that
specialized patient back in.
So I think this--I think you are on the right path. The
VA's on the right path in terms of trying to move these pieces.
Mr. Takano. Well, let me ask this. So Dr. Yehia, from the
point of view of the veteran, they are just going to see
whether the doctor is in network or out of network, right? They
just--it is--they will see if the VA provider they want to go
to is eligible and that is, kind of, a point one, but not every
veteran will be eligible to see certain practitioners; is that
right?
Dr. Yehia. They will not see in and out of network. They
will just see one network, and that network will have all the
VA facilities and the community providers. So there is not an
out-of-network benefit.
Mr. Takano. So it is much, so from a standpoint of
veterans, much simpler than the task I have, right?
Dr. Yehia. Yes.
Mr. Takano. Because I have to figure out who is in network,
who is out of network--
Dr. Yehia. Exactly.
Mr. Takano [continued]. --where I can--and who is going to
be paid, which facility, which emergency room will take me. So
for the veteran, it is potentially a lot simpler.
Dr. Yehia. That is right. And I think you made an important
point, which is, I think some folks think of the community care
network, or the community care program, as an insurance plan.
It is not. It cannot stand alone. If there was no direct VA
care, that program cannot stand alone to provide all the health
care needs of veterans. We have to think of it as an integrated
system where together internal VA care, community care, now
that actually forms the health plan, that actually forms what
is called, you know, minimal essential--
Mr. Takano. So if you are a provider, if you get everything
in order, all your ducks in order, the payments, and you
attract a lot more physicians, a lot more partners, the veteran
could probably have a lot more choice than someone like me
potentially.
Dr. Yehia. They probably will. Yeah, I mean we have a--not
only that, because of some of our specific relationships, they
all have access to some services that people in the private
sector don't have that don't have access to. Let me give you a
quick example. In my practice, in Philadelphia, we were doing--
across the street at the university we had clinical trials that
no one else had access to except for our veterans. And so our
veterans were getting access to some of the new hepatitis C
medicines before they came on the market. And so I think our
network and what is part of our network, not only delivers good
quality care, but access to some state of the art care that
other folks don't have access to.
Mr. Takano. Well, I don't have time to get into the cost,
but potentially, even the cost at below what some of--and in
the private sector as well, because you negotiate the drugs and
all that sort of stuff. So access to the latest drugs at better
costs, so potentially the choices are even better for the
veteran under the track you are going.
Well, thank you. I yield back.
Mr. Benishek. Dr. Wenstrup?
Mr. Wenstrup. Thank you, Mr. Chairman. So my thought is
that I would like to see the primary care doctors be the
gatekeeper for the referrals. That is the doctor you have a
relationship with, that is what you just did in the example you
gave. And I would even like to see it, whether there is an
option, you know, of the 30 days or 40 miles. This is whether--
even if someone is available within the walls of the VA, but
you know that the doctor down the street is probably the better
one for this patient for whatever reason, shouldn't the primary
care doctor have that authority? Do we need to grant that
authority on this level? How can we help here?
Dr. Yehia. So actually in our plan, because I believe the
heart of care coordination is the veteran-primary care doctor
relationship.
Mr. Wenstrup. Agreed.
Dr. Yehia. And we talk all about that here. And I also
agree that they are the heart of the referrals. And for--if you
have a primary care doctor within the VA, they will be the ones
that coordinate referrals. Some referrals will go inside, some
referrals will go outside.
Mr. Wenstrup. Uh-huh.
Dr. Yehia. That is true. I think it becomes a little bit
harder when you have a primary care doctor outside.
Mr. Wenstrup. Uh-huh.
Dr. Yehia. The only thing that, but I think we can improve
on that. The only thing that we want to do is provide more
visibility to the community primary care doctor about what
services are offered at the VA--
Mr. Wenstrup. Uh-huh.
Dr. Yehia [continued]. --because traditionally, most of the
veteran--the patient they see they would send to their friend
down the street, or someone--
Mr. Wenstrup. Right.
Dr. Yehia [continued]. --else in the community, partly
because they don't know what is offered. And I think if we can
give more visibility on, oh, actually we have really good, you
know, diabetes doctors here, and really good, you know,
cardiologists at the VA, they can start referring things back
in an appropriate fashion. So I agree with you, the center
relationship is that veteran with the primary care doctor.
Mr. Wenstrup. Yeah, and you are right, I mean it just
becomes an awareness of who is at the VA and who is available,
because they are not the person you have traditionally referred
to.
Dr. Yehia. Yeah.
Mr. McIntyre. That is exactly what we did in TRICARE with
that concept I was talking about in terms of right of first
refusal. And then you want to map out what is available
facility by facility so that you are not posing a challenge to
someone when they are trying to find care that needs to be
delivered. In our network, there are 50,000 primary care
providers stretched across every zip code in the 28 states. And
so if you are outside of 40 miles, you have the ability to go
and see a primary care provider if we are able to put that in
place.
Mr. Maynard. If I could just add one point to that. I think
that is why it is very critical that if we are going to
actually have veterans' choice, veterans' choice really needs
to begin with the choice as to where to be linked from a
primary care perspective, to be linked within the VA directly,
or to choose to be linked for primary care purposes in the
community so that then the processes can proceed from there,
and that gateway that you spoke to will actually be
established.
Mr. Wenstrup. Is there anything we need to change from the
legislative end to make that more workable?
Dr. Yehia. I think there is--I think to be able to
highlight that relationship would be important, and we can chat
more offline about some options.
Mr. Wenstrup. Okay.
Dr. Yehia. Thank you.
Mr. Wenstrup. Thank you. I yield back.
Mr. Benishek. Ms. Kuster, you are recognized.
Ms. Kuster. Thank you, Mr. Chair, and thank you to the
panel for being with us.
I have a question on the academic medical centers. And in
New Hampshire, where I am from, we have a top-rate academic
medical center, Dartmouth Medical School, and a close
relationship with the VA. Dartmouth is also affiliated with a
very, very, large medical center, one of the rare rural
tertiary hospitals in Lebanon, New Hampshire. And also a series
of clinics around the state, including my district. And my
question is, when you talk about including academic medical
centers, are you also including their network of care in a
situation like this where they run clinics all around the
state?
Dr. Yehia. Yes, we want to sign up as many providers as
possible. When we talk about the specific partnerships with
academics, we focus on those teaching relationships where we
actually have residents and fellows that go back and forth. And
so I think that there was a point that the Chairman made about
making sure that they have the same standards as everyone else.
And we want that to be the case. So we are not going to like
carte blanche, just because you are an academic, we send you
all our business. There are specific relationships where we
send trainees back and forth, and there is a volume need. So
they need to have a certain case mix, you know, in surgery, to
be able to actually have an accredited residency and to be able
to support trainees. So it is only in those circumstances that
they are considered core providers. If we don't have a
relationship, let's say we don't have any residency in
dermatology, they would compete and be on par with everyone
else in our commercial sector tier.
Ms. Kuster. Okay. I understand that from your perspective;
I want to understand it from the veteran's perspective. Is your
answer meant to lead to the veteran being able to access the
care in their community through these clinics?
Dr. Yehia. Yes, I think from the veteran's perspective and
the community provider's perspective, we are interested, and I
am sure Dartmouth is an excellent institution, we would love to
sign up every single one of the providers. And so from the
community provider perspective, we want them all to join the
network. That means more choice for the veteran.
Ms. Kuster. And along the lines of the indicators of
quality, I just want to make a point, Representative Kaufman
came to New Hampshire for a regional field hearing on our
heroin epidemic, which we now know that four out of five heroin
users started on prescription medication. And we have now
uncovered that part of the problem is an inadvertent use of
quality indicators in Medicare that is leading to reimbursement
decisions being made on the basis of pain surveys, which is
leading to the unintended consequence of over-prescribing of
opiates. And we have a bill, Representative Mooney, our
colleague from West Virginia, and myself, have a bill to change
that. But I am concerned, and I want to put this on the record
right up front, that that not be used as a quality indicator in
anything that you may be doing, because veterans have had a
very challenging experience with this.
Dr. Yehia. Yeah, and I would agree with that. I think there
is some, this is one of the things that we distinguish
ourselves from the private sector. I think they probably had a
well-intentioned reason to do those satisfaction surveys, but I
have seen many of my colleagues that are excellent clinicians
and they are doing the right things, and that may mean not
prescribing an opioid, but maybe physical therapy or
acupuncture. And because the patient didn't walk out with a
prescription, they give them a bad score, but they are actually
excellent doctors. So we have to be very clear about the
metrics that we use. I definitely would agree with that.
Ms. Kuster. Yeah, and if we could just say that right up
front, that any type of--you have to think through what might
happen in using these different metrics.
And then the last question has to do with one that
frequently comes up when we are talking with the Secretary and
the VA, and that is the issue of co-pays, out-of-pocket expense
to the veteran. I know that we want to keep that as low as
possible, but I am concerned, just given that the taxpayers are
at the other end of this equation, that we are not sort of
incenting people to use the VA when they have perfectly good
health insurance from another source that might be more
appropriate. And for this I am talking about not the veteran
experience related, and I think I may be going over my time,
but if we could submit that for the record.
Thank you very much.
Mr. Benishek. Mr. Bilirakis, you are recognized.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it
very much. Thanks to the panel as well.
With regard to the costs, I have a question. Of course
quality of care, veterans deserve the best. No question, that
is imperative. But do you have any metrics as to--are you
tracking what the costs would be within the VA and also outside
the VA under the Choice program?
Dr. Yehia. Yeah, we are monitoring the spend on the Choice
program very closely. We have a set limit that was provided by
Congress, and so we monitor that very closely. So we do have
that.
Mr. Bilirakis. Can you give me some answers?
Dr. Yehia. Sure. So we spent last fiscal year, we had about
$3.5 billion that we used out of Choice funds to deliver care
to veterans. This year we are anticipating kind of something
similar, about $3 billion to $3.5 billion. So that gives you a
little bit of a sense of--at least just from Choice, that is
only Choice care that we spend financially.
I think to your point though, I think what you are getting
at is, as we continue to make the program better, more and more
people are using the program. And that is something that we
have to be very cognizant about, because as we make a product
that people want to use, there comes--there is a cost that is
associated with that. And as we start considering developing
new legislation that will consolidate community care and create
a new program, how do we make sure that we have the right
resources to actually deliver that benefit? We are seeing more
and more people using the program than ever before.
Mr. Bilirakis. How are you getting the word out? I know we
are doing our job here to get the word out, with regard to the
program, the eligibility requirements, what have you. Tell me
that, and also, how are we getting the word out to the
providers or potential providers that want to participate in
the program?
Dr. Yehia. So we have done a number of outreach for both
veterans and community providers, you know, including, we have
a website, that website specifically has an area just for
providers, an area just for veterans. We have issued letters to
all of our community providers that we were working with before
Choice, encouraging them to join Choice, similarly to veterans,
mailers, so we kind of, are trying to use different avenues to
reach more people. I will say probably the biggest thing that
we do is really word of mouth, which is the local medical
center talking to their veterans in town halls and their local
providers, ask them to sign up. And as Dave and Billy can
attest to, we have seen a big increase in the number of
providers that have joined both of the networks.
Mr. McIntyre. And on our end, we had the Blue Cross/Blue
Shield plans and universities that own our company that are
indigenous to the 28 states reach out to their networks across
their states to be able to give them the sense that this was
there, and how they would sign up. And we are signing 300 to
500 doctors up a day.
Mr. Maynard. And it is the same with us and both Dave's
organization and mine also had deep foundations in the TRICARE
program, and were able to approach all of the participating
providers there who also were reimbursed under Medicare and
have been very receptive to expanding access and support of
veterans as well under this new program.
Mr. Bilirakis. With regard to dental care, those who are
eligible under the VA, are they also eligible under the Choice
program?
Dr. Yehia. Yeah, yes, sir. So if you meet the eligibility
criteria for dental, which are pretty high--
Mr. Bilirakis. I know that.
Dr. Yehia [continued]. --there is a number. And we can't--
either we don't provide dental care at the VA, or there is a
wait issue, they can get that care in the community. Also, we
know that a lot of the dental care is already delivered in the
community today. We don't have dental practices at most VAs, so
most of that benefit is delivered in the community already.
Mr. Bilirakis. Very good.
Dr. Yehia. Thank you.
Mr. Bilirakis. Okay. Anyone else want to comment on that?
All right. Thank you very much. I yield back, Mr. Chairman.
Mr. Benishek. Mr. O'Rourke, you are recognized.
Mr. O'Rourke. Thank you, Mr. Chairman, and I would like to
thank everyone who has testified today, and thank you also for
your answers to our questions.
Mr. McIntyre, you mentioned being in El Paso on Friday.
Thank you for being there, for making the commitment to our
community, and we really appreciate TriWest having an operation
center that is hiring veterans in El Paso. And Dr. Yehia,
through you, I want to thank Mr. Joe Dalpiaz, VISN Director for
Texas, who was also there, for his commitment to the community,
and for everything that you all are doing.
I have two questions, I think, on this subject. We were
told by Dr. Clancy last week, that while we thought we had
41,500 authorized funded but unfilled positions at VHA, the
number is now 43,000. Given this consolidation, this admission
that the VA will not be able to provide all things for all
veterans within the walls of the VA medical facilities, this
excellent article by the Under Secretary Shulkin in the New
England Journal of Medicine last week, to that same end, a
couple things. One, can we dispense with the fiction that we
will ever hire, or maybe even need to hire, those 43,000?
Related to that, number two, Dr. Shulkin mentions in the
article the need for the VA to focus on those conditions and
disabilities and illnesses that are connected to military
service and to combat. And I think of post-traumatic stress
disorder, traumatic brain injury, military sexual trauma,
traumatic amputation, those things that you generally are not
going to see in the civilian population. And should there not
be sooner, I hope, rather than later, some kind of behavioral
health dividend related to those conditions, where if we are
not focused on hiring all 43,000, we are going to really focus
on those specialties like mental health that we really need
that will prevent veteran suicide and do a better job for all
of our veterans?
And then the second question, if you can get this in, in
the time remaining, I held a veteran town hall on Saturday, 28
veterans approached the microphone to share their experiences
at the VA. Thirteen of those 28 mentioned that their primary
care physician left the VA in El Paso, they were never
notified. They only found out when they went to refill a
prescription and couldn't, or were waiting for a referral that
never came through. High level person at the El Paso VA medical
center said there is actually a problem right now where we
cannot refer somebody to community care. We first have to have
30 days to demonstrate that we couldn't get it done in here. We
need the flexibility to recommend right away. I know this has
come up in other questions. Could you just address that
specific to those dropped veterans who have lost their primary
care physician and don't know what to do, and wait months to
get an answer?
Dr. Yehia. Yeah, and thank you so much, Congressman. This
gets back a little bit to the eligibility criteria. And the way
that I describe those eligibility criteria is three areas: wait
time, geography, and availability of service. And so I think at
El Paso there is a number of things that are not available
there. So by definition, we automatically partner with the
community to deliver that. Geography, if they live more than 40
miles away. And then wait time, the 30 day criteria.
That is only--the way that I think of it, that is only the
floor. So that is a minimal set of eligibility criteria. We
need to make sure, and this is something that I think Congress
can help us with, is make sure that there is adequate
flexibility so that if there is a special circumstance, if I am
seeing someone in my clinic that I think has to go out of the
community, even though we don't have a wait in that area, we
have some of that flexibility to do that. And some of that was
afforded to us when the most recent iteration of the Choice law
was passed over the summer. So I think keeping that front and
center is important so that it is not so rigid to just those
three areas, but there is some flexibility so that the local VA
can work with their veterans if someone needs to go in the
community.
I don't know specifically about the issue in El Paso and
the primary care providers; however, if there is a wait for
primary care, they automatically are eligible for Choice, and
so that is something that we can make sure that they are aware
of that option, and they can offer that up to their providers--
or to their veterans.
Mr. O'Rourke. And then the other question is, you know, I
would like to get into the specifics of that offline, but the
other question is, can we now tighten our focus on hiring
mental health providers, and if that means increasing what we
pay for them, just having the attention to that, prioritizing
that over other conditions that might be more better served by
a network that they can refer out to, what are you seeing
towards that? I am out of time, so I may need to get your
answer for the record, but we are acutely interested in that
right now.
Thank you.
Mr. Benishek. Mr. Coffman, you are recognized.
Mr. Coffman. Thank you, Mr. Chairman. First of all, if I
understand this right, Dr. Yehia, under your--this VA's
proposal, it is the VA that will do the scheduling for the
third-party providers or administrators?
Dr. Yehia. Yeah, in our proposed plan, we want to be more
of the face of customer service and scheduling. That could
mean, as we talked about before, just saying to the veteran,
``you are eligible for community care, here is your options, do
you want to schedule your own appointment?'' But we would be
more the ones that would be having that conversation, rather
than the contractors.
Mr. Coffman. Yeah, I am very concerned with VA doing the
scheduling, and let me tell you why. The whole reason for the
Choice program was that there was a scandal in the VA on
scheduling, that the level of corruption, systemic corruption
across the VA in scheduling, driven by cash bonuses in order to
bring down the wait times, and they created these secret lists.
And now what you want to do, and what the VA wants to do, is
let's give it back to those same people.
Dr. Yehia. So first of all, the reason why we want to do
this is because we have heard from veterans and community
providers.
Mr. Coffman. Yeah.
Dr. Yehia. So when I--and in all the town halls that I
have, and that I sit down and talk to folks, they say, ``why is
there a middleman--
Mr. Coffman. Yeah.
Dr. Yehia [continued]. --in the scheduling?'' And the folks
that actually do the scheduling for community care are
different than those that do the in-house.
Mr. Coffman. We need to get the system to work. But we need
to get it to work without getting VA back into the system that
got us to where we are today. I mean, unbelievably incredible,
that--and I got to tell you, those who have been responsible
have not been held accountable. We don't even have a mechanism,
and the Secretary doesn't support one, to claw back bonuses for
people that fraudulently got them on this scheduling scandal.
And yet we want to move it back? I mean, I just think that that
is absolutely incredulous. And that is truly an exercise in
poor judgment. And let me tell you, this Member of Congress
will be in a blocking position, if you are familiar with that
term. I don't know if you served in the military.
Dr. Yehia. I didn't, sir.
Mr. Coffman. The blocking position, well, take it from a
Marine Corps officer, infantry officer, that is to stop you
from doing that, because I think that that is an incredible
exercise, again, in poor judgment. You know, and I think you
are reluctant to let go, I think the VA is reluctant to let go
of this and so creating an excuse rather than fixing the
system, let's give it back to the VA. And, again, I think that
that is an incredible mistake.
Mr. Maynard and Mr. McIntyre, both Health Net and TriWest
have experienced managing care networks with TRICARE. Based on
your experiences with both DoD and VA, where can VA learn from
the methods and practices employed by DoD with TRICARE?
Mr. Maynard. I think there are a couple of key points that
would really facilitate, that even though the benefit or
eligibility structure is different, are still there as critical
lessons learned. I think one of them is really clear:
eligibility criteria, linked with standardized reimbursement.
The more we standardize reimbursement around Medicare, there is
sufficient provider support in the community to largely accept
Medicare reimbursement in support of eligible veterans. That
represents a savings itself from commercial rates, but it
standardizes and simplifies and streamlines a good bit of the
provider relationship.
The other, I think, is continuing to remove the very points
that you have been emphasizing, that impede ready access. I
think--I myself believe that scheduling going forward, while it
started as a critical and well-intentioned component of the
initial Choice program, really did have an unintended
consequence of obstructing a bit the ready flow in terms of the
way the facilitation of health care works. I think as we look
forward, that scheduling service should be a secondary or
tertiary availability to veterans who individually need help.
But to the point that you raised, there are very sophisticated
and increasingly capable commercial sector capabilities,
including, for example, our own relationship with 1-800-DOCTORS
that has auto-adjudication and auto capabilities to link into
community care hospital and provider systems to automatically
schedule necessary appointments. So I think keeping an eye on
the evolution of the way that customer services are delivered,
ensuring that industry is not impeded from bringing best
practices to the support of veterans are critical concerns as
we look forward to serving veterans into the future.
Mr. McIntyre. I would agree with Billy. I would add,
though, that I think there is the opportunity to take advantage
of the first right of refusal process so that when we have got
veterans that are far out, making them aware of what is
actually accessible in the VA would be a good idea, but not
force them to go there.
Secondly though, as it relates to rate structures, two-
thirds of our network is actually built at market rate. And it
is a full pass-through to the VA budget. And what that means is
we have doctors and hospitals all over our 28 states that said,
``You know what, we will give you up to Medicare, not
Medicare.'' And you don't want to lose that, because it is
built into the base of the budget.
Mr. Coffman. I just want to, again, just--oh, I am over my
time. Mr. Chairman, I will yield back.
Mr. Benishek. Mr. Huelskamp, you are recognized.
Mr. Huelskamp. Thank you, Mr. Chairman. I apologize for
being late. I had another Subcommittee hearing, Small Business
Committee, also talking about health care. But I appreciate the
questions of Mr. Coffman. I do have my assistant here, my
youngest son, Alexander, on spring break. This is exactly what
every nine-year-old likes to do on spring break, I must admit,
so. But thanks for--Alex for joining me.
I would like to follow up with the questions from my
colleague to the west about scheduling and he already stole my
question about how can we learn from TRICARE experience as
well. But under TRICARE, does the DoD schedule the
appointments?
Mr. Maynard. No. There are no scheduling services.
Originally, there were various services. There are a few
military treatment facilities, or MTFs, that maintain some
appointing support for their own appointing, but not outside
the walls, and neither has it really proven a critical issue at
all in terms of the facilitation of care on behalf of TRICARE
beneficiaries.
Mr. McIntyre. You would have to go back a decade to find
that. And it took a bit of refinement, just like this is doing,
to get it right. And you know, part of the challenge, I think,
in the scheduling space was, we stood this program up in a
little over 30 days, because you were responding to a crisis,
and appropriately so with the right kind of intensity. And how
we are doing scheduling now, in our area, is vastly improved
over the first couple of months of what we were doing it. And
part of that is, we took the geography and broke it down into
segments. So now we are not serving people out of one or two
geographic areas; we have ten operations centers. We stood them
up since the summer. Went from 400 staff to 3,600 as of last
Friday. And so we built a hub and spoke environment. That is
what you have to have. You have got to have a relationship with
the providers in the community. And it takes a little while to
get that refined. At the end of the day, I do believe there are
areas where it makes a lot of sense for the VA to be absolutely
at the nuclear center of scheduling. And Alaska is one of those
examples. Far too complicated for everybody than to be having a
third party involved in that process. But in many parts of our
environment, that is not the case anymore. And we are not
getting the negative feedback from the providers that we were
getting even six months ago.
Mr. Huelskamp. I would agree, and prompt payment helps
lessen feedback, and I appreciate the VA announcing some of the
reductions in paperwork that is making that happen, still have
some pushback, but the idea we would go back. I had a local VA
clinic, or maybe, I guess, maybe this wasn't local, it
certainly wasn't local VA clinic, but they wanted to do some
scheduling for a veteran, and I think they scheduled, said,
``well, the nearest provider is five states away.'' They
misunderstood, they were looking at the city, and didn't
recognize they were states away. I mean, I think that was
online with the VA. You hear that again, but it might be
different, Doctor, maybe in an urban area, but in my district,
they know the hospital. You know, and don't forget, these
veterans, this is not their first rodeo to go to the local
hospital. Most of them are already going to the local hospital.
And that was the fear that somehow they would overwhelm the VA
system as they rushed in. All we are saying is let them keep
going where there are going, in many cases, and they don't need
the VA calling the local doctor they saw at church on Sunday.
And again, it might be different in an urban area where you
have got the VA hospital a couple miles away and you have been
waiting your 30 days. But for our rural areas, if we went back
and centered scheduling, we would have even more problems than
before. We would have even more complaints. The robustness of
this network is developing, and I think is continuing to
improve, and the providers I talk to, they are signing up just
to make sure that they get paid on time. But, again, let's not
envision this as a veteran that is getting 100 percent of their
health care. It is the case sometimes they are starting to drop
in, and then say ``Hey, can we get this taken care of,'' if
this is going to work. So we will hopefully see this continue
to develop and work with the folks that have experience in
other networks.
And again, don't forget that you have a veteran that may be
a senior officer, he has served alongside as TRICARE for life,
he served four years, ``Why can't I go to my local hospital,''
but the guy that has long-term benefits the rest of his life,
you know, he gets to go to the local hospital, but I got to
drive 200 miles. Obviously, we want to avoid that. So let's
continue to work and develop that network. I know in western
Kansas, central Kansas, they are ready and waiting, they are
slowly adding providers, actually quickly, and I have got 70
community hospitals, you know, unlike some of the other areas,
they are begging for patients, you know, and they are hopefully
getting the veteran once. They might even get his wife and get
his kids as well and it is these kind of things that develop.
My concern as well is that the temporary nature of the
language, and I know the Secretary has promised that he wants
to make this permanent, but the sooner we can make this
permanent, the sooner we can make these relationships more long
term, and for the veterans as well as for the providers, Mr.
Chairman. So I appreciate the timeliness of this topic. I yield
back.
Mr. Benishek. Thank you, Mr. Huelskamp.
Does anyone have any further questions? I know there is
lots of--
Ms. Brownley. Just quickly?
Mr. Benishek. Yeah, sure.
Ms. Brownley. If you don't mind. Thank you, just quickly. I
have just a couple of quick questions, and hopefully they are
just all yes answers. But so in my district we are still having
issues with regards to inappropriate billing, when a patient, a
veteran, is seeing a community doctor. And we have a particular
issue, casework that we have not been able to resolve for one
of our veterans that saw an orthopedist, was very satisfied
with his care there. He stepped on a landmine in Vietnam, ended
up getting two splints that he needed, but he is being billed
$500 for those splints. And we have worked really hard in our
district office to resolve this problem. If you could help us
resolve it, I would appreciate it very, very much.
Dr. Yehia. If you give us their name, we would be happy to
work it out.
Ms. Brownley. Terrific.
And in terms of just following up on Mr. O'Rourke's
question about staffing. If you are going to send him
information, I would be interested, you know, in the same
information as well.
And the last question I had is, if you have wait time data
for veterans who are using the Choice program, and if you have
any analysis of comparing that nationally, in terms of wait
times, compared to what the VA is providing with regards to
wait times.
Thank you. Thank you for your indulgence, Mr. Chair.
Mr. Benishek. Oh, no problem.
I am sure there may be other questions that we come up with
as you are developing this program, and I look forward to that
dialogue. But other Members may want to submit some questions
for the record even yet. So thank you all for being here today.
It has been an education, and I am sure it will be as we go
forward.
I ask unanimous consent that all Members have five
legislative days to revise and extend their remarks and include
extraneous material. And without objection, so ordered.
This hearing is now adjourned.
[Whereupon, at 11:35 a.m., the Subcommittee was adjourned.]
A P P E N D I X
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Prepared Statement of Mr. Billy Maynard
Biography of Billy Maynard
Mr. Billy Maynard has been the President of Health Net Federal
Services, LLC since May 1, 2015. Previously, in addition to holding a
variety of defense sector positions, he was a partner at the management
consulting firm InfiniTek for 12 years. At InfiniTek, he specialized in
federal health care strategy and provided strategic business planning
and organization development support to Health Net and other leading
government sector health care service delivery and technology
companies.
A veteran of the U.S. Army, Mr. Maynard was Executive Assistant to
NATO's Supreme Allied Commander, Europe, from 1983 to 1990. During this
period, he was twice decorated with the Defense Meritorious Service
Medal for contributions in support of the NATO Alliance. Mr. Maynard is
a graduate of the U.S. Army Institute of Personnel and Resource
Management (Adjutant General Corps); studied business administration at
the University of Maryland University College Europe; and holds a
postgraduate certification in organization development (strategic
planning and change leadership) from DePaul University.
A History of Partnership
Chairman Benishek, Ranking Member Brownley, and Members of the
Subcommittee, thank you for the opportunity to participate in this
hearing on provider networks under the Department of Veterans Affairs
(VA) plan to consolidate Community Care programs. Health Net Federal
Services (Health Net) is proud to be one of the nation's largest and
longest serving health care administrators of publicly-financed
government and military health care programs. To this hearing, we bring
the perspectives and lessons learned throughout our nearly three decade
history supporting government health care entities at the intersection
of their care capacity and their need to support their beneficiaries
with care in the community. Today, Health Net and its affiliates,
through health plans and government contracts, provide health benefits
and related beneficiary services to more than five million eligible
individuals across the country through VA, TRICARE, Medicare, Medicaid,
group, and individual programs.
For more than 25 years now, we have served as a partner to the
Military Health System (MHS) as a Managed Care Support Contractor
(MCSC) in the TRICARE Program. Health Net was the original CHAMPUS
Reform Initiative (CRI) contractor, the predecessor contract to
TRICARE. Currently, as the TRICARE North Region contractor, we
facilitate the community-based delivery of nearly $3 billion in
spending to support the health care needs of nearly 3 million active-
duty service members, military retirees, guardsmen and reservists, and
their dependents in 22 states and the District of Columbia.
We also deliver a broad range of customized behavioral health and
wellness services to military service members and their families,
including those in the National Guard and reserves. These services
include the Military and Family Life Counseling (MFLC) program, which
provides non-medical, short-term, problem solving counseling; rapid-
response counseling to military units; and reintegration counseling. In
support of MFLC, we have more than 700 professionals deployed with the
military worldwide, including professionals embedded in support of
special operations forces in various theatres.
As an established partner of VA, Health Net has collaborated in
supporting veterans' physical and behavioral health care needs through
Community Based Outpatient Clinics (CBOCs) and the pilot Rural Mental
Health Program. We also have supported VA by applying sound business
practices to achieve greater efficiency in claims auditing and recovery
and, previously, through claims repricing, both of which resulted in
increased funds available for health care services delivered by VA.
Our singular mission in all these endeavors is to enable government
agencies, such as VA, to leverage private sector best practices in
order to supplement and complement their in-house capabilities through
an effective public/private partnership. Our focus on supplementing and
complementing is important because our work as a private sector company
focused on organizing and facilitating community-based capabilities and
services begins where the direct care capacities of the agencies we
support ends. The shared goal from that point is not only to ensure
ready access to care but also to enable our government agency partners
to continue to provide the high-quality and often highly-specialized
services that constitute their core mission.
Our commitment is not just professional; it is personal as well. I
am a veteran; I served 10 years in the U.S. Army, including as the
Executive Assistant to NATO's Supreme Allied Commander, Europe. I am
also the son of a Navy retiree and grandson of a WWII combat veteran
who was one of a family of brothers who all saw combat and were
supported by VA upon their return home. The mission of health care
integration in support of our nation's eligible veterans is one I take
to heart personally. That is true of our other associates, as well.
Many of the top leaders in Health Net are veterans, military retirees,
or military spouses. Several of our younger leaders are still serving
as reservists. We take pride in our commitment to our comrades in arms
and our fellow veterans. We take our work personally because we have
friends who use the services we provide. My remarks are informed as
much by the spirit that led me and so many of my colleagues to service
as by my business experience.
It is from this long-standing commitment to supporting the military
and veteran communities that we offer the following perspectives on
provider networks under VA's plan to consolidate Community Care
programs.
Comments on Building A High-Performing Network
First and foremost, we believe that all health care provided in
support of eligible veterans is VA care, whether delivered directly by
VA or its affiliates or community providers. Therefore, care must be
designed and delivered in ways that care in the community is understood
and considered as VA care by all involved, most especially eligible
veterans and health care providers. For this to be achieved, the
approach to delivering care must be as seamless and integrated as
possible - especially at the point of intersection between VA's
capacity and care delivered in the community. Based on our years of
experience, we believe the only way all care can truly be seen as VA
care is through the establishment of mutual accountability within the
framework of a public/private partnership.
Second, we strongly agree with the Independent Assessment of the
Veterans Health Administration (VHA) released on September 18, 2015.
Specifically, that report highlighted the challenges of VA's current
approach to purchased care through the seven programs already in place
or in development. This report concluded that the programs' ``sheer
multiplicity suggests the drawbacks of a piecemeal approach, absent a
guiding orientation and strategy for VHA's purchased care enterprise as
a whole.'' We strongly support standardization and consolidation across
the full range of Community Care programs.
Turning attention to VA's plan to build a high-performing network
composed of a Core Network of federal partners and academic affiliates
and an External Network of community providers: in principle, we
support the concept that a preferred provider network construct could
deliver the significant community-based access to care that will be
necessary to support eligible veterans and to enable VA to fulfill its
mission in the future. While there are other approaches, given VA's
significant direct-care mission and capacity, a preferred provider
approach - sometimes referred to as a tiered network approach - will be
the most effective way for VA to optimize and integrate care delivery.
We believe that whatever geographic or provider network development
approach VA takes, whether that be tiering or some other preferred
provider design, it is absolutely essential that VA partner with a
single, third-party entity within each geographic area to establish and
administer all community-based aspects of the program.
Like VA care, the TRICARE program also depends on the effective
integration of health care at the intersection of a large direct care
system and supplemental community-based capabilities. After 28 years of
experience, there is perhaps no more important lesson learned than that
the only way to ensure consistency and clear lines of authority and
responsibility across the program is through the responsibility of a
single contractor, on a geographic basis. This approach is the most
effective solution for veterans, providers, and VA. It is also the only
proven way to actually succeed in standardizing a national-level
initiative such as the ``new VCP'' and making it operational in all
locations. A single, third-party entity by geographic region will also
be the most fiscally responsible method.
The effective implementation of any future version of the Veterans
Choice Program is contingent upon optimizing the capacity of VA
(including VA Medical Centers and local community-based outpatient
clinics); making the provider experience as consistent with community
standards as possible; and streamlining veterans' experiences to enable
better control of their health care experience. All this can be done
while maintaining care in the community as a complementary capability
within the broader context of VA health care. We believe this can be
done in ways that will preserve and extend the very important
relationships VA maintains with DoD and its academic affiliates.
Discussion of the Draft Performance Work Statement
Turning attention to VA's Draft Performance Work Statement (PWS)
for Community Care Networks, we support the comprehensive nature of the
requirements outlined and believe it to be a good start toward future
procurements that the managed care industry can effectively support.
The Draft PWS requires contractors, within newly defined health
care regions, to develop the community-based elements of a High-
Performing Network that would provide a full complement of services in
support of the consolidated new Veterans Choice Program (``new VCP''),
including: network management, credentialing, medical management, call
centers, and claims processing.
In the process, VA has defined a draft baseline that is much more
TRICARE-like and incorporates a substantial number of industry
recommendations made during the market research phase of the
acquisition development process. That said, it is important to note the
Draft PWS suggests that VA will retain initial appointing and
appointment scheduling responsibilities, which is a significant change
from the current Choice Program.
The future success of any program, even one based upon an existing
program, is laying the appropriate foundation. The transition period
for the ``new VCP'' should have a baseline transition period of at
least 12 months from contract award to the start of health care
delivery. This will allow the program to ``go live'' with fully
developed and tested networks and operating processes based on lessons
learned.
Among the lessons learned in Choice, and similar to those learned
in the early TRICARE experience, is that a vital element to the smooth
operation of any health care delivery program is a set of standardized
written policies and procedures. These policies must answer the ``who,
what, when, and why'' of delivering care. We commend VA for starting
this process by releasing the beginnings of an operations manual with
the Draft PWS. Much of the friction in the current Choice Program has
come as VA tried to implement the intent of Congress and this friction
translated to the veteran and provider experience. Having a clear set
of guidelines before a complicated question arises, such as how to
compute eligibility or what defines an episode of care, is vital to the
veteran and provider experience. A thorough transition period will
allow for the development of consistent, standardized written policies
and procedures. Clear guidelines will also speed any adjudication
processes and result in a better experience for veterans and providers
through faster responses.
Even with a clear operations manual, however, the veteran
experience will be compromised if the intersection of public policy and
supplemental community-based capabilities is not executed in a context
in which providers are prepared to operate. Therefore, the operations
manual and associated processes must align with industry standards. The
more unique the requirements to participate in and execute the ``new
VCP'' the more friction will result at the provider level, and the more
difficult the experience will be for veterans. Medicare is the common
standard upon which all other government programs are based and
providers across the country are familiar with Medicare requirements.
In addition, VA has stated a goal of moving toward the value-based
reimbursement methodologies that Medicare is driving.
The Way Forward
In closing, let me say that in a program like Choice, veteran and
provider experience and satisfaction is everything. The success of any
future version of the Veterans Choice Program will depend upon
optimizing the capacity of VA (including the VAMC and local community-
based outpatient clinics); making the provider experience as consistent
with community standards as possible; and streamlining veterans'
experiences so that they are able to control the process and receive
care when necessary.
All this can be done while maintaining care in the community as a
complementary capability within the broader context of VA health care.
Health Net has effectively built an excellent customer and provider
experience in other government agency programs such as TRICARE, which
was tied at number one with Kaiser Permanente for customer
satisfaction, according to a national survey on health plans, the 2015
Tempkin Experience Ratings, conducted by the Temkin Group. We see no
reason that VA and industry partnerships should not result in eligible
veterans being just as highly satisfied.
Health Net is proud to stand as a partner with VA and Congress in
helping to deliver care to our nation's veterans. Thank you for the
opportunity to present our views and I look forward to answering any
questions you may have.
Prepared Statement of Mr. David J. McIntyre, Jr.
Introduction
Good morning, Mr. Chairman and Members of the Veterans Affairs
Subcommittee on Health. I am pleased to appear before you this morning
to discuss the status of the development of the community care network
in our geographic area of responsibility, which includes 28 states and
three U.S. territories. The last time I appeared before you on this
particular topic was last Summer, and a lot has occurred since then
that has positively impacted access to care for the Veterans who call
our area of responsibility home.
Before I get started with my remarks, Mr. Chairman, I would like to
thank the Chairman of the full Committee for his leadership and focus
on ensuring that our nation's Veterans have access to the health care
they earned with their service. It has been and remains a privilege to
be of service to his constituents. I know that they are going to miss
him when he retires at the end of this Session; however, know that we
will continue to stay focused at the side of the Department of Veterans
Affairs (VA) in meeting the needs of those he has represented so
capably. And, I am confident that his legacy will long endure. as VA
continues to re-set for this generation's warriors and the next.
It is a privilege to appear alongside Dr. Baligh Yehia, from the
Department of Veterans Affairs. From personal experience, I would like
to observe that his hands-on and focused leadership, and that of a very
capable team within VA, is enabling us all to move the needle and start
to achieve success in the re-setting of VA's leveraging of care in the
community to augment that which is available directly within its direct
delivery system.
TriWest and VA continue to work in close partnership to improve
access to care for Veterans across our service area. While we are
beginning to see the fruit of our labors, I would be the first to admit
that more remains to be done to fully fulfill the promise of the nation
to those who have worn the uniform and sacrificed in service to this
great nation.
A Historical Perspective
During TriWest's 20 year history, the company I was fortunate to
help form with a group of non-profit health plans and university
hospital systems - and have been privileged to lead since then as
President and CEO - has focused exclusively on leveraging the core
competencies of our owner organizations and their strong market
presence to ensure access to needed care when the federal systems on
which those in uniform rely are unable to meet the needs directly. And,
we and our more than 3,500 employees, most of whom are Veterans or
family members of Veterans, count it an honor to be part of the team
stretching ourselves in service to our nation's heroes!
Our first 18 years were spent supporting the Department of Defense
(DoD) in standing up and operating the TRICARE program in a 21-state
area. I'm proud of the work that we did to assist DoD in making TRICARE
the most popular health plan in the country and meet the needs of
millions across the TRICARE West Region who relied on us for that
support. And, as those of us who were around in the early days of
TRICARE can attest, we know it was neither an easy nor painless road.
Now, working at the side of VA, while the challenges of implementing a
new program have been similar to the early TRICARE days, due to the
added layer of complication that led the Choice Program to be brought
forth so quickly, I believe we can achieve the same results for
Veterans who look to VA for their health care needs.
In our experience under the TRICARE program, we had 15 months to
prepare for the start-up of TRICARE and then nine months to stand up
the program before the demand for services arrived. With the Veterans
Choice Program, this 24-month period was shrunk to a little more than
30 days. Since then, you, VA and we, have been focused on making the
changes necessary to achieve the success we all desired with a program
that demanded the aggressive design and implementation schedule given
the crisis out of which it was born.
While not yet where we all want to be in the re-setting of VA and
the programs that exist to support it in the delivery of needed care
and services for our nation's Veterans, I would submit that a lot of
progress has been made and I am proud of the fact that 100,000 Veterans
are now being served each month in our geographic area of
responsibility through the Choice Program.
First, most of the policies that needed to be re-set have been
acted on and are operational. to the benefit of Veterans and the
providers that serve them.
Second, the remaining operations gaps that exist are identified and
the needed adjustments are being made. This is largely a result of the
work that Dr. Yehia has done in bringing all of us together to form a
common focus around five core initiatives: Simplify the Referral and
Authorization Process; Decrease Returned Authorizations; Improve
Customer Service; Get the Right Provider Every Time; and, Better
Visibility into the Networks.
Third, the networks in our vast area of operations, have now been
fully tailored and are being leveraged to begin to deliver on the
demand profile that exists.
And, fourth, just last Friday, we finished the six month roll-out
of an infrastructure and scale that is now beginning to deliver on the
demand that exists. This took us from two sites of operations to 10
sites, with Friday's opening in El Paso.
I know that the road has not been painless or easy on anyone
involved, especially for the Veterans we all seek to serve; however,
there has been tremendous progress in our area, we are maturing the
program and WILL achieve the expectations that you and your fellow
members of Congress had when you mandated the creation of the Choice
Program to more optimally meet the health care needs of our nation's
Veterans. As one who was there at the start of TRICARE, and through all
of the painful periods and the refinements necessary to smooth out the
operation... making it a model program for our nation's defenders and
their families, I would say that we are well on our way. And, enabling
VA to consolidate all of the community care programs should be the last
mile of modification needed to put us on a path to achieving the
excellence we all expect of ourselves and wish for those we are
privileged to serve.
We all know the pathway we have been on, but I think it deserves
repeating.
Where We Started: PC3
In September 2013, VA awarded the brand new Patient-Centered
Community Care (PC3) contracts, and we were selected to serve 28 states
and the Pacific. And, we were given 90 days to begin operations.
TriWest rose to the occasion by leveraging the existing networks
and strong relationships already in place due to our prior work under
the TRICARE contract. Initial access to specialty care from our
existing network providers began in January 2014 with the ongoing
expansion and addition of primary care providers coming online over the
months that followed. That network building continues to this day as VA
and we learn more about where demand exists that was otherwise not
being met before this program began.
PC3 was intended to be a nationwide program giving VA Medical
Centers (VAMC) an efficient and consistent way to provide access to
care for Veterans from a network of credentialed specialty care
providers in the community when VA was unable to deliver the care
directly. This would provide a consolidated network in each area,
rather than continuing the inconsistent and expensive ad hoc approach
of trying to contract by site for an array of providers. This was one
of TriWest's primary missions as a TRICARE contractor. So, we quickly
embarked on the path of putting this together, only to learn that the
VA sites really did not have a good handle on their demand profile. a
challenge that would become even more extreme with the adoption of
Choice. And, when you do not know the size and shape of your demand it
makes it nearly impossible to effectively tailor networks. as we
discovered painfully in the early days of PC3 and Choice. The goal,
though, of having a tailored network of community providers to allow
for the optimization of VA's direct delivery system and meeting the
specific needs of the Veteran population across each state unable to be
met directly by VA remains very doable. as we are now proving in our
area of operation.
I will say that the concept proved its worth early in the State of
Arizona, where an extensive network was available in Maricopa County
starting in January 2014. In fact, it was that network of nearly 7,000
community providers that would prove to be an invaluable tool in the
Spring of that year.
A Historical Perspective of Choice Program
In April 2014, the ``furnace lit off'' in Phoenix, and the country
was shocked to learn of the shortcomings in the system. This served as
the catalyst for fueling a focus on VA reform throughout the nation and
the conversation about what a VA re-set should look like. At that time,
nearly 15,000 Veterans were discovered to be on waiting lists for care
in Phoenix alone. It is but one example of the re-setting that was
needed and has since begun under the leadership of Secretary Bob
McDonald, Deputy Secretary Sloan Gibson, and Under Secretary for Health
Dr. David Shulkin. Since then there have been a number of Office of
Inspector General reports published outlining similar findings. all
pointing to the reality that Veterans were not getting the care they
needed and deserved in a timely manner.
The recognition that further reform was needed to meet Veteran
health care needs led, as you know, to the Veterans Access, Choice and
Accountability Act (VACAA) and ultimately, to the Veterans Choice
Program. In August 2014, Congress appropriately passed VACAA, and
required that this program be stood up quickly in the marketplace. VA
faced with these new revelations and the urgent Congressional mandate
asked its two PC3 contractors, TriWest and Health Net, to help
implement the new Choice Card Act. In fact, we had just over 30 days to
go from the policy specs being received from Congress and interpreted
by VA to having a program designed and stood up by November 5, 2014 -
just 16 months ago.
Within record time, we created the infrastructure, hired and
trained hundreds of staff, and got Choice Cards into the hands of four
million Veterans in our area of responsibility. TriWest stood up a
state-of-the-art contact center making sure that callers to the toll-
free line were greeted by the voice of Secretary McDonald, thus
underscoring the importance of this new initiative. All of this was
accomplished within 30 days which you mandated in law.
I recall vividly sitting in a meeting that VA held with industry in
mid-September 2014, as they were seeking to determine how to implement
this necessary new program, and hearing many say that a program of this
magnitude would take a minimum of 12-18 months to stand up and that DoD
had been given about 36 months to design and then stand up a similar
program with TRICARE.
However, that was just not good enough in the face of the
revelations of the delays that had come to light. Those who served our
country without hesitation are not afforded such luxuries of time when
our nation sends them across the globe in defense of our country. So,
we swallowed hard and agreed to lean all the way forward to stand up
the program knowing that it would be imperfect, just as TRICARE was in
the early days, but that getting it in place and refining as we went
forward would be critical to helping our fellow citizens who were
standing in line because they were in need of care that was not
available directly within VA.
So, we stepped into the fire at the side of VA and did what others
said could not be done and jointly stretched ourselves to stand up this
critical new program in weeks (not months or years). Our contact
centers went into operation, the Choice Cards went out, and care
started to be rendered in the community when it could not be directly
provided by VA.
The partnership between VA and TriWest has progressed and matured
substantially over the past year. This is a dynamic relationship in
which we continue to refine and strengthen operational processes and
communication, both on our end and VA's end. Do we still have work to
do? You bet we do! But, I am very proud of what we have all
accomplished in such a short timeframe. And, I am confident that the
trajectory on which we are all on to improve this much needed program
will produce the same results as experienced with the refinements that
came quickly within the TRICARE program.
One of the core challenges when the PC3 program was first
implemented was that we didn't have a clear view of the demand for
care. Thus, it made it difficult to ensure a precise supply of network
and the subsequent infrastructure of systems and people needed to
support that demand as a company. Additionally, we faced programmatic
and statutory challenges with the Choice Program when it was first
launched (which is discussed in detail later). But, we had to start
moving and then refine later . which is exactly what we have done and
continue to do with intensity, and will continue to lean forward to
ensure that Veterans receive the care they have earned, and that
Congress envisioned with the enactment of Choice!
Volumes were low in the beginning as Veterans were just learning of
the new access they were gaining through this program. Care requests
were about 2,000 for that first month of 2014. While volume increased
each month, care requests under PC3 only reached their peak at about
20,000 per month by the end of that year when the Choice Program came
into the picture.
The second iteration of the program, beginning in January 2015,
focused on implementing Choice and finding solutions to some of those
challenges - both internally at TriWest, as well as within VA itself.
We saw steady increases in care requests month by month. TriWest is now
scheduling over 100,000 Choice appointments per month in 28 states, up
from 2,000 per month in January 2015, a dramatic 50-fold increase.
Network Growth
Foreseeing the likely increase in utilization, we initiated a
process with the team from VA to assess demand and determine the
distribution and supply of network that would be needed in the
community to support that demand. We call it the ``Demand Capacity
Assessment Process'', which last Summer was conducted with nearly every
VAMC within our service area. We met one on one with each medical
center to assess how many providers of each specialty would be needed
in addition to the supply of providers working at the VAMC to meet the
needs of Veterans in each geographic area. This included not only a
projection of the demand that was already known to exist but that which
seemed ready to materialize with the added policy decisions regarding
Choice coming out of Congress. We then took the output of this data-
driven process and turned to our owner/network subcontractors and
started to grow the network on a tailored basis to match the demand.
We implemented the tools for this process Memorial Day weekend of
2014 for the work that we were tasked with to assist the Phoenix VA in
working off the backlog of nearly 15,000 Veterans waiting in line for
care. Those tools allowed us to assess the demand and the needed
provider and staff supply to assist the Phoenix VA in successfully
eliminating the initial backlog by the end of August 2014.
Armed with the Demand Capacity Assessment Tools, we and the VAMCs
in our geographic area of responsibility worked to assess demand and
then we went about mapping the supply of providers that would be needed
in each community to provide that which VA was unable to deliver
directly. This targeted approach has resulted in the tailored
construction of a network that now totals nearly 180,000 providers
across our service area.
[GRAPHIC] [TIFF OMITTED] T5124.006
The following is a map which plots the density and distribution of
provider network:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
While expanding the provider network was of primary focus, we also
recognized that assuring the quality of our provider network also
deserved special focus. To that end, in August 2015, TriWest was
awarded full health care network accreditation pursuant to the Health
Network, Version 7.1 from URAC, a Washington, D.C.-based health care
accrediting organization that establishes quality standards for the
health care industry. TriWest demonstrated that we meet key quality
benchmarks for network management, provider credentialing, utilization
management, quality management and improvement, and consumer
protection. This accreditation is valid for three years, and
demonstrates that those Veterans we are privileged to serve in support
of VA have access to quality care.
And, as we continued to focus on the expansion of our network, this
past Summer 2015, Congress refined the design of the Choice Program by
enacting changes to help expand eligibility, thus providing greater
access to care for Veterans. As a result, the number of care requests
we received for private care has continued to grow dramatically.
The Veteran Experience
As part of our commitment to achieving the same performance outcome
as we produced in TRICARE, we turned to a 20-year partner of ours to
repeat an effort we undertook in that work. Once we had a few months of
experience under our belt at the side of VA, we started a very focused
and intentional effort to assess and understand current experience,
identifying gaps and opportunities for improvement by conducting in
person, ``blueprinting'' sessions alongside the industry leading
Arizona State University's world-renowned Center for Services
Leadership (ASU CSL). In fact, it is they who train such industry
leaders as Proctor and Gamble, Starbucks, Disney, and the like in the
techniques of customer service mapping and process improvement.
One of the initial blueprinting sessions held last Summer included
Veteran representatives, Phoenix VAMC leaders, Veterans Service
Organization leaders and TriWest stakeholders. As a result of the
blueprinting effort, TriWest and VA made changes to processes, program
materials, and training to improve the experience for Veterans. The
very early indications are that this time-tested approach, mirroring
that of the most highly regarded customer service brands in America, is
beginning to yield results that matter. TriWest has also introduced the
ASU CSL process known as ``service recovery'' to address customer
service breakdowns identified in our complaints and grievance process
for inquiries received from Veterans, providers, Congressional offices
and VSOs. This process ensures that root causes are analyzed by the
leadership so that process improvements to customer service can be
made.
The Provider Experience
Similarly, the provider experience is critical to both TriWest's
and our network subcontractors' ability to build and maintain networks
to serve Veterans. The Choice Program only works if it has strong
participation from local providers who are reimbursed by the government
in a timely manner for the service they provide to Veterans. We
recognize that many of the requirements placed on providers to
participate in the PC3 and Choice programs create a significant
administrative burden and often go beyond what is typically required of
providers to treat patients. It is for this reason that we are making
efforts to reduce this burden, where it can be controlled by TriWest,
by streamlining our processes. As a result of the provider blueprinting
effort, TriWest is now revising our provider letters and redesigning
our Provider Portal (similar to what we did this past year with the VA
portal) to improve the overall provider experience. We call this
upgraded experience, ``Provider 2.0'' - that will make it easier for
providers to join the network and receive timely payments for the
services they render under the Choice Program. We are taking the
provider experience to another level for the almost 180,000 providers
in our network who serve the health care needs of our nation's
Veterans.
In an effort to lean forward further in the critical space of
behavioral health, we have worked closely with the Phoenix VA, and
initiated a pilot project to care for Veterans in urgent need of
behavioral health services, who present themselves to the VA emergency
department. TriWest has committed to helping place such individuals
into the private sector for their emergency behavioral health needs in
a timely manner, and to date has ensured that more than 200 Veterans
have received the urgent behavioral health care they needed. That
number represents saved lives. The behavioral health network is being
utilized by some of the VAMCs in our 28-state region; in January 2016,
1,639 Veterans were served in the behavioral health community taking
three days on average to get appointments scheduled, and 90% of them
saw a provider in less than 30 days. We want to thank the team at VA
for having the confidence to turn to us as a teammate, so that together
we might address a challenge they were facing.
Another example which illustrates the great partnership we have
developed with VA - a partnership aimed at taking care of the Veterans
that we are so privileged to serve - occurred in Phoenix (as well as
nine other locations in the regions where we operate).
In November 2015, TriWest energetically joined with VA on a special
initiative - ``Stand Down Day'' to advance efforts to reduce the number
of Veterans with high-priority or urgent care problems waiting longer
than 30 days and to learn together what should constitute our focus in
the months to come as we seek to further refine the operation of
Choice.
In a collaborative effort with VA, TriWest assembled a team to
provide real-time, onsite support for the Stand Down efforts within 10
pre-determined VAMCs. Through this collaborative effort, TriWest worked
6,500 Choice Veterans and the associated referrals. On Saturday,
November 14, 2015 TriWest supported the Stand Down with 868 employees
working across all hub locations. TriWest staff responded to inbound
phone calls from Veterans and VAMC representatives, responded in real-
time to VA comments posted through the shared web portal, data entered
all new referral requests received on the 14th, and placed outbound
phone calls to Veterans to initiate the appointment process. In
addition, TriWest staff (including myself and other senior leadership)
joined the VA staff in 10 specific VAMCs to provide real-time, onsite
support.
As a result of VA initiating the Stand Down project, VA and TriWest
were able to close the gap on outstanding health care service requests
at VA and place a significant number of Veterans in the care of a
community provider. The results for clinically urgent care were
particularly strong as the large majority of care requests were
appointed within five business days.
For example, in Phoenix, the Phoenix VA submitted a file to TriWest
containing Choice referrals for approximately 298 Veterans. TriWest
identified 502 referrals for this population. Beginning on November 14,
2015 (and continued through December 11, 2015) TriWest staff researched
all unresolved referral requests and initiated contact with Veterans,
providers, and VA staff. Overall, TriWest has been successful in
reducing the number of those pending referrals to less than 30. The
results for Phoenix demonstrate the growth of the network of community
physicians as well as the tremendous collaboration between TriWest and
VA to drive favorable outcomes in a timely manner.
In the area of educating Veterans, providers and others about this
program and its operation, TriWest has shown its presence at a number
of local town hall and community meetings, as well as attendance and
support at a number of Congressional Veteran Resource Clinics. We have
briefed government, non-profit and civic leaders on the program and
efforts to improve the processes. We are also very active with our
support of the Veterans Economic Community Initiatives (VECI) program
that was launched by Secretary McDonald in June 2015. This program is
committed to providing employment opportunities for Veterans and their
families through a network of support at the community level. In fact,
many of our operations centers we have opened throughout the country
are located in VECI communities, and we opened our last Operations
Center in El Paso, TX on March 18, 2016.
Operational Growth, Innovations and Program Improvements
Beginning in May 2015, TriWest responded to the growth in care
requests by ramping up our workforce, expanding our footprint and our
network, and working on operational efficiencies. To meet the increase
in demand of care requests that is on pace to hit over 110,000
authorization requests by the end of this month, we have added eight
new operations centers across our geographic areas of responsibility
and implemented a VISN-centric strategy with each of our locations, to
better serve those geographic areas ``on the ground''. Over the past
few months, TriWest has opened operations centers in: San Diego (270
employees), Kansas City (over 500 employees); Tempe, AZ (400
employees); Nashville (250 employees); Honolulu (60 employees);
Sacramento (270 employees); New Orleans (300 employees) and just a few
days ago opened a final location in El Paso (235 employees) with the
full collaboration of Congressman O'Rourke and his dedicated staff. My
expectation is that once we are fully staffed at each of these sites
(based upon the eligibility criteria that exists today), with all new
staff online, that we will be able to fully handle the increasing
demand coming through this program, which frankly has continued to be a
bit of a struggle, as demand has continued to exceed all of our
projections.
At the same time, TriWest spent 2015 focused on innovations to help
improve program operations across the enterprise. In addition to
opening operations centers, hiring thousands of new employees and
building networks, a large focus has been on upgrading systems. We
stood alongside our partners at the Phoenix VA almost one year ago
today to obtain their requirements for a new portal - a region-wide
system that enables VA staff to seamlessly order and track health care
services between themselves and TriWest. We had a team of people
working in shifts, around the clock for three months, to develop the
upgraded portal, which was implemented in several phases beginning in
May 2015. The new portal was available to every VAMC within our region
by July 2015. Today, VA has over 2,500 trained users on the system, and
they rely on this system to manage most aspects of community health
care delivered through the Choice Program.
Another major initiative TriWest implemented to help manage the
surge in program volume and growth in usage among Veterans, and aimed
at customer service, was a new Customer Relationship Management System.
This new tool will ultimately assist our staff in delivering effective
and efficient customer service encounters, just as we did in TRICARE
for those who have served. The system also brings improvements to the
user interface and the ability to document outbound and inbound calls
with Veterans - all aimed at improving customer service.
And within our operations centers, we recently have also
implemented a Behavioral Analytics Call Monitoring System which helps
improve staff interactions with customers, VA staff, providers and
Veterans alike. TriWest operations centers are now fielding nearly
300,000 incoming calls for care per month. Our operations centers are
being built just as they were under our TRICARE contract - which was
recognized for call center operation customer satisfaction excellence
for five consecutive years under the J.D. Power and Associates Call
Center Certification Program. That distinction acknowledges a strong
commitment by TriWest operations centers to provide ``An Outstanding
Customer Service Experience.'' It is how we have always operated, and
we are committed to that high level of customer service operations
again under this program.
On the provider side, we have worked to streamline the claims
payment process whereby providers submit their claims electronically
which helps improve provider satisfaction with claims processing.
Today, TriWest pays clean claims at a rate of 97% in less than 30 days.
With all of these initiatives, tools and expansions in mind, I
would be remiss if I did not mention that all these needed upgrades
that have been implemented over the past 12 months or so, do not come
without cost. Our company's sole line of business is to care for
Veterans - it's who we are; it's what we do. And from all we have done
in dedicating ourselves to this mission, we have put the priority on
getting this right for our nation's Veterans because we and our non-
profit owners believe that is the right thing to do.
Investing around $70 million of our owner money thus far to further
our and VA's joint objectives to develop more optimal tools, tailor
networks, and scale and re-footprint the company to more optimally
deliver customer service at the side of VA, we are pleased with the
refinement that is starting to materialize. The fact is that we
continue to work hard alongside VA to do whatever it takes to make this
program meet the vision from which it was created.
Still Hard At Work to Tackle Challenges
Choice is working. We all know that challenges remain as the
program continues to progress and mature, but the customer experience
under the Choice Program is getting better with each passing day.
Information provided by TriWest staff is more consistent and more
accurate; providers are more familiar with the program; and we have
implemented an initiative that allows any provider in our region to
register online with us to be a Choice provider. Knowing who is willing
to treat a Veteran under the Choice Program, even if they are not
already a TriWest network provider, goes a long way towards speeding up
the appointing process.
Every day we focus on improving the program. I say this because
each challenge presents an opportunity to make the system better and
prove to Veterans that good can come from their utilization of this
system which you created to facilitate the benefits they have earned.
Whether it's the 95-year old Veteran in northwestern Arizona who used
to drive three hours to Phoenix for care (and now gets his physical
therapy 10 minutes from home) or the Veteran who spoke with one of our
staff after his knee replacement, noting he's had 20 surgeries in his
life and the process through Choice was ``the easiest of them all'' and
``perfect'', we know that Veterans are beginning to recognize the
benefit of this program as utilization increases.
TriWest Performance - Becoming ``the Answer'' for VA
General George Patton said ``a good plan violently executed now is
better than a perfect plan executed next week''. I think we now know
personally the definition of ``violently executed'', as that has been
required of us. We adopted this mindset to begin working off the
significant care backlogs in place when we were called upon to
implement Choice in addition to our initial contract. And while more
time to implement the program would've been ideal, not one of us
involved in this wanted Veterans to wait a moment longer than
absolutely necessary. It was critical to begin coordinating Veteran's
health care immediately.
Beginning in 2014 when PC3 was implemented, the program started out
slowly with a couple thousand care requests per month. Networks were
being developed, and we phased our implementation by region beginning
in January 2014. Then, in April 2014, the furnace lit off in Phoenix,
which ignited a rapid increase in program utilization nationwide. Over
time, program adoption grew, and by the end of 2014, TriWest received
almost 22,000 care requests from VAMCs throughout our regions, as
displayed below:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
At the tail end of 2014, and moving into 2015, the Choice program
was birthed. At the start of the Choice program, we received requests
for only 2,000 appointments for the entire month. This number has
skyrocketed and expected to surpass 110,000 this month - just one year
into the program. For those of us who are math minded, that's over a
4,900% increase in volume. The chart below shows the upward trajectory
for the number of authorizations received per day in 2015, and the
first two months of 2016:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Although this massive growth is a positive indication that more and
more Veterans are receiving the care they deserve, it does call upon us
to push the envelope in meeting the challenges. Despite having added
numerous operations centers since last Summer, increasing staffing by
thousands, adding several innovations to systems and process, we are
still not finished with our task of catching up fully with the
continually increasing demand.
What is particularly staggering is the growth in the number of
phone calls received. Just this last month, total calls were nearly 1
million. The growth in calls has been a bit like chasing a Tsunami, as
the chart below illustrates.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
And, while we are still refining our operations in this area of
staggering growth, I believe that the statistics are something about
which we can be justifiably proud and demonstrate that we are gaining
on it. They are as follows: less than 16 seconds average speed to
answer, and an abandonment rate of 2%.
In the midst of this surge in demand, a number of policy and
operational improvements have been made. For example, most recently VA
implemented a change order to our contract in early October 2015, which
aimed at lessening the wait lists and speeding the Veteran's access to
care. That change involves using a more proactive approach to making
health care appointments for Veterans, through the use of outbound
calling. That is, through a streamlined process with VA, we now reach
out to call the Veteran directly versus waiting for the Veteran to call
us. The new outreach processes we have developed jointly with VA keeps
the care requests moving rapidly through the system, so the Veteran
receives care more expeditiously.
Finally, processes improvements continue to be worked as we fully
implement additional operations centers, rounding out our presence in
each of the VISNs within our regions. As any of us do in a new
implementation or new job, we are striving to embrace a steep learning
curve. Our employees will continue to become more efficient in their
work, systems will continue to be tailored, and processes refined,
ultimately resulting in the kind of favorable outcome that all Veterans
deserve - thus fulfilling the overall goal of this program.
Refinements in Policy
At the outset of this crisis, Congress acted quickly to implement a
program which provided enhanced access to Veterans health care. Since
then, many legislative changes have occurred to address some nuances of
this program that were unforeseen in the beginning.
The first of such changes began in January 2015, under the Omnibus
Appropriations Act, when Congress addressed the rate issues and this
change helped align rates in the area with the marketplace - a key
component to provider satisfaction and contracting in that state.
Several months later, in July 2015, to further improve the program
from a policy perspective, the ``Surface Transportation and Veterans
Health Care Improvement Act of 2015'' modified several requirements of
the Veterans Choice Act of 2014.
First, the Act repealed the 60-day limit on follow up care.
Instead, the authorization extends for the entire episode of care. In
January 2016, we received the formal modification to implement this
change, which has opened the doors for many Veterans who need urgent
services lasting beyond 60 days, and helps with certain provider groups
who desire to provide care to Veterans, but had been stifled by the 60
day authorization rule. Now, Veterans who face serious conditions (such
as the case studies I shared with you earlier) are able to receive the
entire episode of care (chemotherapy treatment, maternity care, etc.)
that is required to complete their treatment.
Second, the Act repealed the August 1, 2012 enrollment limitation
on eligibility of Veterans in the patient enrollment system. This
critical change removed the requirement that you have to be enrolled in
VA prior to August 2, 2014, to be eligible for Choice Program. The
impact was great to Veterans, allowing near instantaneous determination
of eligibility by the VAMC.
Third, the Act extended provider eligibility to any health care
provider meeting VA criteria - this change helped open the pool of
providers who could provide health care to this deserving population.
Finally, the Act based the 40-mile distance requirement as the
distance traveled from a VA medical facility instead of `as the crow
flies', including one offering primary care for a Veteran seeking
primary care. This gave more Veterans access to the program, especially
in complicating geographic areas.
Another program change last Summer that was directed at improving
access was VA's implementation of the Choice First program - which
immediately expanded eligibility and opened the flood gates to care by
giving a Veteran the ability to obtain services in the network when
such specialty was not available at all within their local VA medical
facility.
Congress continued assessing necessary program modifications later
into 2015. In September 2015, TriWest received a contract modification
regarding outbound calls, and elimination of blind appointing, and we
were authorized to begin working these changes on October 1. This more
proactive approach to making health care appointments for Veterans
prevents an authorization from sitting and aging, awaiting a phone call
from the Veteran. As a result, more Veterans receive health care, and
they receive it more timely.
In late 2015, Congress expanded access to private doctors where its
Community Based Outpatient Clinics lacked sufficient provider access,
expanding the number of patients who are eligible to seek care in the
community under the Choice Program. As a result, if VA has no primary
care doctor on staff, a referral for private care is not required. This
change alone estimated opening up the program to about 160,000 more
Veterans.
Finally, in November 2015, we received federal approval within our
contract to allow TriWest to staff employees at VAMCs with the
execution of an appropriate Memorandum of Understanding. As a result,
TriWest has several cells of ``embedded staff'' within a multitude of
medical centers, including New Orleans, Dallas, Harlingen, Anchorage
and Phoenix, to more optimally coordinate work at the local level.
Oftentimes, Veterans are able to walk right down the hall after a
medical appointment that identified need for care in the community. In
that office, they can get educated about the program, we learn of their
preferences, and we start the process of securing them an appointment
in the community. We know from our work during the TRICARE program that
having staff embedded in a medical facility can go a long way toward
making the use of the program a more seamless experience. Those TriWest
staff got to know the government staff, the beneficiaries, and also the
providers in the community. All of that helped speed the process of
getting care provided in a timely manner in the community.
Overall, I commend Congress for all the steps it has taken this
past year which have driven great program improvements. In addition to
the changes that have already been modified into our contract, we also
anticipate a change in Medicare payment, whereby providers no longer
have to be Medicare participating in order to see one of our nation's
Veterans. This change has recently occurred with behavioral health
providers, whereby behavioral health care can now be provided by
master's level counselors; therefore, master's level counselors will
now be able to participate in PC3 or Choice and will be eligible to
receive authorizations to provide behavioral health care to Veterans.
This change will help enhance Veterans' access to such services, and
will be another piece to the puzzle of opening up more access to care
for those providers who wish to provide care for Veterans nationwide.
The pace is swift and, as you can see, changes are plentiful, but
we are implementing quickly, changing programs and refining processes
along the way, and MUCH has been done to set the groundwork to improve
the overall program and enhance access to care for our nation's
Veterans.
Looking Forward -Pushing the Art of the Possible
Now that we have had a glimpse into the past, let me take you to a
very important part - the future and the `next generation' of the
program, so that Veterans get the best care they need and deserve.
Here's what I see over the next six months that is part of the formula
for success moving forward.
At this point, I can confidently say that the Choice Program is
working--more Veterans are receiving the care they have earned and
deserve. It must work even better and faster to meet Veterans' needs,
and TriWest is committed to the continued partnership with VA to
continue to close the gaps.
One thing we know for certain is that through all of this, the
Choice Program brought significant availability to health care for
Veterans by making many community providers available to enhance access
when access to care in VA is not sufficient to meet the need. Deputy
Secretary, Sloan Gibson, stated during the House VA Committee hearing
on November 18, 2015 that there have been seven million more
appointments scheduled this year compared to last year. While not all
of this has flowed through Choice, the volume is continuing to increase
as we refine our capability and enhance our supply of network and staff
to match demand. Despite all the maturation that still needs to occur
to perfect the program, this is great progress, because millions more
Veterans are receiving health care under this program than last year.
Now, Veterans are demonstrating that they are gaining trust in the
program and TriWest, and they are seeking the care they need. Veterans
are voting with their feet-despite the start-up challenges, in the
TriWest area of responsibility, last month over 100,000 Veterans chose
to use Congress' VA Choice Act, including the 95 year old Veteran in
Phoenix who no longer has to drive three hours for his physical
therapy.
Demand for health care will grow as Veterans who may have become
discouraged and given up seeking care will return as the backlogs are
reducing across the system and as we continue to work together to
effectively address access issues. We expect that as Veterans continue
to gain trust in the Choice Program, they will continue to seek out
this care when VA is unable to meet the need directly. It is for this
reason that we will continue to expand our operations over the next six
to nine months and beyond to ensure we do our part to see that Veterans
get the care they have earned.
The network will continue to expand and be high performing, so that
the Veterans we serve - and the VAMCs we serve alongside - will
continue to have the ability to access needed care in a timely fashion.
Legislative advances to help move this program forward will have
taken a strong foothold. And, we and VA just executed a change in the
contract that allows us to decouple the receipt of medical
documentation from payment for a provider. While we will still pursue
the needed medical documentation from the provider, so that it can get
to the VA doctor quarterbacking the care for the Veteran and end up in
the Veteran's consolidated medical record in VA, this will speed up our
ability to pay the provider so that nearly all payments will match our
performance on clean claims of more than 97% being paid within 30 days.
We are in the midst of a major VA health care reform, and we have
the opportunity to make the health care delivery model the most
efficient it can be. In my opinion, the best system for Veterans is a
VA public-private partnership that builds on what VA does best, while
leveraging private sector provider networks and best business practices
created by TriWest. This partnership provides accountability and
transparency while also fostering innovation. But, VA must ultimately
be the backbone, focusing on their core mission of taking care of its
soldiers inside the four walls of VA. And, VA must allow their private
sector partner, TriWest, to do what we do best which is to build and
enhance networks, process claims, schedule appointments, and help
coordinate care for the best outcomes for the Veteran, with
flexibility, effectiveness and efficiency. We must continue to work
together for the betterment of VA health care, alongside VA and
Congress, and we all must continue to build upon the core that we have
already developed.
Conclusion
Mr. Chairman, I hope my testimony has provided some useful
information as to how TriWest became a part of this effort, where we
are today, and where we are headed in the future. I also hope it has
convinced you that the company I am proud to lead considers it an honor
and privilege to work every day to provide access to care for those who
have served this nation in uniform. We have always stood ready to
implement VA health care needs within record speed and record time, and
will continue to dedicate ourselves to this critical task, all in
support of our nation's Veterans. It is an awesome responsibility and
our non-profit owners look forward to continuing to be a large part of
the formula for future success in assisting VA in delivering on its
responsibilities to our heroes on behalf of a grateful nation!
Thank you again Mr. Chairman for this opportunity to appear before
you and your colleagues this morning. I look forward to answering any
questions you might have.
Prepared Statement of Dr. Baligh Yehia
Good morning, Chairman Benishek, Ranking Member Brownley, and
Members of the Subcommittee. Thank you for the opportunity to further
discuss the plan to provide Veterans access to a community care network
as described in the Department of Veterans Affairs (VA) October 30,
2015, report on the consolidation of community care programs. The
community care network will provide Veterans with access to
high-quality providers and the ability to make an informed choice
regarding their health care. I am accompanied today by Dr. Gene
Migliaccio, Deputy Chief Business Officer for Purchased Care.
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 the 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, community providers, and 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 a plan to
consolidate all VA's purchased care programs. The plan included some
aspects of the current Veterans Choice Program established by Section
101 of the Choice Act and incorporated additional elements designed to
improve the delivery of community care.
VA currently has a variety of agreements with providers in the
community, but limited national visibility into supply and demand
needs. There are no standardized approaches for provider credentialing,
quality monitoring, or identification of
best-in-class providers. High-performing networks in health care
apply standardized credentialing and quality criteria. They can
identify and recruit high-quality providers for the network. As
described in the plan, the VA Core Network includes high-quality health
care assets in the Department of Defense (DoD), Indian Health Service
(IHS), Tribal Health Programs (THP), Federally Qualified Health Centers
(FQHC), and academic teaching affiliates. The community care network
includes commercial providers in Preferred and Standard tiers based on
quality and value performance. Standardized credentialing will decrease
administrative barriers for providers, while more rigorous and
consistent quality monitoring will promote high-quality care for
Veterans.
Background
To identify provider eligibility requirements and design a high-
performing network for VA, we have examined best practices for provider
networks, credentialing, and quality standards. Provider network design
and implementation are constantly shifting to accommodate changes to
the U.S. health care landscape, including coverage requirements and
provider incentive models. A provider network consists of licensed
health care professionals (e.g., doctors, nurse practitioners,
physician assistants, and nurses) and medical facilities (e.g.,
hospitals, outpatient surgery centers, and diagnostic imaging centers)
that agree to provide services at pre-negotiated rates. A robust
provider network has an adequate number of health care professionals in
terms of quality, mix/type of specialty, and geographic distribution,
as well as facilities, to meet demand needs.
High-performing tiered networks promote high-quality care, improve
health outcomes, and reduce system costs. They include providers who
meet the minimum standards and preferred providers who meet additional
quality and value standards. These networks help patients identify
providers who can deliver culturally competent care and publish
provider information for patients (e.g., quality designations and
patient feedback).
To effectively develop and maintain high-performing tiered
networks,
industry-leading organizations use network development, contracting
and reimbursement, provider relations, credentialing, and clinical
quality monitoring functions. The network development function
implements provider payment strategies and determines the optimal size,
composition, and geographic distribution of the network. Contracting
and reimbursement capabilities include negotiating provider agreements,
obtaining exception approvals to standard provisions as needed, and
maintaining reimbursement data. The provider relations function manages
ongoing communication and education initiatives with the provider
community, while also addressing inquiries and grievances. To improve
the stakeholder experience and simplify processes, leading
organizations invest in customer service personnel and web-based tools
for patients and providers (e.g., navigation tools to help patients
become familiar with care processes).
Credentialing is the process of reviewing the general
qualifications and practice history of providers using guidance from
organizations such as the National Committee for Quality Assurance
(NCQA) or The Joint Commission. Commercial provider networks review
education, training, employment, and disciplinary history. Leading
organizations use credentialing systems that automate tasks and
incorporate analytics-driven decision-making. The processing time for
credentialing a new provider in a commercial network is typically 30
business days. Commercial networks re-credential providers to monitor
ongoing adherence to standards based on regular intervals (usually 24 -
36 months). Providers that do not meet specific standards (e.g.,
because of recurring malpractice claims or sanctions against a
professional license) can be removed from the network.
In the U.S., health care is not delivered consistently. There are
notable differences in health care spending, resource utilization, and
quality of care depending on factors such as the licensed health care
professional, medical facility, geographic region, and patient
population. Increased utilization and spending do not always lead to
better outcomes. To promote consistent high-quality care that is safe,
timely, effective, efficient, and patient centered, industry-leading
organizations are working to measure provider performance and recognize
high performers. Metrics employ evidence-based performance criteria
based on rigorous and transparent methodologies. Sources for quality
measures can include NCQA, the National Quality Forum, Agency for
Healthcare Research and Quality, and The Joint Commission. Effective
coordination of care and health information management also directly
affects quality of care.
Current State
Current VA community provider relationships are formed through
multiple overlapping programs with federally funded health care
entities and commercial providers. VA contracts or has agreements with
approximately 40 DoD facilities (with access to TRICARE Managed Care
Contractors on a case-by-case basis), 100 IHS facilities, 80 THPs, 700
academic teaching affiliates, 700 FQHCs, 76,000 locally contracted
providers, and 200,000 additional providers through current national
contracts, such as PC3 and Choice. Despite the large numbers of
providers, VA does not have ongoing visibility into many provider
locations, nor an understanding of supply and demand imbalances.
Therefore, VA does not have coverage in certain areas to provide
accessible care to Veterans, nor a single mechanism to actively manage
provider relationships.
VA has multiple processes for credentialing community providers and
different credentialing criteria, depending on the authority that is
the basis for furnishing community care. VA does not have a
standardized approach to measure delivery of quality care furnished
through contracts and agreements with community providers. Some sharing
agreements are administered locally, and quality reporting requirements
vary depending on the agreement. As a result, VA currently has limited
visibility into best-in-class providers. Once providers have agreed to
provide care to Veterans, VA does not have a national mechanism to
track quality of care issues. With variable quality monitoring
processes, providers are held to different standards and VA faces a
larger burden in monitoring quality compliance.
Future State
To align with VA's mission to better serve Veterans, VA plans to
provide access to a high-performing network drawing from best practices
across industry and federally funded organizations. Key elements of the
high-performing network include:
Appling industry-leading health plan practices for tiered
network design;
Enhancing unique relationships with federally funded and
academic teaching affiliates;
Promoting Veteran choice, access to care, and high-
quality care delivery;
Using streamlined and consistent credentialing and
quality monitoring processes;
Incorporating network management functions, including
network development, contracting and reimbursement, credentialing,
clinical quality monitoring, and provider relations;
Consistently monitoring supply and demand changes to make
appropriate network adjustments, achieving access standards, and
coverage for primary and specialty care;
Effectively coordinating care in a Veteran-centered way;
and
Using clinical and administrative metrics to continually
measure and improve performance.
As proposed in the October 30, 2015, report on the consolidation of
community care programs, the VA Core Network will include providers in
the DoD, IHS, THPs, FQHCs, and academic teaching affiliates. VA's
relationships with these providers are unique and have evolved over
time. Sustaining and expanding Core Network relationships aligns with
VA's mission, vision, and strategies. VA will work to develop simple
and consistent agreements with Core providers that are principle-based
and focus quality and outcomes.
External providers - those outside the Core Network - can belong to
Standard or Preferred tiers, which will expand over time. VA plans to
make the process for joining the external network simple. Providers in
the Preferred and Standard tiers must meet uniform credentialing
requirements to participate in the high-performing network. Based on
industry feedback received from the Department's February 9, 2016 ``VA
Community Care Network'' draft performance work statement, VA is
working to develop requirements that match industry standard. Providers
in the preferred tier must meet minimum credentialing requirements
while also demonstrating high-value care.
The high-performing network will require network development,
contracting and reimbursement, credentialing, clinical quality
monitoring, and provider relations functions. VA will employ an audit
function to oversee credentialing and adherence to quality standards.
Veterans will have the ability to choose community providers and make
informed decisions based on publicly available information. Veterans
currently accessing community care can remain with their community
providers, if the provider meets minimum requirements, or choose other
providers in the network. Veterans also can recommend their providers
for inclusion in the network. VA will consider publishing provider
designations, credentials, and Veteran feedback. To promote awareness
about military culture and unique issues Veterans face, VA will
encourage providers to complete relevant trainings and make available
educational resources.
VA faces significant access challenges in delivering care to
Veterans due to geographic limitations and the unique needs of the
Veteran population. VA plans to include the highest quality providers,
but also recognizes the need to establish a broad and flexible network
providing convenient care near to where Veterans live. In the high-
performing network, credentialing processes will be simple, consistent,
and in alignment with best practices. The re-credentialing process will
evaluate ongoing provider qualifications to confirm health outcomes and
adherence to standards. These can include value, complaint history,
Veteran experience, and a baseline assessment of care appropriateness
every 24 - 36 months. VA will audit and enforce credentialing practices
in the high-performing network. High-level provider credentialing
standards include:
Educational credentials, certifications, licensure,
training, and experience;
Employment and pre-employment history;
Supplemental attestation questions, disciplinary
screening, and sanctions; and
Agreements with providers to meet access and quality of
care standards.
VA will work directly with providers currently caring for Veterans
to include them in the network for continuity of care. Providers who
meet credentialing criteria will complete a simple enrollment process
and can join the VA network. Over time, poor performing providers will
be removed from the network.
In the VA Core Network, VA will delegate credentialing or perform
credentialing functions when applicable. Federally funded credentialing
institutions include DoD, IHS, FQHCs, and THPs. In the external
network, either VA or a ``network manager'' will assume ownership of
credentialing and will apply industry-leading practices. VA will work
toward establishing simple, consistent, and high-quality agreements
with Core and external providers in the high-performing network. In
order to promote quality of care, VA will monitor and enforce rigorous
quality reporting and performance standards in line with industry,
conduct data analytics on disease management, and share VA critical
pathway information. VA plans to shift toward adopting value-based care
models in the high-performing network.
Creating a community care network will maximize the use of high-
quality federally funded health care assets, while sustaining unique
and important VA relationships. In addition, VA promotes high-quality
care by creating preferred and standard tiers. For the preferred
designation, providers must meet quality and value metrics that are
based on evidence-based care guidelines. VA plans to uniformly apply
best practices to determine criteria for both tiers. VA will work to
determine specific metric reporting and performance benchmarks using
recognized institutions.
Conclusion
VA appreciates the opportunity to discuss the community care
network element of our plan. The Network system described in our plan
would empower Veterans to make informed decisions about which providers
they want to use, by highlighting providers with higher quality, care
coordination, and satisfaction scores. Additionally, it will help
reduce confusion for Veterans as they interact with and transition
between VA facilities and community facilities. This provision also
supports our efforts to make our system more in line with industry
standards, as tiered networks are common in the delivery of value-based
care, as seen with TRICARE and many private sector health plans.
As we have described at other hearings, VA will implement
improvements to the delivery of community care through an incremental
approach as outlined in the plan. VA looks forward to continued
discussions on how to refine the approach described in our 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. These improvements, like many of the enhancements VA
has already made, are only possible with Congressional support,
including legislation and necessary funding.
Mr. Chairman, I appreciate the opportunity to appear before you
today. We are prepared to answer any questions you or other Members of
the Committee may have.
Statements For The Record
THE AMERICAN LEGION
The American Legion believes in a strong, robust veterans'
healthcare system that is designed to treat the unique needs of those
men and women who have served their country. However, even in the best
of circumstances there are situations where the system cannot keep up
with the health care needs of the growing veteran population requiring
VA services, and the veteran must seek care in the community. Rather
than treating this situation as an afterthought, an add-on to the
existing system, The American Legion has called for the Department of
Veterans Affairs (VA) to ``develop a well-defined and consistent non-VA
care coordination program, policy and procedure that includes a patient
centered care strategy which takes veterans' unique medical injuries
and illnesses as well as their travel and distance into account.''
Chairmen Benishek, Ranking Members Brownley and distinguished
members of the Subcommittees on Health on behalf of National Commander
Dale Barnett and The American Legion; the country's largest patriotic
wartime service organization for veterans, comprising over 2 million
members and serving every man and woman who has worn the uniform for
this country; we welcome this opportunity to comment on ``Choice
Consolidation: Leveraging Provider Networks to Increase Veteran
Access.''
Background
Historically, one of the main missions of VA is to be a provider of
direct healthcare to veterans through the Veterans Health
Administration (VHA). However, for many decades the VA has also acted
as a payer by relying on non-VA care providers, i.e., care in the
community, when it has not been able to provide that care in a timely
or cost effective manner.
The 2014 veterans' access to care crisis revealed, though, that VA
was not appropriately utilizing these provider/payer programs to meet
the needs of the growing veteran population requiring VA services.
As a result, Congress created the Veteran Choice Program (VCP)
after learning that VA facilities were falsifying appointment logs to
disguise delays in patient care. However, it quickly became apparent
that layering yet another program on top of the numerous existing non-
VA care programs, each with their own unique set of requirements,
resulted in a complex and confusing landscape for veterans and
community providers, as well as the VA employees that serve and support
them.
Therefore, Congress passed the Surface Transportation and Veterans
Health Care Choice Improvement Act of 2015 (VA Budget and Choice
Improvement Act) in July 2015 after VA sought the opportunity to
consolidate its multiple care in the community authorities and
programs. This legislation required VA to develop a plan to consolidate
existing community care programs.
On October 30, 2015, VA delivered to Congress the department's Plan
to Consolidate Community Care Programs, its vision for the future
outlining improvements for how VA will deliver health care to veterans.
The plan seeks to consolidate and streamline existing community care
programs into an integrated care delivery system and enhance the way VA
partners with other federal health care providers, academic affiliates
and community providers. It promises to simplify community care and
gives more veterans access to the best care anywhere through a high
performing network that keeps veterans at the center of care.
Generally, The American Legion supports the plan to consolidate
VA's multiple and disparate purchased care programs into one New
Veterans Choice Program (New VCP). We believe it has the potential to
improve and expand veterans' access to health care and address many of
the existing problems currently experienced by veterans who elect to
receive some of their care in the community when they can't do so
within the VHA.
Leveraging Provider Networks to Increase Veteran Access
Under the New VCP program, VA would establish a single set of
eligibility criteria for private care; expand access to emergency
treatment and urgent care; simplify the referral and authorization
system; and improve the claims, billing and reimbursement processes.
The health care network under New VCP would be larger as well. VA
Undersecretary Shulkin aptly describes it in a recent New England
Journal of Medicine article.
The network would consist of three groupings of providers. The core
network would include all VA-run hospitals, clinics, and centers, as
well as appropriate facilities run by other federal agencies, tribal
health partners, and academic teaching institutions that have already
established relationships with the VA. Many of these facilities have
expertise in military service-related conditions, and all have the core
competencies required for providing comprehensive, coordinated care.
These facilities would increase access to highly specialized care and
address the needs of some veterans living in remote areas.
The second network would include organized private-sector delivery
systems that meet performance criteria for clinical outcomes,
appropriateness criteria, access standards, and service levels. The
process for acceptance into this second network would be highly
competitive and based on documented results. Integrated systems of care
would be ideally suited for inclusion, since their providers have been
investing in coordinated care for some time.
A third network would allow veterans to obtain care from additional
participating private-sector providers, ensuring access for veterans
who don't live within a reasonable distance of providers in the other
networks. Providers in this network would need to agree to submit
clinical data and documentation to VA health information exchanges.
At a March 15, 2016, Senate Veterans Affairs Committee hearing, The
American Legion commented on VA's concept of a Tiered High Performance
Network indicating that we support Senator Tester's language in S.
2633: Improving Veterans Access to Care in the Community Act which
allows VA to set up tiered networks.
As we understand it, this structure is meant to empower veterans to
make informed choices, provide access to the highest possible quality
care by identifying the best performing providers in the community, and
enabling better coordination of care for better outcomes. However, it
does not dictate how veterans will use the network.
The American Legion wants to make clear, though, that we do not
support a wholesale option to circumvent the VA infrastructure or
healthcare system entirely. Veterans can and should receive their care
within the VHA system, as the benefits available to them within this
system are myriad. Not only do veterans vastly prefer to receive care
within VA and comment highly favorably on the care they get when they
have timely access, the VHA system is specifically designed with the
needs of the veterans in mind. No other healthcare system or network
provides the kind of comprehensive care that considers the factors of
the circumstances of a veteran's military service. No other system is
primed to ensure that veterans who have served in areas with known
associations to toxic exposures such as Vietnam or the Persian Gulf
region are screened for conditions known to be associated with those
exposures. No other system is as proactive in screening for and
providing treatment for posttraumatic stress disorder (PTSD) and
traumatic brain injury (TBI) the ``signature wounds'' of the Global War
on Terror.
In addition, for over half a century, the VHA has had a long-
standing and outstanding relationship with their medical school
affiliates. VHA uses medical school affiliations to recruit, and retain
high quality medical professionals to provide veterans with access to
cutting edge technologies that may have not be offered in the private
sector. VHA has the largest coordinated education and training program
for health care professionals in the country and medical school
affiliations allows their new medical professionals to be trained in
the VA healthcare system. Clearly leveraging public-private
relationships, particularly with educational institutions, will be a
key component in building successful networks of providers to handle
the overflow from VA in community care.
A secondary advantage of the partnerships with medical schools is
it opens a clear and natural avenue for research partnerships. Often
overlooked while solely focusing on the provision of care aspect of
VA's mission is the research component of VA's core mission. VA can and
should return to its top position as a cutting edge innovator in
America medicine and affiliations with medical schools and research are
a critical component of that ascendency. The American Legion is
strongly committed to support for mutually beneficial affiliations
between VHA and medical schools.
The root of the problem comes down to the question of whether or
not VA is capable of building the required networks of care, or whether
this task should be outsourced to third party agencies (TPAs) as was
done for the Choice program. While VA has struggled in the past with
large scale project organization, such as with the four recent hospital
development plans in Florida, Nevada, Colorado and Louisiana, the
decision to use TPAs may not be much better. The two TPAs chosen for
the Choice program, TriWest and HealthNet, were chosen during the very
short 90 day period VA had to begin implementing the program. There
were certainly problems working with those providers getting Choice up
and running including infrastructure problems as well as billing. When
the options for building the network of providers are VA doing it
themselves and using TPAs, both sides perhaps raise more questions than
they answer.
This is a complicated problem and The American Legion can't attest
to VA's capabilities one way or the other that would support or deny
success, but we can say that if VA is capable of building such a
network as they propose, that it will be more cost effective and
support VA's mission to be in a better position to provide better and a
more seamless healthcare experience for veterans. Based on our
experience with Access Reach Closer to Home (ARCH), Patient Centered
Community Care (PC3), and Community contracted care, in many ways, VA
is already doing it.
A plan for a New Veterans Choice Program needs approval from
Congress. VA needs to overhaul its outside care reimbursement programs,
consolidating them into a more efficient bureaucracy able to
dynamically interact with the network of federal, public, and private
providers that are to supplement VA direct provided care. The American
Legion believes that VA's plan is a reasonable one given the desired
results.
As you know, Senators Tester and Burr in conjunction with the
Senate Veterans Affairs Committee are crafting legislation to fix the
Choice program and codify the New VCP. The American Legion encourages
this committee to work closely with your senate colleagues on a final
compromise bill which incorporates the best of the proposals that are
being considered.
In conclusion, The American Legion believes that together we can
accomplish legislative changes to streamline Care in the Community
programs before the end of this session of Congress. We can't let
another year slip away. Our veterans deserve the same sense of urgency
now that Congress has shown numerous times since the VA scandal first
erupted in 2014.
As always, The American Legion thanks the Subcommittees on Health
for the opportunity to explain the position of the over 2 million
veteran members of this organization. For additional information
regarding this testimony, please contact Mr. Warren J. Goldstein at The
American Legion's Legislative Division at (202) 861-2700 or
[email protected]
VETERANS CHOICE IN HEALTH CARE FACTSHEET
The structure of the network facilitates provider
participation; it does not dictate how Veterans will use the network.
A Veteran seeking community care will have the ability to
choose his or her providers.
Tiered Networks empower Veterans to make informed
decisions about which providers they want to use, by highlighting
providers with higher quality, care coordination, and satisfaction
scores.
Use of tiered networks is common in industry and
government (e.g., Medicare TRICARE Prime), and is useful in delivering
value-based care.
Veterans will have Choice in Providers:
A Veteran will have the ability to choose which provider
he or she would like to see for care. The tiered network structure will
allow VA to provide the Veteran with information to make an informed
choice about the right provider to see.
The tiered network will improve the way Veterans interact
with community care by reducing confusion in where to seek care,
providing the highest-quality care available, and streamlining the
transition from a VA facility to a community facility.
A Veteran seeking community care will be asked which
provider he or she would like to see and will primarily fall into one
of the following scenarios:
,I Veteran with specific provider request: The Veteran has
requested a specific provider (e.g., cardiologist) in mind. If the
provider is in the network, the Veteran will be able to schedule an
appointment with that provider. If the provider is not in the network,
they will be asked to join the network. Once the provider is in the
network, the Veteran will be able to schedule an appointment with that
provider.
,I Veteran without specific provider request: The Veteran does not
have a specific provider (e.g., cardiologist) in mind. VA will provide
a recommendation of providers in their geographic area for Veterans to
choose from. Providers will be organized based on quality and alignment
with academic affiliates and Federal partners.
Bottom line is that a tiered network structure creates
value for Veterans by providing informed choice on which provider to
see for care.
Tiered Networks are Useful to Organize Providers:
VA is proposing 3 tiers:
,I Tier 1: DoD, Indian Health Service, Tribal Health Programs,
Federally Qualified Health Centers, and academic affiliates providers
,I Tier 2: Top rated community providers (e.g., quality)
,I Tier 3: Community providers who meet standard criteria (e.g.,
Medicare-eligible and have an active health care licensure)
The tiered network will be a back-end structure used by
VA to
,I Monitor quality of care Veterans receive
,I Improve the Veterans experience with care
,I Provide oversight
Advantages of Using a Tiered Network Structure
A tiered network structure will enhance Veterans choice.
It will:
,I Empower eligible Veterans to make an informed decision on which
community provider he or she wishes to see.
,I Provide Veterans access to the highest quality care by
identifying the best performing providers in the community.
,I Incentivizes providers to continuously evaluate and improve
their performance.
,I Provides comprehensive care coordination between VA and
community providers.
Tiered Network Structure is Critical for Academic Affiliate
Partnerships
VA accomplishes critical education and training efforts
through coordinated programs and activities in partnership with
affiliated U.S. academic institutions. VA is affiliated with more than
1,800 educational institutions (95% of allopathic medical schools and
over 87% of osteopathic medical schools).
A tiered network structure maintains VA's commitment to
teaching and training health care professionals through the inclusion
of Academic Affiliates in Tier 1.
Some Academic Affiliates did not choose to participate in
the Choice Program and therefore were no longer able receive Veteran
patients since VA was using Choice as the first option in buying care.
This dramatically impacted the teaching programs of some Academic
Affiliates. Inclusion of Academic Affiliates in the Tiered Network will
enable VA to sustain and strengthen relationships with affiliated and
allow Veterans access to the high quality, timely care they deliver.
VA's ability to provide clinical care depends on our
relationships with Academic Affiliates as many internal VA providers
are Affiliated with Academic Institutions. As a result, deterioration
in these relationships could result in less providers available to care
for Veterans.
Tiered Network Structure is Critical for Department of Defense (DoD)
A tiered network structure maintains VA's commitment to
teaching and training health care professionals through the inclusion
of Department of Defense facilities in Tier 1.
Partnership with VA enables DoD appropriate personnel
readiness as:
,I Treating Veteran patients allows DoD health care professionals
to see the additional volume of patients with the diversity of needs
necessary for maintenance of certain licenses.
,I VA provides resident training programs for Military health care
providers
,I DoD providers gain additional hands-on health care experience,
contributing to the improvement of overall quality of care.
Partnership Highlight: VA and DoD recognize the
importance of providing coordinated and comprehensive rehabilitation
services to support recovery form polytrauma. Both agencies have a long
history in partnership in providing polytrauma care that is a patient-
centered, interdisciplinary approach that works with the injured
individual and his or her family to address all aspects of the injury
as it impacts the person's life.