[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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                     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

                              ----------                              

                        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

                              ----------                              

                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.