[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


   SHAPING THE FUTURE: CONSOLIDATING AND IMPROVING VA COMMUNITY CARE

=======================================================================

                                HEARING

                               BEFORE THE
                               
                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         TUESDAY, MARCH 7, 2017

                               __________

                            Serial No. 115-5

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BRAD R. WENSTRUP, Ohio               JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   KILILI SABLAN, Northern Mariana 
JODEY ARRINGTON, Texas                   Islands
JOHN RUTHERFORD, Florida             ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

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 
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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 
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further refined.
                            
                            C O N T E N T S

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                         Tuesday, March 7, 2017

                                                                   Page

Shaping The Future: Consolidating And Improving VA Community Care     1

                           OPENING STATEMENTS

Honorable David P. Roe, Chairman.................................     1
Honorable Timothy J.Walz. Ranking Member.........................     3

                               WITNESSES

Honorable John McCain, U.S. Senate, Arizona......................     5
    Prepared Statement...........................................    47
Honorable David J. Shulkin M.D., Secretary, U.S. Department of 
  Veterans Affairs...............................................     7
    Prepared Statement...........................................    48
        Accompanied by:

    Baligh Yehia M.D., Deputy Under Secretary for Health for 
        Community Care, Veterans Health Administration, U.S. 
        Department of Veterans Affairs
Honorable Michael J. Missal, Inspector General, Office of the 
  Inspector General, U.S. Department of Veterans Affairs.........     8
    Prepared Statement...........................................    49
Randy Williamson, Director, Health Care, Government 
  Accountability Office..........................................    10
    Prepared Statement...........................................    56

                       STATEMENTS FOR THE RECORD

Veterans of Foreign Wars.........................................    72
HVAC.............................................................    75
Paralyzed Veterans of America (PVA)..............................    76
The American Legion..............................................    79
Disabled American Veterans (DAV).................................    82
TriWest..........................................................    87

 
   SHAPING THE FUTURE: CONSOLIDATING AND IMPROVING VA COMMUNITY CARE

                              ----------                              


                         Tuesday, March 7, 2017

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 7:36 p.m., in 
Room 334, Cannon House Office Building, Hon. David P. Roe 
[Chairman of the Committee] presiding.
    Present: Representatives Roe, Bilirakis, Coffman, Wenstrup, 
Radewagen, Bost, Poliquin, Dunn, Arrington, Rutherford, 
Higgins, Bergman, Banks,Walz. Takano, Brownley, Kuster, 
O'Rourke, Rice, Correa, Sablan, Esty, and Peters.

          OPENING STATEMENT OF DAVID P. ROE, CHAIRMAN

    The Chairman. The Committee will come to order.
    Good evening and thank all of you all for being here and 
joining us tonight.
    Though it is somewhat unusual for the Committee to meet in 
the evening hours, tonight's topic is one well worth staying up 
late for. I want to keep our work this evening laser focused on 
the future. On how we can all work together to create a better, 
brighter, healthier one, for our veterans, and for the health 
care system that was built to serve them, rather than on 
rehashing mistakes that we have made long ago. Yet as we begin 
to move forward this evening, we must not lose sight of where 
we started.
    Three years ago, next month, in this very room, the 
Committee heard testimony from a veteran named Barry Coats, who 
spoke about waiting almost a year for care from the Department 
of Veterans Affairs medical facility in South Carolina. When 
Barry was finally seen, long after he should have been, he was 
diagnosed with stage IV colon cancer that had spread to his 
liver and to his lungs. He passed away in January last year.
    It was Barry's story and accompanying allegations, that 40 
veteran patients had died while waiting to receive care from 
the VA Medical Center in Phoenix Arizona, that kicked off a 
nationwide access and accountability scandal the likes of which 
the VA had never seen.
    It also led directly to the creation of the Choice Program 
and to the allocation of billions of more taxpayer dollars to 
increase access to care for veteran patients. In the 3 years 
since then, more than 2 million authorizations for care have 
been approved and over 1 million veterans have been able to get 
care that otherwise might not have been readily available.
    However, all of us around this dais continue to hear from 
veterans, day after day, experiencing lengthy and frustrating 
delays when attempting to schedule appointments through VA 
using Choice. In fact, just a couple of weeks ago, I was 
contacted by a veteran with a story much like Barry's. This 
veteran was diagnosed with cancer last fall and referred to 
Choice for treatment.
    While I am relieved to say he is now receiving the care 
that he needs, from the provider of his choice, he suffered 
through weeks of doubt due to a series of mishaps and 
miscommunication between VA, the third-party administrative 
managing Choice, in this particular region, and the community 
provider who had agreed to treat him. It appears that 3 years 
after Barry's testimony, a lot has changed, but too much has 
stayed the same.
    What is more, recent work performed by the VA inspector 
general, and the Government Accountability Office, illustrate 
very clearly that Choice is not set up to succeed at its 
primary mission: providing timely care to veterans who cannot 
access that care within the VA because it is either not 
offered, not available within a reasonable amount of time, or 
would entail a veteran traveling a great distance. For example, 
GAO is going to testify this evening that veterans could 
potentially wait up to 81 calendar days before receiving care 
due to the burdensome bureaucratic process the VA imposed on 
Choice. That is unacceptable to me and I am sure everyone in 
this room.
    I ran a practice in east Tennessee for over 30 years, and I 
assure you it does not have to be this complicated and should 
most certainly not take this long.
    Luckily, Choice is not the same program today as it was 
when it was reviewed by GAO and the IG last year, and it is 
certainly not the program that when it was first created. 
Through a series of four legislative changes and 70 contract 
modifications and counting, Choice has been continually 
improved upon and made stronger.
    It remains far from perfect and in far too many cases it 
fails the very veterans it was created to serve. I am working 
diligently with the Ranking MemberWalz. with the Secretary and 
his senior leaders, and with our Senate colleagues, and with 
our veterans service organization partners to chart a path 
forward for Choice and for all VA care and the community 
programs in short order.
    I hope to have draft language to share in the coming weeks 
and to have a VA health care reform bill on the President's 
desk this year. However, the first step to reforming Choice is 
making sure that there is a smooth transition to lead the way. 
This is why it is critical that this Committee act tomorrow to 
mark up H.R. 369, a bill I introduced earlier this year, to 
remove the current 3-year sunset date from the Choice Program.
    Absent legislation, Choice will begin shutting down in just 
a matter of weeks and will end completely in 5 short months 
from today, cutting off a key access avenue at a time when 
veterans are seeking care in the community more than ever 
before and critically at a time when the VA's nonChoice 
community care account has been unable to absorb additional 
demand for care.
    VA is already facing a $3.4 billion deficit in the 
community care account next fiscal year that VA leaders have 
told the Committee, staff will require additional 
appropriations to address. By removing the sunset date to the 
Choice Program, we are not endorsing the program in its current 
state, but we are ensuring that emergency funds that Congress 
made available for critical veterans care are used for that 
purpose until they are expended.
    Community care appointments have increased by 61 percent 
overall since Choice was created, and last year, 30 percent of 
all VA appointments were held in the community rather than in 
VA medical facilities. The future of VA relies on not only a 
strong VA health care system, but on a VA health care system 
that is inextricably linked with community resources to fill 
the gaps and meet the need of our veterans when and where they 
are.
    We must get this right and learn from the mistakes, 
miscommunication, and undue bureaucratic processes that have 
plagued Choice since its inception, not only for the veterans 
who depend on this system today, but also for generations of 
American heroes to come. That is what I am committing to once 
again this evening.
    With that, I will now yield to Ranking MemberWalz.for any 
opening statement that he may have.

      OPENING STATEMENT OF TIMOTHY J. WALZ, RANKING MEMBER

    Mr. Walz. Well, thank you, Chairman Roe, for holding this 
important hearing. A special thank you to Senator McCain, 
always a champion for our veterans, and it is a pleasure to 
have you over here, Senator.
    A special thank you to Secretary Shulkin. Again that sounds 
very good, and we appreciate you being here. We also have the 
inspector general and the GAO as well as the Committee Members 
who are here, the VSO's who sit behind you, and the American 
public, all who have the same issues and the same goal: the 
highest quality care in the most timely manner for our 
veterans. So I am grateful to each and every one of you.
    Last Congress we heard from health care and veteran policy 
experts at VA, including Secretary Shulkin, our veterans 
service organizations, the independent assessments blue ribbon 
panel, and the commission on care about how we should shape the 
VA of the future. Now it is time to get to work, together, to 
make some decisions, pass some legislation to ensure our 
veterans receive the health care they deserve.
    One of this Committee's highest priorities is to ensure 
that veterans receive the highest quality health care in a 
timeline manner in a safe environment, this includes care at 
the VA medical facilities and through community health care 
providers. I think we can all agree that care in the community 
must be utilized so that veterans do not have to wait too long 
or travel too far to receive care. However, from listening to 
our veterans and constituents who are still waiting too long to 
receive care, we need to make some changes to the Choice 
Program.
    Our witnesses, the inspector general, and the GAO will 
testify to survey and audit data that back up what our 
constituents have been telling all of us: veterans are still 
waiting too long for community care and in many cases have been 
forced to manage care on their own. As Dr. Roe said, it should 
never take 80 days to get an appointment in the community. 
Veterans in need of mental health care and our elderly veterans 
should not be struggling to make their own appointments and 
coordinate complex care.
    Care decisions should be made between the doctor and the 
veteran, and the VA should be there to make sure the veteran 
gets a timely appointment, make sure a doctor has a health care 
record to treat the veteran, and make sure the veteran is not 
stuck with a huge medical bill after seeing that doctor.
    As VA moves forward with its community care consolidation 
plan, I hope we can take some of the lessons we learned from 
Choice. We need strong leaders at the VA hospitals who are 
committed to putting the plan in place. Our VA facilities were 
responsible for filling in inadequate community care networks 
under Choice and providing the staff to support this new 
program. They should be involved in this new community care 
plan every step of the way.
    We need technology to support our providers at the VA and 
our community providers treating veterans. This requires the VA 
to have a modern electronic health record and an IT system to 
reduce the time it takes for VA to coordinate care and process 
claims. VA's current IT system, or lack of IT systems, to 
support care coordination, are contributing to delays and 
increasing workload for staff, who are manually processing 
them.
    To get this plan right, this will cost a significant amount 
of money. Our President has said he is committed to increasing 
funding for our veterans, but this does not mean the VA gets a 
blank check to continue programs that are not working, or that 
this money should all go to community care when veterans need 
the specialty care and coordination that only the VA can and 
should provide. This also means the VA must be able to better 
forecast the resources and staff it to provide veterans the 
care and the facilities and through its network of community 
providers.
    Tomorrow we will be marking up legislation that will allow 
for the remaining Choice Program funds to be spent. Along with 
this, I think we have come to a bipartisan agreement that VA 
should be billed first before a veteran is billed for receiving 
community care and that community providers should be able to 
have access to veterans' medical records. This was a bipartisan 
agreement working with experts, and I applaud Dr. Roe and his 
folks for making this happen.
    I hope that we can continue working together and make 
decisions that move forward to improve health care for our 
veterans and be good stewards of our taxpayer dollars.
    Thank you, Chairman Roe. And I yield back.
    The Chairman. Thank you very much. It is my pleasure to 
welcome a fellow veteran, American hero, and our colleague from 
across the Capitol, the Honorable John McCain, Senator from the 
great state of Arizona--
    Senator McCain. Well thank you Chairman Roe and--
    The Chairman [continued].--We thank you for your service 
both in uniform and in the Senate on behalf of our 
servicemembers, veterans, and their families. I appreciate your 
willingness to be with us this evening to talk about a topic 
that I know is a very personal and passionate one for you and 
for all of us.
    You are now recognized for 5 minutes, Senator McCain.

                    STATEMENT OF JOHN MCCAIN

    Senator McCain. I thank you very much, Chairman Roe and 
Ranking MemberWalz. And thank you for your kind words.
    Mr. Chairman, I am one of those whose number of landings 
does not match the number of take-offs. And I thank you for 
allowing me to be here. I would like to submit my full 
statement for the record, and I will try to be brief, since it 
is past my bedtime.
    The Chairman. Without objection.
    Senator McCain. I would also like to comment on my strong 
support for Dr. Shulkin as the head of the VA, and I think all 
of us have great respect for his work.
    Mr. Chairman, yesterday the front page of the Arizona 
Republic reported that there was a $2.5 million settlement to 
an individual named Steve Cooper, an Army veteran of 18 years. 
Steve waited for almost 2 years before seeing a doctor at the 
Phoenix VA. By the time he received care, his routine urology 
appointment had turned into a diagnosis of terminal cancer. 
Everyone in this room has heard a similar story. It is not 
acceptable, it needs to be stopped, and I want to thank every 
Member of this Committee for their dedication to our veterans 
and to make sure that never again is there another Steve 
Cooper, who served his country with honor and then, because of 
a failure to get an appointment, is terminally ill.
    He wasn't alone in his need for care. In 2014 our country 
was shocked to learn that Steve was one of 15,000 veterans 
standing in line for care in Phoenix, 3,300 of whom were 
urology patients. This disgrace served as a catalyst for the 
Veterans Access Choice Accountability Act. It created the 
Veterans Choice Program, which has enabled veterans to see 
providers in the community for their health care needs. More 
than 7 million appointments with community providers, for 
everything from diagnostic tests and urology screenings, to 
lifesaving heart and cancer treatment has been a result. There 
has been significant progress improving veterans health care. 
We have a long way to go to change the status quo plaguing the 
VA, and that is why I know none of us will abandon our effort 
to provide choice and flexibility in veterans' health care and 
why we must continue the hard work of refining and improving 
the Veterans Choice Program.
    We need, as you mentioned Mr. Chairman, to reauthorize the 
Veterans Choice Program, which was set to expire in a few short 
months. If we let the program lapse, hundreds of thousands of 
veterans will lose their ability to visit a community provider, 
the VA system will once again become overwhelmed.
    I come from a rural State. Members of the Committee come 
from large and small States. I don't want to have a veteran to 
drive for 50 miles or 40 miles in order to go to the VA, when 
he can go to a local area health care provider. It isn't any 
more complicated than that.
    Could I say that the Choice authorization expiration is 
approaching, I understand the VA already has begun limiting 
care under the Veterans Choice Program for veterans whose 
treatments would extend beyond August 7, 2017. I think that 
lends urgency to your action.
    I am concerned that veterans nationwide may encounter 
significant lapses in care if we don't act quickly. The outcome 
is not only avoidable, but it is unacceptable, and we in 
Congress must act. Today I was pleased in the Senate side, we 
are the place where the snobs reside, we took a critical step 
forward by joining Senate Veterans Affairs Committee Chairman 
Johnny Isakson, Ranking Member John Tester, Senator Jerry Moran 
and others to introduce the Veterans Choice Program Improvement 
Act, companion to what you are doing, Mr. Chairman, you and the 
Members of the Committee.
    Let me be clear. No one is advocating that we privatize the 
VA. Many veterans are satisfied with the VA, known for 
providing superior specialized treatment in the areas of mental 
health, post-traumatic stress disorder, and traumatic brain 
injury. At the same time, we can't afford to go back to the 
pre-scandal days when a VA bureaucrat had the final say on 
where and when a veteran received care. Such thinking was what 
resulted in nearly 15,000 veterans standing in line for care in 
Phoenix.
    I know this Committee agrees, as does Secretary Shulkin, 
and I look forward to working with all of you and my colleagues 
in the Senate to extend the Veterans Choice Program and 
continue to keep faith with our Nation's veterans.
    My dear friends, the world is in turmoil, and I believe 
that we will be sending our young men and women into harm's way 
in a lot of places in the world for years to come, and they 
will be veterans and they will come home someday. And I believe 
that the work that you are doing is the Lord's work, and 
because you are committed, as all Americans are, to giving the 
veterans the care that they need and deserve and they earn by 
defending this Nation.
    I thank you for allowing me to appear before you. God 
bless.

    [The prepared statement of Senator John McCain appears in 
the Appendix]

    The Chairman. I was going to thank Senator McCain, but he 
got out of here too quick. So, I didn't get a chance to do it.
    I now invite our second panel to the witness table, where I 
am honored to welcome the newest Secretary of Veterans Affairs, 
who will be testifying for the first time in his new role, Dr. 
David Shulkin. And I certainly enjoyed, with the Ranking 
Member, being at the White House during your swearing in with 
your lovely family.
    Secretary Shulkin. Thank you.
    The Chairman. Mr. Secretary, thank you for being here, and 
congratulations once again on your confirmation. One hundred to 
zip, I might add. I look very much forward to working with you, 
and beginning with tonight's hearing.
    The Secretary is accompanied tonight by Dr. Baligh Yehia, 
the Deputy Under Secretary for Health and Community Care. Thank 
you for being here. Also, finally we are also joined by the 
Honorable Michael Missal, VA Inspector General, and Randy 
Williamson, Health Care Director for the Government 
Accountability Office. Gentlemen, thank you for joining us 
tonight.
    Secretary Shulkin, we begin with you. You are recognized 
for 5 minutes.

                STATEMENT DAVID J. SHULKIN, M.D.

    Secretary Shulkin. Great. Good evening, Chairman Roe, 
Ranking MemberWalz. Members of the Committee. Thanks for being 
here so late. And thank you for this opportunity to discuss 
community care.
    I also did want to thank Senator McCain, but he ran out so 
quick, for his leadership. I couldn't agree more with him that 
we have to act now to ensure that our veterans have timely 
access to the care that they need.
    I also just wanted to offer my condolences tonight to the 
family of Dr. Thomas Starzel. He was a World War II Navy 
veteran and the father of modern transplantation, who worked in 
the VA and with veterans for over 50 years, and conducted the 
very first liver transplant at VA in 1963.
    As you know, VA has provided community care to veterans for 
over 70 years. Since August 2014, we have also provided care 
through the Veterans Choice Program, and we appreciate your 
support in providing this legislation and funding to better 
serve our veterans. As directed in the law, VA implemented this 
program in 90 days nationwide. That is unprecedented for a 
program of this scope and complexity. And because of the design 
of the law and this quick implementation, we did run into 
challenges, many of which are going to be identified tonight in 
the evaluations by the GAO and the VA inspector general.
    But since then, the Choice Program has evolved. We have 
worked with Members of Congress on four different amendments 
and with contractors on over 70 different contract 
modifications to improve access and efficiency, and as a result 
of these improvements, shortcomings identified in both the GAO 
and IG reports are now outdated. Choice is not the program it 
once was that these evaluations were released. I call it a 
living, growing program.
    Since the start of the program, over 1.2 million veterans 
have received some community care. A million appointments in 
fiscal year 2015 now has increased to 5.5 million in fiscal 
year 2016. Even with these improvements and increases, we have 
much more work to do. We are not satisfied with it.
    Our overarching concern is that veterans have access to 
high quality care when they need it regardless of whether it is 
in a VA facility or in their communities. Our goal for VA 
community care is to deliver a program that is easy to 
understand, simple to administer, and meets veteran needs. We 
know we are not there right now.
    Both VA and community care are critical. Veterans rely 
heavily on both. Despite the large increases in the use of 
Choice, only about 5,000 veterans use the Choice Program as 
their sole health care provider. The overwhelming use both VA 
and Choice. And as, you know, many veterans prefer only to use 
the VA.
    VA looks forward to continuing to partner with Congress to 
address the requested budget and legislative change, including 
provider agreements, making VA the primary coordinator of 
benefits and recording obligations to the time of payment. We 
have worked with veterans, community providers, VSOs and other 
stakeholders in the past, and we are going to continue to seek 
their input moving forward.
    However we do need your help. The Veterans Choice Program 
is going to expire in less than 6 months, but our veterans' 
community care needs will not expire. This looming expiration 
is a cause for concern among veterans, providers, and VA staff, 
and we need help in eliminating the expiration date of the 
Choice Program on August 7, 2017, so that we can fully utilize 
the remaining Choice funds. Without congressional action, 
veterans will have to face longer wait times for care.
    Second, we need your help in modernizing and consolidating 
community care. Veterans deserve better, and now is the time to 
get this right. We believe that a modernized and revised 
community care program must have seven key elements: first, 
maintain a high performing integrated network that includes VA, 
Federal partners, academic affiliate and community providers.
    Second, increase choice for all veterans, starting with 
those with service-connected conditions.
    Third, ensure that enrolled veterans get the care they need 
closer to their homes when appropriate.
    Fourth, optimize coordination of VA health care benefits 
with the health insurance that an enrolled veteran already has.
    Fifth, maintain the affordability of health care options to 
the lowest income of enrolled veterans.
    Sixth, assist in coordination of care for veterans served 
by multiple providers.
    And last, apply industry standards for performance quality 
patient satisfaction, payment models, and health care outcomes.
    We look forward to working with Congress and other 
stakeholders to enact these changes for veterans. And within 6 
months, we hope to present a plan, although we are still early 
in developing this. We actively are seeking input from VSOs and 
veteran advocates, and will continue to do so as we move 
forward.
    We know our number one priority is to provide veterans 
access to the high quality care they have earned, in a VA 
facility, or as close to home as possible, in the communities 
were they and their families live.
    Thank you for this opportunity to be before you today, and 
I look forward to any questions.

    [The prepared statement of David J. Shulkin, M.D. appears 
in the Appendix]

    The Chairman. Thank you, Dr. Shulkin.
    Mr. Missal, you are recognized for 5 minutes.

                  STATEMENT MICHAEL J. MISSAL

    Mr. Missal. Mr. Chairman, Ranking MemberWalz. and Members 
of the Committee, thank you for the opportunity to discuss the 
Office of Inspector General's work concerning VA's Choice 
Program and the future of VA's Community Care program. My 
written statement includes details of our extensive work in 
this area, and I invite your attention to those matters.
    For years, VA has relied on non-VA programs to help it 
carry out its mission of providing medical care. Today VA's 
purchase care programs include Veterans Choice Program, 
patient-centered community care, individual authorization, and 
other non-VA care programs. We have reported in our audits, 
reviews, and health care inspections, and discussed in 
hearings, the challenges VA faces administering these programs.
    In October 2015, VA provided Congress with a plan to 
consolidate all VA's purchase care programs into VA's Community 
Care program. Under consolidation, VA continues to have 
problems determining eligibility for care, authorizing care, 
making accurate payments, providing timely payments to 
providers, and ensuring the necessary coordination of care 
provided to veterans outside the VA health care system. Without 
improvement in these areas, these issues will continue to be 
obstacles to ensuring veterans receive timely access to quality 
care.
    To increase the program's overall effectiveness, VA and 
Congress must understand the historical barriers and control 
weaknesses that have plagued VA's purchase care programs and 
ensure they are adequately addressed in future purchase care 
programs.
    With respect to the Veterans Choice Program, we have 
recently completed audits and reviews concerning the Choice 
Program, and our findings have substantiated problems with 
authorizing and scheduling appointments, consult management, 
network adequacy, and timeliness of payments to providers. 
Moreover, our hotline has received hundreds of contacts about 
the Veterans Choice Program. Most of these complaints were 
about appointments, scheduling, referrals, authorizations, and 
consults.
    We also identified issues in the Patient-Centered Community 
Care program. The PC3 program is a VHA nationwide program that 
provides eligible veterans access through health care contracts 
to certain medical and mental health services. The PC3 program 
is used after the VA medical facility exhausts other options 
for purchased care and when local VA medical facilities cannot 
readily provide the needed care to eligible veterans due to 
lack of available specialists, long wait times, geographic and 
accessibility, or other factors.
    We published a series of five reports on PC3 in fiscal 
years 2015 and 2016. We reported that the PC3 program, prior to 
including the Veterans Choice Program, did not achieve its 
estimated cost savings, provide timely access to care, or 
ensure that contractors provided clinical documentation and 
reported critical findings as specified in their contract 
performance requirements.
    In addition, we reported that PC3's inadequate provider 
network contributed significantly to VA medical facilities' 
limited use of PC3, and that PC3 contracts were not adequately 
developed and awarded.
    A theme that was clear from our work was that VA clinical 
and support staffs were dissatisfied with PC3 in such areas as 
authorizing payer, scheduling appointments, and veterans 
waiting for care. These are some of the same issues we hear 
today about the Choice Program.
    In summary, our audits, reviews, and inspections have 
highlighted that VA's has had a history of challenges in 
administering the purchase care programs. Veterans access to 
care, proper expenditures of funds, timely payment of 
providers, and necessary coordination of care are at risk to 
the extent that VA lacks adequate processes to manage funds and 
oversee program execution.
    While purchasing health care services from community 
providers affords VA flexibility in providing expanded access 
to care and services that are not readily available at VA 
medical facilities, it also poses a significant risk to VA when 
adequate controls are not in place. We will continue to provide 
significant oversight of VA's Community Care programs.
    Mr. Chairman, this concludes my statement. I would be happy 
to answer any questions you or Members of the Committee may 
have.

    [The prepared statement of Michael J. Missal appears in the 
Appendix]

    The Chairman. Thank you very much.
    And Mr. Williamson, you are recognized for 5 minutes.

                 STATEMENT OF RANDY WILLIAMSON

    Mr. Williamson. Thank you, Chairman Roe, Ranking 
MemberWalz. and Members of the Committee.
    In August 2014, Choice legislation was enacted for the 
express purpose of providing more timely health care access for 
eligible veterans. Currently, however, VHA has established a 
cumbersome bureaucratic Choice appointment scheduling process 
that sometimes does not provide timely health care access for 
veterans.
    This process allows up to 81 days for the veteran to 
receive routine care from the time the VHA provider determines 
a veteran needs care, but in many cases, documented by GAO, the 
VA Office of Inspector General, and the press, wait times have 
been even longer for those veterans who have opted into the 
Choice Program.
    For example, one of the VA Medical Centers we visited 
referred a veteran to the Choice Program for maternity care 
since VA Medical Centers do not offer this care. VA confirmed 
her pregnancy at 6 weeks, but waited almost a month and a half 
before sending an urgent referral to the VA's third-party 
contractor, who was responsible for making a prenatal 
appointment for her. It took another 2 weeks for the contractor 
to attempt to make an appointment for her. At this point, she 
was 15 weeks pregnant. Finally, when she was 18 weeks pregnant, 
almost halfway through her pregnancy and still without an 
appointment, she made her own appointment with the Choice 
provider. There was no way to know whether this case or cases 
like these are typical, because VA has no reliable data to 
measure how long the entire process takes.
    As the current Choice Program is slated to sunset in August 
2017, and the Congress is considering proposals to reauthorize 
what has been referred to as Choice 2.0 program, VHA faces 
daunting challenges that must be addressed.
    One major challenge involves streamlining its current 
appointment scheduling process. Currently, both the VA Medical 
Center staff and third-party contractors are involved in this 
process, but in the Choice 2.0 program, VA is now considering, 
VA Medical Center staff would perform all of the scheduling and 
contractors would bill provider networks and pay claims.
    A key to achieving a streamlined appointment scheduling 
process is having an up-to-date and user friendly IT capability 
to help process the millions of Choice referrals linked with 
community providers to schedule appointments and connect with 
both the providers and the contractors to transfer medical 
records and process claims. VA is in a very early stages of 
procuring such an IT system. This will be a complex 
undertaking, one that will likely take years, not months, to 
become fully operational.
    Another major challenge is establishing a robust network of 
community providers who can offer veterans the services they 
need. This has been somewhat problematic through much of the 
current program's almost 3-year implementation, especially in 
rural areas.
    Finally, substantial resources will likely be needed to 
carry out Choice 2.0. Resources needed to fund IT upgrades and 
new applications for Choice are largely unknown but could be 
costly. Proposed changes in Choice eligibility requirements, 
such as eliminating 30-day, 40-mile requirement for 
eligibility, could potentially greatly increase the number of 
veterans seeking care through community providers and drive 
costs up considerably.
    Also, if medical center staff begin scheduling all 
appointments under Choice 2.0, as VA currently envisions, 
hiring more VA staff will likely be costly and tediously slow. 
Already since Choice was established, VA Medical Center staff 
devoted to helping veterans access nonVA care have increased 
three-fold or more at many locations. VHA has not fully 
analyzed the cost or feasibility of increasing staffing at its 
medical centers to schedule Choice 2.0 appointments.
    VHA is proceeding down the path toward its vision of 2.0, 
and as it does so, it needs to do so thoughtfully and carefully 
with goals that embody timely access for veterans to quality 
care and in the community at a reasonable cost.
    Achieving these goals will require a clear approach derived 
from data-driven analyses of the benefits and costs of various 
proposals, a comprehensive action plan and roadmap for 
successfully implementing Choice 2.0, including specific 
timeframes and resources needed, and a robust system to measure 
performance, including wait times, that can be used to identify 
program improvements and hold VHA staff accountable for 
delivering timely services to veterans.
    This concludes my statement.

    [The prepared statement of Randy Williamson appears in the 
Appendix]

    The Chairman. Thank you, Mr. Williamson.
    I will now yield to vice-chair, Mr. Bilirakis, for 5 
minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. Thank you, Mr. 
Secretary. I appreciate the entire panel for testifying this 
evening. Thank you for your service to our true American 
heroes. I look forward, Mr. Secretary, to working with you on 
your role, and I am hopeful that together we can find the right 
balance, the entire Committee, the VA in providing both VA and 
community care to our Nation's true American heroes.
    We have spoken about credentialing private providers who 
desire to see VA patients as VA providers in the community. How 
do you think we can best equip these providers to understand 
the nature of the wounds, both visible and invisible, our 
warfighters incur during military service, and how do we direct 
private providers interested in providing service for veterans 
through Choice that are currently not qualified providers in 
the VA health network?
    Secretary Shulkin. Well, thank you, Congressman. This is a 
big challenge for us. Our studies have shown that the lack of 
military competency among community providers is quite 
significant. In the case of mental health providers, we have 
found that only 13 percent of community mental health providers 
have an adequate sense of military competency to be able to 
perform the right type of psychosocial counseling.
    VA is very active in trying to work with its community 
providers, and that is why we are trying to develop a core 
network of providers so we can go out and provide education and 
do it through webinars, we do it through face-to-face academic 
encounters as well. We believe our Federal partners, Federal 
health care providers and our academic partners in particular 
are very eager to increase these relationships with us and have 
the military competency that we know we need.
    Mr. Bilirakis. How do you speed up the process? I mean, we 
advertise the Choice Program when we talk to our constituents, 
you know, and in a lot of cases, it is not working. The wait 
times are too long and, you know, they kind of get disgusted. 
And they deserve the best health care, the best timely care.
    So, I mean, what is going wrong? How can we fix it? I know 
we talked about the third-party administrators, what have you, 
but I hear this on a daily basis--
    Secretary Shulkin. Right.
    Mr. Bilirakis [continued].--and it's unacceptable to me.
    Secretary Shulkin. Congressman, I hear it too. I travel 
around the country. I get letters from all of you and from 
veterans directly.
    We are now embarking on listening sessions with our 
veterans groups to make sure that we have a good, comprehensive 
sense about what they believe the solutions are so we can 
design a system that works for them. And we are eager to 
continue our dialogue with all of you, to get your ideas, but 
here is what we do know. The system was designed, it was too 
complex and too difficult to maneuver.
    Mr. Bilirakis. I will agree with that.
    Secretary Shulkin. And so we have proposed--that is why we 
have 70 contract modifications, we have issued 23 letters of 
correction to our TPAs, we have come back to you four times, 
you have helped us change the law, but we have more that we 
need to happen.
    We have identified four specific changes to the program 
that we need now that we hope will be considered, including 
provider agreements, flexibility in funding, the ability for us 
to obligate our funds when we use them, and to be able to 
coordinate other health insurance in a way that makes sense for 
veterans so they are not finding themselves getting billed 
inappropriately.
    And so we want to work with you to get this right. And we 
believe right now we have to extend the Choice program, because 
veterans once again are getting caught in the middle, but we 
want to come back and we want to get this program so it works 
well.
    Mr. Bilirakis. Very good. Thank you.
    Mr. Williamson, GAO found that in some cases clinically 
indicated dates were changed by VA staff. As you all know, the 
falsification of wait time data is what led to the 2014 Access 
Accountability Act and the creation of the Choice Program in 
the first place.
    Through your investigative work and interviews, why were 
the clinically indicated dates changed by the VA staff? What 
reason did they give? And what response did you receive from VA 
community leaders--care leaders when you brought this to their 
attention?
    Mr. Williamson. That is an excellent point, and one that I 
find quite disturbing, because out of the 196 c, in 60 cases, 
those clinically indicated dates were changed. We tried to get 
to the bottom of finding out why, but we could not. You know, 
one could only surmise what happened.
    As you know, VA policy only allows the provider, the 
clinician who first sets that date to change it, and it is not 
supposed to be changed because VA couldn't deliver the care in 
30 days. So we don't know, but it is a doggone good question.
    Mr. Bilirakis. Okay. I have got a couple more questions, 
but in the interests of time--
    The Chairman. The time has expired.
    Mr. Bilirakis. Yes.
    The Chairman. The time has expired.
    Mr. Bilirakis. Thank you. I yield back.
    The Chairman. Mr. Walz. you are recognized for 5 minutes.
    Mr. Walz. Thank you, Mr. Chairman. And again, thank you all 
for being here, again, that commitment that all of us have to 
make this work.
    Secretary Shulkin, you talked about this, the complexity of 
this program and certainly the stepping it up, the provider 
networks and all that. In your assessment, was the complexity 
due to how Congress wrote it or the implementation between VA 
and the third-party providers?
    Secretary Shulkin. I think there is enough blame here to go 
around for all of us, so I would say--
    Mr. Walz. But certainly--
    Secretary Shulkin. Yes.
    Mr. Walz [continued].--no one's intent to was to that.
    Secretary Shulkin. Right.
    Mr. Walz. In other words, we wrote it, sent it out, to try 
to make it go there. Is there a way of think about this in 2.0? 
Do you feel comfortable we are all working together that we are 
very clear on our intent that we are very clear on how we want 
it to be delivered?
    Secretary Shulkin. We have learned a great deal. You know, 
I come from the private sector. I will tell you, we would not 
have designed the system quite as complex, but if you remember, 
the managed care industry, which developed over the last two, 
three, decades, also at one point was extremely complex and not 
user friendly, with gatekeeping and pre-authorizations and all 
that, and that industry learned.
    We had 90 days to do this. We know TRICARE did this over a 
period of years. We know the system is working much better 
today than it did when it started in 2015. So we have all of 
that knowledge together that we can go back and make this 
system work for veterans. I am absolutely confident we can do 
this.
    Mr. Walz. Are you concerned, and I share the GAO's concern 
on this, that I think the technology interface piece is going 
to be critical, and if it is not stood up when you try and 
stand up your community-based coordination, that seems to me 
that we are setting ourselves up for failure again.
    Secretary Shulkin. Yeah. I couldn't agree more. We are 
putting 35,000 schedulers in the VA system in a position where 
they have to be making judgments about how to record their 
appointments. That system doesn't work. We are going to have to 
do this through technology.
    Our new scheduling system that is being rolled out actually 
records this in a technologically automated way, so it takes 
the scheduler out of having to make those decisions.
    Mr. Walz. What do you think the best thing to come out of 
Choice was?
    Secretary Shulkin. Well, I think we helped a lot of 
veterans. I think that is the--that was the intent. I applaud 
Congress for doing this. I think it was a national emergency, 
and I think it was the right thing to do, and I think we all 
tried to get it up as soon as we possibly can. And we have 
helped millions of veterans, 7 million appointments have been 
scheduled, and those are veterans who needed that care and 
shouldn't be waiting for care. So I think it was essential.
    Mr. Walz. We were discussing some of the positives on this. 
And one of the things we mentioned was do you think we got a 
more honest, transparent look at real wait times, that they 
were no longer hidden because of Choice?
    Secretary Shulkin. I think one of the things that surprised 
us all, even when we began to use Choice, the wait times grew 
longer. And what that was saying is there was a demand from our 
country's veterans for services that we weren't adequately 
addressing or meeting. And I think it exactly did that, which 
it showed us what the real demand is, and that gave us a look 
into this now.
    Mr. Walz. Because, I am curious about that. And for the IG, 
Mr. Missal, you concluded Choice did not reduce wait times for 
veterans in VISN 6. I do not know if that can be extrapolated 
to all. Usually that is the case. Do you concur with Dr. 
Shulkin that increased care and explosion that maybe came out 
of that could account for that in addition to Choice being 
complex?
    Mr. Missal. Yes, I think it could. What we saw in VISN 6 
obviously is limited to VISN 6, but it is not inconsistent with 
what we saw in wait times both with what the GAO found and some 
other work that we did.
    Mr. Walz. All right. And to the GAO, Mr. Williamson, what 
is it going to take to get them off the high risk list? What 
can they do right now to get off the high risk list?
    Mr. Williamson. Well, I think one of the major things, of 
course, is to improve their oversight and accountability. You 
know, I think one of the early steps is to have also a detailed 
action plan that talks about timeframes, talks about resources 
needed, and so on.
    It is just not a simple matter of addressing GAO 
recommendations. There are five different criteria for getting 
off the list, and certainly leadership commitment is among 
them. I think VA has, you know, offered leadership commitment 
on this matter.
    Mr. Walz. Over my time with this, that has been my 
experience, that the one constant amongst facilities that 
succeed or do not succeed is that leadership from the top, and 
that accountability, talk about personnel accountability, 
whether it be acquisition accountability, all of the things 
that go to that, but I would encourage, and Mr. Secretary, I 
know it is your desire too, whatever you need to help us do 
that, restoring that faith, expanding that care, we all have 
the same mission, and I think this community-based initiative 
is going to be critical for what the VA is going to look like 
in the future.
    Secretary Shulkin. Yeah. Congressman, I just want to add 
that last week I went over, I brought my team over to meet with 
Mr. Dodaro, who heads up the GAO. He and his team were very 
open. I told him it is my commitment to make significant 
progress to get us off that list, and that is my commitment.
    Mr. Walz. I appreciate that.
    I yield back. Thank you, Mr. Chairman.
    The Chairman. I thank the gentleman. Mr. Coffman, you are 
recognized for 5 minutes.
    Mr. Coffman. Thank you, Mr. Chairman.
    I guess for the GAO representative, on the--so in 2014, we 
had the appointment wait time scandal and we passed the Choice 
act.
    Mr. Williamson. I am sorry, Mr. Coffman. What was that?
    Mr. Coffman. I am sorry. In 2014 we had the appointment 
wait time scandal and passed the Choice act.
    Mr. Williamson. Right.
    Mr. Coffman. Because at that level of the VA in terms of 
those who did the appointments, were responsible for the 
appointments, essentially cooked the books to receive cash 
bonuses, and left veterans a number of veterans without 
treatment on the secret waiting list, starting with the Phoenix 
VA, but we found it in other parts of the VA system.
    And so I understand the intention now is to get it--give 
the appointment--get the appointment process back to those same 
employees. How does that make sense?
    Mr. Williamson. You know, I really--I really don't know on 
that one. It is a very difficult situation to deal with, I 
think.
    Mr. Coffman. Mr. Shulkin, how does that make sense, Dr. 
Shulkin?
    Secretary Shulkin. Well, look, we have a choice and this is 
a choice that we are seeking feedback on. We know that when we 
gave it to a contractor, when we gave it outside VA, that we 
had a lot of problems with that. And so what we have done in 54 
of our medical centers is we have actually brought the TPA 
staff back in working with our medical centers.
    So whether it is a combination of outside and inside people 
or whether it is VA staff that--under new leadership, new 
policies, no incentives to cook the books, as you said, and 
really strong oversight, which is what the GAO is recommending, 
we believe the most important thing is is to meet the veterans' 
needs, and that is what we are committed to doing.
    Mr. Coffman. I just have a question, because it would seem 
to me to be--so VA couldn't manage its own employees, it 
doesn't surprise me that it couldn't manage the contract with 
the appointment process, and so I am not sure that we are 
really making progress here.
    Secretary Shulkin. Well, Congressman, I--listen, the very, 
very best solution is to let veterans schedule it themselves 
with these self-scheduling applications, and we are working on 
that as well.
    So my feeling is, and I share your concern, I do not want 
to go backwards on this, and so we are going to have to 
approach this in multiple avenues and ultimately make sure that 
we get the most direct way for a veteran to get an appointment.
    Mr. Coffman. I was talking about this, talking to some of 
my health care providers back home, and the PC3, these PC3 
agreements came up, where the VA has had--in fact, prior to the 
Choice Act had the ability to have direct negotiation with 
providers and arrive at an agreement to refer veterans directly 
to those facilities.
    Every agreement is negotiated separately, and it takes a 
very long time to negotiate these agreements. So it doesn't 
seem like there is a boilerplate framework for that, yet we 
have the Medicare system with its well-established 
reimbursement rates. Why don't we simply use that in these 
provider agreements?
    Secretary Shulkin. Well, one of the areas we have had great 
success on is in getting providers into our network. Today it 
is over 480,000 providers. TriWest, who is here today, 180,000 
providers in their network. And because of the Choice law, we 
use Medicare rates, with some exceptions of rural areas.
    So I think we are trying to simplify this. We have been 
successful at building the network. We don't do a lot of rate 
negotiation, because of the way that the law was written.
    Mr. Coffman. On the Choice act, but on the PC3, why don't 
we use Medicare rates on PC3?
    Secretary Shulkin. We probably should. We want to move 
towards one set of rules. Maintaining two different systems 
with two different rules, two different fee schedules adds to 
administrative complexity, confuses our providers. So I am all 
in favor of moving towards the simplified single system.
    Mr. Coffman. Do you need legislation for that or can you--
    Secretary Shulkin. We do. We do. We have asked for, we call 
it funding flexibility. Now, maybe that is not a good term, but 
we are looking--
    Mr. Coffman. That is different.
    Secretary Shulkin. Yeah.
    Mr. Coffman. In terms of specific--
    Secretary Shulkin. Yes.
    Mr. Coffman [continued].--that is the consolidation issue.
    Secretary Shulkin. Yes.
    Mr. Coffman. You raised it, that is separately. What we are 
talking about here is do you have the authority to use--I would 
assume you do. If you have the ability to negotiate the rate 
structure and doing it separately with each particular entity 
on the PC3, I would assume that you do have the ability to say 
this is what we are going to do, we are going to do--we are 
going to do Medicaid reimbursement, period, on the rate--
    Mr. Coffman. I don't know if that takes legislation.
    Secretary Shulkin. No. On the rate issue, I agree with you. 
On the rules that we have to do to manage these separate 
programs, we do need legislation, but there is some flexibility 
in there like you are saying, yes, sir.
    Mr. Coffman. Mr. Chairman--
    The Chairman. The gentlemen's time has expired. Mr. Takano, 
you are recognized for 5 minutes.
    Mr. Takano. Thank you, Mr. Chairman. I have long said that 
the lack of continuity at the VA is a challenge to the 
organization, and I am glad we are joined by Secretary Shulkin 
tonight and many of the other familiar faces at the table. We 
need the institutional knowledge that Secretary Shulkin and his 
team provide to make the long-lasting improvements at the VA.
    Now, as long as--now, as we have heard tonight, the Choice 
Program was a temporary fix to improve veterans' access to 
care. Unfortunately, as we have also heard tonight, that fix 
still resulted in long wait times, confusion about payments, 
and administrative headaches for veterans and staff at the VA.
    It is our task now to come up with a long-term solution 
that gives veterans the care they deserve, and strikes a 
balance between care at the VA and care in the community, and 
keeps the VA's central role to improve care and coordination.
    I would like to first turn my attention to staffing levels 
at the VA tonight, Mr. Secretary, and how that has impacted the 
program. Secretary Shulkin, the IG found that in VISN 6, the 
nonVA care coordination staff workload increased over 200 
percent since the implementation of Choice and that VISN 6 did 
not provide sufficient staff to meet the growing work 
requirements, causing authorization delays and insufficient 
oversight of the contract with the third-party administrator.
    Are these positions exempt from the Federal hiring freeze 
and has VISN 6 hired more staff?
    Secretary Shulkin. Yeah. Congressman, this was one of those 
unintended consequences that we learned. We thought if we 
outsourced all of our care to a third-party administrator, the 
workload would go down. In fact, as the IG found, our workload 
went up, because we had to be making more calls in chasing down 
veterans. So we have been in catchup mode and we have been 
adding to those staff.
    The clinical staff are exempt from the hiring freeze. We 
have made that request, and that was granted. Business staff 
would not be at this point. So we sort of have to separate out 
those two functions. And we are developing staffing guidelines 
and staffing grids to be able to make sure that we are staffing 
up to meet the veterans' needs, but you are absolutely right. 
This caught us by surprise.
    Mr. Takano. But the hiring freeze and the fact that some of 
your VISN staff aren't exempt, that has complicated your 
ability to do your job. Am I not correct?
    Secretary Shulkin. Well, we have made the request of the 
White House of 37,000 clinical staff and support staff that we 
think are essential for patient safety. That has been granted 
for us. We are closely looking at the additional, approximately 
8,000 staff, that we look at almost every week, to see whether 
they are impacting our ability to deliver care, and when we do 
find that they are impacting our ability to deliver care, then 
we are making those additional requests. We just made some 
additional requests.
    Mr. Takano. But are the VISNs across the country hiring 
more staff to reduce authorization of processing times?
    Secretary Shulkin. I am going to--I am going to let you 
answer that, Dr. Yehia.
    Dr. Yehia. Yes. We are seeing an increase in staff across 
the country, but I don't want us to miss the key point. This 
process is too complicated. The GAO report and the IG report 
both showed that our traditional Community Care program works 
much better, and so it doesn't make sense to keep putting staff 
in a system that needs to be fixed.
    So I hope that when we work on Choice 2.0, we make it 
simpler to administer than what it is today.
    Mr. Takano. Well, I also believe the VA has a central role 
to play in regards to care coordination that improves patient 
outcomes. Under VA's plan to consolidate Community Care, how 
does VA plan to address potential fragmentation of care between 
VA and community providers?
    Secretary Shulkin. Why don't you take that.
    Dr. Yehia. Care coordination is critical. We are developing 
an integrated system, so the more integrated we become, the 
more we have to coordinate care.
    We are testing today processes across the country that 
allow doctors to access our medical record completely for every 
lab, every radiology test. We want to make sure that they get 
the information they need to take care of veterans within the 
community. So we are front and center focused on this. We know 
we need to do more coordination when we do more community care.
    Mr. Takano. Yeah. Well, one study cautioned that veterans 
being seen in two different health systems, the VA and the care 
in the community with different electronic records and 
different policies, procedures, face risks from a dual system 
health care that should not be ignored. What do you have to say 
about that?
    Dr. Yehia. Well, that is exactly why we want to get them 
read access only to our medical records so they don't repeat 
unnecessary tests, they don't order drugs that should not be 
ordered, so we are trying to prevent that by giving them full 
access to a record for those patients that they are seeing.
    Mr. Takano. Mr. Chairman, my time has expired.
    The Chairman. I thank the gentleman for yielding.
    Dr. Wenstrup, you are recognized.
    Mr. Wenstrup. Thank you, Mr. Chairman. Thank you all for 
being here. Mr. Secretary, congratulations.
    Secretary Shulkin. Thank you.
    Mr. Wenstrup. And welcome back, if you will.
    You mentioned earlier about the military competency of the 
providers, and I think that is important, especially in certain 
areas, and you specifically mentioned mental health and as it 
relates to PTSD, I am sure, and I could think of other areas 
like if you are treating TBI, the effects of agent orange, 
those types of things. What other medical categories have you 
identified where you feel there is a strong need for that level 
of competency?
    Secretary Shulkin. Well, you know, I think that the primary 
areas that we are thinking about are in primary care and mental 
health, and the primary care provider has to understand the 
full comprehensive nature of what it takes to support well-
being.
    And, you know, the example that I use is that when a 
veteran who comes back from conflict comes in and talks to 
their primary care provider or their mental health provider 
about an IED, and the response is, ``What is an IED?,'' you 
know, you sort of lose all that confidence and trust. So we 
think that is important.
    Mr. Wenstrup. And I agree. And also there are other areas 
in health, things that are endemic to the area they served, 
they should be pretty well versed on those types of things, or 
at least know where to turn to for that.
    Would you be in favor of the system allowing the primary 
care doctor, when working with the patient, to have the 
authority to decide who they can see in Choice, or Choice or 
not Choice? In other words, you know, you may need to see an 
ophthalmologist, but you may need to see one that specializes 
in glaucoma. So just because the VA has an ophthalmologist 
doesn't mean that that is the best one for you to see.
    So the question is, would you be in favor of the primary 
care doctor being able to say, yeah, there is one here within 
the walls that you can see next week, but I need you to see the 
glaucoma specialist, and that is the referral I want to make, 
without having to jump through a lot of hoops.
    Secretary Shulkin. Yeah. As long as I state my conflict of 
interest that I am a primary care provider, yes, I do support 
that. You know, second-guessing our physicians and our 
providers is never a good idea. I would support that.
    Mr. Wenstrup. Yeah, and I think that a deterrent to 
recruitment too--
    Secretary Shulkin. Yes.
    Mr. Wenstrup [continued].--if that is the kind of system 
you have to operate in.
    So just one last question. Solution to the delay in payment 
to providers. You know, the system is too complicated and you 
really going through two systems, as I understand it. Is that 
correct? And so the money is not flowing the way it should. So 
what would your recommendations be to solve that problem?
    Secretary Shulkin. Well, we are doing a number of things. 
First of all, before coming to VA, I spent my life trying to 
get paid by insurance companies, so I am a firm believer if you 
deliver a service, I know you did too, if you deliver a 
service, you deserve to be paid for it.
    Today we are at 83 percent of payments within 30 days. That 
is a lot better than we were, but not good enough. We need to 
have greater electronic claims. Today VA is at 63 percent 
electronic claims. We should be at 99 percent. And we are 43 
percent above where we were this time last year. So we are 
making progress, but we still have more to go.
    We have to automate more. And we are also looking at other 
options, including if it can be done better outside VA, we are 
looking at those options in our new RFP process.
    Mr. Wenstrup. And I appreciate that. And that is all I 
have. Thank you. Mr. Chairman, I yield back.
    The Chairman. I thank the gentleman. Ms. Brownley, you are 
recognized.
    Ms. Brownley. Thank you, Mr. Chairman. And I also want to 
say congratulations. I am delighted that you are at the helm of 
the VA, where the buck stops with you, but I can't think of a 
better leader, so thank you very, very much.
    I think--you know, I think the GAO report, I think, 
identified very well where the chokepoints are in this process. 
And we keep talking about, you know, the process is too 
complicated and where we need to improve upon in the processes, 
et cetera, lack of controls and all of that.
    But I think the underlying issue in all of this, to me, is 
our IT systems. It still feels like we are driving a Model T 
down an L.A. freeway trying to keep up with the Teslas and the 
BMWs. And I--you know, when I see this report and just, you 
know, even one step saying, if we don't reach the veteran by 
telephone, then we will send them a letter.
    And it just is mind-boggling that we are still, you know, 
in sort of this bureaucratic maze that is just prolonging, and 
this report says it can prolong it up to 10 days in the 
process. To me it seems that is a no-brainer. Why can't we fix 
that, like, now.
    But the area for all of the hearings that we have had, the 
area that I have the least confidence in is all of the 
automation and all of the IT that has to take place. And so I 
guess my question is, how do you alleviate my fears that we 
will always be as slow as an un-automated process will be, and 
how are you going to allay my fears that we are on this and we 
are going to get it right?
    Secretary Shulkin. Well, I don't want you to stop worrying 
until we actually do something to give you confidence that we 
have this right. I think I too, and many of you have shared 
your concerns that you have heard us make promises before in 
this area and failed to deliver on it.
    I have come to the conclusion that VA building its own 
software products and doing its own software development inside 
is not a good way to pursue this and we need to--
    Ms. Brownley. Hallelujah.
    Secretary Shulkin [continued].--we need to move towards 
commercially tested products. If somebody could explain to me 
why veterans benefit from VA being a good software developer, 
then maybe I would change my mind, but right now we should 
focus on the things veterans need us to focus on and work with 
companies who know how to do this better than we do.
    So you are going to see that change in direction, and--but 
I don't want you to stop worrying about it until we can 
actually show you we do it differently.
    Ms. Brownley. Well, I am delighted to hear that answer. I 
think we all are. So thank you very much for that.
    Mr. Williamson, do you have a comment to make with regard 
to kind of the statement that I just made and where the 
chokepoints are and improvement, and do you think this 
consolidation program is going to help to improve that process?
    Mr. Williamson. Yes, as I said in my opening comments, I 
think IT is really a critical component. And I think Secretary 
Shulkin's willingness to look at commercially available off-
the-shelf systems is a really good move. And I think, even with 
that, however, VA still has to integrate any new system with 
legacy systems, like Vista, and and also integrate the new 
systems with provider systems and the TPA systems. So it is not 
a slam dunk, but I think IT is probably the number one issue, I 
would say.
    Ms. Brownley. Thank you for that.
    Mr. Williamson, the other thing that popped out at me in 
your report too, a very troubling aspect, was when you 
identified 88 returned authorizations that were found, these 
were veterans sent to Choice for appointments but then returned 
to VA for various reasons. Not only does this greatly increase 
the length of time veterans have to wait for care, but GAO was 
also unable to determine if 20 of those veterans received any 
care at all. They sort of got lost, seems like, in the system.
    Mr. Williamson. Right. And we have shared those 20 names 
with VA so they can make sure that those veterans did get care 
they need.
    Ms. Brownley. And, Mr. Shulkin, in terms of rectifying 
that, is it rectified now within the system?
    Dr. Yehia. Yeah, we have looked at every one of those 
different cases and made sure that veterans got the care they 
need.
    Ms. Brownley. Thank you very much.
    I will yield back, Mr. Chairman. Thank you.
    The Chairman. I thank you for yielding.
    And, Mrs. Radewagen, you are recognized.
    Mrs. Radewagen. Thank you Chairman Roe and Ranking 
MemberWalz. Delighted also to add my congratulations, Mr. 
Secretary.
    Before I ask my question, I would like to just briefly 
highlight some of the different challenges American Samoa and 
the U.S. territories face regarding community care for 
veterans. While living on a tropical island in the middle of 
the Pacific Ocean may be pleasant most of the time, it also 
means our territories' veterans live far away from any fully 
equipped VA health care facility well outside the Choice Act's 
40-mile range or other distance qualifiers--3,000 miles away, 
in fact.
    Compounding this issue, small island hospitals like the LBJ 
Tropical Medical Center in American Samoa may not be 
sufficiently equipped or staffed to provide veteran care. This 
means our veterans cannot take advantage of the Choice Act to 
reduce their travel and wait times even if they wanted to.
    Having said this, would anyone on the panel please tell us 
what the VA is doing or planning to do to ensure that our 
veterans, who would otherwise qualify for the Choice Act but do 
not have access to adequate nearby facilities, are receiving 
the care they need in a timely manner? And are there any other 
insights you would like to share regarding access to care for 
veterans in remote, rural areas?
    Secretary Shulkin. Well, you know, we have talked about 
this several times, and I appreciate and really acknowledge 
your continued advocacy on behalf of the people you represent. 
We know America Samoans are some of the most patriotic 
Americans that there are and that they serve at very, very high 
levels and they do deserve the very best that we can give them.
    The challenge that we have, whether you are on a Pacific 
Island 3,000 miles away from larger islands or in other parts 
of rural America, are actually similar. And while we need 
health care professionals in those areas, we are not always 
able to get people to go to those areas.
    So we are looking primarily at technological solutions, and 
we are looking at the use of telehealth, which we are doing 
across VA on a scale that no other health system in America is 
even approaching: 2.1 million visits, over 700,000 veterans 
getting access through telehealth services. And so we are 
looking at this very seriously about dramatically expanding its 
use to be able to support where we don't have health 
professionals.
    Mrs. Radewagen. Thank you, Mr. Chairman. I yield back.
    The Chairman. I thank the gentlelady for yielding.
    Ms. Kuster, you are recognized for 5 minutes.
    Ms. Kuster. Thank you, Mr. Chairman.
    And thank you, Secretary Shulkin, for being with us. We are 
delighted to have you confirmed and get to work. And this is 
very big news that you have just announced about looking into 
an off-the-shelf IT program, and we hope we can move forward 
with you on that.
    I too want to speak about rural America. I just had a VA 
roundtable in the northern part of my district in New 
Hampshire, and I just want to quote real quickly. A nurse, 
Caroline Jordan of Berlin, New Hampshire, she was there with 
her husband, and she just cautioned about all this care outside 
the VA. ``I don't want to see the VA medical centers closed. I 
don't know where this VA Choice card will take us. My concern 
is that the bonding of brother and sisterhood will be lost. 
They won't have the symbols, the flags, the stories, the jokes, 
crying together, laughing together. I am afraid that will be 
lost.''
    And she was very eloquent. And I said I wish she could have 
come here to testify. But how can you reassure veterans across 
the country, as we move into this patient-centered care and the 
programs such as the one that we are about to test out in 
northern New Hampshire, the coordinated care program, which I 
am excited about, but how can we reassure our veterans that we 
won't lose the camaraderie of the Veterans Administration care?
    Secretary Shulkin. Yeah. This is a significant issue for 
us. This is not just the camaraderie, which we think is 
important, but these are the real expertise that we have in our 
VA health care system. Remember, we have four missions. The 
clinical care is what we always talk about, but we also have an 
education mission.
    We train more American health care professionals than any 
other organization in the country. We have research that is 
dedicated solely to the improvement of the well-being of 
veterans, and we also serve a national emergency preparedness 
role. So all four of these missions are very important to us.
    I would just say two things: One thing is, we know from the 
Choice Program that only 5,000 of the several of more now than 
1 million veterans have used the program chose only to use the 
Choice Program. So they are saying exactly what your 
constituent told you, which is the VA is essential and 
important to them.
    But we are not going to allow this--the VA programs to be 
diluted. And one of the reasons why that is so important is 
that we need to modernize the VA system. Our lack of 
capitalizing the VA system in terms of the buildings, the 
equipment, the IT systems, could make it a noncompetitive 
system. But we are going to make sure that the facilities that 
are open are the best for veterans, and veterans are going to 
want to continue to get their care there. The community care 
program is a way to make sure that we supplement the VA in an 
integrated fashion.
    Ms. Kuster. Well, I think you have our bipartisan support 
about providing the access, but it was just a reminder on 
making sure we keep that veteran-centered focus that we all 
have.
    I just want to speak briefly, I am the founder and cochair 
of our Congressional Bipartisan Task Force to combat the heroin 
epidemic. And I am very concerned about opioid use and 
substance use disorder, particularly in the context of opioids 
from surgery or high rates of opioid medication being used for 
pain management.
    Could you comment on what is being done in the VA? And I 
would like to work with you going forward, and your team, to 
work on pain management techniques that would reduce the use of 
opioid medication and treat addiction and substance use 
disorders for our veterans.
    Secretary Shulkin. Yeah. We recognize and understand that 
this is a public health crisis not only in the VA but across 
America. The VA recognized this as a crisis in 2010 before 
there was a lot of attention across the general media, and we 
started a campaign with a number of strategies to reduce opioid 
use.
    I am pleased to say we have reduced opioid use by 22 
percent. We have done it by involving our patients. They now--
patients have to use informed consent to start these 
medications. We do academic detailing to our physicians. We do 
use information systems to be able to prescribe, to be able to 
help remind providers of other alternatives. We build up 
complementary care. We coordinate with the State prescription 
data monitoring programs.
    So we are doing a number of things, and frankly, places 
around the country are coming to us to learn how we have done 
this. So we would be glad to work with you. We think that there 
is much more to do. And developing research in alternative pain 
management strategies is clearly one of our priorities right 
now.
    Ms. Kuster. Terrific. We look forward to working with you. 
Thank you.
    I yield back.
    The Chairman. Thank you.
    Chairman Bost, you are recognized.
    Mr. Bost. Thank you, Mr. Chairman.
    And congratulations, Mr. Secretary. I look forward to 
working with you.
    I am going to go down on a little bit of a different road. 
I am a little concerned, and the Department itself has 
estimated that it can treat and cure most of the remaining 
124,000 diagnosed cases of hepatitis C within the next 3 years. 
Is it the VA's commitment that that timeline will be held to 
and that these will be treated regardless of the level of their 
liver disease or where they might be at?
    Secretary Shulkin. Yes. Thanks to the support from 
Congress, we were provided the resources to meet that timeline. 
I actually think we are going to beat it, but with one caveat. 
What we have learned is is that our initial outreach is we were 
getting thousands and thousands of veterans to come in and to 
get treatment. We have a treatment, of course, as you know, 
that now cures more than 95 percent of hepatitis C, so it is 
tremendous medical advance.
    The doctor to my right is one of those doctors. He is an ID 
doctor who does this in his clinical work at the VA.
    Mr. Bost. Thank you.
    Secretary Shulkin. What we are finding now is--and if Dr. 
Yehia wants to comment on this--we are finding that we are now 
seeing less and less veterans coming in to get cured. There is 
a substantial number of veterans for a number of reasons, 
either psychological reasons or social reasons, who are not 
taking advantage of this care. And so this is now becoming a 
research question for us. How do we have to begin to approach 
people that are saying, I have a disease that may end up 
killing me, but I am not interested in the treatment?
    And so I think we are going to beat your 3-year timeline, 
but there is still going to be a subset of veterans that don't 
want to come in and get care. And so I don't know if--
    Dr. Yehia. Dr. Shulkin is exactly right. We call this 
linkage to care. So we have effective treatments when people 
actually get in, but actually getting them through the door is 
now our biggest challenge. It is not actually offering them 
therapy.
    We had the same thing when the HIV epidemic first started. 
We had really effective therapies. We couldn't get people in 
the door. So now we are figuring out how we do outreach, 
working with our homeless coordinators and other things to get 
people into the VA to get their therapy.
    Mr. Bost. Is it a lack of understanding that the cure is 
there or is it something other than that? That is very shocking 
to hear that, that is why--
    Dr. Yehia. A lot of it has to do with kind of the social 
behavioral aspects of not only health care but of people's 
situations. So I think a lot of folks understand that there is 
therapy there, but are they ready to take that next step.
    Mr. Bost. Well, thank you for the answer on that.
    And I have one more quick question, actually a couple 
questions in regards to what we are wanting to do tomorrow. 
Okay? You know, the importance of the extension that we are 
going to be working on in our markup tomorrow, what would 
happen if we didn't make that extension go past the August 7, 
and what would be the final cutoff if we don't get it passed?
    Secretary Shulkin. Yeah. Well, first of all, if we don't do 
this extension, this is going to be a disaster for American 
veterans. We are going to see the same situation that we saw in 
April 2014 that Senator McCain started out tonight with that we 
saw in Phoenix.
    And so here is the timeline: We do need to do this now, as 
I think Chairman Roe referred to. Already today, veterans are 
not able to use the Choice Program because the law states that 
we have to obligate the funds now for when the care is going to 
be delivered. So a pregnant veteran who comes to us and says, I 
want to get care using the Choice Program, they no longer can 
because 9 months from now is past August 7.
    But this is now beginning to happen with care that is 
multiple months in length, like oncology care and chemotherapy 
and other types of therapies. We have a chart that shows that 
when you start getting towards the end of April to May, this is 
where you are going to start seeing a large number of veterans 
not being able to get access to care, because episodes of care 
that we are used to, like hip replacements and other things, 
are generally 3 to 4 months. So we think the time is now that 
we need to act.
    Mr. Bost. Okay. So--but what we are doing is not any 
intention to privatize or anything like that. This is just 
making sure that those people who are on the Choice Program, 
that we are moving forward to make sure that those services are 
provided.
    Secretary Shulkin. Not only that, but this is not going to 
cost any additional money. We are just seeking the authority to 
spend the money that you have already given us past August 7 of 
this year.
    Mr. Bost. Thank you, Mr. Chairman. I yield back.
    The Chairman. I thank the gentleman for yielding.
    Mr. O'Rourke, you are recognized.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    Secretary Shulkin, when you first started as under 
secretary for VHA, El Paso, the community I serve and 
represent, was ranked worst in the country in terms of mental 
health care access for veterans in our community. And we were 
able to work together on a pilot program that we are 
implementing now in El Paso that allows the VA to focus on 
PTSD, TBI, military sexual trauma, those conditions unique to 
service in combat. And the doctors and providers in our 
community have stepped up to fill in the gap and care for those 
veterans and those other conditions that are not unique to 
service in combat. We also had the partnership of Texas Tech 
Health Science Center, and it is really making a difference. 
Our access to mental health care has improved markedly, and we 
are focusing on hiring those mental health care professionals.
    I think the most serious crisis facing veterans in this 
country today and for this Committee is veteran suicide, which 
you now estimate is 20 a day. That is the best estimate that 
the VA can come up with. I am convinced that it is connected to 
access to mental health care. Can you talk a little bit about 
what you are proposing and how that will impact the ability to 
access mental health care and reduce the number of veteran 
suicides in this country?
    Secretary Shulkin. Well, thank you for your leadership on 
this issue. You are always pushing us, and frankly, it is 
welcomed.
    There is no other clinical issue that I am as concerned 
about or that has my attention than veteran suicide, number 
one, for sure. What we are doing now--and we are doing a lot--
isn't enough. And so we are not satisfied, and we are 
continuing to look for new approaches to be able to address 
this issue. We are reaching out to the very best and brightest 
from the academic world and the community world to come in and 
say, tell us what else we can do, because we need to do 
something else. So stay tuned for that.
    But I will tell you something tonight that may make more 
news than the IT news, and that is is that--and I do want to 
thank Representative Coffman for this, because it was a program 
that I went to that he was at that proposed his bill that 
actually changed my whole view on this, so this is really his 
leadership.
    We are going to go and we are going to start providing 
mental health care for those that are other than honorably 
discharged for urgent mental health. And we want to work with 
Representative Coffman on his bill on this, and we want to do 
as much as we can. But I don't think it can wait, and so we are 
going to start doing that now. I believe that is in the 
Secretary's authority to be able to do that.
    So many veterans that we see are just disconnected from our 
system. That is the frustration. Of the 20-a-day, as you know, 
14 are not getting care in the VA, and yet we have this great 
comprehensive mental health system. So we are going to do 
whatever we can. We want to work with you. We want to work with 
Representative Coffman, all of you, to try to get this--because 
it is a--it is unacceptable. I don't think anybody thinks it is 
acceptable.
    Mr. O'Rourke. I want to thank you for the decision that you 
have made in not waiting for Congress to force the 
Administration to do it and showing the leadership in getting 
that done. And I also want to put a plug in for your vet 
centers.
    Secretary Shulkin. Yes.
    Mr. O'Rourke. I visited one in Laredo, met with 20 Vietnam 
veterans. We know that that is the single greatest cohort that 
is being affected by veteran suicide.
    Secretary Shulkin. Yes.
    Mr. O'Rourke. And they have access to your VA medical 
center, but they really prefer being at the vet center where 
they have, essentially, group therapy facilitated by one 
therapist, and all of them swore to it, to a person.
    Secretary Shulkin. Yes.
    Mr. O'Rourke. Quick question: Page 17 of the GAO report 
says, ``VHA cannot calculate average number of days that the 
medical centers take to prepare Choice Program referrals.'' Are 
you able to calculate that today? Do we have that number? What 
is it?
    Dr. Yehia. Yes, we are working on getting those numbers.
    Mr. O'Rourke. How long before you have that number?
    Dr. Yehia. We do have those numbers. The problem is that we 
want to make it automated so that it is easier to pull.
    Mr. O'Rourke. Can you share that with us? What is the 
average time?
    Dr. Yehia. We are happy to share that, yeah.
    Mr. O'Rourke. Can you do it right now?
    Dr. Yehia. I don't have it off the top of my head, but we 
are happy to share it.
    Mr. O'Rourke. I think when we are talking about wait times 
and we were reminded about the wait time manipulation scandal, 
we need to know real wait times and we need to hold you 
accountable for that. And we are not doing our job in an 
oversight capacity if we don't know the real wait time across 
all care delivery within the four walls of the VA or through a 
Choice provider. So how soon can I get that from you?
    Dr. Yehia. Tomorrow.
    Mr. O'Rourke. Okay.
    Dr. Yehia. Yeah.
    Mr. O'Rourke. And we will share that with the Committee. 
Thank you.
    I yield back.
    The Chairman. Thank you, Mr. O'Rourke.
    Mr. Poliquin, you are recognized.
    Mr. Poliquin. Thank you very much, Mr. Chairman, appreciate 
it.
    Mr. Shulkin, congratulations. It is good to see you again, 
sir. And I just want to, from the bottom of my heart, thank you 
very much for all the great work you did coming up to northern 
Maine. And we really, really appreciate you reauthorizing that 
program such that our veterans in the most rural part of our 
State, one of the most rural parts of the country, can get 
their health care close to home instead of driving 5 hours with 
the snow blowing sideways in Aroostook County. So thank you 
very much.
    And, Mr. Chairman, I didn't tell you this, but we 
recommended that Mr. Shulkin fly into Portland, Maine, and 
drive to Aroostook County, so by the time he got there, he was 
exhausted and he knew how rural our district was, but it paid 
off. And thank you very much, and congratulations, Mr. 
Secretary.
    Mr. Secretary, I am very concerned about the claims 
processing part of your organization. I know you have a very 
big job. I understand that, sir. My understanding is that when 
claims are processed at Medicare, about 90 percent of the 
claims to pay our providers never touch a human hand. And then 
over at--for the TRICARE program rather, about 75 percent.
    But here is what I am concerned about, sir, is that this is 
the accounts receivable over at Eastern Maine Medical Center in 
Bangor, and they are one of the largest health care providers 
in our State. They have, you know, Inland Hospital in 
Waterville and the Aroostook Medical Center up in Presque Isle, 
what have you. And I am looking at this, sir, and they are owed 
$13 million by you folks, and about 60 percent of the claims 
have been outstanding for over a year. That is a real concern.
    Now, this is another graph of the claims--excuse me, Mr. 
Chairman--of the claims backlog over the last year. You can see 
it is flat lined. And this is for Maine Medical Center, which 
has another network of hospitals throughout our district 
throughout the State. So you can see it is not getting any 
better. They are owed about $9 million and Eastern Maine 
Medical Center is owed about $13 million.
    Now, my understanding, and help me out with this please, 
Mr. Secretary, is that there are about 95 claims processing 
centers around the country that do this work. And unlike for 
TRICARE and unlike for Medicare, they are processed manually. 
So my question to you is the following: My first question is 
what does that mean? What does a manual claims process look 
like? That is the first question.
    Secretary Shulkin. Right. So let me try to do this, and I 
will invite my colleague who probably knows five times as much 
as me on this topic. You are exactly right, Congressman. The VA 
is not using as much automation as you would find in the 
industry. We are moving towards that, and we are seeing our 
percent go up significantly.
    But one of the reasons is the complexity of our program. We 
have to determine on each claim whether it was service-
connected or not service-connected. Medicare or TRICARE does 
not have to do that. We have to adjudicate our claims in a more 
thorough way than you see in the private sector as well. So our 
process, again, of the complexity goes back to why this is 
taking us so long.
    In terms of Maine Medical Center and Eastern Maine Medical 
Center, you know, this is the business I was in. I will tell 
you that they think that we owe them more money than we think 
we owe them, and this is not uncommon, because claims get 
rejected--
    Mr. Poliquin. Well, I know you will err on the side of 
Maine.
    Secretary Shulkin. Right, of course. Of course.
    Mr. Poliquin. Thank you very, very much.
    Secretary Shulkin. So we have been in touch with Eastern 
Maine Medical Center, and we will send a team or have a team go 
over those claims, and we do want to settle those as quickly as 
possible.
    Mr. Poliquin. Yeah. If I may interrupt you too, Doctor, 
before you speak.
    Secretary Shulkin. Yes.
    Mr. Poliquin. Again, sir, you know, this is $13 million--
    Secretary Shulkin. Yes.
    Mr. Poliquin [continued].--and we are a small State. Could 
you give us an idea, or Eastern Maine an idea. Because it is 
not just Eastern. I mean, it is all the health care providers 
throughout their system--when do you think they will get their 
$13 million?
    Dr. Yehia. So we actually had a conversation with them 
today. We have a meeting later this week. We have been working 
with them. I think the--I don't want to miss this point that 
Dr. Shulkin made is, we want it to work like Medicare.
    Mr. Poliquin. I know you do.
    Dr. Yehia. Help us do that. The Choice law has eight 
different eligibility criteria. We have to determine if they 
are service-connected or not, we have to determine if they have 
another health insurance or not, we have to look at if it is ER 
care or not, so we want to be able to get to the point where it 
is actually simpler.
    Mr. Poliquin. I only have 30 seconds left. We promise we 
will work with you on that. But, Doctor, could you tell me 
again, please, so everybody can hear, when Eastern Maine will 
get their $13 million and when Maine Medical will get their $9 
million, roughly? Today is Tuesday.
    Dr. Yehia. I don't think it is actually $13 million, but we 
are meeting with them this week.
    Secretary Shulkin. So just to be clear, they think it is 13 
million; we don't. Whatever number we agree with, we will cut 
them a check.
    Dr. Yehia. Exactly.
    Mr. Poliquin. Soon.
    Secretary Shulkin. And make his day. Is it going to be 
within 3 weeks?
    Dr. Yehia. We can do it in 3 weeks.
    Mr. Poliquin. You know, the weather is clearing up. We 
don't have any more snowstorms coming. It is a good time to go 
to Maine.
    Thank you very much, Mr. Secretary. Appreciate it.
    Thank you, Mr. Chair.
    The Chairman. I thank the gentleman for yielding.
    Mr. Correa, you are recognized for 5 minutes.
    Mr. Correa. Thank you, Mr. Chair, and thank you Ranking 
MemberWalz.and the Committee for organizing this Committee 
hearing. And Secretary Shulkin, again, congratulations.
    I live in a community, southern California, very multi-
ethnic, a lot of new Americans who English is their second 
language. First question to you: As you know, the number of 
Latino veterans is rapidly rising in this country. Over the 
next decade, they will probably make up 15 percent of all the 
veterans. So with that in mind, maybe language challenges. How 
are Latino veterans finding and fairing under the Veterans 
Choice Program?
    Secretary Shulkin. You know, I have not seen a specific 
study on that issue. It is probably a good thing for our office 
of minority and diversity to take a look at to make sure that 
they are not fairing any worse.
    Our workforce tends to reflect the makeup of our veterans 
since more than 40 percent of our workforce are veterans, so we 
do have a large contingent of Latino workforce as well. And I 
hope that we are certainly meeting the needs of all of our 
veterans, but that is something that I think we would like to 
work with you on.
    Mr. Correa. Mr. Chair, I would like to see, you know, some 
goals or maybe some data on that area.
    Secretary Shulkin. Yes.
    Mr. Correa. A lot of them, again, their families are 
Spanish speaking, possibly English is their second language as 
well. I just want to make sure that language is not a barrier 
to them receiving the proper benefits, veteran services that 
they are, you know, entitled to.
    Second question is an important one. Under existing 
immigration laws, if a legal permanent resident veteran is 
convicted of a crime, even nonviolent offense or minor 
infraction, some of them face deportation. These men and women 
have defended our country with honor, yet their lives continue 
to be disproportionately affected. So are we doing anything to 
ensure that these veterans, resident veterans who fall into 
these categories, have the access to health care without 
fearing deportation?
    Secretary Shulkin. That is something that I think that we 
are going to have to work with our general counsel on. I 
understand the concern. I am not aware of any particular 
circumstances right now, but we certainly--we have a veterans 
court program. We have a veterans justice outreach program. We 
work very closely with veterans who do get into trouble with 
the law, and we work with judges in particular on those issues. 
So I would hope that we could work in a way that would help our 
veterans.
    Mr. Correa. And I would love to work with you on this issue 
in Orange County. Our district was probably the first in 
California to have a veterans court. This is a unique issue, a 
unique wrinkle in the sense that legal permanent residents who 
violate the law are convicted are--lose their residency and are 
being deported. So it is a little bit of a different wrinkle.
    And I know a lot of them are now concerned about where do 
they go, where do they access, and do they face deportation. 
There is a growing group of these veterans right south of the 
border who are now living there because, of course, they have 
lost their legal permanent residency. I would like to maybe 
explore this issue with you a little bit further.
    Secretary Shulkin. Absolutely. Thank you.
    Mr. Correa. Thank you, sir.
    The Chairman. I thank the gentleman for yielding.
    Dr. Dunn, you are recognized for 5 minutes.
    Mr. Dunn. Thank you, Mr. Chairman.
    And thank you also, Secretary Shulkin, and all of you 
gentlemen for spending your evening with us. I am sure that it 
is exciting for you to be here.
    I also want to thank Secretary Shulkin for mentioning Dr. 
Tom Starzl, who passed away this last weekend. He was a 
champion for veterans, a champion and a pioneer in the 
transplant surgery realm, and I was fortunate to study under 
him many years ago.
    Mr. Secretary, just yesterday, a veteran I represent 
provided to my office an account of his experience receiving 
specialty care through the Choice Program, and it underscored a 
number of the challenges we have discussed here today. In 
particular, the veteran encountered poor communication between 
the VA and the third-party administrator and also between the 
VA and his Choice provider, and it severely delayed his access 
to care.
    And although he ultimately did get an appointment with a 
podiatrist through the Choice Program, the nearest provider was 
hours and hours away from his home. And he had some difficulty 
getting his prescribed custom prosthesis and orthotics. And 
ultimately, he did the math on the round trip, multiple, 
multiple round trips to these, and the prosthesis was cheaper 
and the medical care was cheaper out of his pocket, and that is 
what he did.
    And this letter is actually, it is an amazingly lucid and 
articulate and polite letter. And I will make that available to 
the Committee because it reads like a Marx Brothers skit. It 
is--I won't bother you with it now, though.
    My question to you, Mr. Secretary, is what should this 
Committee keep in mind in regard to the particular needs of the 
specialty care of patients like this? And how does that differ 
from the primary care referrals that this is sort of a special 
situation?
    Secretary Shulkin. Yeah. Well, what we are doing to make 
sure that we get this right is we are doing community-by-
community assessments, because there is, you know--just like 
real estate, all health care is local. And so there is some 
areas that have over supply of specialists and some under 
supply, and it sounds like your constituent lives in an area 
where there might be a shortage of specialists in some of those 
areas.
    Mr. Dunn. Yeah, on your panel clearly, and I know there are 
specialists near him, but for whatever reason they are not on 
the panel.
    Secretary Shulkin. Yeah. Yeah. We are continuing to grow 
our network, so if there are available specialists in the area 
and we have a shortage of them, we are continuing to grow that 
area. We actually have a slide of this where you can see the 
progress that we are making in provider growth right now. It 
might not pop up. Oh, there it is, 133 percent growth. But we 
need to continue to build out the network. And stories like 
that are impactful, so I am glad you are going to make it part 
of the record and we can look at that.
    Mr. Dunn. In my practice, we were on your Choice network, 
and I will say that a lot of times the problem was not that 
the--I mean, the veterans are there in town, we are there in 
town, we have slots for them, we can see them, but the problem 
was authorizations. I mean, the system in a number of ways is 
dysfunctional.
    Mr. Poliquin mentioned the payment system is just also 
pretty dysfunctional, but more basically, it is important to 
get them in and get them taken care of. And they had to go back 
for authorizations again and again and again just to see the 
same doctor about the same problem. You know, what are we going 
to do to make that system work a little better?
    Secretary Shulkin. When we started, our authorizations were 
only good for 60 days. We did a contract modification. We made 
it for a year. And so as we learned the problems in the 
program, much like the way that you are describing, we are 
doing these modifications, and have had 70 of them since the 
contract started. So--
    Mr. Dunn. So they would come to see me and they wouldn't be 
able to get x-rays. I mean, I could see them, I could prescribe 
them medicine, which they would have to go get at the VA, but 
they couldn't get the x-rays and I couldn't see the x-rays. The 
delays were just atrocious.
    Dr. Yehia. Yeah. In addition to lengthening the breadth 
(ph) of care, what we are doing now is bundles. So, you know, 
if you are getting your hip replaced, the PT comes with it, the 
x-ray comes with it, the MRI comes with it. So we are trying to 
tackle that problem as an episode together so we don't split up 
and we maintain continuity of care.
    Mr. Dunn. Thank you. We look forward to working with you. 
We are all excited about the possibility.
    Thank you, Mr. Chairman, I yield back.
    The Chairman. Thank you, Dr. Dunn.
    Mr. Sablan, you are recognized.
    Mr. Sablan. Well, thank you very much. And good morning, 
everyone, because where I am from, it's 11 o'clock in the 
morning. I know I have been nodding off a bit, but when it 
takes you 25 hours to get here, you get tired.
    And because it is so far away--Mr. Secretary, 
congratulations also on your appointment, on your confirmation. 
I truly wish you all the success in your term in office. You 
were successful in your previous job running a huge hospital.
    But the veterans in my district believe that our country 
has forgotten them. When I first got in, in 2009, I don't stop 
over anywhere in the country going home or coming back, but I 
stopped over in Hawaii. I met Dr. Hastings. I urged him to 
complete the contract that he was negotiating with one doctor 
who actually now provides service to a certain number of 
veterans, the only doctor on the island providing service to 
veterans. And then we now have one VHA employee. But the 
Department--the country--the veterans feel that the department 
that is tasked with administering veteran benefits and services 
have done little to change their feelings about they are being 
forgotten.
    Over the years, we have had VA cases, but in the last 9 
months, my office has seen a significant increase in complaints 
about VA service from veterans, their family members, 
advocates, and service providers, that I have taken it upon 
myself--I have no use of VA resources--have brought in people 
who helped with teaching breathing methods for people with 
PTSD.
    I brought in this documentary and Tom Voss who walked the 
country to handle--learn how to handle his demons. We just had 
a resource fair 2 weeks ago, sir, and I have never had a more 
successful fair. For veterans, we put together all potential 
resource providers and brought our veterans in and--in all 
three islands and were very successful.
    And then all of a sudden comes in your administrator from 
Hawaii and his deputy or her deputy. And they couldn't make it 
to the fair, but now they are having a 1-1/2 hour townhall, 
after stopping in Guam for the night. So my question is, will 
you pledge to work with me please to improve the quality of and 
access to veteran VA services for our veterans? I am from the 
Northern Mariana Islands. Somehow we truly need your service, 
sir.
    Secretary Shulkin. Yeah. I would like to come and see you, 
and let's try to figure this out together.
    Mr. Sablan. Thank you very much. Thank you, Mr. Secretary. 
That commitment is important.
    Mr. Missal, that is you, sir. Right?
    Mr. Missal. Yes, it is.
    Mr. Sablan. You are inspector general?
    Mr. Missal. Yes.
    Mr. Sablan. Yes, sir. In your evaluation of the Choice 
Program implementation, what have you found to be the 
experience of veteran patients in the outlying areas or insular 
areas or territories, some people say the colonies, such as the 
Northern Marianas, in accessing health care in a timely manner 
under the Choice Program?
    Mr. Missal. Well, sir, we have looked at it in a number of 
different ways. We haven't just isolated it in those particular 
areas you mentioned. But the same issues we found, whether it 
is with VISN 6, whether when we looked at it more nationally, 
are going to be the same issues that impact people in those 
more rural areas, which are the complexity of the programs make 
it very difficult to administer, which increases the time 
involved.
    And then one of the other issues that I know we have talked 
about already is care coordination, to make sure that when a 
veteran leaves the VA system--and one of the strengths of the 
VA system, it is an integrated system where they can watch very 
closely the care for the patient. When they leave that system, 
you have to make sure the records go out with the patient and 
you have to make sure they come back in. And we have seen 
challenges to both of those situations where they are not going 
out as quickly and coming back as quickly as they should.
    Mr. Sablan. Well, my question was, so that is the 
experience you have found in veterans accessing health care in 
a timely manner, or is that an answer that says really that you 
don't know what you are talking about?
    The Chairman. I would hold that answer, and we will come 
back.
    Mr. Rutherford, you are recognized for 5 minutes.
    Mr. Sablan. My time is up.
    Mr. Rutherford. Well, thank you, Mr. Chairman.
    Mr. Secretary, thank you for your long testimony here 
tonight. You have probably heard the old saying, you know, that 
vision without action is just daydreaming, and action without 
vision is chaos. And sometimes I hear from veterans in my 
district--I am from Florida 4, which is the northeast corner of 
Florida, and we have a very large veteran population.
    Secretary Shulkin. Sure.
    Mr. Rutherford. Sometimes they talk about the chaos of the 
system. But I have heard a couple things here tonight that 
really struck me. One was that your number one concern is--and 
it happens to be mine as well--is veteran suicide.
    Secretary Shulkin. Yes, sir.
    Mr. Rutherford. I am very pleased to hear that.
    In addition to that, I heard that another vision that you 
have is that the VA is going to get out of developing IT 
software and those kind of things and look for those off-the-
shelf type packages. Those are significant cultural shifts, I 
think, within the VA.
    Secretary Shulkin. Yes.
    Mr. Rutherford. Could you just give me one or two more that 
you had--you know, visions that you have about the VA and how 
to--what will change the culture?
    Secretary Shulkin. Yeah. The three biggest areas that I am 
focused on are, number one, giving veterans additional choice. 
And, you know, I think that I have already explained tonight, 
this means keeping the VA system strong. I happen to believe 
the way you keep the VA system strong is by allowing veterans 
to decide where they want to get care and giving them more 
choice, and I believe that is going to make us a stronger 
system.
    I think it goes along with, secondly, what Dr. Roe has 
introduced, which is accountability. For me, accountability--
and we have had this discussion with the Chairman and the 
Ranking Member as well, that accountability is not only making 
sure that if you lose your way and you lose your values, you 
shouldn't be working in the VA, but also that the Secretary has 
the tools to recruit and retain the very best in health care. 
And I do believe we have among the very best health care 
professionals in the country working at the VA today. I want to 
keep them there.
    And third is I want the system to be modernized. I believe 
veterans deserve the very best that this country can offer, 
that means modern IT systems, modern facilities, modern types 
of programs and professionals and technology. So I think those 
three areas are really what is driving the transformation of 
the VA.
    Mr. Rutherford. Thank you, Mr. Secretary. And I can tell 
you, I believe the entire Committee looks forward to working 
with you and making that happen.
    And in light of the hour, Mr. Chairman, I will yield back.
    The Chairman. I thank the gentleman for yielding.
    Ms. Esty is recognized.
    Ms. Esty. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, and all those who are staying in 
the late hours with us here tonight.
    I think we are all extremely heartened to hear the word 
about IT. I certainly heard a lot about that over the last few 
days in meetings with veterans across my district, and it is 
urgently needed.
    This issue about coordinated care, I had--one of my 
roundtables yesterday, someone came forward and said a friend 
of theirs had just gotten a $36,000 hospital bill that went 
straight to the veteran despite Medicare, Medicare Extension, 
Aetna, or Blue Cross Blue Shield, and VA. And the hospital sent 
him a $36,000 bill.
    Now, this is someone who is recovering from surgery, is 
already qualified, served this country, and is over 65. And 
that is just shameful and wrong. And we absolutely need to have 
a system where that can't happen. They cannot, a first recourse 
when you go outside the system, send that bill.
    I heard the same issue with ER care. Again, veterans 
getting those ER bills, they don't know what to do. They are 
told they have a bill to pay, they panic, and they don't pay 
other bills, and they pay the ER bill. That is wrong. And we 
need to have clarification about what these rules are. It 
should not take a 150-page manual I spent the last 2 days fully 
with veterans, and it just should not be that hard.
    Ms. Esty. On military suicide, I think we are all very 
heartened to hear your commitment around that. I find for a lot 
it is people who have not come into new system at all. So you 
may have the best care available, but if nobody is coming into 
the system, you don't--like my friend, Beto, I know our veteran 
centers are providing that care for many of our Vietnam 
veterans now.
    We need to figure out how to reach out over the last 20 
years for them at least, for veterans, because they are not in 
the system whatsoever. And we are getting those calls in our 
office. And we have had to have--we have had suicide calls come 
into the office and had to patch people through and track down 
their provider. You shouldn't be having to call your Member of 
Congress to get help.
    So we need to work together and figure out how to actually 
bring people in so that we are not saying, hey, we have got 
great care, but you are never going to see it.
    One of the issues you did not flag, which I would like you 
to, is on women veterans. That needs to be a priority. We are 
integrating our forces. There have been some unwelcome news out 
of the Marines in the last couple of days, which if you want to 
talk about the damage that does to our system and our ability 
to attract and retain the best and the brightest, that does 
real damage.
    And that underscores the need to have that kind of care. It 
is a little specialized. And as we look at care outside of the 
system, those distances become an issue. Mine is one of those 
districts. I am in Connecticut, but it is rural. The northwest 
corner of my State looks a lot like Vermont or Maine, and so to 
actually get to a VA facility might be 60 miles or 70 miles.
    But there is a CBA (ph) that is 20 miles away. We need to 
deal with that issue about where you may have outpatient that 
is really close, but actually what you need is going to be 
further.
    So I would like your feedback on whether we can have Choice 
recognize the difference between a facility that is within the 
40 miles and actually what you need. And it may not even be 
that specialized, but if you are talking women veterans, it may 
be more specialized.
    Secretary Shulkin. Yeah. Well, Congresswoman, you have 
identified so many important issues, I don't even know how to 
begin to address them all, but let me just try to make one 
point about each one.
    On the putting the veteran in the middle with these bills, 
absolutely horrible. I am going to tell you what to do: Call 1 
(877) 881-7618. That is a special hotline for veterans who are 
in the situation where they are being billed inappropriately, 
and we are going to get them out of that credit situation.
    On the issue of veteran suicide, thank you for your 
recognition on that. We know VA can't do this alone. It has to 
work with community providers, and we are strongly looking for 
community groups and other partnerships who are willing to go 
into the community and reach people that you are talking about.
    On the issue of women veterans, absolutely. It is an 
oversight not to mention it as one of our key areas, fastest 
growing group of veterans. We have done a lot, but we need to 
do a lot more, and it is not uniform across all of our 
facilities, our specialized women's care, but we are getting 
there.
    On the Choice Program, as I have said, if I were designing 
a program, I would not have picked mileage and wait times as my 
criteria, you know. I tend to think more clinically about how 
you meet health care needs of veterans and patients. So that is 
what we look forward to working with you.
    If I didn't mention it, we are very supportive of an 
extension program now for Choice, but we want to come back and 
we want to work with you on a redesigned Choice 2.0. We are 
going to have a better name for that too. And we really want to 
get that done with you by September. That would be our goal to 
get that done and to get a system that makes sense.
    Ms. Esty. Thank you. And I see my time has expired. Thank 
you very much.
    The Chairman. I thank the gentlelady for yielding.
    Mr. Higgins, you are recognized for 5 minutes.
    Mr. Higgins. Thank you, Mr. Chairman.
    Secretary Shulkin, I very much support H.R. 369, the 
extension of Veterans Choice Program. The remaining $1 billion 
of American treasure certainly needs to be dedicated to 
American veterans.
    In your testimony, you noted that Congress should pass 
legislation to clarify criteria for veterans to receive care 
closer to home, to facilitate the development of a network of 
community care providers, and to better coordinate veterans 
benefits.
    I would like to bring our conversation completely closer to 
home, all the way to the home. As you know, many of our most 
severely wounded veterans prefer to receive their care from 
their family at home, so I am referring to family caregivers. 
And specifically, as we move forward with what you referred to 
as Choice 2.0, with an eye towards making a real difference in 
the lives of American veterans that are seeking health care and 
need it, do you believe it is in the best interest of American 
veterans to expand the program of comprehensive assistance of 
family caregivers to include pre-9/11 vets whereby they can 
receive their care from those that know them the best, their 
loved ones? Would you please give us your feedback on that?
    Secretary Shulkin. Yeah. One of the parts of VA that I am 
most proud of is our support for caregivers. I think we have 
demonstrated, when we send somebody off for war, we are not 
just sending them off, we are sending their entire family. And 
the family needs to be part of the solution when they come back 
home, and our support for caregivers is something vital.
    Now, as you mentioned, it was only authorized for veterans 
post-9/11. I do believe it needs to be for all veterans, 
particularly our older veterans who want to stay at home, and 
then maybe they wouldn't have to leave their home into an 
institution.
    The cost for that program right now, it would be scored in 
the--about $4 billion. I believe that is not an accurate 
reflection on the true cost because I believe we are going to 
save money--
    Mr. Higgins. Save money.
    Secretary Shulkin [continued].--by not institutionalizing 
people. So we are now beginning to come back with a true 
reflection of the cost, but I am supportive of that.
    Mr. Higgins. I thank you for that answer. It is very 
encouraging. God bless you for that, sir.
    I yield my time back, Mr. Chairman.
    The Chairman. I thank the gentleman for yielding.
    And, Mr. Banks, you are recognized for 5 minutes.
    Mr. Banks. Thank you, Mr. Chairman.
    Secretary, it is an honor to have you here today. You have 
answered so many questions and addressed so many issues.
    As a recently deployed veteran, post-9/11 veteran, I am 
especially interested in transition assistance programs. To get 
to the heart of the veteran suicide rates among post-9/11 
veterans, what can we do at the outset, the beginning of the 
process?
    My personal experience was in Sembach, Germany, in the 
Navy's Warrior Transition Program, which was a terrific program 
that, in hindsight, benefited me greatly on my return home trip 
from Afghanistan. I wonder, what lessons have you learned about 
other TAPS programs in the other branches?
    As I understand, the Navy has a model program in Sembach. 
Can we protect it? Can we model it, any other branches? What 
can this Committee do to support you with TAP programs as well?
    Secretary Shulkin. Well, first of all, thank you for your 
service. And I would like to work with you because it sounds 
like you have some experience that maybe we could benefit from.
    I do believe this transition period and the TAPS program is 
an area that is ripe for even doing better in. And we hear too 
many stories where people just didn't think about the 
transition in the way that we would like them to and then find 
themselves without knowing how to seek help.
    I was speaking to the President about this last night. And 
one of the things that we are going to be doing is Secretary 
Mattis and I are going to be getting together to talk about how 
we can get organizations to focus on this in a different way 
and work together in a closer way. So with your input, I think 
we would be better prepared for that conversation.
    Mr. Banks. I look forward to working with you on that.
    On another note, we have a number of veterans in Indiana, 
where I live, who are interested in alternative treatments like 
hyperbaric oxygen chambers or other alternative treatments to 
the traditional treatments to PTSD and TBI. What, under your 
leadership, can we look forward to in opening up new avenues 
for treatment for our post-9/11 veterans especially?
    Secretary Shulkin. Well, first of all, I was just in 
Indiana last week visiting the VAs there and toured the VA with 
the governor, Governor Holcomb. The areas that I am most 
concerned about are areas that veterans have a high 
predilection of, like PTSD, traumatic brain injury, other 
conditions, that today we do not have great state-of-the-art 
treatments in. So I am not as worried about treating 
pneumococcal pneumonia, because we have penicillin, but in 
these areas, I think we have to be looking for new solutions 
and treatments.
    We have established a new office called the Office of 
Compassion and Innovation, where ideas such as hyperbaric, 
where the VA had traditionally been very close to, have an 
opening to come in, and we will work with them to explore new 
ideas.
    It so happened the very first one of these that we looked 
at and that we have granted access to is the use of service 
dogs for veterans who have PTSD or other emotional disorders. 
And while there isn't, believe it or not, great science behind 
the fact that service dogs help, I think it is commonsense that 
service dogs help. And so we hear it every day from veterans. 
So now we have started to make them available.
    And so ideas such as what you are talking about, hyperbaric 
is a very interesting story because DoD and VA have studied it 
three times and found the negative association, but yet we are 
finding veterans who say they have been helped by it. So we 
want to continue to look at issues like that.
    Mr. Banks. Well, thank you. I am excited about your 
leadership. I look forward to working with you.
    And, Mr. Chairman, I yield back.
    The Chairman. Thank you, Mr. Banks. And actually, two 
Sheltie dogs and a bluegrass guitar keep me sane, so I believe 
in it.
    We are going to have a roundtable later in the year. I had 
several meetings over the recess and just yesterday on trying 
to bring a lot of the people out in the community who are 
working with veterans, try to bring together and coordinate 
some of these efforts.
    So many people--I have met with now three people in the 
last 4 days who are doing something here, somebody over here. 
But let's get everybody, not with the cameras on but just 
around the table, and find out how we can better coordinate 
this with the VA.
    Gentleman, you are recognized for 5 minutes.
    Mr. Bergman. Thank you, Mr. Chairman. And I am last, right?
    Thank you, all of you, for being here tonight. Just before 
coming in, I had a tele-townhall, 2,000 people or so dialed in. 
About 50 percent of the questions that came were related to 
veterans.
    Michigan, as a State, has a higher than average percentage 
of veterans. The first district of Michigan has double the 
percentage of veterans of the other districts. So we have got a 
lot of folks in our district that--let's put it this way: They 
laid it all on the line for the country; now we need to lay it 
all on the line for them.
    By the way, Mr. Missal, did I get it right? Is that how you 
pronounce it?
    Mr. Missal. That is how you pronounce it.
    Mr. Bergman. Okay. Just want to make sure because, you 
know, pronunciation counts.
    You know, in your written testimony, you discuss how the VA 
accounts for community care expenses. The topic is extremely 
complex. Let me try to state it in laymen's terms, as I 
understand it.
    I am a Marine, so this will be simple here. Currently, the 
VA estimates how much each individual episode of care is going 
to cost and sets aside funds for that care. That doesn't happen 
quickly or accurately. When the estimate is too high, the 
excess funds remain set aside and the VA has to do an 
adjustment to put them back in the pot.
    Mr. Missal. Correct.
    Mr. Bergman. Those adjustments don't happen very quickly 
either. The Department wants to change this to stop estimating 
each episode of care and instead do one big estimate at the 
beginning of the year.
    My question for you is, if we allow VA to make this 
procedural change, but they don't get more accurate in their 
estimates, what are the potential downside consequences that 
could result?
    Mr. Missal. Well, they are a pretty significant downside. 
Accounting for dollars in the community was seen as a material 
deficiency in the audit that we conducted of the financial 
statement. So obviously, as you are getting into estimating, it 
is very tricky. By doing it at the beginning of the year where 
you are doing it as more broadly, you are going to have some of 
the same issues that you are going to have when you are doing 
it on a case-by-case basis.
    Mr. Bergman. Okay. And also, Mr. Missal, you mentioned in 
your testimony the VISN 6 report released publicly last week 
that included shortcomings within Choice, particularly that 
most veterans reviewed were waiting in average of 84 days to 
receive care.
    Mr. Missal. Correct.
    Mr. Bergman. Your staff informed the Committee that it 
provided the VA its findings around August of 2016 for agency 
review. In the 7 months from when they were provided to VA 
until the report was released publicly, did the OIG make any 
substantive changes to the findings, and if so, what types of 
information was changed?
    Mr. Missal. We did make some changes. Our process is when 
we finish a report, we do share it, the draft, with VA. It is 
our report. We are going to stand by our finding. But the 
important thing is we want to make sure we get it right. So we 
did meet with senior leadership at VA to talk about it. We 
wanted to clarify some things. So I would put it more in terms 
of we didn't change our findings, we just clarified things to 
make it absolutely clear exactly what we had looked at, what 
the methodology we used, and any comments from VA.
    So Dr. Shulkin, who is an under secretary, responded with 
some comments that are included in our report.
    Mr. Bergman. Okay. Thank you.
    And in the interest of the lateness of the hour, I yield 
back, Mr. Chairman.
    The Chairman. I thank the gentleman for yielding.
    And Mr. Missal and Mr. Williamson, you are finding out the 
same as I do; it is always good to do a townhall with a Senator 
because they never have to answer any questions, just like the 
Secretary tonight when you two are here, he answers most of the 
questions.
    I will use my 5 minutes very quickly and just state some 
things that we have heard tonight.
    I think, number one, we all agree that we need Choice 
extension sooner rather than later; number two, I think we need 
the Choice consolidation, and what I am hearing is a reform of 
the Choice Program, and I am going to ask a specific question; 
number three, it was a breath of fresh air to hear that, I 
think, the VA is going to quit developing IT and try to be 
Microsoft or Apple and go ahead and let somebody do that and we 
will absolutely work together with you.
    I think if we can accomplish getting the IT started and 
those other two things this year, it would have been one of the 
most successful years in VA history. I believe that. And I 
think we can do that. I truly do.
    The Chairman. I have laid that out, and that is--we know 
where we have been with the VA, we know where we are now. And I 
think I would like to hear, Dr. Shulkin, you go ahead and tell 
us your personal vision for transforming the VA and how this 
Committee can be of help to you in doing that.
    Secretary Shulkin. Well, first of all, thank you. And 
having sessions like this where we really do get a chance to 
share opinions, I think, is a really important start, because 
any solution is going to have to be all of us wanting to get 
this done together.
    I think the vision for the VA is to transform this 
organization to be a veteran-centric organization. In order to 
do that, it is not rocket science. You have to have the right 
people caring for veterans. And I think we are very fortunate 
that we have such a great workforce, but we have all seen 
examples where there are people that shouldn't be working in 
the VA that it has been too hard to get them to leave, and I 
think your accountability bill is an important step forward in 
that.
    I also need the tools, as we have talked about, and I 
appreciate your willingness to consider both the carrots and 
the sticks, because that is the dual part of accountability, 
getting the right people in the door and getting the great 
people to stay in the organization.
    I think we need to transform the culture in many ways that 
we learned our lessons in 2014 by having the wrong incentive 
systems in place, by not having management understand their 
jobs, and by not being transparent enough. So I think we need 
to change our culture that way.
    I think we do need to put the control of health care back 
into the hands of veterans so it is their choice on where they 
get health care. They are the ones who make their appointments, 
they are the ones that essentially say whether we are doing a 
good job or not, and we have to--we have to do that.
    And, finally, the last piece, as we have talked about 
several times tonight, is modernizing the VA system. And by the 
way, there is probably not enough money to completely modernize 
the system, so we are going to have to be creative in our 
solutions. We are going to have to leverage existing technology 
that is out there in the market. We are going to have to 
partner with our community partners to provide the right types 
of facilities. So it may mean that VA is not going to be 
building as many brand-new hospitals, but working with 
community hospitals to share resources with the Department of 
Defense and other Federal facilities.
    So it is doing business differently, it is being willing to 
take some risks that maybe we haven't, and that is where I 
think us doing it together is really going to be the right 
formula for success for veterans in this country.
    The Chairman. You are seeing that consolidation on the 
private side too--
    Secretary Shulkin. Yes.
    The Chairman [continued].--that is going on in this country 
right now. So it is not just the VA system.
    Just a couple of quick questions. Do you believe, I don't 
think there are, but do you believe the provider networks now 
are robust enough to provide care for veterans in a timely 
fashion?
    Secretary Shulkin. You mean--
    The Chairman. The Choice Program.
    Secretary Shulkin [continued]. Well, I think we have come a 
long way, but I think that we have much more to do. Our vision 
is a network of providers that have made commitments on both 
the service and the clinical side to caring for America's 
veterans, and that is what we want to work towards developing.
    The Chairman. I would suggest, Dr. Shulkin, that you and I 
take the suits off one day and probably go in a VA, put our 
stethoscopes back on, and go in an examining room and find out 
the frustrations. And I would say if you were back in the 
examining room and you had a patient you felt that needed to 
see a cardiologist, a rheumatologist, and how hard we have just 
described tonight that is--
    Secretary Shulkin. Yeah.
    The Chairman [continued].--and the lengths of time people 
go, months, to get an appointment, it would--the rest of the 
hair, the few that are still on my head, would fall out.
    Secretary Shulkin. Yeah.
    The Chairman. And I want you to tell me how you--if you 
were making that appointment, what would you expect to happen?
    Secretary Shulkin. Well, first off--
    The Chairman [continued]. You just said--
    Secretary Shulkin [continued]. First off, you just gave me 
a softball. I am inviting you to join me the next time I go and 
put on my stethoscope, because I see patients in Manhattan and 
in Oregon. So you can decide where you want to go with me. And 
Dr. Yehia sees patients as well.
    Look, we have focused in the VA on making sure that urgent 
care is delivered at the right time. That is why we have same 
day access now in every one of our medical centers for mental 
health and primary care. We are focused on getting stat 
consults down. Right now, there is less than 100 across the VA 
that are stat consults more than 30 days, so it is a functional 
zero. And we are working to make all of our specialty care more 
accessible, but of course, we do need to use community care to 
do that.
    The Chairman. I thank you. My time has expired.
    I am going to open it up for a second round for 1 minute, 
and the Chairman will be very--very, very careful about the 1 
minute.
    Mr. Walz.
    Mr. Walz. Yeah. Thank you, Mr. Secretary. Your vision is 
where we are all at. I appreciate it, and know that we are 
there to try and give you the tools. We will have our 
discussions in here, we will have family discussions, we will 
deliver you something, Veterans First Act that we had. We want 
to give you accountability, because I am glad you mentioned--
what I can tell you is we can say we are going to remove people 
fast, but without leadership, without hiring, without due 
process, those are going to be things that aren't going to give 
you the tools, so we are going to work on giving you that. Your 
vision is solid.
    We have been followed tonight online by a lot of folks who 
are watching. They care deeply about this. I can tell you 
overwhelmingly the veteran suicide issue resonated. There was a 
military spouse, Alesandra, said, I am a mother, my father--my 
son's father served 25 years. My son will not serve because of 
his suicide.
    We understand that this is a faith issue. I just appreciate 
your vision, I appreciate the leadership, I appreciate the 
Chairman being there. And the folks sitting behind you, they 
have got your back, they have been out there, and there is a 
lot of those groups. So let us get this done together.
    Secretary Shulkin. Thank you.
    Mr. Walz. Thank you, Mr. Secretary.
    The Chairman. Thank you, Mr. Walz.
    Mr. Bilirakis.
    Mr. Bilirakis. Thank you. Thank you, Mr. Chairman.
    For Mr. Missal, there have been many instances and issues 
that have related to veterans care which the VA has attributed 
those failures to poor training. In instances when a VA 
employee engaged in suspected criminal activity such as fraud, 
falsification of patients' records, or failures that have led 
to patient harm, is the VA OIG authorized to investigate?
    Mr. Missal. Yes, we are. Under the Inspector General Act of 
1978, we do have the authority to work with the Department of 
Justice and other law enforcement to bring criminal charges, 
and we have done that on a number of occasions over the years.
    Mr. Bilirakis. Okay. Very good. That is what I wanted to 
know, and I appreciate it.
    How do you prioritize these particular cases that are 
brought to your attention?
    Mr. Missal. We look at it in a number of different ways. We 
look at the extent of the harm, the number of veterans 
impacted, the amount of dollars impacted, how long the conduct 
has been going on. So we look at a variety of different factors 
and try to prioritize the one that are the most serious in 
nature.
    Mr. Bilirakis. Very good. Thank you very much.
    I yield back, Mr. Chairman.
    The Chairman. I thank the gentleman for yielding.
    Mr. Takano, you are recognized.
    Mr. Takano. Thank you, Mr. Chairman.
    Secretary Shulkin, we are hearing from veterans online who 
want to ask you questions. Many of the questions are about 
improving mental health care. What more can we do to ensure 
timely access to mental health care and how can we better 
recruit and retain mental health care providers?
    Secretary Shulkin. Well, I think we are working on two 
things right now. One is we need to hire more mental health 
professionals. So if people are following us online and they 
are interested in coming to work for the VA, we are interested 
in talking to them. So we need about 1,000 more mental health 
providers.
    The second thing we are doing, we are leveraging our areas 
of the country where we do have a good supply of mental health 
providers, which are what we call our hubs, for telemental 
health. And so we are providing those professionals to the more 
rural areas of the country where we don't have the providers. 
So we are trying to leverage it that way. And we are working 
with our community providers, like Beto O'Rourke mentioned in 
El Paso, where there are great centers like Texas Tech that we 
can work with.
    Mr. Takano. Mr. Chairman, at some future time, I would like 
to ask more about graduate medical school, GMEs, and how we are 
using those, but my time is up.
    The Chairman. Okay. Mr. Coffman.
    Mr. Coffman. Thank you, Mr. Chairman.
    Dr. Shulkin, thank you again for your service to this 
country. The one question I have is that doesn't the VA--I have 
read that the VA has a certification system for mental health 
professionals within the community outside the VA where they 
can be certified to deliver care to our veterans. And I think 
you mentioned your concern that the average provider outside 
the VA may not understand the culture of the military--
    Secretary Shulkin. Yes.
    Mr. Coffman [continued].--and that is a real concern. I 
wonder if you can explain how this program, this certification 
program works, and is it being utilized today to sign up more 
providers outside the VA?
    Secretary Shulkin. Yeah. We are doing outreach to our 
community providers that we are working with to make sure that 
they do have the education and the materials to be able to see 
veterans. This is part of our concept of our high performance 
network to get providers in there who want to and are committed 
to seeing veterans to provide the type of quality care we 
believe they deserve.
    Mr. Coffman. But it is a formal certification process, is 
it not?
    Secretary Shulkin. Yes.
    Mr. Coffman. Okay. And so tell me, can you give some, you 
know, metrics in terms of how that program is going right now?
    Secretary Shulkin. We measure the number of providers that 
take advantage of our educational programs in that and that we 
have outreach too. So we can get you more information on the 
number of providers. We feel we need to do more of it.
    Mr. Coffman. Because I would just think that that is--there 
is a multiplier capability--
    Secretary Shulkin. Yeah.
    Mr. Coffman.--in terms of having resources by virtue of 
leveraging what is in the community but certifying them or 
making them go through a training process where we know that 
they meet the requirements--
    Secretary Shulkin. Yeah.
    Mr. Coffman [continued].--for the VA.
    Secretary Shulkin. I think we have more work to do on 
formalizing that program. I think that is the direction that we 
are headed in, though.
    Mr. Coffman. Okay. Thank you, Mr. Chairman. I yield back.
    The Chairman. The gentleman's time has expired.
    Mr. Correa, you are recognized for 1 minute.
    Mr. Correa. I will pass.
    The Chairman. Okay. The gentleman yields.
    Mr. Rutherford, you are recognized.
    Mr. Rutherford. Thank you, Mr. Chairman.
    Mr. Secretary, I just want to say, you must be a real man 
of action, because that mental health--service dogs for the 
mentally ill, our members who are veterans who are suffering 
from PTSD and TBI were told 3 years ago that there was going to 
be a study to, you know, determine the efficacy of it, and then 
at the end of that 3 years they were told, well, it is going to 
be another 3 years before that report will be finalized. You 
have done it like in 30 days.
    Secretary Shulkin. What--
    Mr. Rutherford. Thank you.
    Secretary Shulkin [continued]. Let me tell you about that 
study. First of all, it will be another 3 years before we get 
the study results, and I am not willing to wait--
    Mr. Rutherford. Thank you.
    Secretary Shulkin [continued].--because there are people 
out there today suffering. But when they did the study, this is 
what I learned. They did--like any good study, there are two 
arms, right, one that should be with dogs and one without dogs 
so they can learn.
    Mr. Rutherford. Right.
    Secretary Shulkin. They couldn't find a single veteran who 
was willing not to take a dog. I mean, I think that tells you 
something right there. So I said, give them all dogs.
    Mr. Rutherford. Well, thank you very much, because I can 
tell you that is going to be a resounding success back in my 
hometown. God bless you.
    Secretary Shulkin. Thank you.
    The Chairman. Mr. Sablan, you are recognized.
    Mr. Sablan. Yeah. Thank you very much, Mr. Chairman.
    Mr. Missal, let me go back again. I don't mean to be 
disrespectful in any way, and I know that you have said that 
you have looked at veterans in other rural areas. I am talking 
about my area, my district, the Northern Mariana Islands, sir. 
The experience there and experience in rural areas are not the 
same, so I am asking you to consider looking at the veteran 
experience in the outlying areas, like my district.
    You do know where the Northern Mariana Islands are?
    Mr. Missal. Yes, I do.
    Mr. Sablan. Yes, sir, because you guys come through Guam 
all the time, but don't--again, Mr. Secretary, your director 
out of Hawaii and her assistant are on site for an hour and a 
half today. I mean, it has been a while since anyone has been 
there, but they took an hour and a half today. Thank you very 
much. But I would like to work with you again some more. Thank 
you.
    The Chairman. I thank the gentleman for yielding.
    I am now going to yield my time to Dr. Wenstrup, who I 
rudely ignored a minute ago.
    Mr. Wenstrup. Just call me Skip, Mr. Chairman.
    I want to go to something that Mr. Takano was bringing up, 
and that is the GME and residency programs. And as you know, 
most doctors in America spend some time in a VA as part of 
their training. So what are you looking at with that where we 
can be of help as far as what specialties we may want to engage 
with further, such as in mental health, but also association 
with academic institutions in making those more robust 
programs?
    Secretary Shulkin. Right. Well, we are doubling down on our 
relationships with our academic centers. We think it is one of 
the best and strongest features of the VA, and it benefits not 
only veterans, but all Americans in the way that we train our 
health care professionals.
    The Choice Program, as you know, gave us the additional GME 
spots. We have taken advantage of those. Almost all have gone 
to mental health or primary care. We believe that we could 
still do more. I would like to look at some ways of getting 
them into some of our rural parts of the country that don't 
have teaching programs. That would be a big, I believe, 
addition to helping us in increasing the quality of the 
environments that our veterans get care in. So we would like to 
work with you for ways to expand it.
    As you know, the country needs more graduate medical 
education spots. They have been expanding the undergraduate 
medical education spots but not the GME spots, and somehow that 
formula is not going to work out if we don't expand the GME 
spots.
    Mr. Wenstrup. Thank you.
    The Chairman. I thank the gentleman for yielding.
    Mr. Higgins, you are recognized.
    Mr. Higgins. Secretary Shulkin, I am a veteran. I represent 
the portion of my State, my district has the highest density of 
veterans in the State, and only about 20 percent of my fellow 
veterans regularly access the health care system.
    We have seen improvements in the Choice Program, and I have 
confidence that it is going to allow greater access to health 
care for all veterans to penetrate that number and help more 
veterans access the health care that they have earned and 
deserve. I have a high degree of confidence that tomorrow this 
sunset window will go away and a billion dollars will be 
invested, as it should, in the lives of our veterans that have 
earned it.
    Will you work with this Committee and this body to help us 
develop a furtherance of the Choice Program and continued 
improvement of it? Please share with us in the remaining 3 
seconds a resounding yes.
    Secretary Shulkin. Yes.
    Mr. Higgins. Thank you, sir. I yield back.
    The Chairman. I thank the gentleman.
    General Bergman, you are recognized.
    Mr. Bergman. Secretary Shulkin, by the way, 
congratulations, you are now the dog that is caught in the 
tire.
    Secretary Shulkin. Yeah.
    Mr. Bergman. But some of the rest of us are in the same 
boat. So the point is that vehicle has multiple tires, and 
there are a lot of us with our teeth into it right now.
    There is, and I believe it has some visibility within the 
Veterans Administration already, of a proposed beta project, 
Cherry Tree, out of Traverse City, Michigan, that involves not 
only health care for veterans, but education, jobs, housing. 
And I am looking forward to working with the Veterans 
Administration to bring Project Cherry Tree to a level where it 
gets a good look to see what is in the art of the possible, 
because we are all in this together, and the results that we 
are going to achieve will only be limited by our desire to 
achieve them. So thank you very much.
    And I yield back.
    Secretary Shulkin. Thank you.
    The Chairman. I thank you all. And the questions now have 
ceased.
    I want to thank the panel. You all have been very, very 
generous with your time tonight. And I think you can see the 
interest from the number of members that have stayed around 
this long and the folks in the audience too that have stayed 
here. It is truly one of the most important things we will have 
tasked to us as Congress men and women, is to help make the VA. 
We have learned what the problems were in the last 114th, and 
pointed those out clearly and we have had help with the GAO and 
the IG in clarifying that, but I think now it is to solve the 
problems, and I look forward to doing that with you all. I 
think this entire panel does. They are huge and not easy, I 
certainly understand that, and we have mentioned and brought up 
a lot more tonight. But I am optimistic, and I am certainly 
more optimistic after tonight's hearing. I think we have all 
got the oars in the right and we are all pulling in the same 
direction, and I think that is going to get some results.
    Mr. Walz. you have a--
    Mr. Walz. Mr. Chairman, I ask unanimous consent to submit 
into the record a statement on some case study work on Choice 
from Mr. Nolan, our colleague.
    The Chairman. Without objection, so ordered.
    The Chairman. Do you have any closing comments?
    Mr. Walz. I do not. I would just like to echo the 
Chairman's comments. We are in this together. We are grateful. 
The right people are on the bus and on the right seats, and so 
we are here to do what we can do. So thank you. And thank you, 
Mr. Chairman, for all your work.
    The Chairman. Thank you.
    I ask unanimous consent that all Members have 5 legislative 
days to revise and extend their remarks and include extraneous 
material. Without objection, so ordered.
    This hearing is now adjourned.

    [Whereupon, at 9:57 p.m., the Committee was adjourned.]



                            A P P E N D I X

                              ----------                              

              Prepared Statement of Honorable John McCain
    Thank you Chairman Roe and Ranking MemberWalz.for the opportunity 
to appear before this committee to discuss the Veterans Choice Program.
    I want to talk to you about veterans' access to care and how we got 
here, starting with the Steve Cooper, an Army veteran who served his 
country for 18 years. In return for his service, Steve waited for 
almost two years before seeing a doctor at the Phoenix VA. By the time 
he received care, his routine urology appointment turned into a 
diagnosis of terminal cancer.
    Steve wasn't alone in his need for care. In 2014, our country was 
shocked to learn that Steve was one of 15,000 veterans standing in line 
for care in Phoenix - 3,300 of whom were urology patients. This 
national disgrace served as the catalyst for the Veterans Access, 
Choice and Accountability Act that created the Veterans Choice Program, 
which has enabled veterans to see providers in the community for their 
health care needs.
    The Choice Act required the VA to implement the Veterans Choice 
Program in under 90 days - an ambitious undertaking that experienced 
some growing pains. Despite a few road-bumps, the Veterans Choice 
Program to-date has accomplished its intended goal of increasing access 
to care for our Nation's veterans. In fact, since its inception, 
veterans have made more than seven million appointments with community 
providers for everything from diagnostic tests and urology screenings, 
to life saving heart and cancer treatment.
    While there has been significant progress in improving veterans' 
health care, we have a long way to go to change the status quo plaguing 
the VA. That is why we must not abandon our effort to provide choice 
and flexibility in veterans' health care, and why we must continue the 
hard work of refining and improving the Veterans Choice Program.
    In order to achieve this, Congress must first act quickly to 
reauthorize the Veterans Choice Program, which is set to expire in a 
few short months. Have no doubt: if we let this program lapse, hundreds 
of thousands of veterans will lose their ability to visit a community 
provider, the VA system will once again become overwhelmed, and 
veterans will go back to the pre-scandal days of unending wait-times 
for much-needed care. Continuing the Veterans Choice Program is the 
only way we can fully eliminate the wait-time problem at the VA and 
ensure veterans have access to timely and quality care.
    With the expiration of Choice authorization rapidly approaching, I 
understand the VA already has begun limiting care under the Veterans 
Choice Program for veterans whose treatments would extend beyond August 
7, 2017. I also understand that the VA's new plan for community care 
will not be fully operational until at least 2019. Given this reality, 
I am concerned that veterans nationwide may encounter significant 
lapses in care if we do not act quickly. This outcome is not only 
avoidable, but it is unacceptable and we in Congress must act.
    I am pleased to have introduced the Veterans Choice Continuation 
Act, with the Senate Veterans Committee Chairman, Senator Johnny 
Isakson, the Committee's Ranking member, Senator Jon Tester, as well as 
Senator Jerry Moran. This bipartisan legislation would remove the 
current sunset date for the Veterans Choice Act. I applaud you and your 
committee for taking up companion legislation that would do the same.
    Reauthorizing the Veterans Choice program would not only benefit 
veterans, but it would also provide Congress with the time we need to 
work with Secretary Shulkin to refine the next generation of Choice - a 
consolidated and even more standardized network of community care. The 
VA has provided Congress with its proposal for the future of community 
care, and we deserve time to study that proposal to ensure it strikes 
the right balance.
    In closing, let me be clear - no one is advocating that we 
privatize the VA. Many veterans are satisfied with the VA, which often 
provides superior specialized treatment in the areas of mental health, 
post-traumatic stress disorder and traumatic brain injury. At the same 
time, we simply cannot afford to go back to the pre-scandal days when a 
VA bureaucrat had the final say on where and when a veteran received 
care. Such thinking was what resulted in nearly 15,000 veterans 
standing in line for care in Phoenix. I know you agree, as does 
Secretary Shulkin, and I look forward to working with all of you and my 
colleagues in the Senate to extend the Veteran Choice Program and 
continue to keep faith with our nation's veterans.
    Thank you for the invitation to join you this evening and for your 
leadership on this critical matter. I'm confident that by working 
together, we can preserve access to health care for those who have 
borne the price of battle.

                                 
         Prepared Statement of Honorable David J. Shulkin, M.D.
    Good evening, Chairman Roe, Ranking MemberWalz. and Members of the 
Committee. Thank you for the opportunity to discuss VA Community Care, 
including the Veterans Choice Program, which makes it easier for 
Veterans to access the care they need and deserve. I am accompanied 
today by Dr. Baligh Yehia, Deputy Under Secretary for Community Care at 
the Veterans Health Administration.

History of Choice

    The Veterans Access, Choice, and Accountability Act of 2014 
(VACAA), which established the Veterans Choice Program, was enacted in 
August 2014 to help Veterans access timely care both within the 
Department of Veterans Affairs (VA) and in the community. VA 
appreciates Congress' support in providing this legislation that 
enhanced authorities and provided funding to better serve Veterans.
    VACAA gave VA only 90 days to fully implement a nationwide program. 
This was unprecedented and created many growing pains. To put things in 
perspective, the TRICARE program took approximately three years to 
fully implement. The law also directed VA to change the way it operated 
both internally and with community partners, creating additional steps 
to purchase care.
    In order to implement the Choice Program on this aggressive 
timeline, VA held an industry day seeking partners in the private 
sector to operate the program. Unfortunately, given the short 
implementation timeline, there was limited interest from industry. VA's 
only option was to modify previously existing national contracts for 
community care, which were never intended to handle the scale, scope, 
and complexity of the Choice Program. Despite these challenges, VA met 
the congressionally mandated deadline and launched the Choice Program 
on November 5, 2014.

Veterans Choice Program Improvements

    The new requirements set forth in VACAA and the aggressive timeline 
for implementation presented challenges for the VA. VA is aware of 
these issues and has been working continually with all our stakeholders 
to make immediate and long-term improvements.
    VA appreciates the evaluations that the Government Accountability 
Office and VA Office of Inspector General (OIG) conducted regarding 
implementation of the Choice Program. The OIG report reviewed the first 
11 months of the Choice Program, a period that started more than two 
years ago. Specifically, the report highlighted three issues: (1) 
cumbersome Veterans Choice Program processes requiring Veterans to 
schedule their own appointments using third party contractors; (2) an 
inadequate network of community providers; and (3) reluctance by 
Veterans to use the Choice Program because of potential financial 
liability for treatment by community providers. VA has made significant 
improvements to address these and other issues. As a result, the Choice 
Program is no longer the program it was when it rolled out.
    VA and Congress worked together on four amendments to VACAA since 
2014 that improved the Veteran experience with the Choice Program 
including by increasing the number of Veterans eligible and expanding 
the number of community providers who can treat Veterans under the 
Program. Working with our contractors, VA issued over 70 contract 
modifications to improve access, efficiency, and address many of the 
issues raised by our oversight organizations. For example, in November 
2015, VA implemented a modification requiring the contractors to 
initiate calls to Veterans, simplifying the cumbersome scheduling 
process described in the VA OIG report.
    Prior to this modification, Veterans had to call the contractor, an 
unnecessary step. In late February 2016, VA completed a modification 
that decoupled the receipt of medical records from payment to the 
contractors. This helped improve the timeliness of payments to 
providers, addressed issues in the VA OIG report, and resulted in more 
providers joining the Choice network. In Spring 2016, VA clarified 
timeframes for the contractors to schedule and complete appointments, 
shortening the time it takes to receive community care. VA learned from 
TRICARE that embedding contractor and VA staff together is an effective 
model to improve operations and assist Veterans. In late 2015, VA 
implemented this model at the first location. Since that time, we have 
embedded contractor staff at over 50 VA medical centers across the 
country.
    As a result of these changes and many others, more Veterans are 
utilizing the Choice Program than ever before. Since the start of the 
Choice Program, over one million Veterans have received some Choice 
care. In Fiscal Year (FY) 2015, Veterans received 380,000 
authorizations for Choice care. In FY 2016, Veterans received over 
2,000,000 authorizations for Choice care. VA has quadrupled the number 
of authorizations from FY 2015 to FY 2016.
    Looking at early data for FY 2017, we are on a trajectory to 
increase use of the Choice Program even more than last year. In the 
first quarter of FY 2017, the number of Choice authorizations, 
approximately 750,000, is over 35 percent more than the same period in 
FY 2016. In addition to increasing the number of Veterans accessing the 
Choice Program, VA is working to increase the number of community 
providers available in the program. In April 2015, the Choice Program 
network had approximately 200,000 providers and facilities contracted. 
As of February 2017, the Choice Program network had over 400,000 
providers and facilities contracted a growth of more than 125% during 
this time period.

Future State of VA Community Care

    While progress has been made, and we are moving in the right 
direction, we recognize there is still work that needs to be done - and 
there is no time to waste. The Choice Program is set to expire in less 
than six months. We need Congressional action to extend the program 
beyond August 7, 2017 and improve the program to positively impact the 
Veterans' and community providers' experience. Many Veterans are using 
the Choice Program today, and it is important to continue to care for 
and support those Veterans.
    These improvements are just the beginning for community care. We 
think Veterans deserve better, and now is the time to get this right 
for the future. We need a bold transformation, which will require 
legislation. This legislation must do three things: (1) provide 
standardized, clear eligibility criteria for Veterans to get care 
closer to home; 2) facilitate building a high-performing network of 
community care providers, which has our Department of Defense, other 
Federal, and academic affiliate partners as the foundation, and 
reimburses for care using contemporary payment models; and (3) better 
coordination of benefits for Veterans, allowing VA to work directly 
with third-party insurers. We look to Congress and our stakeholders to 
help enact these changes for Veterans within six months. This way, once 
all the Choice funds are depleted, there will be a plan in place and 
Veterans will continue to receive uninterrupted community care.
    We are committed to moving care into the community where it makes 
sense for the Veteran. The ultimate judge of our success will be our 
Veterans. So, our only measure of success will be our Veterans' 
satisfaction. With your help, we can continue to improve Veteran's 
community care.
    Thank you and we look forward to your questions.

                                 
           Prepared Statement of Honorable Michael J. Missal
    (7 footnotes inbedded from pdf)
    Mr. Chairman, RankingWalz. and Members of the Committee, thank you 
for the opportunity to discuss the Office of Inspector General's (OIG) 
work concerning VA's Choice Program and the future of VA's Community 
Care Program. Our statement covers our work related to issues discussed 
in VA's Plan to Consolidate Programs of Department of Veterans Affairs 
to Improve Access to Care (Consolidation Plan), submitted to Congress 
as required by Public Law 114-41, Surface Transportation and Veteran 
Health Care Choice Improvement Act.

BACKGROUND

    For years, VA has relied on Non-VA programs to help it carry out 
its mission of providing medical care, including delivering outpatient 
services, inpatient care, mental health services, dental services, and 
nursing home care to veterans via purchased care. Today, VA's purchased 
care programs include Veterans Choice Program (VCP), Patient-Centered 
Community Care (PC3), Fee Basis Care, and other non-VA care programs. 
We have reported in our audits, reviews, and healthcare inspections and 
discussed in hearings the challenges VA faces administering these 
programs.
    In October 2015, VA provided Congress with a plan to consolidate 
all VA's purchased care programs into VA's Community Care Program. 
Under consolidation, VA continues to have problems determining 
eligibility for care, authorizing care, making accurate payments, 
providing timely payments to providers, and ensuring the continuity of 
care provided to veterans outside the VA healthcare system. Without 
improvement in these areas, these issues will continue to be obstacles 
to ensuring veterans receive timely access to quality care. To increase 
the program's overall effectiveness, VA and Congress must understand 
the historical barriers and control weaknesses that have plagued VA's 
purchase Care programs and ensure they are adequately addressed in 
future purchased care programs. I would like to highlight our work in:

      Veterans Choice Program
      Financial Accounting of Community Care Funds
      Patient Centered Community Care (PC3) Program
      Non-VA Fee Program

VETERANS CHOICE PROGRAM

    We have recently completed audits and reviews concerning the 
Veterans Choice Program and our findings have substantiated problems 
with authorizing and scheduling appointments, consult management, 
network adequacy, and timeliness of payments to providers. \1\
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    \1\ Audit of Veteran Wait Time Data, Choice Access, and Consult 
Management in Veterans Integrated Service Network 6, March 2, 2017; 
Review of the Implementation of the Veterans Choice Program, January 
30, 2017; Review of Alleged Consult Mismanagement at the Phoenix VA 
Health Care System, October 4, 2016; Review of Alleged Patient 
Scheduling Issues at the VA Medical Center in Tampa, FL, February 5, 
2016; Review of Alleged Untimely Care at the Colorado Springs Community 
Based Outpatient Clinic, Colorado Springs, CO, February 4, 2016
---------------------------------------------------------------------------
    VA initiated the Veterans Choice Program in response to the 
Veterans Access, Choice, and Accountability Act of 2014 (VACAA) (P.L. 
113-146). Following enactment of VACAA, VA contracted with Health Net 
Federal Services, Limited Liability Corporation (Health Net) and 
TriWest Healthcare Alliance Corporation (TriWest), the administrators 
of the Patient-Centered Community Care (PC3) program, to administer the 
program including establishing provider networks nation-wide. The 
Veterans Choice Program allows staff to identify veterans to include on 
the Veterans Choice List, a list that includes veterans with 
appointments beyond 30 days from the clinically indicated or preferred 
appointment dates or veterans who live more than 40 miles from a VA 
facility. From November 5, 2014 to December 31, 2016, about 2.1 million 
appointments were provided to veterans under the Veterans Choice 
Program. Total program expenditures during that period were over $2.2 
billion, of which $2.0 billion (89 percent) was spent for medical care 
and the remaining $235 million (11 percent) was paid to Health Net and 
TriWest for program start up and administration costs. An additional 
$1.7 billion of Choice funding, which was reallocated through the 
Veteran Health Care Choice Improvement Act of 2015 (Public Law 114-4), 
was spent on Hepatitis C and Emergency Care in the Community during the 
same time period.
    Our OIG Hotline has received over 700 contacts about the Veterans 
Choice Program from October 1, 2015 through January 31, 2017. These 
complaints fall into the following general categories:

      48% had concerns about appointments and scheduling
      35% had concerns about referrals, authorizations, or 
consults
      12% had concerns about veteran and provider payments
      5% had concerns about program eligibility or program 
enrollment.

    In February 2017, we published Audit of Veteran Wait Time Data, 
Choice Access, and Consult Management in Veterans Integrated Service 
Network 6 (VISN 6). We assessed the reliability of wait time data and 
timely access within a VISN. We selected VISN 6 for this audit to 
determine whether they provided new patients timely access to health 
care within its medical facilities and through Choice, as well as to 
determine whether VISN 6 appropriately managed consults. We reported 
that veterans who were authorized Choice care in VISN 6 did not 
consistently receive the authorized health care within 30 days as 
required by Health Net's contract with VA.
    We reviewed a statistical sample of 389 Choice authorizations 
provided to Health Net by VISN 6 medical facility staff during the 
first quarter of fiscal year (FY) 2016. Based on our sample results, we 
estimated that for the approximately 34,200 veterans who were 
authorized Choice care in VISN 6, approximately 22,500 veterans who 
received Choice care waited an average of 84 days to get their care 
through Health Net. We estimated it took VA medical facility staff an 
average of 42 days to provide the authorization to Health Net to begin 
the Choice process and 42 days for Health Net to provide the service. 
We identified delays related to authorizations for primary care, mental 
health care, and specialty care. VHA's Chief Business Officer addressed 
a potential cause for delay in creating appointments by executing a 
contract modification effective November 1, 2015. This change allowed 
Health Net to initiate phone contact with a veteran to arrange a Choice 
appointment, rather than require the veteran to contact Health Net as 
was required prior to the change. Our analysis showed that, while still 
untimely, this change lowered the percentage of veterans who waited 
more than 5 days for Health Net to create an appointment from 86 
percent to 69 percent.
    The Under Secretary for Health concurred with our 10 
recommendations and provided a responsive action plan and milestones to 
address the recommendations regarding monitoring controls over 
scheduling requirements, wait time data, and access to health care and 
consult management. There were also recommendations to ensure staff 
used clinically indicated and preferred appointment dates consistently, 
medical facilities conduct required scheduler audits, and staffing 
resources are adequate to ensure timely access to health care. The 
report's recommendations remain open.
    We also published in January 2017, Review of the Implementation of 
the Veterans Choice Program. Our objective was to determine whether 
veterans were experiencing barriers accessing Choice during its first 
eleven months of implementation ending September 30, 2015. We reviewed 
monthly reports to identify average wait times for multiple stages of 
the Choice process, including the authorization of care, scheduling, 
and the delivery of health care to veterans. We determined several 
barriers existed in accessing care through Choice, to include 
cumbersome authorization and scheduling procedures, inadequate provider 
networks, and potential veteran liability for treatment costs. VHA 
identified approximately 1.2 million appointments to the Veterans 
Choice List (VCL) from November 1, 2014, through September 30, 2015, 
for veterans waiting over 30 days for care at VHA medical facilities. 
During the same period, about 283,500 Choice authorizations were 
created for veterans who opted into the program because VHA medical 
facilities could not provide treatment within 30 days. In total, 
veterans waited approximately 45 days on average from the time they 
opted into the program to pursue medical treatment to the time they 
received care through Choice. We calculated a 13 percent rate of Choice 
utilization based on the number of Choice appointments that were 
provided (149,000) compared to the number of veteran appointments that 
were eligible to receive care (1.2 million) through Choice (as shown on 
the VCL).
    We recommended the Under Secretary for Health streamline procedures 
for accessing care, develop accurate forecasts of demand for care in 
the community, reduce providers' administrative burdens, ensure 
veterans are not liable for authorized care, and ensure provider 
payments are made in a timely manner. The Under Secretary for Health 
concurred and provided a responsive action plan and milestones to 
address our six recommendations. The report's recommendations remain 
open.
    In October 2016, we published Review of Alleged Consult 
Mismanagement at the Phoenix VA Health Care System (PVAHCS). We 
analyzed all open consults at PVAHCS through August 12, 2015, and 
determined that more than 22,000 individual patients had 34,769 open 
consults at PVAHCS. This included all categories, statuses, and ages of 
consults. Of the open consults at that time, about 4,800 patients had 
nearly 5,500 consults for appointments within PVAHCS that exceeded 30 
days from their clinically indicated appointment date. These included 
consults in a status of pending, active, scheduled, and partial 
results. In addition, more than 10,000 patients had nearly 12,000 
community care consults that exceeded 30 days. Consults for care in the 
community included traditional non-VA care and Choice.
    The Under Secretary for Health and the VISN 22 Director concurred 
with our 14 recommendations and provided a responsive action plan and 
milestones to address them. The Under Secretary for Health agreed to 
update VHA's consult policy. The remaining 13 recommendations were 
issued to the VISN 22 Director to improve consult management, to follow 
up with patients who may not have received the requested care and to 
close consults in accordance with national and local policy. The 
report's 14 recommendations remain open.
    In another report issued in February 2016, Review of Alleged 
Untimely Care at the Colorado Springs Community Based Outpatient 
Clinic, Colorado Springs, CO, we substantiated the allegation that 
eligible Colorado Springs veterans did not receive timely care in six 
reviewed services. These services were Audiology, Mental Health, 
Neurology, Optometry, Orthopedic, and Primary Care Services. We 
reviewed 150 referrals for specialty care consults and 300 primary care 
appointments. Of the 450 consults and appointments, 288 veterans 
encountered wait times in excess of 30 days. For all 288 veterans, VA 
staff either did not add them to the Veterans Choice List or did not 
add them to the list in a timely manner. For 59 of the 288 veterans, 
scheduling staff used incorrect dates that made it appear the 
appointment wait time was less than 30 days. For 229 of the 288 
veterans with appointments over 30 days, Non-VA Care Coordination staff 
did not add 173 veterans to the Veterans Choice List in a timely manner 
and they did not add 56 veterans to the list at all. In addition, 
scheduling staff did not take timely action on 94 consults and primary 
care appointment requests. As a result, VA staff did not fully use 
Veterans Choice Program funds to afford Colorado Springs Community 
Based Outpatient Clinic veterans the opportunity to receive timely 
care.
    The Acting Director of Eastern Colorado Health Care System 
concurred and provided a responsive action plan and milestones to 
address our four recommendations. We recommended that scheduling staff 
use the correct clinically indicated date or preferred appointment date 
when scheduling primary care patient appointments, new patients are 
scheduled timely appointments, eligible veterans are added to the 
Veterans Choice List, and there are sufficient staff to act on 
consults. The report's recommendations were closed in September 2016.
    We are continuing to provide ongoing oversight of the Choice 
Program. For example, we will submit as required by VACAA a report 
after 75 percent of the almost $10 billion dollars appropriated to the 
Veterans Choice Program is spent or when the program ends in August 
2017, whichever occurs first. That project is ongoing. We also plan 
access to care reviews at other VISNs over time.

FINANCIAL ACCOUNTING FOR COMMUNITY CARE FUNDS

    Careful management of funds for purchased care is also important to 
ensure their availability to pay providers. Our contractor for the 
audit of VA's consolidated financial statements, CliftonLarsonAllen LLP 
(CLA), an independent public accounting firm has reported VA purchased 
care under the Community Care Program as material weaknesses in VA's 
FYs 2016 and 2015 Financial Statements.
    CLA's audit of VA's FY 2016 Financial Statements identified 
Community Care obligations, reconciliations, and accrued expenses as a 
material weakness. \2\ This audit is an annual requirement of the Chief 
Financial Officers Act (CFO) of 1990. Key control deficiencies were as 
follows:
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    \2\ Audit of VA's Financial Statements for Fiscal Years 2016 and 
2015, November 15, 2016

      The manual process for estimating costs of care caused a 
wide variation in amounts estimated. CLA noted numerous examples of 
obligations being overstated compared to the actual payments made 
during testing. VA management performed its own analysis and recorded 
journal entries in the approximate amount of $1.9 billion to liquidate 
the overstated Choice obligations and $2.6 billion to liquidate the 
overstated Fee Basis obligations in VA's general ledger at September 
30, 2016.
      VA did not have a centralized and consolidated process to 
validate or monitor the obligation amounts recorded for Choice or Fee 
Basis programs. As a result, funds were being held as obligated when 
they should have been closed out. Furthermore, untimely liquidation of 
obligations due to patients having other health insurance also 
contributed to obligations being overstated for the Choice program 
during FY 2016.
    VA's Financial Management System (FMS) accrued the entire 
outstanding balance of an obligation when the end date for the 
contractual performance period had passed, regardless of whether goods 
or services were provided at period end. As a result, the 
overestimation of medical care obligations resulted in an overstatement 
of accrued expenses at period end. Management performed its own review 
and recorded journal entries in the amount of $1.1 billion to reverse 
the Choice accrued expenses in excess of actual needs and $1.9 billon 
to reverse the Fee Basis over accrued expenses at September 30, 2016.

      A nationwide consolidated reconciliation for community 
care authorizations recorded in the Fee-Basis Claim System-exceeding 
$4.9 billion as of September 30, 2016-was not performed with the 
amounts recorded in FMS for obligations and disbursements throughout 
most of the year.

    CLA also reported processing and reconciliation issues related to 
purchased care as a material weakness during its audit of VA's FY 2015 
financial statements. \3\ CLA increased its focus on purchased care 
given increased funding and implementation of the Choice Act. CLA 
reported problems with the cost estimation process and additionally 
noted the lack of reconciliation between the Fee Basis Claims System 
used to authorize, process, and pay for non-VA Care and VA's Financial 
Management System where obligations are recorded.
---------------------------------------------------------------------------
    \3\ Audit of VA's Financial Statements for Fiscal Years 2015 and 
2014, November 16, 2015
---------------------------------------------------------------------------
    All of these issues-lack of tools to estimate VA purchased care 
costs, lack of controls to ensure timely deobligations, and the 
difficulty in reconciling purchased care authorizations to obligations 
in FMS-makes the accurate and timely management of purchased care funds 
challenging. In addition, the Office of Community Care (OCC) did not 
have adequate policies and procedures for its own monitoring 
activities. OCC's activities also were not integrated with VA and VHA 
CFO responsibilities under the CFO Act of 1990 to develop and maintain 
integrated accounting and financial management systems and provide 
policy guidance and oversight of all Community Care financial 
management personnel, activities, and operations.
    To address the difficulties in estimating costs, VA has requested 
legislation that would allow VA to record an obligation at the time of 
payment rather than when care is authorized. In its consolidation plan, 
VA said this would likely reduce the potential for large deobligation 
amounts after the funds have expired. We recognize that the current 
process and system infrastructure are complex and do not provide for 
effective funds management. We caution that such a change alone-i.e., 
obligating funds at the time of payment-would not necessarily remove 
all of VA's challenges in this area. VA would still need adequate 
controls and sufficient staff trained to monitor accounting, 
reconciliation, and management information processes to ensure they 
effectively manage funds appropriated by Congress.

PATIENT-CENTERED COMMUNITY CARE

    The PC3 program is a VHA nationwide program that provides eligible 
veterans access through health care contracts to certain medical and 
mental health services. The PC3 program is used after the VA medical 
facility exhausts other options for purchased care and when local VA 
medical facilities cannot readily provide the needed care to eligible 
veterans due to lack of available specialists, long wait times, 
geographic inaccessibility, or other factors. In September 2013, VA 
awarded Health Net and TriWest PC3 contracts totaling approximately $5 
billion and $4.4 billion, respectively. As noted above, on October 30, 
2014, VA amended the PC3 contracts with Health Net and TriWest to 
include administration of the Veterans Choice Program.
    We published a series of five reports on PC3 in FYs 2015 and 2016. 
\4\ We reported that the PC3 program prior to including the Veterans 
Choice Program did not achieve its estimated cost savings, provide 
timely access to care, and did not ensure contractors provided clinical 
documentation and reported critical findings as specified in their 
contract performance requirements. In addition, we reported that PC3's 
inadequate provider network contributed significantly to VA medical 
facilities' limited use of PC3, and that PC3 contracts were not 
adequately developed and awarded. A theme that was clear from our work 
was that VA clinical and support staff were dissatisfied with PC3 in 
such areas as authorizing care, scheduling appointments, and veterans 
waiting for care. These are some of the same issues we hear today about 
the Choice Program.
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    \4\ Review of VA's Award of the PC3 Contracts, September 22, 2016; 
Review of Patient-Centered Community Care Health Record Coordination, 
September 30, 2015; Review of Patient-Centered Community Care Provider 
Network Adequacy, September 29, 2015; Review of Alleged Delays in Care 
Caused by Patient-Centered Community Care Issues, July 1, 2015 Review 
of VA's Patient-Centered Community Care Contracts' Estimated Costs 
Savings, April, 28, 2015
---------------------------------------------------------------------------
    In September 2016, we published Review of VA's Award of the PC3 
Contracts, where we determined whether VA's PC3 contracts were 
adequately developed and awarded. VA awarded the PC3 contracts to 
provide veterans with a comprehensive, nationwide network of high 
quality, specialty health care services. The contracts were awarded for 
an estimated $9.4 billion, with a potential cost to VA of $27 billion. 
OIG found significant weaknesses in the planning, evaluation, and award 
of the PC3 contracts. The PC3 contracts were not developed or awarded 
in accordance with acquisition regulations and VA policy intended to 
ensure services acquired are based on need and at fair and reasonable 
prices. The contracting officials solicited proposals from vendors 
without clearly articulating VA's requirements. Thus, the vendors 
bidding on the solicitation did not have sufficient information on the 
type of specialty health care services they would need to provide, 
where to provide them, and the frequency. Although the contracting 
officer had the authority to execute these contracts, accountability 
for ensuring the effective award of these contracts was not vested with 
a senior executive at VA for the level of oversight for this degree of 
contract risk. We recommended the Interim Under Secretary for Health 
revise VA's PC3 cost analyses. Additionally, we recommended the 
Executive Director, Office of Acquisition, Logistics, and Construction, 
require contract documents be maintained in the PC3 contract files. The 
Interim Under Secretary for Health and the Principal Executive Director 
for Acquisition, Logistics, and Construction concurred and provided a 
responsive action plan and milestones to address our report 
recommendations. The report's four recommendations are still open.
    In another OIG report from September 2015, Review of Patient-
Centered Community Care (PC3) Health Record Coordination, we reported 
that VHA lacked an effective program for monitoring the performance of 
their two contractors, Health Net and TriWest. We estimated that only 
about 32 percent of the PC3 episodes of care had complete clinical 
documentation provided within the time frame required under the PC3 
contracts. This was well below the 90 percent contract performance 
standard for outpatient and 95 percent for inpatient documentation. As 
a result, we found that VA lacked adequate visibility and assurance 
that veterans were provided adequate continuity of care, and VA was at 
risk of improperly awarding incentive fees or not applying penalty 
fees. We estimated 20 percent of the documentation was incomplete, and 
an additional 48 percent was not provided to VA within the timeframe 
required by the contracts. This delayed the processing of payments and 
we estimated that from January 1 through September 30, 2014, VA made 
about $870,000 of improper payments. Additionally, we reviewed 433 
episodes of care and identified 3 critical findings related to the 
providers discovery of malignant colon tissue affecting patients in 
TriWest's network. We examined each critical finding and did not find 
contract-required elements annotated in the clinical documentation 
returned by TriWest's providers, such as the name of the VA medical 
facility staff member contacted and date and time notified. Without 
this information and the timely receipt of critical findings, VHA 
lacked assurance that critical findings were being reported in 
accordance with the contract's performance standards. The Under 
Secretary for Health concurred and provided a responsive action plan to 
address the seven recommendations in our report. We recommended VHA 
implement a mechanism to verify PC3 contractors' performance, ensure 
PC3 contractors properly annotate and report critical findings in a 
timely manner, and impose financial or other remedies when contractors 
fail to meet requirements. All of the report's recommendations were 
closed in December 2016.
    In our September 2015 Review of VHA's PC3 Provider Network 
Adequacy, we reported that inadequate PC3 provider networks contributed 
significantly to VA medical facilities' limited use of PC3. VHA only 
spent $3.8 million of its $2.8 billion FY 2014 non-VA care budget on 
PC3. During the first 6 months of FY 2015, VHA's PC3 purchases 
increased but still constituted less than 5 percent of its non-VA care 
expenditures. VHA staff attributed the limited use of PC3 to inadequate 
provider networks that lacked sufficient numbers and mixes of health 
care providers in the geographic locations where veterans needed them. 
For these staff, inadequate PC3 provider networks were a major 
disincentive to using PC3 because it increased veterans' waiting times, 
staffs' administrative workload, and delayed the delivery of care. VHA 
could not ensure the development of adequate PC3 provider networks 
because it lacked an effective governance structure to oversee the 
Chief Business Office's (CBO) planning and implementation of PC3; the 
CBO lacked an effective implementation strategy for the roll-out of 
PC3; and neither VHA nor Health Net and TriWest maintained adequate 
data to measure and monitor network adequacy. The Under Secretary for 
Health concurred and provided a responsive action plan and milestones 
to address the recommendations in our report to strengthen controls 
over the monitoring of PC3 network adequacy and planning for future 
complex healthcare initiatives. The report's five recommendations were 
closed in November 2016.
    In our July 2015, Review of Allegations of Delays in Care Caused by 
Patient-Centered Community Care (PC3) Issues, we examined VHA's use of 
PC3 contracted care to determine if it was causing patient care delays. 
We found that pervasive dissatisfaction with both PC3 contracts had 
caused the nine VA medical facilitieswith both PC3 contracts had caused 
the nine VA medical facilitieswith both PC3 contracts had caused the 
nine VA medical facilitieswith both PC3 contracts had caused the nine 
VA medical facilitieswith both PC3 contracts had caused the nine VA 
medical facilities \5\ we reviewed to stop using the PC3 program as 
intended. We projected Health Net and TriWest returned, or should have 
returned, almost 43,500 of 106,000 authorizations (41 percent) because 
of limited network providers and blind scheduling. \6\ Health Net and 
TriWest scheduled appointments without discussing the tentative 
appointment with the veteran, which VHA refers to as blind scheduling. 
We determined that delays in care occurred because of the limited 
availability of PC3 providers to deliver care. VHA also lacked controls 
to ensure VA medical facilities submitted timely authorizations, and 
Health Net and TriWest scheduled appointments and returned 
authorizations in a timely manner. VHA needed to improve PC3 contractor 
compliance with timely notification of missed appointments, providing 
required medical documentation, and monitoring returned and completed 
authorizations. We recommended the then Interim Under Secretary for 
Health ensure PC3 contractors submit timely authorizations, evaluate 
the PC3 contractors' network, revise contract terms to eliminate blind 
scheduling, and implement controls to make sure PC3 contractors comply 
with contract requirements. The Interim Under Secretary for Health 
concurred and provided a responsive action plan and milestones to 
address our report recommendations. The report's 10 recommendations 
were closed in June 2016.
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    \5\ Four facilities were serviced by Health Net and located in 
Denver, CO; Fayetteville, NC; Minneapolis, MN; and Richmond, VA. The 
remaining five were serviced by TriWest and located in Phoenix, AZ; 
Portland, OR; Prescott, AZ; Seattle, WA; and Tucson, AZ.
    \6\ VA prohibits VA medical facilities from scheduling appointments 
without the discussing details with the veteran. VA commonly refers to 
this scheduling practice as ``blind scheduling''.
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    At the request of the U.S. House of Representatives Committee on 
Appropriations, we reviewed VA's budget submission that stated PC3 
contracts would save VA $13 million, respectively, in FYs 2014 and 
2015. In April 2015, we published, Review of PC3 Contracts' Estimated 
Cost Savings, which we analyzed disbursed FY 2014 PC3 payments. We 
reported that inadequate price analysis, high up-front contract 
implementation fees, and low PC3 utilization rates of contract services 
by veterans impeded VA from achieving its $13 million PC3 cost saving 
estimate in FY 2014. Further, VA lacked sufficient price analysis to 
support its $13 million cost savings estimate. VA also lacked an 
implementation plan to ensure adequate utilization of PC3. VA had 
established contractual arrangements that the PC3 contractors would 
develop adequate provider networks, medical facilities would achieve 
the desired utilization rates, and the accrued PC3 cost savings for 
health care services would more than offset the contractors' fees. 
Flawed assumptions contributed to significant PC3 contract performance 
problems and a 9 percent utilization rate in FY 2014. Because of the 
under-utilization of veterans using PC3, we estimated that VA would 
need a utilization rate between 25 and 50 percent to achieve their $13 
million cost saving estimate. The Under Secretary for Health and the 
Executive Director, Office of Acquisition, Logistics, and Construction, 
concurred and provided a responsive action plan and milestones to 
address our report recommendations to revise VA's PC3 cost analyses, 
address VA's low PC3 utilization rates, and maintain required contract 
documents in PC3 contract files. The report's three recommendations 
were closed in March 2016.

Non-VA Fee Program

    VA can purchase health care service on a fee-for-service or 
contract bases under Title 38 of the United States Code, Sections 1703, 
1725, and 1728, when VA medical facilities cannot provide services 
economically due to geographical inaccessibility, or in emergencies 
when delays may be hazardous to a veteran's life or health. We have 
conducted numerous audits, reviews, and inspections on VA's non-VA Fee 
program. \7\ In October 2016, we published Review of Alleged Consult 
Mismanagement at the Phoenix VA Health Care System, which reported 
consult management issues at the Phoenix VA Health Care System 
(PVAHCS). We determined that, as of August 2015, more than 22,000 
individual patients had 34,769 open consults at PVAHCS. The total open 
consults included all categories, statuses, and ages of consults. Open 
consults included traditional clinical consults within the facility, 
community care consults, such as non-VA care and Choice, prosthetics 
consults, and administrative consults. Of all the open consults at that 
time, about 4,800 patients had nearly 5,500 consults for appointments 
within PVAHCS that exceeded 30 days from their clinically indicated 
appointment date. In addition, more than 10,000 patients had nearly 
12,000 community care consults exceeding 30 days. We made 14 
recommendations, including that the Under Secretary for Health update 
VHA's consult policy. The remaining 13 recommendations were issued to 
the VISN 22 Director to improve consult management and to follow up 
with patients who may not have received the requested care. This 
included recommendations to develop a routine review of closed consults 
and documenting consults in accordance with national and local policy. 
Ten of the 14 recommendations remain open.
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    \7\ Review of Alleged Improper Non-VA Community Care Consult 
Practices at Ralph H. Johnson VA Medical Center, Charleston, SC, 
December 20, 2016; Review of Alleged Consult Mismanagement at the 
Phoenix VA Health Care System, October 4, 2016; Review of VHA's Alleged 
Mishandling of Ophthalmology Consults at the Oklahoma City VAMC, August 
31, 2015; Audit of Non-VA Medical Care Claims for Emergency 
Transportation, March 2, 2015; Audit of Selected VHA Non-Institutional 
Purchased Home Care Services, September, 30, 2013;Review of VHA's South 
Texas Veterans Health Care System's Management of Fee Care Funds, 
January 10, 2013; Review of Alleged Mismanagement of Non-VA Fee Care 
Funds at the Phoenix VA Health Care System, November 8, 2011; Audit of 
Non-VA Inpatient Fee Care Program, August 18, 2010; Review of 
Outpatient Fee Payments at the VA Pacific Islands Health Care, March 
17, 2010; Audit of Veterans Health Administration's Non-VA Outpatient 
Fee Care Program, August 3, 2009

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CONCLUSION

    Our audits, reviews, and inspections have highlighted that VA has 
had a history of challenges in administering its purchased care 
programs. Veteran's access to care, proper expenditure of funds, timely 
payment of providers, and continuity of care are at risk to the extent 
that VA lacked adequate processes to manage funds and oversee program 
execution. While purchasing health care services from community 
providers may afford VA flexibility in terms of expanded access to care 
and services that are not readily available at VA medical facilities, 
it also poses a significant risk to VA when adequate controls are not 
in place. We plan to provide significant oversight of VA's Community 
Care programs over the next 3 years.
    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or members of the Committee may have.

                                 
                Prepared Statement of Randy Willliamson
                         VETERANS' HEALTH CARE
  Preliminary Observations on Veterans' Access to Choice Program Care
    Chairman Roe, Ranking Member Walz, and Members of the Committee:
    I am pleased to be here today to discuss our ongoing work related 
to veterans' access to health care services through the Veterans Choice 
Program (Choice Program). The majority of veterans utilizing health 
care services delivered by the Veterans Health Administration (VHA) of 
the Department of Veterans Affairs (VA) receive care in VHA-operated 
medical facilities, including 168 VA medical centers (VAMC) and more 
than 1,000 outpatient facilities. However, some VHA medical facilities 
have long wait times for veterans to obtain appointments or do not 
offer certain specialty care services on site. In recent years, we and 
others have expressed concerns about VHA's ability to provide health 
care services within its own facilities in a timely manner. \1\ In some 
cases, the delays in care or VHA's failure to provide care reportedly 
have resulted in harm to veterans. Due to these and other concerns, we 
concluded that VA health care is a high-risk area and added it to our 
High Risk List in 2015. \2\
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    \1\ See, for example, VA Health Care: Reliability of Reported 
Outpatient Medical Appointment Wait Times and Scheduling Oversight Need 
Improvement, GAO 13 130 (Washington, D.C.: Dec. 21, 2012); GAO, VA 
Health Care: Management and Oversight of Consult Process Need 
Improvement to Help Ensure Veterans Receive Timely Outpatient Specialty 
Care, GAO 14 808 (Washington, D.C.: Sept. 30, 2014); GAO, Primary Care: 
Improved Oversight Needed to Better Ensure Timely Access and Efficient 
Delivery of Care, GAO 16 83 (Washington, D.C.: Oct. 8, 2015); and GAO, 
VA Mental Health: Clearer Guidance on Access Policies and Wait-Time 
Data Needed, GAO 16 24 (Washington, D.C.: Oct. 28, 2015). See also: 
Department of Veterans Affairs, Office of Inspector General, Healthcare 
Inspection: Gastroenterology Consult Delays, William Jennings Bryan 
Dorn VA Medical Center, Columbia, South Carolina, Report No. 12-04631-
313 (Washington, D.C.: Sept. 6, 2013) and Department of Veterans 
Affairs, Office of Inspector General, Veterans Health Administration, 
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling 
Practices at the Phoenix VA Health Care System, Report No. 14-02603-267 
(Washington, D.C.: Aug. 26, 2014).
    \2\ GAO, High-Risk Series: An Update, GAO 15 290 (Washington, D.C.: 
Feb. 11, 2015). GAO maintains a high-risk program to focus attention on 
government operations that it identifies as high risk due to their 
greater vulnerabilities to fraud, waste, abuse, and mismanagement or 
the need for transformation to address economy, efficiency, or 
effectiveness challenges.
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    These serious and longstanding problems with veterans' access to 
care were highlighted in a series of congressional hearings in the 
spring and summer of 2014, when a well-publicized series of events 
raised additional concerns about VHA's ability to deliver health care 
services in a timely manner. In response to these concerns, the 
Veterans Access, Choice, and Accountability Act of 2014 (Choice Act) 
was enacted on August 7, 2014. This law provided temporary authority 
and $10 billion in funding through August 7, 2017 (or sooner, if those 
funds are exhausted) for veterans to obtain health care services from 
non-VA community providers to address long wait times, lengthy travel 
distances, or other challenges accessing care at VA medical facilities. 
\3\ Under this authority, VA introduced the Choice Program in November 
2014, and as of October 1, 2016, about $4.5 billion of the $10 billion 
originally appropriated remained available for the program.
---------------------------------------------------------------------------
    \3\ Pub. L. No. 113-146, 128 Stat. 1754 (2014).
---------------------------------------------------------------------------
    In accordance with the law, VHA had up to 90 days to prepare for 
Choice Program implementation from the time the Choice Act was enacted. 
To cope with the compressed implementation timeframe, VA modified 
contracts it had previously established with Health Net Federal 
Services (Health Net) and TriWest Healthcare Alliance (TriWest) for the 
administration of a different VA community care program to give them 
responsibility for Choice Program administration. Each contractor-or 
third party administrator (TPA)-is responsible for delivering Choice 
Program care in a specific multi-state region, where they establish 
networks of community providers, schedule appointments for eligible 
veterans, and pay community providers for their services. Recent media 
reports and congressional hearings have highlighted weaknesses 
affecting the Choice Program, such as insufficient provider networks, 
significant delays in scheduling appointments, and a lack of timely 
payments to network providers. \4\
---------------------------------------------------------------------------
    \4\ See, for example, Lawrence Quil, Eric Whitney, and Michael 
Tomsic, ``Despite $10B `Fix,' Veterans Are Waiting Even Longer To See 
Doctors.'' Morning Edition (radio program), May 16, 2016. Accessed 
January 27, 2017. http://www.npr.org/sections/health-shots/2016/05/16/
477814218/attempted-fix-for-va-health-delays-creates-new-bureaucracy. 
Also see Lee Romney, ``Veterans Choice is flawed, but Congress is 
stymied on a solution,'' The Center for Investigative Reporting, 
September 28, 2016. Accessed January 27, 2017. https://
www.revealnews.org/article/veterans-choice-is-flawed-but-congress-is-
stymied-on-a-solution.
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    My statement today will draw from our ongoing work examining the 
timeliness of veterans' access to care through the Choice Program. We 
plan to issue a final report on our review in spring 2017. In 
particular, this statement reflects our preliminary observations 
examining:

    1.the process VA has established for scheduling Choice Program 
appointments for routine care;

    2.what is known about the timeliness of veterans' Choice Program 
appointments for routine care and urgent care; and

    3.VHA's recent actions and plans to improve the timeliness with 
which veterans receive health care services through the Choice Program.

    As part of our ongoing work, we reviewed applicable laws and 
regulations; VA's contracts with the TPAs; relevant VA and VHA policy 
directives, guidance, and training materials for VAMCs; and relevant 
VHA documentation about Choice Program improvement projects, such as 
summaries and fact sheets. We also interviewed a VA contracting 
official and officials from VHA's Office of Community Care (the office 
responsible for implementing and overseeing the Choice Program), as 
well as officials from the two Choice Program TPAs, Health Net and 
TriWest.
    In addition, we examined non-generalizable samples of six VAMCs and 
196 authorizations for veterans who were referred to the Choice Program 
by those six VAMCs between January 2016 and April 2016. \5\ We selected 
our sample of VAMCs to include variation in geographic location, three 
VAMCs that serve rural veteran populations, three VAMCs that serve 
urban veteran populations, three VAMCs that were served by Health Net, 
and three that were served by TriWest. (See table 1.)
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    \5\ These were the most recent Choice Program authorization data 
that were available when we began our ongoing review.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


    To select our random, non-generalizable sample of 196 Choice 
Program authorizations, we obtained VA data on all authorizations 
created by the TPAs between January and April 2016 for veterans who 
were referred to the program by the six VAMCs we visited. The 196 
authorizations included 55 randomly selected authorizations for routine 
care and 53 randomly selected urgent care authorizations for which the 
TPAs succeeded in scheduling appointments for veterans. \6\ We selected 
our sample of routine and urgent authorizations to include only 
authorizations for which the TPAs did not meet VA's appointment 
scheduling goals at one phase of the appointment scheduling process: 
when the TPAs attempt to schedule appointments after the veterans have 
opted in to the program. \7\ This was to ensure that our sample 
included only authorizations for which scheduling was delayed, so that 
we could examine the potential causes of appointment scheduling delays, 
whether delays also occurred at other phases of the process (such as 
when VAMCs were preparing the veterans' referrals or when the TPAs were 
attempting to reach the veterans to opt them into the program), and the 
veterans' overall wait times for Choice Program care. \8\ The 196 
authorizations also included 88 randomly selected authorizations that 
the TPAs returned to VA without scheduling appointments for any one of 
the following three reasons-(1) VA requested the authorization be 
returned, (2) VA data was missing from the referral, and (3) the 
veteran declined or did not want Choice Program care. \9\ For all 196 
Choice Program authorizations in our sample, we reviewed VHA 
documentation (specifically, the veterans' VA electronic health 
records) and TPA documentation to track the number of calendar days 
that elapsed at each step of the Choice Program appointment scheduling 
process. \10\ For the authorizations that the TPAs returned to the 
VAMCs without making appointments, we examined VHA and TPA 
documentation to determine whether the veterans eventually obtained 
care through other means-such as through another VA community care 
program, a different Choice Program referral, or at a VA medical 
facility-and how long it took to receive that care. To assess the 
reliability of the authorization data we used, we interviewed 
knowledgeable agency officials, manually reviewed the content of the 
data, and electronically tested it for missing values. We concluded 
that these data were sufficiently reliable for the purposes of our 
reporting objectives. The findings from our review of Choice Program 
authorizations cannot be generalized beyond the VAMCs and the veterans' 
Choice Program authorizations we reviewed.
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    \6\ Under VA's contracts with the TPAs, Choice Program referrals 
and authorizations are to be marked as ``urgent'' when a VA clinician 
has determined that the veteran needs care that (1) is considered 
essential to evaluate and stabilize conditions and (2) if not provided 
would likely result in unacceptable morbidity or pain when there is a 
significant delay in evaluation or treatment. Under VA's Choice Program 
contracts, urgent care is not the same as care provided for a medical 
emergency, which is covered through different VA community care 
programs. Urgent care (rather than emergent care) delivered through the 
Choice Program is care that is delivered when there is no threat to the 
veteran's life, limb, or vision but the veteran's condition needs 
attention to prevent it from becoming a serious risk to the veteran's 
health.
    \7\ Under VA's contracts with the TPAs, VA requires that the TPAs 
schedule routine Choice Program appointments within 5 business days 
after veterans opt into the Choice Program. VA also requires that the 
TPAs schedule veterans' urgent Choice Program appointments and ensure 
that veterans attend them within 2 business days after veterans opt in 
to the Choice Program.
    \8\ As we discuss later in this statement, VHA could not provide 
complete, reliable data that would have allowed us to include 
authorizations in our sample that were delayed at other points of the 
Choice Program appointment scheduling process, such as the period when 
VAMCs prepare referrals for the TPAs or the period between the TPAs' 
receipt of referrals and initiation of appointment scheduling.
    \9\ We limited our sample of returned authorizations to these three 
return reasons because we wanted to determine if the return reasons 
entered by the TPAs could be substantiated by evidence from the 
veterans' VA electronic health records.
    \10\ In this statement, ``days'' refers to calendar days, unless 
otherwise indicated.
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    We are conducting the work upon which this statement is based in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our preliminary 
findings and conclusions based on our audit objectives.
    We shared the information in this statement with VA to obtain its 
views. Officials provided us with technical comments, which we have 
incorporated as appropriate. When we complete our ongoing work, we will 
also make recommendations related to improving the timeliness of 
veterans' Choice Program care as appropriate.

Background

Choice Program Eligibility and Required Referral Hierarchy

    As stated in VA's December 2015 guidance, the Choice Program allows 
eligible veterans to obtain health care services from the TPAs' network 
providers rather than from VHA providers when the veterans meet any of 
the following criteria:

      the next available medical appointment with a VHA 
provider is more than 30 days from the veteran's preferred date or the 
date the veteran's physician determines he or she should be seen;
      the veteran lives more than 40 miles driving distance 
from the nearest VHA facility with a full-time primary care physician;
      the veteran needs to travel by air, boat, or ferry to the 
VHA facility that is closest to his or her home;
      the veteran faces an unusual or excessive burden in 
traveling to a VHA facility based on geographic challenges, 
environmental factors, or a medical condition; \11\
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    \11\ A determination about whether the veteran meets this criterion 
will be made in conjunction with staff at the veteran's local VHA 
medical facility.
---------------------------------------------------------------------------
      the veteran's specific health care needs, including the 
nature and frequency of care needed, warrants participation in the 
program; \12\ or
---------------------------------------------------------------------------
    \12\ A determination about whether the veteran meets this criterion 
will be made in conjunction with staff at the veteran's local VHA 
medical facility.
---------------------------------------------------------------------------
      the veteran lives in a state or territory without a full-
service VHA medical facility. \13\
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    \13\ Specifically, veterans who reside in Alaska, Hawaii, New 
Hampshire, or a U.S. territory would be eligible for the program under 
this criterion. Veterans residing in New Hampshire are only eligible if 
they reside more than 20 miles away from the White River Junction VAMC, 
which is located in Vermont.

    In addition, in May and October of 2015, VHA issued policy 
memoranda to its VAMCs requiring them to offer eligible veterans 
referrals to the Choice Program before they authorize care through 
other VA community care programs. \14\
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    \14\ Specifically, when services are unavailable or the veteran 
cannot receive an appointment within 30 days; these memoranda require 
VAMCs to determine whether needed services are available in a timely 
manner from another VA medical facility or from a facility with which 
the VAMC has a sharing agreement, such as a Department of Defense, 
Indian Health Service, or Tribal Health facility. If care cannot be 
arranged in this manner, VAMCs must offer eligible veterans the 
opportunity to receive care through the Choice Program before 
attempting to arrange care through any other VA community care program.

Choice Program Utilization from Fiscal Year 2015 through Fiscal Year 
---------------------------------------------------------------------------
    2016

    From fiscal year 2015 through fiscal year 2016 (the first two years 
of the Choice Program's implementation), data we obtained from the TPAs 
indicate that more than half of the veterans who were referred to the 
Choice Program and for whom the TPAs scheduled appointments were 
referred because the services they needed were not available at a VA 
medical facility. \15\ The second-most-common reason for referral was 
that the wait time for an appointment at a VA medical facility exceeded 
30 days. (See figure 1.)
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    \15\ Prior to obtaining these data from the TPAs, we requested data 
from VHA on the number of veterans who were referred to the Choice 
Program because (1) services were unavailable, (2) there was a greater 
than 30-day wait, or (3) the veteran resided more than 40 miles from a 
VA facility or faced other travel burdens. However, VHA officials 
stated that VHA's data grouped veterans who were referred to the Choice 
Program because services were unavailable together with the veterans 
who were referred because of 30-day wait times. Only the TPAs could 
break these groups of veterans out separately, so we are instead 
reporting the TPAs' data here.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


    Note: This excludes 7,198 veterans with scheduled appointments who 
were referred to the Choice Program in fiscal year 2015 and fiscal year 
2016 because they faced an unusual or excessive travel burden to access 
care at a VA medical facility. Only one of the two third party 
administrators (TPA) could separately report veterans who were referred 
under this Choice Program eligibility criterion. The other TPA does not 
distinguish veterans who were referred for unusual or excessive travel 
burden from the other three Choice Program referral reasons listed 
---------------------------------------------------------------------------
here.

Process for Choice Program Appointment Scheduling

    Through its policies and standard operating procedures for VAMCs 
and its contracts with the TPAs, VA has established a process for 
Choice Program appointment scheduling. \16\ The process differs 
depending on the criterion under which a veteran is utilizing the 
Choice Program. Table 2 below provides an overview of the appointment 
scheduling process that applies when a veteran is referred to the 
program because the veteran cannot obtain an appointment within 30 
days. VA's contracts require that routine care appointments for these 
time-eligible veterans shall take place within 30 days of the 
clinically indicated date on the VAMC's referral to the TPA, which is 
consistent with VA's wait-time goal for care at a VA medical facility. 
\17\
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    \16\ Officials from VA's Denver Acquisition and Logistics Center 
are responsible for developing and managing Choice Program contracts 
with the TPAs. Contracting officer's representatives in VHA's Office of 
Community Care are responsible for monitoring the TPAs' performance. 
VHA's Office of Community Care is also responsible for developing 
policies and standard operating procedures, communicating contract 
modifications and other programmatic changes to VAMCs, and providing 
training for VAMC managers and staff on their roles in coordinating 
veterans' Choice Program care.
    \17\ The clinically indicated date on the VAMC's referral is the 
date that it would be clinically appropriate for the appointment to 
occur, as determined by the sending VA provider. The clinically 
indicated date determination is based upon the needs of the patient and 
should be the soonest date that it would be clinically appropriate for 
the veteran to receive care. While appointments for routine care for 
time-eligible veterans must occur with 30 days of the clinically-
indicated date on the VAMC's referral, VA's contracts require that 
these veterans' appointments for urgent care shall take place within 2 
business days of the TPA accepting the VAMC's referral.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


    Note: VA's contracts require that Choice Program appointments for 
routine care for time-eligible veterans shall take place within 30 days 
of the clinically indicated date on the VAMC's referral to the TPA. The 
clinically indicated date on the VAMC's referral is the date that it 
would be clinically appropriate for the appointment to occur, as 
determined by the sending VA provider. The clinically indicated date 
determination is based upon the needs of the patient and should be the 
soonest date that it would be clinically appropriate for the veteran to 
receive care. While appointments for routine care for time-eligible 
veterans must occur with 30 days of the clinically-indicated date on 
the VAMC's referral, VA's contracts require that Choice Program 
appointments for urgent care take place within 2 business days of the 
TPA accepting the VAMC's referral.aVeterans are time-eligible for the 
---------------------------------------------------------------------------
Choice Program when no VA appointments are available within 30 days.

    When veterans are eligible for the Choice Program because they 
reside more than 40 miles from a VA medical facility, VA's contract 
requires the TPA to schedule an appointment within 30 days of the 
veteran's preferred appointment date. For these veterans, VAMCs do not 
prepare a referral and send it to the TPA. Instead, these veterans can 
contact the TPA directly to request Choice Program care. See table 3 
for an overview of the Choice Program appointment scheduling process 
that applies for distance-eligible veterans.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


Future Consolidation of VA Community Care Programs

    The VA Budget and Choice Improvement Act, which was enacted on July 
31, 2015, required VA to develop a plan for consolidating all non-
Department provider programs (currently about 10) into a new, single 
program to be known as the ``Veterans Choice Program.'' \18\ VHA 
submitted this plan to Congress on October 30, 2015, and according to 
this plan, the agency expects to implement a consolidated community 
care program in fiscal year 2018. While the existing Choice Program 
will expire on or before August 7, 2017, the consolidated community 
care program VHA described in its October 2015 plan and in the December 
2016 request for proposals (RFP) issued by VA's Denver Acquisition and 
Logistics Center is similar to the current Choice Program in certain 
respects. For example, VHA's consolidated community care program would 
be partly administered by TPAs, which would establish regional ``high-
performing networks'' of community providers and process payments to 
those providers. However, the RFP states that staff at VAMCs will have 
responsibility for appointment scheduling. The RFP also indicates that 
the department is planning to award contracts before the end of fiscal 
year 2017. To support VHA's planned consolidation of its community care 
programs, VA has requested that Congress enact legislation to 
streamline and simplify veterans' community care eligibility 
requirements.
---------------------------------------------------------------------------
    \18\ Pub. L. No. 114-41,  4002, 129 Stat. 443, 461 (2015). 
In addition to the Choice Program, VHA has purchased health care 
services from community providers through other programs since as early 
as 1945. The primary means by which VHA has traditionally purchased 
care is through individual authorizations. In addition, VHA purchases 
community care (for example) through two different emergency care 
programs and through the Patient-Centered Community Care Program, which 
is also administered by Health Net and TriWest. For more information 
about VA's other community care programs, see GAO, Veterans' Health 
Care: Proper Plan Needed to Modernize System for Paying Community 
Providers, GAO 16 353 (Washington, D.C.: May 11, 2016).

VA Has Established a Choice Program Appointment Scheduling Process 
    Under Which Veterans' Wait Times for Routine Care Could Exceed VA's 
---------------------------------------------------------------------------
    30-Day Goal

    Our preliminary analysis of VA's process indicates that veterans 
who are referred to the Choice Program for routine care because 
services are not available in a timely manner at VA could potentially 
wait up to 81 calendar days to obtain care. This is in contrast to VA's 
wait time goal for the Choice Program, which is that time-eligible 
veterans receive routine care no more than 30 calendar days from the 
date an appointment is deemed clinically appropriate by a VA health 
care provider (referred to as the clinically indicated date), or if no 
such determination has been made, 30 calendar days from the date the 
veteran prefers to receive care. In practice, the maximum potential 
wait time of about 81 calendar days encompasses 21 or more calendar 
days for VAMCs to prepare veterans' Choice Program referrals, 30 
calendar days for TPAs to schedule appointments, and another 30 
calendar days for appointments to occur, as follows:

  VAMCs' process and timeframes for preparing routine Choice 
    Program referrals. According to VHA policies and guidance, VAMC 
    staff have at least 21 calendar days to confirm that veterans want 
    to be referred to the Choice Program and to send veterans' 
    referrals to the TPAs: \19\
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    \19\ According to officials from VHA's Office of Community Care, 
VAMC staff are to follow VHA's policy directive for consult management 
when they are preparing veterans' Choice Program referrals. See VHA 
Directive 1232(1), Consult Processes and Procedures (Aug. 24, 2016, as 
amended on Sept. 23, 2016). VHA's Office of Community Care has provided 
further guidance related to the responsibilities of VAMC staff in 
preparing Choice Program referrals through standard operating 
procedures and training materials. The 21-calendar-day time period 
begins with the date the veteran's VA clinician signaled the veteran's 
need for care by entering a consult into the veteran's VA electronic 
health record. A consult is a request entered by a VA clinician on 
behalf of a patient seeking an opinion, advice, or expertise regarding 
evaluation or management of a specific problem.
---------------------------------------------------------------------------
      They have up to 7 calendar days after a VA clinician has 
determined the veteran needs care to begin contacting an eligible 
veteran by telephone to offer them a referral to the Choice Program.
      They have up to 14 calendar days after initiating contact 
to reach the veteran by telephone or letter and confirm that they want 
to be referred to the Choice Program.
      After confirming that a veteran wants to be referred to 
the Choice Program, however, VA has not set a limit on the number of 
days VAMCs should take to compile relevant clinical information and 
send referrals to the TPAs.

  TPAs' Choice Program appointment scheduling process. Through 
    its contracts with the TPAs, VA has established a process that 
    allows the TPAs about 21 business days (or approximately 30 
    calendar days) after receiving VAMCs' Choice Program referrals to 
    schedule veterans' routine care appointments: \20\
---------------------------------------------------------------------------
    \20\ The contractual requirement that Choice Program appointments 
for routine care shall take place within 30 calendar days of the 
clinically indicated date does not account for the potential 21 days 
that may have already elapsed during VAMCs' process for preparing 
Choice Program referrals.

      2 business days to review the VAMC's referral and accept 
it if it contains sufficient information to proceed with appointment 
scheduling,
      4 business days to contact the veteran by telephone and 
confirm they want to opt in to the Choice Program (which means that the 
veteran wants to receive care through the Choice Program and have the 
TPA proceed with appointment scheduling),
      if the veteran is not reached by telephone, 10 business 
days for the veteran to respond to a letter confirming that they want 
to opt in, and
      5 business days to contact providers and successfully 
schedule the veteran's Choice Program appointment. \21\
---------------------------------------------------------------------------
    \21\ The TPAs would have 29 calendar days to complete the 
appointment scheduling process if the VAMC sent the referral on a 
Monday, Tuesday, Wednesday, or Thursday and 31 calendar days if the 
VAMC sent the referral on a Friday. If there are holidays, the total 
number of calendar days permitted to elapse may be greater than 29 or 
31 calendar days.
---------------------------------------------------------------------------
  VA's method for monitoring the timeliness of appointment 
    completion. When VHA monitors the timeliness with which Choice 
    Program appointments for routine care occur, the date it uses as a 
    starting point varies. Although VA's contracts require routine care 
    appointments for time-eligible veterans to take place within 30 
    days of the clinically indicated date in the veteran's referral, VA 
    does not always use the clinically indicated date to monitor the 
    TPAs' timeliness of appointment completion. If the clinically 
    indicated date on VA's referral occurred before the date the TPA 
    received the referral-as was the case for about 76 percent of the 
    Choice Program authorizations in the sample we reviewed-VA uses the 
    date on which the TPA succeeded in scheduling the veteran's initial 
    appointment as the starting point for determining whether veterans' 
    Choice Program appointments for routine care occur in a timely 
    manner. \22\ In these cases, VA considers an appointment to be 
    timely if it occurred within 30 days of the date the TPA scheduled 
    it. \23\
---------------------------------------------------------------------------
    \22\ Our 76 percent calculation is based on 134 of the 196 Choice 
Program authorizations in our sample. We could not identify either VA's 
clinically indicated date or the date the TPA received the referral for 
a total of 62 of the authorizations in our sample because (for example) 
the authorizations were for distance-eligible veterans who self-
referred to the Choice Program or they were related to requests for 
additional services after veterans had already initiated an episode of 
Choice Program care.
    \23\ According to VA's contracts with the TPAs, performance metrics 
for timeliness start with a valid authorization for services and 
specifically state that the contractor will not be penalized in its 
metrics for delays caused by VA.

    See figure 2, below, for an illustration of the 81-day potential 
wait time for veterans to receive routine care through the Choice 
---------------------------------------------------------------------------
Program.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


    Note: This figure illustrates potential wait times for veterans who 
are referred to the Choice Program because services are not available 
in a timely manner at a Department of Veterans Affairs (VA) medical 
facility. Veterans who are using the Choice Program because they reside 
more than 40 miles from a VA medical facility would begin the 
appointment scheduling process by contacting the third party 
administrator (TPA) directly to request an appointment. For these 
veterans, the appointment scheduling process would begin at step 7 in 
the figure above. Because these veterans do not have referrals from VA 
medical centers (VAMC), VA measures the timeliness of routine 
appointment scheduling and completion for these veterans on the basis 
of whether the initial Choice Program appointment occurred within 30 
days of the date the veteran preferred to receive care.
    aVAMCs must attempt to contact veterans at least once by phone, and 
if the veterans are not reached, VAMCs must then send letters to the 
veterans and wait up to 14 calendar days for the veterans to respond 
that they want to be referred to the Choice Program.
    bThe 30-calendar-day appointment completion timeframe begins with 
the date the TPA scheduled the appointment only if the TPA receives the 
VAMC's referral for routine care after the clinically indicated date 
for a time-eligible veteran has already passed. If the TPA receives a 
referral before the clinically indicated date has passed, VHA measures 
timeliness of Choice Program appointment completion on the basis of 
whether the veteran's appointment occurred within 30 days of the 
clinically indicated date.
    cThe potential wait time attributable to TPAs would be 59 calendar 
days if the VAMC sent the referral on a Monday, Tuesday, or Wednesday 
and 61 calendar days if the VAMC sent the referral on a Thursday or 
Friday. If there are holidays, the total number of calendar days 
permitted to elapse may be greater than 59 or 61 calendar days.

VHA's Monitoring of the Overall Timeliness of Choice Program Care is 
    Limited, and Selected Veterans Have Experienced Lengthy Waits for 
    Routine and Urgent Care

Data Limitations Hamper VHA's Monitoring of Veterans' Overall Wait 
    Times for Choice Program Care

    Our preliminary analysis indicates that VHA lacks complete, 
reliable data to monitor the overall timeliness with which veterans 
have received routine and urgent care through the Choice Program. Our 
analysis of a random, non-generalizable sample of 196 Choice Program 
authorizations indicates that the data VHA uses to monitor appointment 
wait times in the Choice Program have several key limitations, which 
include (1) an inability to monitor VAMCs' timeliness in preparing 
Choice Program referrals, (2) a lack of data on the TPAs' timeliness in 
accepting referrals and opting veterans in to the Choice Program, (3) 
issues with the reliability of clinically indicated dates on VAMCs' 
Choice Program referrals, and (4) VAMCs' and TPAs' miscategorization of 
routine Choice Program referrals as urgent care referrals.

VHA Cannot Calculate the Average Number of Days VAMCs Take to Prepare 
    Choice Program Referrals

    Our preliminary analysis indicates that the data VHA currently uses 
to monitor the timeliness of Choice Program appointment scheduling and 
completion do not capture the days it takes for VAMCs to prepare 
veterans' referrals and send them to the TPAs. This is because VHA has 
not standardized the manner in which VA clinicians and VAMC staff 
categorize consults that lead to Choice Program referrals. \24\ We 
observed inconsistency in the titles of consults that were associated 
with the non-generalizable sample of Choice Program authorizations we 
reviewed. For example,
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    \24\ A consult is an electronic request entered in VA's electronic 
health record by a VA clinician who is seeking an opinion, advice, or 
expertise regarding evaluation or management of a veteran's condition. 
For the purposes of the Choice Program, the consult entry date is the 
date a veteran's need for care was originally identified. When there is 
a wait for a VA appointment or services are unavailable at VA, staff at 
the VAMC use information from the consult-such as the clinically 
indicated date determined by the VA clinician and a description of 
needed services-to prepare veterans' Choice Program referrals.

      consult titles sometimes included the word ``Choice,'' 
but in other cases they included the words ``non-VA care.''
      Some of the consult titles indicated the criterion under 
which the veteran was eligible for the Choice Program and the type of 
care the veteran needed (for example, ``Choice-First Physical 
Therapy''), while other consult titles only indicated the type of care 
the veteran needed (for example, ``pain management''). \25\
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    \25\ The term ``Choice-First'' pertains to veterans who are 
referred to the Choice Program because services are unavailable at a VA 
medical facility or the veteran cannot receive an appointment at a VA 
medical facility or another federal medical facility within VHA's 
timeliness standards. It comes from VHA's May and October 2015 policy 
memoranda, which required VAMCs to offer eligible veterans the 
opportunity to receive care through the Choice Program before 
attempting to arrange care through any other VA community care program.

    We observed this variability among consult titles both within 
single VAMCs and across all six of the VAMCs we visited.
    In the absence of standardized consult titles, VHA has no automated 
way to electronically extract data from VA's electronic health record 
and calculate the average number of days it takes for VAMC staff to 
prepare veterans' Choice Program referrals after veterans have agreed 
to be referred to the program. Further, without standardized consult 
titles, VHA cannot monitor veterans' overall wait times-from the time 
VA clinicians determine veterans need care until the veterans attend 
their first appointments with Choice Program providers.
    The lack of standardized consult titles also prevents VHA from 
tracking average overall wait times and monitoring the timeliness of 
care for veterans whose Choice Program authorizations are returned by 
the TPAs without scheduled appointments. When authorizations are 
returned, VAMC staff must attempt to arrange care either at a VA 
medical facility, through the Choice Program by initiating a new Choice 
Program referral, or through another VA community care program.

Available VHA Data Do Not Capture the Time Spent By TPAs in Accepting 
    VAMCs' Referrals and Opting Veterans into the Choice Program

    Our preliminary analysis indicates that the data VHA currently uses 
to monitor the timeliness of Choice Program appointments for routine 
and urgent care capture only a portion of the process that the TPAs 
carry out to schedule veterans' appointments after they receive 
referrals from VAMCs. Specifically, VHA's data reflect the timeliness 
of appointment scheduling and completion after the TPAs create 
authorizations in their appointment scheduling systems, which 
(according to VA's contracts) the TPAs must do only after they have 
received all necessary information from VA and the veteran has opted in 
to the Choice Program. Therefore, VHA's timeliness data do not capture 
the time TPAs spend (1) reviewing and accepting VAMCs' referrals, and 
(2) contacting veterans to confirm that they want to opt into the 
Choice Program.
    During our ongoing work, when we asked how they are monitoring the 
timeliness of Choice Program appointments, VHA officials provided us 
the following types of data on the TPAs' appointment scheduling 
timeliness, all of which reflect the time that elapses only after 
veterans have opted into the Choice Program and the TPAs have created 
authorizations:

      the average number of business days the TPAs take after 
creating authorizations to schedule appointments for routine and urgent 
care,
      the percentage of appointments for routine care that the 
TPAs schedule within 5 business days after they create authorizations, 
and
      the percentage of appointments for urgent care that the 
TPAs schedule within 2 business days after they create authorizations.

    In addition, VHA officials have provided us data on the timeliness 
with which Choice Program appointments have occurred. Specifically, VHA 
has provided the following types of data, almost all of which reflect 
the timeliness with which appointments occur only after veterans have 
opted into the Choice Program and the TPAs have either created 
authorizations or successfully scheduled veterans' appointments:

      the average number of business days after the TPAs create 
authorizations in which appointments for routine and urgent care occur,
      the percentage of appointments for routine care that are 
completed within 30, 60, 90, and 120 business days or more after the 
TPAs create an authorization,
      the percentage of appointments for routine care that are 
completed within 30 calendar days of either (1) the TPAs scheduling 
appointments, (2) the clinically indicated date on the VAMC's referral, 
or (3) the veteran's preferred date, and \26\
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    \26\ If a veteran is using the Choice Program because services at 
VA are unavailable or cannot be accessed in a timely manner, VHA's 
method for determining whether appointments for routine care occur in a 
timely manner is dependent upon whether the clinically indicated date 
on the VAMC's referral occurs before or after the date the TPA received 
the referral. If the clinically indicated date on the VAMC's referral 
occurred before the date the TPA received the referral-as was the case 
for about 76 percent of the 134 Choice Program authorizations in our 
sample for which we could identify clinically indicated dates-VHA uses 
the date the TPA succeeded in scheduling the appointment as the 
starting point for monitoring the timeliness of appointment completion. 
If the clinically indicated date on the VAMC's referral occurs after 
the date the TPA received the referral, VA considers an appointment for 
routine care as having occurred in a timely manner if it occurs within 
30 days of the clinically indicated date on the VAMC's referral. If 
veterans are using the Choice Program because they reside more than 40 
miles from a VA medical facility, VHA measures the timeliness with 
which appointments for routine care are completed on the basis of 
whether the initial Choice Program appointments occurred within 30 days 
of the date the veterans preferred to receive care.
---------------------------------------------------------------------------
      the percentage of appointments for urgent care that are 
completed within 2 calendar days of the TPAs creating the 
authorizations.

    Because, as previously explained, VHA lacks data on the average 
timeliness with which VAMCs prepare Choice Program referrals, and VHA 
also lacks data on the average amount of time that elapses between when 
the TPAs receive VAMCs' referrals and when veterans opt in with the 
TPAs, our preliminary analysis indicates that VHA cannot track 
veterans' overall wait times for Choice Program care-from the time VA 
clinicians determine that veterans need care until the veterans attend 
their first appointments with Choice Program providers. In addition, 
the lack of data on the timeliness with which the TPAs have (1) 
accepted VAMCs' referrals and (2) opted veterans in to the program also 
prevents VHA from assessing whether the TPAs' average timeliness in 
completing these actions has improved over time.

Clinically Indicated Dates Are Sometimes Changed by VAMC Staff

    Our preliminary analysis of a sample of 196 Choice Program 
authorizations shows that another limitation of available VHA data is 
that the clinically indicated dates included on referrals that VAMCs 
send to the TPAs may not be identical to the clinically indicated dates 
that were originally entered by the VA clinicians who treated the 
veterans. The clinically indicated date is the earliest date an 
appointment is deemed clinically appropriate by a VA clinician. It 
could be the same as the date the VA clinician determined the veteran 
needed care, if there is no clinical reason that the veteran should 
delay care. If VAMCs' Choice Program referrals have clinically 
indicated dates that are different from than the ones VA clinicians 
originally entered, there is risk that VHA's data will not accurately 
reflect veterans' actual wait times.
    VHA's policy directive on consult management and its Choice Program 
standard operating procedure for VAMCs state that the clinically 
indicated date is to be determined by the VA clinician who is treating 
the veteran. However, in reviewing VA's electronic health records for 
our sample of Choice Program authorizations, we identified 60 cases 
where the clinically indicated dates VAMC staff entered on Choice 
Program referrals they sent to the TPAs differed from the clinically 
indicated dates that were originally entered by VA clinicians. \27\ We 
could not conclusively determine the reason the dates differed. It is 
possible that VAMC staff mistakenly entered incorrect dates when they 
manually entered clinically indicated dates on the veterans' Choice 
Program referrals. It is also possible that VAMC staff inappropriately 
entered later clinically indicated dates when they sent the referrals 
to the TPAs because the VAMC staff were delayed in completing the 
necessary steps of contacting the veteran, compiling relevant clinical 
information, and sending the referral to the TPA.
---------------------------------------------------------------------------
    \27\ We were able to identify clinically indicated dates for 134 of 
the 196 Choice Program authorizations in our sample. We could not 
identify VA's clinically indicated dates for a total of 62 of the 
authorizations in our sample. Clinically indicated dates were missing 
for these 62 authorizations because (for example) they were for 
distance-eligible veterans who self-referred to the Choice Program or 
the authorizations were related to requests for additional services 
after veterans had already initiated an episode of Choice Program care.

VAMCs and TPAs Frequently Miscategorize Routine Choice Program 
---------------------------------------------------------------------------
    Referrals as Urgent Referrals

    Our preliminary results indicate that another limitation of VHA's 
available data on the timeliness of Choice Program care is that VAMCs 
and TPAs do not always adhere to the Choice Program's contractual 
definition for urgent care when they are processing referrals and 
scheduling appointments. If Choice Program referrals for routine care 
are inappropriately categorized as urgent care referrals, VHA's data on 
the timeliness of urgent appointment scheduling and completion will not 
accurately reflect the TPAs' performance.
    Among the sample of 53 Choice Program authorizations for urgent 
care we reviewed, VHA and TPA documentation showed that 39 
authorizations (about 74 percent) did not consistently apply VA's 
contractual definition for urgent care authorizations. According to 
VA's contracts with the TPAs, Choice Program referrals are to be marked 
as ``urgent'' when a VA clinician has determined that the veteran needs 
care that (1) is considered essential to evaluate and stabilize 
conditions and (2) if not provided would likely result in unacceptable 
morbidity or pain when there is a significant delay in evaluation or 
treatment. \28\ It is VA's goal that the TPAs schedule appointments for 
urgent care and ensure that they take place within 2 business days 
after veterans opt in to the Choice Program. In some cases, VA 
clinicians marked consults as routine but VAMC staff changed the status 
to urgent when they sent the referrals to the TPAs. In other cases, TPA 
staff changed the referrals from routine to urgent after receiving them 
from the VAMCs. Based on our preliminary analysis of the 
authorizations, it appeared in some cases that these changes were made 
in an effort to administratively expedite appointment scheduling when 
the VAMCs or TPAs were delayed in sending referrals and scheduling 
veterans' Choice Program appointments.
---------------------------------------------------------------------------
    \28\ Under VA's Choice Program contracts, urgent care is not the 
same as care provided for a medical emergency, which is covered through 
different VA community care programs. Urgent care (rather than emergent 
care) delivered through the Choice Program is care that is delivered 
when there is no threat to the veteran's life, limb, or vision but the 
veteran's condition needs attention to prevent it from becoming a 
serious risk to the veteran's health.

Selected Veterans Experienced Lengthy Overall Wait Times for Choice 
---------------------------------------------------------------------------
    Program Care in 2016

    The sample of 196 Choice Program authorizations we reviewed 
included only authorizations for which there were delays when the TPAs 
attempted to schedule appointments after the veterans had opted into 
the program; however, our preliminary analysis of these authorizations 
indicates that delays occurred at other phases of the referral and 
appointment scheduling process as well. Many veterans in our sample 
experienced lengthy overall wait times for Choice Program care-as 
measured from the time their need for care was identified until they 
attended their initial appointments-and only a portion of the overall 
wait time could be explained by the TPA's delay in scheduling an 
appointment after the veteran opted into the Choice Program. Our 
analysis of veterans' VA electronic health records and the TPAs' 
records for a sample of 55 routine care authorizations and 53 urgent 
care authorizations for which the TPAs succeeded in scheduling 
appointments identified the following average review times:

      It took VAMC staff an average of 24 calendar days after 
the veterans' need for routine care was identified to contact the 
veterans and confirm that they wanted to be referred to the Choice 
Program, compile relevant clinical information, and send veterans' 
referrals to the TPAs. It took an average of 27 calendar days for the 
VAMCs to complete these actions for the urgent care authorizations in 
our sample. \29\
---------------------------------------------------------------------------
    \29\ Our calculation for the average number of days it took VAMCs 
to send Choice Program authorizations for routine care to the TPAs is 
based on 41 of the 55 routine authorizations in our sample, and our 
calculation for authorizations for urgent care is based on 36 of the 53 
authorizations in our sample. We could not include in our calculations 
all the authorizations in our sample because either the date the 
veteran's need for care was identified or the date the VAMC sent the 
referral to the TPA was missing. We also could not determine what 
portion of the total time it took VAMCs to prepare veterans' Choice 
Program referrals was accounted for by the interim steps of contacting 
the veteran or compiling relevant clinical documentation because we 
could not find in VA's electronic health record sufficient evidence of 
the dates these actions were completed for all of the authorizations in 
our sample.
---------------------------------------------------------------------------
      For the routine care authorizations in our sample, it 
took the TPAs an average of 14 calendar days to accept referrals and 
reach veterans by telephone or letter to opt them in to the Choice 
Program. It took the TPAs an average of 18 calendar days to complete 
these actions for the urgent care authorizations in our sample.
      After the TPAs succeeded in scheduling veterans' 
appointments for routine care, an average of 26 calendar days elapsed 
before veterans in our sample completed their initial appointments with 
Choice Program providers. For urgent care authorizations in our sample, 
it took an average of 18 days for the veterans to complete their 
initial appointments after the TPAs scheduled them.

    See the following text box for specific examples of the overall 
wait times experienced by some veterans in the samples of routine and 
urgent Choice Program authorizations we reviewed.

Examples of Delays Experienced by Veterans for whom the Choice Program 
    Third Party Administrators (TPA) Scheduled Appointments

      One veteran was referred to the Choice Program for 
magnetic resonance imaging (MRI) of the neck and lower back because 
these services were unavailable at a Veterans Affairs (VA) medical 
facility. It took almost 3 weeks for VA medical center (VAMC) staff to 
prepare his Choice Program referral for routine care and send it to the 
TPA, and then it took an additional 2 months after the VAMC sent the 
referral for the veteran to receive care. Notes in the veteran's VA 
electronic health record indicated that his follow-up appointment with 
a VA neurosurgeon was at risk of being rescheduled because VA had not 
received the results of the MRI after the appointment with the Choice 
Program provider occurred. Ultimately, the veteran's appointment with 
the VA neurosurgeon-where the imaging results and treatment options 
were discussed-did not occur until almost 6 months after the VA 
clinician originally identified the need for the MRI.
      One veteran was a diabetic who was referred to the Choice 
Program for his annual retinal exam because there was a wait for 
services at a VA medical facility. However, it was not until 30 days 
after the VA clinician determined the veteran needed this care that 
VAMC staff sent the Choice Program referral to the TPA. It then took 
the TPA 36 additional days to reach the veteran and confirm he wanted 
to opt in to the Choice Program. In all, the veteran waited almost 5 
months after his VA clinician determined he needed this routine care 
until his appointment with a Choice Program provider occurred.
      Three veterans were referred to the Choice Program 
because they needed maternity care, which is generally not available at 
VA medical facilities. For one of these veterans, almost a month and a 
half elapsed from the time VA confirmed her pregnancy (when she was 6 
weeks pregnant) to when the VAMC sent the Choice Program referral for 
urgent care to the TPA. It then took 2 additional weeks for the TPA to 
attempt to schedule a prenatal appointment; by that point, she was 
almost 15 weeks pregnant. At 18 weeks pregnant, the veteran finally 
scheduled her initial prenatal appointment herself, almost 3 months 
after her pregnancy was confirmed at a VA medical facility.
      One veteran was referred to the Choice Program for 
thoracic surgery to address a growth on his lung because there was a 
wait for VA care. TPA documentation we reviewed indicated that VAMC 
staff contacted the TPA four times to inquire about the status of the 
veteran's appointment, and the TPA contacted five Choice Program 
providers in its unsuccessful attempts to schedule the urgent 
appointment for the veteran. Ultimately, the veteran scheduled his own 
initial appointment with a thoracic surgeon in the community and 
informed the TPA that he had done so. The veteran's initial appointment 
occurred 3 weeks after the VAMC sent his referral to the TPA. -
Source: GAO analysis of VHA and TPA documentation. / GAO 17 397T

    Note: The above examples come from GAO's random, non-generalizable 
sample of 55 authorizations for routine care and 53 authorizations for 
urgent care for which the Choice Program TPAs scheduled appointments 
between January 2016 and April 2016.

    Our preliminary results also show that veterans in our sample 
experienced lengthy overall wait times to receive care when the TPAs 
returned their authorizations without scheduling appointments. When 
veterans' Choice Program authorizations are returned, VAMCs must 
attempt to arrange care through other means-such as through another VA 
community care program, a new Choice Program referral, or at a VA 
medical facility. Among the 88 returned authorizations in our sample, 
we determined that 53 veterans eventually received care through other 
means after their authorizations were returned. \30\ These 53 veterans 
ended up waiting an average of 111 days after the VA clinician 
originally determined they needed care until their first appointment 
with a VA clinician or with a community provider occurred. See the text 
box below for some examples of delays experienced by veterans in the 
sample of 88 returned Choice Program authorizations we reviewed.
---------------------------------------------------------------------------
    \30\ These 53 veterans received care either at a VA medical 
facility, through another VA community care program, or through a new 
Choice Program authorization. We could not conclusively determine 
whether 20 of the 88 veterans in our sample received the care they 
needed after the TPAs returned their Choice Program authorizations. We 
provided these veterans' names to VHA officials in December 2016, and 
the officials said they would follow up on these cases. In addition, 14 
of the 88 veterans in our sample either declined care or no longer 
needed the care that was authorized. Three of those 14 veterans no 
longer needed care because they died before the TPAs or VAMCs could 
schedule appointments. Two veterans had been diagnosed with cancer, had 
emergency inpatient admissions after they were referred to the Choice 
Program, and died before the TPAs could schedule appointments. The 
third veteran had been referred to the Choice Program for in-home 
physical therapy but also had a series of inpatient admissions that 
made it difficult for the TPA to arrange his care. The one remaining 
veteran in our sample was no longer eligible for services, which is why 
the TPA returned her authorization to VA.

Examples of Delays Experienced by Veterans Whose Authorizations were 
    Returned to Veterans Affairs Medical Centers (VAMC) by the Choice 
---------------------------------------------------------------------------
    Program Third Party Administrators (TPA)

      The VAMC took almost 3-and-a-half months to refer one 
veteran to a physical therapist to address her pelvic floor prolapse. 
When the preferred provider listed in the VAMC's referral was outside 
the TPA's network, the TPA sent a message to the VAMC via its Web-based 
portal to ask if they should try scheduling the appointment with a 
different provider. By the time VAMC staff responded to the message in 
the TPA's portal, the TPA had already returned the authorization-almost 
2 weeks after accepting it. Two months later, the VAMC realized that 
the veteran still needed this care and sent a new Choice Program 
referral to the TPA. It then took the veteran another 2-and-a-half 
months to attend her first appointment. Overall, this veteran waited 
more than 8 months to receive physical therapy.
      It took about 2-and-a-half weeks for the VAMC to send one 
veteran's referral for pain management to the TPA after a VA clinician 
originally determined he needed these services. However, information 
the TPA needed for scheduling the Choice Program appointment was 
missing from the VAMC's referral. The TPA requested the information 
from the VAMC twice using its Web-based portal, but VAMC staff did not 
reply, and the TPA returned the authorization 2 weeks after receiving 
it. It then took another month before the veteran ended up receiving 
pain management services at a VAMC. Overall, this veteran waited almost 
2-and-a-half months for pain management services.
Source: GAO analysis of VHA and TPA documentation. / GAO 17 397T

    Note: The above examples come from GAO's random, non-generalizable 
sample of 88 Choice Program authorizations that the TPAs returned to 
six VAMCs between January 2016 and April 2016.

VHA Is Taking Steps to Improve the Timeliness of Veterans' Choice 
    Program Care, Although Nationwide Implementation of these Actions 
    Has Been Limited

    During the course of our ongoing work, VHA officials told us about 
several recent actions they have taken or that they plan to take that 
are intended to improve the timeliness of veterans' Choice Program 
care. Below is a chronological summary of several such actions, along 
with VHA's progress in implementing them. \31\ Many of VHA's changes 
have been implemented within the last calendar year, and so far, 
implementation of these actions has often been limited to a few VAMCs 
or to the VAMCs that are located in a few Veterans Integrated Service 
Networks (VISN). \32\
---------------------------------------------------------------------------
    \31\ VHA has taken actions to address various other Choice Program 
weaknesses. In this statement, we are highlighting our preliminary 
observations on those actions which relate most directly to improving 
the timeliness of veterans' access to care.
    \32\ VHA's health care system is divided into areas called VISNs, 
each responsible for managing and overseeing medical facilities within 
a defined geographic area. VISNs oversee the day-to-day functions of VA 
medical facilities that are within their boundaries. Each VA medical 
facility is assigned to a single VISN. At the start of fiscal year 
2016, there were 21 VISNs, but VA is in the process of consolidating 
some networks so that by the end of fiscal year 2018, there will be 18 
networks.

  Co-Locating TPA staff at selected VAMCs. In November 2015, VA 
    modified the Choice Program contracts to allow for TPA staff to be 
    co-located at selected VAMCs-an action that VHA officials said 
    could help improve communication between VAMC and TPA staff as they 
    work to schedule veterans' Choice Program appointments. For 
    example, VHA officials expect that one potential benefit of co-
    locating TPA staff will be that fewer veterans' Choice Program 
    referrals will be returned to VAMCs due to missing clinical 
    information because TPA staff can help resolve such issues locally 
    before the TPA returns referrals. As of December 2016, TPA staff 
    were working at 54 of VHA's 168 VAMCs-or about one third of all 
    VAMCs. However, according to VHA documentation, only 13 of those 54 
    VAMCs had co-located TPA staff prior to October 1, 2016, which 
    means that the majority of the 54 VAMCs with co-located TPA staff 
---------------------------------------------------------------------------
    have only recently received such support.

  Automating VAMCs' preparation of Choice Program referrals. 
    VHA is in the process of establishing a Web-based tool that it says 
    would automate the process by which VAMC staff compile clinical 
    information for veterans' Choice Program referrals. Currently, VAMC 
    staff must manually retrieve and collate key clinical and contact 
    information from veterans' VA electronic health records. If there 
    are mistakes or missing information, the TPAs may either contact 
    the VAMC to correct or obtain the missing information or return the 
    referral to VA without attempting to schedule an appointment, and 
    this could delay veterans' access to Choice Program care. In early 
    2016, to decrease the rate of returned authorizations and speed up 
    the process for VAMCs to prepare veterans' Choice Program 
    referrals, staff from two VAMCs developed a Web-based tool-called 
    the ``referral documentation'' (REFDOC) tool-which, according to 
    VHA documentation, automates the process of gathering necessary 
    information and assembling it in a standardized format. VHA's 
    initial analyses of the REFDOC tool's effectiveness found that it 
    sped up the process of preparing Choice Program referrals by about 
    20 minutes per referral. VHA officials we interviewed said they 
    intend to roll out the REFDOC tool across all VAMCs, but nationwide 
    implementation has been slowed by limitations of VA's information 
    technology systems. As of November 2016, according to documentation 
    provided by VHA, the REFDOC tool had been implemented at only 18 of 
    VHA's 168 VAMCs. Officials have stated that they expect to 
    implement the REFDOC tool at all VAMCs in March 2017.

  Requiring TPAs to return referrals if appointments are not 
    scheduled within required timeframes. A June 2016 VA contract 
    modification requires the TPAs to return Choice Program 
    authorizations to VAMCs when the TPAs do not meet standards set 
    forth in the contract related to the timeliness with which they 
    review and accept referrals and schedule appointments after 
    veterans have opted into the program. Previously, the TPAs had to 
    return referrals if veterans had not opted in 10 days after the TPA 
    sent a letter, but there was no requirement for the TPAs to accept 
    referrals within a certain timeframe or to return authorizations if 
    the TPAs had not scheduled appointments within required timeframes 
    after veterans opted in. This contract modification has the 
    potential to limit appointment scheduling delays that would be 
    attributable to the TPAs, but it does not affect the timeframes by 
    which VAMCs are required to prepare veterans' Choice Program 
    referrals and send them to the TPAs.

  VAMC scheduling pilots. In July 2016 and October 2016, VHA 
    began implementing pilot projects at two VAMCs, whereby staff at 
    the VAMCs have taken over the responsibility of scheduling 
    veterans' Choice Program appointments from the TPAs, according to 
    VHA officials. Specifically, VA modified its contracts with TriWest 
    and Health Net to implement the two VAMC scheduling pilots at the 
    Alaska VA Health Care System and the Fargo VA Health Care System, 
    respectively. In these two locations, VAMC staff schedule veterans' 
    appointments and send relevant clinical documentation to the Choice 
    Program providers, and the TPAs send authorizations to the Choice 
    Program providers before veterans attend their appointments. VHA 
    officials told us that they plan to make similar contract 
    modifications to implement pilots at four other VAMCs prior to the 
    Choice Program's expiration. They also plan to evaluate the 
    implementation of the appointment scheduling pilots and use the 
    findings of those evaluations to help inform the design of the VAMC 
    appointment scheduling process they plan to include in the 
    consolidated VA community care program they intend to implement 
    after the Choice Program expires.

  Real-time, Web-based communication tool for VAMCs and TPAs. 
    Between August and October of 2016, VA implemented a real-time 
    communication tool (specifically, a Web-based chat program) at 
    VAMCs in five VISNs. VHA officials and VAMC staff can use the tool 
    to communicate with TPA officials about problems that have arisen 
    with specific Choice Program referrals (such as missing clinical 
    information), or patterns of problems that have emerged with Choice 
    Program referrals. VHA officials told us that they planned to 
    implement the chat room at all VAMCs nationwide by the end of 
    January 2017.

  Planned standardization of consult titles for Choice Program 
    referrals. According to documentation VHA officials provided to us 
    in December 2016, they plan to implement a process for 
    standardizing the consult titles associated with Choice Program 
    referrals over the course of calendar year 2017. They planned to 
    pilot the process at four VAMCs beginning in February 2017 and 
    expected to gradually roll out the standardized consult titles 
    across all other VAMCs over the remainder of calendar year 2017. As 
    previously discussed, having standardized consult titles associated 
    with Choice Program referrals will allow VHA to monitor (1) the 
    timeliness with which its VAMCs prepare veterans' Choice Program 
    referrals and send them to the TPAs, and (2) veterans' overall wait 
    times for Choice Program appointments.

    Chairman Roe, Ranking MemberWalz. and Members of the Committee, 
this concludes my prepared statement. I would be pleased to respond to 
any questions you may have at this time.

GAO Contact and Staff Acknowledgments

    If you or your staffs have any questions about this statement, 
please contact me at (202) 512-7114 or [email protected]. Contact 
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may be found on the last page of this statement. GAO staff who made key 
contributions to this statement include Marcia A. Mann (Assistant 
Director), Alexis C. MacDonald (Analyst-in-Charge), Daniel Powers, and 
Michael Zose. Also contributing were Christine Davis, Krister Friday, 
Jacquelyn Hamilton, and Vikki Porter.

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                       Statements For The Record

          VETERANS OF FOREIGN WARS OF THE UNITED STATES (VFW)
                 STATEMENT OF CARLOS FUENTES, DIRECTOR
                      NATIONAL LEGISLATIVE SERVICE
    Chairman Roe, Ranking MemberWalz.and members of the House Committee 
on Veterans' Affairs, on behalf of the nearly 1.7 million members of 
the Veterans of Foreign Wars of the United States (VFW) and our 
Auxiliary, I thank you for the opportunity to submit a statement for 
the record regarding the Choice Program and how to consolidate and 
improve VA community care.
    The VA health care system delivers high quality care and has 
consistently outperformed private sector health care systems in 
independent assessments. The VFW's numerous health care surveys have 
also validated that veterans who use VA health care are satisfied with 
the care they receive. In fact, our latest survey found that 77 percent 
of veterans report being at least somewhat satisfied with their VA 
health care experience. When asked why they turn to VA for their health 
care needs, veterans report that VA delivers high quality care which is 
tailored to their unique needs and because VA health care is an earned 
benefit.
    VA has made significant strides since the access crisis erupted in 
2014 when whistleblowers across the county exposed how long veterans 
were waiting for the care they have earned and deserve. However, VA 
still has a lot of work to do to ensure all veterans have timely access 
to high quality and veteran centric care. But VA cannot be everything 
for everyone. It must leverage private sector providers and other 
public health care systems to meet its obligation to the veterans it 
was created to serve, but community care is only part of the solution.
    Veterans deserve reduced wait times and shorter commutes to their 
medical appointments. This means turning to community care when needed, 
but also means improving VA's ability to provide direct care. The VFW 
thanks Congress for its commitment to improving VA's community care 
authorities and programs. VA also needs the resources and authorities 
to quickly recruit and properly compensate a high performing health 
care workforce, properly train its employees, hold wrongdoers 
accountable, and update its aging capital infrastructure.
    In the past three years, the VFW has assisted hundreds of veterans 
who have faced delays receiving care through the Choice Program, and 
has surveyed more than 8,000 veterans specifically on their experiences 
using VA community care and the Choice Program. Through this work, the 
VFW has identified a number of issues with the program which must be 
addressed. For example, veterans continue to receive bills from private 
sector doctors who were unable to receive payment from VA because of 
complicated rules determining when VA is able to pay and when it serves 
as a secondary payer. Veterans should never be billed for care that VA 
is responsible for paying. To address this issue, the VFW urges 
Congress to remove the secondary payer requirement under the Choice 
Program.
    Choice Program doctors also tell us it takes too long for them to 
receive the medical documentation from VA that they need in order to 
treat veterans. One doctor said ``it's easier to get gold out of Fort 
Knox, than it is to get medical records from VA.'' VA is taking steps 
to improve this process and will implement a new program soon to ensure 
Choice providers can view a veteran's medical record. However, an 
outdated law which requires VA to withhold the medical information of 
veterans who have been diagnosed with substance use disorder, human 
immunodeficiency virus, and sickle cell anemia hinders VA's ability to 
transfer medical records with its community care partners. Congress 
must remove this statutory limitation to ensure veterans who use the 
Choice Program do not encounter scheduling delays.
    As the VFW has highlighted in our two Choice Program reports, which 
can be found on our website, www.vfw.org/vawatch, the eligibility 
criteria for the Choice Program must also be reformed. The VFW thanks 
this Committee and VA for making several VFW recommended improvements 
to the Choice Program, such as measuring mileage by driving distance 
instead of ``how the crow flies'' and making the clinically indicated 
date the date on which veterans become eligible for community care. 
However, several recommendations remain.
    First, the VFW firmly believes that VA must reevaluate how it 
measures wait times. In the VFW's most recent VA health care report, 
only 67 percent of veterans indicated they had obtained a VA 
appointment within 30 days, which is significantly less than the 93 
percent VA reported in its most recent access report. This is because 
the way VA measures wait times is not aligned with the realities of 
scheduling a health care appointment.
    VA uses a metric called the preferred date to measure the 
difference between when a veteran would like to be seen and when they 
are given an appointment. However, this completely ignores and fails to 
account for the full length of time a veteran waits for care. For 
example, when veterans call to schedule an appointment they are asked 
when they prefer to be seen. The first question they logically ask is, 
``When is the next available appointment?'' If VA's scheduling system 
does not preclude them from doing so, schedulers have the ability to 
input the medical facility's next available appointment as the 
veteran's preferred date--essentially zeroing out the wait time. VA 
must correct its wait time metric to more accurately reflect how long 
veterans wait for their care.
    However, VA's wait time measurement must not be used as an 
eligibility criterion for the Choice Program. While the VFW agrees that 
using a clinically indicated date to determine eligibility is the right 
approach, we do not believe Congress or VA should dictate how long 
veterans must wait before receiving care from community care providers. 
Arbitrary thresholds such as 30-days or 40-miles do not reflect the 
health care landscape of our country. Veterans may not need to be seen 
within 30 days for appointments such as routine checkups. Likewise, 
such arbitrary thresholds do not account for veterans with urgent 
medical needs for which they need to be seen before 30 days, or 
veterans who suffer from disabilities which prevent them from traveling 
40 miles.
    A recent independent assessment on VA access standards by the 
Institute of Medicine (IOM) was unable to find a national standard for 
access similar to the Choice Program's 40-mile and 30-day standards. 
Instead of focusing on set mileage or days, IOM found that industry 
best practices focus on clinical need and the interaction between 
clinicians and their patients. That is why Congress should not dictate 
eligibility for community care with arbitrary or federally regulated 
access standards, such as 30-days or 40-miles. When and where a veteran 
needs to be seen is a clinical decision made between a veteran and his 
or her doctor.
    Overall, Congress and VA must take the lessons learned from the 
Choice Program and other community care programs such as Project ARCH, 
Project HERO, and PC3, and create a single, sustainable community care 
program that integrates the private sector into the VA health care 
system. VA has outlined its vision for consolidating its community care 
programs in a report it was required to send Congress under Public Law 
(PL) 114-41, the Surface Transportation and Veterans Health Care Choice 
Improvement Act of 2015. It is time for Congress to act on VA's 
proposal to ensure VA is able to transform the way it provides 
community care.
    Congress' self-imposed budget rules have stopped several bills that 
would have enabled VA to begin implementing its consolidation plan. As 
the Choice Program gets closer to expiring, Congress continues to 
debate on the way forward. Instead of waiting until the 11th hour to 
act on a consolidation bill, which would limit VA's ability continue to 
serve veterans, Congress must allow VA to continue the Choice Program 
under its existing community care authorities.
    To be clear, VA has the authority to carry out the Choice Program 
past its expiration and is willing to do so, but lacks the community 
care appropriations. While it would be best for Congress to pass a 
consolidation bill that would improve the Choice Program and 
consolidate VA's numerous community care authorities, the VFW does not 
believe Congress can do so without slowing or degrading VA's ability to 
carry out the existing program. That is why the VFW believes it is best 
for Congress to simply provide VA the resources it needs to carry out 
the program under its existing authorities, rather than move forward 
with a comprehensive community care consolidation bill which is 
unlikely to become law.
    Veterans have used approximately $3 billion in care through the 
Choice Program per year and that demand for care will only continue to 
increase as more veterans turn to VA for their health care needs. VA 
currently sends nearly 200,000 authorizations for care a month through 
the Choice Program and will be required to immediately cease the 
program--requiring it to start from scratch and losing the trust and 
confidence it has worked so hard to restore--if it does not receive the 
funding needed to continue the program before it expires.
    VA estimated that its authority to use the $10 billion emergency 
mandatory appropriations account Congress created to fund the Choice 
Program will expire before funds are fully exhausted. To ensure these 
funds are used for their intended purpose, the VFW supports eliminating 
the expiration of this account. But to be perfectly clear, the VFW 
would oppose any future efforts to refill this account. Appropriations 
for VA community care must be included in VA's annual budget. 
Furthermore, VA must have that ability between its community care and 
medical services accounts to ensure care is delivered where veterans 
demand it, not where Congress dictates.
    VA has also requested authority to develop a nationwide system of 
urgent care at existing VA medical facilities, and to reimburse 
veterans for urgent care they receive from smaller urgent care clinics 
around the country to fill the gap between emergency care and 
traditional appointment-based outpatient care. Doing so would ensure 
veterans with acute medical conditions that require urgent attention, 
such as the flu, infections, or non-life threatening injuries, do not 
wait days or weeks for a primary care appointment. Establishing urgent 
care would also curb the reliance on emergency rooms for non-emergent 
care, which is more expensive for veterans and VA. The VFW urges 
Congress to consider and swiftly pass legislation authorizing VA to 
reimburse veterans for using community urgent care clinics.
    The VFW also urges Congress to swiftly pass provider agreement 
legislation. Authorizing VA to enter into non-federal acquisition 
regulation (FAR) based agreements with private sector providers, 
similar to agreements under Medicare, would ensure VA is able to 
quickly provide veterans with care when community care programs like 
the Choice Program are not viable options.
    Provider agreements are particularly important for VA's ability to 
provide long-term care through community nursing homes. The majority of 
the homes who partner with VA do not have the staff, resources or 
expertise to navigate and comply with FAR requirements and have 
indicated they would end their partnerships with VA if required to bid 
for FAR contracts. In fact, VA's community nursing home program has 
lost 400 homes in the past two years and will continue to lose 200 
homes per year without provider agreement authority. This means 
thousands of veterans are forced to leave the place they have called 
home for years simply because VA is not able to renew agreements with 
community nursing homes. Congress must end this injustice by quickly 
passing provider agreement legislation.

                                 
                                  HVAC
    Dear Chairman Roe and Ranking MemberWalz.

    Thank you for holding tonight's hearing on ``Shaping The Future: 
Consolidating And Improving VA Community Care'' to examine the 
Department of Veterans Affairs' Choice Program and the future of VA 
community care programs, authorities and budget impact. While the 
Veterans Choice Program was stood up in a time of need and with the 
best of intentions, I believe modest improvements could be made that 
would address many of the program's issues and frustrations, many of 
which are exemplified in the following examples my staff and I have 
personally resolved since the program came online.

    Casework Example #1) ``Tom'' was automatically eligible to use his 
Choice card and a local provider because of the distance he lived from 
the nearest VA healthcare facility, but was having trouble scheduling 
an appointment for an MRI. Our office contacted our HealthNet Liaison 
requesting that his request be reviewed and approved as soon as 
possible. They responded and the appointment was conducted. The result 
of the MRI called for immediate orthoscopic knee surgery. The provider 
contacted HealthNet requesting approval for the knee surgery, which 
HealthNet granted along with additional service visits. The hospital 
submitted the bill for the approved procedures and was denied payment 
from HealthNet, who claimed the appointments weren't approved so they 
would not reimburse for any of the procedures including the MRI, knee 
surgery, follow up appointment, and knee injection. Our office had to 
go back to the beginning with HealthNet and use the authorization they 
sent to pressure them to pay the provider. It was ultimately paid for, 
but not without their unnecessary error delaying payment and 
contradicting their own authorization that had been sent to the 
patient, provider, and our office.

    Casework Example #2) ``Russ'' was waiting over a year for a neck 
epidural, so our office became involved and we were able to schedule a 
Veterans Choice appointment within a week of contact, but only to find 
out that HealthNet scheduled the appointment with an unauthorized 
provider. The veteran was thus turned away the day of his appointment. 
We then called to reschedule and fix this error. He was rescheduled 
with a provider after a prolonged back-and-forth about which doctor to 
use. We then found out that this appointment was for testing and 
examination, and he would have to wait again for the neck epidural. 
HealthNet repeatedly had errors in which provider to use. At this 
point, I had to personally intervene and call HealthNet. Ultimately, 
Russ was able to a see Doctor who had access to all of his testing and 
examinations from previous visits, and HealthNet covered the cost, well 
over a year from the initial contact.

    Casework Example #3) ``Darin'' came to our office because he was 
having problems getting a past Choice appointment for a cancer check-up 
paid for and because he was having a hard time getting another Choice 
appointment set for an Orthopedic assessment. This veteran is located 
over 300 miles from the Minneapolis VA Hospital, so he strongly desired 
to utilize more local treatment whenever possible. Our office started 
reaching out to HealthNet in March 2016. It took multiple emails over a 
period of two months to HealthNet to finally get a response. It then 
took another set of inquiries back and forth to get a response on his 
request for a new appointment to see an Orthopedic specialist in the 
Twin Cities. We eventually got his original appointment set and the 
past bill paid for after a period of five months, which included at 
least 10 inquiries out to HealthNet and the VA, many phone calls, and a 
lot of confusion all around.

    As these examples illustrate, the Choice program would be much 
better served by ensuring greater accuracy (of at least 95%) of 
provider payments and timely reimbursements (within 30 days), and 
better education - especially on the provider side - regarding the 
billing and authorization process. I would also urge the Committee to 
examine moving the program more towards a ``case-management'' model so 
that Veterans do not have to repeat their particular situation each 
time they speak with a different TriWest/HealthNet representative, 
particularly when there is a problem.
    Finally, in the transition between the VA's administrative efforts 
and the enactment of legislative solutions to improve the delivery of 
community care, I do want to voice my support for allowing Veterans who 
have faced extraordinary difficulty with Choice utilize the Traditional 
VA Care in the Community/Non-VA Medical Care Program (previously known 
as ``fee basis care''). However, a wholesale transfer of Veterans in 
Choice to Non-VA Medical Care could create serious unforeseen 
consequences and additional backlog problems, so I would urge the 
Committee and VA to proceed with deliberation if such a policy is to be 
considered.
    Thank you for your review and consideration of these 
recommendations and examples from my rural Congressional District in 
Minnesota. Please do not hesitate to contact me if I may be of further 
assistance.

    Sincerely,

    Richard M. Nolan
    Member of Congress

                                 
                  PARALYZED VETERANS OF AMERICA (PVA)
    Chairman Roe, Ranking MemberWalz. and members of the Committee, 
Paralyzed Veterans of America (PVA) would like to thank you for the 
opportunity to offer our views on consolidating and improving the 
Department of Veterans Affairs' (VA) delivery of community care. The 
magnitude of the impact that veterans health care will have on present 
and future generations of veterans cannot be overstated, and we are 
proud to be part of this important discussion.
    PVA's historical experience and extensive interaction with veterans 
around the country leads us to confidently conclude that veterans 
prefer to receive their care from VA. We recognize, however, that while 
for most enrolled veterans VA remains the best and preferred option, VA 
cannot provide all services in all locations at all times. Care in the 
community must remain a viable option. As VA seeks to take the next 
major step in improving access to quality care for veterans, we 
appreciate the Committee's significant efforts in this matter.
    As an initial matter, PVA supports the Chairman's bill, H.R. 369, 
which would eliminate the August 7, 2017 sunset date for the current 
Choice program and allow VA to continue to provide care with the 
remaining funding. VA currently estimates that remaining funds can 
carry the program an additional three months. This would provide both 
more time to formulate a plan for the next phase of community care and 
a mechanism to bridge the gap during the transition. Trying to pin down 
exactly when funds will run out, however, is like shooting at a fast-
moving target. It is imperative that Congress not lose its sense of 
urgency as we push toward consolidation and reform. Failing to protect 
against overly-optimistic funding projections could lead to a painful 
transition if the Choice program came to an abrupt halt prior to the 
next iteration being implemented.
    Specialized services, such as spinal cord injury care, are part of 
the core mission and responsibility of VA. As the Department continues 
the trend toward greater utilization of community care, Congress and 
the Administration must be cognizant of the impact those decisions will 
have on veterans who need VA the most.
    Any legislation designed to reform VA health care must incorporate 
or match the attributes that make VA's specialized services strong. For 
example, VA utilizes outcome-based standards of care across the spinal 
cord injury or disease (SCI/D) system, which, in turn, allows us to 
measure and scrutinize the quality of care provided. When individual 
facilities are lagging behind, the evidence is not just anecdotal. When 
the entire system is questioned, Congress can commission an independent 
assessment, similar to the one carried out as part of the original 
Choice legislation. What are the equivalents in the private sector? 
Congress should examine more closely how VA will monitor the quality of 
care veterans are receiving in the community. This question goes beyond 
a plan for care coordination. If VA is unprepared to retain ownership 
of responsibility for care delivered in the private sector, Congress 
will be helpless in conducting adequate oversight.
    Many advocates for greater access to care in the community also 
minimize, or ignore altogether, the devastating impact that pushing 
more veterans into the community would have on the larger VA health 
care system, and by extension the specialized health services that rely 
upon the larger system. Broad expansion of community care could lead to 
a significant decline in the critical mass of patients needed to keep 
all services viable. We cannot emphasize enough that all tertiary care 
services are critical to the broader specialized care programs provided 
to veterans. If these services decline, then specialized care is also 
diminished. The bottom line is that the SCI system of care, and the 
other specialized services in VA, do not operate in a vacuum. Veterans 
with catastrophic disabilities rely almost exclusively upon VA's 
specialized services, as well as the wide array of tertiary care 
services provided at VA medical centers.
    PVA, along with our Independent Budget (IB) partners, Disabled 
American Veterans (DAV) and Veterans of Foreign Wars (VFW), developed 
and previously presented to this Committee a framework for VA health 
care reform. It includes a comprehensive set of policy ideas that will 
make an immediate impact on the delivery of care, while laying out a 
long-term vision for a sustainable, high-quality, veteran-centered 
health care system. Our framework stands on four pillars: 1) 
restructuring the veterans health care system; 2) redesigning the 
systems and procedures that facilitate access to health care; 3) 
realigning the provision and allocation of VA's resources to reflect 
the mission; and 4) reforming VA's culture with workforce innovations 
and real accountability. With this perspective, we offer our views on 
consolidating and strengthening the delivery of care in the community.

I. Restructuring the system in a way that establishes integrated health 
    care networks designed to leverage the capabilities and strengths 
    of existing local resources in order to provide more efficient, 
    higher quality and better coordinated care.

    PVA strongly supports the concept of developing high-performing 
networks that would seamlessly combine the capabilities of the VA 
health care system with both public and private health care providers 
in the community. This approach is gaining consensus among 
stakeholders, including the most recent and current VA Secretaries, the 
IB, most major Veteran Service Organizations (VSO), the Commission on 
Care, and congressional leadership. As stakeholders coalesce around 
this concept, though, divisions are still apparent as to the dynamics 
that govern the boundaries of this network.
    PVA believes, like many stakeholders and members of Congress have 
stated, that the definition of an integrated VA network is one that 
utilizes private providers to supplement, not supplant, the VA health 
care system. Unfettered choice of provider granted to all veterans is 
not an acceptable outcome for a healthy VA health care system capable 
of sustaining critical, veteran-centric, specialized services. It is 
flat-out cost-prohibitive and, in many cases, leads to fractured care 
as veterans attempt to navigate the private health care system without 
assistance in care coordination. We believe that the design and 
development of VA's network must be locally driven with national 
guidance and reflect the demographics and availability of resources 
within that area. While faith in VA to develop dynamic provider 
networks on its own may be weak, the proactive efforts of Third Party 
Administrators (TPAs) to work with VA and evaluate gaps in service have 
proven to be a valuable asset thus far in filling gaps.
    VA would be able to make greater strides in this area if given the 
ability to bring more community providers into the fold with flexible 
provider agreements. The current requirement that providers enter into 
agreements with VA governed by the federal acquisition regulation (FAR) 
system has suffocated VA's attempts to expand access to care in a 
timely manner. Smaller health care provider organizations otherwise 
disposed to serve the veteran population are especially resistant to 
engaging in the laborious FAR process. And yet they remain a vital 
piece to filling the gaps in health care services in certain areas, 
especially rural areas.
    Care coordination is an essential part of delivering quality health 
care. VA must continue to own the responsibility for care coordination 
for veterans. VA's proposal for care coordination in its Plan to 
Consolidate Community Care Programs revolved the patient's 
circumstances, specifically the intensity of coordination needed and 
whether or not the non-VA care was being provided based on a wait time 
or geographical distance. \1\ In light of the Secretary's recent 
comments indicating a desire to remove the 30-day/40-mile standards for 
determining eligibility for community care, this aspect may soon need 
to be revisited.
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs, Plan to Consolidate Programs of 
Department of Veterans Affairs to Improve Access to Care, October 30, 
2015, pp. 21-24, http://www.va.gov/opa/publications/va--community--
care--report--11--03--2015.pdf.
---------------------------------------------------------------------------
    There is also another serious concern that has been overlooked in 
the expansion of community care access. When veterans receive treatment 
at a VA medical center, they are protected in the event that some 
additional disability is incurred or health care problem arises. Under 
38 U.S.C. Section 1151, veterans can file claims for disability as a 
result of medical malpractice that occurs in a VA facility or as a 
result of care provided by a VA provider. Responding to PVA's 
inquiries, VA confirmed that this protection does not follow the 
veteran receiving care in the community. If medical malpractice occurs 
during outsourced care, the veteran must pursue standard legal remedies 
unlike similarly situated veterans who are privy to VA's non-
adversarial process. Adding insult to literal injury, these veterans, 
if they prevail on a claim, are limited to monetary damages instead of 
enjoying the other ancillary benefits available under Title 38 intended 
to make them whole again.
    This is simply unacceptable. Congress must ensure that these 
protections follow the veteran into the community. Congress must ensure 
veterans who receive care in the community retain current protections 
unique to VA health care under Title 38, particularly including medical 
malpractice remedies governed by 38 U.S.C. Section 1151, clinical 
appeal rights, no-cost accredited representation, and Congressional 
oversight and public accountability.

II. Redesigning the systems and procedures that facilitate access to 
    care in a way that provides informed and meaningful choices.

    PVA firmly believes that eligibility and access to care should be a 
clinically based decision made between a veteran and his or her doctor 
or health care professional. Once the clinical parameters are 
determined, veterans should be able to choose among the options 
developed within the high-performing network and schedule appointments 
that are most convenient for them. Access decisions dictated by 
arbitrary wait times and geographic distances have no comparable 
industry practices in the private sector. We are encouraged by the 
Secretary's recent comments indicating a desire to move away from the 
current 30-day/40-mile standard in favor of a clinical determination. 
VA should be able to ensure that when and where the veteran receives 
care is based on clinical need and availability of services. It shifts 
the organizational mindset and focus of VA to clinical outcomes instead 
of catering to arbitrary metrics governing access to care in the 
community.
    PVA and our fellow IBVSOs continue to advocate for adding urgent 
care services to the standard medical benefits package to help fill the 
gap between routine primary care and emergency care. This is consistent 
with current health care trends. VA previously proposed in its Plan to 
Consolidate Community Care Programs a more common sense determination 
of what constitutes reimbursable emergency and urgent care, thereby 
expanding access, but it came with the imposition of cost-sharing for 
otherwise exempt veterans. We strongly oppose co-payments for veterans 
who are otherwise exempt. Using co-payments as a means to discourage 
inappropriate use of emergency care by service-connected veterans is 
not an acceptable method of incentivizing behavior. VA should instead 
incentivize use of primary care providers by increasing the ease with 
which veterans access care in its integrated network.

III. Realigning the provision and allocation of VA's resources to 
    reflect the mission.

    While much of the focus is keyed to addressing smooth integration 
of community care, we reiterate that the access issues plaguing VA have 
been exacerbated by staffing shortages within the VA health care 
system. PVA is proud to have been an integral part of the efforts that 
led to reinstating the capacity reporting requirement last Congress. 
Evaluating VA's capacity to care for veterans requires a comprehensive 
analysis of veterans health care demand and utilization measured 
against VA's staffing, funding, and infrastructure. However, VA's 
capacity metrics have been based on deflated utilization numbers that 
fail to properly account for the true demand on its system.
    The nurse shortage within the Spinal Cord Injury and Disease (SCI/
D) system of care has precluded SCI/D centers from fully utilizing 
available bed space and forced SCI/D centers to reduce the amount of 
veterans they admit. A decrease in the daily average census at some 
SCI/D centers naturally followed, suggesting that there is a lack of 
demand in the system. In reality, veterans who want to access SCI/D 
care are turned away because those centers lack the staff to man 
available beds.
    A reduction in capacity to provide services is the immediate effect 
of staffing shortages. But second and third order effects follow and 
create a negative feedback loop that is detrimental to the entire SCI/D 
system of care. As staffing thins and those remaining behind attempt to 
cover more responsibility, individual patients receive less attention 
and staff burn out. It impacts morale and eventually erodes the overall 
quality of care. As this cycle takes hold, demand for care in these 
facilities shrinks. When VA calculates demand under these conditions, 
the new demand metrics have been artificially depressed and tend to 
justify reduced staff, further perpetuating the downward spiral.
    With the capacity reporting requirement reinstated, Congress now 
has the means to conduct effective oversight and ensure VA stays ahead 
of the curve in determining where shortages exist and what gaps need 
filled. Congress should start immediately by determining how VA plans 
to abide by the newly reinstated reporting requirement. A Government 
Accountability Office (GAO) report in October 2014 revealed that VA 
utterly failed to address staffing shortages after years of trying to 
implement a nationally standardized methodology for determining an 
adequate and qualified nurse workforce. \2\ Specifically the report 
found a lack of oversight and a failure to ensure preparedness for 
implementing the staffing methodology, including the necessary 
technical support and resources. Without strong Congressional oversight 
and the provision of adequate resources, history will repeat itself.
---------------------------------------------------------------------------
    \2\ U.S. Government Accountability Office. (October 2014). VA 
Health Care - Actions Needed to Ensure Adequate and Qualified Nurse 
Staffing. (Publication No. GAO-15-61). Retrieved from www.gao.gov/
assets/670/666538.pdf on March 2, 2017.
---------------------------------------------------------------------------
    These types of issues are not new, and the Independent Assessment's 
report in September 2015 repeated findings similar to those in a report 
from a bipartisan presidential task force back in 2003: there is a 
disconnect in alignment of demand, resources and authorities. Beyond 
simply providing more and more funds, though, PVA supports certain 
changes being requested by VA that would impact how those funds are 
spent.
    One change would increase efficiency and accuracy in funding by 
allowing VA to record non-VA care obligations at the time of payment 
instead of when the care is authorized. The current practice requiring 
VA to project obligations at the time of authorization incentivizes 
over-obligation to avoid violating the Anti-Deficiency Act and 
ultimately results in forgoing funds previously provided by Congress-
money which could otherwise be spent on medical care.
    The second change we support is giving VA the flexibility to 
allocate funds in a way that accommodates shifts in demand for health 
care services. While consolidation of community care programs might 
obviate the need to lift restrictions on using Choice Program funds to 
reimburse community providers operating under Patient-Centered 
Community Care (PC3), any consolidation effort should permit VA to 
develop internal capacity if utilization patterns demonstrate 
increasing demand for care in VA facilities.

IV. Reforming VA's Culture with Transparency and Accountability

    It is no secret that VA's administrative bureaucracy has ballooned 
in recent years. Arguably, resources devoted to expanding 
administrative staff have significantly jeopardized the clinical 
operations of VA. We believe serious consideration needs to be given to 
rightsizing the administrative functions of VA to free critical 
resources and dedicate them to building clinical capacity.
    Additionally, VA has struggled with the notion of accountability. 
Too often, VA staff who should be terminated are ``removed,'' but not 
in the way the ordinary citizen in the workforce would envision that 
action. VA has allowed too many VA employees who have compromised the 
public's trust to collect a full paycheck while under reassignment in 
one of those positions that are neatly tucked away from public view, or 
to simply retire with full benefits. The public has grown tired of this 
happening. So have America's veterans. We implore Congress to provide 
the new VA secretary whatever authority he needs to prevent this from 
continuing.
    PVA believes that substantial reform in health care can be 
achieved, and the time is ripe to accomplish this task. Our 
organization represents clients with some of the most complex issues, 
and we cannot stress enough that moving forward should not be done at 
the expense of the most vulnerable veterans. We must remain vigilant 
and appreciate the benefits of bringing together the variety of 
stakeholders who are participating and bringing different perspectives 
and viewpoints-it is a healthy development process that ensures 
veterans remain the focus. Thank you for the opportunity to present our 
views on these issues.

                          THE AMERICAN LEGION
``DEPARTMENT OF VETERAN'S AFFAIRS (VA'S) CHOICE PROGRAM AND THE FUTURE 
       OF VA COMMUNIYT CARE PROGRAMS, AUTHORITIES, AND BUDGET. ``
    Mr. Chairman, Ranking MemberWalz.and distinguished members of this 
critical, veteran-serving committee, 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 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.'' \1\
---------------------------------------------------------------------------
    \1\ Resolution No. 46 (2012): Department of Veterans Affairs (VA) 
Non-VA Care Programs
---------------------------------------------------------------------------
    As congress is now discovering and as The American Legion 
predicted, costs are skyrocketing beyond all budget predictions because 
congress failed to implement established cost control measures that had 
been used by VA for years, and instead opted to open access using the 
Choice act which encouraged virtual uncontrolled spending. By 
committing $10 billion to this new procurement vehicle congress removed 
all established contracting control measures used in VA's other 
community care programs; instituted third party administrators, 
additional eligibility criteria, higher and inconsistent reimbursement 
rates, and a disconnected billing authority; in addition, the Choice 
act required VA to issue physical Choice cards to every enrolled 
veteran that were essentially worthless, wasting millions and millions 
of dollars on designing and procuring millions of these cards in 90 
days or less.
    The one thing the Choice act did do effectively was expose VA's 
practice of managing to budget as opposed to managing to need. While 
the Choice act set a restrictive access boundary of 30 days of wait 
time, and 40 driving distance miles by presenting it as increasing 
access, the truth is, VA already had the authority to contract those 
patients out they just rarely used the authority because their budget 
could serve twice as many veterans if redirected toward campus or 
established community care contracts.
    Every year VA would send their budget request to the Office of 
Management and Budget (OMB) as calculated by the number of veterans 
they projected would require medical care from VA in the upcoming 
fiscal year, and every year OMB would recommend less money than VA had 
requested for the president's annual budget request. To congress' 
credit, each year congress would fund VA at an amount greater than what 
the president would request, but still lower than what VA had predicted 
their needs would be. This budgetary tug-o-war continued for years 
while returning injured veterans became new patients of VA, aging 
Vietnam and Korean War veterans consumed more medical services, 
congress opened free access to all returning combat vets regardless of 
whether or not they had a service connected disability, and The 
Affordable Healthcare Act pushed veterans into VA who were eligible for 
VA care but never used VA because they had access to private care, but 
who's private care didn't qualify for Obamacare. It was this 
combination of events in tandem with the national shortage of primary 
care doctors that contributed to the backlog of patients that erupted 
in 2014.
    Over the years, VA has implemented a number of non-VA care programs 
to manage veterans' health care when such care is not available at a VA 
facility, could not be provided in a timely manner, or is more cost 
effective through contracting vehicles. Programs such as Fee-Basis, 
Project Access Received Closer to Home (ARCH), Patient-Centered 
Community Care (PC3), and the Veterans Choice Program (VCP) were 
enacted by Congress to ensure eligible veterans could be referred 
outside the VA for needed, and timely, health care services.
    Congress created the VCP after learning in 2014 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.
    Last year Congress passed the Surface Transportation and Veterans 
Health Care Choice Improvement Act of 2015 (VA Budget and Choice 
Improvement Act) after VA sought 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 sought 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 promised 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. That 
legislation was never enacted.
    The American Legion commends this committee for recognizing the 
need to fix the Choice program. The American Legion supported passage 
of the Veterans Access, Choice and Accountability Act of 2014 as a 
temporary fix to help veterans get the health care they need, 
regardless of distance from VA facilities or appointment scheduling 
pressure. As congress now recognizes long-term solution requires 
consolidating all of VA's authorities for outside care, including 
Choice, PC3, Project ARCH and others, under one authority to help 
veterans only when and where VA cannot meet demand. The American Legion 
supports a strong VA that ultimately relies less and less on outside 
care, rather than move toward vouchers and privatization. An initial 
hope for the emergency Choice program was that whatever worked from 
that program, or previous programs such as ARCH and PC3 could be 
incorporated into a single program that learned best practices and 
lessons from the predecessors.
    While many veterans initially clamored for ``more Choice'' as a 
solution to scheduling problems within the VA healthcare system, once 
this program was implemented, most have not found it to be a solution, 
indeed, they have found it to create as many problems as it solves. The 
American Legion operates the System Worth Saving Task Force, which has 
annually traveled the country examining up close the delivery of 
healthcare to veterans for over a decade. What we have found, directly 
interacting with veterans, is that many of the problems veterans 
encountered with scheduling appointments in VA are mirrored in the 
civilian community outside VA. The solutions in many areas may not be 
out in the private sector, and opening unfettered access to that 
civilian healthcare system may create more problems than it solves. 
National Public Radio recently noted that ``thousands of veterans 
referred to the Choice program are returning to VA for care - sometimes 
because the program couldn't find a doctor for them'' or ``because the 
private doctor they were told to see was too far away.'' \2\
---------------------------------------------------------------------------
    \2\ NPR - May 17, 2016
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    Additionally, we note that the $10 billion originally appropriated 
for the Choice Program which was expected to be depleted by May 2017 
still has funding available, and The American Legion wants to make sure 
that VA retains access to those funds until fully depleted.
    The American Legion has serious concerns about future years funding 
shortfalls for the VA. We urge this committee and Congress to take 
additional steps now to ensure VA has the tools and resources it needs 
to address the needs of America's veterans next year and for years to 
come. The American Legion expects a fully funded VA from Congress. 
Since the access to care crisis, it was apparent that VA needed to 
expand its ability to provide care through its own facilities and by 
providing access for eligible veterans to private-sector health care. 
In short, VA needs enhanced capacity and that takes funding.
    As predicted by The American Legion, sending patients off VA 
campuses to community providers absent well-crafted contracts such as 
those used for Project ARCH and PC3 has led to inadequate compliance by 
local physicians to return treatment records to VA following care 
provided by Choice. When the Choice legislation was being developed, 
The American Legion insisted that any doctor treating a referred 
veteran have access to the veteran's medical records so that doctors 
would have a complete history of the veteran's medical history and be 
able to provide a diagnosis based on a holistic understanding of the 
patients medical profile. This is important for a litany of reasons, 
not the least of which includes the risk of harmful drug interaction, 
possible overmedication, and a better understanding of the patients 
previous military history - all important factors in wellness.
    Also, The American Legion was adamant that any treating physician 
contracted through Choice had a responsibility to return treatment 
records to be included in the patients VA medical file so that VA could 
maintain a complete and up-to-date medical record on their patients. We 
believed that safeguarding of the veterans medical records was so 
important, that we helped craft a provision that was included in the 
language that prevented VA from paying physicians until they turned 
over the treatment records to VA. Sadly The American Legion was forced 
to acquiesce our position in favor of paying doctors whether they 
turned over the medical records or not, because doctors weren't sending 
the records - it just wasn't that important to them, and when VA 
refused to pay, they blamed VA for not paying them, ultimately billing 
the veterans and refusing to see any more VA-referred patients until 
they got paid. Since it was more important that veterans had access to 
sufficient medical care and not have their credit damaged, The American 
Legion supported repealing the current provision.
    Chairman Roe, this, among other reasons including unsustainable 
cost, is why Choice is not the answer. The equation is simple; a 
dramatic increase in cost is guaranteed to result in an increased 
financial burden to veterans using VA care which will include higher 
co-pays, premiums, deductions, and other out-of-pocket expenses 
currently suffered by non-VA healthcare programs.
    Mr. Chairman, Ranking MemberWalz. and other committee members, The 
American Legion thanks you for your time, and urges you to take serious 
action to make access to quality care across this nation a priority of 
the 115th Congress.

                                 
                    Disabled American Veterans (DAV)
                        STATEMENT OF JOY J. ILEM
                   DAV NATIONAL LEGISLATIVE DIRECTOR
    Chairman Roe, Ranking MemberWalz.and Members of the Committee:

    Thank you for inviting DAV (Disabled American Veterans) to submit 
testimony for the record of this hearing to examine the Department of 
Veterans Affairs (VA) Choice program, as well as plans to consolidate 
community care programs and reform the VA health care system. As you 
know, DAV is a non-profit veterans service organization comprised of 
1.3 million wartime service-disabled veterans that is dedicated to a 
single purpose: empowering veterans to lead high-quality lives with 
respect and dignity. Today's hearing is critically important to DAV 
because most of our members choose and rely heavily or entirely on VA 
health care.
    Mr. Chairman, in exactly five months the authorization to provide 
community care through the Choice program - established by the Veterans 
Access, Choice and Accountability Act (VACAA) (Public Law 113-146) - is 
set to expire, even though there is projected to be approximately $1 
billion remaining in Choice account at that time. Born out of the 
waiting list scandals and access crisis in that culminated in the 
spring of 2014, the Choice program has never met Congress' or veterans' 
expectations. Despite the difficult rollout of the program, VA saw both 
increased access to care in the community and increased demand for care 
in VA. If the Choice program and its resources were to suddenly 
disappear in August without an effective and functioning replacement, 
there would be tremendous dislocation and hardship for hundreds of 
thousands of veterans who would find themselves unable to access timely 
care in an already overburdened VA health care system.
    For these reasons, Congress and the new Administration must take 
action soon to ensure that veterans who currently receive care through 
the Choice program continue to have access to needed medical services. 
We urge Congress to pass a temporary extension of Choice while also 
moving forward with the next evolution of the VA health care system in 
order to provide all enrolled veterans with timely access to 
comprehensive, high-quality and veteran-focused care.
    Over the past year, DAV, along with our partners in The Independent 
Budget (IB) (Paralyzed Veterans of America and Veterans of Foreign 
Wars), other major veterans service organizations (VSOs), VA Secretary 
Shulkin, the Commission on Care and many Members of the House and 
Senate, have discussed, debated and ultimately coalesced around a 
common long-term vision for reforming the veterans health care system. 
All support the concept of developing an integrated network that 
combines the strength of the VA health care system with the best of 
community care to offer seamless access for enrolled veterans. VA 
should remain the coordinator and primary provider of care with 
community partners, including the Department of Defense and Indian 
Health Service systems, providing additional expertise and access 
whenever and wherever necessary. That is a system that puts veterans 
first and gives them real choice. However, the continuing push by some 
for unfettered and unlimited ``choice'' is unrealistic and has the 
potential to delay and distort plans to move forward with implementing 
the shared vision of the veterans community and active users of the VA 
health care system. In order to better understand where VA needs to go 
in the future, it is important to first understand the lessons and 
problems of the past.

BACKGROUND

    Since the catalyst that began this debate was lack of access, it is 
important to understand the true underlying causes of the access 
problems facing veterans.
    For more than a decade, DAV and our IB partners have testified to 
Congress about the challenges in accurately measuring and consistently 
providing veterans with timely access to VA health care; and these 
testimonies have been validated by outside audits. For example, in 
December 2012, GAO investigated reports of long wait times for 
outpatient medical appointments and found that the metrics provided by 
VHA were ``unreliable.'' Furthermore, GAO found that VHA's scheduling 
policy and training documents were ``unclear'' and led to inconsistent 
reporting of wait times. We have also consistently testified about the 
inadequate scheduling, financial and IT systems, as well as aging 
infrastructure that all hindered VA's ability to meet veterans health 
care needs on a timely basis. Furthermore, the limited funds provided 
to local facilities too often forced them to choose between meeting 
internal clinical needs or expanding purchased community care.
    The ability of VA to provide veterans timely access to medical care 
is primarily driven by four factors: how many medical personnel are 
available to provide medical care (resources), how much usable space is 
available to treat veterans (infrastructure), how well VA leverages 
health care capacity in the community (purchased care), and can VA 
produce accurate and valid data to properly manage access issues 
(metrics). Each of these interrelated issues challenged VA for years 
and the inability to fully address them eventually led to the most 
recent access crisis and subsequently, enactment of the VACAA in 2014.
    When Congress created the Choice program, they also authorized an 
``independent assessment'' of VA health care to study the causes of and 
offer solutions for the access problems, resulting in a report by the 
MITRE Corporation, the Rand Corporation, and others in September 2015. 
The independent assessment's first finding was that there was a 
``disconnect in the alignment of demand, resources and authorities'' 
for VA health care. Its first recommendation was that VA must ``address 
the misalignment of demand with available resources both overall and 
locally.'' In terms of access to care, it found that ``increases in 
both resources and the productivity of resources will be necessary to 
meet increases in demand for health care over the next five years,'' 
with a core recommendation of ``increasing physician hiring.'' The 
report also identified key barriers that limited provider productivity, 
including ``a shortage of examination rooms and poor configuration of 
space,'' and ``insufficient clinical and administrative support 
staff,'' all of which would require additional funding for the VA 
health care system.
    Furthermore, the assessment found that the ``capital requirement 
for the Veterans Health Administration (VHA) to maintain facilities and 
meet projected growth needs over the next decade is two to three times 
higher than anticipated funding levels, and the gap between capital 
need and resources could continue to widen.'' It estimated this gap at 
between $26 and $36 billion over the next decade, although management 
strategies could potentially lower the projected gap down to between $7 
billion and $22 billion.
    The findings of this assessment confirmed what The Independent 
Budget veterans service organizations (IBVSOs) have reported for more 
than a decade: the resources provided to VA health care have been 
inadequate to meet the mission of care for veterans. While there are 
many factors that contributed to the access crisis, when there are not 
enough doctors, nurses, and other clinical professionals or enough 
usable treatment space to meet the rising demand for care by enrolled 
veterans, the result will be rationing of care, waiting lists and 
access problems.
    To be clear, DAV and our IB partners have not suggested that simply 
increasing funding by itself-without making significant reforms in VA-
will lead to better health outcomes for veterans over the next 20 
years. However, history shows that no VA reform plan has any chance of 
success unless sufficient resources are consistently provided to meet 
the true demand for services. With more and more veterans seeking out 
VA as it improves access, Congress will have to continue investing 
resources to allow VA to keep up with rising demand, or make difficult 
decisions to restrict enrollment or propose increased fees or 
copayments for veterans' care.

CHALLENGES IMPLEMENTING AND OPERATING THE CHOICE PROGRAM

    As approved by Congress on August 7, 2014, the Choice Program 
allows certain veterans to choose community care if they would 
otherwise be forced to wait more than 30 days for required care or to 
travel more than 40 miles to a VA facility to receive such care. 
However, despite the scope and scale of the law, VA was required to 
stand up this nationwide program for potentially all 9 million enrolled 
veterans in just 90 days.
    Since its inception just over 2 years ago, the Choice program has 
been beset with problems, some resulting from the flawed design of the 
law and others due to the unrealistic implementation schedule mandated 
by Congress. Within weeks of the Choice program's commencement, both 
veterans and VA health care personnel reported confusion about how, 
when, and for what types of care the program was to be utilized. 
Problems with scheduling, health record transfers, care coordination, 
doctor payments, and veterans' copayments all hindered usage of the 
Choice program during its first several months. To address these and 
other technical and implementation challenges, Congress passed, and the 
President signed, two subsequent pieces of legislation (Public Law 113-
175 and Public Law 114-41) which, among other changes, redefined how to 
calculate the 40-mile distance criteria for Choice eligibility and 
removed a requirement that medical records be returned to VA before 
provider payments were made.
    These adjustments, as well as additional training of VA personnel, 
slowly increased utilization of the program. Today, about 31 percent of 
all care paid for by VA is delivered through Choice and other community 
care programs, up from about 22 percent just a couple of years ago. At 
the same time, the VA is also delivering more care inside its own 
facilities and wait times are dropping, according to VA, as new access 
programs, such as same day care, are instituted. The challenge is how 
to move forward with a long-term solution that continues to close 
access gaps, while maintaining a robust VA health care system that 
millions of disabled veterans choose and rely on.

DEVELOPING PLANS FOR REFORMING VA HEALTH CARE

    As mandated by Public Law 114-41, VA developed and submitted a plan 
to Congress in September 2015 to consolidate non-VA community care 
programs, including the Choice Program. VA's plan called for creating a 
``high-performing network'' comprising both VA and community providers 
to create seamless health care access for enrolled veterans. In 
building its network, VA proposed first relying on the most cost-
effective, compatible, and highest quality community partners 
(particularly the Department of Defense [DOD], the Indian Health 
Service [IHS], and other federal health systems), then university 
hospitals that have existing academic affiliations with VA, followed by 
the best of private providers. Under its plan, VA would serve as the 
coordinator and guarantor of care for veterans to ensure that all 
veterans have a seamless experience when accessing VA and non-VA care 
in the community. Most enrolled veterans would continue to get most of 
their care directly from VA, with network partners filling in access 
gaps whenever and wherever they occur.
    In 2015, DAV and our IB partners developed our proposed Framework 
for Veterans Health Care Reform based around four main pillars. First, 
we proposed restructuring the veterans health care delivery system by 
creating local integrated veteran-centric networks to ensure that all 
enrollees have timely access to high quality medical care. VA would 
remain the coordinator and primary provider for most veterans. We also 
called for establishing a veterans-managed community care program to 
ensure that veterans living in rural and remote areas have a realistic 
option to receive veteran-centric, coordinated care wherever they may 
live. This would require local communities to work with VA's Office of 
Rural Care to develop relationships with local providers, as well as 
increased flexibility in reimbursement rates to attract and retain 
community partners.
    Our second pillar for reform called for redesigning the systems and 
procedures that facilitate access to health care by creating a new 
urgent care benefit and taking other actions to expand access to care, 
such as extended hours in evenings and on weekends, as well increased 
use of telehealth. We recommended that as the new integrated networks 
are fully phased in, decisions about providing veterans access to 
community network providers should be based on clinical determinations 
and veteran preferences, rather than arbitrary time or distance 
standards that exist in the current Choice program.
    Third, we proposed realigning the provision and allocation of VA's 
resources to better reflect its mission by making structural changes to 
the way federal funds are appropriated, distributed and audited. Our 
plan calls for strengthening VA's budget and strategic planning process 
by establishing a Quadrennial Veterans Review, similar to the 
Quadrennial Defense Review currently used by the Department of Defense.
    The fourth and final pillar of our framework called for reforming 
VA's culture with transparency and accountability. In this regard, we 
strongly support the MyVA initiative, which has already resulted in 
good progress in making system-wide changes putting veterans in the 
center of VA's planning and operations, so that their needs and 
preferences are paramount.

COMMISSION ON CARE

    VACAA also required Congress to create an independent Commission on 
Care to study and report recommendations to VA and Congress about how 
to strengthen the VA health care system over the next 20 years. The 
Commission examined a wide range of ideas and options, including the 
IB's proposed Framework and VA's Community Care Consolidation Plan. It 
also considered proposals to privatize or dismantle the VA health care 
system, but ultimately the Commission rejected such radical ideas, 
instead reaching an overwhelming consensus on a series of 
recommendations to strengthen and reform the VA health care system.
    The Commission's principal recommendation called for establishment 
of ``high-performing, integrated community-based health care 
networks.'' Similar to the VA and IB plans, the Commission 
recommendation would maintain VA as the coordinator and primary 
provider of care and use community providers to expand access in 
circumstances in which VA is unable to meet local demand for care. 
Unlike the IB framework or VA plan, the Commission proposed allowing 
veterans to choose any primary or specialty care provider in the 
network even when VA is able to provide the requested care in a timely 
fashion. The Commission itself recognized that this would likely result 
in higher costs for networks under its recommended ``choice'' option, 
cautioning that VA ``must make critical tradeoffs regarding their size 
and scope. For example, establishing broad networks would expand 
veterans' choice, yet would also consume far more financial 
resources.'' In fact, the Commission's economists estimated that the 
recommended ``choice'' option could increase VA spending by at least $5 
billion in the first full year and that it could be as high as $35 
billion per year without strong management control of the network. The 
Commission also considered a more expanded ``choice'' option to allow 
veterans the ability to choose any VA or non-VA provider without 
requiring it to be part of a VA network. The economists estimated such 
a plan could cost up to $2 trillion more than baseline projections over 
just the first 10 years.
    The Commission acknowledged that, ``veterans who receive health 
care exclusively through VHA generally receive well-coordinated care . 
. . [whereas] . . . fragmentation [of medical care] often results in 
lower quality, threatens patient safety, and shifts cost among 
payers.'' While veterans' individual circumstances and personal 
preferences must be taken into consideration, decisions about access 
must first and foremost be based on clinical consideration, rather than 
on arbitrary distances or waiting times. However, in order to ensure 
consistently reliable access as well as high-quality care for enrolled 
veterans, VA must retain the ability to coordinate and manage the 
networks. As the commission's report states, ``well-managed, narrow 
networks can maximize clinical quality,'' while ``achieving high 
quality and cost effectiveness may constrain consumer choice.''
    With such broad consensus among veteran experts and stakeholders, 
the question that this Committee and this Congress face is whether to 
continue debating prohibitively expensive, clinically unsound and 
politically unrealistic proposals to offer every veteran unfettered 
``choice,'' or whether to move forward and build integrated networks 
capable of ensuring that all veterans have a real choice for quality 
care.

EXTENSION OF TEMPORARY CHOICE PROGRAM

    Mr. Chairman, with just five months until the current authorization 
ends, it is critical that Congress work with VA to extend the Choice 
program to allow VA to utilize all of the remaining funds in the Choice 
account and to ensure continuity for veterans who access care through 
this program. H.R. 369, legislation you introduced earlier this year, 
would accomplish that by removing the sunset date and allowing the 
program to continue until the funds provided for this program are 
exhausted. DAV supports this legislation as a short-term and temporary 
measure to ensure that veterans using Choice do not fall through the 
cracks while waiting for further reforms, as discussed above, to be 
enacted and implemented.
    However, Choice should be extended on a short-term basis and only 
for as long as necessary to enact and implement a long-term solution 
based on the integrated network model. Choice should not be expanded to 
open up the program to new categories of veterans for both clinical and 
fiscal reasons. Absent a well-managed, high-performing network, putting 
more veterans into the Choice program would result in less coordination 
of care, increased fragmentation of services, lower quality and 
ultimately worse health outcomes for more veterans. In addition, even a 
limited expansion of the current eligibility for the Choice program 
would add significant fiscal costs at a time when demand for VA health 
care is already rising faster than resources provided by Congress.
    In order to ensure continuity, Congress will need to act quickly, 
however there are additional changes that have been proposed to address 
related issues with Choice and community care programs, including 
making VA the first payer, changing when obligations are recorded, and 
authorizing new provider agreement authority. These changes would 
strengthen not just Choice, but all community care programs, and are 
essential to support the creation of an integrated network proposed by 
DAV, VA, the Commission and others. Whether some or all of these and 
other improvements to integrated community VA care are included in the 
legislation to extend the Choice program's authorization, these changes 
should be fully debated, carefully drafted and subsequently enacted in 
order support development of integrated networks necessary to provide 
veterans with real choices for quality care.
    In addition to providing a short-term bridge, VA needs to move 
forward with its Request for Proposal (RFP) that was drafted and issued 
late last year. The RFP developed by VA in consultation and 
collaboration with a number of stakeholders, including DAV and other 
VSOs, would lead to a contracting process with national health care 
providers capable of serving as VA's community partners in an 
integrated network. Given the history of problems standing up the 
Choice program, it is essential that VA and its new partners have 
sufficient time to carefully develop and implement the new integrated 
network model of care. There are, however, a number of critical issues 
that still need to be fully resolved before such implementation; 
including new scheduling and claims payment systems, as well as the 
ability for sharing health records, providing care management and 
defining patient eligibility. While continuing to appropriately fulfill 
its oversight responsibilities, we urge Congress to support VA's 
efforts to move the RFP process forward so that VA can enter into 
contracts with appropriate national providers before the end of this 
year.
    Furthermore, Congress must work with VA to set realistic 
expectations for the implementation of these much needed long-term 
reforms. Many of the supporting systems and technologies necessary to 
support a truly seamless integrated network capable of delivering 
consistently high-quality and timely care will need to be developed, 
optimized and customized for VA before full implementation of the new 
system. Also, the goal of eliminating all access limitations on 
community care, including the current 40-mile and 30-day Choice 
standards, can only be phased out as the integrated network becomes 
fully operational to avoid unintended negative fiscal and clinical 
outcomes. Further, the challenge of providing seamless, timely access 
to veterans living in rural and remote communities will require special 
attention, creative approaches and sufficient time and resources to be 
accomplished. The Commission's charge was to develop plans to 
strengthen the VA health care system over the next 20 years. In its 
report, the Commission makes clear that this is a significant 
undertaking that will likely take a decade or more to accomplish. The 
report states: ``The fruits of the transformation. will not be realized 
over the course of a single Congress or a single 4-year 
administration.'' Considering the magnitude and importance of this 
transformation, it is imperative that Congress and VA begin moving 
forward, now.

SETTING THE RECORD STRAIGHT

    Unfortunately, despite the broad agreement among stakeholders and 
policymakers, there are still some individuals and organizations 
promoting an unrealistic vision of ``choice'' without providing any 
clear definition or specifics, adding confusion and delay. That's why 
DAV is continuing its ``Setting the Record Straight'' campaign: to 
ensure that the cost and consequences of ``choice'' are understood in 
any plan that Congress considers. Last month we released a short video 
entitled ``Putting Choice in Context'' that explores the real costs and 
consequences of unrealistic ``choice'' options, and debunks a number of 
misconceptions about ``choice'' and VA health care. For example, the 
idea that veterans would be able to choose any doctor in their 
community is simply not true. Some doctors don't accept ``choice'' 
payment rates and in many communities, particularly rural America, 
there are not enough or even sometimes any physicians to choose from. 
For too many veterans, simply having a ``choice'' card could leave them 
without any options to find a qualified physician.
    Another false premise is that allowing all veterans to go to 
private providers would lead to better quality health care and 
outcomes. The reality is that numerous independent studies by Rand 
Corp. and others have consistently shown that VA today provides equal 
or better care than the private sector. Furthermore, if expanding 
``choice'' forces more veterans to receive part of their care in the 
community - without first establishing a managed and coordinated 
network, the result will be more care that is fragmented, which can 
actually lower quality and lead to worse health outcomes for many 
veterans. Even the idea that ``choice'' will increase access for 
veterans is a much more complicated issue. If ``choice'' were 
significantly expanded, moving more veterans to the private sector, VA 
would almost certainly be forced to significantly downsize or close 
some hospitals and clinics, and curtail medical services in others due 
to lesser demand. However, veterans who continue to choose VA for their 
care would find fewer services being offered, or they would have to 
travel further or wait longer to receive care. The result for many 
veterans, particularly disabled veterans who disproportionately rely on 
VA, could be less access and no ``choice'' to use VA.
    The idea that ``choice'' is a ``magic bullet'' capable of solving 
all of VA's health care challenges is simply not supported by objective 
facts, was not the conclusion of the Independent Assessment or 
Commission on Care and does not have significant support within VA or 
the veterans community. The use of community care, or ``choice,'' 
should certainly be a part of the long-term solution, but only if it 
fits into the big picture of strengthening and reforming the VA health 
care system as outlined above.
    Mr. Chairman, after more than two years of spirited and passionate 
debate in the 114th Congress over the future of veterans health care, 
there is now a growing consensus on how best to strengthen, reform and 
sustain the VA health care system. Veterans and their representative 
organizations, independent experts, VA leaders and many members of 
Congress agree that the best veterans health care system would consist 
of integrated networks that combine the strength of VA with the best of 
community care to offer veterans real choices for quality and timely 
care. We look forward to working with you to help fill in the details 
of such a plan for the next evolution of VA health care and we urge you 
and your colleagues in the 115th Congress to start implementing this 
shared vision so that ill and injured veterans can get the care they 
have earned and deserve, whenever and wherever they need it.

                                 
                           TRIWEST HEALTHCARE
              Written Testimony Mr. David J. McIntyre, Jr.
                           President and CEO
Introduction

    Good evening, Mr. Chairman and Members of the House Committee on 
Veterans Affairs. Thank you for the opportunity to submit this 
statement regarding the status of the Choice Program in our geographic 
area of responsibility, which includes 28 states and three U.S. 
territories. It is a privilege to be of service to the Veteran 
constituents of so many on this distinguished committee in support of 
VA's critical mission to care for those who have borne the cost of the 
battle.
    We count it a privilege to have been working in close partnership 
with VA since the start of the Choice Program to improve access to care 
for Veterans across our service area. And, we look forward to doing our 
part to support Secretary Shulkin and his team in the successful 
execution of the elements of his 10 Point Plan that are relevant to our 
work.
    As I am sure we would all agree, there is still work to be done to 
mature the program so that it fully fulfills what was envisioned by 
Congress when it was necessarily enacted quickly in response to the 
access crisis. I am pleased to report, however, that our provider 
network has now delivered more than 4.2 million appointments for 
Veterans in support of VA's critical mission to care for those who have 
borne the cost of the battle.

A Historical Perspective

    TriWest was formed 21 years ago by a group of non-profit Blue Cross 
Blue Shield plans and university hospital systems for the sole purpose 
of bringing their core competencies and unrivaled market presence to 
the side of government as it sought to fulfill the nation's commitment 
to those who answer the nation's call and their loved ones by turning 
to community providers to provide the needed elasticity to fully meet 
demand. For the leadership team of TriWest and our more than 3,000 
employees, most of whom are Veterans or family members of Veterans, 
what we do is more than a job; it is an honor to which we are 
steadfastly and passionately committed!
    Our first 18 years were spent supporting the Department of Defense 
(DoD) in standing up and operating the TRICARE program in what would 
ultimately be a 21-state service area. I'm proud of the work we did to 
assist DoD in making TRICARE a great success. While the early days of 
TRICARE were also challenging, we soon made it through them and that 
platform fulfilled its potential. especially at the height of the War 
on Terror, as it gave the DoD the ability to deploy a substantial 
portion of its medical assets to support the war fighter while we and 
our provider network handled a substantial portion of the need 
domestically.
    Getting to success in TRICARE, just has been the case with each new 
large health program, starting with the implementation of Medicare and 
Medicaid in the 1960's, took several years. And, with TRICARE, DoD and 
the contractors had 15 months to prepare for the start-up of TRICARE 
and 9 months to implement it. With the Veterans Choice Program, 
however, this 24-month period was necessarily shrunk to a little more 
than 30 days. And, like after the start-up of TRICARE, we are very 
focused on the needed refinements so that the program matures to what 
was envisioned with its passage. To this end, Mr. Chairman, we look 
forward to responding to whatever refinements that your Committee and 
the Administration believe will be needed to get the program to its 
next iteration.

Progress Made in Refining Choice and Enhancing Access

    In April 2014, the country was shocked to learn of the access 
crisis at the Phoenix VA Medical Center and the 14,700 Veterans 
standing in line waiting for care (including some 3,300 urology 
patients). Of course, as we now know, Veterans in many other 
communities were also suffering from a lack of access to needed care. 
Thus, it is little surprise Mr. Chairman that you and your colleagues 
in Congress would respond to the crisis with the sense of urgency that 
you did.
    Shortly after the August 2014 enactment of the law creating the 
Choice Program, VA conducted an industry meeting to seek input on 
implementing the Choice Program and were told by most in industry that 
they simply could not respond in the timeframe required. Not believing 
it was appropriate to leave our fellow citizens who had borne the cost 
of war in a line waiting for needed care, we took a deep breath, rolled 
up our sleeves and stepped forward to answer the call. At that point, 
we and VA had a little more than 30 days to design and stand up the 
Choice Program; however, it was an opportunity to step up and answer 
the call in support of those who did whatever it took to respond in the 
nation's hour of need!
    While I understand that it is hard for most to see past the very 
early challenges we experienced and those that still remain, I will 
tell you that I have never been more impressed in my two decades of 
being engaged in this work than with the uncommon focus and tireless 
efforts of the team at VA who rose to the occasion and collaborated 
fully and vulnerably to ensure that we were operational on Day One. 
Within record time, we created the infrastructure, hired and trained 
hundreds of staff, and got Choice cards into the hands of 4 million 
Veterans in our area of responsibility. We even stood up a state-of-
the-art contact center architecture even making sure that callers to 
the toll-free line would end up with the right contractor and were 
greeted by the voice of the Secretary, thus underscoring the importance 
of this new initiative.
    That spirit of full collaboration between VA and TriWest has 
progressed and matured significantly over the past two years, 
completely earning our respect in this very complicated and challenging 
journey on which we necessarily find ourselves. This is a dynamic 
relationship in which we all continue to refine and strengthen 
operational processes and communication. Although there is still work 
to do, I am very proud of what we have collectively accomplished and I 
am confident that the trajectory on which we are on will lead to 
continued refinement to make it even better than the solid TRICARE 
program is today.
    One of the core challenges when we started our work with VA was 
that they did not have a clear view of the demand for care, which is 
likely part of how we all ended up here in the first place. Thus, it 
made it difficult to ensure a properly tailored network of providers 
and the subsequent needed infrastructure of systems and people to 
support the real demand as a company. But, after a lot of effort and 
expense that reality is now well behind us in our area of 
responsibility.
    And, then when we turned everything on we found the initial volumes 
to be very low and take a time to build as Veterans were just learning 
of the new option for access they had as a result of this program. In 
fact, in the first month, January 2015, we responded to and facilitated 
a mere 2,000 appointment requests across our entire 28 state service 
area. Today, we are scheduling over 100,000 Veterans a month for care 
in the community. a dramatic 50-fold increase in just over two years. 
In total, the 180,000 providers in our network have served the health 
care needs of more than 800,000 Veterans to the tune of over 4.2 
million appointments. The average number of days to make an appointment 
with a community care provider is now 3 days, with less than 2% of the 
care requests being returned due to lack of a network provider of the 
specialty type needed. Further, we are now processing and paying about 
97% of clean provider claims within 30 days.
    Not only is the network tight and mapped to the demand profile of 
each market to optimally support VA in the markets in which we are 
privileged to serve in support of VA, to optimize customer service 
delivery we rolled out an infrastructure model that provides localized 
service in now 10 operational sites. with at least one per VISN. And, 
our performance is reasonably tight, with an average speed of answer 
below 30 seconds and servicing more than 800,000 calls per month.
    Not yet finished, we and VA are in the process of building new 
enhancements and piloting ways to make the program even more Veteran 
centric and to improve the experience for community providers, just as 
was done in the early years of TRICARE.
    I know that the road has not been painless or easy for anyone 
involved, especially for the Veterans we are here to serve and the 
providers we have asked to join us in taking care of their needs. 
However, tremendous progress has been made in refining the Choice 
Program in our area of responsibility and a lot of access is being 
provided.
    But the mission is not yet complete, and we know that is part of 
the reason for today's hearing.
    Mr. Chairman, like you, your colleagues on this Committee and in 
the rest of Congress, and the team at VA, we believe that understanding 
the challenges and gaps that still exist is critical to ensuring that 
we are focused on the right things in fulfilling the promise you all 
had in mind with the creation of the Veterans Choice Program.
    To that end, the work of the VA OIG and GAO, and your own 
Committee, is critical to understanding where we sit and the road still 
to be travelled.
    As you know, the IG recently released a report regarding their 
assessment of the early days of the Choice program. And we know that 
the GAO has been looking at the same. The work of both entities is 
imperative to understanding where we were in the early days of this 
understandably challenging journey. So, too, is knowing where we stand 
today. so that any action might be informed by today's reality rather 
than yesterday's challenges. To that end, you will find an attachment 
to this testimony that takes the OIG Report findings for our area of 
responsibility and brings the data and program performance information 
to the present period. We hope this will be a helpful lens to you and 
your colleagues on the Committee as you contemplate where we really 
stand with regard to this program in at least one half of the country 
and what makes sense for the way ahead as you and VA seek to continue 
to refine this invaluable tool to enhance access to care for our 
nation's most treasured asset. its Veterans.

Appointments/Program Demand

    As I stated previously, the network of 180,000 providers built by 
TriWest Healthcare Alliance's non-profit Blue Cross Blue Shield and 
University Hospital system owners has now facilitated 4.2 million 
appointments for Veterans in our area of responsibility. Without the 
Choice Act, those appointment requests would have increased appointment 
wait times at VA hospitals and clinics for all Veterans in need of 
care. Moreover, 95% of all appointments are being scheduled within 5 
business days of authorization.
    As a result of now streamlined processes, in the first 6 weeks of 
2017, TriWest's staff had scheduled Veterans from the creation of their 
authorization within an average of 2 business days (a decrease of 60% 
from the 2015 average of 5 business days). And rather than the required 
30 days in which the appointment must be completed, TriWest's network 
is seeing Veterans on average in 15 days, a decrease of 33% from our 
average wait time in 2016 of 20 days.
    Since the beginning of the year, we have already appointed over 
87,600 Veterans to care in the community.
    We have also been very focused on trying to increase the accuracy 
of appointing. And, while we are not yet finished with the initiative, 
we are pleased to report that TriWest is now scheduling 98% of Veterans 
with the correct provider the first time.
    Also important, as highlighted in one of the recent reviews, is the 
need to shrink the amount of time that it takes for an appointment to 
be scheduled with the community provider from the time that VA 
identified the need. While VA has been focused with its parts of the 
process in order to speed up the time it takes to get a Veteran to us 
for appointing once the need is identified, we have been focused on our 
part of the process that pertains to when we receive the appointment 
request to the date on which the Veteran is seen. We are pleased with 
the progress that we have made in reducing the cycle times for the 
various steps in our part of the process of getting the Veteran placed 
with the needed provider. The chart below highlights the progress we 
have made in this area of significant focus from the period of January-
April 2016 to December of 2106:
[GRAPHIC] [TIFF OMITTED] T9371.006


Claims Processing

    If community providers are asked to provide care that VA is unable 
to provide itself, it is critical that they get reimbursed for the 
services they provide on a timely and accurate basis. Unfortunately, 
the early struggles in TRICARE have somewhat repeated themselves with 
this work in support of VA.
    At the start of TRICARE it became apparent that DoD had not had a 
good history of paying provider claims prior to when the network was 
built and brought to the side of the DoD direct care system to provide 
access to care when DoD was unable to meet the needs of TRICARE 
beneficiaries themselves. Early on in that work it became apparent that 
DoD was challenged in setting up the necessary systems and processes to 
enable us to pay the providers on an accurate and timely basis. And it 
took three years to get our arms wrapped around it and get it 
completely fixed. The result of that work, though, is that TRICARE 
contractors are processing quickly and accurately and DoD is rapidly 
reimbursing them for the claims they pay providers on their behalf. DoD 
then subsequently audits the accuracy of claims payment on the back 
end. But getting to that solid place of performance was very painful 
and was frustrating to the provider community as they thought that 
things would magically get better when we arrived.
    In this work with VA, history has unfortunately somewhat repeated 
itself.
    First, when we began to set up the provider network we heard from 
provider after provider who had not been paid timely or accurately for 
the services purchased from them directly by VA over the years. As we 
would soon discover, this was not the experience of only a few. In 
fact, some providers are still owed vast sums of money for services 
that had been ordered and were to be paid for directly by VA. They 
expected that it would be different with us coming onto the scene. yet 
some of the same gaps early on drove a repeat of their prior experience 
with VA. Fortunately, that is now starting to turn.
    Second, VA set up this work in a fashion that had them re-
adjudicating each claim we paid on its behalf, rather than reimbursing 
us for the claims that we paid to providers for the care authorized by 
VA and then performing audits for accuracy. And, what's more, they did 
not provide us with the rules logic so that we could map our processing 
system to match the way in which they wanted us process claims, nor did 
VA establish a process to review and resolve those claims that VA 
rejected. Instead, VA allowed them to stack in a queue with no process 
for resolution,,, just as we learned has been the experience of many 
providers across the country prior to us engaging in this work.
    Third, they started with the work being processed manually by each 
VISN. which led to a very inconsistent performance picture in that 
there was inconsistency in approach, staffing, and performance.
    The difficulty of having to set up the programming of our own 
systems in such short order added to these complications, as did the 
lack of maturity in the work. which was new to all of us.
    In January 2016, I brought the challenges of this issue to then 
Secretary McDonald, Deputy Secretary Gibson, and UnderSecretary for 
Health Shulkin, and Dr. Baligh Yehia, and we began the collaborative 
work to rectify the issues. Frankly, a lot of progress was being made 
quickly with the result being that we were successfully working down 
what had become a massive accounts receivable. In fact, nearly a year 
ago, we had reached a place where we were processing within 20 days 
against the 30 day standard. And, then in the Summer, with no 
forewarning to VA, HealthNet dropped 500,000 claims in VA's lap on a 
single day looking for reimbursement. Needless to say, with limited 
staff within VA and the aging of the dates of service for those claims, 
VA's ability to process our invoices came to a dead stop. And, by the 
Fall, our performance had nosedived to nearly 65 days to process and 
pay providers and VA again had built up a massive accounts receivable 
with TriWest.
    In mid-October, I reached out to the same leaders in VA and they 
agreed to again roll up their sleeves in search of a solution that 
would solve the underlying issues while eliminating our accounts 
receivable so that we could get back to timely processing and payment 
of provider claims. While it has not been a journey without 
complication, I am pleased to report that as a result of the hard work 
and focus of the entire team, and a $45 million capital infusion by our 
non-profit owners, that we are nearly complete with the execution of 
all of the pieces of that November 5 agreement and are now back to 
processing and paying nearly all clean claims within 30 days.
    There are three things I believe, however, that still need 
resolution.
    First, we believe that VA should not be in the claims processing 
business when they have private sector organizations paying the 
providers in their own networks for the care that is rendered in the 
community. Like TRICARE and Medicare Risk, claims should be paid by the 
entity that built the network and then VA should audit the contractors 
for compliance on the back end.
    Second, the antiquated process of having to estimate the nature of 
the encounter and the cost of every unit of care for a Veteran before 
he or she leaves the VA medical center for that care in the community 
and then reconciling it on the back end needs to come to an end. It is 
inefficient, ineffective, costly and slows the ability of the Veteran 
to get to the care they need.
    And third, the turnaround for VA payment of claims invoices for 
contractors should be no more than 7 days. We are in effect functioning 
as the bank for VA. In a perfect world we would be drawing from an 
account they have established, but if that can't be made to happen then 
we should be reimbursed in more than 7 days.
    While work still remains, I would be remiss if I did not compliment 
the team at VA. They are focused, led by a hands on Secretary and team 
underneath him (just as was the case prior to him stepping up into his 
new role), who are collaboratively attempting to resolve the issues 
that have been complicating our ability to achieve the success we all 
desire.
    And, while we still have work to do, just as we did at this 
juncture in the early days of TRICARE, I am pleased to report that we 
have now processed and paid in excess of 6.5 million claims (455,000 in 
the month of January alone) and are again honoring our obligation to 
pay providers on a timely basis as VA is doing in reimbursing us for 
those payments.

Streamlined Processes and Procedures for Accessing Care

    TriWest has worked collaboratively with VA to address a number of 
operational gaps that have been identified and needed adjustments are 
being made around five core initiatives which Dr. Yehia and his team at 
VA have led since January 2016:

  Simplifying the Referral/Authorization Process:
    Transmitting packages to the contractor through a portal and 
scheduling an appointment using the Veteran's preferences is a 
complicated process which results in work duplication and care delivery 
delays. We are working closely with VA to streamline the process, with 
a goal of implementing an automated process that is easy to understand 
and complete.

  Decrease Returned Authorizations/Make the Capturing of Return 
    Reasons More Accurate: Authorizations are returned for several 
    reasons, such as when no network provider is available; the Veteran 
    declined the appointment or distance; we are unable to reach the 
    Veteran; VA requested the authorization be returned due to 
    inactivity or other reasons; or the authorization is a duplicate. 
    We have worked with VA to refine and expand return reasons from the 
    very limited number of options from which to choose to a broader 
    set so that we can analyze the gaps by category and track 
    performance in remediating them. In addition, we have embedded 
    staff in over 40 VAMCs to facilitate better coordination between VA 
    and us; continued to focus on training staff on return reasons and 
    the return process; and spent a massive amount of money to re-
    tailor our network to ensure that it is sized to meet the actual 
    needs of each VAMC in our area of responsibility. These initiatives 
    are indeed producing success and the number of returns continues to 
    be on the decline.

  Improve Customer Service: TriWest has improved customer 
    service for Veterans by developing an entirely new Customer 
    Relationship Management (CRM) System that is customized to this 
    work, assisting in the delivery of effective and efficient customer 
    service encounters through an improvement in the user interface and 
    the ability to document outbound and inbound calls with Veterans. 
    We also have implemented a Behavioral Analytics Call Monitoring 
    System which helps improve staff interactions with customers, VA 
    staff, providers and Veterans alike.

  Improve Process Efficiency: TriWest's VA portal is the medium 
    through TriWest and VA staff order and track health care services 
    in the community for Veterans, as well move information and data/
    information relevant to the provider and needed back in the hands 
    of the VA provider and the medical record of the Veteran. To 
    improve the overall process, TriWest solicited feedback on our 
    initial VA Portal from VAMCs. Based on VA feedback, a new 
    redesigned portal was rolled out in July 2015, bringing streamlined 
    processes, which increased portal utilization and improved the 
    efficiency and effectiveness for both VAMCs and TriWest.

    The pace of identifying gaps and resolving them necessarily remains 
aggressive between our company and VA, so that we can speed the needed 
changes to Veterans that reside in our area of responsibility in our 
collective quest to enable the Veterans Choice Program to achieve its 
potential and enhance access to care for Veterans thus enabling VA to 
fulfill its mandate to care for those who have borne the price of the 
battle.

Continuing to Pursue the ``Art of the Possible''

    Mr. Chairman, I believe the Choice program is working in our 
geographic area of responsibility. Having said that, though, we are not 
finished with the refinement of the program and are in the midst of 
developing or testing a series of prototypes and pilots to explore that 
which will be most effective in further improving the program.
    First, we are launching a self-appointing pilot this month in 
Tennessee that will leverage common technology on smart phones to allow 
Veterans, under controlled circumstances, to self-appoint with certain 
categories of providers. This is aimed at increasing efficiency for 
Veterans in gaining access to the care they need. We expect it to be 
very successful and will be looking to quickly expand it across our 
geographic area of responsibility once we have proof of concept.
    Second, with a desire to enhance access to needed behavioral health 
services in order to give VA the enhanced access to these critical 
services it needs, we are moving beyond simply appointing to our 
substantial behavioral health network numbering more than 25,000 
providers. We have invested in and are training our behavioral health 
providers in evidenced-based therapies that are known to be maximally 
effective in meeting the needs of Veterans. And, we have designed and 
deployed a tele-behavioral health platform to connect community 
behavioral health providers with Veterans in need of counseling, who 
desire the use of this tested modality of care delivery. The initial 
rollout of this initiative is in Phoenix and San Diego, with geographic 
expansion to come soon as this is now taking hold.
    Third, in an effort to ensure that those who are presenting 
themselves in VA Medical Center Emergency Rooms, where there is a lack 
of inpatient mental health beds to meet the needs of Veterans, we and 
VA just designed and deployed a pilot program in Wichita, KS that has 
us placing the Veteran in an inpatient bed in one of our nearby 
behavioral health network providers rather than letting them wander out 
the front door without receiving services and putting their life at 
risk. This pilot builds on a similar one we conducted in Phoenix, which 
was very successful in eliminating suicides of this category.
    Fourth, we are testing whether it is possible to provide Veterans 
with ready access to lab and radiology services in the community in 
which they reside, drawing from our extensive network, rather than 
forcing them to drive great distances to a VAMC for such services. This 
pilot will start soon in support of the VA community based outpatient 
clinics in Show Low, Arizona and just north of Los Angeles, California.
    Fifth, to enhance access to primary needed primary care services, 
particularly in the evenings and on the weekend for a Veteran suffering 
from an ailment such as a sinus infection, they will be able to go to a 
convenience clinic to receive their care, like those in the private 
sector, rather than waiting for the VA facility to have an available 
appointment. This pilot, which we and VA have been developing, will 
start to be tested in Phoenix, Arizona in the next couple of weeks.
    Sixth, leveraging a network that includes more than 50,000 primary 
care providers, there are communities within our area of responsibility 
where VA is evaluating whether it makes sense to leverage that network 
versus operating or contracting for community based outpatient clinic 
services. In many areas, VA operates community-based outpatient clinics 
that are staffed by either a single provider or a part-time provider. 
These small clinics create continuity of care and access issues; not an 
ideal situation. There are also other areas where the demand just does 
not seem to justify the existence of the site when care is otherwise 
available in the network. A test is underway in a couple of communities 
across our geographic area of responsibility for making primary care 
available in the zip code in which the Veteran resides rather than 
making them travel to a sparsely used and staffed CBOC that is far from 
where they reside. In the long term, I wonder whether the VA ought not 
to simply leverage the network they already paid for and provide access 
to primary care in all zip codes but those where the density truly 
justifies the investment. It would be more cost effective for taxpayers 
and convenient for Veterans.
    Lastly, in a constant effort to improve the performance of the 
program for Veterans and providers, VA and TriWest are in the process 
of launching a prototype that leverages network providers who are high-
performing through a process that will enable the community based 
outpatient clinic and community providers to serve the Veterans right 
in Harlingen, Texas rather than having to drive 5 hours each way to San 
Antonio or go without needed care. I believe this model will stand as 
one of the models that should be replicated across communities with 
similar attributes in order to provide Veterans will access to a 
collaborative approach that fully leverages the best of both VA and the 
community providers to meet the needs of Veterans in the most efficient 
manner possible. At the end of the day, the key outcomes for Veterans 
will be an expedited process that will offer same day authorizations 
for community care appointments, electronic filing and payment of all 
claims, and digital sharing of medical records between community 
providers and VA.
    Mr. Chairman, it goes without saying that we are in the midst of a 
major reform of VA health care. We collectively have an opportunity to 
enhance access and make the health care delivery model more efficient 
and effective. I believe doing so will necessitate leveraging the best 
of both the public and private sectors, and we are excited about the 
framework defined in Secretary Shulkin's 10 Point Plan and are looking 
forward to learning of his specific thoughts with regard to Choice 2.0. 
We count it a privilege to be involved in this critical effort to 
enhance access to care for Veterans and will continue to push ourselves 
at the side of you, the rest of your colleagues in Congress and VA in 
attempt to achieve the optimal state of operation. A strong public-
private partnership that builds on what VA does best and leverages 
private sector provider networks and best practices will foster 
innovation. It also, if configured correctly, will provide 
accountability and transparency, both of which are essential for 
regaining Veterans trust of the system. Know that we look forward to 
continuing to work together for the betterment of VA health care, 
alongside VA and Congress, and to doing whatever it takes to make sure 
Veterans receive needed health care promptly and easily.

Conclusion

    Mr. Chairman, I hope my testimony has provided some useful 
information on the status of the Choice Program in TriWest Healthcare 
Alliance's area of responsibility, as well as what I believe to be the 
``art of the possible.'' I also hope this testimony and the progress 
that we have made since the necessarily very rapid design and start-up 
of the program has demonstrated the steadfast commitment of TriWest's 
leadership, owners and 3,000 employees to push ourselves in the quest 
to bring optimal performance and access to enable VA to be able to 
optimally serve those who have served. It is an honor and awesome 
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 remain dedicated to this critical task, as you and 
your colleagues challenge all of us to continue to raise the bar in 
support of our nation's Veterans. We 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!
                           TRIWEST ATTACHMENT
TRIWEST HEALTH CARE ALLIANCE RESPONSE TO VA OIG REPORT

    TriWest Healthcare Alliance respects the Department of Veterans 
Affairs (VA) Office of Inspector General (OIG) review of the Veterans 
Choice Program (VCP) in its report dated January 30, 2017, and supports 
its recommendations to improve the program. In fact, we have been 
working closely in support of VA to address many of the items in this 
report. Given the fact that the OIG review of VCP in this analysis only 
covered the period up to September 2015, the report does not reflect 
the current state of the program. In fact, over the past 16 months, VA 
and Congress have worked together to successfully adopt and implement 
several important improvements to the program that have resulted in 
significant progress for Veterans and increased their access to care in 
the community. TriWest has proactively worked alongside VA to execute 
these program changes.
    While there were predictably real challenges associated with 
setting up a program of this size and scope in only 90 days (with 
little over 30 days for the Choice contractors), our partnership with 
VA and the 180,000 community health care providers in our 28-state area 
of responsibility has now connected Veterans with over 4.1 million 
total medical appointments since January 2015. That's real progress for 
our nation's Veterans. In fact, TriWest has now served over 800,000 
Veterans and is now receiving over 100,000 Choice requests for care 
each month. And, across all categories of care, the average number of 
days to make an appointment with a community care provider is 3 days. 
Today, less than 2% of the care requests are being returned due to lack 
of a network provider of the specialty type needed. Further, TriWest is 
now processing and paying claims within 30 days for those receiving 
care through the network.
    As we look back on the launch of VCP two years ago, the program 
today provides VA more elasticity to meet the ever-growing demand for 
care. Because of the very focused leadership of Congress and VA to 
recognize and resolve policy gaps during this implementation and early 
refinement phase, Veterans' access to needed community care has 
significantly grown over the past 16 months.
    But the mission is not complete. As the Veterans Choice Program 
continues to grow and more and more Veterans receive care in the 
community, TriWest will continue to work closely with VA, Congress, and 
community health care providers to refine and strengthen the program, 
enhance the Veteran and provider experience, and ensure Veterans have 
greater access to high-quality care closer to home.
    Below is a snapshot of TriWest's operational growth from the start 
of the Veterans Choice Program.

Network:

      VA OIG's report cites inadequate provider networks 
immediately following the 90-day implementation timeline to stand up 
the Veterans Choice Program. At the time (November 2014), TriWest's 
network consisted of approximately 90,000 community health care 
providers.
      Since that time, TriWest has worked directly with every 
VA medical center in our 28-state geographic area of responsibility to 
assess demand for care, and has tailored the network accordingly. Now, 
TriWest's customized and tailored network is comprised of approximately 
180,000 providers, more than doubling since January 2015.
      Since the end of the VAOIG analysis in September 2015, 
TriWest has grown its network by 32%, increasing from 135,000 to over 
179,000 unique providers, to meet the growing demand of the program (IG 
Recommendation #2 and #6).
      Using our innovative Demand Capacity Tool to refine and 
strengthen our network since 2015, TriWest's community providers meet 
Veterans' appointment scheduling needs in each local service area. 
Beginning in July 2015, TriWest's executive leaders met with every 
Veterans Integrated Service Network (VISN) and VAMC director to learn 
exactly what type of network they needed. Today, less than 2% of the 
care requests are being returned due to lack of a network provider of 
the specialty type needed.

Appointments/Program Demand (IG Recommendation #2):

      TriWest has scheduled over 4.1 million total appointments 
(including initial and follow up care) since the start of the Choice 
Program. Without the Choice Act, those appointment requests would have 
increased appointment wait times at VA hospitals and clinics for all 
Veterans using VA care.
      95% of all appointments are scheduled within 5 business 
days of authorization.
      The report cites that at the onset of the Choice program, 
the time from a Veteran opting in to receive care through the Choice 
program to the first completed appointment took an average of 48 days - 
18 days longer than VHA's 30-day standard. Now, as a result of 
streamlined processes, and TriWest's staff of more than 3,000, the 
average number of days to the first completed appointment with a 
network provider is 14 days, a decrease of 33% from the 2015 annual 
wait time average.
      TriWest has worked diligently to address scheduling 
issues over the past two years. Now, as the result of a dedicated 
quality improvement initiative, TriWest schedules appointments with the 
correct provider the first time, 98% of the time.
      Since August 2015, the number of care requests TriWest 
receives on a monthly basis has increased by 120%. Today, TriWest 
receives nearly 110,000 authorizations for Veteran care in the 
community, compared to 50,000 authorizations in August 2015. Program 
usage continues to grow as the program matures and enhances access to 
care for Veterans.
      Over 800,000 unique Veterans across TriWest's 28-state 
territory have received care from a community care provider under the 
Choice program.

Customer Service:

      Since the fall of 2015, TriWest has opened or expanded 
from 2 to 10 operations centers. at least one per VISN. Our volume of 
calls has more than tripled since the beginning of 2015; with our staff 
responding to over 800,000 calls per month, with an average speed to 
answer below 30 seconds.

Claims Processing (IG Recommendation #5):

    TriWest understands the importance of paying community providers on 
a timely manner, and has gone to great lengths to make the provider 
claims submission process easier for providers and ensure claims are 
paid to providers on a timely basis.
      The number of claims received each month has grown from 
114,000 in September 2015 to over 420,000 in December 2016. That 
represents an increase in volume of 268% since the analysis period 
covered by the OIG report.
      During that same period of time, since September 2015, 
the average days TriWest is taking to process claims has overall 
averaged 25 days. In recent months, paying claims on a timely basis 
became complicated by the volume moving through the system. Through the 
effort of both TriWest and VA, the issues have been resolved, payments 
have been made, and a long-term fix has been put in place. Today, all 
claims have been brought current through additional resources from VA 
and TriWest (including $45 million from TriWest's company's non-profit 
owners) in order to decrease the backlog and honor our commitment to 
provide timely and accurate payment to providers.
      The average number of days from receipt of the claim to 
it actually being paid to the provider is currently down from a high of 
65 days (when we and VA started to aggressively confront the backlog 
that has built up through October 2016) to now processing and paying 
claims within 30 days for those receiving care through the network.

Streamlined Processes and Procedures for Accessing Care (Recommendation 
    #1):

    TriWest has worked at VA's side on several initiatives to 
streamline processes and procedures and help improve the PC3/VCP 
programs, including:

      New CRM: TriWest has improved customer service for 
Veterans by investing in an entire new Customer Relationship Management 
(CRM) System to help deliver effective and efficient customer service 
encounters. 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.
      VA Portal: TriWest solicited feedback on the then-
existing VA Portal from VAMCs. This system is the way TriWest and VA 
staff order and track health care services between the two 
organizations. Based on VA feedback, a new redesigned portal was rolled 
out in July 2015, bringing streamlined processes, which increased 
portal utilization and improved efficiency for both VAMCs and TriWest.
      Embedded Staff in VAMCs: In 2015, TriWest worked with VA 
to begin to embed cells of staff within a multitude of VAMCs. Veterans 
accessing VAMCs with embedded TriWest staff are educated in-person 
about program benefits and receive customer service quickly; TriWest 
works directly alongside VA staff to help coordinate Veteran care. 
Today, TriWest has embedded cells of staff in over 40 VAMC locations 
within our geographic area of operations, providing better daily 
coordination at a personal level.
      Top Priorities Workgroups: TriWest collaborated with VA 
to initiate workgroups to develop solutions for VA's Top 5 Priorities-
improving customer service, improving visibility into the network, 
reducing returned authorizations, getting the right provider every 
time, and simplifying the referral process. As a result of these 
meetings, we jointly developed a detailed plan of action and timelines 
to address and execute plans to address each of these five priorities.
      Tele-Behavioral Health (Tele-BH) Pilots: In October 2016, 
TriWest implemented state-of-the-art, tele-behavioral health pilots in 
support of VA's same day behavioral health access initiative. As a 
result, Veterans in several states are experiencing increased access to 
BH care, including in rural areas. The pilot is being expanding to 
multiple states throughout our geographic areas of our responsibility.

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