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




 
         TRACKING TRANSFORMATION: VA MISSION ACT IMPLEMENTATION

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

                             JOINT HEARING

                               before the

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

                                and the

                     COMMITTEE ON VETERANS' AFFAIRS
                              U.S. SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                      WEDNESDAY, DECEMBER 19, 2018

                               _______

                           Serial No. 115-85

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
        
        
        
                             ______

               U.S. GOVERNMENT PUBLISHING OFFICE 
 35-950                  WASHINGTON : 2019
 
 
 
        
        
                  HOUSE 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
BILL FLORES, Texas                   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                   CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas               ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
BRIAN MAST, Florida
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

                 SENATE COMMITTEE ON VETERANS' AFFAIRS

                   JOHNNY ISAKSON, Georgia, Chairman

JERRY MORAN, Kansas                  JON TESTER, Montana, Ranking 
JOHN BOOZMAN, Arkansas                   Member
BILL CASSIDY, Louisiana              PATTY MURRAY, Washington
MIKE ROUNDS, South Dakota            BERNIE SANDERS, Vermont
THOM TILLIS, North Carolina          SHERROD BROWN, Ohio
DAN SULLIVAN, Alaska                 RICHARD BLUMENTHAL, Connecticut
MARSHA BLACKBURN, Tennessee          MAZIE K. HIRONO, Hawaii
KEVIN CRAMER, North Dakota           JOE MANCHIN, III, West Virginia
                                     KYRSTEN SINEMA, Arizona

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                              ----------                              

                      Wednesday, December 19, 2018

                                                                   Page

Tracking Transformation: VA Mission Act Implementation...........     1

                           OPENING STATEMENTS

Honorable David P. Roe, Chairman, U.S. House Committee on 
  Veterans' Affairs..............................................     1
Honorable Johnny Isakson, Chairman, U.S. Senate Committee on 
  Veterans' Affairs..............................................     2
Honorable Mark Takano, Ranking Member, U.S. House Committee on 
  Veterans' Affairs..............................................     4
Honorable John Tester, Ranking Member, U.S. Senate Committee on 
  Veterans' Affairs..............................................     6

                               WITNESSES

Honorable Robert Wilkie, Secretary, U.S. Department of Veterans 
  Affairs........................................................     9
    Prepared Statement...........................................    51

        Accompanied by:

    Melissa Glynn Ph.D., Assistant Secretary, Office of 
        Enterprise Integration, U.S. Department of Veterans 
        Affairs

    Steven L. Lieberman M.D., Executive in Charge, Veterans 
        Health Administration, U.S. Department of Veterans 
        Affairs

                        STATEMENT FOR THE RECORD

Veterans Of Foreign Wars Of The United States (VFW)..............    56
American Veterans (AMVETS).......................................    58
Jacob Gillison (Sanders).........................................    60
American Health Care Association (AHCA)..........................    65
Goverance Charts.................................................    67
National Committee for Quality Assurance (NCQA)..................    68


         TRACKING TRANSFORMATION: VA MISSION ACT IMPLEMENTATION

                              ----------                              


                      Wednesday, December 19, 2018

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committees met, pursuant to notice, at 2:00 p.m., in 
Room HVC-210, Capitol Visitor Center, Hon. David P. Roe 
[Chairman of the House Committee on Veterans' Affairs] 
presiding.
    Present from the House Committee on Veterans' Affairs: 
Representatives Roe, Bilirakis, Coffman, Radewagen, Dunn, 
Arrington, Bergman, Banks, Takano, Brownley, Kuster, O'Rourke, 
Lamb, and Esty.
    Present from the Senate Committee on Veterans' Affairs: 
Senators Isakson, Moran, Boozman, Tillis, Sullivan, Tester, 
Murray, Sanders, Brown, Blumenthal, Hirono, and Manchin.
    Also Present: Representative Sablan.

     OPENING STATEMENT OF HONORABLE DAVID P. ROE, CHAIRMAN

    The Chairman. The Committee will come to order.
    Before we begin, I'd like to ask unanimous consent that 
Congressman Sablan be allowed to sit on the dais and 
participate in today's proceedings.
    Hearing no objections, so ordered.
    Welcome, and thank you all for joining us today for the 
joint hearing of the House and Senate Committees on Veterans' 
Affairs.
    This afternoon, we will discuss implementation of the John 
S. McCain, Daniel K. Akaka, and the Samuel R. Johnson 
Department of Veterans Affairs Maintaining Internal Systems and 
Strengthening Integrated Outside Networks Act of 2018, better 
known as the VA MISSION Act.
    The MISSION Act is a truly transformative piece of 
legislation that will impact virtually every aspect of care 
that VA provides. Developing it took many months of intense 
negotiation and close collaboration between our Committees, the 
Trump administration, the Department, and numerous veterans 
service organizations, stakeholders, and advocates. We should 
all be proud of our work on the VA MISSION Act and of the 
benefits our Nation's veterans will derive from it in the years 
ahead.
    However, in many ways, the real work has just begun. Almost 
6 months ago, the MISSION Act was signed into law. Almost 6 
months from now, one of the act's most noteworthy requirements, 
the creation of a consolidated community care program, will go 
into effect.
    Today, at the midpoint between enactment and execution, we 
are here on a bicameral and bipartisan basis to evaluate both 
the progress the VA has made thus far with regard to the 
implementation of the MISSION Act and the barriers that may 
exist to full, on-time, and on-budget implementation in the 
coming months.
    Seeing the MISSION Act signed into law took the collective 
effort of all of us working closely together with one another 
and with the VA's senior leaders, with the White House, and 
with our veteran's service organization partners. Seeing the 
MISSION Act implemented appropriately will require no less than 
the same amount of teamwork.
    In 2014, we passed the Choice Act in response to what can 
rightfully be categorized as a crisis in access. A recent news 
article has criticized the execution of that program--namely, 
the high cost of administrative fees. While I do not dispute 
that the costs of this community care expansion were higher 
than typical government insurance coverage, the Choice program 
represented a transformational first step in how VA provides 
care where and when it is needed. These contracts were stood up 
in record time, and changes were made both legislatively and 
contractually over the past 3 years as the program matured.
    And I will say this. As a physician, we asked the VA at 
that point in time to do something no one could do, which was 
to stand up a nationwide network in 90 days. No one could have 
accomplished that on time.
    The Choice program is not perfect, but it did allow for an 
undeniable expansion of access and care, both internal to VA 
and in the community for veterans. This is why it is so vitally 
importantly that the MISSION Act, which will guide VA's future 
coordination of care, be executed efficiently and thoughtfully.
    Mr. Secretary, thank you for being here today to provide 
concrete answers to our many questions about the work that the 
agency has been doing these last 6 months and the work that 
lies before you in the next 6 months and beyond. The importance 
and the enormity of the task ahead cannot be overstated. But I 
have faith in you and your team, and I know that considerable 
support from this administration and this Congress is behind 
you. We want you to succeed.
    I implore you to be as up front as possible today and every 
day about the challenges you are facing and the help that you 
need from us to ensure success for our veterans. I look forward 
to working together to overcome any barrier that may be in your 
way.
    I will now yield to Chairman Isakson any opening statement 
that he may have.

     OPENING STATEMENT OF SENATOR JOHNNY ISAKSON, CHAIRMAN

    Senator Isakson. Well, Chairman Roe, thank you very much 
for the introduction, and thanks for spearheading the calling 
of this meeting today to look at the first 6 months under the 
MISSION Act. I am glad we are doing it.
    And before I make my comments on the MISSION Act, I want to 
say this. Your service when working with you has been a 
privilege. You have done a phenomenal job as Chairman in the 
House, have helped us in the Senate immensely. Your goal-
setting and what you focused on has been unbelievable. And with 
the exception of a few minor things, mainly where we might have 
dropped the ball, we have carried the ball and made significant 
changes in the Veterans Administration that are going to serve 
us well for a lasting and long period of time.
    So I just wanted to publicly thank you for your cooperative 
spirit, your desire to work. It is so great to have a physician 
at the top of the leadership in the House, or the Senate for 
that matter, because we make better decisions when we have 
people who actually have done it. Talking about it is easy for 
somebody like me. I am a professional patient. We need a 
professional doctor. And you have done a great job. And I 
appreciate your friendship, what you have done, and the 
leadership you have provided the Committee.
    And John Towers deserves a lot of credit too. He does a 
great job.
    And let me say this. We are prepared in the next 2 years to 
do everything we can do to continue the cooperative spirit 
between Republicans and Democrats that we have had on the 
Senate side and to work on fine-tuning the acts that we have 
passed and implementing things that need to be done to help you 
in the VA, those that are here from the VA, get your jobs done.
    We understand that what is ahead of us is tough, but we 
have no choice but to see to it the VA is functioning at the 
highest possible level so those who have risked their life for 
our Nation and pledged their service to us as soldiers have the 
same treatment back to them when we are ensuring their health 
care and those benefits they are promised under the laws of the 
United States of America.
    So I look forward to serving with you and working with you, 
and I want to tell you how much I appreciate the great job that 
you have done. I want to tell my Senate membership and our 
Committee Members that are here, Democrat and Republican, we 
have had the greatest cooperative spirit we could have. We had 
the MISSION Act, passed in Committee with only one negative 
vote, sail through the floor. You all did a great job on your 
end.
    We realize that we dropped the ball with you on one thing. 
You all got the Blue Water Navy through on a voice vote on the 
floor, or a suspension vote, I think, on the floor. We failed 
in the Senate on two UCs, one today and one last week. And we 
are going to try one time or another, but I still have a 
difficulty with one or two objections.
    But we are going to come right back and hit the ground 
running. Secretary Wilkie has done a great job of indicating 
that he wants to work with us and help us where he can. And I 
am not going to take that bone out of my mouth. This is one 
bulldog from Georgia that is going to keep that bone in my 
mouth until we get it done. Because a lot of people on the 
House Committee have worked on the Blue Water Navy issue, and 
we have in the Senate as well, and we want to do the same 
teamwork where possible.
    But I primarily want to just thank you and thank Secretary 
Wilkie for bringing a breath of fresh air to the leadership of 
the VA. He has done a great job. He took over after a 
problematic and a tumultuous time, but he has a good bedside 
manner, which most physicians--good physicians have. He is a 
good leader for the agency. He is doing a great job.
    We welcome you and all your VA membership here today.
    So thank you very much, Chairman Roe.
    Merry Christmas to everyone in the audience today.
    The Chairman. Thank you, Mr. Chairman. And I wish that 
bulldog for Georgia could have done something to those folks in 
Alabama. I really wish that could have happened, but--
    Senator Isakson. I can't talk about what we want to do to 
the Alabama people in public, but I will do one other thing. I 
have to slip out in a minute, and I apologize. When you see me 
slip out, it is not that I am walking out on you, but I have 
one more thing to do on our side.
    Thank you, Mr. Chairman.
    The Chairman. Yes, sir. Thank you, Mr. Chairman. It has 
been a privilege to work with the Senate this year too--this 
term, I should say, the last 2 years. And I was going to 
reserve my remarks until the end for you, but I didn't realize 
you had to leave. But how incredible you and Senator Tester 
have been to work with this year. My goodness, we could have 
never passed 80 bills in the House and had so many heard in the 
Senate. And our staffs, as you pointed out, worked hand-in-hand 
behind us to make this possible. It wouldn't have happened 
otherwise. And I think either 29 or 30 pieces of legislation.
    And just very briefly, a small thing like a contract, a 
cable contract you might have signed, or a contract on an 
apartment, and then your spouse loses their life in service to 
the country, and you not being able to get out of that contract 
for a year; now you are going to hopefully be able to do that. 
Little things like that that don't seem like big things, but if 
you are the person on the end of that, they are big things. And 
I personally have seen it and witnessed it with my friends that 
have had to deal with this.
    So these are ideas that came from both sides of the aisle, 
and I want to thank all of my colleagues, both in the Senate 
and the House, for those ideas.
    I will now yield to Mr. Takano for any remarks he may have.

        OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER

    Mr. Takano. Thank you, Chairman Roe.
    And, Chairman Isakson, I look forward to working with you 
in the next Congress to serve our Nation's veterans.
    Thank you, Ranking Member Tester, for also being here.
    Good afternoon, Mr. Secretary. Thank you for taking the 
time to testify before us today. We will always welcome the 
opportunity to speak with you about the progress you have made 
regarding the implementation of the MISSION Act.
    It has been a little over 6 months since the MISSION Act 
was passed and 7 months since you were confirmed as Secretary 
of Veterans Affairs. I commend you on your hard work so far and 
assure you that, as we move into next Congress, you will 
continue to find a willing partner on this Committee, meaning 
me, and that, as the most bipartisan Committee in this 
Congress, I intend to work with my colleagues on both sides of 
the aisle, with you, Mr. Secretary, and with our VSO partners 
to ensure veterans get the benefits that they have earned.
    Transparency and open communication between the Department 
and Congress is key to our oversight efforts and to ensure that 
our work here is effective.
    Now, we have asked for and need information from the 
Department so that we have an understanding of the steps VA 
must take to achieve the objectives mandated under the MISSION 
Act over the next 6 months. We also need to know more about the 
reported outsized influence a group of advisors may have had on 
your decisions, as VA should not be subject to outside 
influence or the whims of individuals or interests who cannot 
be held accountable and who do not have veterans' best 
interests in mind.
    However, VA should ensure that the voices of veterans 
expressed through our veterans' service organizations are 
adequately considered when important decisions, such as the 
adoption of the designated access standards, are made.
    The term ``designated access standard'' seems a bit wonky, 
so what I would like to hear from you today is a simple 
explanation of what those different scenarios look like in 
practice. And I think, to unpack designated access standards, I 
think, for the public, we can just simply understand them as 
the criteria by which the VA refers veterans out to private-
sector doctors, outside the VA, non-VA providers.
    What are those criteria? And, of course, we only began with 
an arbitrary criteria of living 40 miles outside of a VA 
radius, the radius of a VA health center, and somebody who has 
been waiting for more than 30 days. Without those arbitrary 
standards initially, we would have spent large sums of money, 
diverted large sums of money of VA health care dollars. So it 
is important that we get these standards right.
    The truth is we have always, always at the VA--the VA has 
always embraced outside, non-VA medical providers as part of 
the solution. And so this is nothing new in terms of how we 
take care of our veterans. But we can't do that at the expense 
of maintaining and adequately growing the internal capacity of 
the VA.
    So these access standards will outline when and where and 
how veterans will be referred to private-sector providers under 
the MISSION Act and how much of your budget will be needed to 
pay for this private-sector care, which we know is often more 
expensive than VA's internal services.
    And we know based off of multiple studies by the likes of 
the RAND Corporation and Dartmouth University, VHA care is 
often--or is frequently of higher quality than the private 
sector. So standards that are too liberal for access to private 
care could easily jeopardize that high-quality VA care that our 
most vulnerable veterans rely on as the dollars that support 
this care will be diverted into private-sector care. So we need 
that right balance.
    So we need answers to these questions, and I remain 
concerned with the Department's lack of transparency. For 
instance, yesterday we discovered via the media, not the VA, 
that yet another veteran has taken his life at the Bay Pines VA 
medical facility. This is the fifth suicide since 2013. We 
should not be first learning about this in the press. We should 
be notified immediately with facts that will help us act so 
that we can prevent other veterans from taking their lives.
    The GAO report requested by Ranking Member Walz demonstrate 
a lack of leadership and commitment by the Department to 
prevent veteran suicide. This is the Department's top clinical 
priority. When veterans between the ages of 18 and 34 are 
committing suicide at the highest rate, the Department's 
failure to communicate services and attempt to reach veterans 
in this age group via social media is shameful. VA offers 
excellent mental health services, but to quote disabled 
American veterans, they are useless in actually preventing 
suicide if veterans and family members don't know they exist or 
are unable to access them.
    Now, it is simply wrong--simply wrong--that only $57,000 in 
funds Congress prioritized to address preventing veteran 
suicide has been sent and $6.2 million has been left on the 
table. Now, I am committed to achieving progress over the next 
2 years. And I hope that you will, in fact, make suicide 
prevention the priority that the department claims it to be so 
that we, as Congress, can support, not criticize, your efforts.
    The same offer applies to the implementation of the MISSION 
Act. Now, the implementation of the MISSION Act thus far has 
been rocky, and, all too often, Members, their staff, and 
veterans feel misled or misinformed.
    In the next Congress, let's work towards having a 
productive relationship and open dialogue so that we can work 
together on behalf of the veterans we serve. And I look forward 
to our discussion today and hope that it is the beginning of a 
strong partnership between the Department and Congress.
    I yield back, Mr. Chairman.
    The Chairman. I thank the gentleman for yielding.
    I now yield to Ranking Member Tester for any opening 
comments that he--

    OPENING STATEMENT OF SENATOR JOHN TESTER, RANKING MEMBER

    Senator Tester. Yeah, thank you, Chairman Roe, Chairman 
Isakson. If Tim Walz was here, I would be thanking him too. 
And, Congress Takano, thank you very, very much.
    Before I get into my written statement, I just want to say 
it has been a pleasure, this last Congress, working with all 
the other three corners. And I think what has made the 
relationship work is communication. We have tried not to 
surprise one another. We have tried to keep one another 
informed of where we want to go.
    And I just want to give you a prime example of it. When I 
was walking over here to this hearing just now, one of my staff 
Members said: Dr. Roe wants to say something about 
confirmations, and he is concerned it might embarrass you. That 
is damn nice of you. I just want to tell you that.
    And, by the way, give them hell on the confirmations, 
because it is ridiculous that these folks aren't confirmed for 
ID and the Office of Whistleblower Protection.
    The last thing I just want to say before I go to my opening 
statement is Blue Water. We just did a live UC in the Senate, 
and it was objected to. I know that the VSOs in this room have 
been providing information after information after information 
on this issue.
    I am going to tell you, if we aren't willing to take care 
of our veterans, we shouldn't be making them. And the bottom 
line is we have to get this done. The science is clear.
    And I would say that I think that maybe the folks in the 
legislative branch don't realize it, but we are different than 
the executive branch, and we need to make the call. And if they 
want to veto the damn bill, then let the executive branch veto 
it. In the meantime, we need to take care of our veterans.
    Secretary Wilkie, thank you for being here.
    Implementation of the MISSION Act was going to 
fundamentally transform the delivery of health system for our 
Nation's veterans. For more than a year, we all worked 
carefully with the White House and the VA to negotiate the text 
of that bill. We were in regular communication with the VA on 
how it would interpret and implement the bill, passing it back 
and forth for technical assistance, ensuring that we were all 
on the same page. Since that time, though, I have grown 
increasingly concerned with the Department's planned 
implementation of the new Veterans Community Care Program 
created in the bill.
    Mr. Secretary, the VA is moving away from the direction it 
was headed just 6 months ago; make no mistake about that. The 
most dramatic example has to do with the VA designating certain 
types of care as nearly automatic eligibility for community 
care. Six months ago, we agreed that if veterans faced 
excessive wait times or driving times or distance to access 
certain services at a VA facility, they should be offered 
referrals in the community. Specifically, we discussed 
designating access standards for services like routine lab work 
and x-rays. But we agreed to give the VA the authority to 
decide exactly which services or categories of care should make 
veterans automatically eligible to receive care within the 
community.
    Now that we have passed the VA MISSION Act, VA has decided 
to head in what I believe is a completely different direction. 
VA now indicates it plans to designate access standards that 
apply to each and every type of care a veteran might need. This 
would essentially outsource all segments of VA health care to 
the community based on arbitrary wait times or geographic 
standards, which we were supposed to be moving away from by 
ending the Choice program.
    And that is despite the fact that several studies, one as 
recently as last week, have indicated the quality of care at 
the VA is good or better than the private sector. Let me say 
that one more time, because it is not said enough. As recently 
as last week, we received yet another study that indicated that 
VA care is as good or better than the private sector.
    To make matters worse, VA officials have offered only vague 
verbal descriptions of the various sets of potential access 
standards under consideration by you, Mr. Wilkie.
    It also concerns me that, each time we have discussed this 
issue in the last 2 months, VA officials have given us wildly 
different estimates of budgetary resources needed to implement 
these sets of access standards that you are considering. For 
example, if the Department chooses to go with the same access 
standard used by TRICARE Prime, we have been told it could cost 
anywhere from $1 billion for the first year to more than $20 
billion over 5 years.
    Some of the VA estimates indicate that costs will be less 
than what we spent on Choice but would make a greater 
percentage of veterans eligible for community care referrals. 
That doesn't make sense.
    So we need to know what you are doing, Mr. Secretary, and 
how much it is going to cost. No conflicting or vague answers, 
no fuzzy math, no games, because the stakes are simply too 
high.
    Mr. Secretary, not even 6 months ago, you came before the 
Senate Veterans' Affairs Committee, and you said you would 
oppose attempts to privatize the VA health care system. I 
believe you. I believed you then; I believe you now. But if you 
move further down this path, gutting the VA health care system 
for those veterans who want and need to use it, you will end up 
bringing down the whole boat. And you are going to spend a 
whole lot of time and money sending veterans in the community 
for care that is less timely and not as high in quality.
    That is a bad deal for our taxpayers. It is a bad deal for 
our veterans, who would ultimately bear the brunt of cuts to 
other services or benefits to cover the increased costs of 
community care. And that will lead to a bad deal for veterans, 
because, at some point, you will burn through the funds quicker 
than expected and come to us because VHA is running out of 
money again. Veterans will be in limbo when seeking community 
care as Congress sorts out the VA's fiscal issues.
    I am frustrated because this hearing would have been a 
great opportunity to talk about the great work being done by VA 
employees across this country every single day--and, indeed, 
they are--and about how their critical work will be bolstered 
by additional high-quality health care professionals hired 
under the new authorities within the MISSION Act and about how 
streamlining various community care programs in the new 
Community Care Network will make care more efficient, more 
timely, and more seamless for veterans.
    Instead, we are here left trying to figure out why the VA 
decided to take things in a different direction than what I 
believe Congress has intended and certainly what veterans have 
advocated for. My suspicion is that it is politics. I hope I am 
wrong, because at the end of the day I really hope that 
meaningful consultation will take place before final decisions 
are made. We have gotten this far by working together and by 
taking our cues from veterans, and it would be a shame to 
undermine those efforts and relationships because of a 
political agenda.
    I have said it before, and I will say it again: I have 
tremendous faith in you, Secretary Wilkie, to make sure that 
the VA is run in a way that our veterans deserve. We need to 
really step up and do it.
    Thank you for being here.
    The Chairman. I thank the gentleman for yielding.
    We are joined on our first and only panel today by the 
Honorable Robert Wilkie, Secretary of the Department of 
Veterans Affairs.
    And welcome, Secretary Wilkie. Thank you for being here 
this afternoon.
    The Secretary is accompanied by Dr. Melissa Glynn, the 
Assistant Secretary of the Office of Enterprise Integration, 
and Dr. Steven Lieberman, the Executive in Charge of the 
Veterans Health Administration.
    Thank you all for being here.
    Secretary Wilkie, you are now recognized.

            STATEMENT OF THE HONORABLE ROBERT WILKIE

    Secretary Wilkie. Thank you, Mr. Chairman, and thank you, 
Chairman Isakson, Chairman-elect Takano, and Senator Tester, 
and distinguished Members of both Committees. I want to thank 
you for the opportunity to address the efforts underway to 
implement the VA MISSION Act as well as share with you the 
governance and management approach instituted over the last 130 
days.
    As you have said, we are on cusp of the greatest 
transformative period in the history of VA, and your leadership 
led to the passage of that historic legislation.
    As I testified in front of the Senate Veterans' Affairs 
Committee earlier in the year, I am happy to report that the 
state of the Department of Veterans Affairs is better. And it 
is better because of the work of these Committees and the 
attention paid to our department by the President.
    As Secretary, I have visited 17 States in 130 days, 23 
hospitals from Anchorage to Orlando, 4 claims processing 
centers, and the Veterans Treatment Court in Maryland, and I, 
as Senator Tester said, am astounded by the commitment of the 
VA workforce. It is dedicated, and it is, in my opinion, the 
finest workforce in the Federal Government.
    Today, I am honored to have with me two senior VA leaders: 
Dr. Steven Lieberman, the current Executive in Charge of the 
Veterans Health Administration, and Dr. Melissa Glynn, the 
Assistant Secretary for Enterprise Integration.
    We are committed to implementing the MISSION Act by June 
2019 and describe how that commitment is being fulfilled. We 
have established a task force representing key offices across 
VA and guided by experienced program leaders. We now have a 
battle rhythm of progress reviews to align resources, identify 
and mitigate risks, and deliver on the promise to transform VA 
health care that puts veterans at the center of everything that 
we do. This effort is emblematic of the new governance and 
management structure we established throughout the Department.
    That is how we were able to identify that the technology 
supporting the GI Bill implementation was untenable. I made the 
decision to define a new approach to deliver education and 
housing benefits to our veterans and their family members. And 
I want to emphasize that we will execute the law as written and 
every post-9/11 GI Bill beneficiary will be made whole for 
their housing benefits based on both Sections 107 and 501 of 
the Forever GI Bill. I made the decisions not only to stabilize 
the delivery of services but to improve the current Choice 
programs.
    The expansion and extension of the TriWest contract ensures 
access to community care for our veterans. The decision allows 
for smoother transition to the Community Care Network contracts 
when awarded. After multiple delays prior to my arrival at VA, 
the acquisition process and subsequent awards are back on 
track. Community care regions 1 through 3 will be awarded 
before the end of February 2019, and region 4 is expected to be 
awarded in March. Once active, these contracts will support a 
key pillar of the MISSION Act by giving veterans expanded 
choice in their health care.
    As part of our new community care program, we are 
addressing the timeliness and accuracy of payments to 
providers. We are moving away from paper claims and requiring 
providers to submit electronic claims through our new 
electronic claim administration and management system that will 
be deployed next year.
    Through the MISSION Act, we have established a Center for 
Innovation for Care and Payment to develop new approaches to 
testing payment and service delivery methods. The Senate has 
developed a charter and is developing criteria for pilot 
projects to drive health care quality and efficiency.
    Another pillar of the MISSION Act is groundbreaking support 
for caregivers. There are 5.5 million veteran caregivers across 
the country. I had the privilege several weeks ago to address 
the third annual national convening of military and veteran 
caregivers, jointly sponsored by the Elizabeth Dole Foundation 
and Veterans Affairs. The work of Senator Dole to invest in 
caregivers and their experiences will strengthen our ability to 
successfully execute an expanded program of comprehensive 
assistance for family caregivers under the MISSION Act.
    I would be remiss if I did not thank the foundational VSOs 
for their efforts to making sure that this benefit was 
incorporated into the legislation.
    And I will take the opportunity also to thank in person 
someone who is familiar to all of you and who was instrumental 
not only in the development of the MISSION Act and the 
caregiver program but someone who has been on point for 
veterans for many years. He is retiring. And that is Garry 
Augustine of Disabled American Veterans. And I thank him for 
being here as well.
    The other most meaningful aspect of this legislation is the 
series of related products that ultimately support the work of 
the Asset Infrastructure Review Commission. These include 
outputs of national market assessments and our strategic plan 
and a data-driven asset and infrastructure assessment and 
recommendations with input from our veterans, employees, VSOs, 
local communities, and other key stakeholders. The VA is 
embracing the opportunity to assess our footprint and develop 
recommendations for modernization and realignment of 
facilities.
    Mr. Chairman, I would like to beg your indulgence for a 
minute, and I am going to go off script. And it is partially in 
response to a series of stories that I read this morning, 
stories that have particular meaning to so many Members of 
these Committees, and that is on the issue of suicide 
prevention.
    When I was Acting Secretary of the Department for 8 weeks, 
I declared that suicide prevention is the number-one clinical 
priority of the Department. In addition to that, I named a 
permanent head of our Office of Suicide Prevention, Dr. Keita 
Franklin, who was the head of our efforts at the Department of 
Defense when I was the Under Secretary.
    In addition to that, we have developed with the Department 
of Defense a streamlined and comprehensive program to begin 
addressing the issues that impact our veterans and the issue of 
suicide beginning from the time that they enlist. Our 
Transition Assistance Program is done in conjunction with 
Secretary Mattis. And now, thanks to the work of this 
Committee, we are including other-than-honorable dischargees in 
our education and outreach efforts when it comes to suicide.
    The tragic aspect of this is that, for the 20 American 
warriors who take their lives on a daily basis, 14 of those 
warriors are outside of the Department of Veterans Affairs. 
When I have gone across the country, I have asked Governors, I 
have asked mayors, I have asked VSOs to help us find those 
veterans. When I was in Alaska recently, I spoke to the Alaska 
Federation of Natives. Fifty percent of the veterans in the 
State of Alaska are outside of the VA system. And I have asked 
them to help us find those who might be in danger.
    Suicide prevention is the number-one priority of this 
department when it comes to our clinical efforts to keep our 
veterans healthy and well.
    In addition to that, I do want to say that I echo what 
Senator Tester said. Last week, Dartmouth, in the Annals of 
Internal Medicine, indicated that the Department of Veterans 
Affairs' health care, medical care, is as good or better as any 
in the private sector. That is a story I wish to tell.
    The other part of that story is--and it will come as a 
confounding statement for some in the press that a conservative 
Republican is here saying this--I am incredibly proud to be 
part of the workforce that I consider to be the finest in the 
Federal Government. In my travels, I have seen the dedication 
of our men and women, 370,000 strong. And it is my pledge to 
tell the good news stories that they have created on the behalf 
of our veterans.
    In addition to that, another story that I am proud of is 
that the Partnership for Public Service for the first time in 
memory has now included the Department of Veterans Affairs in 
the top third of all Federal departments when it comes to 
workplace satisfaction and the pride that our workers have in 
being part of the VA. That is a great step forward. Without 
that pride, we will not be able to deliver the kind of customer 
service that our veterans expect.
    In addition to that, I am also happy to say that the 
Department of Veterans Affairs, when Time issued its list of 
the 50 most influential health care minds and providers in this 
country, the Department of Veterans Affairs had researchers on 
that list.
    It is a good news story to tell. It is one that I am proud 
to tell. And I am very happy and humbled to be part of that 
outstanding workforce that, on a daily basis, helps veterans 
remind all of us why we sleep soundly at night.
    Mr. Chairman, I thank you for the indulgence and look 
forward to your questions.

    [The prepared statement of Secretary Wilkie appears in the 
Appendix]

    The Chairman. I thank you very much.
    And just very quickly, since we have a large number of 
people here, I will be dropping the gavel at 5 minutes, 
including myself.
    I appreciate you being here, but I would like to focus 
today, in this hearing, on the implementation of the VA MISSION 
Act, specifically the community care part, because that is 
coming up in 6 months.
    And, really, it is literally--if we can do three things, I 
think, Mr. Secretary, and if you can lay out and give me some 
ease about how I feel about this: One, will we have networks in 
place? Number two, can you schedule an appointment to the 
doctor in those networks? And number three, will you pay the 
bills once the veterans have seen them, so they don't get 
dunned for the bills? I think if we can do those three things.
    And my concern--we have the four regions of the country. 
The various regions have a year, according to the law, to put 
these networks together. And I know you are signing the 
contracts for 3, you said, hopefully by February and then 
region 4 by March. That is less than 90 days from the time this 
thing goes live, that last contract. Because I remember very 
well in 2014 the fiasco that occurred there.
    So, of those three things, when we go live--or are you 
going to need more time? And, quite frankly, if you see it 
isn't happening, I would rather keep doing exactly what we are 
doing and implement it a month later than I would have this 
thing fall on its face and we fold up all the community care 
programs we have into one and it not work.
    Secretary Wilkie. Yes, sir. Obviously, the goal is to 
fulfill those time commitments. I am going to take a step back 
and answer the third part of your question first, and that is 
the timely payment to our community caregivers and particularly 
our small-town doctors across the country. Without that, the 
entire Choice system contained in the MISSION Act fails.
    We have learned valuable lessons from the experience of 
Choice. I do believe that we have the beginnings of a 
comprehensive set of standards we will take to the country to 
bring those community care providers into the networks. Those 
contracts are ready to go. We do have the lessons learned from, 
as I said, the problems that we had with Choice right now.
    And I will go ahead and address an issue that was raised in 
the media this morning. TriWest is the bridge to the expansion 
of our program through the community care networks. And I am 
confident that, given the governance structure that we have in 
place, that we will be able to reach those goals.
    I will also say that if at any time I don't think we can, I 
will be up here posthaste to make sure that we inform the 
Congress of that contingency.
    I don't know if Dr. Lieberman wants to say anything about 
where we are in terms of the contracts.
    Dr. Lieberman. So we are really pleased with how our 
contracting has been going. We have been meeting weekly on 
this, and, as the Secretary said, we expect it to be completed 
on schedule, as he told you. And then we are ready to go with 
all the topics that you have brought up.
    You know, we certainly are implementing a number of things 
to help with timeliness, including the timeliness of the 
payments. We are going to be requiring, except in rare 
circumstances, that the payments be electronic, which speeds up 
the claims process. We also are going to have an off-the-shelf 
product that will auto-adjudicate the claims and pay them 
timely.
    Secretary Wilkie. And I would note--sorry, Steve--that is 
key. The Department of Veterans Affairs, as these Committees 
have noted on more than one occasion, has an IT problem. When 
it comes to claims processing, hands have to touch each claim.
    What we have done is look to the market for off-the-shelf 
technology that will allow us to automate the claims process so 
that individuals are not having to touch each claim. And this 
will put the Department of Veterans Affairs in line with the 
most modern health care administrations in the country.
    The Chairman. Well, my time has about expired, but this is 
what I want to have happen. If I am a patient and I come to see 
the doctor, and I need to go see a neurologist or whomever, 
well, I am seeing the VA doctor that day. I walk out front. The 
VA doesn't have that specialist in the hospital. I get my 
appointment scheduled, I get it made. I go see the doctor. That 
information is transmitted back, and the doctor gets paid. That 
is how the system work.
    I had surgery 2--well, 18 months ago. Two weeks after 
surgery, the bills had been paid by the third-party 
administrator. And that is the kind of--I know it is not going 
to be that quick, but that is the kind of efficiency we want, 
and I hope that we have it. I am not expecting it on June 7, 
but I am expecting it sometime fairly soon.
    Mr. Takano, you are recognized.
    Mr. Takano. Thank you, Mr. Chairman.
    Mr. Secretary, over the last few months, Committee staff 
has heard from various stakeholders, including VA, conflicting 
information regarding VA's development and/or adoption of what 
I talked about in my opening statement, designated access 
standards.
    We have also heard from VA staff the President is likely to 
announce the adoption of a designated access standard model 
during his State of the Union address. However, Congress has 
not yet been made aware of which models are being considered 
and the reasoning behind any imminent decisions.
    Would you commit to us today that you are willing to offer 
each of the four corners--and, I would say, Members of the 
Committee, but, I mean, it should be made available to all of 
us--a briefing by Milliman, who is the actuary, prior to the 
State of the Union, and reasonably before the State of the 
Union?
    Secretary Wilkie. Well, Mr. Takano, what I will promise is 
that, as soon as the President is briefed--I owe him that 
courtesy, and certainly he is responsible for the final 
decision. And once he makes that decision, I will be up here 
with our team to brief this Committee, these Committees, for 
any comments and advice you have and any corrective actions 
that you might have.
    It is absolutely vital. I think I mentioned in my 
confirmation hearing, I grew up in this institution. I know why 
Article I is the first article. And I will commit to coming up 
here when the President does make his decision.
    And it is still not clear if he is going to announce 
anything at the State of the Union, but I hope to have him 
briefed and have those decisions made before then.
    Mr. Takano. Well, Mr. Secretary, I am a little concerned 
that this decision could be made, you know, the night before he 
delivers his speech and makes a grand speech about how every 
veteran is going to be able see any doctor they want to see. I 
mean, that is one model, any veteran they can see any doctor 
they want to see. Of course, that sounds good, but there are a 
lot of downsides to that kind of a model.
    All the more reason why the VSOs are--many of them are 
complaining that there is a lack of participation as per what 
we said in the MISSION Act, that they should be participating 
in the development of these access standards.
    And so I am not really satisfied with the answer. I wish we 
were able to get better insight as to what models you are 
considering, what the costs are associated with each of those 
models. Because that has a lot to do with how much money might 
be diverted from, you know, regular central VA care.
    Secretary Wilkie. Mr. Takano let me answer the second part 
of the question first, in terms of engagement with the VSOs.
    I can say that they are a vital part of what we do at the 
Department. In my time as Secretary, we have doubled the number 
of VSO engagements that the Department had prior to my arrival. 
The majority of our VSO engagements are handled at the Under 
Secretary level or above. Over the last 9 weeks, our VSOs have 
experienced briefings from senior leadership in the Department 
that last well over 4 hours a week.
    I will also tell you that in my travels across the country 
I have made it a point to reach out to veterans' organizations 
in the rest of the United States. In Alaska, I spoke to the 
largest VFW post, I think, west of the Mississippi. I was just 
in your area of California, spent 2 hours with veterans' 
leadership in southern California. Did the same thing with the 
Indian Nations, the Native Nations in Oklahoma and also in 
Senator Hirono's State, in Hawaii, on the Big Island and also 
in Oahu. So that is important to me. If the veteran is not at 
the center of the decisions, it won't work.
    But I will say, when it comes to access standards, I have 
in mind not only Senator Tester's State of Montana when it 
comes to the ability of our veterans to get to services but 
also have in mind some of the most heavily congested 
metropolitan areas of this country. We have to make it easier 
for our veterans to get the care that they need.
    But I will also say--and I will repeat what I said when I 
testified in the Senate in September. My observation, my 
experience--and Senator Tester said it earlier today--veterans 
are happy with the service they get at the Department of 
Veterans Affairs. I have not seen any indication that the 
majority of our veterans are champing at the bit to find 
alternative ways to take care of themselves.
    The most important of this is the one that is not 
quantifiable, and that is the communal nature of veterans' 
care. Veterans want to go places where people speak the 
language and understand the culture. That is what I have 
experienced in my lifetime around the military, and that has 
certainly been validated in the travels that I have undertaken 
in the very short time that I have been the Secretary. Veterans 
will always be at the center of any decision that I make.
    The Chairman. Appreciate the gentleman for yielding.
    Senator Tester, you are recognized.
    Senator Tester. Yeah, thank you, Mr. Chairman.
    I want to thank, Mr. Secretary, you and Dr. Glynn and Dr. 
Lieberman for being here.
    I am sure, Mr. Secretary, you are aware of an article that 
was published yesterday outlining the overhead costs of the 
Choice program. It was reported that $1.9 billion, nearly a 
quarter of the funds spent on Choice, were for admin fees. I 
have a huge problem with that. Do you have a problem with that?
    Secretary Wilkie. Absolutely.
    Senator Tester. Okay. So, moving forward, what are you 
going to do, or what are you doing, when it comes to admin 
costs from the private providers?
    Secretary Wilkie. Well, in order to move forward, Senator, 
may I please take a step back?
    Senator Tester. A quick step.
    Secretary Wilkie. This Committee addressed the problems 
with Choice with the MISSION Act. The article in question 
addressed the problems with the system before MISSION was 
passed, before I became the Secretary. I am cognizant of what 
went on with Choice, and you mentioned it: hastily put together 
in response to a tragedy in Arizona.
    So it is my direction and I believe, because of the 
negotiations that we have been having with potential community 
care providers, that those administrative costs you will not 
see at the level that we experienced during Choice, because the 
Department, I will admit, was taken advantage of because of the 
hasty nature--
    Senator Tester. Okay.
    Secretary Wilkie [continued].--that took place when the 
program was put together.
    Senator Tester. I will kind of accept that. But a lot of 
the folks who are delivering the care now under your thumb are 
close to one-quarter in admin costs--close to one-quarter. Now, 
I asked my staff to find out where the VA was before Choice for 
admin, but, as I recall, it was one of, if not the cheapest 
delivery care systems in the Nation when it comes to an admin 
cost. So I would say that.
    The other thing I would say is this. And Congressman Takano 
talked about this. If access standard models are expanded to 
the point--and I don't think it was congressional intent for 
this; in fact, I know it wasn't--for unfettered choice, we got 
a big problem. Because it is going to cost more money. The care 
isn't going to be good. I talked in my opening statement about 
Blue Water veterans. You know why we can't get Blue Water folks 
covered? Money.
    So extrapolate this out a little bit. If it costs more to 
be in the private sector, if admin costs are higher, benefits 
are going to be cut. And so, while you say it is the 
President's decision--and it is; he is the boss--there better 
be some good, good information coming from you and the people 
that know better that this access standard needs to have some 
controls around it.
    Would you agree?
    Secretary Wilkie. I agree with you.
    Dr. Lieberman. I just want to mention that the 
administrative costs were not as high as was quoted in that 
article. The number is less, and it has actually been over 
years, so it is a much lower percentage.
    We have learned since Choice was first implemented in a 
hurry. What we have now moved towards is itemization of the 
administrative charges, so there is now a range of what the 
charges are, and to--close to the amount that was in the 
article for individual. But then with the Community Care 
Network, we actually have learned more, and we are going to go 
to a new model which will further decrease the administrative 
costs.
    Senator Tester. Okay. And so are you planning on putting 
overhead caps in those contracts?
    Dr. Lieberman. We are moving towards a standard similar to 
what the community does.
    Senator Tester. So that is a no, correct? You are not going 
to put caps in them?
    Dr. Lieberman. We certainly can--
    Senator Tester. No, I am not advocating for it, but what I 
am saying is somebody has to have the finger on these costs. 
Because I will tell you, we are talking billions of dollars, 
and, after the fact, we can't get it back. And those are 
dollars that should be spent taking care of veterans.
    So do we have a plan? Because the truth is the MISSION Act, 
we passed it with the best of intentions, but it could be a 
train wreck too. And I hate to tell you this, but it is kind of 
in your lap. It is in your lap. And so, when we are talking 
about too-high admission costs, when we are talking access 
standard models that were basically unfettered choice, we could 
end up with a problem where we are actually cutting benefits 
for our veterans moving forward. And my guess is, if you asked 
any of the VSOs, that that would not be a good thing. So I just 
want to make sure that is on your radar screen.
    I have to have one more because I have to get it--I only 
have 25 seconds left. You talked about giving information to 
the VSOs, you talked about briefings. Are you gathering 
information back from them? That this isn't an information dump 
on the VSOs, that you are actually listening to them and 
finding out what their concerns are. Because I am telling you, 
it is critical. It is critical for us; it is critical for you.
    Did you want to answer that, Dr. Glynn?
    Secretary Wilkie. I can do it.
    Senator Tester. Go ahead.
    Secretary Wilkie. Absolutely. In fact, many of the people 
in the audience will be with me tomorrow morning in my office 
discussing what was discussed here, and they will be telling me 
their input after--
    Senator Tester. So I am not throwing anybody under the bus 
here, but I am going to tell you that a lot of VSOs have talked 
to me about the communication within the VA. It is not where it 
needs to be.
    Secretary Wilkie. Senator let me add one thing to that.
    Senator Tester. Okay.
    The Chairman. If you could add that quickly.
    Secretary Wilkie. I will do it real fast.
    Something has happened in the makeup of our veteran's 
population. For the first time since the fall of Saigon, half 
of our veterans are now under the age of 65, which means they 
have different cares, they have different interests.
    What I have done in my short time is actually opened the 
aperture to the table at the Department of Veterans Affairs to 
bring in veterans who are not traditionally part of the 
system--Purple Heart, blinded veterans, student veterans. In 
fact, we have more veterans at the table discussing their 
issues with us than we have ever had, and that mirrors the 
change in the Active Duty, Reserve, and retiree population that 
we have seen.
    So you have my commitment that every veteran who wants to 
talk will be heard and input be given.
    Senator Tester. Thank you.
    The Chairman. I thank the gentleman for yielding.
    Senator Moran, you are recognized.
    Senator Moran. Chairman, thank you very much.
    Mr. Secretary, thank you for you and your team's presence 
today.
    I asked my staff to give me the statutory requirements of 
your consultation with Congress, and it turned out to be pages. 
In the MISSION Act, you are directed to consult with us as you 
develop regulations. And the goal of that language was to make 
certain that Congress was informed before the regulations were 
determined, not a consultation that says: This is what the 
regulations will be.
    My understanding is that those consultations that have 
occurred have progressively gotten better. We still want more 
specificity, and you seem to be headed in that direction, but I 
would encourage you and your team, as we get those briefings, 
to give us the details so that we can encourage, comment, 
suggest in advance of decisions made at the Department of 
Veterans Affairs. That was a very intentional aspect of the 
language included in the bill.
    Let me see if I can get a couple of things in the 4 
minutes, I now have left that are specific.
    First of all, how you define how the Department of Veterans 
Affairs defines episodic care is a hugely important issue in 
regard to how the MISSION Act will be implemented and what kind 
of care our veterans will receive.
    Can you, Mr. Secretary, in a specific way tell me how you 
will define episodic care?
    Secretary Wilkie. Well, I will let the doctor describe 
that.
    Senator Moran. Doctor, thank you.
    Dr. Lieberman. So it will depend on what the issue is. 
Certainly, we have the six different criteria that go into it. 
If it is something where you require orthopedic surgery, 
require physical therapy, we will bundle the care for that, 
whereas, if we can't provide it, we would provide it outside. 
So--
    Senator Moran. Obviously, in 4 minutes there is not a way 
to be terribly specific, but it will be something we will 
continue to ask you.
    Dr. Lieberman. Sure.
    Senator Moran. I would tell you that my interest in these 
topics is generated by our casework, what veterans bring to our 
office and what problems they have had under Choice. The idea 
that you have to go back to the VA every time to get the 
laboratory work, the x-ray, that is not an efficient system and 
one that is designed to fail and not be beneficial to the 
veteran.
    Would you commit that we will be able to review your 
definition, Mr. Secretary, of episodic care before the 
regulatory process--
    Secretary Wilkie. Absolutely.
    Senator Moran. Thank you, sir.
    Let me then turn to access standards, which has been a 
topic of conversation by most of my colleagues who have spoken 
already this morning.
    Here is what I would look for in today's setting: I would 
like to have assurance that access standards will be applied to 
where a veteran actually lives, not his or her post office box, 
as has been the case in the past.
    Secretary Wilkie. Absolutely. And I have said on many 
occasions--and most of my focus has been on the western United 
States. That is absolutely necessary if we are going to make 
Choice work. It is striking to me that still, in 2018, we don't 
understand the scale of the American West. And what you have 
said is absolutely essential if we are going to make access 
standards work.
    Senator Moran. Another piece of casework that has become a 
challenge for us is the definition of ``in the VA.'' And that 
is that, in circumstances in which our veterans are trying to 
access care, the VA's response is: The care is available within 
the VA broadly. In my view, the question is, is the care in the 
VA available at the facility, the hospital where the veteran 
lives? And our veterans are being asked to travel long 
distances because the care is available in the VA but not 
geographically available.
    Secretary Wilkie. And that is one of the things that we 
will fix as a result of the MISSION Act, and we will get a 
system in place that allows the veteran the opportunity to get 
that care that is most convenient to him and to his family.
    Senator Tester is gone. The example I use is the 700-mile 
round trip in Montana. In Kansas, the distances are almost as 
great. So, absolutely.
    Senator Moran. Thank you, Mr. Secretary.
    Thank you, Mr. Chairman.
    Secretary Wilkie. Thank you, sir.
    The Chairman. I thank the gentleman for yielding.
    Senator Murray, you are recognized.
    Senator Murray. Yeah, thank you very much, Mr. Chairman.
    Mr. Secretary, before I get into the main focus of this 
hearing and my concerns about the caregiver bill, I do want to 
mention the current chaos with the GI Bill.
    Secretary Wilkie. Yes.
    Senator Murray. It is unacceptable to leave veterans 
without a stipend or an incorrect stipend or a delayed stipend, 
especially when they rely on that to pay for rent or food. And 
it is unacceptable to put veterans' enrollment at risk by 
failing to get tuition payments to the universities, as well, 
on time. These are basic tasks that the VA cannot get wrong.
    You have had more than a year now to implement the changes 
in the Forever GI Bill. I have written you two letters, one 
more than a month ago, one 3 weeks ago, looking for answers on 
how the VA is going to fix these payment problems, how they are 
going to address the shortcomings with the GI Bill comparison 
tool, and, especially in light of the recent collapse of the 
ECA, to explain why the Department of Education has stopped 
sharing accreditation information with the VA.
    I don't want you to take the time to answer right now. I 
would like a written response back to those--
    Secretary Wilkie. Yes.
    Senator Murray [continued].--and I want you to know we are 
all very concerned about it.
    Senator Murray. But I do want to ask about the caregivers 
program, because, according to briefings from the VA, the 
Department has ruled out trying to narrow the eligibility 
criteria for the caregiver program, but I am still very 
concerned that there is a number of issues the VA is looking at 
that I am concerned about, including changes to the stipend, 
restricting veterans based on their type of injury, or 
requiring a minimum disability rating. This seems to be VA 
still focused on keeping people out of the program instead of 
making it work better for our veterans.
    And, yesterday, NPR reported on several cases where 
veterans, including a double and a triple amputee, were 
downgraded or kicked out of the program completely 
inappropriately. And these are, by the way, not one-off VA 
cases; we are hearing that this is a continuing problem in the 
VA's management of this program.
    When the VA previously downgraded and terminated 
caregivers, the VA assured me that it had resolved the problems 
that led to these types of actions, but it is very clear that 
is not true. And I would like you to immediately reinstate a 
ban on downgrades and terminations until VA can demonstrate to 
us that the serious management problems have been corrected and 
these types of outrageous errors will not occur again.
    Secretary Wilkie. Senator, I will say that caregivers is 
especially important to me. I am the son of a gravely wounded 
Vietnam--
    Senator Murray. I appreciate that.
    Secretary Wilkie [continued].--warrior, and I have seen my 
mother and family take care of my father prior to his passing 
last week.
    Senator Murray. I appreciate that.
    Secretary Wilkie. The--
    Senator Murray. So will you reinstate the--
    Secretary Wilkie. Yes?
    Senator Murray [continued].--ban? Will you reinstate the 
ban?
    Secretary Wilkie. I am not familiar with all the rules, but 
I will tell you that the National Public Radio story, that 
problem was corrected within 24 to 48 hours.
    Senator Murray. Those are not isolated cases. We are 
hearing many of them.
    Secretary Wilkie. And those cases, is my understanding, 
have been corrected because of directives from this department, 
that people were not reading the regulations properly.
    So my promise to you is that I am going to do everything I 
can to make sure everybody stays in the program. It is that 
important to me personally.
    Senator Murray. Can I have your assurance that no one else 
will be downgraded or kicked out of the program until you look 
and make sure that the regulations are being implemented at 
every level correctly?
    Secretary Wilkie. Absolutely. I will make that commitment 
and will brief these Committees.
    Senator Murray. Okay. And also--I won't have enough time, 
but I would like you to get me what your guidance to the 
program office is and your guidance to the field on how this is 
being implemented so that we can see what you are telling your 
staff.
    Secretary Wilkie. Yep. Yes.
    Senator Murray. Okay. And I am also very concerned about 
the implementation of the changes to the caregiver program that 
were passed as part of the MISSION Act. Before the expansion 
can begin, you have to certify that a new IT system is in 
place. And the law required you to have that system in place by 
October 1st. That was a month and a half ago.
    This was not a new requirement. GAO's initial 
recommendation to fix the IT system was made in September of 
2014. And the VA has repeatedly assured us that it is working 
on that issue. I want to know when you will have that IT system 
in place and make the certification as the law requires.
    Secretary Wilkie. The goal is October 1st.
    Senator Murray. That--
    Secretary Wilkie. I would not be telling you the truth if I 
told you that that I was absolutely certain that, given the 
state of VA's IT system, that that date will be met.
    Senator Murray. That was a month and a half ago. The date 
has passed.
    Secretary Wilkie. No, I am talking about for--no, it is 
October of 2019--
    Senator Murray. No.
    Secretary Wilkie [continued].--to certify that the IT 
works. Are we confusing two dates?
    Senator Murray. That is your new goal. That is not the goal 
you were given by Congress.
    Secretary Wilkie. Go ahead.
    Ms. Glynn. The timeline to certify the new system is ready 
is 2019--October 2019.
    Senator Murray. Okay.
    Ms. Glynn. We did miss the October 2018 date to support the 
new system.
    Senator Murray. So you gave yourselves another year?
    Ms. Glynn. Well, there were two dates--there are two dates, 
Senator, associated with the requirement. The first date, which 
was October of this year, was for validating and deploying a 
new system. We have not deployed the new system, but--the 
certification of that system, which is required prior to 
expansion--
    Senator Murray. Okay. Have you fully defined all of the 
requirements for that system?
    Ms. Glynn. We have worked on--we have fully defined 
requirements. We are working, as the Secretary mentioned, on 
user-acceptance testing of the system, and we are working 
through that. We do not want to deploy a system until it has 
been thoroughly tested and we feel it is capable of serving 
caregivers' and veterans' needs.
    Secretary Wilkie. And I would say that has been the problem 
that I identified and talked, discussed, with the Members of 
this Committee. GI bill was a classic case, Senator, of a 
program being imposed on a system that was incapable of 
handling it. That is why I had to make the decision to go back 
to the old system on the GI bill.
    The same applies here. The system was not capable of 
addressing it. I give you my commitment: I am doing everything 
that I can, and so is the Department, to bring the IT system up 
to modern standards.
    The GI bill, we were talking about a 50-year-old IT. 
system. And it is not acceptable, but you have my commitment 
that we are working with the best minds we can find to make VA 
a modern health care administration and benefits--
    Senator Murray. Mr. Chairman, I know my time is out. I have 
been on this Committee for more than 20 years, and I always 
hear we are not going to get an IT system because there is a 
problem. Every time it changes, every time, there are problems. 
We have got to get this right. People are counting on it.
    The Chairman. I appreciate the gentlelady yielding back, 
and all I can say is amen to that IT. I have heard it for 10 
years.
    I now yield--and please be respectful of everyone's time. 
There is a lot of people here. General Bergman, you are 
recognized for 5 minutes.
    Mr. Bergman. I could yield back right now. But I won't.
    Folks, we will get to the heart of the matter very quickly. 
You are designing a system that you are going to implement for 
the benefit of the outcome of the veterans. In my district, the 
First District of Michigan, if any system will work in that 
district, it will work anywhere because you have a largely 
rural district with some small cities. So I am hoping, or at 
least optimistic, that you have factored that in, that whatever 
system you are designing to get the veterans, caregivers in 
this case, into a functional status, that you consider the 
tyranny of distance, the tyranny of weather, and all of that.
    Now, in setting up your network, I am guessing--although I 
don't see it in the slides--there are certain assumptions that 
you have made, and certain risk assessment involved with those 
assumptions. And I would like to ask you to just take this for 
the record. If you could--we don't need to talk about it here, 
but if you would give us that list of assumptions and the risks 
that you have, you know, put together, that would be greatly 
helpful.
    And I noticed in the slides here--great slides--I would 
guess that these meetings that are, whether they be weekly, 
daily, bimonthly, when you find there is a course correction as 
a result of a meeting or an update, that needs to be made, what 
do you do? I mean, I don't see that in the slides, okay, we 
have ID'd it--and I am a pilot. You see a need to change your 
heading, change your heading. Don't wait.
    Ms. Glynn. Thank you, Congressman. Right now, our team 
actually is engaged in 180-day reviews back at the VA on all 
elements and the provisions of the MISSION Act. And we are, as 
you say, identifying risks and identifying, as Senator Murray 
highlighted, concerns with things like IT, how do we take 
different, parallel paths towards getting to that October date. 
So we are bringing that through our executive Committee, and 
then issuing guidance to the teams, working through resource 
requirements, working through changes in project plans, 
understanding what our needs are, and bringing forward a 
stakeholder engagement protocol so we can continue to uplift 
this program and make sure we can hit the--
    Mr. Bergman. Do you feel that there is--seems like--you 
know, as a Chairman on the Subcommittee on Oversight and 
Investigations, one of the questions was always asked in every 
hearing: Is there a sense of urgency? You know, within your 
folks that are trying to implement, you got good people trying 
to do the right things. Is there a sense of--this may sound 
like an oxymoron--bureaucratic urgency?
    Secretary Wilkie. Yes, sir. And that is one of the reasons 
why a battle rhythm was implemented. I have, as you know, a 
military background, not as extensive as yours. The Department 
has never had a governing structure for anything this--and we 
do now, and we have timelines to meet just as we would on the 
flight line in my Air Force life. So, yes.
    And I will also point back to what I said earlier about the 
attitude of those in the Department. It has been my experience 
that we have incredible support from those in the career 
leadership because they understand that VA can't fail on this 
one. And I am very happy with that attitude.
    Mr. Bergman. Okay, well, number one, thank you for your 
service, and all honorable service is--it should be respected 
by all. And I could just say personally the biggest, proudest 
moment I have had is to lead marines and be mentored by lance 
corporals who have a 20-year-old view of the world, and that is 
what drives us.
    But, with that, in the interest of time, I am going to 
yield back 50 seconds.
    The Chairman. I thank the gentleman for yielding. And one 
of the things our Senate colleagues could do to help the 
Secretary is to confirm his Assistant Secretary for IT That 
would be helpful.
    I now yield to Ms. Brownley for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman, and thank you, Mr. 
Secretary for being with us today. I wanted to follow up with 
Senator Murray's questioning with regards to the caregiver 
program. And if I could, I heard you make a commitment, but I 
want to be abundantly clear that you are committing to us today 
to not modify any of the current eligibility requirements 
within the caregiver program as it expands?
    Secretary Wilkie. I am committing to review every case 
involving a caregiver who is in distress. I am also committed 
to making sure that before any decision is made on the future 
of the program, that this Committee is involved in it. And as I 
told Senator Murray, I will be reporting to her on the path 
forward.
    It is important to me personally because of my own 
experiences. And we are going to get this right for the 5.5 
million family caregivers out there.
    Ms. Brownley. You had mentioned earlier in response to some 
other questions with regards to the importance of the input of 
VSOs and veterans in general. You responded, I think, by 
saying, you have even expanded that audience of veterans from 
younger veterans and trying to get a broader representation, 
which I think is good.
    On the other hand, the leadership of the VSOs really lead 
by consensus within their organization, and representing that 
broad census. And I, too, have heard from many of the VSOs that 
they don't feel, and particularly in the caregiver expansion, 
that they are--or have not been involved to the degree that I 
believe, and I think we all believe that they should be, in 
terms of properly making right decisions as you move through 
this process.
    Secretary Wilkie. Well, you have my commitment, and so do 
they, that they will be involved, they are involved, in making 
sure that we make the right decisions. But I will fall back on 
what I said earlier. It is important for us, as you pointed 
out, to make sure that we hear from the entire cross section of 
the Nation's veterans.
    I said in my statement that, on the caregiver effort, that 
would not have been able to come to the finish line without the 
work of what I call the foundational VSOs, and that is my 
recognition that they are central to the entire issue of 
caregivers because the majority of veterans who are in that 
category and who need that family care at home come from 
Vietnam, the Vietnam era. Some less in the Korean era. And the 
foundational VSOs are the ones who represent the community most 
impacted by the caregiver.
    Ms. Brownley. And can you commit to providing our Committee 
progress reports in terms of the IT system for the caregiver?
    Secretary Wilkie. Yes.
    Ms. Brownley. So that we can feel as confident as you do in 
terms of meeting the October 2019 deadline.
    Secretary Wilkie. Absolutely.
    Ms. Brownley. That would be great.
    Just in terms of broadly, you know, the governance 
structure that you have set up for assistance in the 
implementation of the MISSION program, I think, you know, one 
of my frustrations on the Committee--I have served on the 
Committee now for 6 years--is that we have VA representatives 
come to testify that are updating--in this case, we are going 
to want, obviously, frequent updates on the progress with the 
implementation of the MISSION program. But many times they 
come, they avoid answering the tough questions. The response is 
usually: We will take it for the record; we will get back to 
you.
    I have found that I don't get--I don't get responses. If I 
do, it is months and months later. So I just, you know, would 
like, again, to get your commitment that if it is you or others 
representing you, that you will provide us with the best 
information possible to be informed and prepared for our 
questions, and at the end of the day, given you have set up a 
governance structure that--I want to hear from you that, at the 
end of the day, the buck stops with you and that you alone are 
accountable for the successful, hopefully, completion of the 
MISSION Act.
    Secretary Wilkie. Congresswoman, that is right. I mean, I 
am accountable to you. I am accountable to the VSOs. And I am 
accountable to veterans. I will say--and I mentioned having 
grown up in this institution--that I will note that in the time 
that I have been the Secretary and the Acting Secretary, we 
have seen a 20-percent increase in terms of the number of 
roundtable briefings that we have given to Committees--the 
Committee and staff.
    And we have seen a 50-percent increase in terms of the 
number of actual individual congressional engagements with 
offices across the Congress. That is part of the commitment I 
made to Senator Isakson and Senator Tester in my confirmation 
hearing. I will make that better. Again, having grown up in the 
institution, I am aware of Article I.
    Ms. Brownley. Thank you, Mr. Secretary, and I yield back.
    The Chairman. I thank the gentlelady for yielding.
    Mr. Banks, you are recognized.
    Mr. Banks. Thank you, Mr. Chairman.
    Mr. Secretary, in my mind, the MISSION Act is about making 
sure the community care dollars that Congress appropriates 
actually makes it and reaches the veteran. Our Committees have 
a spirited debate every year about the funding levels, but the 
reality is--and you can pick your analogy here--it seems like 
we have been pouring money into a leaky bucket, or through a 
clogged-up pipe.
    When authorizations get delayed or lost, the veteran does 
not receive the necessary care in a timely fashion. When the 
providers do not get paid, they eventually drop out of the 
network, and the veteran far too often winds up in collections. 
So, by consolidating all of the different, legal authorities 
and programs for community care, the MISSION Act actually gives 
the VA the first chance in years to actually make the system 
work.
    My question to you, though, is this: Do you agree that the 
MISSION Act merely makes it possible, and the law's 
implementation is only the beginning of a lot of hard work to 
establish better payment procedures, stronger audits, connected 
IT systems, improved customer service, clear communication to 
veterans, and in so many other areas?
    Secretary Wilkie. Absolutely. Absolutely, it is the 
greatest first step, but it can't stop.
    Mr. Banks. I appreciate that sentiment. But I do want to 
explore one aspect of that hard work. Achieving 
interoperability with the community providers and their EHRs is 
one of my top priorities. And I know, from speaking with you 
personally, it is one of your top priorities as well.
    The VA implementing Cerner is going to advance 
interoperability with community providers that already run 
Cerner, but what about the other medical practices that have 
other EHRs? What is the linkage between the Office of Community 
Care and the Office of Electronic Health Record Modernization 
to start specifically attacking that problem?
    Secretary Wilkie. Right now--I will confess I am not an IT 
expert, but right now, we are testing those standards, those 
operations in the Pacific Northwest and in Alaska so that these 
systems talk to each other. Our first goal was to make sure 
that DoD and VA talk to each other. I think we are pretty far 
along the road on that.
    The next is to make sure that we communicate with doctors 
in the private sector, community-care hospitals, as well as 
private pharmacies, and to talk to those systems that are not 
part of the Cerner network. It is done in other areas of the 
country. I am confident that it will be done here.
    I will say quickly, you are absolutely right about the 
interoperability, and I will also say to the issue of 
privatization, I have argued that the success of the electronic 
health record system ensures that VA will stay at the center of 
a veteran's health care, that VA will be the central node, no 
matter what that veteran decides to do, and that that is one of 
the answers when it comes to the issue of privatization. I see 
that as a veteran myself, I see that when I look at the 
experiences of people in my family as well.
    Mr. Banks. I appreciate that. One of the other key areas is 
claims processing. We have talked about this a little bit 
already, but the VA is essentially asking the consolidated 
community care network contractors, whoever wins the contracts, 
to bring to the table a new and improved claims processing 
system. VA is still going to have to pay the company somehow, 
though. But the idea here seems to be to outsource the IT 
system along most of the claim--along most of the claims-paying 
function. Can you please comment on the thinking here and how 
that will improve the situation?
    Ms. Glynn. Thank you, Congressman. Overall, we are making--
as you have mentioned specifically, there are many changes. It 
is not just the consolidation of the regulations that govern 
the Choice Program now. We are implementing an electronic 
claims payment system so we can auto adjudicate claims.
    We also are changing the way we will pay the third-party 
administrators as well so that they have the funding available 
to pay the providers. So all of that has to happen in tandem 
and as part of the implementation to get to June 6. So, as you 
mentioned, there are many aspects of this, and it is certainly 
not just the consolidation of programs and new regulations; it 
is building up the technical infrastructure associated with the 
community care program.
    And there will be changes in how the TPAs are paid as well. 
And we have committed significantly to looking at the potential 
for fraud, waste, and abuse in that system.
    Mr. Banks. Thank you. My time has expired.
    The Chairman. I thank the gentleman for yielding.
    Mr. Lamb, you are recognized for 5 minutes.
    Mr. Lamb. Mr. Secretary, thank you for joining us today. 
Are you aware the Congressional Budget Office estimated that 
the MISSION Act would cost around $46.5 billion over the 4 
years from 2019 to 2023?
    Secretary Wilkie. Yes, sir.
    Mr. Lamb. That number is familiar to you?
    Secretary Wilkie. Yes.
    Mr. Lamb. Now, as far as I am aware, there is no pay-for 
that is specifically for that $46.5 billion, right?
    Secretary Wilkie. Correct.
    Mr. Lamb. Okay. And those would be discretionary funds?
    Secretary Wilkie. Yes.
    Mr. Lamb. So they would count against the budget cap on VA 
under the current arrangement?
    Secretary Wilkie. Yes, sir.
    Mr. Lamb. And if we went over that budget cap because of 
this $46.5 billion or any other spending, that would trigger 
sequestration, right?
    Secretary Wilkie. Correct.
    Mr. Lamb. So, in other words, for that $46.5 billion, in 
order to avoid the sequestration, we will have to find the 
money within VA's current budget, right?
    Secretary Wilkie. Correct.
    Mr. Lamb. Okay. Now, are you aware that the President has 
asked that each of his agencies cut their total budget by 5 
percent?
    Secretary Wilkie. Yes, I am.
    Mr. Lamb. Did you receive that request yourself from the 
President?
    Secretary Wilkie. I did. I did.
    Mr. Lamb. Okay, now do you have a plan to do that?
    Secretary Wilkie. I have discussed the plan with OMB.
    Mr. Lamb. What is the plan?
    Secretary Wilkie. I have discussed the plan with OMB. The 
President hasn't approved it, so I will wait for his decision.
    Mr. Lamb. Will the money for community care be cut by 5 
percent?
    Secretary Wilkie. I am--well, first of all, for the--I will 
just say for the Choice Program, we are fully funded. We are 
funded into next year. I have no--and I will say that in the 
submission that I made, there were no cuts in community care.
    Mr. Lamb. There were no cuts in community care. So the 5 
percent would come from the rest of the VA's budget that does 
not involve community care, correct?
    Secretary Wilkie. Absolutely. And as a steward of the 
taxpayers' money, I am going to do my best to make sure that we 
are as efficient and lean as possible.
    Mr. Lamb. So actually the non-community care part of the 
VA's budget is going to be cut twice, right? It is going to be 
cut by this 5-percent requirement, and it is going to be cut by 
whatever needs to be spent on community care?
    Secretary Wilkie. Well, we don't know where it is going to 
be cut. I have made--I have made proposals--
    Mr. Lamb. You have made a proposal?
    Secretary Wilkie. I have made a proposal.
    Mr. Lamb. And you are not sharing with us any of the 
details of that proposal?
    Secretary Wilkie. Because I have not had that conversation 
with the President.
    Mr. Lamb. Does it involve cuts to personnel?
    Secretary Wilkie. It makes efficiencies in the system, I 
will say that.
    Mr. Lamb. Does it involve fewer personnel 2 or 3 years from 
now than there are today?
    Secretary Wilkie. No, I can't say that. I can say that in 
the last fiscal year, we have hired 11,000 more employees at 
VA. So we have been hiring at a very steady rate.
    Mr. Lamb. Will you commit to providing us, before the end 
of this year, an itemization of the things that you propose to 
be cut with that 5-percent requirement?
    Secretary Wilkie. I commit to discussing with the 
Committee, at the earliest possible date, the decisions that 
are made by the people who are responsible for those decisions. 
Again, I owe the President the courtesy of having him make the 
decision and then come to the Congress. And you are the 
ultimate arbiter of what that budget will be.
    I can tell you from my experience what usually happens in 
Democrat and Republican administrations when a budget comes to 
Congress. I can't think of the last time one was passed as it 
came over from the White House. That is just the practical 
nature of the business.
    Mr. Lamb. Do you know when you will find out from OMB or 
from the President?
    Secretary Wilkie. Oh, I certainly hope in the next few 
weeks.
    Mr. Lamb. Okay. And we do have your commitment, once you 
receive word from them, to brief us on your proposed cuts to--
    Secretary Wilkie. Once the President has given the all-
clear--and you know the dance that goes on with the budget 
process, usually coming in to the finish line sometime in 
February. I will be as transparent as I can be within the 
strictures of the system as it has existed all the way back to 
1974.
    Mr. Lamb. Well, we would like to see an itemized proposal 
that you have given to the White House as to what should be 
cut, and we would like to see that at the earliest possible 
date.
    Secretary Wilkie. Absolutely.
    Mr. Lamb. Thank you.
    Mr. Chairman, I yield back.
    The Chairman. I thank the gentleman for yielding. Just to 
clarify a little of this, it does get wonky, but the fact that 
you would cut 5 percent doesn't necessarily mean it would come 
out of the VA's budget. And I would refer to this graph right 
here. You can take a look at--these are the number of employees 
right here, Mr. Lamb, that have been hired. And I have been 
here 10 years and looked at this, and the VA has had an average 
of employees who left, from 2013 to 2017, of about 25,000 per 
year, and they have averaged hiring 31,000 during that time.
    And on the budget caps, if we go back to the sequester 
levels--that was the way for 2 years--we have gone from $97 
billion when I showed up here in 2009 to this--I think this 
last budget was $206 billion, so it is over doubled in the last 
10 years, and we found that money elsewhere in the caps. It 
didn't necessarily come from the VA. The VA actually benefitted 
under the caps.
    Secretary Wilkie. Mr. Chairman, may I make one more 
comment--
    The Chairman. Yes.
    Secretary Wilkie [continued].--to Mr. Lamb's line of 
questioning? And I may be out ahead of my skis--I have come 
from the Department of Defense. I am now at the other 
Department in the Federal Government whose needs, its mission, 
is unique. I mean, you have served in one of the two--one of 
the two Departments. As the Chairman has said, our budget has 
been going up. It is at record levels.
    I do expect the President to continue his robust support 
for this Department, as he has for the Department of Defense. 
We are different, and as the Chairman has said, that has been 
reflected in the increase of our budget and the priority which 
this administration has placed on both Department of Veterans 
Affairs and the Department of Defense.
    The Chairman. I thank the gentleman for yielding.
    Thank you.
    Mrs. Radewagen, you are recognized.
    Mrs. Radewagen. Talofa. I want to thank Chairman Isakson, 
Chairman Roe, and Ranking Members Tester and Walz, who is not 
here, for holding this joint hearing, and greetings, Chairman-
elect Takano.
    I want to thank Secretary Wilkie and the panel for their 
testimony.
    I also want to thank the VA for working directly with my 
staff in keeping me informed on the status of the community 
care network contracts in the U.S. territories.
    The Pacific territories, including my home of American 
Samoa, face unique challenges due to their relative isolation 
both physically and economically from the rest of the United 
States. So one-size-fits-all measures simply do not work for 
the territories, and special care must be taken to ensure that 
the unique health care needs of Pacific veterans are 
considered.
    To that end, I am glad that VA is considering the 
uniqueness of the territories in handling their CCN contracts 
separately.
    Secretary Wilkie, VA staff briefed my office on CCN 
contracts just last month, and I would like to take this 
opportunity to touch on the topic once again. Could you go over 
how the unique challenges faced by the Pacific territories will 
affect both the timeline for the CCN contracts and your ability 
to comply with MISSION Act requirements?
    And could I also get your commitment to work with Congress 
so that implementation of the MISSION Act, the contracts, and 
any future related legislation is in line with the needs of the 
territories? To put it another way, will you help us help you 
provide for our Pacific veterans? Timeliness is always a 
factor, but we also want to make sure we get this right.
    Secretary Wilkie. Thank you. I just returned from Hawaii, 
and I made a commitment to one of your counterparts, the 
Governor of the Northern Marianas, that I will be visiting 
American Samoa, Guam, and the Northern Marianas. It is 
important to me.
    I have made a commitment in the continental United States 
to reach out to the Native peoples of this country. The same 
applies to the American citizens in the Pacific. No group 
serves in the military at a greater rate than the men and women 
of the Pacific Islands or the Native peoples of the continental 
United States.
    The unique nature of the challenge is 4.5 million square 
miles that we have to take care of in the Pacific. My 
commitment is that that special categorization of the community 
care network for the Islands in the Pacific will address the 
unique needs.
    We will make sure, particularly through the implementation 
of additional telehealth services, more robust visits from our 
major medical center in Hawaii, to the Pacific Islands, that we 
always take care that the Islands are recognized for the 
special needs that they have.
    Dr. Lieberman. And I just wanted to add--and you probably 
are also briefed on this--that we want to look at how TRICARE 
has succeeded in these areas, lessons learned from them also. 
And, yes, we have to get this right, and so we will continue to 
work until we get this right.
    Mrs. Radewagen. Thank you, Mr. Chairman.
    I yield back.
    The Chairman. I thank the gentlelady for yielding.
    Ms. Esty, you are recognized for 5 minutes.
    Ms. Esty. Thank you, Mr. Chairman.
    I want to thank Chairman Roe and Chairman Isakson and 
Ranking Members Tester and Walz, in particular for their 
efforts on the Blue Water Navy veterans. This is an incredibly 
important issue. These are folks who served decades ago, and we 
owe it to them, and it is relevant to today's hearing. Because 
if we are not managing these budgets appropriately, they will 
not be able to get the care they deserved.
    They say: If you bought it, you broke it.
    When we break people, when we ask them to serve this 
country, we owe it to them to find the means, not just the 
will, but the means to do right by them, and I, again, thank 
our colleagues in the Senate for their enduring efforts to get 
this passed.
    I wanted to quickly say something on the CARE for All 
caregivers, as Senator Murray did. Several of us have worked on 
these issues. And, again, this is an area where we have made 
commitments; we know it is the preference of our veterans; and 
we need to find a way to honor those commitments.
    And that brings me to today's hearing, the utter importance 
of managing these budgets appropriately. We have made promises 
to people that we are going to get them care where they want 
it, how they want it. And in order to do that, we have to 
manage those budgets. So first--and I see I have not lost all 
my time here, but we will continue on. They have me at negative 
12 seconds already.
    Will you have sufficient funds in the 802 account given 
what we know right now? Do you have sufficient funds for the 
community care networks in the 802 accounts, given closeout 
costs, given authorizations and contested claims, that you 
still need to finish? So this wanting to make sure that we make 
that transition to MISSION, but we can't let go of what we 
currently have.
    Ms. Glynn. Let me assure you that overall we are 
monitoring, on a very close basis, the expenditures related to 
802 and the current Choice and PC3 Programs, and we do believe 
and forecast that we will have funding available through the 
end of this fiscal year and have taken account all closeout 
costs and what we believe from a claims perspective in those 
projections.
    Ms. Esty. Thank you, Dr. Glynn. And if it turns out not to 
be correct, please do let us know because obviously it is very 
important. We should not leave anything in that transition.
    Secretary Wilkie. And I would add to that: You are correct. 
This is the wave of the future for medicine, for VA care, 
particularly for--even though the majority are from the Vietnam 
era--for the new veteran. They demand service at home. They 
expect service at home, and the trends in medical care in this 
country, as you have rightly pointed to, are that people get 
better when they are at home.
    And you have my commitment to do everything I can to make 
sure that this is fully funded, and it reaches every veteran 
that we can touch.
    Ms. Esty. Thank you. Thank you again, Secretary, for being 
with us here today. I wanted to just review again, from the 
very beginning, what timeline we are to expect right now with 
the awarding of the contracts for Regions 1, 2, 3, and 4, 
because they are a little bit different than what we had in 
briefing, and I want to make sure we are all on the same page, 
please.
    Dr. Lieberman. For 1 to 3 is by the end of February, and 4 
is by the end of March.
    Ms. Esty. All right. Well, we will want to be, you know, 
looking at that timeframe again.
    And I would like to return for a moment to the discussion 
we had on the number one clinical priority, and that is on 
military suicide prevention. And it is, Secretary Wilkie, in 
part that connection between the handoff from DoD to the VA 
that is something we need to do a much better job of. I would 
suggest those of us working on this, on the Committee, really 
do believe a checkback in 6 months after returning would be a 
very helpful time, to make sure people are in the system; that 
is number one.
    But, number two, I do have to push back, as my colleagues 
have, if we know for younger veterans that they are using 
social media and they are not already involved in the system 
with VA, why in the world have we barely touched the money that 
this Congress has allocated for you to do that outreach? It is 
just astounding to me, knowing that this is a group who is not 
in the system, they need different ways of being connected. We 
are baffled as to--with this epidemic of military suicide, how 
we have done so little to use those funds that we have 
allocated.
    Dr. Lieberman. So we actually used $1.5 million of that, 
not as--as the year went on, we used $1.5 million, but overall, 
we actually have used--$12.2 million we spent last year in 
outreach, and we have done a number of different efforts.
    We were in the Nielsen top 10 for the public service 
announcements. We did 22,000 outreach events. Last week--last 
year our suicide coordinators reached 2.2 million individuals. 
We also had the Be There campaign. I don't know if you saw the 
advertisement with Tom Hanks. And we actually set up a Web site 
with information and actually had over 100,000 hits to that 
site. So we have actually been very active.
    And this year, I am making sure that we are spending the 
funding 100 percent, and so I am reviewing the budget monthly 
and making sure that this moves forward. We certainly have 
obligated all the dollars, and we have plans to reach out, 
including social media this year. We have to get it right.
    Secretary Wilkie. And I would also say that I was 
responsible, as the Under Secretary of Defense for Personnel 
and Readiness, for instituting the training and the awareness 
on the part of Pentagon commands on the challenges and the 
threats to our servicemen and women, regarding suicide. We 
instituted the Transition Assistance Program to include those 
markers indicating that there is a potential for a very tragic 
event. Secretary Mattis has committed to that. I am committed 
to being part of that.
    We also, thanks to these Committees, are treating those who 
have other than honorable discharges and making sure that they 
have that transition assistance and that we join with the 
Department to try to catch this before it becomes tragic.
    Ms. Esty. Thank you, and I yield back.
    The Chairman. I thank the gentlelady for yielding.
    Senator Boozman, you are recognized.
    Senator Boozman. Thank you, Mr. Chairman.
    Secretary Wilkie, thank you for being with us, and we 
really do appreciate your service very, very much. I have had 
the opportunity to serve on the House or Senate VA Committee 
since I came to Congress, and over the years, I have seen the 
VA go, repeatedly, through pains of implementing many new 
programs.
    This Congress may pass significant legislation that will 
bring, quote, fundamental transformation to the VA. As you 
know, when the VA fails to properly implement programs, these 
Committees become the backstop to ensure resources are surged 
to mitigate the impact to the greatest degree possible.
    During a staff briefing about how the VA is going to fix 
its implementation of the Forever GI Bill monthly housing 
stipend payments, the VA was unprepared to answer basic 
oversight questions about how much funding had been spent on 
failed attempts, how much funding had been spent on efforts to 
react to the problem, and what lessons the VA had learned from 
the situation that it can take forward to other implementation 
efforts in the future and under way at the current time.
    These aren't hard-hitting questions. These are just the 
basics. More to the topic of this hearing, MilCon-VA staff had 
a meeting with your staff to get an update on where the 
Department is with determining access standards, a key factor 
that will have an impact on our VA funding levels.
    When I hear that one set of information is provided to 
authorizing staff, another set of information is provided to 
appropriating staff, and a different set of information is 
provided in briefing to all Committee staffers, that is a 
problem.
    And I agree with you, totally, the VA is filled with truly 
wonderful people, but when your staff comes over without their 
act together, with no semblance of transparency, that reflects 
on VA leadership, which you have direct control over. We know 
that it just works better when we can trust each other and work 
together. We simply don't have any other choice.
    For fiscal year 2019, the Congress appropriated $5.2 
billion for the Veterans Choice fund and $9.4 billion for 
community care. Can you tell us what the current burn rate is 
of community care in the Choice programs?
    Dr. Lieberman. It is--I don't remember the exact number, 
and we can get it for you, but it is somewhere--
    Senator Boozman. We have gotten two different ones, 460 or 
340.
    Dr. Lieberman. Yeah. My understanding is, it is around the 
460 one.
    Senator Boozman. Okay.
    Dr. Lieberman. But we will get back to you with the exact 
number.
    Senator Boozman. And you are saying under current 
estimates, funding is sufficient. I guess the next question 
would be: If it is not--and times have come up in the past when 
it wasn't--how does VA intend to address any possible 
shortfall?
    Secretary Wilkie. Well, I would certainly come to the 
Congress with that, but let me talk about the burn rate for a 
second. One of the things that we saw with the Choice Act is 
that many fewer veterans decided to take advantage of it than 
was originally projected after what happened in Phoenix. Of 
those veterans eligible for 100 percent care outside of the VA, 
less than 1 percent took advantage of that. That number of 
veterans is in the three- or four-thousands.
    So every trend that I have seen indicates that we are well 
positioned to take care of Choice funding for the rest of this 
year.
    Senator Boozman. As the VA develops regulations that will 
govern things like rates and access standards for the MISSION 
Act implementation, many decisions will have significant budget 
implications. Certainly those do.
    We understand VA continues to explore multiple options, 
ranging from TRICARE standards to variations of Choice and 
Medicare Advantage. What is the estimated budgetary impact of 
the range of options? When will you be prepared to let the 
Committee know how much you expect MISSION Act-compliant, 
community care to cost annually?
    Secretary Wilkie. Senator, I expect to be up here as soon 
as the President approves the recommendations that I give him.
    In terms of the access standards, I perceive them to be a 
hybrid of several of those programs that you just discussed--
CMS, TRICARE--and that we will come to a conclusion based on 
the combination of those standards and what is best for 
veterans. But I will be up here as soon as the President 
approves the access standards.
    Senator Boozman. Good. Thank you, and thank you, Mr. 
Chairman.
    The Chairman. Thank you for yielding back.
    Senator Sanders, you are recognized for 5 minutes.
    Senator Sanders. Thank you, Mr. Chairman. Let me get 
unanimous consent to place into the record a recent article 
that appeared in ProPublica and PolitiFact.
    The Chairman. Without objection.
    Senator Sanders. Thank you. And it talks about the fact 
that several private companies have been paid nearly $2 billion 
for overhead, including profit, to provide health care to 
veterans, and that is about 24 percent of the company's total 
program expenses.
    So we have enormous administrative costs in private care 
for veterans at a time when I hope we could agree that the 
function of the VA is to provide the highest quality care to 
all veterans in a cost-effective way.
    And, Mr. Chairman, my ongoing concern--and this article 
kind of demonstrates that--is that we are in the process of 
dismembering the VA, taking resources away from the VA, putting 
it into the private sector, and the results will be that many 
of our veterans will not get the quality care that they 
deserve.
    Mr. Secretary, it is no secret--and by the way, thank you 
very much for being here--it is no secret that I opposed the 
MISSION Act. There are parts of the law that I obviously 
support, like expanding the caregivers support program and 
increasing loan repayment through the education debt reduction 
program.
    However, I remain very concerned that, as written, and 
without needed funding, this law puts us into a situation where 
we are forcing the VA to pay for private-sector care at the 
expense of investing in its own facility budget, staff, and 
infrastructure. And I remain very concerned about the level of 
understaffing at the VA that continues to exist.
    I fear this is nothing short of a steady march toward the 
privatization of the VA. And I think sometimes when people talk 
about the privatization of the VA, they think that one day the 
Secretary is going to come forward, and he is going to announce 
the VA is now privatized. That is not the way it is going to 
happen.
    It is going to happen piece by piece by piece until, over a 
period of time, there is not much in the VA to provide the 
quality care that our veterans deserve.
    No one disagrees--we have been through this discussion a 
million times--that veterans should be able to seek private 
care in cases where the VA cannot provide the specialized care 
they require or when wait times for appointments are too long 
or when veterans might have to travel long distances for that 
care. There is no disagreement. The VA has done that for 
decades.
    But to my mind, the way to reduce wait times is not to 
direct resources outside the VA as the MISSION Act does, but to 
strengthen the VA. VA should be focused on recruiting and 
retaining the best health care professionals in our country to 
care for those who have put their lives on the line to defend 
us. VA should be focused on investing in its aging 
infrastructure so veterans can benefit from the best health 
care facilities, and VA should be focused on figuring out the 
budget it needs to provide the demands of our veterans--our 
veteran patients.
    Mr. Secretary, let me start off by asking you a simple 
question, and that is: The veterans' organizations, to my mind, 
do a very good job in understanding where the veterans are at, 
the problems that the veterans of our country see when they 
interface with the VA. To my mind, what the law says is that 
you are to consult with the VSOs. That is what we have in law, 
but that does not simply mean a one-way discussion. It does not 
mean simply you telling them what is going on. It means you are 
listening to them.
    So let me just ask you this, Mr. Secretary, can you tell me 
exactly, in as precise a way as you can, how you have solicited 
feedback from the VSOs, and how that feedback has been 
incorporated into the regulations currently being written on 
quality and access standards, Mr. Secretary?
    Secretary Wilkie. Well, thank you, Senator. In the little 
less than 4 months that I have been the Secretary, I have 
doubled the number of VSO engagements. I have also opened the 
aperture on VSO engagements by including groups that represent 
the new breed of veterans, even some that represent veterans 
going back to Vietnam that have not been included, like the 
blinded veterans, the Purple Heart veterans.
    I am meeting tomorrow with many of the people who are in 
the audience today. It is absolutely essential. I have served; 
I have a long line of family service. Without talking to the 
veterans--and when I say, ``talking to the veterans,'' when I 
am out in the country, in the great Nations of the plains, when 
I was out in Oahu--
    Senator Sanders. I am sorry to interrupt.
    Secretary Wilkie. I do meet with them. It is not a one-
way--
    Senator Sanders. Here is the point, here is the point. And 
I appreciate that, and I know you are trying to do that. But 
meeting with them and talking to them is different than 
listening to them. Can I have your commitment that you will 
incorporate their ideas and their concerns into the work that 
you do?
    Secretary Wilkie. Absolutely.
    Senator Sanders. I think my time has expired.
    Secretary Wilkie. Mr. Chairman, may I add, sir, a comment--
    The Chairman. Go ahead.
    Secretary Wilkie [continued].--make a comment about what 
Senator Sanders said. I agree with him about privatization, and 
I agree with him about understaffing the VA. But I do need to 
make it clear that we do not exist in a vacuum.
    The United States, as you have pointed out in many floor 
debates that I heard when I worked in this institution, is 
suffering from a shortage of mental health professionals. It is 
suffering from a shortage of women's health professionals. It 
is suffering from a shortage of primary care and internists. We 
are competing for those.
    What has happened with the MISSION Act, and one of the 
benefits that I have now, is that I have the opportunity to 
offer more impressive packages to bring those health care 
providers into the VA. We are doing our level best because you 
are absolutely right: we are short on those.
    And I will also say that when it comes to privatization, 
you and I discussed this in your office several months ago 
prior to my confirmation. I believe this strongly. I have said 
it all across the country. I don't believe that veterans will 
allow VA to be privatized, and I will tell you why. It is not 
anecdotal, but it is emotional. Veterans want to be where 
people understand their culture and speak their language.
    Senator Sanders. Good.
    Secretary Wilkie. I am from that world; I understand it. 
And I agree with you that my job right now is to ensure that 
those veterans who need that care outside of the VA--and we 
don't have it--get it. So--
    Senator Sanders. Thank you. Let's continue the discussion.
    Secretary Wilkie. Yes, sir. Thank you.
    The Chairman. I think, gentlemen, I would also encourage 
support from the VA and from the Senate and House on a bill 
that I have on an immigration bill to help allow doctors who 
are trained here in this country to stay here. We are sending 
them out of the country, and it is ridiculous that we are doing 
that when we have such a need here.
    Mr. Arrington, I recognize you for 5 minutes.
    Mr. Arrington. Thank you, Mr. Chairman, and Mr. Secretary, 
thank you for your service.
    If a veteran doesn't get good care at the VHA, do the 
doctors still get paid over there?
    Secretary Wilkie. Well, they get paid because they are on a 
Federal scale. However--
    Mr. Arrington. So the Federal Government will pay them 
whether they serve the veterans or not. Will the administrators 
get a paycheck whether or not the veterans are receiving good 
quality care and service?
    Secretary Wilkie. Well, I can give you an example of how I 
acted on that.
    Mr. Arrington. Just historically, just historically, is the 
answer that they get paid regardless of the outcome for the 
patient?
    Secretary Wilkie. Historically, before the Accountability 
Act was passed, historically, before the MISSION Act was 
passed, the Secretary of the Department of Veterans Affairs was 
under the same strictures that every Cabinet leader was under, 
that there was a laborious process involved in removing Federal 
workers who did not perform. That does not exist anymore.
    In the 1 year that--well, the 1 year that I had been in and 
out of VA, we have removed 5,000 employees, including the 
director of one of our largest VA medical centers. I did that 
because the work was not getting done, veterans were not 
getting treated, and I felt that the powers that the Congress 
had given us needed to be exercised.
    And I intend to exercise those powers whenever I see a 
problem because veterans are first; the institution is not 
first. And--
    Mr. Arrington. And I hope you continue to do that. That is 
the only way you are going to stay relevant. It is the only way 
you will prevent the veterans from voting with their feet about 
where they want to go and what this all is going to look like.
    Let's not be so arrogant that we think we can build a mouse 
trap from the Federal Government from Washington that is going 
to satisfy the customer.
    Either you deliver good service and either they are 
satisfied, or they are not. And if they aren't, they will make 
the decision on whether this is privatized or not privatized, 
or some hybrid. Good for you, I hope you continue to do it. 
Because in the private sector, if they don't delight the 
customer, the private providers, they don't have a business; 
they can't pay the bills; they can't feed their families. That 
is the incentive you are competing with, and that is why I am 
for choice.
    That is why I am for giving the veterans freedom to choose, 
to opt out of a system that may not be working for them. Maybe 
a union-controlled monopolistic bureaucracy isn't the best way 
to provide service to our heroes. I don't know. Where it is 
working, good, great. Continue to do good. Where it is not, I 
get why it is not because it is a very different animal 
altogether. So, okay.
    It was good to meet you the other night, by the way.
    Secretary Wilkie. Good to meet you too, sir.
    Mr. Arrington. And your wife. I am really not an angry guy. 
I just get fired up when I talk about this, and I know you're 
passionate about it, too.
    Let me ask you this. Are people choosing to go to community 
care at a greater rate today than they did a year ago?
    Secretary Wilkie. They are not choosing to go to community 
care at a greater rate than they did when Omar Bradley ran the 
VA in 1945 to 1947. It has been about the same level, which is 
30 to 35 percent, historically. I think we are even seeing, Dr. 
Lieberman, a slight dip in the use of community care.
    Mr. Arrington. So fewer veterans are choosing to go outside 
of the VA today than they did a year ago, 2 years ago, 5 years 
ago?
    Secretary Wilkie. A little bit. A little bit. It is a 
small, small number.
    Mr. Arrington. Let me ask you--I will take your word for 
it--I assume you guys measure the quality and the overall 
service that veterans get at the VHA. Do you all measure the 
quality of care and overall service at your various facilities 
in the VHA? Yes or no, Doctor?
    Dr. Lieberman. Within VHA?
    Mr. Arrington. Yes, sir.
    Dr. Lieberman. Yes, sir.
    Mr. Arrington. And do you all compare the quality metrics 
and the service metrics in community care with the quality care 
and service at the VHA?
    Secretary Wilkie. Absolutely. But we also compare it to--
    Mr. Arrington. How do they compare, Mr. Secretary? Are they 
comparable? Are they better at the VA?
    Secretary Wilkie. I will tell you, The Dartmouth released 
its most recent study a week or so ago in the Annals of 
Internal Medicine, and their conclusion was that care at the 
Department of Veterans Affairs is as good or better than any 
care in the rest of the country. Of course, that includes 
community care. So we are being judged by comparison to--
    Mr. Arrington. Well, that is good--that is good to hear.
    Secretary Wilkie [continued].--the biggest health networks 
in the country.
    Mr. Arrington. Last question. I represent a big swath of 
rural west Texas. How are the access standards going to affect 
their access to VA care?
    Secretary Wilkie. I have talked a lot--
    Mr. Arrington. And I yield back.
    Secretary Wilkie [continued].--Congressman, about the scale 
of the American West. I have sometimes joked that the loneliest 
sign in America is on Interstate 10 in Houston that says, ``El 
Paso, 910 miles.'' What we see access doing is, is offering our 
veterans, particularly in rural America, the opportunity to 
alleviate a burden on themselves and their families by giving 
them the option to seek care that is closer to home, if they 
have to embark on a 300-, 400-, 500-mile round trip journey to 
get to a VA center.
    As I have said many times, it is incredible that in 2018--
and I saw this in Hawaii last week--we do not understand the 
scale of the West, and we certainly don't understand the scale 
of the Pacific.
    The Chairman. I thank the gentleman for yielding.
    Mr. Arrington, I was in Greg Walden's district in Oregon a 
year ago. And his congressional district has more square miles 
than the State of Tennessee does. So our challenge in this 
Committee was to devise a MISSION Act, a program that was good 
for rural America and for urban America, and that is hard to do 
when you are trying to do both.
    So, if you are on the 405 in Los Angeles, you may be 
quicker to somewhere else, if you are stuck on there to get an 
appointment, if you don't live 10 miles from somewhere. So it 
is a real challenge to do this, and to get it right where you 
provide the care at the point of service for those veterans.
    And I think the VA's moving in the right direction with 
their CBOC model, taking the care of the veterans, I absolutely 
believe that.
    Mr. O'Rourke, you are recognized.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    Mr. Secretary, in answer to Senator Tester's question about 
administrative costs totaling around 24 percent, and then that 
number was disputed, but in response, you said: We were taken 
advantage of.
    Could you clarify by whom the VA was taken advantage of?
    Secretary Wilkie. I meant in a generic way, that the Choice 
Act--and I think there is agreement from the leadership of both 
Committees--that the Choice Act was rushed, and we were given 
such unreal, unnatural timelines to implement a program in a 
370,000-person Department.
    Mr. O'Rourke. So there was no actor or third-party 
administrator or outside contractor who took--
    Secretary Wilkie. We were forced to take what we could get 
to implement a law based on the timeline that was created by 
that act which has now been rectified by the MISSION Act. So, 
when I said, ``taken advantage of,'' we--and I wasn't there; I 
was happily in the Department of Defense.
    Mr. O'Rourke. But--
    Secretary Wilkie. My understanding was VA had to move as 
rapidly as possible, and there was not that time for reflection 
that you would usually have in an issue like this.
    Mr. O'Rourke. The articles about the recently released GAO 
report about unspent suicide prevention outreach dollars, $6.2 
million allocated, as of September, 57,000 spent, and then, 
Doctor, you suggested there was, perhaps, another 1-, 1.5 
million spent on top of that out of the 6.2. You say you will 
exhaust that before the end of the year. You say that you got 
100,000 hits on the Web site. Another thing the GAO says that 
is perhaps more alarming than the unspent money is that you 
have not established targets for the efficacy of this outreach 
effort.
    So hits to the Web site, don't know what it means and don't 
know if it matters. How do you know how you are doing on what 
you have established as your number one clinical priority, 
suicide reduction, which I am grateful for, that that is a 
priority? How do you know how you are doing against that 
priority? What are your goals?
    Secretary Wilkie. Well, let me talk about the national 
situation that we face. First of all, I was responsible for the 
Department of Defense end of this.
    Mr. O'Rourke. I have got limited time. I don't want to hear 
an anecdote. I want to hear the goals--
    Secretary Wilkie. I am not going to give you an anecdote. 
Fourteen of the 20 veterans who die by their own hands every 
day are outside of VA.
    Mr. O'Rourke. Correct. We have known that for years.
    Secretary Wilkie. We spent $12.2 million on that outreach 
just in the time I believe that I have been in charge, which is 
just a few months. But I have to go beyond what that GAO report 
says, talk with Governor Brown, talk with Governor Inslee, talk 
with Governor Ige. I am busy.
    Mr. O'Rourke. If it is your priority, what is your goal, 
and how are you doing against your goal? I am not blaming you 
for where we are.
    Secretary Wilkie. No.
    Mr. O'Rourke. And I don't know what to know what you have 
done in the short tenure. I want to know what your goal is and 
how we are doing against it.
    Secretary Wilkie. The goal is to do our best to make sure 
that we have done everything possible.
    Mr. O'Rourke. And we will never be able to judge you on 
that.
    Secretary Wilkie. And that's right. We can't.
    Mr. O'Rourke. Do our best, what does that mean.
    Secretary Wilkie. The majority of those warriors who take 
their own lives come from my father's warrior generation. That 
means these are problems that are 50 years in the making. I am 
not going to tell you that I can wave a magic wand and correct 
problems that began when Lyndon Johnson was President. I am 
doing my best through the outreach that we have, and the 
resources that start with the Department of Defense. We never 
had a transition program or and awareness program on suicide 
until the last year or so at the Department of Defense. That is 
where it has to start so that we make sure that the mistakes 
that began back in 1968 and 1969 and 1970 are not replicated 
now. That is not anecdote. That is just historic.
    Mr. O'Rourke. I hear you, but if you don't measure it, you 
will never be able to improve it. So do you or do you not agree 
with the GAO's finding that you have not established targets 
for the majority of metrics you use to gauge the effectiveness 
of your suicide prevention outreach campaign. If you agree with 
that, what are you doing to correct the finding?
    Dr. Lieberman. So we concur that we did not have robust 
enough metrics at the time of the GAO evaluation. We have 
responded to the report. We are in the process of developing 
more robust ones.
    Mr. O'Rourke. When will you have them?
    Dr. Lieberman. Later this year.
    Mr. O'Rourke. This year. This year, or--
    Dr. Lieberman. I'm sorry. 2019.
    Mr. O'Rourke. Okay. Thank you.
    Secretary Wilkie. As I said, Congressman, I put in place, 
that is as the number one clinical priority, and I can promise 
you that we will expend everything that we can to try to 
correct this and address this great national tragedy.
    The Chairman. I thank the gentleman for yielding. I think 
Mr. O'Rourke's question was if you don't know where you are 
going, you might end up someplace else. If you don't have your 
goals set, you don't meet those goals. I think that is what you 
were asking. Mr. Coffman, you are recognized.
    Mr. Coffman. Thank you, Mr. Chairman. Mr. Secretary, I 
think the VA has always had the authority to reach out to 
community providers. Prior to the Choice Act, I think in 
specific relationships--I am trying to remember the name of the 
program. Is it the P3 program? P3 program. One of the 
complaints I have heard about that program that still exists 
today is that every separate agreement is negotiated 
independently, and what I think--in Colorado, we have had some 
potential providers under the P3 program drop out because of 
the length of the negotiations and the complexity of the 
negotiations where I think one question they always raise to me 
was why don't we simply use Medicare rates as reimbursement on 
the P3 program so we are not renegotiating every new agreement 
from scratch?
    Dr. Lieberman. Well, we actually are moving away right now 
with the TriWest and in the future with the agreements, the 
community care agreements with the MISSION Act, and right now, 
we have--TriWest has stood up, actually, in Colorado, in 
Denver, and in the first week--and they are getting Medicare 
rates. And in the first week, they actually have entered 2,700 
consults, and already scheduled 500 patients, and so they have 
been able to create the network that the facilities have been 
struggling to do on their own, and so they are creating it. And 
that is what is going to be part of the community care networks 
as we roll them out.
    Mr. Coffman. Okay. And how are we doing in terms of 
efficiency on telemedicine? I think it was raised about rural 
America, certainly rural Colorado. It is a struggle. We have 
got people in Grand Junction, Colorado. There is a CBOC there, 
but for--oftentimes for care, they have to go to the VA medical 
center, regional medical center which is now in Aurora. That is 
a 4-hour drive. I know they are reimbursed for the mileage for 
that, but are we doing better in terms of telemedicine?
    Dr. Lieberman. Through support of the Congress, we are 
investing in increasing bandwidth at many of our CBOC locations 
which is really important. We also are doing the anywhere-to-
anywhere, so when someone has internet access in their own 
home, we can provide telehealth into the home.
    We also are joining in partnerships with different private 
entities to--they are going to give us a private room in a more 
rural area, and the veteran can go there and have their 
appointment in that location that is closer to their home. So 
we are really working a lot in this area.
    Mr. Coffman. Okay. There was legislation passed that I 
authored, I think it was included in a larger bill, that 
requires an independent study as to those veterans who died, 
who committed suicide who were under VA care, and I think one 
of the objectives of it is to go look into what prescriptions 
that they had at the time of their death, because I do have a 
concern that we are overprescribing some of our veterans in 
mental health.
    Secretary Wilkie. Yeah. Let me talk about the opioid issue, 
which is part of that continuum, and also to Congressman 
O'Rourke's well-founded observations about the suicide program. 
I do want to say that we are not divorced from national 
problems. We are one part of that, which is why, in the answer 
to your question, I will say in this case, VA has taken the 
lead in creating alternative therapies, alternative 
prescriptions for those with great pain. The one factor about 
VA care that is not shared in the private sector is that we 
help people who come from a dangerous profession, people like 
my father after 30 years of jumping out of airplanes, needed 
two knees, two new hips, and had lead in his body from Vietnam. 
So what we have done is we have been able to reduce the amount 
of opioid prescriptions by 41 percent, just in the last 2 
years.
    In addition, we are on the cutting edge of alternative 
therapies, occupational therapies, Tai Chi, acupuncture, things 
that would have been unimaginable 10, 15, 20 years ago. And 
that is part of the answer to those veterans who are suffering 
from pain and subsequent issues like mental health.
    Mr. Coffman. Chairman, I yield back.
    The Chairman. I thank the gentleman for yielding. Ms. 
Kuster, you are recognized.
    Ms. Kuster. Thank you. Thank you very much. And just to 
pick up right there, I very much appreciate the progress that 
is being made by the VA on the opioid epidemic, and I hope that 
we can spread new alternative pain management strategies not 
only within the VA, but frankly, within the private sector as 
well.
    I just want to revisit briefly this issue because I think 
certainly my constituents, but I think constituents across this 
country were so shocked and concerned to read today about this 
issue that your Department had only spent 1 percent of the $6 
million for suicide prevention. We have had a little bit more 
testimony on that today. You say that you are doing your best, 
but what I am concerned about is that that can't be true when 
we have so many leadership vacancies at key posts in the VA 
related to these programs. What are you going to do about 
getting the right people in the right place? And I just want to 
give you one chance to revisit Mr. O'Rourke's question because 
we can't really respond here in our oversight function to the 
concept of doing your best if we don't know what your goals 
are. And you talk about the majority of the suicides are 
committed by people outside the system. That is true. That is 
our frustration. How do we bring them into the system?
    Secretary Wilkie. As Dr. Lieberman said, we began to move 
when I became Acting. The vacancy that you talked about at the 
head of the Suicide Prevention Office was immediately filled by 
me by making permanent the position.
    Ms. Kuster. And does that person have the staff they need 
on board.
    Secretary Wilkie. Yes. Also the expertise as having been 
the leader at the Department of Defense in the Suicide 
Prevention Office.
    Dr. Lieberman. We are in the process of hiring staff just 
for the record.
    Ms. Kuster. I am sorry. There are other vacancies, and you 
are in the process of hiring for that.
    Dr. Lieberman. We are building a larger office underneath 
this individual, so we are hiring more people to support her.
    Ms. Kuster. And does that program have functional capacity 
at all the VSNs around the country as well.
    Dr. Lieberman. They certainly work with all the VSNs. The 
VSNs have their own responsibility to roll out and work with 
her what ideas are coming out. I also just want to let you know 
that we really are focusing in a new way on the high-risk 
veteran populations, both within VHA and the ones outside. And 
so number one, there is an executive order to work on 
transitioning veterans, and so we have been working with DoD on 
that. The Other Than Honorable, we have been working on that 
since 2017, but this month--this week, I am sorry, and the rest 
of the month, we are actually mailing out letters to the over 
500,000 Other Than Honorable encouraging them to come to us to 
seek whether they are eligible for care here in mental health.
    And we are also looking at the Reserve and the Guard that 
have never served. They have been identified recently. As our 
data gets mature, we can identify more at-risk populations, and 
they are at risk, and so we do mobile vet center outreaches to 
them on the weekends when they are doing their drills, and we 
are reaching out to leadership in those areas. And then, 
finally, another risk that we identified recently was that if a 
veteran came to the emergency room in the prior 3 months, and 
had just a little bit of suicidal ideation, not enough to have 
to admit them or--if we did research, and we found that if we 
made a suicide safety plan with them where if they are having 
suicidal thoughts, what are they going to do? Are they going to 
call a loved one? Are they going to call their therapist? Are 
they going to listen to music? What are they going to do? And 
it has been shown to reduce the suicide rate by 50 percent. And 
so, what we have done is we have actually implemented this 
rapidly at all our VAs across the country. So we are trying new 
novel things as they come along.
    Ms. Kuster. Well, and I think the research is important. My 
time is running short. I had another question about the whole 
issue under the VA MISSION Act and the designated access 
standards, but I guess I will just leave it at this. New 
Hampshire is one of the rare States without a full service VA 
Hospital, and I think we are all trying to find this balance of 
care at the VA, and if that is not possible, then care within 
the community, but I would just use New Hampshire as a 
cautionary tale and the problems that we had recently at 
Manchester when the level of care drops below what is necessary 
for a robust VA going forward. And I think that was the point 
that Senator Sanders was making, and I think it is instructive 
as we move forward. But at that, I yield back.
    Secretary Wilkie. And I would just add. I agree with you 
completely about suicide. I mentioned that I was in and out of 
the VA as Acting, and then had to go back to DoD and wait 
confirmation. In my first week, I laid down the first path on 
the suicide issue. I will tell you, there is nothing more 
important, and there is nothing more tragic, and you have my 
commitment that as long as I am privileged to be part of the VA 
team, that will continue to be the case.
    Ms. Kuster. If I could, one quick second. I have been in 
Congress for 6 years. You are our fifth VA Secretary in those 6 
years, so I appreciate your personal commitment. I have 
literally heard that five times, and veterans are dying every 
single day, so we will hold you to the commitment. We will want 
to know the metrics. I appreciate the innovative solutions, and 
we will look forward to continued discussion. Thank you.
    The Chairman. I thank the gentlelady for yielding. Senator 
Hirono, you are recognized for 5 minutes.
    Senator Hirono. Mr. Secretary, I am glad to know that you 
are in Hawaii and you obviously--not to mention I have a cold. 
Let me slide over to this mic. Okay. This one is working. Can 
you add to my time? Are you listening?
    The Chairman. We froze the clock.
    Senator Hirono. Thank you very much. I am glad you were in 
Hawaii, and obviously you spoke with Governor Ige, but did you 
let the congressional delegation know that you were going to be 
in Hawaii?
    Secretary Wilkie. Yes. In fact, I think I mentioned it to 
you the last time we spoke, that I would be in Hawaii in 
December.
    Senator Hirono. I don't think we got the date, but not to 
beat you over the head with it, but I think that it would be 
good for your team to alert the congressional delegation--
    Secretary Wilkie. And we do. We do.
    Senator Hirono [continued].--when you are in our State so 
we can to maximize our ability to support and work with you.
    Secretary Wilkie. We did, and I will go back on what you 
and I discussed last time. I made two commitments: one to go to 
Hawaii, and one, to go--if you are not there, I have got to go 
back because I am going to go to Samoa and Guam.
    Senator Hirono. Oh. There you go.
    Secretary Wilkie. Go there when you are there.
    Senator Hirono. Thank you very much. The VA, over the 
years, of course, not only have we had so many Secretaries over 
the last 5 years, as mentioned, though, their ongoing 
challenges whether it be IT, homelessness, suicides, 
construction delays, of course, access to care. So you have 
been asked whether there is a sense of urgency at the VA, but I 
ask you whether you have a sense of urgency?
    Secretary Wilkie. Absolutely.
    Senator Hirono. So if you have a sense of urgency, what are 
your top priorities for the VA?
    Secretary Wilkie. Well, my top priorities for the VA, and I 
mentioned the first clinical priority, which is suicide 
prevention.
    Senator Hirono. Right. That is one.
    Secretary Wilkie. My top priority is to create, with the 
assistance of these Committees, a modern 21st century health 
care administration that keeps veterans at the center of their 
health care. This Committee has already laid down the template 
for that, and it is my duty to carry that out.
    Senator Hirono. So I think I am looking for something a lot 
more measurable. So, for example, you were asked how can we 
verify whether you are reaching your goal regarding suicide 
prevention. So a former VA Secretary said that his goal would 
be to end homelessness. So those are the specific kinds of 
priorities that I am asking you to articulate if you have them.
    Secretary Wilkie. Well, I will tell you. I am not going to 
come to this Committee and tell you that I will end 
homelessness, and I am not going to come to this Committee and 
tell you that I can eliminate suicide amongst veterans.
    Senator Hirono. Well, that is not what I am asking you. 
What I am asking is, out of a sense of urgency, what are your 
top priorities for the VA? So whether it be decreasing 
suicides, increasing--decreasing homelessness, do you have 
those kinds of priorities?
    Secretary Wilkie. Well, I just mentioned them. Modern 21st 
century health care administration for the VA, which means 
modern IT meaning the best medical care possible.
    Senator Hirono. When you say something like best medical 
care possible, you know, how do you come up with a verifiable 
matrix?
    Secretary Wilkie. Well, I can tell you that our health 
care--we have the standards. We have the metrics which we share 
with this Committee. We compare what we provide with health 
care across the country. I have referenced the latest 
comparison that Dartmouth Ivy League has done that was in the 
Annals of Internal Medicine last week, that says--
    Senator Hirono. I am running out of time.
    Secretary Wilkie [continued].--that our care is as good or 
better than any in the country. I want to make sure that--
    Senator Hirono. If you have those priorities for you 
because, you know, I think it would be good for us to hold 
people accountable, and that there be transparency and 
accountability, and I would certainly want to apply that to 
you. So if you have those priorities, and they are listed and 
how you are going to--whether you have verifiable metrics to 
enable us to realize whether you have attained those 
priorities, that would be great.
    I have a question about the family caregiver, comprehensive 
assistance for family caregivers. That is a very important 
program for a lot of veterans, and I am glad that we expanded 
it. So I have received, though, for example, a note from a 
caregiver in Hawaii just this week, and she wrote, quote, ``I 
just received the devastating news that we were no longer 
eligible for the caregiver program. I did not even receive a 
phone call, follow up from my coordinator,'' or even an 
explanation other than the fact that her husband is simply no 
longer eligible. So how are you communicating with the 5,500 
family caregivers as to what it happening with this program and 
what the requirements are, et cetera?
    Dr. Lieberman. So first of all, if your office could share 
with us that individual so we can follow up on it.
    Senator Hirono. Certainly.
    Dr. Lieberman. So the MISSION Act is giving us the tools to 
do this right moving forward and making sure that we have 
objective ways so that we make sure that we are implementing 
the same, no matter what State you are in across the country, 
and part of it is we want--what we are proposing is to move 
away from these reassessments and more towards wellness checks 
to make sure that the caregiver has what they need to succeed, 
and the veteran is receiving the services that they need.
    We have regular ways that we communicate with the 
caregivers. We have phone calls with them around the country. 
We have a phone line where they can call in, but we have not 
yet made our decision on how we are rolling it. We are still 
getting input. Right now it is in the Federal Register, some of 
the ideas of how to improve upon the services available in the 
program.
    Senator Hirono. Thank you.
    Secretary Wilkie. And you are absolutely right. It is 5.5 
million family caregivers--
    Senator Hirono. Oh. Did I say 5,500?
    Secretary Wilkie [continued].--that we have to support. 
Yes, ma'am.
    Senator Hirono. Yes. That is a lot of people to stay in 
touch with. Thank you for the information--
    Secretary Wilkie. Absolutely. But it is the wave of the 
future.
    Senator Hirono [continued].--regarding this particular 
inquiry I got. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator. Senator Blumenthal, you 
are recognized.
    Senator Blumenthal. Thanks, Mr. Chairman. Thank you for 
having this hearing. Thank you to the Secretary and your 
colleagues for being here today. I want to thank my House 
colleagues for passing the Blue Water Navy bill unanimously. I 
want to say how disappointed, in fact, ashamed I am that the 
Senate failed to do the same, even though as recently as a 
couple of hours ago, I was on the floor of the Senate asking 
for unanimous consent from my colleagues to move ahead so that 
that bill would become law. If the VA were doing its job and 
supporting this bill, it would have overcome the opposition of 
a small number, a handful of my colleagues, who are blocking it 
now.
    I am going to ask you to commit, as I have before in 
hearings, that you will help us pass that Blue Water Navy bill.
    Secretary Wilkie. I committed to the Chairman and to 
Senator Tester, that I would do everything I could to help your 
Committee.
    Senator Blumenthal. Well, you have done that before, but 
unfortunately, that support has not been translated into active 
advocacy with my colleagues, and I hope you will do better 
during the next session.
    I want to follow up on a number of questions asked by 
Congressman O'Rourke about metrics. You can't do better unless 
you measure what you are doing, and so far, as I can see, one 
of the chief criticisms of the GAO report has been the lack of 
metrics and measurement. And I would suggest to you, 
respectfully, the two good ones would be whether the rate of 
suicide is coming down, which it is not, and whether the GAO is 
using all the resources at its disposal to bring it down, which 
it is not. Would you agree?
    Secretary Wilkie. Well, I agree with the state of affairs 
at VA that the GAO laid out.
    Senator Blumenthal. You agree with the GAO report?
    Secretary Wilkie. Which is why--
    Senator Blumenthal. And so you would agree that the reason 
that you failed at the VA to spend more than a fraction of the 
money given to you by the United States Congress is, I am 
quoting, ``The reason they did not spend the remaining funds on 
suicide prevention paid media in fiscal year 2018 was that the 
approval of this paid media plan was delayed due to changes in 
leadership and organizational realignment of the suicide 
prevention program,'' and they go on more specifically to say 
on pages 15 and 17 that it was a ``lack of leadership available 
to make decisions about the suicide prevention campaign.'' And 
then on page 17, ``By not assigning key leadership 
responsibilities and clear lines of reporting, the VHA's 
ability to oversee the suicide prevention media outreach 
activities was hindered, and these outreach activities 
decreased.'' That is a failure of leadership.
    Secretary Wilkie. Senator, I am going to agree with you, 
and you and I, I think, discussed in your office when I was the 
Acting Secretary, that the first thing I did when I became 
Acting, which is sort of being in limbo, but I did it anyway, 
was to start moving on the suicide prevention issue. I 
identified leadership, and I made this the number one clinical 
priority. I agree that the Department had not done what this 
Congress and what veterans demand of it, and that is--
    Senator Blumenthal. Well, let me ask you because my time is 
limited. I apologize for interrupting. Can you commit that the 
VA will spend every dime devoted by the Congress, allocated by 
us, to suicide prevention during the coming fiscal year?
    Secretary Wilkie. Absolutely, and I will probably ask for 
more or allocate more because of this national tragedy.
    Senator Blumenthal. How much more do you think is 
necessary?
    Secretary Wilkie. I don't know. I don't know. That is why I 
mentioned it, and you weren't here. In the last few weeks, I 
have been on the phone, or in person with Jerry Brown, with 
Governor Ige, with Governor Inslee, discussing the way ahead. 
We have not had a comprehensive nationwide response to 
veterans' suicide. I need the cooperation of our governors, and 
that is why I put in train the development of the metrics that 
Senator Hirono talks about that you talked about so that we 
have, in place, a program to go and attack this problem. That 
is the best answer I can give you, that I moved on it as soon 
as I moved into VA.
    Senator Blumenthal. Well, I know that you have moved on it, 
but you have to forgive me, and maybe us, that we have seen 
this movie before. As one of my colleagues remarked, we have 
seen a slew of Secretaries who have made commitments and 
promises, and I think we are, at least speaking for myself, 
expressing the frustration and impatience that is well-founded, 
in fact, because of the turnover in leadership from the top 
through the middle ranks, and with all due respect, Dr. 
Lieberman is an example. He follows others who have been in 
that position for small lengths of time. We can't demand 
accountability if there is this constant churn and turnover in 
leadership, which then becomes a failure to spend the money 
that is allocated to suicide prevention and maybe other 
programs.
    Secretary Wilkie. And I agree with your observation about 
suicide. The program, at best, it was inchoate in 2017, and 
that is why I permanently appointed the DoD leader in suicide 
prevention, the person with the most expertise in this matter 
available to the government, and that we are increasing the 
size of that operation. I agree with your criticisms.
    Senator Blumenthal. My time has expired. I apologize, Mr. 
Chairman.
    The Chairman. Thank you, Senator Blumenthal.
    First of all, thank you all for being here, and I would 
like to yield to my colleague, Mr. Takano, next year's 
Chairman, if he has any closing comments.
    Mr. Takano. Thank you, Mr. Chairman.
    Mr. Secretary, I do look forward to hearing as soon as 
possible more about the designated access standards. I know you 
told me in your response to me that you still need to await the 
President's choices, but I hope that you will consider speaking 
to us before that time because I see no reason why the VSOs and 
Congress cannot participate with you, I think, as the spirit of 
the MISSION Act does stipulate that these access standards were 
not to be developed alone between you, Mr. Secretary, and the 
President. And I certainly don't want to see expectations 
unnecessarily raised at the State of the Union speech, and 
Congress being in the position to have to try and pull those 
expectations back.
    So I would like to, in the time between now and the third 
week of January, like to see your Department work more closely 
with the VSOs and Congress in developing these access 
standards, because so much is at stake, and we need to do some 
trust building among the stakeholders, Congress, and your 
department.
    I want to reiterate what Senator Blumenthal has said, the 
frustration of Congress being able to hold, you know, the VA 
accountable when we have seen such changeover or Acting 
Secretaries, and some of it is on, I hate to say, the Senate, 
for not confirming people in a timely manner. But nevertheless, 
it has been very disappointing to see, in the last 2 years, an 
administration that has not been able to put in place stable 
leadership at the VA. And I see the IT failure with regard to 
the BAH payments, the issue with the social media, and adequate 
marketing being done to inform veterans about suicide 
prevention hotlines, all leading back to the same fundamental 
problem which is the unstable leadership at the very top. And 
this has got to change.
    And, so, Mr. Secretary, I would like nothing more than to 
see you succeed and for you to serve out a tenure which allows 
you to implement changes. I certainly do appreciate the 
sentiment you expressed when you quote the Dartmouth study 
recently, and further back, the RAND Study, and that you have 
an understanding about how well our VA does deliver health 
care, and you recall that the RAND Corporation Study indicated 
that the main problem is access. And we have still 41,000 
vacancies. I want to work with you, Mr. Secretary, on not slow-
walking those vacancies, but doing all that we can to improve 
the personnel function of the VA, so that applications are 
acknowledged, people are quickly made offers, and that we also 
take a look at what we need to do to develop the health care 
workforce of this country, because I think that is part of the 
problem. It is not just doctors, it is the technicians. It is 
the allied health professions that we need to pay attention to.
    So not everything needs to be resolved with medical degrees 
and 4-year degrees. Some of this could actually be putting a 
lot of Americans to work in the service of our country. So Mr. 
Secretary, in the spirit of that, I hope we--I intend to work 
with you, and I intend that we change and turn around the 
situation.
    Secretary Wilkie. I thank you, sir, and I intend to work 
closely with both Committees. I mentioned earlier this is where 
I was trained. My respect for this institution knows no bounds, 
and the beauty, as you said at the beginning, is that this is a 
bipartisan effort. I like to think of the Department as being 
nonpartisan, like the Department of Defense, and you have my 
commitment to do everything that we can to make sure that the 
lives of our veterans are better.
    The Chairman. I thank the gentleman for yielding, and I 
will, first of all, thank you, Mr. Secretary, and your team for 
being here today. I want to thank our staffs. We passed a major 
piece of legislation in the VA MISSION Act that would not have 
happened without the staffs, and John and Ray, thank you for 
your leadership in the Senate. We worked very closely with our 
Senate colleagues on both sides of the aisle, so thank you for 
the work that you all did. You were very, very helpful in this.
    And I personally, just as a point of personal privilege, 
one of the great honors of my life is serving as the Chairman 
of this Committee, and I will continue to serve as Ranking 
Member just as passionately as I did before. I also want to 
thank--I look around this room, and I see a lot of our veteran 
service folks out there, our veterans' organizations, and they 
were very instrumental. I remember sitting around that table in 
my office for hours on end hammering out the details of this, 
so you had tremendous input, and it would not be the bill it is 
today without your input, so thank you for that.
    The VA MISSION Act, the idea was to take a bill, a piece of 
legislation, and as I said before, make it applicable to rural 
America, and make it applicable to urban America and make sure 
that the number one thing that happened was that the veteran 
got the absolute very best care this Nation has to offer, 
whether it was at the VA, whether it was outside the VA. I was 
one of those physicians who provided care outside the VA. I 
have also worked in a VA with some of my medical training. I 
have also been a doctor in the Army, so I think I understand 
the system fairly well. And I want to get three things out 
before we leave.
    Number one, on June 6, we are ready to go, and if we are 
not, would you be willing to come back, Mr. Secretary, let's 
say, at the end of March, and give us one more--it could be a 
combined meeting or however we want to do it?
    Secretary Wilkie. Absolutely.
    The Chairman. It would be informal to let the Members know 
we are ready to go live on the June 6 or thereabouts. Number 
two, that we can make appointments at the VA for our veterans 
in a timely fashion. Number three, can we pay our providers so 
they will stay in the network, because I have lots of friends 
personally who want to serve veterans right now who won't 
because they can't get paid. And these are good doctors that 
want to serve, so I would like to see those three things 
happen. And certainly there will be other hearings on the 
caregiver bill and on the asset review. We will certainly do 
that.
    And I would really encourage my Senate colleagues. We have 
a couple of people, your IT position and the accountability and 
whistleblower protections. The young woman who is a staff 
member on our Committee right now, Tammy Bonzanto, an 
incredible young woman, an immigrant to this country who came 
here without any education, served in the U.S. Navy, has gotten 
an RN degree, now a doctorate degree, and has done 
investigations of VAs all over this country. And she could be 
in that position right now doing her job, and I don't go to a 
speech that the President gives if he doesn't talk about the 
Accountability and Whistleblower Protection bill. We need to 
get that done, and she needs to be confirmed sooner rather than 
later. That is a point of frustration for me to hold her up.
    On the mental health side, and we started with Mr. Takano's 
help and Mr. O'Rourke and others. Certainly, Mr. Coffman needs 
to be shouted out for the work he has done. We held a hearing, 
and I looked at this 20 number. That is veterans and Active 
duty military, that number is. I said if we are spending $8, $9 
billion a year, and we haven't moved the needle at all, why 
don't we thoroughly evaluate that and change what we are doing?
    And there are plans out there, one in my State, Guard Your 
Buddy. The commander of the Guard, he took over in 2011, had 
four suicides the first 40 days he was the commander of the 
Tennessee State guard. He instituted a plan called Guard Your 
Buddy. I won't go into the details of it, but he has lowered 
the suicide rate among our Guardsmen in continues by 70 
percent. That is scalable, and it is inexpensive. We should do 
that across the country, evaluate what works and what 
absolutely we are doing. And. Mr. O'Rourke made a great point. 
I was at Canandaigua. We had this great call center there. 
There is one in Atlanta another standing up, but I said are we 
changing anything? We are spending all this money and talking 
to people, but is the number still the same? We need to do 
something different. That is where the metrics are so 
important.
    So, I think working with Mr. Takano, we will continue to 
work on that. It is a tragedy beyond calculable, the suicide 
rates are, because I have said it many times. I have spent 
hours in the operating room operating on a cancer, and then 
treated the patient afterwards and saved one life. Dr. 
Lieberman, what you mentioned, if you have lowered the rate by 
as much as 55 percent by doing a simple thing in the emergency 
room, why are we doing that in every emergency in the United 
States whether you are a veteran or not? That should be done. 
And to Senator Hirono, your question about--it is fairly simple 
in medicine now. If you are looking at quality metrics, they 
are fairly standard, and if you just look at it, you look at 
what Medicare uses. Basically, the VA does the same. And if you 
come in, you are a certain age, you know, you get screened for 
hemoglobin, A1C, have you had your mammogram if you are female, 
your blood pressure checked, do you exercise.
    Always irritates me when my doctor asks me can I stand up. 
I always get a little offended by that, but they ask you those 
questions, and those are scalable. And vision screen, hearing 
screening, all of those things are measurable, and I think the 
VA does an outstanding job. And I want to finish by saying 
this: If what I hear about my VA at home, and this is Mountain 
Home VA in Johnson City, Tennessee, and I have traveled from 
Long Island to Los Angeles and Puerto Rico in the last 2 years, 
is that all, not 100 percent, but a vast majority of people 
like the care they get at the VA. I almost never hear anything 
negative. I do occasionally, as you would in a big organization 
like that. And it is very customer-friendly. The veterans 
believe, and I believe they are getting great care. I want to 
see every veteran get that kind of care, and I am committed to 
that, and other people, the men and women in this room, and Mr. 
Secretary, I absolutely know in your heart that you are 
committed for that.
    I thank you all for being here today, and I thank you for 
the point of personal privilege, and if there are no further 
questions, I ask unanimous consent that all Members--Mr. 
Takano.
    Mr. Takano. I just want to mention. I don't know if I 
mentioned this, but Mr. Sablan could not be with us for the 
questions, but I will be submitting questions on his behalf.
    The Chairman. Okay. That will be fine. I think you are 
going to visit the Northern Marianas also.
    If there are no further questions, I ask unanimous consent 
for all Members to have 5 legislative days to revise and extend 
their remarks and include extraneous material.
    Without objection, so ordered.
    The hearing is adjourned.

    [Whereupon, at 4:40 p.m., the Committees were adjourned.]




                            A P P E N D I X

                              ----------                              

             Prepared Statement of Honorable Robert Wilkie
    Chairman Isakson, Ranking Member Tester, Chairman Roe, and Ranking 
Member Walz, distinguished members of the Committee: Thank you for this 
opportunity to discuss the current state of the Department of Veterans 
Affairs (VA) and my vision for the future of America's Veterans.
    After serving two months as Acting Secretary, and now four months 
as Secretary, I am happy to say that the VA is better. It's better 
because of the work of this Committee; better because of the attention 
paid to Veterans Affairs by the President; better because the turmoil 
of early 2018 is in the rearview mirror; and better because we have a 
workforce dedicated to the care of America's warriors.
    While all Executive Branch departments and agencies must carry out 
their missions without consideration or influence of partisan politics, 
I have said in my visits across the department - visits that in the 
last five weeks cover ten VA hospitals from Boston to Las Vegas--that 
there are two departments of the Federal Government that must be 
especially careful to rise above partisan politics: the Department of 
Defense (DoD) and the Department of Veterans Affairs-this Committee is 
proof of that postulate.
    Now more than ever we are seeing the need for DoD and VA to work 
together to provide quality care for the Nation's Service members and 
Veterans. And now more than ever we also are seeing the benefit of 
strong bipartisan support for our DoD/VA partnership in the many major 
acts of Congress passed in the recent years. Congress has infused VA 
with a $200 billion budget. You have passed the Accountability Act to 
shake up complacency, and you have passed the MISSION Act to strengthen 
VA's ability to ensure Veterans have access to the best care available 
when and where they need it. The future now is up to the department. I 
look forward to working with the Committee and Congress to carry 
forward that work of transformation, and I pledge to make our efforts 
as transparent as possible to you, to Veterans, and to the American 
people.
    I would like to acknowledge the recent Veterans Day observance. For 
the second year in a row, President Trump declared November as National 
Veterans and Military Families Month. On November 11, the 100th 
anniversary of the ending of World War I, I gathered at Arlington 
National Cemetery with my colleagues from VA, DoD, Veterans Service 
Organizations, and others to pay tribute to those who have served and 
sacrificed on our behalf. It was a privilege to attend this ceremony 
and I am honored to serve as Secretary of Veterans Affairs and work 
daily to remember, honor and thank the men and women who embody the 
values and ideals of this great Nation.

Initial Assessment

    From what I have seen and from what I have been told by Veterans' 
advocates, it is clear to me that the Veteran population is changing 
faster than we realize. For the first time since the fall of Saigon in 
1975, more than half of our Veterans are under the age of 65. They are 
computer savvy, they expect quick service, and they expect that service 
to be delivered closer to home. They expect an integrated VA that is 
agile and adaptive and will do what they need, when they need it. My 
goal is to provide them with that service.
    In many cases, I have seen wonderful examples of VA accomplishments 
that deserve more attention than they normally get.

      Not enough Veterans and Americans know that the VA health 
care system continues to outperform the private sector in the quality 
of care and patient safety for our Veterans.
      We are on the cutting edge of medical care and 
rehabilitative services, prosthetics, traumatic brain injury, spinal 
cord treatment, opioid management, mental health care, and telehealth.
      The Department has added its 136th National Cemetery in 
Colorado Springs at Pikes Peak. The first burial took place last month.
      Fifty-two state Veterans homes received construction and 
renovation funds this year.

    For the first time in many years, overall VA customer satisfaction 
rate is on a steady rise. Thanks to an unprecedented series of 
legislative actions aimed at reforming the Department and improving 
care and benefits for our Veterans, we are now tackling issues that 
have vexed VA for decades, including:

      Giving Veterans more choice in health care decisions with 
the historic MISSION Act.
      Increasing accountability and protecting whistleblowers 
with the Whistleblower Protection Act.
      Improving transparency - VA is the first hospital system 
in the Nation to post wait times, opioid prescription rates, 
accountability, settlements, and chief executive travel.
      Adopting the same electronic health record as DoD so 
there can be a seamless transfer of medical information for Veterans 
leaving the service.
      Overhauling the claims and appeals processes to create a 
simplified system for filing to provide Veterans with clear choices and 
timely decisions.

    We are on the cusp of the greatest transformative period in the 
history of VA. With the support of the President, the Congress, and our 
many partners, we are now tackling head-on issues that have lingered 
for years. This is not business as usual. This is fundamental 
transformation, not seen at VA since just after World War II, when 
General Omar Bradley headed the VA.

My Vision for VA

    Many of the issues I encountered as Acting Secretary and more 
recently as Secretary were not with the quality of medical care but 
with getting our Veterans through the door to reach that care. Those 
problems are both administrative and bureaucratic. Alexander Hamilton 
said that the true test of a good government is its aptitude and 
tendency to produce a good administration. That is where VA must go.
    Our first challenge is to improve the culture to focus our 
attention and efforts on offering world-class customer service through 
all our operations. Our second challenge is increasing access to care 
and benefits through VA MISSION Act implementation and business 
transformation, which includes adopting a new electronic health records 
system, implementing a new appeals process for disagreement on VA 
claims, and modernizing our human resources, financial management, 
construction program, and supply systems.
    For the purposes of this hearing, I will focus my testimony on our 
efforts to deliver world-class customer service while implementing the 
historic VA MISSION Act.

Customer Service

    My prime objective is customer service. When an eligible Veteran 
comes to VA, they shouldn't have to hire a team of lawyers to get VA to 
say yes. It is up to VA to get the Veteran to yes, and that is customer 
service.
    VA receives 140 million phone calls a year. Ten million people 
contact VA online each month. We have 348 contact centers, hundreds of 
websites, and dozens of databases. Veterans think of VA as a single 
entity, but we deliver services in silos, forcing the Veteran to figure 
out which VA phone number to call, website to search, or office to 
visit. For many, finding the right office to access the right benefit 
or service is a fractured, frustrating experience.
    Driven by customer feedback, we are integrating VA's digital 
portals, contact centers, and databases so that Veterans easily find 
what they need no matter which channel they choose. On Veterans Day, we 
re-launched our www.VA.gov Website and we are unifying Veteran data, 
adding customer preferences for electronic correspondence to our new 
Vet360 database, and integrating the Vet360 profile service with mobile 
apps. VA has been identified as the ``co-lead'' of the White House 
cross-agency priority goal on improving customer service.
    These efforts were recently recognized by the nonprofit Partnership 
for Public Service which honored VA employee Marcella Jacobs and the 
Digital Service Team during the 17th annual Samuel J. Heyman Service to 
America Medals (Sammies) awards gala in Washington D.C. We are 
demonstrating that it is possible for Federal agencies to give the 
American people the online experience they expect and deserve.
    Our goal is to make accessing VA services seamless, effective, 
efficient, and emotionally resonant. The delivery of world-class 
customer service is my responsibility and the responsibility of all VA 
employees. When the interactions between VA employees and our Veteran 
customers in these areas are positive, our Veterans will trust and 
Choose VA, for their care, benefits, and memorial services across their 
lifetime.
    Customer service must start with VA employees not talking at each 
other but with each other across all office barriers and across all 
compartments. If we don't listen to each other, we won't be able to 
listen to our Veterans and their families and we won't be able to 
provide the world-class customer service they deserve. We must be a 
bottom-up organization, with energy flowing upward from those who are 
closest to those we are sworn to serve. It is from our dedicated 
employees that the ideas we carry to Congress, to Veterans Service 
Organizations, and to America's Veterans will come. Our highest 
imperative to deliver customer service to our Veterans is to execute 
the legislation passed by this Congress and signed by President Trump 
giving Veterans the choice they deserve.

Implementing the VA MISSION Act

    The VA MISSION Act is landmark legislation that will fundamentally 
transform VA health care and improve Veterans benefits and services. To 
successfully implement this historic legislation, we must engage 
stakeholders at all levels and be transparent throughout the process. 
We have established an enterprise program management office reporting 
to Acting Deputy Secretary Jim Byrne with integrated project teams to 
implement specific MISSION Act provisions. We are providing recurring 
updates to Congress, VSO's and others to hear feedback, address 
concerns and course correct when necessary. Mr. Chairman, it is 
critical that we deliver a transformed VA health care system that puts 
Veterans at the center of everything we do.

Community Care

    A key provision of the VA MISSION Act is the consolidation of our 
community care programs into a new Veterans Community Care Program that 
will be much easier to navigate for Veterans, families, VA employees 
and community providers. My vision is to keep VA at the center of any 
Veteran's care to ensure we deliver world-class customer service as 
Veterans navigate the continuum of care between internal and external 
providers. This will ensure our Veterans receive the best health care 
possible, whether delivered in VA facilities or in the community.
    Since October 2017, VA has completed approximately 24 million 
appointments in the community and 58.1 million in our facilities. 
Veterans may now request an appointment without a referral in numerous 
clinics including: audiology, optometry, orthotist (braces and 
splints), prosthetist (prostheses, artificial limbs), women's health, 
podiatry, nutrition, and wheelchair and amputee services. The average 
time it took to complete an urgent referral to a VA specialist has 
decreased from 19.3 days in FY 2014 to 3.2 days in FY 2017 and less 
than 2 days in FY 2018. This figure continues to improve and is now 
down to 1.4 days in October of 2018. In FY 2018, VA completed more than 
619,000 appointments when compared to the previous fiscal year. The 
average new patient wait times for an appointment at a VA health care 
facility were 21.2 days for Primary Care, 22.1 for Specialty Care, and 
11.2 for Mental Health services.
    VA has also made notable progress in ensuring Veterans receive 
time-sensitive follow up appointments. Currently 95 percent of all 
time-sensitive appointments are completed within the provider 
recommended date. Additionally, all VA Medical Centers and Community 
Based Outpatient Clinics now provide same-day services in primary care 
and mental health for Veterans who need them. I have found many 
Veterans prefer to receive their care at VA facilities and we are 
increasing access to meet this need.
    Upon enactment of the VA MISSION Act, we began developing 
regulations required to implement the new community care authorities. 
To ensure continuity of operations, VA extended and expanded its 
contract with TriWest Healthcare Alliance to ensure access to community 
care while the next generation of community care network contracts are 
awarded and implemented.
    As part of our new community care program, we are addressing the 
timeliness and accuracy of payments to providers. We must ensure 
community providers are paid in a timely manner so they are willing and 
able to deliver services to our Veterans. To this end, VA is moving 
away from paper claims and requiring providers to submit electronic 
claims in most cases through a new claims processing system. This 
automated electronic Claims Administration and Management System (e-
CAMS) uses technology with workflow-based analytics to provide feedback 
on potential bottlenecks and business performance issues in our claims 
process. Additionally, providers will have 180 days to submit claims 
for reimbursement rather than waiting years to submit them. This will 
align VA with industry standards and ensure providers are receiving 
timely payments.
    Through the VA MISSION Act, we are establishing a Center for 
Innovation for Care and Payment to develop new approaches to testing 
payment and service delivery models to reduce expenditures while 
preserving or enhancing the quality of VA health care. The center will 
explore models for incentivizing performance internally and when VA 
purchases care in the community. With the support of this Committee we 
hope to improve the lives of those we serve by accelerating and scaling 
VA innovation.

Eligibility for Community Care

    Veterans deserve access to the best health care providers, state-
of-art facilities and cutting-edge technology. The VA MISSION Act of 
2018 will strengthen VA's ability to deliver the quality care and 
timely service Veterans have earned. Eligibility for community care 
will be Veteran-centric and enable VA to deliver care more efficiently. 
With only specific exceptions, VA will stop paying providers above 
Medicare rates and will minimize the use of local contractual 
agreements to further reduce variability in payment rates. Under the 
new walk-in/urgent care authority, we will ensure that if eligible 
Veterans have an urgent health care need, they will be able to see a 
provider quickly. In developing access standards, VA has specifically:

      Discussed access standards with DoD and the Centers for 
Medicare & Medicaid Services.
      Performed research on industry standards including state 
insurance and state Medicaid programs.
      Solicited feedback with a notice in the Federal Register 
published June 29, 2018, and hosted public comments on July 13, 2018.

    As a guiding principle, I have reviewed DoD's TRICARE standards and 
continue to promote interoperability of our health care systems. My 
objective is to ensure Veterans receive care where and when they need 
it and to ensure VA remains on the leading edge for access and quality 
of health care.

Standards for Quality

    A study released this year by the RAND Corporation found VA health 
care generally outperforms the private sector in quality and patient 
safety, but recommended VA address variations in quality among VA 
health facilities. The VA MISSION Act will do this and more by 
requiring VA to establish standards for quality for hospital care, 
medical services and extended care services delivered by VA and 
community providers and establish a remediation process for service 
lines that do not meet those standards.
    We are committed to using industry-standard quality measures to 
compare our performance to that of the community, with consultation 
from key stakeholders, and to use those comparisons to ensure the best 
possible outcomes for Veterans. Our commitment to transparency will 
allow Veterans to compare data across VA and community care and make 
informed decisions when selecting a provider. In developing quality 
standards, VA has:

      Assessed existing industry quality standards including 
those used by DoD, the Department of Health and Human Services, and the 
Centers for Medicare & Medicaid Services.
      Solicited feedback with a notice in the Federal Register 
published August 24, 2018, and hosted public comments on September 24, 
2018.
      Hosted several Veteran Insight Panels, which are online 
focus groups, to hear directly from Veterans about their experiences 
and how we can bridge the gap between VA and community care specific to 
quality.

    We recognize the high level of interest from Veterans, community 
providers, and others in VA about the access standards and standards 
for quality and I am deeply committed to ensuring an open, transparent 
process for implementing the VA MISSION Act. We have developed 
communications products and tools, including a public-facing Website, 
talking points or key messages, frequently asked questions, fact 
sheets, and handouts covering various provisions of the law.
    In May 2018, we began hosting monthly webinars for community 
providers to provide updates and keep them informed of changes to the 
community care program. In September, we participated in a 
collaborative webcast with the Association of American Medical Colleges 
and presented an update on the VA MISSION Act community care 
requirements. In November, we began hosting listening sessions in VA's 
four community care regions to hear directly from Veterans, employees 
and other stakeholders. Our goal is to host 20 listening sessions with 
stakeholders by the end of the calendar year. It is critical that we 
continue to engage stakeholders as we implement this historic 
legislation.

Caregivers Expansion

    As VA expands the Program of Comprehensive Assistance for Family 
Caregivers, we recognize the incredible sacrifice of families who have 
cared for a loved one injured in the line of duty. We expect tremendous 
interest in the program's expansion and anticipate a significant 
increase in applicants. We are also addressing issues identified in the 
August 2018 Office of Inspector General's report on the program.
    VA has engaged with key stakeholders including VSOs, members of the 
public, and House Veterans Affairs' Committee round tables. Several 
consistent themes emerged during these engagements. In expanding the 
program, VA must ensure:

      Eligibility determinations are Veteran and caregiver-
centric, easy to understand and transparent.
      Participation is targeted to those Veterans who will 
benefit the most.
      Program requirements are less burdensome for caregivers 
and Veterans (e.g., a different track for the catastrophically inured).

    While the timeline for expanding the program to all eligible 
Veterans is still under development, VA must develop and implement a 
new information technology system to support administrative and record-
keeping needs. We are working with a developer on a new IT system known 
as the Caregiver Tool, or CareT, to manage the new requirements. Once 
we have fully fielded the new system, we will develop and implement the 
functionality required by the MISSION Act. We need to ensure high 
system reliability before enrolling a new Caregivers cohort.
    VA supports and recognizes the sacrifice and value of Veterans' 
family caregivers not only through this program but through its first 
Federal Advisory Committee for Veterans Families, Caregiver and 
Survivors and its new Center of Excellence for Veteran Caregiver 
Research. Caregivers and Veterans can learn about the full range of 
available support and programs by visiting www.caregiver.va.gov or by 
contacting the Caregiver Support Line toll-free at 1-855-260-3274.

Hiring and Vacancies

    The VA MISSION Act gives us greater ability to recruit and retain 
the best medical providers through improvements to the education debt-
reduction program and improved flexibility for bonuses for recruitment, 
relocation and retention. VA will also pilot a scholarship program for 
Veterans to get medical training in return for serving in a VA hospital 
or clinic for four years. VA is keeping pace with both normal 
retirements and job changes and has added nearly 14,000 more employees 
onboard since January 1, 2017 (3.8 percent growth), which is keeping 
pace with VA's patient base (enrollees) growth of 1.4 percent during 
the same period.
    As required under the law, we are posting quarterly vacancy data 
online. Our recent data shows as of September 30, 2018, VA had 46,522 
overall vacancies and a total of 377,210 employees onboard for an 11 
percent vacancy rate. Indeed, most large organizations will have what 
appears to be many vacancies due to normal retirements and job changes. 
VA's vacancy rate of 11 percent is a normal part of doing business and 
reflects the historical annual 9 percent turnover rate and a 2 to 3 
percent growth rate.
    VA vacancy rates mirror those of the health care industry. There is 
a national shortage of healthcare professionals, especially for 
physicians and nurses. VA remains fully engaged in a fiercely 
competitive clinical recruitment market and has increased its number of 
clinical providers including hard-to-recruit-and-retain physicians such 
as psychiatrists. Additional steps to attract qualified candidates 
include:

      Mental Health and other targeted hiring initiatives.
      Leveraging flexible pay ranges resulting in competitive 
physician salaries.
      Utilization of recruitment/relocation and retention 
incentives.
      Utilization of the Education Debt Reduction Program for 
recruitment and retention of hard-to-recruit/retain healthcare 
providers, including the new higher award amounts authorized by the 
MISSION Act up to $200,000 over a five-year period.
      Targeted nationwide recruitment advertising and 
marketing.
      The ``Take A Closer Look at VA'' trainee outreach 
recruitment program.
      Expanding opportunities for telemedicine providers.
      DoD/VA effort to recruit transitioning servicemembers.

Asset and Infrastructure Review (AIR) Commission

    The VA MISSION Act provides an opportunity for VA to assess our 
health care infrastructure footprints and develop recommendations for 
modernization and realignment of facilities to meet the demand for VA's 
services both today and for years to come. Our Asset and Infrastructure 
Review assessment and recommendations will be data-driven with input 
and feedback from our Veterans, employees, VSO's, local communities, 
and other key stakeholders throughout the process to ensure VA's 
recommendations are robust and fair.
    The AIR process will be informed by the assessment of 96 local 
market areas to identify availability and gaps in furnishing health 
care services to veterans. Each local assessment will consider short 
and long-term demand; VA staffing capacity; VA infrastructure capacity; 
VA's facilities conditions and future costs to maintain or modernize 
them, and non-VA health care capacity. We will provide robust 
recommendations for modernizing and realigning the Veterans Health 
Administration facility footprints to ensure the finest integrated care 
delivery to our Veterans.
    Given the oversight and approval process outlined under the MISSION 
Act for the Asset and Infrastructure Review, VA is confident that the 
AIR Commission, the President, and ultimately, Congress will concur and 
approve our recommendations.

Conclusion

    I would like to again thank Congress for passing VA's FY 2019 
funding bill. Starting the fiscal year with our full year's 
appropriations in place is extremely important as we implement the laws 
Congress has passed.
    As I mentioned, we have instituted strong governance and management 
processes that will facilitate successful implementation of the VA 
MISSION Act. This will be a long journey that will not be accomplished 
overnight. I am committed to providing you with regular updates on our 
progress and the challenges that arise.
    As we look to the next few years and full implementation of the new 
Veterans Community Care Program and an expanded Caregivers Program, VA 
will need to address the necessary funding requirements to meet the 
requirements of the law. We are embarking on the most comprehensive 
improvements to Veterans care and benefits since World War II. Our 
transformation will require fiscally responsible use of additional 
resources and for us to streamline and improve our internal operations 
to become as efficient as possible.
    I look forward to working with you and this Committee and 
appreciate your many courtesies to me. I am also eager to continue 
building on our reform agenda. The mission of this Committee is clear-
you help remind all Americans why they sleep soundly at night because 
of those who sacrificed in uniform. There is no more noble mission in 
all of government.
    Thank you.

                                 
                        Statement For The Record

          Veterans Of Foreign Wars Of The United States (VFW)
                   KAYDA KELEHER, ASSOCIATE DIRECTOR
                      NATIONAL LEGISLATIVE SERVICE

    After four years of tireless work and development, the VA MISSION 
Act of 2018 was signed into law on June 6, 2018. The main prerogative 
of the VA MISSION Act of 2018 is perfectly stated as Title I--Caring 
for Our Veterans. The Veterans of Foreign Wars of the United States 
(VFW) believes that to successfully implement this multifaceted portion 
of the law, the Department of Veterans Affairs (VA), Congress, and 
veterans service organizations (VSOs) must collaboratively work 
together, while maintaining its implementation as the top priority of 
the 116th Congress. The VFW thanks the Committees for the continued 
oversight of this important law and leadership in ensuring VA has the 
resources to properly implement it.
    If the law is effectively implemented, veterans' health care will 
enter a new era of timely access to high-quality care. However, if 
implementation strays from the overwhelming consensus reached by 
stakeholders involved in development of the law, VA health care could 
decline, resulting in negative consequences for the millions of 
veterans who rely on VA for their health care, and threaten the 
viability of VA's teaching, world-class research, and emergency 
response missions. While there are groups that believe VA facilities 
should be downsized and that veterans should receive more care through 
private sector doctors, the VFW's numerous surveys show veterans want 
VA to hire more doctors and increase internal capacity. In fact, our 
latest VA health care survey indicates nearly 60 percent of veterans 
who were offered community care elected to stay with VA. The main 
reason veterans prefer VA is they like the quality of care they 
receive, which a recently published peer-reviewed study entitled 
Veterans Health Administration Hospitals Outperform Non-Veterans Health 
Administration Hospitals in Most Health Care Markets found is better 
than the private sector.
    The law requires VA to develop regulations for new access and 
quality standards to replace the current arbitrary rule of a 30-day 
wait and 40-mile distance standards, by March 6, 2019. This will be 
done by consolidating seven current community care programs, including 
the Veterans Choice Program, into one. This program will be the 
Veterans Community Care Program (VCCP), and will use local health care 
networks and academic affiliates to provide care to all eligible 
veterans. The VFW has serious concerns about the lack of collaboration 
and working communication from VA with VSOs to establish these new 
regulations. While VA has held consistent meetings between VSOs and the 
Office of Community Care, the majority of such meetings have been one-
sided conversations. Without proper stakeholder input, VA will fail. 
For example, VA is considering up to 20 different access standard 
models, none of which have been shared with VSOs. The VFW understands 
Congress intended for VSOs to receive specific data and to work in 
cooperation with VA to develop these future regulations that will 
affect the lives of millions of veterans. The VFW also has concerns 
with the lack of participation at Office of Community Care meetings 
from VA's Executive Steering Committee, which will ultimately assist 
the Secretary in choosing access standard models and how the law is 
implemented. The VFW is encouraged by this past week's decision to 
include VSOs in VA MISSION Act workgroup meetings with VA leadership. 
We hope such meetings will be more productive, and look forward to 
working with VA to ensure this important bill is implemented in the 
best interest of the veterans VA was created to serve.
    The VFW has made clear time and time again that VA must back away 
from setting arbitrary standards for when patients using VA are given 
the option to use community care. VFW members have made clear the many 
negative unintended consequences of not upholding the decision to use 
community care as a clinical decision made between a patient and their 
provider. It is optimistic to hear VA working toward solutions in 
overcoming this range of arbitrary barriers, such as when a patient 
lives within close proximity to a VA facility based on miles, but must 
overcome geographical difficulties such as mountains. VA must adapt 
lessons learned from the Veterans Choice Program and study 
recommendations from industry experts, such as the Transforming Health 
Care Scheduling and Access: Getting to Now independent review conducted 
by the National Academy of Medicine, formerly known as the Institute of 
Medicine, to establish access standards that are appropriate for the 
users of the VA health care system. The VFW warns VA against adopting 
arbitrary standards which would fail to address the uniqueness of the 
VA health care system and the needs of our nation's veterans.
    It is important for VA to establish access standards that define 
objective criteria for access to VA community care networks. Unless 
these standards are pragmatic and clinically appropriate, both veterans 
and VA will suffer negative consequences. VA must establish standards 
that are sensible for VA's capacity, and comparable to measures of 
local health care systems outside VA. As with access standards, quality 
standards must balance the need to maintain the unique features of VA 
that effectually serve veterans, but are different than those in the 
private sector.
    The VFW also has concerns with feedback from facilities that 
veterans are being automatically placed into community care based on 
arbitrary guidelines without discussion or input from their providers. 
The VFW continues to oppose patients being involuntarily placed into 
community care simply because their appointments may not be scheduled 
within 30 days. First and foremost, veterans and their providers must 
remain part of this process to ensure patient understanding and 
continuity of care. Second, many of these patients would prefer to stay 
with VA. Finally, not every appointment must be fulfilled within the 30 
days. If the appointment is not medically necessary in that timeframe, 
veterans must be able to choose whether to wait for VA or seek care 
through the community care networks.
    The VFW also urges VA to account for how the implementation of a 
new electronic health care record impacts productivity. In partnership 
with the Defense Health Agency (DHA), the VFW has kept a keen eye on 
the implementation of the Military Health System GENESIS electronic 
health care record, which is the same system VA has elected to adopt 
for the VA health care system. While the VFW hopes VA adopts lessons 
learned from DHA to ensure a more seamless implementation, we are 
certain VA medical facilities will experience a temporary reduction in 
productivity that comes with change management. However, military 
treatment facilities report an eventual increase in productivity after 
full implementation. The VFW suspects VA medical facilities will 
experience a similar trend in productivity, which will lead to a 
temporary increase in demand for community care.
    This and other temporary spikes in demand for community care, such 
as snowbirds, will require VA to adjust its community care networks and 
VA medical facility capacities to ensure veterans can receive the care 
they need where they need it. VA must make certain that temporary 
increase in demand for community care does not jeopardize the long-term 
viability of capacity at VA medical facilities. That is why the VFW 
urges VA and Congress to consistently evaluate whether VA should be 
expanding its community care networks or increasing internal capacity. 
This must be done by hiring more doctors or having VA deploy a quick 
reaction force of VA doctors to areas facing temporary spikes in demand 
for care.
    VA facilities with service lines that fail to meet established 
quality standards will undergo remediation. Patients who rely on the 36 
service lines that fall under the quality standards will have the 
opportunity to choose if they would rather stay with a VA doctor or use 
private sector doctors in their community. It is important that VA take 
into account what options veterans use and where they would prefer to 
go when developing remediation plans. VA must also take into account 
the ability for VA medical facilities to provide severely disabled 
veterans, such as those in spinal cord injury centers or polytrauma 
network sites, a full continuum of care. Simply closing such service 
lines in favor of community care would fail veterans who prefer to see 
a VA doctor and those who are unable to use community care.
    To ensure access and quality standards are fully vetted and 
understood, the VFW urges VA to issue notice of proposed rulemaking in 
the Federal Register to allow sufficient time for public comments. It 
would be unacceptable for VA to issue an interim final rule, which does 
not allow for public input, specifically if stakeholders were not 
incorporated in developing it. Aside from stakeholders who must be 
consulted in the development of these rules, veterans and individuals 
who will be impacted by them must have their voices heard and 
considered through public comment. Doing so may mean that VA will not 
meet the deadlines established in the law. To the VFW, it is more 
important that VA produce high-quality and accurate regulations than it 
is for VA to rush the decision-making process and repeat previous 
mistakes in order to meet such deadlines. Also, there must be an 
organized outreach campaign for veterans who use VA once these 
regulations are finalized. Since the VA MISSION Act became law, VA has 
worked with VSOs to design pamphlets and other educational materials to 
share with patients when the law is ready to be implemented. This must 
be done so thoroughly and on multiple platforms, while also promising 
that all VA employees who will be involved in this transition 
completely understand the program and are able to explain it to 
patients.
    As the regulations for the VA MISSION Act continue to be planned 
and implemented, the VFW looks forward to continuing to prioritize the 
remaining sections of the law. This includes working with VA and 
Congress to perfect billing, market assessments, expansion of the 
caregiver program, provider education and training programs, and the 
asset and infrastructure review.

                                 
                       American Veterans (AMVETS)
    Chairman Isakson, Chairman Roe, Ranking Member Tester, Ranking 
Member Walz, and members of the Joint Veterans Affairs Committee, on 
behalf of the men and women of American Veterans (AMVETS), as well as 
the 21 million American veterans in our country who we represent, thank 
you for allowing us this platform to contribute to this very important 
discussion on the implementation of the Maintaining Internal Systems 
and Strengthening Integrated Outside Networks, or MISSION, Act of 2018.
    When President Donald Trump signed the highly anticipated VA 
MISSION Act into law on June 6, 2018, it was an inflection moment in 
our country's effort to devise a system of healthcare that our veterans 
have needed and deserved for quite some time. The new law's 
predecessor, the Veterans Access, Choice and Accountability (Choice) 
Act of 2014, had created a new paradigm for delivering care, albeit 
imperfect and challenged by its previously untested standards involving 
coordinating care outside of the Department of Veterans Affairs (VA). 
The VA Mission Act is intended to build on the lessons learned as 
veterans' healthcare continues to evolve.
    For the new law to be effective, it requires all involved to 
account for those lessons learned as we approach the end of one 
community care program and the beginning of another. Along with this 
notion is a requirement that next-generation vision will inspire into 
existence a new system of care that will look as good in three-
dimension as it does on paper through timely and effective 
implementation. Without good implementation in this effort, vision will 
be just another word for hallucination.
    With that in mind, every vision must be driven by a leader. Since 
the law's passage, we have seen changes in leadership in the VA 
Secretary and VHA Under Secretary for Health Offices with the 
unceremonious removal of Drs. David Shulkin and Carolyn Clancy, 
respectively. The Office of Information and Technology, which will be 
critical to the success of the VA Mission Act, also faced a leadership 
shuffle after Scott Blackburn resigned as the chief information officer 
in April 2018. His successor, Camilo Sandoval, has filled the role in 
the interim amid negative reports and skepticism. It is our hope that 
he will be the right person for the job, for the sake of progress above 
politics. VA has not had a permanent CIO in more than 18 months, which 
explains, at least in part, the fits and starts that have hindered 
progress in the plan to fix the VA's IT infrastructure.
    AMVETS calls on our political leaders, from the White House to 
Capitol Hill, to take every necessary step to ensure these important 
offices are staffed and stabilized by permanent decision makers who 
have the freedom to do their jobs without fear of politically motivated 
reprisal. The American taxpayers do not get a refund on wasted time, 
but that is exactly what has happened when key leaders were removed and 
progress stalled by uncertainty.
    One project that has seen much uncertainty is the establishment of 
a Veterans Electronic Health Record system. The VA Mission Act provides 
$1.1 billion for the ongoing integration of VA and Department of 
Defense records to improve the efficiency and quality of veterans' 
health care.
    Creating the largest EHR in the country is an extraordinary 
undertaking, and we anticipate issues along the way, as with any 
endeavor of this scale. However, when asked why the Interagency Program 
Office was not being used as a single point of governance for the 
project, officials reported to the Congress that they did not have the 
authority, staff and funding for the undertaking, an all-too-familiar 
refrain whenever the agency falls short of expectations. These self-
inflicted wounds cannot continue.
    The planned rollout of the EHR for year 2020 in Veterans Integrated 
Service Network 20 in the Pacific Northwest means that veterans will 
have to endure a two-year wait before seeing progress on the initial 
operating capability pilot site to test the Cerner project. Whether 
this two-year wait will be worth the time and expense remains to be 
seen. But veterans and other stakeholders can no longer accept a 
``moving of the goal posts'' like we are already seeing with the 
Program of Comprehensive Assistance for Family Caregivers (PCAFC).
    One of the key provisions of the VA Mission Act is the long-awaited 
expansion of the PCAFC. The law mandates the development and 
implementation of a new information technology system to support 
administrative oversight and record-keeping needs. Section 162 of the 
VA Mission Act directs, ``Not later than October 1, 2018, the Secretary 
of Veterans Affairs shall implement an information technology system 
that fully supports the Program and allows for data assessment and 
comprehensive monitoring of the Program.''
    The implementation deadline, which has since passed, was critical 
because the caregivers who attend to the needs of severely disabled 
veterans who served before September 11, 2001 will not receive benefits 
until the VA Secretary certifies to Congress a viable IT system. 
However, questions persist regarding this mandate to implement a new 
technology because the VA already has the ``Caregiver Application 
Tracking System,'' which is used to manage nearly 20,000 caregiver 
cases. The glitches that need to be addressed, oversight and medical 
records management chief among them, apparently call for the complete 
overhaul of the existing system, to the chagrin of veterans and 
caregivers whose livelihoods are now inextricably linked to the 
agency's ability to correct longstanding IT problems, an ability that 
remains challenged.
    Moreover, given how forcefully some VA leaders had opposed the 
expansion of the program to Pre-9/11 caregivers in the past, many of 
our constituents fear that the VA has found a way to indefinitely stall 
expansion by conditioning progress on a new system in the distant 
future instead of fixing the existing one so that expansion can happen 
much sooner - this while the VA already faces problems with the system 
that manages Post-9/11 GI Bill housing stipends that affect 360,000 
veterans and family members. AMVETS will remain vigilant for evidence 
that either proves or disproves these suspicions as the situation 
unfolds. We encourage VA leaders to remain transparent about all 
milestones and goals, to include timelines, so that progress is 
measurable and expectations more manageable.
    To that point, AMVETS commends TriWest for the corporation 
leadership's transparency and diligence in managing expectations as its 
services expand to all 50 states.
    When Health Net's Veterans Choice Program contract expired on 
September 30th, there was little basis for optimism among veteran 
advocates. VA leadership recruited TriWest to expand services to bridge 
the gap and deliver health care until all community care contracts are 
implemented, which offers lukewarm comfort, at best, given the lack of 
a clear timeline for complete implementation.
    However, TriWest has reportedly been actively engaging VA Central 
Office, Veteran Integrated Service Networks, and VA Medical Centers in 
order to prepare for staggered transition of support in all states 
previously covered by Health Net, while handling an average of 120,000 
requests for care per month. We were pleased to hear from VA leadership 
that the 60,000 consults that were returned to the VA from Health Net 
did not create an immediate backlog or affect future consults. We hope 
this trend will continue and will be monitoring to ensure that it does.
    Chairman Roe, Ranking Member Walz, and members of the Committee, on 
behalf of the men and women of AMVETS and the nearly 21 million 
veterans in the United States whose interests are served by our 
mission, we thank you for the opportunity to contribute to this 
important discussion. AMVETS looks forward to working with this 
Committee and the Department of Veterans Affairs to take every step 
necessary to ensure the successful implementation of the VA Mission 
Act.

                                 
                        Jacob Gillison (Sanders)
    The VA's Private Care Program Gave Companies Billions and Vets 
Longer Waits
    Trump wants to supersize a program that spent almost a quarter of 
its funds on overhead.
    by Isaac Arnsdorf, ProPublica, and Jon Greenberg, PolitiFact
    Dec. 18 1:30 pm EST

    For years, conservatives have assailed the U.S. Department of 
Veterans Affairs as a dysfunctional bureaucracy. They said private 
enterprise would mean better, easier- to-access health care for 
veterans. President Donald Trump embraced that position, 
enthusiastically moving to expand the private sector's role.
    Here ' s what has actually happened in the four years since the 
government began sending more veterans to private care: longer waits 
for appointments and, a new analysis of VA claims data by ProPublica 
and PolitiFact shows, higher costs for taxpayers.
    Since 2014, 1.9 million former service members have received 
private medical care through a program called Veterans Choice. It was 
supposed to give veterans a way around long wait times in the VA. But 
their average waits using the Choice Program were still longer than 
allowed by law, according to examinations by the VA inspector general 
and the Government Accountability Office. The watchdogs also found 
widespread blunders, such as booking a veteran in Idaho with a doctor 
in New York and telling a Florida veteran to see a specialist in 
California. Once, the VA referred a veteran to the Choice Program to 
see a urologist, but instead he got an appointment with a neurologist.
    The winners have been two private companies hired to run the 
program, which began under the Obama administration and is poised to 
grow significantly under Trump. ProPublica and PolitiFact obtained VA 
data showing how much the agency has paid in medical claims and 
administrative fees for the Choice program. Since 2014, the two 
con1panies have been paid nearly $2 billion for overhead, including 
profit. That's about 24 percent of the companies' total program 
expenses -a rate that would exceed the federal cap that governs how 
much most insurance plans can spend on administration in the private 
sector.
    Since 2014, the VA's Veterans Choice Program has spent $10.3 
billion. Most of that money went to private contractors.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    According to the agency's inspector general, the VA was paying the 
contractors at least $295 every time it authorized private care for a 
veteran. The fee was so high because the VA hurriedly launched the 
Choice Program as a short-term response to a crisis. Four years later, 
the fee never subsided- it went up to as much as $318 per referral.
    ``This is what happens when people try and privatize the VA,'' Sen. 
Jon Tester of Montana, the Ranking Democrat on the Senate veterans 
conunittee, said in a statement responding to these findings. ``The VA 
has an obligation to taxpayers to spend its limited resources on caring 
for veterans, not paying excessive fees to a government contractor. 
When VA does need the help of a middleman, it needs to do a better job 
of holding contractors accountable for missing the mark.''
    The Affordable Care Act prohibits large group insurance plans fron1 
spending more than 15 percent of their revenue on administration, 
including marketing and profit. The private sector standard is IO 
percent to 12 percent, according to Andrew Naugle, who advises health 
insurers on ad1ninistrative operations as a consultant at Milliman, one 
of the world's largest actnarial firms. Overhead is even lower in the 
Defense Department's Tricare health benefits program: only 8 percent 
last year.
    Even excluding the costs of setting up the new program, the Choice 
contractors' overhead still amounts to 21 percent of revenue.
    ``That's just unacceptable,'' Rick Weidman, the policy director of 
Vietnam Veterans of America, said in response to the figures. ``There 
are people constantly banging on the VA, bnt this was the private 
sector that made a total muck of it.''
    Trump's promises to veterans were a central message of his 
campaign. But his plans to shift their health care to the private 
sector put him on a collision course with veterans groups, whose 
members generally support the VA' s medical system and don't want to 
see it privatized. The controversy around privatization, and the 
outsize influence of three Trump associates at Mar-a-Lago, has sown 
turmoil at the VA, endangering critical services from paying student 
stipends to pi-eventing suicides and upgrading electronic medical 
records.
    A spokesman for the VA, Curt Cashour, declined to provide an 
interview with key officials and declined to answer a detailed list of 
written questions.
    One of the contractors, Health Net, stopped working on the program 
in September. Health Net didn't respond to requests for comment.
    The other contractor, TriWest Healthcare Alliance, said it has 
worked closely with the VA to improve the program and has made major 
investments of its own. ``We believe supporting VA in ensuring the 
delivery of quality care to our nation's veterans is a moral 
responsibility, even while others have avoided making these investments 
or have withdrawn from the market,'' the company said in a statement. 
TriWest did not dispute ProPublica and PolitiFact's estimated overhead 
rate, which used total costs, but suggested an alternate calculation, 
using an average cost, that yielded a rate of 13 percent to 15 percent. 
The company defended the $295-plus fee by saying it covers ``highly 
1nanual'' services such as scheduling appointJnents and coordinating 
1nedical files. Such functions are not typically part of the contracts 
for other programs, such as the military's Tricare. But Tricare's 
contractors perform other duties, such as adjudicating claims and 
monitoring quality, that Health Net and TriWest do not. In a recent 
study comparing the programs, researchers from the Rand Corporation 
concluded that the role of the Choice Program's contractors is ``much 
narrower than in the private sector or in Tricare.''
    Before the Choice Program, TriWest and Health Net performed 
essentially the same functions for about a sixth of the price, 
according to the VA inspector general.
    TriWest declined to break down how much of the fee goes to each 
service it provides.
    Because of what the GAO called the contractors' ``inadequate'' 
performance, the VA increasingly took over doing the Choice Program's 
referrals and claims itself.
    In many cases, the contractors' $295-plus processing fee for every 
referral was bigger than the doctor's bill for services rendered, the 
analysis of agency data showed. In the three months ending Jan. 31, 
2018, the Choice Program made 49,144 referrals for primary care 
totaling $9.9 million in medical costs, for an average cost per 
referral of $201.16. A few other types of care also cost less on 
average than the handling fee: chiropractic care ($286.32 per reterral) 
and optometry ($189.25). There were certainly other instances where the 
1nedical services cost much more than the handling fee: TriWest said 
its average cost per referral was about $2, I00 in the past six months.
    Beyond what the contractors were entitled to, audits by the VA 
inspector general found that they overcharged the government by $140 
million from November 2014 to March 2017. Both companies are now under 
federal investigation arising from these overpayments. Health Net's 
parent con1pany, Centene, disclosed a Justice Department civil 
investigation into ``excessive, duplicative or otherwise in1proper 
claims.'' A federal grand jury in Arizona is investigating TriWest for 
``wire fraud and misused government funds,'' according to a court 
decision on a subpoena connected to the case. Both companies said they 
are cooperating with the inquiries.
    Despite the criminal investigation into TriWest's management of the 
Choice Program, the Trump administration recently expanded the 
company's contract without competitive bidding. Now, TriWest stands to 
collect even more fees as the administration prepares to fulfill 
Trump's campaign promise to send more veterans to private doctors.
    Senate veterans Committee Chairman Johnny Isakson, R-Ga., said he 
expects VA Secretary Robert Wilkie to discuss the agency's plans for 
the future of private care,when he testifies at a hearing on Wednesday. 
A spokeswoman for the outgoing Chairman of the House veterans 
Committee, Phil Roe, R-Tenn., didn't respond to requests for comment.
    ``The last thing we need is to have funding for VA's core mission 
get wasted,'' Rep. Mark Takano, a California Democrat who ,viii become 
the House panel's Chairman in January, said in a statement. ``I will 
make sure Congress conducts comprehensive oversight to ensure that our 
veterans receive the care they deserve while being good stewards of 
taxpayer dollars.''
    Many of the Choice Program's defects trace back to its hasty 
launch.
    In 2014, the Republican Chairman of the House veterans Committee 
alleged that 40 veterans died waiting for care at the VA hospital in 
Phoenix. The inspector general eventually concluded that no deaths were 
attributable to the delays. But it was true that officials at the 
Phoenix VA were covering up long wait times, and critics seized on this 
scandal to demand that veterans get access to private medical care.
    One of the loudest voices demanding changes was John McCain's. 
``Make no mistake: This is an emergency,'' the Arizona senator, who 
died in August, said at the time. McCain stiuck a compromise with 
Democrats to open up private care for veterans who lived at least 40 
miles from a VA facility or would have to wait at least 30 days to get 
an appointment.
    In the heat of the scandal, Congress gave the VA only 90 days to 
launch Choice. The VA reached out to 57 companies about administering 
the new program, but the companies said they couldn't get the program 
off the ground in just three months, according to contracting records. 
So the VA tacked the Choice Program onto existing contracts with Health 
Net and TriWest to run a much s1naller program for buying private care. 
``There is simply insufficient time to solicit, evaluate, negotiate and 
award competitive contracts and then allow for some form of ramp-up 
time for a new contractor,'' the VA said in a formal justification for 
bypassing competitive bidding.
    But that was a shaky foundation on which to build a much larger 
program, since those earlier contracts were themselves flawed. In a 
2016 report, the VA inspector general said officials hadn't followed 
the rules ``to ensure services acquired are based on need and at fair 
and reasonable prices.'' The report criticized the VA for awarding 
higher rates than one of the vendors proposed.
    The new contract with the VA was a lifeline for TriWest. Its 
president and CEO, David J. McIntyre Jr., was a senior aide to McCain 
in the mid-1990s before starting the company, based in Phoenix, to 
handle health benefits for the 1nilitary's Tricare program. In 2013, 
TriWest lost its Tricare contract and was on the verge of shutting 
down. Thanks to the VA contract, TriWest went from laying off more than 
a thousand employees to hiring hundreds.
    McIntyre's annual compensation, according to federal contracting 
disclosures, is $2.36 million. He declined to be interviewed. In a 
statement, TriWest noted that the original contract, for the much 
smaller private care program, had been competitively awarded.
    The VA paid TriWest and Health Net $300 million upfront to set up 
the new Choice program, according to the inspector general's audit. But 
that was dwarfed by the fees that the contractors would collect. 
Previously, the VA paid the companies between $45 and $123 for eve1y 
referral, according to the inspector general. But for the Choice 
Program, TriWest and Health Net raised their fee to between $295 and 
$300 to do essentially the same work on a larger scale, the inspector 
general said.
    The price hike was a direct result of the time pressure, according 
to Greg Giddens, a former VA contracting executive who dealt with the 
Choice Program. ``Ifwe had two years to stand up the program, we would 
have been at a different price structure,'' he said.
    Even though the whole point of the Choice Program was to avoid 30-
day waits in the VA, a convoluted process made it hard for veterans to 
see private doctors any faster. Getting care through the Choice Program 
took longer than 30 days 41 percent of the time, according to the 
inspector general's estimate. The
    GAO found that in 2016 using the Choice Progran1 could take as long 
as 70 days, with an average of 50 days.
    Sometimes the contractors failed to make appointments at all. Over 
a three-month period in 2018, Health Net sent back between 9 percent 
and 13 percent of its referrals, according to agency data. TriWest 
failed to make appointments on 5 percent to 8 percent of referrals, the 
data shuws.
    Many veterans had frustrating experiences with the contractors.
    Richard Camacho in Los Angeles said he got a call from TriWest to 
make an appointment for a sleep test, but he then received a letter 
from TriWest with different dates. He had to call the doctor to confinn 
when he was supposed to show up. When he got there, the doctor had 
received no information about what the appointment was for, Cainacho 
said.
    John Moen, a Vietnam veteran in Plano, Texas, tried to use the 
Choice Program for physical therapy this year rather than travel to 
Dallas, where the VA had a six-v,eek wait. But it took 10 weeks for him 
to get an appointment with a private provider.
    ``The Choice Program for me has completely failed to meet my 
needs,'' Moen said.
    Curtis Thompson, of Kirkland, Washington, said he's been told the 
Choice Program had a 30-day wait just to process referrals, never mind 
to book an appointment. ``Bottom line: Wait for the nearly 60 days to 
see the rheumatologist at the VA rather than opt for an unknown delay 
through Veterans Choice,'' he said.
    After Thompson used the Choice Program in 2018 for a sinus surgery 
that the VA couldn't perform within 30 days, the private provider came 
after him to collect payment, according to documentation he provided.
    Thousands of veterans have had to contend with bill collectors and 
credit bureaus because the contractors failed to pay providers on 
tin1e, according to the inspector general. Doctors have been frustrated 
with the Choice Program, too. The inspector general found that 15 
providers in Nmih Carolina stopped accepting patients from the VA 
because Health Net wasn't paying them on time.
    The VA shares the blame, since it fell behind in paying the 
contractors, the inspector general said. TriWest claimed the VA at one 
point owed the company $200 million. According to the inspector 
general, the VA's pile of unpaid claims peaked at almost 180,000 in 
2016 and was virtually eliminated by the end of the year.
    The VA tried to tackle the backlog of unpaid doctors, but it had a 
problem: The agency didn't know who was performing the services 
arranged by the contractors. That's because Health Net and TriWest 
controlled the provider networks, and the medical claims they submit to 
the VA do not include any provider information.
    The contractors' role as middlemen created the opportunity for 
payment errors, according to the inspector general's audit. The 
inspector general found 77,700 cases where the contractors billed the 
VA for more than they paid providers and pocketed the difference, 
totaling about $2 million. The inspector general also identified $69.9 
million in duplicate payn1ents and $68.5 n1illion in other errors.
    TriWest said it has worked with the VA to correct the payment 
errors and set aside money to pay back. The company said it's waiting 
for the VA to provide a way to refund the confirmed overpayments. ``We 
remain ready to complete the necessary reconciliations as soon as that 
process is formally approved,'' TriWest said.
    The grand jury proceedings involving TriWest are secret, but the 
investigation became public because prosecutors sought to obtain the 
identities of anonymous commenters on the jobs website Glassdoor.com 
who accused TriWest of''mak[ing] money unethically off ofveteransNA.'' 
Glassdoor fought the subpoena but lost, in November 2017. The court's 
opinion doesn't name TriWest, but it describes the subject of the 
investigation as ``a government contractor that administers veterans' 
healthcare programs'' and quotes the Glassdoor reviews about TriWest. 
The federal prosecutor's office in Arizona declined to comment.
    ``TriWest has cooperated with many government inquiries regarding 
VA's com1nunity care programs and will continue to do so,'' the company 
said in its statement. ``TriWest 1nust respect the government's right 
to keep those inquiries confidential until such time as the government 
decides to conclude the inquiry or take any actions or adjust VA 
programs as deemed appropriate.''
    The VA tried to make the Choice Progrmn run more smoothly and 
efficiently. Because the contractors were failing to find participating 
doctors to treat veterans, the VA in mid-2015 launched a full-court 
press to sign up private providers directly, according to the inspector 
general. In some states, the VA also took over scheduling from the 
contractors.
    ``We were making adjustments on the fly trying to get it to work,'' 
said David Shulkin, who led the VA's health division starting in 2015. 
``There needed to be a more holistic solution.''
    Officials decided in 20I6 to design new contracts that would change 
the fee structure and reabsorb some of the services that the VA had 
outsourced to Health Net and TriWest. The department secretary at the 
time, Bob McDonald, concluded the VA needed to handle its own customer 
service, since the agency's reputation was suffering from TriWest's and 
Health Net's tnistakes. Reclaiming those functions would have the side 
effect of reducing overhead.
    ``Tell me a great customer service company in the vvorld that 
outsources its customer service,'' McDonald, who previously ran Procter 
& Gamble, said in an interview. ``I wanted to have the administrative 
functions within our medical centers so we took control of the care of 
the veterans. That would have brought that fee down or eliminated it 
entirely.''
    The new contracts, called the Community Care Network, also aimed to 
reduce overhead by paying the contractors based on the number of 
veterans they served per month, rather than a flat fee for every 
referral. To prevent payment errors like the ones the inspector general 
found, the new contracts sought to increase information- sharing 
between the VA and the contractors. The VA opened bidding for the new 
Community Care Network contracts in December 2016.
    But until those new contracts were in place, the VA was still stuck 
paying Health Net and TriWest at least $295 for every referral. So VA 
officials came up with a workaround: they could cut out the 1niddleman 
and refer veterans to private providers directly. Claims going through 
the contractors declined by 47 percent from May to Deceinber in 2017.
    TriWest's CEO, McIntyre, objected to this workaround and blamed the 
VA for hurting his bottom line.
    In a Feb. 26, 2018, email with the subject line ``Heads Up... 
Likely Massive and Regrettable Train Wreck Coming!'' McIntyre warned 
Shulkin, then the department secretary, that ``long unresolved matters 
with VA and cutTent behavior patterns will result in a projected $65 
million loss next year. This is on top of the losses that we have 
amassed over the last couple years.''
    Officials were puzzled that, despite all the VA was paying TriWest, 
McIntyre was claiining he couldn't make ends meet, according to agency 
emails provided to ProPublica and PolitiFact. McIntyre explained that 
he wanted the VA to waive penalties for clai1ns that lacked adequate 
documentation and to pay TriWest an administrative fee on canceled 
referrals and no-show appointments, even though the VA read the 
contract to require a fee only on completed claims. In a March letter 
to key lawmakers, McIntyre said the VA's practice of bypassing the 
contractors and refen-ing patients directly to providers ``has resulted 
in a significant drop in the volume of work and is causing the company 
in-eparable financial harm.''
    McIntyre claimed the VA owed TriWest $95 million and warned of a 
``negative impact on VA and veterans that will follow'' if the agency 
didn't pay. Any disruptions at TriWest, he said, would rebound onto the 
VA, ``given how much we are relied on by VA at the moment and the very 
public nature of this work.''
    But when the VA asked to see TriWest's financial records to 
substantiate McIntyre's claims, the numbers didn't add up, according to 
agency emails.
    McIntyre's distress escalated in March, as the Choice Program was 
running out of money and lawmakers were locked in tense negotiations 
over its future. McIntyre began sending daily emails to the VA 
officials in charge of the Choice Program seeking updates and warning 
of impending disaster. ``I don't think the storm could get more 
difficult or challenging,'' he ,vrote in one of the 1nessages. 
``However, I know that I am not alone nor that the impact will be 
confined to us.''
    McIntyre lobbied for a bill to permanently replace Choice with a 
new program consolidating all of the VA's 1nethods of buying private 
care. TriWest even offered to pay veterans organizations to run ads 
supportiI1g the legislation, according to e1nails discussing the 
proposal. Congress overwhelmingly passed the law (named after McCain) 
in May.
    ``In the campaign, I also promised that we would fight for Veterans 
Choice,'' Trump said at the signing ceremony in June. ``And before I 
knew that much about it, it just seemed to be common sense. It seemed 
like if they're waiting on line for nine days and they can't see a 
doctor, why aren't they going outside to see a doctor and take care of 
themselves, and we pay the bill? It's less expensive for us, it works 
out much better, and it's immediate care.''
    The new permanent program for buying private care will take effect 
in June 2019. The VA's new and improved Community Care Network 
contracts were supposed to be in place by then. But the agency 
repeatedly missed deadlines for these new contracts and has yet to 
award them.
    The VA has said it's aiming to pick the contractors for the new 
program in January and February. Yet even if the VA meets this latest 
deadline, the contracts include a one-year ramp-up period, so they 
won't be ready to start in June.
    That means TriWest will by default become the sole contractor for 
the new program. The VA declined to renew Health Net's contract when it 
expired in September. The VA was planning to deal directly with private 
providers in the regions that Health Net had covered. But the VA 
changed course and announced that TriWest would take over Health Net's 
half of the country. The agency said TriWest would be the sole 
contractor for the entire Choice Program until it awards the Community 
Care Network contracts.
    ``There's still not a clear tin1eline moving forward,'' said 
Giddens, the former VA contracting executive. ``They need to move 
forward with the next program. The longer they stay with the current 
one, and now that it's down to TriWest, that's not the best model.''
    Meanwhile, TriWest will continue receiving a fee for every 
referral. And the number of referrals is poised to grow as the 
administration plans to shift more veterans to the private sector.

                                 
                American Health Care Association (AHCA)
    Chairman Phil Roe, M.D.
    United States House Committee on Veterans' Affairs
    335 Cannon House Office Building
    Washington, D.C. 20515

    Chairman Johnny Isakson
    United States Senate Committee on Veterans' Affairs
    Russell Senate Building - Room 412
    Washington, D.C. 20510

    Chairmen Roe and Isakson:

    I serve as the Senior Vice President of Government Relations at the 
American Health Care Association (AHCA), the nation's largest 
association of long term and post-acute care providers. The association 
advocates for quality care and services for the frail, elderly, and 
individuals with disabilities. Our members provide essential care to 
millions of individuals in more than 13,700 not for profit and for 
profit member facilities.
    AHCA, its affiliates, and member providers advocate for the 
continuing vitality of the long term care provider community. We are 
committed to developing and advocating for public policies which 
balance economic and regulatory principles to support quality of care 
and quality of life.
    Therefore, I appreciate the opportunity today to submit a statement 
on behalf of AHCA around the joint Senate Veterans Affairs Committee 
and House Veterans Affairs Committee hearing entitled, ``Tracking 
Transformation: VA MISSION Act Implementation.''
    Prior to the VA MISSION Act, if extended care providers, including 
nursing care centers, accepted a veteran patient, they were considered 
to be a federal contractor and subjected to additional red tape - 
simply because the patient was a veteran. Our centers already meet very 
strict compliance guidelines under the Medicare and Medicaid programs. 
Adding additional regulations on top of this is simply inefficient, 
redundant, adds cost and takes staff time away from these veterans at 
the bedside. This disparity of contracting and reporting requirements 
has deterred many long term care providers around the country from 
accepting veteran patients. As our veteran population ages, we must be 
able to provide them with a continuum of care for their dedicated 
service. Furthermore, we must be able to provide this care closer to 
their home communities or in close proximity to their families and 
support system.
    The American Health Care Association and National Center for 
Assisted Living (AHCA/NCAL) represent more than 13,700 non- profit and 
proprietary skilled nursing centers, assisted living communities, sub-
acute centers and homes for individuals with intellectual and 
developmental disabilities. By delivering solutions for quality care, 
AHCA/NCAL aims to improve the lives of the millions of frail, elderly 
and individuals with disabilities who receive long term or post-acute 
care in our member facilities each day.
    It is long-standing policy that Medicare (Parts A and B) or 
Medicaid providers are not considered to be federal contractors. 
However, if a provider currently has VA patients, they are considered 
to be a federal contractor and under the Service Contract Act. The 
Office of Federal Contracting Compliance Programs (OFCCP) has 
administered onerous reporting requirements and regulations even beyond 
those required by Medicare and Medicaid rules, which have dissuaded 
nursing care centers from admitting VA patients. This limits the care 
available to veterans needing long term care in their local 
communities. Our veterans should not have to choose between obtaining 
the long term care services they need and remaining near loved ones in 
their community. Conversely, the same centers contracting with the 
Centers for Medicare and Medicaid Services (CMS) are not subject to the 
OFCCP regulations.
    AHCA has long been advocating for policies that would make the VA 
requirements for providers the same as they are for CMS and waives the 
OFCCP federal contracting requirements. Provisions in the VA Mission 
Act will help remove some of the existing red tape that may prevent 
providers from being able to provide care to veterans. More 
specifically, the VA Mission Act will ensure that extended care 
providers, including nursing center care, can legally enter into 
Veteran Care Agreements (VCAs). As the VA is working on implementation 
of these agreements we must ensure that they are subject to the same 
rules and regulations as any other Medicare or Medicaid provider as the 
law intended. We also must ensure that the law is implemented in a 
timely manner and our providers have access to VA staff with any 
implementation concerns or questions.
    The use of VCAs for extended care services would facilitate 
services from providers who are closer to veterans' homes and community 
support structures. Once providers can enter into VCAs the number of 
providers serving veterans will increase in most markets, expanding the 
options among veterans for nursing center care and home and community-
based services. AHCA appreciates the fact that your Committees have 
worked to make these VCAs a reality. AHCA asks for your assistance in 
ensuring proper and timely implementation of these agreements so those 
veterans who have served our nation so bravely have appropriate access 
to quality health care.
    Thank you again for the opportunity to comment on this important 
matter. If you have any questions, please do not hesitate to contact me 
at [email protected] or AHCA's Senior Director of Not for Profit & 
Constituent Services, Dana Halvorson, at [email protected].

    Sincerely,

    Clifton J. Porter II
    Senior Vice President of Government Relations

                               
                            GOVERANCE SLIDES
                            
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            National Committee for Quality Assurance (NCQA)

    Better health care. Better choices. Better health.

Key Points

    The National Committee for Quality Assurance is a non-profit that 
works to improve health care quality and value through measurement, 
transparency and accountability.
    NCQA programs and extensive expertise align with MISSION Act 
requirements and can help the VA expedite the law's implementation.
    NCQA is the nation's largest health plan accreditor, stewards 
HEDIS \1\ - the most widely used set of clinical performance measures, 
and has the nation's largest Patient-Centered Medical Home (PCMH) 
program.
---------------------------------------------------------------------------
    \1\ The Healthcare Effectiveness Data and Information Set (HEDIS) 
is a registered trademark of NCQA.
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    NCQA also has the nation's only Patient-Centered Specialty Practice 
(PCSP) program, which closely aligns with VA Mission Act requirements 
for provisions for ensuring quality and access for non-Department 
clinicians.
    The PCSP program requires agreements for information exchange 
between specialty practices and primary care clinicians who refer to 
them.
    The program also includes optional criteria practices can meet to 
earn additional points needed for recognition, such as electronic and 
same-day access, patient experience surveys, and measuring and 
reporting their performance.
    We would be happy to work with the VA and its stakeholders to 
tailor the PCSP program to meet specific MISSION Act provisions.

      For example, we have a PCMH standard on query of 
prescription drug monitoring program we could add to PCSP to align with 
the MISSION Act provision on monitoring opioids.
      We also could make optional criteria like same-day access 
and measuring patient experience must-pass to fully align PCSP with 
other MISSION Act provisions.

    PCSP Recognition there could be a basis for certification of 
eligible providers, as required by the statue, without requiring the VA 
to ``reinvent the wheel'' that we developed through extensive 
literature review, stakeholder engagement and public comment.

    The Honorable Johnny Isakson, Chairman
    U.S. Senate Committee on Veterans' Affairs

    The Honorable John Tester, Ranking Member
    U.S. Senate Committee on Veterans' Affairs

    The Honorable Phil Roe, MD, Chairman
    U.S. House Committee on Veterans' Affairs

    The Honorable Tim Walz, Ranking Member
    U.S. House Committee on Veterans' Affairs

    Dear Chairmen Isakson and Roe & Ranking Members Tester and Walz:

    Thank you for the opportunity to submit a statement for the record 
on VA MISSION Act Implementation. The National Committee for Quality 
Assurance (NCQA) is a non-profit organization established in 1990 to 
improve health care quality through measurement, transparency and 
accountability. We work to build consensus among stakeholders from 
government, private industry, consumers and academia on ways to improve 
quality. As a result, our programs are nationwide market leaders that 
enjoy broad public and private sector support.
    Our programs also closely align with critical Mission Act 
requirements, allowing the VA to adopt them without ``reinventing the 
wheel'' that we already developed through our extensive experience and 
consensus-building approach. We stand ready and eager to help in any 
way we can and hope the Department of Veterans' Administration will 
consider NCQA a valued partner to support its quality improvement 
efforts.
    NCQA's Evidence- & Consensus-Based Process: We develop NCQA 
programs and measures through a systematic, evidence- and consensus-
based process. We start with literature reviews to identify evidence 
and guidelines on the most appropriate or best practices. We then 
establish expert Committees representing patients and families, 
clinicians and other health professionals, employers, insurers and 
industry, academics and state and federal government to build consensus 
on the best way to measure adherence to the evidence. We put the 
resulting consensus out for public comment from all stakeholders and 
incorporate those comments into final decisions. Once implemented, we 
monitor the scientific literature and seek ongoing stakeholder feedback 
on challenges, potential improvements or updated evidence and 
incorporate as needed. And we post results in report cards on the 
ncqa.org website.
    Accreditation: NCQA has the nation's largest health plan 
accreditation program, with over 181 million Americans in NCQA-
accredited plans. We accredit plans by rating their actual performance 
and make the results publicly available to help the VA and many others 
set benchmarks. The federal government requires such performance-based 
accreditation for all plans participating in the Affordable Care Act 
Marketplaces. As a result, more than 85 percent of Marketplace plans 
are NCQA Accredited. In addition, 26 state Medicaid programs 
specifically require NCQA Accreditation for managed care plans and 
another 4 accept NCQA Accreditation. In addition, NCQA has the only 
long-term services and supports (LTSS) accreditation program, which 
four states require for managed care plans providing LTSS.
    We also have accreditation programs for managed behavioral health 
care, case management, disease management, utilization management, 
credentialing, provider networks, wellness and health promotion, and a 
multicultural health care distinction program to help address 
culturally and linguistically appropriate services and reduce 
disparities. We are happy to share the Standards and Guidelines 
materials for any of these programs and explore how they, or parts of 
them, might help meet MISSION Act requirements.
    Quality Measures: NCQA stewards the Healthcare Effectiveness Data 
and Information Set, or HEDISr quality measures. HEDIS is the most 
widely used clinical quality performance measures and includes more 
than 90 measures that track prevention, management of chronic 
conditions, misuse and patients' experience of care. Medicare, most 
states and many private purchasers require HEDIS, and insurers covering 
57% of all Americans now report HEDIS.
    We continuously update HEDIS for new scientific evidence, to remove 
``topped out'' measures with little further opportunity for 
improvement, and to raise the bar in areas that need improvement.
    We are fortunate to have a liaison from the VA, along with other 
private and public entities, on our HEDIS Committee for Performance 
Measurement (CPM) Committee, which guides this work.
    We have specific HEDIS sets tailored to the populations of 
different product lines, such as Medicare, Medicaid and CHIP, 
Marketplace and Commercial plans. We would be happy to work with the VA 
to similarly tailor a set of HEDIS and other measures that meet the 
specific needs of the veterans you serve.
    Comparable Results for Public Reporting: It is critical to have all 
clinicians within each specialty report the same measures to ensure 
comparable information for MISSION Act public reporting. Programs that 
let clinicians choose measures from a menu get the false impression 
that quality is higher than it actually is because people will report 
measures that make them look best.
    It also is important to ensure that clinicians have sufficient 
numbers of patients to obtain statistically valid measurement results. 
Results for clinicians with small numbers of specific types of patients 
are unreliable and will not provide useful comparative information to 
VA stakeholders. Medicare's ``virtual group'' option addresses this 
small numbers problem by letting clinicians voluntarily join together 
for measurement as a group to achieve numbers large enough for valid 
measurement results. The VA therefore may also want to explore virtual 
groups as a way to obtain more valid comparable information for the 
MISSION Act.
    Reporting Burden & Meaningful Measures: We are well aware of the 
amount of time clinicians now spend to report on quality, which takes 
time away from patient care. We are diligently working to reduce 
reporting burden by moving to a system in which we automatically derive 
measurement data from electronic health systems, registries and other 
electronic sources. This will allow us to access more robust clinical 
data that are in these systems compared to health care claims that are 
primary sources for most measures today. It also will let clinicians 
report measures by merely entering data electronically as they do in 
the normal course of patient care without additional data entry as 
required today.
    Additionally, we are working toward the same goals as the Centers 
for Medicare & Medicaid (CMS) Meaningful Measures Initiative that seeks 
to minimize reporting burden, streamline measures and focus on 
outcomes. This includes automated reporting, systematic review of 
measures to retire and developing outcome measures, especially patient-
reported outcome measures (PROMs).
    Patient-Centered Medical Homes & Neighborhoods: NCQA has the 
nation's largest Patient-Centered Medical Home (PCMH) program which 
includes nearly 20 percent of all primary care physicians, plus 
additional primary care clinicians, at over 14,000 sites.
    PCMHs transform primary care into what patients want by building 
better relationships between patients and the teams who care for them 
and directly addressing fragmentation \2\ that plagues health care.
---------------------------------------------------------------------------
    \2\ Frandsen et al, Care Fragmentation, Quality, and Costs Among 
Chronically Ill Patients, 2015.

---------------------------------------------------------------------------
    PCMHs do this by:

      Helping patients get care when they need it, including 
electronically and after hours.
      Coordinating personalized, comprehensive, integrated 
care.
      Preventing costly, avoidable hospitalizations and 
emergency department visits - particularly for complex chronic 
conditions.
      Improving staff satisfaction by ensuring practices have 
systems and structures to work efficiently.
      Leveraging health information technology (HIT) to enhance 
access and coordinate care.
      Reducing health care disparities and clinician burnout.

    A growing body of evidence documents that PCMHs improve cost, 
quality and patients' experience of care while reducing both 
disparities and clinician burn-out. \3\ In Medicare, for example, PCMHs 
reduce per capita spending by 4.9%. \4\
---------------------------------------------------------------------------
    \3\ NCQA, Benefits of NCQA Patient-Centered Medical Home 
Recognition, 2017.
    \4\ Health Services Research, Total Cost of Care Lower among 
Medicare Fee-for-Service Beneficiaries Receiving Care from Patient- 
Centered Medical Homes, 2015.
---------------------------------------------------------------------------
    We also have related ``medical neighborhood'' programs for 
specialists, retail and other clinics. Over 100 public and private 
payers support our patient-centered care programs. Congress recognized 
the value of PCMHs and Patient-Centered Specialty Practices (PCSP) by 
legislating automatic credit for them under Medicare's Merit-Based 
Incentive Payment System. The Department of Defense has worked with 
NCQA to help XXXX of its primary care practices transform to PCMHs. 
Similarly, the Health Resources Services Administration has worked with 
NCQA to transform XXXX federally qualified health centers as PCMHs.
    Patient-Centered Specialty Practices: Our PCSP program, in 
particular, aligns with MISSION Act provisions for quality and access 
of non-Department clinicians. We launched the program in 2013 and 
updated it in 2016. It builds off of a PCMH foundation to establish 
``medical \5\neighborhoods. \6\
---------------------------------------------------------------------------
    \5\ American College of Physicians, The Patient-Centered Medical 
Home Neighbor, 2010.
    \6\ Agency for Healthcare Research & Quality, Coordinating Care in 
the Medical Neighborhood: Critical Components and Available Mechanism, 
2011.

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    The program requires agreements for two-way information exchange 
between specialty practices and primary care clinicians who refer to 
them. The program also includes optional criteria practices can meet to 
earn additional points needed for recognition, such as electronic and 
same-day access, patient experience surveys, and measuring and 
reporting their performance.
    PCSP Recognition therefore could be a basis for certification of 
eligible providers, as required by the statue, without requiring the VA 
to ``reinvent the wheel'' that we developed through extensive 
literature review, stakeholder engagement and public comment.
    The chart below shows how our PCSP standards align with key VA 
MISSION Act provisions for access - including same-day appointments, 
measuring and reporting on quality, coordination and patient surveys.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    We would be happy to work with the VA and its stakeholders to 
tailor the PCSP program to meet specific MISSION Act provisions. For 
example, we have a PCMH standard on query of prescription drug 
monitoring program we could add to PCSP to align with the MISSION Act 
provision on monitoring opioids. We also could make optional criteria 
like same-day access and measuring patient experience must-pass to 
fully align PCSP with other MISSION Act provisions.
    Conclusion: NCQA for nearly three decades has worked toward our 
mission to improve quality, access and patients' experience of care in 
ways that closely align with the VA MISSION Act. We believe our 
extensive experience, consensus-building approach and market leading 
products that track MISSION Act requirements can add real value to your 
efforts. We stand ready and eager to help any way we can, including 
tailoring our work to best meet the VA's unique needs and challenges in 
implementing the MISSION Act.
    Thank you again for the opportunity to submit this statement for 
the record. We welcome the opportunity to discuss these ideas in 
greater depth. Please contact Paul Cotton, Director of Federal Affairs, 
at 202- 955-5162 or [email protected] if you have any questions.